May 23, 2013

Surgeon David Lauter writes about treating gun shot wounds during his second assignment with MSF, in Rutshuru, Democratic Republic of Congo.

DRC 2012 © Aurelie Baumel/MSF

X-rays taken of injured patients at MSF’s facility in Rutshuru, North Kivu.

US surgeon David Lauter is working with MSF in Rutshuru, Democratic Republic of Congo.  

Among the cases toward the end of the afternoon were two men in their early 20s with gunshot wounds, one in the arm, the other in the leg. They had been seen at another smaller hospital where their wounds were bandaged and splinted, then transferred to Rutshuru for definitive care. Ideally we would have x-rayed the injured extremities immediately but the x-ray machine was down for the day so they came to the OR for debridement [the medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue] and wash-out of their wounds without x-rays.

It’s been awhile since I’ve treated someone with a gunshot wound, though I saw my share during residency on the trauma service. There’s a significant difference between wounds from a handgun and a military rifle. The speed of a bullet as it leaves the barrel of a typical 9mm handgun is 300 meters/second compared to 900 meters/ second for a military rifle. The force behind the bullet is in direct proportion to the speed of the bullet squared. This means that if a bullet from a Kalashnikov rifle is traveling three times faster than a bullet from a Glock 9mm handgun, it carries nine times the impact. Compared to gunshot wounds at home, the ones in Rutshuru come with bigger holes and more tissue destruction. The protocol here for treating gunshot wounds is based on the recommendations of the International Committee of the Red Cross (ICRC). It involves two operations, the first being debridement of all infected and dead material, leaving the skin edges of the wounds open, thus avoiding secondary infections that threaten life and limb.

The man with the leg wound had two holes in his upper leg. His smaller hole was the size of a US quarter, coming in the back of the leg at the mid-hamstring and his larger hole was the size of my fi st, coming out in the front just above his knee a bit to the outside. After induction of anesthesia, we removed his splint, pulled the compresses that had been packed into the wounds, and surveyed the damage. There was a large cavity with torn muscle and bone fragments between the two holes. Almost all the bleeding had stopped. I could feel an abnormally rough texture to his femur bone but his leg felt structurally stable. I was comfortable that the main artery in his leg, the superficial femoral artery, was intact because it travels around the other side of the femur away from the damaged area, plus I had felt a good pulse in his foot before we started.

Using a scalpel I cut the bruised, dead skin from around both wounds so that I could better see into the cavity. I removed fragments of cloth and bone and cut away fat and torn, bruised muscle until I was satisfi ed that anything that would act as a source for bacteria to grow in had been removed. I rinsed out the cavity with saline and Betadine, put a loose dressing on both sides so that any infection could wick out, and wrapped the wound. With the help of the nurses in the OR, we put his leg in a plaster splint to immobilize it until he can get an x-ray tomorrow.

The next patient clearly had an open fracture of the upper arm because even with the arm immobilized in a splint, it didn’t look quite anatomically correct. I felt a strong pulse at his wrist, indicating no major arterial damage. It was harder to be certain about the three major nerves (the median, ulnar, and radial nerves) that travel through the upper arm. There is a quick examination to see if they are working, but it can be difficult to rely on when your patient is in pain, has received narcotics, and you don’t share a common language. After induction of anesthesia and the removal of his splint and dressing I could see he had a two-inch diameter hole through his mid-upper arm. By pulling on his arm I could see straight through to the other side. Needless to say, the exposure of his cavity was good. His humerus was broken with the two ends staring at each other 180 degrees apart and a visible gap. Without an x-ray it was impossible to tell how much of the bone, if any, was missing. I debrided skin and fat, cut away pieces of bruised and nonviable muscle with attached bone fragments and washed out the wound. There weren’t that many bone fragments so either he hadn’t lost much bone (good), or a big chunk had already been blown out (bad), or I had done an inadequate debridement and left dead bone fragments (worse). I looked in the cavity to see if I could identify the ends of a transected major nerve but didn’t see any. If I had seen one, I would tag it with a blue suture to help find it at the next operation when it would be repaired. Having completed the debridement, I washed out the wound with saline and Betadine, checked to be sure there wasn’t any more bleeding, placed a dressing followed by a plaster splint, and we were finished.

Like all our patients with gunshot wounds, these two will come back to the OR in four or five days for re-evaluation. For smaller wounds without bone injuries or secondary infections, we close the skin at the time of the second operation (called delayed primary closure, or DPC, if you want to talk like a trauma surgeon). For larger wounds, we wait until they are ready for a skin graft. For patients with open fractures who need an external fixature (our second patient will definitely need one to salvage his arm), it is placed at the time of the second surgery. Some readers may be interested in looking at the ICRC publication “War Surgery” (just Google search “war surgery ICRC” and you will find a downloadable PDF) which talks authoritatively about the treatment of high velocity gunshot wounds (some photos are not for the squeamish). As well, it provides a readable (at least I thought it was readable, but then I’m a surgeon) overview of the tremendous variety of injuries that occur during war and natural disaster and the complexities of treating these injuries.

When I left home to come to Rutshuru, there was a renewed and vigorous debate in the US about the restriction of military-style rifles for personal ownership that began after the recent tragedy in Newtown, CT. The subject is a political hot potato involving powerful lobbies, heartbreaking tragedies, and passionate arguments on both sides. Regardless of where one stands on those issues, there is one indisputable fact: bigger guns make bigger holes. If you ever get shot, hope it’s with a handgun and not an assault rifle.

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