There does not exist a firearm that has a higher chance of achieving a single shot incapacitation on a human target than a shotgun at close range. inside of 10 meters, a 12 gauge shotgun fired to a human target with 00 buck will damage the majority of major soft organs, cause significant soft tissue damage, create multiple wound channels, cause a hypotensive emergency and purely has no equal in terms of single shot power within this envelope.
After a long night in the ED I had just sat down to my computer to answer some emails. I had even pulled up my mobile Teamspeak application to connect with my Spergkin and talk with some former, and some current NSers I am glad to call friends (and one begrudgingly-he IS a Manlet, after all) and some non-NSers. I was looking forward to taking ten minutes to myself.
But no. My phone vibrated suddenly, the same three pulse vibration I get from my hospitals internal memo application. The message popped on my phone.
"Inbound GSW, (my city) ALS Truck 42"
So I went down to the ED and grabbed the headset we use to talk to incoming ambulances. I received the code and patch from the inbound medic who relayed the information to me-Male, late 20s, gunshot wound, Anterior chest, multiple large entrance and several small exit wounds. Blood pressure 148/84, GCS 6, H/R 110, resperatory compromise, 22/Min but maintained via Endotracheal tube with open Pneumothorax currently attempting to resolve. ETA six minutes.
I prepared myself. The trauma nurses and PA, the ED Paramedics and two residents swirrled to trauma receiving as a OR Nurse went and got room C ready for us. My resident for the day looked sick. He had never had a shooting before-this would be his first, and it was a hell of an introduction to shootings. I told him what to expect, and not to take anything I said personally, and if I start speaking Russian to just say English, and I'll correct myself. I told him that the total number of entry and exists would determine our interventions, and that the medic would not be able to supply us with those numbers as he was alone in the back, and if he had tubed the patient, he wasn't going to be rolling him.
The patient arrived after a moment of pregnant silence that makes me wish I never quit smoking. The bay went from silence except the distant sound of the air vents circulation cycle to the distinctive rattling of the stretcher and my head trauma nurse Noah's distinctive Bostonian accent issuing orders. The patients tube was in place, resperstions were being maintained, and plasma was being shunted.
I looked him over. A perfect candidate for surgery. Vitals in tollerances limits. Serious intervention needed to stabilize. If stabilized no major long term effects likely. Excellent.
Prepped and ready we wished our human ballistic gel off. Imaging gave me the story I was expecting and my once over told me I was dealing with a 12 gauge GSW with buckshot-I never see anything but 00 buck, slug or #7½ bird, and this was obviously buck.
My resident, pale as a ghost still beneith his PPE and gloved hands trembling at the thought of stabilizing such a serious set of injuries, nodded to me as I began my task as a human butcher, cutting, pasting, and stitching holes and perforations of the thoracic cavity, as the repertory specialist, ORN, Anesthesiologist and other cogs of the machine that is the modern surgical theater said words I didn't care much for, numbers I didn't pay attention to, and had conversations I didn't listen to. Unless I hear them say my name, my ears are shut or tuned to the music playing through the speakers that every OR has-the most important of the creature comforts besides climate control for most OR staff, and the reason why theatre C is so coveted.
My patient was not in good shape. A low BF% and unpalatable radial pulse, JVD I could have spotted across the room, track marks and lips that had been chewed to hell tell me a opioid derived swan song that has become my home cities biggest hit since 2012. This isnt a new story, and it's not even one that adds a new twist.
This is Friday night.
The drug life did no favours when the ire of someone welding a 12 gauge came down upon my patient. The wounds were spread out so as the entirety of the forgot was hit-our lowest verifiable entry wound was only just superior to the ischial tuberosity, and our highest struck 5cm above the nipple. This patient was what I would describe, in a less clinical environment, as "up shit creak without a paddle".
After getting to a position I felt my resident couldn't fuck up, I began to instruct him in the importance of what I was doing, how to do it, and what to do if it doesn't work. I explained carefully the details of controlling major bleeds in the arteries and remarked how good the body is at helping itself-all you need to do sometimes is give it a hand. I allowed him to extract a shot pellet that was in the way, and had him close a wound.
The patient was lucky. The pellets had struck many things, but the heart and major vessels were not one of them. The surplus of blood in the pelvis was not surprising to me, but came as a shock to my poor resident, who had no idea that a quarter liter of blood could look like *that*.
After three hours and several dozen stitches, clamping and suturing, swearing and some tough and go operations, we washed our hands and headed to get dinner.
Over a plate of what passes for baked Ziti and chicken marsala at a Hospital employee canteen, I discussed in great detail the mechanism of gunshot wounds to my resident, who had never seen a gun in person, who had only a passing understanding of what the difference between a shotgun, pistol, and rifle were, and had absolutely no idea that calibers of rifles even really existed. I explained to him, in the same detail and then some that I might go into here, the fundamentals of ballistic trauma and the management of these injuries in a hospital and field setting, and the complications one can expect. I explained the dynamics of hydrostatic shock and fluid disruption to him, and detailed how to best close a yaw injury as opposed to a fragmentation injury, and explained that never stitching a puncture wound is not the same as a gunshot wound even though they are both a puncture.
He confessed total ignorance of gunshot wounds. He doesn't even want to be a trauma surgeon, he just picked my rotation first because he heard I was "incredibly difficult" to work with, and he wanted to get it over first.
This didn't hurt me. I am intentionally difficult to work with because I do not accept failure in an environment where failure means death. And this was an exact example of it. If the shooter had been lower or higher in either direction just a bit, the patient could have required three or four more other hands on deck to keep him stable. A little to the left or right, a few inches forward, and I might have spent the next hour or two doing E-Mails hear about a GSW from my friend over at the state medical examination office on Monday afternoon.
There was no human being who would have walked away from that. There is no medic, BLS, ILS, ALS, or TALS, Airborne or otherwise, who would have been able to stabilize that patient for more than 30 minutes, and at no point from the medics arrival on scene to the point I finished with the patient did that patient wake up. There was not a single individual person who would have been able to stabilize them. That patient needed, in total, nine direct actors and 22 total persons to intermittently stabilize, transport, reduce to critical condition, prepare, and repair this patient, who will walk with a gait and have breathing issues for the rest of their natural lifespan.
And this is the case with virtually all shotgun injuries. Shotguns are the undisputed close quarter kings. There is simply nothing, on an individual basis, that can hope to compare to the pure deviation a shotgun brings to an individual target in one shot from a man portable package.
After a long night in the ED I had just sat down to my computer to answer some emails. I had even pulled up my mobile Teamspeak application to connect with my Spergkin and talk with some former, and some current NSers I am glad to call friends (and one begrudgingly-he IS a Manlet, after all) and some non-NSers. I was looking forward to taking ten minutes to myself.
But no. My phone vibrated suddenly, the same three pulse vibration I get from my hospitals internal memo application. The message popped on my phone.
"Inbound GSW, (my city) ALS Truck 42"
So I went down to the ED and grabbed the headset we use to talk to incoming ambulances. I received the code and patch from the inbound medic who relayed the information to me-Male, late 20s, gunshot wound, Anterior chest, multiple large entrance and several small exit wounds. Blood pressure 148/84, GCS 6, H/R 110, resperatory compromise, 22/Min but maintained via Endotracheal tube with open Pneumothorax currently attempting to resolve. ETA six minutes.
I prepared myself. The trauma nurses and PA, the ED Paramedics and two residents swirrled to trauma receiving as a OR Nurse went and got room C ready for us. My resident for the day looked sick. He had never had a shooting before-this would be his first, and it was a hell of an introduction to shootings. I told him what to expect, and not to take anything I said personally, and if I start speaking Russian to just say English, and I'll correct myself. I told him that the total number of entry and exists would determine our interventions, and that the medic would not be able to supply us with those numbers as he was alone in the back, and if he had tubed the patient, he wasn't going to be rolling him.
The patient arrived after a moment of pregnant silence that makes me wish I never quit smoking. The bay went from silence except the distant sound of the air vents circulation cycle to the distinctive rattling of the stretcher and my head trauma nurse Noah's distinctive Bostonian accent issuing orders. The patients tube was in place, resperstions were being maintained, and plasma was being shunted.
I looked him over. A perfect candidate for surgery. Vitals in tollerances limits. Serious intervention needed to stabilize. If stabilized no major long term effects likely. Excellent.
Prepped and ready we wished our human ballistic gel off. Imaging gave me the story I was expecting and my once over told me I was dealing with a 12 gauge GSW with buckshot-I never see anything but 00 buck, slug or #7½ bird, and this was obviously buck.
My resident, pale as a ghost still beneith his PPE and gloved hands trembling at the thought of stabilizing such a serious set of injuries, nodded to me as I began my task as a human butcher, cutting, pasting, and stitching holes and perforations of the thoracic cavity, as the repertory specialist, ORN, Anesthesiologist and other cogs of the machine that is the modern surgical theater said words I didn't care much for, numbers I didn't pay attention to, and had conversations I didn't listen to. Unless I hear them say my name, my ears are shut or tuned to the music playing through the speakers that every OR has-the most important of the creature comforts besides climate control for most OR staff, and the reason why theatre C is so coveted.
My patient was not in good shape. A low BF% and unpalatable radial pulse, JVD I could have spotted across the room, track marks and lips that had been chewed to hell tell me a opioid derived swan song that has become my home cities biggest hit since 2012. This isnt a new story, and it's not even one that adds a new twist.
This is Friday night.
The drug life did no favours when the ire of someone welding a 12 gauge came down upon my patient. The wounds were spread out so as the entirety of the forgot was hit-our lowest verifiable entry wound was only just superior to the ischial tuberosity, and our highest struck 5cm above the nipple. This patient was what I would describe, in a less clinical environment, as "up shit creak without a paddle".
After getting to a position I felt my resident couldn't fuck up, I began to instruct him in the importance of what I was doing, how to do it, and what to do if it doesn't work. I explained carefully the details of controlling major bleeds in the arteries and remarked how good the body is at helping itself-all you need to do sometimes is give it a hand. I allowed him to extract a shot pellet that was in the way, and had him close a wound.
The patient was lucky. The pellets had struck many things, but the heart and major vessels were not one of them. The surplus of blood in the pelvis was not surprising to me, but came as a shock to my poor resident, who had no idea that a quarter liter of blood could look like *that*.
After three hours and several dozen stitches, clamping and suturing, swearing and some tough and go operations, we washed our hands and headed to get dinner.
Over a plate of what passes for baked Ziti and chicken marsala at a Hospital employee canteen, I discussed in great detail the mechanism of gunshot wounds to my resident, who had never seen a gun in person, who had only a passing understanding of what the difference between a shotgun, pistol, and rifle were, and had absolutely no idea that calibers of rifles even really existed. I explained to him, in the same detail and then some that I might go into here, the fundamentals of ballistic trauma and the management of these injuries in a hospital and field setting, and the complications one can expect. I explained the dynamics of hydrostatic shock and fluid disruption to him, and detailed how to best close a yaw injury as opposed to a fragmentation injury, and explained that never stitching a puncture wound is not the same as a gunshot wound even though they are both a puncture.
He confessed total ignorance of gunshot wounds. He doesn't even want to be a trauma surgeon, he just picked my rotation first because he heard I was "incredibly difficult" to work with, and he wanted to get it over first.
This didn't hurt me. I am intentionally difficult to work with because I do not accept failure in an environment where failure means death. And this was an exact example of it. If the shooter had been lower or higher in either direction just a bit, the patient could have required three or four more other hands on deck to keep him stable. A little to the left or right, a few inches forward, and I might have spent the next hour or two doing E-Mails hear about a GSW from my friend over at the state medical examination office on Monday afternoon.
There was no human being who would have walked away from that. There is no medic, BLS, ILS, ALS, or TALS, Airborne or otherwise, who would have been able to stabilize that patient for more than 30 minutes, and at no point from the medics arrival on scene to the point I finished with the patient did that patient wake up. There was not a single individual person who would have been able to stabilize them. That patient needed, in total, nine direct actors and 22 total persons to intermittently stabilize, transport, reduce to critical condition, prepare, and repair this patient, who will walk with a gait and have breathing issues for the rest of their natural lifespan.
And this is the case with virtually all shotgun injuries. Shotguns are the undisputed close quarter kings. There is simply nothing, on an individual basis, that can hope to compare to the pure deviation a shotgun brings to an individual target in one shot from a man portable package.
