E
Ballistics—Lessons Learned
Malcolm Q. Russell
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The patient was an adult male who had been shot twice with high-velocity 7.62-millimeter ammunition. He was injured in an austere environment as evening fell, with temperatures not far above freezing and falling. His work colleagues gave him first aid, including the administration of intramuscular (IM) morphine.
On handover to the medical team around 30 minutes after the injury, we were told that he had an abdominal wound and an injury to his lower right leg. ABCs were rapidly assessed; he had a radial pulse of just over 100 beats per minute and delayed capillary refill time. He had an entry wound above his left superior anterior iliac spine, but his abdomen was soft. Exposure of his right leg revealed no obvious wound. Treatment at this stage was oxygen, intravenous (IV) access, and administration of ketamine (the morphine had produced little effect). Good pain relief was achieved and he was packaged for helicopter transport. His findings were put down to a combination of pain, cooling, and early shock secondary to a developing abdominal injury.
During his flight to a surgical facility (approximately 40 minutes away), he lay on the floor of a CH-47 Chinook helicopter with reasonable space, a lot of noise and vibration, and minimal (green) lighting. The only moni- toring that functioned was electrocardiograph (ECG), which, despite arti- fact, was the only way his heart rate could be measured (no pulses palpable with the vibration present, blood pressure (BP), and SpO2modalities not functioning, auscultation impossible). The patient made intermittent eye contact, but communication was otherwise impossible.
The patient’s heart rate steadily climbed while his abdomen remained surprisingly soft. There was nothing to suggest increasing pain as a cause and it became clear that the primary source of blood loss had not been found. Reassessment of ABCs including further exposure showed a dis- tended left thigh with a small entry wound at the knee and minimal exter- nal blood loss. He had a closed fracture of his femur and the round had ruptured his femoral vein internally.
A traction splint was applied, two units of O Rh negative packed cells given, and his pulse stabilized. On arrival at the surgical facility, damage control surgery was carried out; he required 35 units of blood in the first 48 hours and extensive surgery later, but ultimately had a good outcome.
The lessons learned from this experience were:
1. Do not assume that comments during handover are accurate, particu- larly in a hostile environment.
2. Exposure of the patient must be sufficient to detect important injuries, but balanced against the risks from environmental cooling. It is easy to miss significant penetrating wounds. Expose as much as is necessary and be pre- pared to explore further if the condition of the patient fails to match your findings and expectations.
3. Even during transfer in a dedicated medical helicopter, interventions can be difficult to perform and monitoring often functions inadequately.
These problems are amplified by the necessity to transfer patients in a general support helicopter as dictated by operational circumstance. Impro- visation is important; therefore, consider putting an end-tidal CO2probe into an oxygen mask to gauge respiratory rate (and even just to confirm the patient is still breathing). Listen to your clinical instincts—they may be the most important alarm function you have. If you have the feeling something is not right, do something about it fast!
E. Ballistics—Lessons Learned 593
