Introduction
Currently, the number of people delivered to hospitals with gunshot wounds is ever-increasing. A gunshot wound can be defined as a blunt trauma “caused by a very powerful force acting on a small focal area”. Severe gunshot wounds lead to immediate death with paramedics sometimes being unable to deliver a victim to the hospital. Gunshot wounds can be of different types and their severity depends on the part of the body being damaged and on the type of gun use which a wound was inflicted; correspondingly, the treatment of gunshot wounds, as well as their consequences and procedures of the first-aid, varies depending on how damaged the tissues, bones, or organs are.
Types of Wounds
There exist different types of gunshot wounds depending on how exactly a victim was shot. In general, the wounds can be divided into penetrating and perforating. In the case of penetrating wounds, the bullet enters the body causing the damage of internals and/or bones and stays in the tissues. In perforating wounds, the bullet enters the body, damages tissues, bones, and/or internals, and leaves the body. The entrance and exit of the bullet are, as a rule, easy to differentiate. The entrance presents a neat wound with bleeding being minimal, while the exit is a lacerated wound with severe bleeding.
Less generally, the wounds can be of four major categories. First of all, there are contact wounds that occur when “the muzzle of the weapon is held against the surface of the body when the weapon is fired”. Contact wounds can be further subdivided into hard contact and loose contact wounds. Hard-contact wounds take place when the gun is pressed tightly against the skin with the skin enveloping the muzzle. The entrance of such a wound has blackened seared margins with the soot which remains on the skin being impossible to remove afterward. When the contact with the skin is light, loose-contact wounds occur. With these wounds, soot can be easily removed from the skin due to its being deposited around the wound entrance. Further, there are near-contact wounds in which the weapon is held close to the body with a bullet hole being surrounded by seared blackened skin. The distance at which the weapon can be held to cause such a wound is often no more than 10 mm. One more type of wound is an intermediate wound which is marked by powder tattooing around the entrance of the wound. This happens when the muzzle “is held away from the body at the time of firing, yet is sufficiently close so that the powder grains emerging from the muzzle with the bullet strike the skin, producing punctate abrasions on the skin”.(p.138) Finally, there are distant wounds the only mark of which is the entrance of the bullet produced after it perforates the skin.
Apart from leaving a wound, gunshots damage different parts of the body. Therefore, gunshots may lead to organ damage, blood vessel or nerve damage, or bone fracture. When the chest is damaged, there emerges a danger of the lungs collapse. When the damage is inflicted to the liver or spleen, it is accompanied by internal hemorrhage. The damage to blood vessels, in its turn, leads to severe bleeding, while the damage to nerves may lead to paralysis. If the bullet hits the limbs, bone fracture usually occurs with bone fragments scattered along the bullet’s tracking being a common case with perforating wounds. Depending on the wound, bone fragments can leave wound tracks thus damaging surrounding organs and tissues, which often leads to fatal injuries.6 The severity of the damage depends on the part of the body being hit and, in most cases, on the type of gun being used.
Types of Guns
Examination of a wound usually helps in determining the type of gun used. All the firearms can be divided into those of high velocity and those of low velocity. There are no standard boundaries between the two of these groups but in general “low velocity is considered less than 1000 ft/sec, and high velocity is considered more than 1000 ft/sec”. The guns can also be classified according to their caliber. The caliber of the weapon can provide data only about bullet diameter, but not its length and, therefore, mass; despite this, however, it is the only indicator of the weapon’s wounding potential8. Bullets’ caliber can be small, medium, or large with small including 22- and 25 caliber bullets, medium 32- and 35 (9mm) – caliber bullets, and large 38-, 40-, 44-, 45-, and 50- caliber bullets.
However, this information is more valuable for investigation, while what matters for a medical specialist is the extent of damage that the weapon used may inflict. Among the most widely used guns, there are shotguns, handguns, rimfire weapons, and different kinds of rifles. The shotgun (the 12 gauge in particular), especially if fired at close range, is the most destructive. The wounds which it leaves can be characterized by “massive tissue destruction and embedded wadding if the shot was within ten feet”. When a shotgun or a rifle is used, the burn marks on the skin are more extensive. In the case with a handgun, however, the tattooing which is left after contact or near-contact shot has more prominent patterns due to the flake powder being used (in contrast to the ball powder used for shooting from rimfire weapons.22 caliber).10(para. 11) Center-fire rifles can inflict more serious damage due to their affecting bones, tissues, and organs which they do not even contact. These rifles have high velocities, which leads to complete disintegration of the organs with which this weapon comes into contact, as well as to fracturing the bones which are close to the wound. In case of a perforating wound inflicted by a center-fire rifle, the tissues are ejected not only from the exit but from the entrance wound as well.
Treatment of Gunshot Wounds
Treatment of gunshot wounds depends on their severity above all. One of the first and most important steps is debridement which is especially necessary when shotguns or firearms of high velocity are used. To perform this procedure, an incision is done along the length of the track to remove the devitalized tissues, after which the wound is closed. In the case with some high-velocity wounds “in which marked tissue destruction has occurred, a graft may be needed after adequate debridement”. Isolated gunshot wounds which are not severe (when there is only damage to the tissues) are treated using antibiotics in 48 hours. For these purposes, the first-generation cephalosporin is mostly used. Using antibiotics is one of the means of gunshot wounds treatment. However, it is effective when only the tissues are damaged; in other cases, antibiotics are a complimentary treatment.
Surgery is another way of treating gunshot wounds. Consequently, the period of treatment is extended every time the surgery is needed. Gunshot injuries in which hollow internals, trachea, pharynx, etc have been damaged require no less than 7 days of treatment during which antibiotics are given. If a patient has colonic injuries the period of treatment is extended to 14 days. Treatment of gunshot wounds may also involve infectious complications (psoas and lung abscesses, peritonitis, etc) (p.471) which may occur even if debridement has been carried out properly. When dealing with gunshot wounds, special attention has to be paid to the bones. Quite often the bones are fractured due to the high velocity of the bullet. If the bone fracture takes place, the bone fragments (and bullet fragments, if any) have to be removed to avoid toxicity. If the bone was shattered, large pieces are likely to be reconstructed and, in case the joints are greatly destructed, the replacement of the joint may be needed. This requires surgical involvement, which significantly prolongs the period of treatment.
Recovery
The period of recovery from the gunshot wounds depends on what exactly has been damaged and on whether or not there have been any complications. Short-term recovery takes place when treating the patient with antibiotics is enough. When the wound is properly treated and no infection has got into the patient’s blood or tissues then the full recovery is unlikely to take more than a month. However, when surgery has been involved or, even more serious, the damage was caused to the brain or spine, the patient’s recovery will be long-term; at this, full recovery may not always be possible. Long-term recovery may require a rather long rehabilitation period during which a patient will have to restore walking ability (if the spine was seriously damaged or the bones were fractured), speaking and writing skills (if the damage to the brain took place), or ability to eat and drink properly (if the internals were damaged). When no complications have been involved and the bullet did not damage the internals, the blood vessels, or the nerves seriously, full recovery may take less than a year. The patients with spinal gunshot injuries, for instance, have shown full recovery in a year in 33% of the instances with incomplete lesions and 25% instances with complete lesions. However, even after the discharge from the hospital, the patients are advised to observe the wounds for the signs of infection and turn to the hospital if redness or swelling appears.
Consequences
Any gunshot wound can harm the health of a patient, irrespective of how serious it is. Thus, the consequences of a simple, at first glance, gunshot wound into an arm or shoulder without even involving bone fractures may result in infections and inflammations. If they are not dealt with in time, they cause swelling and even bacterial decay. This may lead to the necessity of tissue transfer or the like surgical operations. If bone fractures were involved, the consequences can also be severe. Unstable fractures can sometimes require a second surgery, which extends significantly the period of recovery. If blood vessels have been damaged, the recovery is also longer than usual. Restoring the normal blood circulation in a limb with damaged blood vessels is not always possible, which eventually may lead to the amputation of the injured limb.
Serious consequences may be involved when a patient has received a spinal gunshot wound. At this, injury of the spinal cord may be caused not only by the bullet itself but by its fragments or the fragments of bones. Injury of the spinal cord may lead to paralysis, mostly below the point of injury. If the injury to the spinal cord is complete, the paralysis may be total. Paralysis can be caused by a gunshot wound of the head or neck as well. In this case, however, the paralysis is facial due to the facial nerve getting injured. Apart from physiological consequences, there may also be psychological ones with a great number of the patients having to turn to psychologists to manage stress.
Procedures
There exist several procedures which health care professionals carry out when helping a person with a gunshot wound. First of all, bleeding has to be stopped by applying a pressure dressing. Quite often blood coagulant is used to control bleeding. Among the most widely used is Quick-Clot which is poured into the wound; it quickly absorbs the water contained in the blood thus forming a clot around the wound. This substance belongs to one of the wound care technologies used in modern medicine. Such technologies allow treating the wounds quickly, stopping the bleeding, and fully closing the wounds which would take weeks and months to close using the traditional methods. Wound care technologies have become irreplaceable not only during the first aid but in treating the patient further because their use accelerates the healing process.
Another procedure that has to be carried out is immobilization. After the bleeding is stopped, the patient has to be immobilized even if the spine or neck is not directly injured. Due to the high velocity of the bullet, the damage to the spinal column may be done even if a person was shot into the thigh or abdomen. For the bullet to stop it has to transfer its energy to the surrounding tissues; since the amount of this energy is great the spinal column can be seriously damaged. This is why the victim has to be immobilized. After immobilization, the patient is delivered to the hospital where he is X-rayed if necessary (in case of splintered bones) and treated further.
Conclusion
Gunshot wounds are dangerous to human health even though some of them may seem not severe. Such wounds can be penetrating or perforating, as well as contact, near-contact, intermediate, and distant. The severity of the gunshot wound depends on the part of the body which was hit. If only the tissues were damaged, the recovery is unlikely to take much time, unless different complications (or infections) appear. More serious damages can be caused by gunshot wounds of the spine, head, or abdomen (this one may cause damage to the internals). The first two can lead to different kinds of paralysis and require a long period of rehabilitation. The procedures used to treat gunshot wounds include controlling bleeding (in which modern wound care technologies are quite helpful), immobilization, and delivering the patient to the hospital for further treatment.
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