What to do if you are shot

Even if  the S does not HTF, in our society, if you are out and about, there is a small but real possibility you could be shot (see my last post). If S DOES HTF, the potential for death and disability,  which could lead to death, increases dramatically. Shot folks continue to die with the finest, state of the art trauma care, even if they make it to a level 1 center in that critical first “golden hour”.

Gunshot wounds cause death by a number of mechanisms: first, by direct destruction of a vital organ, most obviously heart and brain (although not every brain shot kills, aka Gabbie Giffords. Location and kinetic energy transfer are key. Had Jared Loughner been loaded with 147gr JHP rather than 115gr FMJ,and  shot her in the midbrain the Congresswoman would have died at the scene.). A 36gr HP 22LR behind the ear is an efficient way to kill; enough energy to penetrate the skull but insufficient to exit, so it ricochets. Think Winchester Brainamatic. A penetrating wound to the chest not only destroys lung tissue for oxygen transfer, but more acutely collapses the lung (pneumothorax) or fills the cavity with blood (hemothorax) preventing lung function or increasing pressure in the chest to the point where venous blood return to the heart is impaired. Bleeding (hemorrage) is the next quickest way to die from a bullet. A gunshot to the vena cava behind the liver or the iliac vein in the pelvis are technically difficult to stop even if you were shot in an operating room. Normal adult human blood volume is about five liters. A 1 cm hole in your portal vein draining to your liver (size of your thumb) with normal cardiac output will have you dead in less than ten minutes. Interestingly, bleeding from veins is more rapidly fatal than arteries as arteries tend to go into spasm after injury and bleed during systole (when the heart pumps ) whereas veins bleed during systole and asystole (both parts of the heart’s cycle).  The final, more painful way to die from a bullet is from sepsis (infection) in the abdomen. A bullet passing through the colon or small bowel, full of bacteria, seeds a previously sterile field with multiple types of bacteria and blood and devitalized tissue, perfect culture media for bacteria in the warm incubator that is your abdominal cavity. Urine or bile spilling into the abdomen causes chemical peritonitis,  or inflammation of the belly, that causes a response similar to infection.

So far we’ve considered gunshots to the head, abdomen and chest. What about neck and extremities? This is where disability factors in, and death, especially in post-SHTF, lurks. Penetrating, cavitation wounds to the neck lead to death from hemorrage and airway obstruction, in fairly short order.  Less cavitating rounds can penetrate the spinal cord, as could occur in the abdomen,  leading to respiratory impairment and paralysis.  Paralysis, post-SHTF, leads to death. Extremity wounds can exsanguinate (bleed to death) if the vessel is large enough (think femoral vein in the groin), paralyze if nerve injury occurs, or kill you with sepsis from gangrene. Recall that the most common operation in the War of Northern Aggression (sorry, couldn’t help myself) was extremity amputation. Few abdominal explorations were done due to lack of knowledge, technique, anesthesia and, well, you mostly  just died if you were gutshot. If you lived you probably drained stool through a hole in your belly until you wasted away. After existing  resources are depleted, the medical/surgical landscape will seem a lot like 1864, post-SHTF. 

So, what to do if you are shot? Well, if you are aware that you are shot, that’s a plus. Statistically,  most gunshot wounds don’t kill. I wish I had a nickel for every thug I have operated on and discharged or ED -treated and released, for nonfatal or nonthreatening gunshot wounds, but, again, that’s with state of the art care, not post-SHTF. Next, assess where you’ve been shot and what you’ve been shot with. A deer rifle or 5.56/7.62 round to your abdomen post-SHTF in a remote location probably means it last rites time. Not trying to be Debbie Downer, but it is what it is. Rapid infusion of IV fluids can briefly maintain pressure, but may paradoxically also maintain bleeding. This is where morphine is important, and a selfless attitude not to get your team killed futilely trying to save you. Military survival rates from such injuries in Iraq/Afghanistan are impressive due to efficient air evacuation and rapid, specialized treatment. Certainly similar rounds to head (you’ll never know), neck or extremities kill as well. Internal bleeding from abdominal or chest wounds cannot be controlled with external pressure. Bleeding from extremity soft tissue wounds and smaller vessels is controllable with pressure. This is not the time to worry about a tetanus booster (go get one, now). Take some antibiotics if you have them, ciprofloxacin or levofloxacin are good choices to keep on hand because few people are allergic to them, though they rarely work against MRSA (resistant Staph). MRSA, if you have it, is the least of your problems,  at this point. Wash the wound, irrigate it, until all dirt and grass and clothing fragments are gone. In the operating room we would debride (surgically excise) devitalized tissue with powered irrigators, sterile saline solution and blades. Not an option in the field. Treated canteen water is better than nothing. Last, apply the cleanest dressing you have and immobilize the wound if possible.  Motion and friction lead to bleeding. Then get to a higher level of care as quickly as you can, if it exists near your AO. 

All of this changes if you have a medic, transport, and aid station/hospital.  Every layer of care increases survivability.  My scenarios and recommendations assume the worst, but that’s what prepping is about. So, let’s get to the homework assignment.  Take a man target (a roll of butcher paper and a marker creates a template to draw an outline). Fire a magazine load from your carry piece at it. Remember how to target body armor for kills….groins and necks. For every “hit”, describe what you have injured (get Ed Grouch’s recommended Gray’s Anatomy Coloring Book out), the likelihood of death and by what mechanisms death would/could occur, and how you would temporize/treat the injury. Comment below with questions/answers. Images of the targets would be great!

 

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As I lounge about my home this week recovering from a laparoscopic hand-assisted radical nephrectomy,  a procedure involving a fair bit of medical technology, I am struck by how few people appreciate the rapidity and degree to which their health care availability and delivery would decline in a grid-down post-SHTF scenario. This week, doctor as patient ponders that he would be screwed, tumor still in place, as such operations would not only be unavailable,  they would be impossible,  with no such resources likely at the ready,  and not survivable for lack of support if they were.

Simple things often taken for granted, like tetanus shots, will be scarce.  That rusty nail you stepped on during a recon patrol may kill you, as Clostridium tetani does not sleep, like the Pseudomonas aeruginosa in your shoe. Got ciprofloxacin?  Little infections become big problems when you have nothing to treat them with.

A former patient of mine was taking out her trash at dusk in an urban neighborhood of a midsized southern city. Confronted by two men, she gave them the car keys they demanded, yet they still shot her in the abdomen. Less than a mile from a level I trauma center. Despite rapid transport, modern technology, and state of the art care, she died. How do you think you will fare if you are gut-shot at night on patrol, in twenty degree weather, miles from even a basic aid station? You climb a tree to establish your position or establish a more favorable comm link; it’s raining. You slip and fall, and now your thigh has a forty five degree angle. Femur fractures can easily lose two to four units of blood in short order. Got packed cells? Morphine?

In William Forschten’s post-EMP novel One Second After, the protagonist’s overriding concern is scavenging for and maintenance of a supply of insulin for his diabetic daughter, who eventually dies from diabetic coma that he is powerless to prevent. Americans are the most heavily medicated society in history; while diseases related to obesity would likely fade as food supplies dwindle, the prospect of dealing with the hordes of dependent people suddenly cut off from their psychotropic medications, and there are millions of them,  seems unpleasant indeed. Chronic maintenance medications,  from insulin requiring refrigeration to anticonvulsants to bronchodilators for lung disease to antiplatelet agents for coronary stents, will dwindle in supply until they are unavailable. Those people will simply die if there is no natural, available alternative. My wife awaits a kidney transplant…Got sterile dialysis supplies? Got cyclosporine? Many of you had the flu this year. Imagine the misery without the supportive medications you took.

Modern American medicine has enabled many of us with chronic problems to live productive, functional lives, extended our lifespans and kept the Reaper at bay. The margin,  though, is razor – thin.  Existing inventories are scant with just-in-time delivery systems which, analogous to food and produce delivery, are easily disrupted with no alternative.  The purpose of this blog, as it develops,  is to promote an appreciation of the problems faced in the grid-down world, and provide a forum for discussion of how to handle them.