Gunshot wound: ambulance and hospital protocol

I've got two issues with the scenario: one, the idea of the shoulder being a safe place to get shot is a myth. It is one of the most complex joints in the body, with major blood vessels and an important nerve cluster running through it. So while it may not necessarily kill you it will probably cause major damage, likely with some permanent loss of function.

Issue two is her passing out from blood loss. If that happens she's not going to wake up again. Passing out from blood loss means you're in uncompensated hemorrhagic shock. This will kill you without what the textbooks like to term "immediate and aggressive intervention." That means if she doesn't get the proper treatment right away, she's gonna die.

So, questions :

1) That depends on what the bullet destroyed in there.

2) If she is in hemorrhagic shock it's load and go. But I guess that's not what you're after. So, non-life-threatening GSW: bullets are usually sterile, but if the wound is contaminated the medics might flush it with saline. They'll put a pressure bandage on the shoulder and immobilize it.

IV is standard. If she is in hemorrhagic shock she'll get two, and big ones. Painkillers are possible, but it depends. Pain is pretty subjective. EMS typically carries narcotic painkillers and those go in through the IV.

The third question depends on how serious her condition is. If time is of the essence the cops can ride along or follow them to the hospital, but patient treatment always takes precedence over their investigation.

3) Our patients are rarely that doped up from our painkillers, and we use fentanyl (very potent). They're more likely to feel dizzy and nauseous, but only occasionally dazed and confused.

4) I don't know much about what's going on beyond the ER, but I'll try. People who know better are welcome to chime in.

The post-OP patients I've encountered were in the recovery room, but only for an hour or two, and then they'd be moved elsewhere. They were usually dopey and sometimes nauseous, but it'd take a while until they felt pain. No visitors in the recovery room, but once moved, and at the discretion of the docs, she can have visitors. I don't see any reason why she can't eat as soon as she's hungry, or why she couldn't have solids, but like I said, anesthesia tends to make people feel sick. How long she stays and how long the arm needs to be immobilized depends on the wound, its development, and the judgment of the doctor.

I hope that helps. If you want to know more about the ambulance procedure, feel free to ask.

ETA: Oh yeah, credential-wise I'm a certified EMT-Paramedic. We get a lot of gunshot wounds.

There have been many gunshow wound questions the last few months. At least one was a situation very much like yours. You might want to do a search and read those other responses.

NikkiSloan said:

[FONT=&quot]She gets shot in the shoulder – nothing serious hit...[/FONT]

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Might want to look at an anatomy chart. Hard to miss all the serious stuff in a shoulder. It's also hard to have a non-serious wound where she passes out from blood loss. That much blood loss is always serious.

Aside from that, police will be responding but if she's passed out she won't be talking. If she's awake, maybe. Medics will stop the bleeding, start a saline drip to help with blood pressure and hit the lights and siren. No pain medication is normally given and, if it's just blood loss, no other treatments. Getting the blood flow stopped is number one, getting her to the hospital is number two.

In a hospital, they may or may not take her to surgery. Once blood loss is stopped, x-rays, MRI, etc will be done. Depending on those a treatment is decided on. Could be as simple as bandages and Tylenol(R). You did say no serious injury.

Surgery depends on the diagnosis. From your description, any surgery would be short, pulling bullets/fragments, cleaning and stitching. Recovery, assuming general anesthesia (not guaranteed with no serious injury) she'd have an hour or two in recovery, then be discharged. Bandage yes, sling only if warranted.

Post op care would be changing bandages, cleaning/disinfection and antibiotics. Maybe physical therapy. A week or so until bandages are gone would be likely. Again, you said no serious injuries.

Bottom line, figure out what you need to make the plot work, then write it to meet those needs.

Jeff

asroc said:

ETA: Oh yeah, credential-wise I'm a certified EMT-Paramedic. We get a lot of gunshot wounds.

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Tell us where you are so we don't make the mistake of moving there.

Jeff

Yes, on a muscular adult man the space where you can be safely shot is less than an inch thick, and only about four inches long. On a muscular woman, or a guy my size it is less than a half inch.

And the only rounds that can pass through without destroying the shoulder is small handgun/rifle or high velocity rifle. Really, with most weapons, the only wounds you can take without permanent injury would probably not be fatal in most other parts of the body. But they do happen.

One thing that makes Hollywood injuries difficult is an effect called hydrostatic shock. Which is where the energy of the bullet passing through the tissues gets carried into other parts of the body by shock waves. I've seen pictures where a person has had their knee shattered by a bullet that passed through his thigh Inches from the bone. Split his skin seven ways till Sunday too.

As mentioned up page, when you pass out from blood loss it takes a lot of effort to stop death from following. But there are other things that an cause a pass out. Pain, shock, or fear are good examples.

Unless she isn't hurt badly enough to need an ambulance ride, the police are going to have to wait.

Strange. How'd that post twice?

WeaselFire said:

Tell us where you are so we don't make the mistake of moving there.

Jeff

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Just so that there are no misunderstandings, are you asking because of our violent crime rate or are you questioning my competence?

I'd expect the violent crime rate.

Wilderness EMT-I here. We have hunters doing stupid things all the time. Except for through-and-through wounds of the extremities I'd expect she'd be backboarded. I'd also expect to put her on oxygen, so what blood she has left will be able to perfuse the tissues.

Control bleeding with direct pressure, backboard, O2, two large-bore IVs running normal saline or Lactated Ringer's, and transport. Let the surgeons figure it out.

James D. Macdonald said:

I'd expect the violent crime rate.

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I hope so. Either way I'm not sure it's a good idea to share on a public board. It's really nice though. I just cover the gangland area.

James D. Macdonald said:

Wilderness EMT-I here. We have hunters doing stupid things all the time. Except for through-and-through wounds of the extremities I'd expect she'd be backboarded. I'd also expect to put her on oxygen, so what blood she has left will be able to perfuse the tissues.

Control bleeding with direct pressure, backboard, O2, two large-bore IVs running normal saline or Lactated Ringer's, and transport. Let the surgeons figure it out.

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Precautionary backboarding without a MOI indicating a spinal injury is actually no longer advised. It generally doesn't help and probably even hurts, so it got removed from our protocol. Of course, since this kind of stuff takes years to make the rounds, there are hundreds of EMS companies who still do it.