If you are ever unfortunate enough to be the victim of gun violence, it is quite possible that you may not hear the word “gunshot wound” mentioned in the halls of the hospital as you are wheeled into the trauma bay, tethered to IV’s, connected to monitors, and attached to breathing equipment. That’s because gunshot injuries are so common, that we often simply refer to them as “GSW,” followed by the location of the injury. Perhaps you are patient “GSW back” with a spinal cord injury, unable to move your legs. Maybe you are “GSW head” with a severe brain injury, or “GSW chest” unable to breathe from a collapsed lung.
In any of these events, after being stabilized in the trauma bay, you are very likely to end up in the operating room, where a skilled team of doctors, nurses, and technicians will fight to save your life.
In the operating room an anesthesiologist and trauma surgeon will dictate your care in conjunction with the OR nurses. The anesthesiologist will be responsible for keeping you alive during this very critical period. They will insert a breathing tube, manage the status of your breathing, and make sure to treat any potentially fatal acidosis. He or she will administer life saving medications, fluids, and transfuse blood as necessary. Electrolytes, body temperature, blood loss, urine output, and cardiac output must all be monitored closely as changes can occur rapidly within seconds to minutes, and can be fatal. Often patients are too unstable to tolerate even small amounts of anesthesia, and awareness, or some level of consciousness under anesthesia is more common in trauma surgery than any other type of surgery.
While this is occurring, the trauma surgeon will work rapidly to identify and treat the injury, especially if the gunshot wound has caused life-threatening bleeding. Your surgeon must often deal with multiple injuries at the same time, in the setting of severe trauma and bleeding. This is a great challenge as identifying important anatomy becomes very difficult when bullets change the appearance of normal tissues and organs. They may repair the injury but often complete resolution is impossible at the time of initial surgery. You may have tubes coming out of your chest and/or abdomen. Many times the abdomen is left wide open with a large midline incision packed with gauze and plastic wrapping to keep the intestines from protruding.
From the operating room you will be transferred to the intensive care unit (ICU). In the ICU a doctor called an intensivist will manage your care. He or she will keep you on a breathing machine and you will be placed on many medications just to keep you alive. Lab work will determine further care and additional studies or treatment may be administered such as x-rays, CAT (computed axial tomography) scans, or even dialysis for failing kidneys. You will be sedated during most of this time but at regular intervals the sedation will be stopped to assess your mental status. Avoiding ventilator-associated pneumonias, wound infections, breakdown of the surgical repairs, and a myriad of other potential complications are goals of care and essential to a good outcome.
If you survive your injuries, you may eventually have your breathing tube removed, many of your IV lines removed, and blood pressure medications discontinued. Occasionally a tracheostomy may be needed. This is a tube placed in the neck which can stay in place long-term if you are not ready to breathe on your own. You will then be transferred to a less acute area of the hospital. You may require help to manage your injuries such as how to change an ostomy bag, or assistance with a walker or wheelchair. Eventually you will be discharged, possibly to rehab, but may face a lifetime of recovery, therapy, and further surgeries. Many of your injuries may be permanent or lead to future complications, so additional healthcare may be needed for decades. Furthermore the psychological trauma can lead to Post Traumatic Stress Disorder (PTSD), depression, anxiety, and panic disorder.
Highly-trained multidisciplinary teams of doctors, nurses, and technicians, stand ready to treat you should you suffer a GSW. However, we would prefer to avoid it in the first place, and look forward to a future where we see significant decreases in gun related injuries.
What you need to know
- Trauma and ICU teams are multidisciplinary, and require coordinated efforts between physicians, nurses, and technicians
- In the operating room injuries must be identified rapidly, and breathing and circulation must be maintained if the patient is to survive
- In the intensive care unit, patient’s are often in very critical condition and may require many life saving interventions
- Both physical and psychological injuries may be lifelong, and require long term treatment
Where we need more research
- Moving quickly to the OR is essential but more research is needed with regards to time to the OR, especially for torso injuries that are non-compressible
- More research is needed regarding massive transfusion and the appropriate ratios of blood products, as well as non-blood-based hemoglobin resuscitation
- More research is needed on Extracorporeal membrane oxygenation (ECMO) and ECMO based cardiac resuscitation
- More research is needed regarding traumatic brain injury and spinal cord regeneration after injury