Gunshot Wounds

Gunshot Wounds

Gunshot Wounds
Written By Meg Marinis, Director of Medical Research

I know.

My heart hasn't stopped pounding either. And there's still popcorn all over my office from when I threw it after watching tonight's Season 6 Finale... And I even KNEW what was going to happen.

And with the tragedy that occurred at Seattle Grace Mercy West Hospital tonight, we had many patients suffering from gunshot wounds—patients that sadly, included many of our people. Dr. Alex Karev suffered from a gunshot wound to the side of his chest, underneath his armpit; Dr. Charles Percy suffered a bullet to his abdomen; and, Dr. Derek Shepherd also suffered from a gunshot wound to the chest, but the bullet entered closer to his heart...

Gunshot wounds to the abdomen

When a bullet penetrates the abdomen, it can cause severe vascular injury and massive amounts of blood loss—which we can see Bailey desperately attempt to staunch in Charles' case. Organs commonly damaged can be the small bowel, colon, liver, stomach, vascular structures, and kidney—all places with a rich blood supply that usually cannot be controlled if away from an acute care facility.

Why couldn't Bailey save Charles? Unfortunately, several reasons. Due to the threat of the shooter roaming the hospital, Bailey did not have access to many resources she needed to save Charles' life—such as units of blood to replace the large amounts he lost. When people lose close to 40% of their blood volume without replacement, they usually do not recover. But most importantly, the survival rate of abdominal gunshot wounds is only high with rapid transport to the OR. If the patient seems stable, diagnostic tools may be used such as peritoneal lavage, laparoscopy, ultrasound, and CT. But still, exploratory laparotomy (surgery of the abdomen) remains the best option for diagnosis and treatment of a gunshot wound to the abdomen. Therefore, when we see Bailey's emotional distress outside the elevators, we understand she knows she has reached the end of her abilities to save Charles.

Gunshot wounds to the chest

Similar to penetrating abdominal injuries, gunshot wounds to the chest also involves massive amounts of blood loss. The large blood vessels, the aorta and the vena cava, carry blood to and from the heart. A bullet can severely damage these vessels as well as the heart and lungs. The rib cage may also be a source of bleeding if one of the blood vessels underneath each rib has been affected, but this type tends to be bleeding of a slower pace.

When Mark and Lexie discover Alex in the elevator, even though he is conscious, they see his struggle to breathe, indicating the presence of a collapsed lung (pneumothorax). Mark wants to put in a chest tube, in order to relieve the pressure and help Alex's ability to breathe, but Alex REALLY does not want one. Why? A chest tube, a hollow and flexible drainage tube, is inserted to drain blood, fluid, or air to allow the lungs to normally and fully expand. But the insertion of a chest tube is a SURGICAL procedure, and it HURTS. With or without anesthesia it hurts, because you can only really numb up the skin and not the whole pathway into the lungs. Usually people will get pain medicine along with local anesthesia but in this incidence, they did not have that option. Hence, Alex's screaming in pain.

Now with McDreamy's case... Oh my FREAKIN' goodness, he shot McDreamy... Fortunately, Cristina somehow took charge. She managed to gather Meredith and April in order to transport Derek to the OR floor where she knew a team would be. And even though Cristina did not find Teddy or Owen, she still had the resources of a surgical team and OR, so that they could establish a stable airway, anesthetize and begin fluid replacements for Derek.

Due to the location of the entry wound, Cristina and Jackson knew they needed to open up Derek's chest in order to repair any vessel or heart damage that the bullet caused. When a patient with a gunshot wound to the chest arrives to the ER, it is the emergency doctor's and surgeon's responsibility to resuscitate, diagnose, and treat the patient within minutes. And when the patient presents with continued hemodynamic deterioration (such as Derek), the patient should be taken to the OR immediately for a thoracotomy (incision on the side of the chest) or median sternotomy (incision down the middle of the chest). Bleeding should be rapidly controlled, then the repair of the vessels and/or heart chambers may begin. And depending on the injury, the use of cardiopulmonary bypass, grafts, or intracardiac shunts may be required.

... And I'm afraid to say any more...

Except for thank you for a great Season 6, and have a happy, happy summer, and we'll continue this conversation in the fall with the arrival of Season 7!

And rather than a link this blog posting, I have decided to include some facts about gun-related violence. So for more information, please read below!

- According to the National Academies Press, "in any given year, firearms account for over half of all known suicides, two-thirds of all reported homicides, and less than one percent of known accidental fatalities."

- "For fifteen to twenty-four year olds, homicide is the second leading cause of death, and suicide is the third."

- And according to the National Vital Statistics System, "in 1999, there were 28,874 firearm related reported deaths in the United States."