Author Question: Gunshot Wound to the Chest

Virginia Asks:

I’m putting the final touches on a romantic suspense novel in which my hero is shot. The most important part of this is that he has to continue to function until he saves the day, then falls and has to be treated. The wound cannot be bad enough that he can’t pass the physical and qualify to become an FBI agent within a few weeks.

My fit male character (34 years old) is in a shootout. He’s shot with a 9mm handgun but the bullet ricochets, grazes his chest, and fractures a rib. He doesn’t notice initially. He begins to feel some pain after about five minutes. Then feels woozy and has a head rush. I want him to fall after the action is over, but be able to talk a little with some struggling.

He’s far from a hospital when he’s shot, but a military medic is there with his kit. The hero can be medevaced to a hospital on a military helicopter. What would the medic do in the field? I don’t want the bullet to penetrate the chest wall, but would the medic check for pneumothorax and if so how?

What would happen at the hospital? How long would he be hospitalized?

I’ve read and re-read about pneumothorax and hemopneumothorax, but think that might require too much recovery time and be too much for him to qualify and be able to pass the physical. I’ve done some research on pulmonary contusion but am a bit overwhelmed with the possibilities of the use of continuous positive airway pressure and high-frequency chest wall oscillation. And the long term recovery.

Since I really don’t know what would be best as a gunshot wound that my hero can recover from and pass a physical in a few weeks, I really need some guidance and specific information that can easily be explained in a romantic suspense novel. I’m hoping this “bullet grazes the rib” scenario is workable. If not, what should I consider instead?

Jordyn Says:

Thanks so much for sending me your question, Virginia.

I think the simplest thing to do is to have the bullet graze his chest. It could potentially hit the rib, break it, and ricochet away. Leaving a nasty gash with a broken rib underlying but nothing else injured. Generally, a fractured rib will heal in 4-6 weeks so he will have pain and limited movement until then. The worst pain will probably be in the first 1-2 weeks and then should taper off after that.

As far as the military medic assisting off duty. I think it’s fine if he has a small first aid kit that he could dress the wound with. He likely would not be carrying an oxygen tank, etc. So the dressing to control bleeding is necessary. Lots of emergency medical types might have a small kit in their car (I do), but not an oxygen tank or a way to deliver oxygen to the patient.

The military medic could check for a pneumothorax by listening to your hero’s breath sounds. Clear and equal breath sounds bilaterally generally indicate no pneumo (though a small one could still be present). It will hurt to take deep breaths if his rib is fractured.

If he’s transported by a military medevac then they could start oxygen, an IV, and give some IV fluids. Place him on a monitor to keep tabs on his heart rate, breathing, oxygen levels, and blood pressure.

In the hospital, he’ll get chest and belly films and possibly a CT of his chest and abdomen. If it seems like a fairly benign wound, the wound could just be irrigated with a lot of saline and sutured closed. He needs an updated tetanus shot if he hasn’t had one in over five years.

If his breathing is good and he suffers just one cracked rib, there is likely not enough injury criteria for him to be admitted into the hospital. He’d likely be observed in the ER for several hours to make sure everything is okay. He’d be sent home with a short course of narcotics (like three days) and instructed to take over the counter pain relievers to help with the pain as well. He should have limited activity but not be bedridden. He’d be encouraged to take deep breaths (usually at every commercial break if watching TV) to prevent lung complications because patients don’t like to breathe deep when they have a cracked rib.

Hope this helps and good luck with your story!

What is the Glasgow Coma Scale?

Often times on television and in movies, you’ll hear a medical character exclaim, “His GCS is 5!” or some other variation. What is this score? What does it mean for the patient?

The Glasgow Coma Scale (GCS scale) is one way to gauge the significance of brain injury. There are three components to the measurement. Eye Opening. Verbal Response. Best Motor Response. In general, the highest score is 15. The lowest score is 3. You can be dead and still score a 3 so the higher the score the better.

Eye opening looks at four components and each is given a score:
4: The patient opens their eyes spontaneously.
3: The patient opens their eyes after being spoken or shouted to.
2: The patient opens their eyes to a painful stimulus.
1: No eye opening at all.

Verbal response looks at five components:
5: The patient knows person, time and place.
4: The patient can speak but is not oriented.
3: Speaks unintelligibly.
2: Moaning.
1: No verbal response.

Best motor response looks at six components:
6: The patient can obey a two part request such as touch your nose and then your shoulder.
5: The patient moves to push away a stimulus. For instance, if I’m starting an IV in your left hand, you take your right hand to push it away. This is called localizing pain and the patient usually needs to move across their midline or above their clavicle (if the stimulus is placed to the head) to score here.
4:  Pulls extremity away from pain.
3: Abnormal flexion.  Also referred to as decorticate posturing.
2: Abnormal extension. Also referred to as decerebrate posturing.
1. No motor response.

Initially, we might look at the overall score to determine whether or not a patient needs to be placed on a breathing machine. Generally, a score equal or less than eight is used as a cut off point. The lower the initial score, the more likely the patient will be intubated. Over the long term, the GCS can be used to trend improving or worsening neurological status.

Have you ever heard this scale used on television or in a movie?

The Use of Hypothermia Post Cardiac Arrest

Emily Asks:

I am playing around with one of my character’s being shot life threateningly, but of course it’s gotta be something he recovers from with time.

This character is in his late 20s and in good health before the incident takes place.

At first, I was toying around with the idea of making the gunshot wound similar to what Kate Beckett had in the show Castle at the end of season three. The trouble is, I do not know how medically realistic her wound was, as you have pointed out Castle’s medical inaccuracies before. If you have possibly seen the episodes in question, could you give me some feedback on the medical aspects of Beckett’s shooting?

In relation to this, her heart supposedly stopped twice during the whole ordeal. I have been researching induced comas, and while they seem to be used for patients having more of a direct injury to the head, in the case when a victim’s heart stopped twice and is resuscitated both times, would there be any reason to keep them in an induced coma for a time due to lack of oxygen to the brain?

Then, after researching, I am playing around with giving this guy a collapsed lung from the bullet, which is small caliber.

1. In what hypothetical cases would this kind of injury require immediate surgery?

2. Are there any complications that could be serious enough for the said character to have to go back into surgery at a later time?

3. My character happens to be a bass singer for an acapella band. Would a collapsed lung affect his career at all even after he made a full recovery?

Thank you for taking the time to read and respond to my questions!

Jordyn Says:

Beckett’s Gunshot Wound:

I had to go back and find some videos that were related to this. Shockingly, I found this scene pretty medically accurate. I found one that showed her coding one time. Though I definitely could have missed some. The determination to put someone in therapeutic hypothermia or targeted temperature management (as now termed) related to their heart stopping is dependent on whether or not they wake up immediately after their code.

A patient that wakes up spontaneously and quickly after a pulse is restored has intact neurological function. Those that remain comatose have a concern for neurological injury related to oxygen loss to the brain during the resuscitation and therefore the medical team could choose to put the pt in a “hypothermic” state to try and prevent this neurological injury.

This is slightly different from a medically induced coma that patients with traumatic brain injury might be placed in to prevent brain swelling. The difference is actively cooling the patient. I have not seen the use of hypothermia in the traumatically brain injured population (though this does appear to be an area of study), but use of medically induced comas, yes.

There are definite guidelines that the American Heart Association has put out that outline this course of treatment. You can find one such article here.

If your character codes and doesn’t wake up– then this would be a reasonable course of action medically, but written under the guidelines in the article.

In regards to your specific questions.

1. It’s more likely than not that a gunshot wound to the chest would go to surgery, particularly if the patient presents with any abnormal vital signs especially low blood pressure. There’s just so much there that could be damaged. The heart. The lungs. The blood vessels.

2. Yes, there could be a number of scenarios where the character could require more surgery such as a blood vessel that’s leaking that’s not found the first time during surgery and continues to bleed. Infection– specifically some sort of abscess formation could be another reason, but that would take some time to develop.

3. I don’t personally foresee a problem with his acapella career after his lung is healed. It would take time to get to the point where he was. If you wanted to affect his career, a patient who is intubated (placed on a breathing machine) can develop vocal cord damage as a rare complication.

Best of luck with your story!

Treatment of Car Accident Victim with a Brain Injury

Leslie Asks:

My character has been in a car accident and sustained head damage (swelling to the brain)— is there a medical term for that? Also, the swelling becomes so bad the doctors have to remove part of her skull— is there a name for that? How long does that swelling usually take before it goes down so they can replace the skull? Does the character regain consciousness? I have her in an induced coma which I want her in for a while.

Jordyn Says:

Upon further clarification of this question from the author, she says there is not a significant description of the motor vehicle collision in the manuscript and the scene is being told from the POV of a nurse.

The brain swelling is called cerebral edema. Usually, if it’s a significant car accident then there is usually bleeding as well. This is why I ask about the car accident. It should be pretty serious.

A nurse will use language that a family can understand. So, I might actually avoid a lot of medical terminology when speaking to the family unless I also clarify what the words mean.

I might say something like, “Your mother (or whatever relation) has a lot of swelling in her brain as a result of the car accident. We call this cerebral edema.”

A craniectomy is where they remove a portion of the skull.

Peak brain swelling is generally 48-72 from the time of injury and diminishes from there. Induced coma is a reasonable medical scenario here.

Whether or not this patient regains consciousness is up to you as the writer. Statically, the odds are pretty low for her to be the same person she was before. If she does wake up, she’ll have extensive rehab needs for sure– but you could write it either way.

Best of luck with your story!

Author Question: Motorcycle Injuries

Tory Asks:

I’m currently writing a fan fiction and the two main characters get in a motorcycle crash. The female just found out she was pregnant. I have three (very unrelated) questions. Could the crash send her into cardiac arrest? Would the male (who was driving) be able to survive with just a broken arm and a sprained ankle? And would the baby survive?

Jordyn Says:

Hi, Tory. Thanks for sending me your questions.

1. Yes, a motorcycle crash could send someone into cardiac arrest.

2. Could the male survive with just a broken arm and a sprained ankle? Sure, this is possible, but I don’t know if it’s probable. When looking at accidents, medical people always look at the injuries of the other people involved to determine how serious everyone’s injuries might be.

If the female in the accident suffers a cardiac arrest, it would be surprising that the male walks away with just, essentially, a broken arm. You could make it more believable in the description of how the accident happens. For instance, the female is thrown from the bike, but the male is trapped underneath it. You could also have them differ in the type of protective equipment they’re wearing (helmet, jackets, etc.)

3. Would the baby survive? Again, it depends on a lot of factors. How far along is she in the pregnancy? Cardiac arrest— how long is she pulseless? What other injuries does she get in the accident? The sicker she is from her injuries, the more likely she will miscarry the pregnancy. The body will defer energy and resources to the mother over the pregnancy. Then again, some women have maintained a pregnancy through terrible injuries so you would have some leeway as an author here.

If the mother is far along in the pregnancy (at least 22-24 weeks along) and in cardiac arrest the providers might consider C-section to save the infant. So, without more details as to the nature of the accident, her injures and the state of her pregnancy, it would be hard to say if the baby would likely live or die.

Good luck with your story!

PSA: Drowning Doesn’t Look Like Drowning

This is an educational post from your friendly neighborhood pediatric nurse.

During summertime, pediatric nurses are confronted with an increasing incidence of preventable injuries— the biggest one in my opinion is drowning.

It is not uncommon to get pediatric near-drowning cases in the summer. Obviously, more kids are playing in large bodies of water whether it be a shallow baby pool, regular pool, lake or ocean. Kids can drown in very shallow water. Also, just because your child has passed a few swimming lessons doesn’t mean they won’t drown. Kids in open bodies of water should be wearing life jackets.

The classic set-up is a party where there is some type of pool where all the kids are enjoying themselves. The adults are drinking and socializing and no one is watching the children play. Some adults feel that the older kids can keep an eye out for the younger ones— I cannot scream enough at the top of my lungs how patently false this is. If you have a teen who is a certified lifeguard and is tasked with watching the children in the pool I might agree. Otherwise, no.

At any party where kids are swimming, including a little tiny baby pool, there needs to be a sober adult who is watching the children AT ALL TIMES! I truly cannot express this enough. Drowning can happen in a minute or less. You cannot merely check on them every ten to fifteen minutes— that can be too late.

Also, drowning may not look like drowning and I’m including a couple of videos that highlight the point.

Enjoy the summer, but be safe! Keep an eagle eye on those kiddos enjoying the water.

Author Question: Gunshot Wound to the Torso

Heather Asks:

If my hero gets shot in the torso, is there somewhere it can hit that won’t be fatal? It can be a “miraculous” miss, that kind of thing. He can be weakened and bleeding, but I just need him to stay conscious for maybe five to ten minutes after? Any ideas?

Jordyn Says:

Sure, there are always miracles.

In medicine we view the torso as including the chest and abdomen. Generally the diaphragm is the dividing line between the two. So the chest is everything above the diaphragm and the abdomen is everything below it.

Gunshot wounds to the chest not hitting anything is tough. Think about everything that’s there. The heart, lungs, major vessels and arteries. Can a bullet pass through and miss everything— or hit something less minor and just cause bleeding? Sure. Anything is possible. I would recommend staying away from the left side of the chest for the wound— just so much there. The right chest and lower might be more believable because it’s just the lung sitting there. There are major blood vessels that underline each rib so nicking one of those could cause the bleeding you want. Hit outside or inside enough and you could miss the lung.

Abdominal wounds could go either way. A lot to hit in the belly as well, but also good odds for missing. If he’s wearing a bullet proof vest, you could have the bullet enter through his side and low– just under the lung and diaphragm. Problem is you have highly vascular organs on either side– the liver on the right and the spleen on the left. So, I’d aim below that as well or merely have them be grazing wounds to these organs. This could also cause significant, but survivable bleeding.

Hope this helps and happy writing!