Wednesday, March 26, 2008


The bookend to the reflective, careful ethics of the doctor blogs is EMT blogs -- that’s as in Emergency Medical Technicians -- first responders. The guys who jump out of the ambulance as it arrives and dash to the victim with a kit and a radio contact back to the emergency room in the hospital. They see everything, including things no one should see -- like deep insides splattered on outsides. But their attitude is far from somber and grim -- they are masters of bloody humor. Plus a certain amount of pent-up exasperation, if not real rage at the damage one person can do to another and at the constant abuses of the system by the stupid, the selfish and the hooked.

Recently an EMT in Boston was interviewed on “Here and Now,” a lunchtime NPR program. That was:

Rocky Mountain Medic is one I check fairly often. His writing is a bit purple, very atmospheric, but then he’ll hit a sweet spot and be brilliant. Some day he’ll be a famous novelist -- I have no doubt.

Everyone’s favorite is Partly, we love him because we’ve been with him through the problems of his very special little girl and the tragic conflagration of his marriage -- then his finding new love and losing forty pounds. This guy lives a dramatic life and he lives it in the SE US, which usually features in redneck jokes, sinister tropical mysteries, and TV shots of poodle-eating alligators in swamps. By the time Our Hero gets through walking us into unpromising situations like the last rotting room of a collapsing ancient hotel, making a hip-shot diagnosis of a four-hundred-pound alcoholic with a purple face and bloody vomit, intubating, hooking up lines, and somehow helping his partner horse the guy down the tilting stairs in a chair because a stretcher won’t fit -- and then the guy sits up in the hospital and cusses him... We’re there.

This man is a teacher of EMT’s and I’d pay for the classes even though I’m no EMT and have no intention of becoming one. He’s been asked to give a talk to EMT’s about bullet wounds. Before holding forth, he shows he is a good teacher by asking his readers for info and advice. This IS useful to me because I write and someone might shoot someone else in a story. (I hope that the ONLY time it’s useful!)

As it turns out, there’s a lot to unlearn. Most of the research has been done by firing guns into gelatin or a relatively small animal (dead or alive) while a camera runs and then analyzing the results. That means at least one medical fact has gone unrealized. The bullet makes one destructive “cavitation” (hole) through the flesh where the cells are outright destroyed, called “tissue crush.” But flesh is resilient and around that destroyed tunnel is a secondary enveloping tube of flesh that is “tissue stretched,” basically bruised -- maybe badly. The practice has been to use surgery to remove all the destroyed tissue and also to take out much of the bruised tissue around it, assuming that it can’t recover. More recent studies show that it CAN heal and rebuild.

There has been speculation about “sonic impact” but a doctor named Fackler, who has made it his business to investigate and reflect, points out that a lithotripter used to break up kidney stones generates much stronger sonic pressure waves without harming soft tissue.

Another main point made by commenters is that the gun doesn’t matter as much as the ammunition, the most dangerous bullets being those that expand or tumble. Except that one city EMT explained that if bullets explode and fragment in the victim, who is not likely to be the most pristine slice of life, then the greatest danger to the EMT is being stabbed by a fragment when inserting a finger to try to find out the path of the bullet. This means being exposed to AIDS, HepC, and other blood-borne disease. Therefore, he wears double gloves, and he reports that though they have indeed been torn by fragments, so far his finger skin was saved. In fact, fragmenting bullets are far more deadly than high velocity bullets, though velocity is a favorite preoccupation.

Not all bullets tumble. “Bullet yaw” inside the body is much more pronounced than “bullet yaw” during the flight trajectory. What happens inside depends on how soft the tissue is where the bullet hits. A bullet can be hot and burn tissue deep inside. A bullet that crushes flesh is not so efficient at killing as an arrow that slices it.

First-on-the-scene witnesses report that the movie dramatics of being thrown backwards by the bullet is against Newton’s Laws (unless the actor is wearing a stuntman’s harness) and likewise spinning is unlikely if not just silly, though five-year-olds dearly love to spin while they groan, “You got me!”

The most dangerous gunshots, they say, are the ones fired by an expert who wishes to kill and knows how to do it. In the argument about whether it is better to stop an attacker, to “drop him in his tracks,” as they say, by shooting him in the head or in the heart, the winning answer is to shoot him (well, or her) in the pelvis, so that locomotion is mechanically prevented. This is meaningful to me because one of my jobs in the Sixties was to shoot a gopher every morning to feed the eagle. I learned NOT to shoot them in the head because they had enough reflex left to kick themselves down their holes and I hated to put my hand in there after I pulled one out that we’d shot the week before. (I was the only one with a hand small enough to fit down the hole.) A gopher shot in the heart with a .22 is exploded enough to drop.

But a person trying to repair the damage doesn’t need to know what kind of gun or even what kind of bullet was involved, except from the point of view of solving the crime. Doc Fackler says the treating physician is much better off looking directly at the damage and evaluating it with no assumptions at all.

One looks for the exit wound but, remarkably, bullets may not emerge but rather lodge just inside the skin which is tough and stretchy. Also, things in pockets (wallets, watches, Bibles, love letters) can alter outcomes greatly. One soldier had a mini-mortar in his abdomen that would have exploded except that a fragment of his uniform was stuck in the striker, keeping it from making contact. In the old days, I once read, people worried about clothing lodged in the body because of infection, but antibiotics have greatly eased that concern. X-rays help enormously since they can show where the bullet is, whether it is fragmented, and what kind of bone damage has been caused. But that’s after you get to the hospital. It’s up to the EMT to get them there alive.


dr. hypercube said...

I'd read a really good analysis of the 'thrown backwards effect' at Insultingly Stupid Movie Physics a while ago - Hollywood action movies leading us astray - I never! I'm sure the EMTs could speak to another action film staple that ISMP goes after - the ability of folks to go through windows w/o getting sliced to ribbons...
Along the same lines, years ago I lived in an apartment with a view of the alley/parking lot behind a local biker bar. I'd say that the average bar fight consisted of 2 or 3 landed punches (emphasis on landed) - although these were garden variety disagreements. I'm sure more sober, nastier folks could stretch it out a bit longer (but just a bit).

prairie mary said...

In my experience most large animals engage in a lot of huffing and puffing, some big swipes at each other, more stalking around, and then averted eyes as they leave the scene.

Did that apartment of yours charge an entertainment fee? ;-)

Prairie Mary

dr. hypercube said...

I'm sure the landlord would have loved to charge for the entertainment, but he had enough trouble finding tenants. To the left of our front door, it was biker bar then fire station, to the right, building w/ blank wall, then major intersection. Across the street - parking lot, plating company then the B&M Railroad's Boston to Portland main line. Behind the building - the Blunderdome (biker fight club). He was selling into a niche market and a bunch of broke boys filled the niche nicely *grin*.
I know exactly what you're saying about the huffing and puffing - normal 'status' fights seem to be 90% posturing and 10% figuring out how to get out of the situation. Folks out to 'settle a score' and groups (mobs) - those scare me.