Q&A: How Are Multiple Gunshot Wounds to the Chest Treated?

I got this fun question from my friend Dave Corbett.

Q: For my story, I need to know what someone with three small caliber wounds to his lungs, with a not-so-good time lapse before hospitalization (say 30-45 minutes) and internal bleeding, would face in the ICU. How would they treat him? I assume surgery to repair the internal wounds and stop the bleeding, but how does one do that with lung tissue? Post-op, what drugs would be used and what concerns and complications (heart attack, etc.) might he face? In the end, a friend helps smuggle him out of the hospital, because he’d rather die at home. Basically, I need the details to make the hospital scene vivid and credible.

David Corbett
http://www.davidcorbett.com

A: What happens to your shooting victim and how he is treated depends upon what injuries he received. A gunshot wound (GSW) can be a minor flesh wound or can be immediately deadly or anywhere in between. It all depends on the caliber and speed of the bullet and the exact structures it hits. A shot to the heart might kill instantly—or not. The victim could die in a few minutes or survive for days or could recover completely with proper medical care and surgery. It’s highly variable but ask any surgeon or ER doctor and they will tell you that it’s hard to kill someone with a gun. Even with a shot or two to the chest.

A small caliber, slow speed bullet, such as those fired by a .22 or .25 caliber weapon, are less likely to kill than would heavier, higher velocity bullets from .38, .357, or .45 caliber weapon. Also the type of bullet makes a difference. Jacketed or coated bullets penetrate more while hollow point or soft lead bullets penetrate less but do more damage as the bullet deforms on impact. All that is nice, but the bottom line is that whatever happens, happens. That is, a small, slow bullet might kill while a large, fast one might not.

Since in your victim the bullets penetrated the chest wall and damaged the lung, he would cough up blood, be very short of breath, and could die from bleeding into the lungs, basically drowning in his own blood. Or the lung could collapse and again cause pain and shortness of breath. But we have two lungs and unless the GSWs are to both lungs and both collapse, the victim would be able to breathe, speak, even run away, call for help, or fight off the attacker. If he’s tough, that is.

Most likely your guy would be very short of breath and cough and wheeze out blood in a fine mist or in larger droplets and even clots. He would quickly become very weak and dizzy, his blood pressure would drop, and he could slip into shock. With the injury to his lung, the oxygen content in his blood could dip to very low levels and he could lose consciousness if you want. Or not. Anything is possible. All this could happen in a very few minutes or over an hour or more, depending upon the rapidity of blood loss and the degree of injury to the lungs.

Once rescued, the paramedics might place an endotracheal (ET) tube into his lungs to help with breathing, start an IV to give fluids, and transport him to the hospital immediately. He would then be seen by a trauma or chest surgeon and immediately undergo surgery to remove the bullets (if possible) and to repair the damaged lung or whatever else was injured. The surgeon might simply repair the lung or he might have to remove one or more lobes (sections) of the injured lung. Each lung has three lobes—upper, middle, and lower. The left lung has a very small middle lobe, called the lingula, since its space is occupied by the heart.

After surgery, he would be on a ventilator for as long as needed but usually only overnight. We always try to remove ET tubes as quickly as we safely can since there are many complications if they remain in place for several days. Most commonly this is pneumonia. Also, being tied to an ET tube and a ventilator immobilizes the patient and sets him up for deep venous thrombosis (DVT—clots in the leg veins) and a pulmonary embolus (PE)—this is when the leg clot breaks free and travels to the lungs. Very dangerous and potentially deadly and a common occurrence in these situations.

He would have a chest tube (actually a thoracostomy tube but we call them chest tubes) in place. This is a flexible plastic tube that is inserted through the chest wall and slipped into the space between the chest wall and the lung. It is attached to a suction device and is used to evacuate air and any residual blood or body fluids from the chest cavity, which helps keep the lung inflated. Once the lung heals and can stay inflated on its own, the tube is pulled out. This could take a couple of days or up to a week. It’s highly variable.

He would be treated with antibiotics to prevent lung and wound infections and of course pain meds. Once he was off the ventilator, he would be mobilized from the bed to a chair as soon as possible. This helps prevent pneumonia, DVT, and PE. He would then begin respiratory therapy, initially with deep breathing exercises to help the lung stay inflated and heal more readily, and then to walking and strength building.

Most patients in this situation recover quickly without complications and go home in a week, rest there for a couple of weeks, return to part time work for a few weeks and be full speed by 3 to 4 months. Or he could have one of any number of complications and die. Or be permanently disabled. It all depends upon the nature of Injuries, the effectiveness of the treatment, and luck. None of this fits your guy though, since he plans to leave the hospital a bit early.

He could of course sneak out or could sign himself out of the hospital Against Medical Advice (we call it AMA) at any time after he was off the ventilator. If he did, they would give him antibiotics and pain meds and have him see his MD every couple of days for the first week or so. Then less frequently after that until he was well again. Or died peacefully at home as seems to be his plan.