30 March 2011

The suburban lottery winner

I'm lucky enough to work at a place in a lower-to-middle class suburb, which doesn't see too much penetrating trauma. Sure, we have a knife & gun club, like any other town, it's just that ours are a bunch of wussies, relatively speaking. It's rare to have a savage, prolonged beat-down like we saw in the inner city where I trained. There was a ritual there, so I am told, that if you wanted out of a gang you had to subject yourself to a beating which was called a "punkinhead." Each gang member would get to take a couple of shots at your face, and they would hold you up to ensure every member got their licks in. By the end, your face was swollen up to the size and shape of a pumpkin. If you survived, you were out of the gang. I don't know if that was true, but I do know we saw a lot of inner-city youths with incredible facial injuries from these beatings. Where I am now, a fat lip or busted jaw is about the worst we see. And the gunshot wounds in the city were astonishing. On a summer weekend night shift, half a dozen was not uncommon. Chest tubes and thoracotomies became boring enough that we let med students and interns do them (supervised, of course). Now, in our lower-middle class suburban paradise, if we see three gunshot wounds a month, it's unusual, and we probably see as many wound from hunting accidents as we do from actual homicide attempts.

So it was a Big Deal when the medics called to let us know that there had been an outbreak of gunfire at a local nightclub and we should expect multiple casualties. Fortunately, we're all trauma trained and ready and we scurried around preparing for the victims to roll in. I was pretty proud of our response: in five minutes, we had three resuscitation room ready to go.

We were sadly disappointed by the first few victims to roll in. (Did I say disappointed? I meant relieved.) They were fine: flesh wounds only, minor extremity injuries. But, the medics warned us, the next one coming (which happened to be mine in the queue) was hit directly in the left chest. They shook their heads when I asked how bad she looked and said there was a lot of blood at the scene. It sounded bad.

Sure enough, when they got there, the impression was scary. A young woman, flat on the gurney, pale and terrified with a shirt saturated with blood hanging off the sides where the medics had cut it, and one burley paramedic straddling the gurney compressing a trauma dressing against her chest in an attempt to stanch the bleeding. 

We jumped into action. Exposure, IV access, vitals, all that good stuff. I talked to her and she was alert: she told me she had no idea what had happened. She heard some pops and felt something hit her and she fell down. She was healthy, with a three-month old baby and was scared that she was going to die. I reassured her as best I could and we went to work. Sure enough, just above her left nipple was an entry wound. We couldn't find an exit wound or any other injury. A chest x-ray was done to track the bullet in her torso, to see if there was blood in the lung or a collapsed lung or the bullet had crossed to the other side of the chest. Strangely, there was nothing at all. No bullet present, and no evidence of injury. We x-rayed her neck and abdomen, searching for the bullet: nothing. Incidentally, her vitals were fine, and her color had improved after some rewarming and reassurance. Finally, I expored the wound. Bloody (as you would expect in a lactating breast) but it didn't seem to penetrate more than a couple of inches, and that on the outside of the chest. 

Then one of the techs, going through the heap of bloody clothing discarded in the corner, triumphantly produced the bullet. It had apparently stopped after hitting her chest, and fallen out into the lining of her jacket.

And that was it. We washed her wound out, dressed it, observed her a couple of hours and repeated the chest x-ray, and she went home. First time I've ever had a Discharge Diagnosis of: "Gunshot wound, left chest."

The police later explained that the patient's location had been at an extreme range from the shooter, so we figured the bullet's energy was mostly spent by the time it hit her. There was also an icky possibility that it had passed through another victim before hitting her, which would also have attenuated its energy enough that the superficial injury would make sense.

So that's life at the suburban trauma center. Even our gunshot wounds are weak. But wow was she lucky. As she left, she turned and told the nurse that the next thing she was going to do was to buy herself a lottery ticket.


  1. Amazing. May she parlay that fortune into positive action in her community.

  2. Wow. Lucky her, especially when you hear stories about people getting hit in crossfire from idiots they had nothing to do with. Nice to hear it worked out for her.

  3. I once had a guy whose entrance wound was L temple,exit from R temple - never penetrated the skull just went around. Some people have good luck/karma/whatever.
    -whitecap nurse

  4. In Sydney Australia where I live, many ER doctors could go a whole career without ever seeing a gunshot wound. At all. They'd certainly never see multiple gunshot wounds.

  5. We've not now had a gun homicide in London for 13 weeks but the other night some youths chased some others into a store in south London and managed to shoot and injure a five year old girl and a man, both bystanders. Both are stable. This is why we are determined to rid the streets of guns here.

  6. For future "mass casualty" events, how's the new ER coming along?

    I anticipate a blog post about the wonders of space and new equipment...

  7. I was just yesterday ranting about how Lower-to-Middle Class Suburban Medical Center lacks experience with penetrating trauma. How exited they get over something that would have merited a little more than a bandage and a shot or two at "Inner City Dump Hospital" where I started my career become major traumas in the eyes of some folks there. I think if it were possible everyone should start their career in some hell hole to get the experience.

    As for the breast wound, it's weird when that happens. Saw a hooker once who got shot in the belly from only a few feet and bullet was lodged in her Panniculus. I couldn't decide which to be more amazed at, the luck of the wound, or the idea of a prostitute with a Panniculus. Some people are just plain lucky, if anything to do with being shot can be called lucky.


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