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One of our readers (thank you Loyd) sent us this video yesterday. While the vast majority of the intro is the anesthesiologist trying (failing?) to give an overview of guns in the United States and then spouting off a TON of relatively useless and irrelevant facts, there are some gems in here about the presentation of gunshot wounds in the emergency environment and their treatment. And while you’re free to watch the video yourself, I thought I’d tease out the important parts and talk about treatment in the field . . .

The #1 thing I took away from this video is something I already knew, specifically that the biggest cause of death from handguns is due to exsanguination (bleeding to death) rather than from the bullet impacting a critical link in the nervous system.

For the self defense shooter, that means even if you hit the guy, best case scenario you’ve probably still got about 10 seconds before they’re combat ineffective. For the recreational shooter, that means having a good first aid kit at hand could be the difference between life and death.

In the pre-hospital environment, the primary goal of gunshot wound management is to stop the bleeding. The average human can lose about a liter of blood before going into hypovolemic shock, and a little over two before having insufficient volume to perfuse adequately through your brain (AKA pretty much dead).

Up until that point your body will systematically shut off blood flow to your extremities, concentrating the remaining volume in your abdomen and head. Which is kinda cool.

For managing that blood loss, it all depends on where the wound is located.

On extremities, people always seem to want to avoid the tourniquet. And sure, for smaller bleeds that can be controlled with direct pressure it might be overkill. But it’s notoriously difficult to identify the severity of a gunshot wound in the field, so my first action is always to grab that TK and slap it on the extremity. Unless that extremity is your head, that is.

From the moment you put it on, you’ve got two hours before you start to see irreversible tissue damage, but that’s still better than the whole “bleeding to death” thing.

For abdominal wounds, it gets a little more complicated. Since there’s so much space in the abdomen for blood to pool, its often extremely difficult to identify just how bad the bleeding is. The larger blood vessels in the abdomen run along the inside of the spine for most of their journey through your body.

That means you won’t typically see any spurting or pulsating flows that would normally indicate a laceration if they have been ruptured. In short, assume the worst. Slap a large trauma pad on there, apply direct pressure and transport immediately.

That right there is the key to survival — immediate transport. Or, as we like to call it, “diesel therapy.” For gunshot wounds, getting the patient to definitive care is the key to survival. Definitive care in this case meaning an operating room — just getting them to the nearest ER is nice, but they need to be sewn back together to survive.

For the civilian, getting someone to definitive care fastest may not mean waiting for an ambulance. Consider that it will take the ambulance between two and five minutes to get the call, an additional two minutes to get rolling, and then it still needs to get from its station to where you’re located.

We’re talking about maybe 10 minutes where you’re bleeding and not getting any closer to the hospital, and that doesn’t even begin to factor in the police having to come and secure the scene before the EMTs roll in.

I may catch hell for this, but if you know where the hospital is located and it’s less than a five minute drive, take the victim yourself. You’ll find that rolling up to the emergency room and yelling “gunshot wound victim” will get you more help than you need to get them on a stretcher and into the ER.

Speaking of rapid transport, something your county may have on hand (which can be very useful if you’re in the middle of nowhere) is a helicopter service. Ambulances can take forever to get to your location and even longer getting back out. A helicopter can often zip in and fly directly to the hospital with much less wasted time.

When you call 911, ask if a helicopter is available — the 911 dispatchers will usually defer to the eyes on the ground (if they sound calm, cool and in control) and dispatch resources as requested. Just be aware that they like a good 50-100 yards (squared) of open field for a landing zone, so if you’re in the woods it might not be an option.

Those are my takeaways from the video, but I just wanted to throw something else in here.

There are a lot of people who stock tampons and quick clot in their bags in case of a gunshot wound, and while those are going to stop the obvious bleeding, they may not stop the actual source of the leak. I’m not going to discourage their use, but I just wanted to remind you guys that just because there’s no gross (obvious) bleeding doesn’t mean the patient isn’t losing tons of blood quickly on the inside.

So, in summary, RAPID TRANSPORT. Worry about the speeding tickets later. And invest in a tourniquet.

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    • Well according to our fellow AI Little John “the 45 will take your attacker down with one shot no matter where you hit him/her” not sure if the doctor or Foghorn would agree.

      • Well one thing I did get from this video is that it’s a good idea to use +P ammo in my 45, not that is wouldn’t go through the sternum, but at least it’ll make its way back to the spine.

    • The doctor really only compares rifle and handgun rounds in terms of devastation. He does mention that hollow points expand, meaning an increased likelihood of hitting something important but at the cost of potentially less penetration. He also makes it clear that often time multiple impacts to the chest with pistol caliber rounds will not immediately incapacitate.

  1. The bias against tourniquets reminds of the days when first responders would try to squeeze the victim out of their seat without doing further damage to the car.

  2. as one who has taken himself to the hospital with a bleeding non gunshot leg wound i can attest to the fact that you get to go to the head of the line. as an aside while the e.r. people were working on me a security gaurd had me sign a waiver so he could move my car from the e.r. doors and not get sued if he damaged it. if you’d seen the hoopty i was driving you would’ve seen the humour in this.

  3. Words create images in the mind, and there’s nothing like sipping your morning cup of coffee and then reading words such as tampons and bleeding. I’m sure glad roasted coffee beans are brown or black and not red.

  4. While time is of the essence, often driving yourself/loved one to the hospital in a life or death situation can tilt the scale more in death’s favor.

    Driving yourself: you have no way of knowing when that blood loss is going to be enough to make you pass out and lose control of your vehicle. Also, massive bloodloss/injury can greatly impair your coordination and ability to perform tasks safely, such as driving. Again, crashing is just going to worsen your prognosis and possibly injure others.

    Driven by one other person: They will be focused on driving to the hospital (mostly) and won’t be able to intervene when there is a status change (Blocked airway, cardiac arrest, ect). That takes life saving interventions off the table until arrival.

    Driven by two people: Slightly better than single transport, but still not ideal. One driver, and one person provides medical attention. The problem being that there is no good way to perform CPR in a car, and medical supplies, even MacGyver style, are virtually nonexistent.

    Wait 7-10 min for ambulance:
    People at the scene provide medical care. Tourniquets, direct pressure, open airway, feet above level of head and heart, ect. If cardiac arrest, do CPR until help arrives (though significant blood loss may make CPR less effective due to the lower circulating blood volume). Once the EMTs arrive, give times of significant events (ie gunshot wound at 1345, pressure applied at 1346, stopped breathing at 1349, CPR started at 1350). They will have all the nice things that aren’t available in a trauma kit such as oxygen, synthetic blood for transfusion, and rescue drugs (amiodapine, epinephrine, adrenaline, ect) and fluids.

    For what it’s worth, my training and experience says ambulance is better in almost every situation.

    • I think OHgunner makes some good points. I think some of these however are overstated. With a life threatening GSW to the abdomen, the only thing you can do is get an exploratory surgery ASAP. There is nothing you can do to stop an intrabdominal bleed in the field. Everything else is wasting time. There are no airway issues. So in that situation, throw the person in the back of the vehicle and get trucking. Certain chest/head/extremity wounds are different and transporting without EMS may or may not be a good idea depending on the details.

    • I live 30-40 minutes to the nearest hospital and 20 minutes to the nearest EMT center with any ambulances, so add the 7-10 minutes to answer the call to the 20 minutes out to my home, then the 30 minutes to a hospital. Do you still think it’d be good to wait for an ambulance, or should someone be there, drive me? Honestly, i’d drive myself applying pressure rather than wait on the ambulance where I live.

      • Yup, which is why my trauma kit is predicated on the theory that I have to keep the guy alive for one hour — by which point the pros in the Big Flashy Woo-Woo Box should have arrived and taken over.

        However, I live in a rural area, and shoot on rural land where a cell signal might not be attainable without moving around (or on top of) a terrain feature. And our EMS service is way understaffed (we have stations that are completely unmanned several days a week.). By the time you move to an area to make the call, and you add in the reponse time (especially if the location they need to respond to is a wee bit more involved than a straight street address), it’s about the same time to go straight to the hospital, or call 911.

        • BTW — my “one hour survival kit” time limit is based on an average response time in my area of 15 minutes or more (AFTER the 911 call) is made in some parts of the county. Doubled that time to account for possibly having to move to get signal to call 911. Doubled that again to account for the unexpected such as EMS can’t figure out how to find the actual location – again, RURAL area; “5th & Main” isn’t an option for a response address, plus, a single “street address” might cover quite a large hunk of rolling wooded land — and I’m only going to be in ONE of those ravines. (I prefer to shoot below grade when possible – if 90 degrees of berm is good, 360 degrees of berm is better! )

  5. Nick,
    Good summary to the video. I agree wholeheartedly definitive care saves lives. If you have basic first aid skills (first responder level), and know enough not to make the situation worse, it is a good thing to transport someone yourself rather than wait on help to arrive. One quick alibi… here is how the American College of Surgeons classifies blood loss:

    A Class I Hemorrhage is considered 15%, or less, of an adult’s blood volume. In an 80 kg person this would be about 0.84 liters. At this level there are almost no signs or symptoms.

    A Class II Hemorrhage is 15 to 30% loss of an adult’s blood volume. In an 80 kg person this would be about 1.68 liters. At this level the heart will start to beat faster, and the person will start to look pale, and feel cool. This is the beginning stages of shock.

    A Class III Hemorrhage is 30 to 40% loss of blood. In an 80 kg person this would be about 2.24 liters. At this level the heart will be beating very fast, trying to keep up with the bodies needs. The person will look very pale, and start to be confused. This person is in shock, and in trouble. Fluids are needed very quickly.

    A Class IV Hemorrhage is as described above. This is usually greater than 40% and in an 80 kg adult this would be more than 2.24 liters. The body can no longer keep up with the blood loss and the person is in serious trouble. Without very fast help the person will die.

  6. in my case it was transport myself. no phone and no way to call for help. on the way to the hospital i kept an eye out for police or fire personnel. no dice. self transport is the least desirable method, but there are times when it can’t be helped. i much prefer an ambulance, but it ain’t aleays an option.

  7. I’m an EMT and have worked in the Emergency Dept. for 8 years. I agree with Nick about transporting yourself if you know you can get them there in, say, 10 minutes max. And even though we are a Level 1 trauma facility yes, driving up yelling anything like “gun” or “shot” would get our immediate and undivided attention! Part of that is because 95% of the GSW’s in Vermont are self inflicted, fatal, and are not even transported by EMS. The unofficial EMS term for that is DRT: Dead Right There. CPR? “Trauma Codes” in the field have a survival rate right around 0%. But do the chest compressions and call 911 anyways; you’re not going to make things any worse!
    I found the video very interesting. That doc has a wry sense of humor, and seems to be very matter of fact about guns.

  8. If you decide to transport the victim yourself, keep in mind that the ED where the patient is taken won’t have any “heads up” about the incoming patient–so, no time to (1) call the trauma surgeon (if one isn’t “in house”, i.e. the hospital), (2) notify the OR and to insure an anesthesiologist is present, (3) insure that the lab, x-ray, blood bank, etc are all prepared to meet the incoming patient. Where I work, we get many “home boy ambulance” drop offs and it’s always a cluster.

    Perhaps the BIGGEST reason NOT to transport the patient yourself is that all ED’s are not created equal. Many ED’s are not equipped to handle the traumatically injured patient. For that reason, in every part of the U.S., there are designated trauma centers. There are even “sub-designations” of trauma centers–Level 1 (the most sophisticated) all the way to Level 3 (or some say 4).

    I have worked in trauma centers for > 25 years as an ED doc, and unless there is going to be an unreasonable transfer time to the ED, one is better off waiting for EMS to arrive. There are just too many variables that the average citizen isn’t aware of.

    • Just track down the trauma center to home and work before the bleeding starts, and let EMS handle it if you are in unfamiliar territory.

    • Second OakieDoc

      If you have a legit life threatening injury, you need to be at a legit Level I or II trauma center. Otherwise you are probably going to die. Trauma is a highly choreographed team sport. I trained in a level I center and though I can still do the operation necessary to save your life, if the homeboy ambulance deposited you at the door of the ER of my medium sized urban hospital at midnight tonight, the overwhelming likelihood is that I would never get the chance. The ER would be slow to react. They’d take 10 minutes to assess you instead of 2-4. They would probably get a breathing tube in, but I doubt they’d be able to do it and get a central line and a chest tube in time if you had a tension pneumo. There wouldn’t be 2 units of O negative blood sitting in the fridge in the trauma bay. Instead they’d have to call for it. Then find someone to go get it. Maybe a 10 minute delay. If you had an injury in the the box, I doubt they’d be able to crack your chest, I’m certain they wouldn’t have slightest idea what to do after they did. I’m pretty sure they don’t do trauma bedside ultrasound. They might waste time scanning you when you really need to be in the OR right away. Or if you did need a scan it would take 10 or 15 minutes instead of 8. It would take me a minimum of 15 minutes to get there. There wouldn’t be a team ready to start the case for another half hour after I called them in. They don’t have experience with massive blood loss so they don’t have a massive transfusion protocol or the huge blood bank that could support you. If you did make it off the table then the ICU nurses wouldn’t have experience with trauma patients. The intensivists are good but they’re pulmonologists not surgeons so they don’t have the same experience.

      I could go on and on. But the bottom line is your best chance is if EMS does a scoop and go, where they pick you up and get you to the ER ASAP, they intubate you and line you up in the field, the trauma surgeon meets you at the door and you are immediately resuscitated and triaged to OR or scanner in 7 minutes or less.

      The good news is that if you’re not a dirt bag and you don’t hang out with them, you have a very low chance of needing a trauma center.

  9. TTACer thanks for remembering about the 45…… most cases I would advise wait for the EMS to arrive to take care of any heavy bleeding guys….. they will save your life… they are the pros..

  10. “From the moment you put it on, you’ve got two hours before you start to see irreversible tissue damage, but that’s still better than the whole “bleeding to death” thing.”

    I know this is taught by many organizations, but the trauma doctors I’ve talked with in my recent military deployments have told me that this is not very true. They restrict blood flow far longer than that during surgeries and there isn’t much evidence that tissue actually gets damaged after many hours of a tourniquet.

    I’m not a doctor, only meant to broach the subject and see if a doctor could verify or refute this.

    • Tourniquet time is a very complicated and controversial subject. There are so many variables including such seemingly benign things such as where the tourniquet is applied, the width of the tourniquet (in general, the wider the tourniquet, the less muscle and nerve damage from the direct pressure of the tourniquet itself), the pressure to which the tourniquet is applied, the underlying health of the victim and their co-morbid (meaning other medical problems, i.e. are they diabetic? do they have renal insufficiency?) One hour is usually given as a safe time, but is extended to 90-120 minutes. Occasionally for a long procedure, the tourniquet will be deflated and blood will be allowed to perfuse the extremity. Bottom line: the less time a tourniquet is applied, the better.

  11. I go out into the forest and cut firewood for a living. Often, we’re 30 minutes away from the nearest cell phone signal. Injuries on a jobsite for us is a major concern, especially wounds from a chainsaw. Most deaths on the forest are from bleeding out.

    Because of that, I carry a first aid kit that would make most EMT’s green with envy. I actually have 3 tourniquets plus I also carry a clotting agent called CELOX. You could cut your leg off, severing what is called the Femoral Artery, and I could get you to the hospital with rosy red cheeks. The people that make CELOX even have it in a dispenser that’s made to plunge into the channel created by a GSW. This stuff is wicked cool. No heat, no problems with it breaking off and blocking a vessel somewhere else in the body, just apply it and add some pressure, then wrap. Simple as that.

  12. I always get a kick out of these recommendations given for urbanized areas, where the hospital is easily within an hour’s pedal-to-the-metal drive of the scene.

  13. If you can, I say wait on the ambulance. Odds are the EMTs are going to be able to do a better job of patching him up than you can. And they’re probably going to push fluids into him and give oxygen therapy, both of which are things you cant do in your car. They’re not just going to throw him on the gurney in the back and then drive while they let him bleed everywhere…thats why its called pre hospital care. Not only that, but they should be in contact with the hospital getting things set up. You roll up in your car, they aernt going to be ready for you. They roll up in an ambulance, they’ll be waiting with bells on.

    Unless help is either too far away to be useful or you can not get in contact with them, I would say it is a horrifically bad idea to try and transport a GSW victim yourself.

  14. I live in the sticks, no cell coverage, 30-40 min to the HSP. I was a local EMT and dealt with severe trauma caused by logging and logging trucks. We would apply TKs on a regular basis as transport to the local school/helipad was around 30 min and another 20 for a dust-off, another 10-20 to get to the Hosp. There were times that the only tramua pads I could secure were the small throw pillows supplied by Wal-Mart, they worked.

  15. I would also like to add that there is quite a bit of debate about how long a tourniquet can stay on before it starts to cause severe damage. I’ve read several periodicals and case studies. And even then, its better to lose function in an arm than it is to bleed to death. So screw it, put a tourniquet on. And make sure you twist it tight enough they start to scream, if they’re still conscious. And then twist it a little tighter.

    And if you’re too cheap to shell out $40 for a good TQ, any boy scout knows how to make one. You just need a belt and something to torque it with. Preferably, their belt, and not yours.

  16. Helo normally has about a 15-30 minute dispatch process. That’s before they take off. If you live in an urban area and your don’t have crazy bad traffic you can usually drive the victim to the hospital faster than a bird will get them there. The general rule I was taught was that if you can get the victim to a hospital (ANY hospital) faster then EMS can arrive you should drive them right now. Even the smallest hospital has all sorts of stuff than an ambulance doesn’t have, and a lot more hands. And a little hospital also has a helo pad for transport to a trauma center. But calling 911 on the way is certainly a good idea, as it really helps if they know they are getting a GSW.

    It’s also in the $10,000 range for a ride in a bird last I heard. While that shouldn’t be a serious concern when you are a ways out, it also doesn’t make a lot of sense to choose the slower and vastly more expensive option if that is what it is.

    • In the rural west, the price for the helo ride is more in the range of $25K to $40K, depending on what they have to do to support you en route.

      And the time from when you call to when you arrive at the ER might be in the 90 to 120 minute range – which, while it looks like a long time, is less than the four+ hours of driving at 80+ MPH.

      There are times when the helo can’t be dispatched (lots of instances in winter) and some times when you’re in a remote location when it’s going to be a drive to get to where the helo can land. These aren’t like a military dust-off, with super-hot pilots who have ice water in their veins. These are businesses, with liability insurance, rules, procedures, civil aviation regs, etc, etc.

      One of my buddies has taken two flights on a helo to the ER (heart problems and a non-GSW critical internal bleed) for a total of nearly $100K in helo costs (picked up by insurance, thankfully) and another buddy drove himself 90 minutes to the ER with a heart attack. In the rural west, be prepared to do what you have to do, which isn’t always the nice, clean formulation of urban area trauma MD’s.

    • 1) 15-30 minutes before dispatch? Say what? I don’t know where you get your information, but this is WAY off from my world (more like 5-10 min MAX–I work in a trauma center with an active helicopter program.)
      2) Once again, just driving to ANY ol’ hospital might be a HUGE mistake. Not all ED’s are created equal. In fact, delaying definitive care by going to the “wrong” hospital could be fatal. Sorry to tell you that there are just some injuries which can only be repaired by a TRAUMA surgeon in a TRAUMA center.
      3) Calling 911 only gets you an operator. You do NOT get dispatched to speak to an ED. You do not get to play EMS and give an ETA to the local hospital.

  17. Excellent post!

    As an LEO, I have let every driver en route to the ER with a serious medical emergency go. Mind you, I’m not buying an emergency chiropractor or medical appointment that was pre-planned. Regardless, even if you were to get a ticket (which would probably be a jerk move), it should be fought or dismissed by a judge.

    Personally, I have a fast car with excellent brakes and a first aid kit just for times like these (plus, I just like fast cars), and I’ve made a few high – speed ER trips. Both suspected heart attacks, one could have been fatal if untreated. One I gave aspirin to prior to transport from my first aid kit. I’m going to add a couple of quik clot bandages to the kits soon.

  18. Love this guy’s accent. The Die-ahm-eter.
    People have survived unimaginably bad gun shots about as often as some have died from seemingly small wounds from tiny calibers. It helps to have luck on your side.

  19. My father is a recently retired ER doctor who has seen numerous gunshot wounds. He was a Navy Corpsman on Iwo Jima, a Navy Doctor in Korea and an emergency room doctor for 30 plus years (he was also a plastic surgen). Here are some facts that he has told me over the years concerning gunshot wounds:
    Criminals use cheap ammo. He doesn’t know what hollow points or any speciality ammo does.
    One cannot tell the difference between a gunshot from a .45 and a 9mm. The damage is the same (again, using fmj).
    A .22 is suprisingly lethal as the bullet tends to ricocett around the body. .22 also gives good penetration. He told me that once a guy got shot in the arm by a .22 and the bullet ended up in his throat.
    He carries a .22 magnum, a .38 Smith and Wesson, a .38 special, or a .380 for protection. He is concered about overpenetration, as he has seen people wounded by bullets passing through people. He thinks those rounds are good enough to get the job done.
    If he had to shoot someone, he would much prefer a rifle or shotgun. Even birdshot a close range will take someone’s head off. He has seen cases where someone was shot in the head with birdshot, and most of the skull and brain were gone, but the face was still there like a empty holloween mask.
    They usually don’t dig bullets out of people. Unless the bullet is causing problems, they leave it in.
    Any questions y’all want me to ask?

  20. “For abdominal wounds, it gets a little more complicated. Since there’s so much space in the abdomen for blood to pool, its often extremely difficult to identify just how bad the bleeding is. The larger blood vessels in the abdomen run along the inside of the spine for most of their journey through your body.”

    I think you meant the larger blood vessels in the abdomen run along the side of the spine for most of their journey through your body, as the ascending, descending and abdominal aorta are on the left, and the superior and inferior vena cava are on the right of the spine. Severing those will result in fairly rapid blood loss. The radicular and spinal arteries supplying the spinal cord are well anastamosed and fairly small diameter (even the largest of it: artery of Adamkiewicz) when compared to the abdominal aorta.

    Otherwise, a good article. Basically, rifle > pistol, Fragmentation > straight poke, CNS > major blood vessels > peripheral tissue. Those are more important than calibre alone.

    • +1 for the artery of Adamkiewicz…one of the great pimp questions in trauma rounds. As used to be the saying, “Leave no ‘tern unstoned”.

  21. “so my first action is always to grab that TK and slap it on the extremity. Unless that extremity is your head, that is.” Except if it your ex wife then the head is ok! Just kidding..
    Great article Nick…
    I would have to agree, getting to help is priority one. Proper wound treatment is also critical. Our nearest hospital is only five minutes away if I obey traffic laws so I can be there sooner if needed.

  22. On a seizure, not GSW, the advice we got from an ER / Trauma nurse in NYC was go to a particular hospital and drive yourself. As ours was neurological, presenting most of the symptoms of a stroke, we got bumped ahead of several folks who were grazed GSW, stabbed and so on. This was about 14 years ago.

  23. My nearest ambulance station is 15 minutes away at ambulance speed.
    I can be at the ER in half that.
    Whether I would wait for them to come to me depends on the kind of injury & going by past personal experience of their poor response to an emergency.
    On balance, I’d drive to ER.

  24. This gives me the security of knowing that we have enough for a period of time if we break down.
    Break downs and accidents can leave you with no heater, radio, or
    lights. Fleece is lightweight and wool can prevent the effect of flame.

  25. I was just curious as to how long it took to die from a self-inflicted gunshot wound, something I’ve wondered about ever since a former friend committed suicide by gun. I being one who realized that, taking into account his unique circumstances in life, he did the ” right thing for himself”. He was an Army Vet who served in Vietnam and had bad PTSD.

  26. Aw, this was a really nice post. Taking the time and actual effort to generate
    a good article… but what can I say… I hesitate a whole lot and don’t seem to
    get nearly anything done.


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