"I've Been Shot!" What Happens Next Is Pretty Amazing

Because shootings happen every day in the United States, the medical community led by trauma surgeons coordinates a complex system to treat severely injured patients. If you or a loved one has been shot, expect a lot to happen.

Emergency Medical Services

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Trauma happens suddenly and in unexpected places. To stop gunshot wound victims from bleeding out, a network of police, firemen, emergency medical technicians will work together to get an injured person safely to the hospital. Whole TV series have been dedicated to the work these teams do from the moment "911" is called.

Some hospitals have been defined as trauma centers. There are multiple levels to this system, and the sickest patients (generally, any gunshot wound victim) will be brought to a Level 1 Trauma Center.

The ABCs of trauma

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The first thing any trauma-trained healthcare provider will do is assess the ABCs (airway, breathing and circulation). A severely-injured gunshot wound victim will need to be stabilized as quickly and aggressively as possible. Control of life-sustaining functions is fundamental while plans are made to halt the bleeding caused by the bullets.

Intubation and Vascular Access

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When any of the ABCs are compromised by injury, doctors will insert a breathing tube. Preferably, this tube is inserted through the mouth then into the lungs. When this is not possible, a tube can be placed directly into the airway in the neck, a procedure called cricothyroidotomy. Specially-trained EMS providers may do this.

Large catheters will be inserted into veins to rapidly give large amounts of fluid and blood. Catheters can be guided into a major, central vein using wires. As a last resort, an infusion device may even be inserted directly into a bone.

The Level One Rapid Infuser

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An essential piece of equipment when someone is bleeding extensively from a gunshot wound, the Level One Rapid Infuser can pump up to a liter of fluid a minute. That means that it could potentially replace all your blood in five minutes. But let's hope that's not necessary.

The Trauma Surgery Team

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Doctors (MDs/DOs) who have specialized surgical training in care of the injured patient and the management of critical illness will quickly assess whether a patient needs to go immediately to the operating room or if there is time to do further studies.

They will perform necessary emergency procedures in the trauma bay and lead resuscitation of the crashing patient.

Insertion of a Chest Tube

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If the gunshot wound goes through your chest, a tube may be inserted between your ribs to reinflate a collapsed lung, drain collected blood pushing on the heart and to gauge how severe the injury is.

Imaging

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If a gunshot wound victim's ABCs have been stabilized enough to get further tests, the trauma surgeon may use x-rays, CT scans and ultrasound to assess the major body cavities for bleeding.

The CXR above shows a bullet near the heart and lungs.

The FAST Exam

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Usually, if a patient is shot in the abdomen, an operation is necessary. However, in instances where an abdominal operation may not be necessary (e.g. if the tract of a bullet is unclear) a special ultrasound exam can be give vital information.

Called the Focused Abdominal Sonogram for Trauma (FAST), an ultrasound is used to look for blood or other body fluids collecting around the internal organs. In the image above, the black area between the liver and kidney is fluid, most likely blood. If this is seen in the setting of trauma, an emergency operation is needed.

CT Scans

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CT scans are three-dimensional X-rays that allow trauma surgeons to assess the extent of damage done along the tract of a bullet wound. These scans help guide the planning and execution of operations.

The above CT shows a transcranial bullet tract. This is very bad.

The ER Thoracotomy/Laparotomy

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Famous on shows like ER, an operation done in the emergency room or trauma bay is a heroic measure to attempt to save the sickest patients who are too unstable to get to the operating room.

The classic indication for this operation is a gunshot to the heart. The goal would be to open the chest as fast as possible, repair the hole in the heart and restart the heart before the patient runs out of blood.

These types of operations have a drastically-low survival rate, but they are sometimes the only way to stabilize dying patients. VIDEO NSFW.

Emergency Operation

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If a patient's injuries are so severe that an operation is necessary, trauma surgeons will immediately explore parts of the body in order to control severe bleeding. They will repair or remove damaged organs and get the patient to the surgical ICU before he gets too sick to survive the operation.

One of the difficult decisions to make when someone is shot multiple times is which injury to approach first. Sometimes, a team of trauma surgeons will operate on multiple areas at once with one surgeon controlling bleeding in the chest at the same time another surgeon is operating in the abdomen or pelvis.

Massive Transfusion Protocol

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In cases of severe, uncontrolled bleeding, trauma surgeons and anesthesiologists will initiate rapid transfusion of blood and blood products to keep oxygen circulating through the body. This process can be dangerous, but sometimes, a gunshot wound victim's entire blood volume will need to be replaced multiple times over, making the MTP absolutely necessary.

Surgical Critical Care

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After stopping major bleeding, trauma surgeons will begin the often long process of helping an injured patient's body heal. Unlike on TV shows and movies that depict patients getting miraculously better as soon as a bullet has been removed, the reality is that recovery actually takes much longer. (Also in reality, surgeons rarely make an effort to search for and take out bullets).

During the days or weeks of surgical critical care, several monitors may be inserted into arteries, veins and the heart and used to measure beat-to-beat blood pressure, heart rate and lung function. Frequent blood tests will be done to guide how medications can optimize recovery.

Mechanical Ventilation and Renal Replacement Therapy

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After major trauma, the body's organs will often become dysfunctional. Even if a bullet went nowhere near them, the lungs and kidneys often get sick as a result of the injury.

Trauma surgeons use various machines to do the work of these organs while they slowly heal, making daily changes to slowly wean a patient from this support. If prolonged mechanical ventilation is necessary, a tracheostomy operation will take place to insert a smaller breathing tube directly into a patient's neck.

A special form of dialysis called CRRT and its varieties can be used to augment at patient's weakened kidney function and avoid the need for longterm dialysis.

Bronchoscopy

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Injured patients are at very high risk of developing pneumonia and acute respiratory distress syndrome. When the lungs get this sick, trauma surgeons may insert a scope with a camera frequently to clean out the lungs and take samples to guide the treatment of pulmonary infections.

Tube Feeding and Total Parenteral Nutrition

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Gunshot wound patients have very high metabolism and need extra nutrition. This nutrition may be delivered with a tube inserted through the nose into the stomach, a tube going directly to the stomach through the skin or with special chemicals infused into the veins.

There are risks to every one of these ways of feeding. Total parenteral nutrition (TPN) given through the veins of a trauma patient can increase the risk of infection.

Physical Medicine and Rehabilitation

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As a critically-injured gunshot wound patient heals, physical therapists will initiate mobility. Sitting up in bed will turn to a few steps at a time and eventually to walks around the surgical ICU.

Very sick patients often get delirious in the surgical ICU and will need careful treatment of their mental function before discharge.

Rehabilitation specialists will determine whether a patient can ultimately go home or need temporary care in an outpatient center.

It Takes A Village...

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From the moment someone gets shot to the moment he or she leaves the hospital, a large team led by trauma surgeons will provide intricate and complex care.

Trauma surgeons will stabilize, operate on and medically-treat trauma-related organ dysfunction. They will coordinate with other doctors and healthcare providers, social workers, police and hospital administrators to help patients and their families heal.

The human body is fragile, and when it gets shattered by a gun, it takes a lot of good and dedicated people to put it back together again.