List Archives

Wed Jun 13 09:24:08 BST 2012

Sorry if I opened a can of worms. I was simply curious about some of the
comments made about a particular injury that was being discussed on the
list. Thereby, my question to Norman.

I have been a war surgeon with the Red Cross-Red Crescent for over 30
years. I do not regularly see handgun bullet wounds. AK-47, M-16, landmines
and various bombs and shells are my meat and potatoes. Much has been
written about wounds provoked by such weapons in the last few years, for
obvious reasons, and the reason for the present discussion about the future
of Landstuhl.

Briefly:

"Treat the wound, not the weapon" comes from Lindsey D. The idolatry of
velocity, or lies, damn lies, and ballistics. *J Trauma* 1980; *20*: 1068 –
1069.

Fackler's 1987 study, although containing much information that is still
pertinent, has been superseded by other work, as Norman mentioned.

If I may quote myself: Although the study of ballistics may be
“interesting” in its own right, the clinician does not always know what
weapon inflicted the injury; and *never *knows the energy available at
point of impact. One can only estimate the transfer of energy in the
tissues from the extent of tissue damage. The study of ballistics gives us
an understanding of the basic mechanisms at work during wounding. The
importance of this knowledge lies in the fact that projectile injuries
should be neither under- nor over-treated. (*War Surgery: Working with
limited resources. Volume 1* Geneva: ICRC; 2009.)

I think that this is the exact point that Norman was making. An
understanding of wound ballistics helps in understanding the pathology that
the surgeon sees.

Is this clinically important?

I offer just one example from the recent literature: Tien HC, van der Hurk
TWG, Dunlop MP, Kropelin B, Nahouraii R, Battad AB, van Egmond T. Small
bowel injury from a tangential gunshot wound without peritoneal
penetration: a case report. *J Trauma* 2007; *62*: 762 – 764. (in
attachment)

If you read this article, you will find that: "The patient did have small
bullet fragments in the left flank area, likely corresponding to the bullet
track. …trauma room ultrasound showed no fluid …It was thought that he had
a tangential gunshot wound to the left flank with no peritoneal
penetration. However, since we did not have CT or laparoscopic capability
at the time, the patient was taken to the operating room for an exploratory
laparotomy." At laparotomy, a full-thickness lesion was found of the small
bowel that required excision and repair.

In the ICRC, we regularly operate with plain X-ray films; no CT,
ultrasound, or any other imaging. An entry-exit wound through a significant
distance of tissue and showing *fragmentation of the bullet* demands
exploration even if there is no clinical evidence of peritoneal
penetration. This type of wound can only be created by a very considerable
transfer of kinetic energy to the tissues, whatever the weapon. Therefore,
an understanding of ballistics helps in understanding the pathology and its
clinical implications. Not always, though. Many, if not most ballistic
wounds, do not fall into this category. But an understanding of ballistics
allows me to determine which ones do. Another point that I think was made
by Norman.

best regards
-- 
christos giannou
Monemvasia Lakonia
23070 Greece
tel & fax: (++30) 27320-61772
-------------- next part --------------
A non-text attachment was scrubbed...
Name: Small_Bowel_Injury_From_a_Tangential_Gunshot_Wound.pdf
Type: application/pdf
Size: 369336 bytes
Desc: not available
URL: <http://list.mistral.net/pipermail/trauma-list/attachments/20120613/fdc6f97d/attachment-0001.pdf>

List Archives

For your convenience, find the Trauma List Archive Below

Ballistics