It may be the title of your favorite Rage Against the
Machine song, but it’s also a grim reality in our
society. Although the murder rate in many of our
major cities has recently been on the decline, the
United States still leads the world in civilian gun violence.
Even some of our nation’s
smaller cities—like its
DC—have held the title of “Murder
Capitol of the World”
by boasting the highest annual
of murders per capita.
The “upside” to these circumstances is that, in times of
relative peace, our military surgeons in training can visit
major trauma centers to receive experience in treating
“penetrating” trauma (gunshot and knife wounds); it’s
the sort of life-saving experience these doctors cannot
otherwise obtain when there is no battlefield.
In contrast to penetrating trauma, “blunt” trauma refers
to more common injuries like those incurred in motor
vehicle accidents and falls from heights. The distinct
mechanical nature of these types of injuries requires that
they receive different methods of treatment. Most severe
trauma calls for the expertise of specially trained surgeons
who can find and control internal bleeding and
patients who suffer
from blood loss.
Gunshot wounds (GSW) to the head have lately been
prevalent in the media, following the shooting of Arizona
Congresswoman Gabriel Giffords,
members of her
and constituents. No less disturbing was the recent
shooting in Los Angeles in which a female student was struck in the head by a bullet fired, apparently
by accident, from a gun carried in another student’s
As I listened to the media report on these two incidents,
it occurred to me that most people have limited or no
understanding of the treatment and conditions of those
whose brains have been injured by handgun projectiles.
My training as a neurosurgeon in Washington, DC and
my work in Oakland, California in major “inner city”
trauma centers has given me the opportunity to treat
more than my fair share of penetrating head injuries. Let
me do my best to shed some light on the repercussions
of cranial gunshot wounds.
Several things make GSWs to the head different from,
say, the damage done by striking one’s head on a windshield
at 75 miles per hour.
In the latter case, the damaging
transmitted through the head is distributed
the brain. In cases of GSWs, however,
is created as a bullet passes through the brain.
Cavitation denotes the large column of damaging energy
that surrounds the course of a much smaller missile as it
travels at a high velocity through solid matter. Almost
all GSWs that cross the brain from the entry point to the
opposite side of the head end in death. Naturally, highvelocity
military grade weapons are even more devastating
than the handguns that pollute our city streets. Even
“grazing” injury from an M16 can emit enough force
the brain to cause death.
Since the presence of a resting bullet in the brain seldom
causes harm, removing the bullet is not a recommended
surgical treatment—in fact, such a procedure may result
in more damage. The same holds true for most GSW
cases throughout the body. This is why a number of
gunshot victims continue to walk around with bullets
lodged inside of them.
It is recommended, in cases of GSWs to the head, that
the entry and exit points simply be debrided (cleaned
up) and closed (sewn up). Bone fragments should be
removed if near the surface and easily accessible, and
the dense covering of the brain (called the dura mater)
should be repaired to keep spinal fluid from leaking.
Any aid beyond this will not help the brain recover.
The similarity between penetrating and blunt brain trauma
lies in the fact that destroyed brain cells cannot
While “stunned” brain cells can recover
there is no way to predict how much a person
improve after an injury.
It generally takes three to
months for a GSW patient to reach maximum
Few treatments are available for brain
injury and most of them have little effect on outcome.
Because nothing can be done to aid brain cells
destroyed by the initial injury, modern treatment focuses
instead on salvaging those cells that hold the potential to
recover. One of the reasons the brain is particularly
sensitive to the effects
of trauma is because
is confined within a rigid box: the skull. All
swell when they are injured, but the skull
the brain no room to swell. As a result,
rises inside the head and makes it more
for blood to reach the brain.
In light of this fact, the focus of acute brain
injury treatment is on reducing swelling or
“intracranial pressure” while maintaining enough
blood supply to meet the demands of the brain’s
healing tissue. A number of medical treatments
are applied to achieve these ends. First, the
patient’s ventilator rate is increased to lower carbon
) in the blood stream and
decrease the volume of blood vessels in the
brain. This must be done carefully to avoid
restriction of blood flow. Intravenous solutions
of a drug called mannitol or highly concentrated
salt solutions are also used to reduce swelling.
As in the case of Ms. Giffords, the patient might
also be placed in a “medical coma”—deep general
anesthesia—for several days. While asleep,
brain requires less oxygen and nutrients, and
thus less vulnerable if blood flow is inadequate.
In dire situations of brain swelling, one or
halves of the skull can be temporarily
to allow the brain more room to swell.
about one week after injury,
on its own.
It’s worth noting that some glaring absences
occurred in the media reports about Giffords’
condition. It is what the doctors were not saying
that concerned those of us “in the know”. The
bullet reportedly struck Giffords in the left temple
and exited on the same side of her head, near
forehead. The good news here is that the bullet
did not cross through the center of the brain—
it done so, the injury would likely have been
the left temporal and frontal
of the brain not only control movement
the right side of the body,
but also, in most of
the ability to speak and understand speech.
of yet, the media has not fully disclosed the
gravity of Ms. Giffords’
Ms. Gifford was recently moved to a rehabilitation
reported she will receive
therapy from speech, occupational, and
therapists. Their goals will be to facilitate
the recovery of use of Giffords’
leg, as well as her ability to speak and understand
speech. Our thoughts are with her and
those injured or killed in the incident, as well as
with their families and loved ones.
by Thomas Chappell, MD
Excerpts from the Kathy Ireland Issue Feb/Mar 2011:
Kathy Ireland — Interview
Blind Fishing Boat — New Fishermen Take the Bait
Yahoo — Expanding the Digital Highway
Heart Transplant — An Uncommon Cardiac Connection
Sean Forbes —Not Hard To Hear
ABILITY Best Practices Award — Sprint
Gunshot Wounds — Bullet Points
Articles in the Kathy Ireland Issue; Humor — Love Hurts; Ashley’s Column — Back in the Saddle; Sean Forbes— Not Hard To Hear; Gunshot Wounds — Bullet Points; ABILITY Best Practices Award — Sprint; Blind Fishing Boat — New Fishermen Take the Bait; Yahoo — Expanding the Digital Highway; Rehabilitation — Hitting New Strides; Terri Cheney — A Plea for Innocence, growing up Bi-Polar; Kathy Ireland — A Model Businesswoman; Heart Transplant — An Uncommon Cardiac Connection; Leigh Brill — Excerpt From A Dog Named Slugger; ABILITY's Crossword Puzzle; Events and Conferences... subscribe