View Full Version : A GSW "first" in my career

07-04-2009, 18:33
For those in the medical field taking care of patients shot by a low velocity projectile (<1500fps).......
I recently had a patient shot with a .45 caliber round at a distance of about 2 feet from end of barrel to abdominal wall. The bullet went across his abdomen from right to left in the soft tissue; it did NOT penetrate the deeper layer of fascia or the peritoneum, in other words it did not enter the abdominal cavity. On the right side it was above the anterior layer of fascia, at the midline it carved a furrow into the anterior fascia and rectus muscle but did not violate the posterior fascia at all which I visually inspected. There was no contusion of the fascia either........case over.
2 days later, has a distended abdomen and a CT is performed which shows free air and ascites...back to O.R. and found a tangential wound of a loop of small bowel spilling enteral contents into the abdominal cavity....there was NO EVIDENCE OF THE BULLET ENTERING THE PERITONEAL CAVITY, THE FASCIA AND PERITONEUM WERE INTACT.
So time to review wound ballistics....size of temporary cavity from a low velocity bullet is minimal. No obvious injuries are typically seen 1-3mm away from permanent cavities 'usually'. I have operated on a lot of patients where you scratch your head (figuratively in surgery) wondering how the bullet passed within 1-2 mm of a structure and there was no damage seen.
Lesson learned....nothing is perfect in this world and no gel model could ever predict this....only through operative experience or an autopsy, can we really learn the truths and myths of wound ballistics....
This case represents a "beware" of something I thought couldn't happen based on available literature about wound ballistics for low velocity projectiles.