The importance of assessment before automatically treating.

[lightsandsirens5]

Take a look at the inside of a body bag after a trauma and tell me that. LOL

True, I guess I was thinking of all the DOA GSW to the head calls I have been on.

Yea.....yea.....you are right. :blush:

 

[usafmedic45]

True, I guess I was thinking of all the DOA GSW to the head calls I have been on.

So was I. LOL

 

[mycrofft]

Well, here we are comparing calibers...

Yeah, people drain out. Big cratered cranial GSW sure does, but nice little perfs...not so much.
Have we drifted off subject?
I think part of the art of field response is to look like Ginger Baker during a drum solo break, doing four things at once and moving it forward. Looking the pt over again in the nice well lit ambulance is always a good idea.

 

[lightsandsirens5]

Yeah, people drain out. Big cratered cranial GSW sure does, but nice little perfs...not so much.
Have we drifted off subject?
I think part of the art of field response is to look like Ginger Baker during a drum solo break, doing four things at once and moving it forward. Looking the pt over again in the nice well lit ambulance is always a good idea.

That has got to be one of the best analogies I have ever heard.

 

[Aidey]

Who is Ginger Baker?



Edit: I'm showing my age aren't I?

 

[usafmedic45]

Big cratered cranial GSW sure does, but nice little perfs...not so much.

You'd be surprised.

Have we drifted off subject?

When don't we?

Who is Ginger Baker?

The drummer for Cream. One hell of a drummer. Crazy as a :censored::censored::censored::censored: house rat, but one talented dude.

 

[Afflixion]

You do realize that a .45 caliber round is .45 inches across right?

You do realize that skin is not like paper in which you poke a hole with a pencil the hole in said paper would be the exact diameter of the hole, where as skins elasticity will cause the appearance of a significantly smaller wound than the size of the object that penetrated the skin.

Yea....entrance wound from a (roughly) .30 cal round to the head prolly won't bleed much. As mycrofft already said, dead people really don't bleed too bad. Now on the other side where the round exited, (assuming it did) there will be probably quite a bit of blood and/or brain matter.

I personally know four people who were shot in the head with a 7.62 and are still alive and are still on active duty in the army. Though yes the exit wound would be considerably larger with a large amount of hemorrhaging but, not all entrance wounds have exit wounds despite the size of the round (yes, most do of course but not always.)

 

[mycrofft]

Kudos for the 7.62 saves!!

Heck, I saw a small cal GSW that looked like an incision, abdomen of a really obese individual who was diving for the floor when shot (hyperextended/stretched skin over adipose tissue) who, when he readopted a normal stance, had this little wound like an incision. Didn't get past the blubber, but we had the slug extracted and it went into evidence.

The point of the post is, look 'em over, and visualization has to be in conjunction with the rest of exam, and if you have time, look 'em over again enroute.

(Just to get all CSI again, I drove past an execution style GSW on HWY 12. We were crawling past the crime scene tape, the deceased was head lower on a steep older bridge, and the blood/CSF drained into the gutter from under the yellow blanket went in a thin trail for about two hundred feet).

 

[firetender]

Not in the Textbooks, an ongoing series

30 y.o. black male staggers into ER clutching his chest, panicky, SOB, Grey pallor. After a semi-struggle, he lifts his hands to reveal a bullet wound center sternum! ALERT BUZZER SOUNDS, MAN YOUR BATTLE STATIONS! Everyone SPRINGS into action. No exit wound; how is this SOB still alive? (You gotta picture this poor guy, facing one professional after another looking at him like he SHOULD be dead!)

Seemed to take forever but there was a funny smudge on the X-Ray film and when palpated, a .22 Cal slug was found snugly wedged between the guy's skin and rib cage, underneath his ARMPIT!

Bullets CAN enter at an angle and then skim or ricochet around bone and hard tissue without leaving an exit wound or leaving one so small it gets missed while you're looking for the big HOLE!

 

[usafmedic45]

You do realize that skin is not like paper in which you poke a hole with a pencil the hole in said paper would be the exact diameter of the hole, where as skins elasticity will cause the appearance of a significantly smaller wound than the size of the object that penetrated the skin.

I think I realize that quite well. I've probably spent more time "up close and personal" with GSWs than anyone else on this list. That's the luxury of dealing with the dead: you get to take your time and can examine every last freaking detail.

For the sake of clarification, scalp when struck by that large of a round generally has a rather large defect in it. Scalp skin tends, especially in relatively tightly adherent areas to not be all that elastic (when speaking in comparison to the skin of the abdomen or extremities) which is one reason it tends to tear so dramatically in a stellate manner with tight contact wounds. One pathologist I know likes to compare the makeup of a human scalp to the toughness and complexity of the floor matts in a car.

Now, I do realize that it's relatively easy to miss gunshot wounds even with large caliber rounds. I've been off by six gunshot wounds myself in a preliminary scene count for a guy who was shot with a Thompson; the total count at autopsy was around 27 BTW. To quote the pathologist "This guy obviously made whomever shot him very upset". That said, of all areas of the bodies, the head is among the easiest to find gunshot wounds on (at least in men without long hair). Also, .45s and other large rounds do generally leave an easily palpable defect in the skull. That's actually often the easiest way to find a GSW to the head rather than visually seeking it out.

 

[MEDIC802]

I think(yes my head hurts) all Medics should go through a T3C (Tatictal combat cassualty care)class. Ems is always evolving it's up to all of us to try and keep up.
yes a .45 to the head is hard to miss. generally have blood and csf coming from any opening, normally at lest one eye bulged out ect.

 

[usafmedic45]

I think(yes my head hurts) all Medics should go through a T3C (Tatictal combat cassualty care)class.

Sadly, as someone who both used to help teach TCCC courses and has a paper to his credit that was cited as a reference for the most recent revisions to those standards, I don't necessarily agree with that. It's a great course, but most of us see penetrating trauma with such infrequency, that you would have to repeat the course in the name of skill and knowledge retention so often that it becomes almost absurd and most certainly impractical. Should those standards be taught? Yes, most certainly, but at the same time, unless local protocols are being updated along with the evolving standards all the education in the world isn't going to help that much until we move beyond the "mother may I" method of cookbook treatment we currently work under here in this nation.

normally at lest one eye bulged out ect.

You see mostly tight contact GSWs to the head (execution style to the occiput or high posterior parietals) and transoral suicidal GSWs I'm guessing. LOL

 

[mycrofft]

There I was, minding my own business in orientation...

Guy staggers in, face covered in blood from multiple small rounded wounds to forehead and anterior scalpline. Took him down, while other were taking care of stuff, I was trying to visualize the actual wounds, wiping off blood....they were semicurcular. Hit repeatedly by hooker with her highheel. MD was ready to call it a GSW til then.

Another time in jail postop care, pt hit at angle behind ear with .38 at about fifteen feet or so, slug slid between skin and skull, exited at occiput. No fx. Each wound a nice round scar, not even infected or foreign object reaction! Luckiest man alive, literally, and amongst the stupidest.

What else do you do for a GSW victim but bandage, maybe immobilize, support CAB's including fluids, maybe a chest tube, and gogogogo to facility with imaging and OR?

 

[Sasha]

You don't need an assesment you have protocols.

 

[Sasha]

Sadly, as someone who both used to help teach TCCC courses

Dude, what haven't you done? you have a "As someone who used to..." for every situation.

 

[usafmedic45]

One of the "Holy f**k" moments of my career was seeing a guy walk into the ED triage area holding a dishrag to his forehead and ask to see the doc. He had been assaulted by some guys who broke into his house and he thought he'd been hit in the head. He moved the rag and there was an exit wound in his forehead. Small entrance wound at the back of his head. Bullet passed "cleanly" (to quote the neurosurgeon) between the cerebral hemispheres and did minimal damage. Guy had walked a couple blocks to the hospital because he "didn't want to waste the ambulance's time. There's sick and really hurt people out there." His only serious effects were the scar on his forehead and the fact that he'd been knocked out for "several hours" after being shot in the head before coming to on his own. I've seen him in grocery stores and other places several times. He remembers me and when asked about it, he jokes that "the best part about getting shot in the head" is that his chronic sinus problems went away. I'm not sure that had anything to do with it but I don't have any evidence to say that it didn't. :lol:

Sometimes terminal ballistics adds up to something best chalked up as a miracle....

 

[lightsandsirens5]

One of the "Holy f**k" moments of my career was seeing a guy walk into the ED triage area holding a dishrag to his forehead and ask to see the doc. He had been assaulted by some guys who broke into his house and he thought he'd been hit in the head. He moved the rag and there was an exit wound in his forehead. Small entrance wound at the back of his head. Bullet passed "cleanly" (to quote the neurosurgeon) between the cerebral hemispheres and did minimal damage. Guy had walked a couple blocks to the hospital because he "didn't want to waste the ambulance's time. There's sick and really hurt people out there." His only serious effects were the scar on his forehead and the fact that he'd been knocked out for "several hours" after being shot in the head before coming to on his own. I've seen him in grocery stores and other places several times. He remembers me and when asked about it, he jokes that "the best part about getting shot in the head" is that his chronic sinus problems went away. I'm not sure that had anything to do with it but I don't have any evidence to say that it didn't. :lol:

Sometimes terminal ballistics adds up to something best chalked up as a miracle....

How about that guy who was impaled through the head with a piece of rebar after an MVA involving a construction equipment truck. (I thought it was in Spokane here. I'll have to find the story.) Rebar passed clean through his head and (quite literally) pinned his head to the car seat. Apparently it simply passed right through the two hemispheres and left him with no lasting effects whatsoever. I want to know how you stabilize and cut that! A saw would move it to much, a torch is way to hot and I'd think the hydraulic cutters would simply move it all over as they bit in.

I'll try to find that story.

 

[lightsandsirens5]

Sometimes terminal ballistics adds up to something best chalked up as a miracle....

Knew a guy who was in the Army and got hit in the head with a 20mm HE round. By some miracle it was a dud and didn't detonate. Talk about lucky on a number of levels. He lost some brain function. (Really just a little. He still lives a perfectly normal life.) Can you imagine if that had detonated. He would not have had a head.

 

[mycrofft]

Sasha's Law of EMS #2:

You don't need an assesment you have protocols.

 

[Sasha]

what's number 1?