Trauma Scenario #2 with Dirty Pic ;)

[apssbc]

Ive been slacking around here so here is another scenario. You and your group of 5 other armed adults are ambushed by a group of undesirables, you respond and eliminate the threat. A member of your group is wounded in the abdomen by gunfire. This is the entrance wound, there is no exit wound. Recent total collapse TEOTWAWKI scenario, your skills and resources is all you have. Here is the patients info:

-25 year old Male
-GSW from approx 40 yards, victim saw the shooter
-Patient Screaming in extreme pain throughout the abdomen
-No Exit wound
-No major visible bleeding
-Skin pink warm and dry
-Rapid strong radial pulse and breathing

http://i647.photobucket.com/albums/uu198/emmettfire45/IMG_0038_zpsfbdad3dd.jpg (http://s647.photobucket.com/user/emmettfire45/media/IMG_0038_zpsfbdad3dd.jpg.html)

Some questions:
How would you treat the patient?
How could you secure the scene?
What can you do to determine the weapon and extent of injury?
Follow up question, Why is the weapon type, ammo and distance important?

GO!!

[ditchmedic]

Im not very good at these from the medical side, and im sure bilat 16's with LR and NS and transport to trauma center isnt feasible :D

Honestly, Im not keen on field surgery to look for a foreign object in someone's abdomen.

The pulse and breathing concern me as he may decompensate Pretty quick. The caliber concerns me cause of the size of the cavity and shock wave. Im more worried about the bullet not exiting. Not only does he have a bullet in him, but it tells me the bullet dumped its energy quick, Thats potential for a large temporary cavity.

Where in the abdomen He was hit and what the pain feels like would help me base my decision better, but he's probably done for.

[The Stig]

Does the GSW victim in this scenario have his guts hanging out as depicted in the picture?

Weapon, ammo type and distance would be handy to guess at the extent of the internal injuries. If it's a FMJ there's a chance it could have passed through. The absence of gushing blood perhaps means that while painful nothing major was hit. That said, he'd have to be monitored to ensure he wasn't bleeding out internally.

If it was a JHP or soft point the he could potentially be seriously hosed.

I think the key would be securing the scene pronto. 2 of the group would have to take up hasty overwatch positions to ensure the badguys friends don't respond to gunfire and screaming. You and your assistant would have to make an evaluation to see if the patient could be moved, even if only a few yards, to a position that would offer any cover if out in the open.

From there....well.....I guess calling a medvac isn't real likely eh?

[apssbc]

Awesome responses guys. Yes he is evicerated like in the picture.

As for the bleeding, remember with intestines hanging out they are plugging the hole. Also the abdomen can hold a lot of blood without it coming out. So it doesn't necessarily mean there is no major arteries hit.

[ditchmedic]

Awesome responses guys. Yes he is evicerated like in the picture.

As for the bleeding, remember with intestines hanging out they are plugging the hole. Also the abdomen can hold a lot of blood without it coming out. So it doesn't necessarily mean there is no major arteries hit.

Oh I thought the picture was just for funzies. He isnt having a good day, and tomorrow will be worse.

[Stormfeather]

Yup. . .what he ^^^ said.

[helomech]

If that is me, than end if for me quickly please. I don't see any real recovery from something like that without real medical care. And I sure as hell don't want to live for days suffering.

[bacpacker]

I agree with Helo. If SHJHTF that is just a slow painful death if they arent bleeding out internally.

[izzyscout21]

http://nexusorg.org/wp-content/woo_custom/110-Send_Booze.JPG

[apssbc]

Not all is lost on abdominal wounds. Don't get me wrong it would be a very very rough go of it. Not only the surgery but the recovery. Read through the NATO war surgery book. It's able to he found on the interwebs. Good material there.

[Twitchy]

Ha, I used that pic in an EMT project...

In this case, rapid extraction to a safe location after Sealing wound with a moist sterile dressing... (moisten with NS)
Once in a safe(r) location, treat for shock, and try to find a doc... as an EMT-B not much we can do other than that since the pre hospital care system is hosed, as well as any hospitals in the area... Odds are this dude is probably not going to make it unless you can find a Surgeon, some good antibiotics, and other meds... Odds are he has some pretty bad internal bleeding, and a blood transfusion may be necessary depending on his situation... Lots of monitoring vitals to see if he stabilizes or falls further into shock...

[infamous1]

would a grazing non-entry wound be a possibility? i say sterilize, poke his junk back into the hole, tape up said hole and find a doc!!

[Twitchy]

would a grazing non-entry wound be a possibility? i say sterilize, poke his junk back into the hole, tape up said hole and find a doc!!

*cringe*

Yikes... Not the best of ideas for a protruding abdominal wound...

[The Stig]

My honest first thought when reading this was....."If I'm hit like this, give me a couple mags, a pint of booze and point me towards the direction of trouble. Leave my ass and get to safety. I'll hold them off as long as I can".

I don't mean that to sound all over-dramatic but in a true post-apocalyptic/total meltdown scenario you ain't coming back from that.

The reality is there are no hospitals, no medvacs, no trauma teams, etc. Get a serious wound and you are likely fucked.

Doesn't mean I'm giving up at the first scratch but if I look down and see my guts hanging out.......get the fuck out of dodge and leave me to slow em down a bit.

[Twitchy]

My honest first thought when reading this was....."If I'm hit like this, give me a couple mags, a pint of booze and point me towards the direction of trouble. Leave my ass and get to safety. I'll hold them off as long as I can".

I don't mean that to sound all over-dramatic but in a true post-apocalyptic/total meltdown scenario you ain't coming back from that.

The reality is there are no hospitals, no medvacs, no trauma teams, etc. Get a serious wound and you are likely fucked.

Doesn't mean I'm giving up at the first scratch but if I look down and see my guts hanging out.......get the fuck out of dodge and leave me to slow em down a bit.

That seriously depends on your level of preparedness, if you had a Team of Paramedics, CCRN's, and EMT's, hell maybe even a PA or two... Then you atleast have a fighting chance if you have the supplies... This is why Medical Preparedness is so important, and one of my better stocked categories... All I can say is, your not dead until I have tried everything at my disposal, or my group's disposal...

[infamous1]

*cringe*

Yikes... Not the best of ideas for a protruding abdominal wound...

how much ground could the group cover if ole Jimmy keeps getting his "junk" caught on the bushes?
I am also of mind that if no medical assistance is availible he is in bad shape anyway and at least if it is back inside we don't have to look at it!!:eek:

[izzyscout21]

My honest first thought when reading this was....."If I'm hit like this, give me a couple mags, a pint of booze and point me towards the direction of trouble. Leave my ass and get to safety. I'll hold them off as long as I can".

I don't mean that to sound all over-dramatic but in a true post-apocalyptic/total meltdown scenario you ain't coming back from that.

The reality is there are no hospitals, no medvacs, no trauma teams, etc. Get a serious wound and you are likely fucked.

Doesn't mean I'm giving up at the first scratch but if I look down and see my guts hanging out.......get the fuck out of dodge and leave me to slow em down a bit.


^^this

If you've got someone who has all their snausage hangin out like this, chances are you aint getting them back to anywhere if SHTF.

Even if you can, my immediate worry after bleeding is shock. Thats going to be big in this one.

If it were me, I'm with Stig. Gimme a wal-mart sack to put it all in, some extra mags, lemme cause some pain in my last few.

You go back and split up my gear.

[izzyscout21]

Wow.... I got 2 likes for that post.

guess i know who wants my gear.....:rolleyes:

[ditchmedic]

This is sepsis waiting to happen, which opens into a whole new world of probelms. I love a good train wreck.

[Gunfixr]

Some questions:
How would you treat the patient?
How could you secure the scene?
What can you do to determine the weapon and extent of injury?
Follow up question, Why is the weapon type, ammo and distance important?

GO!!

No one really answered most of this, so I'll try.
In no particular order:
Weapon type, ammo type, and distance is important to help evaluate the extent of the wound, prior to "going in". The more powerful and closer the weapon, the more debris will have been driven inside the wound cavity, and therefore more "dirty crap" to cause infection. Ammo type will help determine what type of damage is to be expected internally, as well as to whether you'd be looking for one projectile, broken pieces of said projectile, or even multiple projectiles. Since I have no real experience in this, without physical knowledge, I could not tell by just looking. So I would probably be unable to tell myself.
Secure the scene? Kill everything that I don't know to be friendly, immediately and with the most extreme prejudice.
Buys the most time. I think you'd have to pretty much stretcher him out, and if there's pursuit, and you're on foot, that's not going to be an option. If you're staying put, after taking all threats out, try to get the patient covered and the area cleaned up as best you can, provided you're going to try to repair the wound. Put out security and let your docs get to work.
How would I treat the patient? Since I don't have the skills to properly deal with this, you're probably fucked. If I can sit and stay alive, I'll wait with you. You could ask me to just "end it" for you. Or, if more threats are on the way, I could just give you my ammo, and let you make pain for them when they arrive. After all, I'm getting your ammo when I get back to camp.
If it happened from a distance, and we know there's only one projectile, and it's what you want, I'll do my best. Realistically, I'd probably only be extending your suffering, since I don't have medical training or any sort. I know I'd be looking and feeling around for internal bleeds, finding the projectile, trying to get everything packed back in without any binds, and get it sewn shut. It'd be tough not to be just filling it all with infection.

[apssbc]

Excellent answer. I think the surgery is doable if you have the skills or reference material to attempt it. However this brings up another major question post SHTF?

Do you know what you, your family, or group members want if severely injured?
Also do you keep the body to learn to do surgery?

Me personally would want the surgery if someone was capable. I would want to perform the surgery on someone if given the chance. I've seen abd surgeries they can be trickey but I watched surgeons pack the intestines back in like they were stuffing a piniata.

[izzyscout21]

Great observations, Gunfixr

[Gunfixr]

Thanks guys. Really, I look at it kind of like anything else. Fix the leaks, repair the broken things, etc. Yes, the techniques are different, and the cleanliness thing is important, but a lot of it seems more straightforward than I think most non-medical people realize.

Me and my wife have already discussed this sort of thing, although not really as a post-shtf plan. We are both settled on quality of life over quantity of life. We need to evaluate it in a post-shtf setting as well.
Keep the body for practice? That's going to depend. I don't think I could keep one of my kids or my wife's body to practice on.
I'd hate to even leave them on the field, but understand me getting killed to bury a body isn't a proper trade. After all, who we are has "left the building" so to speak, nothing but physical remains are left.

[infamous1]

so would you open the abdomen up more for exploratory on the possible fragments??

[Gunfixr]

Personally, with my lack of real medical knowledge, I wouldn't be opening up an abdomen just to go exploring for possibles. Since I'd be about as likely to create almost as much damage as I could fix, I'd need a pretty solid reason to go inside.

Others with more expertise in this area may do otherwise.

[Twitchy]

Excellent answer. I think the surgery is doable if you have the skills or reference material to attempt it. However this brings up another major question post SHTF?

Do you know what you, your family, or group members want if severely injured?
Also do you keep the body to learn to do surgery?

Me personally would want the surgery if someone was capable. I would want to perform the surgery on someone if given the chance. I've seen abd surgeries they can be trickey but I watched surgeons pack the intestines back in like they were stuffing a piniata.

Good point on the cadaver exploration concept... Not so sure on doing it with humans, but deceased animals could be used to get basic anatomy down... The big question during any surgery is, while it may be easy to do the cutting, what do you do once you see the full extent of damage?

[ditchmedic]

I had an opportunity to go to a cadaver lab earlier this year. I passed cause it was pretty expensive. Im planning to do it next time.

Once a year my employer has pig cadavers brought in as well but ive always had to work that day :(

[Gunfixr]

Bummer.

Speaking of pig cadavers, apparently they are used for several things, as in many ways they replicate working with human flesh. I was getting stitches on a work injury once, watching and asking about stitching. The doc showed me the basic stitch, and then said it would be good to buy pigs feet at the store to practice on, as it was very close to stitching human flesh. He said that was how many docs practice during med school.

[Fidel MD]

Excellent thread!

Hi, Everybody! I'm new here, and so far loving it. Great topic, and great questions/answers.

As far as long term outcomes, keep in mind that as recently as the late 1800's a belly wound like that was a slow, painful death. A few things happened that changed that, and allowed medical science to figure out how to fix wounds like that.

Those things were the discovery of anesthesia, the understanding of the germ theory of disease, and the discovery of antibiotics.

Field treatment would be cover the protruding viscera with a damp dressing, cover that with an occlusive dressing, don't try and replace anything (it'll just have to come out later, anyway), nothing by mouth except perhaps a combat pill pack with antibiotics, maintain hydration with an IV if possible, and get to higher levels of medical care.

What higher levels would do is anesthetize the patient, administer pretty large doses of IV antibiotics and a tetanus booster, open the belly up (xiphoid to pubis), pick out all the foreign matter, tie off bleeders, check the bowel and other organs for leaks and make certain blood flow isn't compromised, flush the abdominal cavity out with sterile saline, and close up the many layers of stuff that make up the anterior abdominal wall, using different suture materials, needles, stitches and techniques for the different layers. Then bandage and wait, checking for bowel sounds and signs of infection.

- - - Updated - - -


I had an opportunity to go to a cadaver lab earlier this year. I passed cause it was pretty expensive. Im planning to do it next time.

Once a year my employer has pig cadavers brought in as well but ive always had to work that day :(


Pigs feet, with the skin on, work. So do bananas, and if you're really good, oranges. But sewing is easy, knowing when to suture and more importantly NOT to suture is key. Closing up a dirty, or bleeding wound is a really, really bad idea. I won't do primary closure on wounds (clean or dirty) that are more than 8 hours old: The risk of infection is too high. The patient can wait a couple of days and then have the wound closed.

[bacpacker]

Good info. Wel ome to the forum MD, glad to have you on board.

[Twitchy]

Excellent thread!

Hi, Everybody! I'm new here, and so far loving it. Great topic, and great questions/answers.

As far as long term outcomes, keep in mind that as recently as the late 1800's a belly wound like that was a slow, painful death. A few things happened that changed that, and allowed medical science to figure out how to fix wounds like that.

Those things were the discovery of anesthesia, the understanding of the germ theory of disease, and the discovery of antibiotics.

Field treatment would be cover the protruding viscera with a damp dressing, cover that with an occlusive dressing, don't try and replace anything (it'll just have to come out later, anyway), nothing by mouth except perhaps a combat pill pack with antibiotics, maintain hydration with an IV if possible, and get to higher levels of medical care.

What higher levels would do is anesthetize the patient, administer pretty large doses of IV antibiotics and a tetanus booster, open the belly up (xiphoid to pubis), pick out all the foreign matter, tie off bleeders, check the bowel and other organs for leaks and make certain blood flow isn't compromised, flush the abdominal cavity out with sterile saline, and close up the many layers of stuff that make up the anterior abdominal wall, using different suture materials, needles, stitches and techniques for the different layers. Then bandage and wait, checking for bowel sounds and signs of infection.

- - - Updated - - -




Pigs feet, with the skin on, work. So do bananas, and if you're really good, oranges. But sewing is easy, knowing when to suture and more importantly NOT to suture is key. Closing up a dirty, or bleeding wound is a really, really bad idea. I won't do primary closure on wounds (clean or dirty) that are more than 8 hours old: The risk of infection is too high. The patient can wait a couple of days and then have the wound closed.

Glad to see you hear Doc! Great info!