Bullet casing

Bullet casing.

by James Hubbard, M.D., M.P.H.

A paramedic told me that when she was in training, a patient came in who had been shot in the right upper chest. They ended up finding the bullet not in the back, not even in the other side of the chest, but way down in the right butt cheek, pushing against the skin.

In my last post, I covered general gunshot-wound treatment—the basics for survival situations when you can’t get to a doctor. Now, I’ll go into more detail for specific wounds.

As I said in the first post, one bullet can cause multiple injuries—both internal and external. Even if you can’t get expert treatment right away, you need to get it as soon as you can. There are some lifesaving things I don’t cover here that you just can’t do outside a hospital.


Signs of Internal Bleeding

Since you can’t see all the bleeding, it’s important to note the initial vital signs. Warning signs of internal bleeding include:

  • Decreasing alertness
  • Nausea/vomiting
  • Weak pulse
  • Lowering blood pressure, or faster and faster pulse.
Important Note

These treatments for gunshot wounds are complicated and require advanced knowledge. I can’t cover everything in a blog post. (I’ll be writing about gunshot wounds in a future book.)

I’ve tried to give you a good overview so you have the best chance to save a life, but as always, my blog isn’t meant to be your sole source of information.

Someone with internal bleeding is probably not going to survive without rapid transfer to a medical facility.


For a Gunshot Wound in the Head

Think about: the airway.

Tips:

  1. Attempt to control the bleeding with direct pressure as best you can (no tourniquets around the neck).
  2. Make sure the blood doesn’t choke the person. You can have a conscious person sit up and lean forward, or turn an unconscious person on their side and bend the top knee forward to keep them that way.
  3. If you believe a carotid artery (that large artery on either side of the neck that supplies the brain) is nicked, you can apply soft direct pressure, and include an occlusive dressing. (See the box to the right.)
How to Make an Occlusive Dressing out of a Driver’s License

For an open, or “sucking,” chest wound, you want to keep air from getting in but also let excess air escape.

One makeshift way to do this is to lay a driver’s license or plastic wrap on the wound. When the diaphragm contracts and pulls in air (the same mechanism that makes us breathe), the vaccuum will suck the object onto the wound. But if air needs to escape, it can easily push the object up.

You could also use Vaseline gauze or put petroleum jelly on gauze. No petroleum jelly? Try any type of ointment or even honey.

The victim needs other treatment, such as a chest tube, right away. The occlusive dressing is just a temporary treatment to keep the situation from getting worse.

Learn how to treat other wounds when there is no doctor in The Survival Doctor’s Guide to Wounds.


For a Gunshot Wound in the Chest

Think about: air sucking, spine injury.

Tips:

  1. Open chest wounds are also nicknamed sucking chest wounds because they suck air in and can lead to a collapsed lung. You can help stop the sucking by closing the open wound with an occlusive dressing.
  2. Remember the spine is also included in the back of the chest. Be very careful about movement of these victims. You want to keep them as still as possible and not damage the spinal cord.
  3. If the heart, the lungs, the spine, or a large blood vessel is damaged, there’s not much you can do outside getting immediate expert medical care.


For a Gunshot Wound in the Abdomen

Think about: organ protection.

Tips:

  1. If the wound is open and you can see the intestines, find a moist, sterile dressing to place on top of the wound (to protect the organs).
  2. If the intestines are ripped open, the victim needs immediate medical care. If they don’t bleed to death, they’ll likely die of the coming severe infection.
  3. The victim should take nothing at all by mouth until the pain lets up, and then wait a day or two. This is obviously a difficult situation, but this step is very important and a time when a slow drip of IV fluids would be useful.
leg and arm arteries

If an arm wound won’t stop bleeding despite direct pressure to the wound and elevation, press on the brachial artery around the place where the arrow in the left picture is pointing (below the armpit). Do this by grabbing underneath the person’s arm, wrapping your fingers to the artery (inner arm), and pressing firmly on it with your fingers. You’ll know you probably have it right when the bleeding slows down. If it’s still not controlled, try pressure nearer to the heart.

Here’s a trick to try it out now: Get a partner, and find the person’s radial pulse (in the wrist on the thumb side). Then grab the upper arm as described above. You should feel the pulse stop. Only do this for a couple of seconds, of course, since you’re stopping blood flow.

For a leg wound that won’t stop bleeding, apply pressure to the femoral artery, shown in the picture on the right. The best place to do this is in the middle of the bend between the front of leg and the hip. (This is not the place where the arrow is pointing; it’s above it.)

 


For a Gunshot Wound in the Arms or Legs

Think about: bones.

Tips:

  1. Direct pressure, elevation, pressure bandage—in that order. Elevate the wound above the heart, and apply a pressure bandage. Then if it’s still bleeding, take your fingers and apply pressure to the brachial artery for the arm or the femoral artery for the leg. (See the box to the right.)
  2. If all else fails in an extremity, go to a tourniquet. (It may come down to “lose a limb or lose a life.” See The Survival Doctor’s Guide to Wounds for dos and don’ts of tourniquet use.)
  3. If the area is rapidly swelling, that’s a sign of internal bleeding. Also, consider that a bone might have been injured, even shattered. If you suspect this, the area needs to be splinted.


For a Superficial Wound

If the gunshot wound is superficial, clean it as much as you can and follow the steps in “Puncture Wounds” in my e-book The Survival Doctor’s Guide to Wounds. Start antibiotics when you’re finished taking care of the wounds.


One More Thing: What About the Bullet?

In most circumstances, you don’t want to remove an implanted bullet. It’s almost impossible to find, and it may actually be corking up a big blood vessel.

Thousands of military members live daily with shrapnel in their bodies. Unless there’s initial infection from the wound itself, the body adapts to most metal without much serious problem.

Gunshot wounds can run the gamut. Some people are too severely injured to save. Get expert treatment as soon as possible.

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Artery photos by Rob Swatski, assistant professor of biology, Harrisburg Area Community College – York Campus, York, PA. Email: rjswatsk@hacc.edu.