Wound trauma -a surgeon’s perspective

[Mosin77]

Pure anecdote of course, but… chatting with a new acquaintance this evening, we were talking about carry/keeping a gun. He’s a trauma surgeon. He confessed to us that he’s stitched up so many gunshot victims, at the present time he’s not comfortable carrying, would rather de-escalate, etc. (I think he will come around on this one honestly. He spoke like he was trying to convince himself and asked to go to the range with me.)

So I asked for his perspective on caliber and stopping power. He said “I like the idea of carrying a 9mm because most of the time the wounds are easy to stitch up, there’s not a lot of tissue damage, the bullets usually stay in the body…” “I see more gunshot victims with 9mm than anything else and they usually survive.” In other words, as someone not quite comfortable with armed self defense, he likes the idea that 9mm probably won’t hurt the bad guy too much.

My friend interjected “what about hollowpoints?” and pulled out his spare magazine to demonstrate. “Hollowpoints don’t make much of a difference, it’s still not a lot of tearing and easy to stitch up usually.”

“Now those .22 cal bullets from an AR15? Those are nasty. 9 times out of 10 there’s nothing I can do to help them. There’s so much destroyed tissue, the wound channel is massive and repairing it usually isn’t possible.”

Of course, before we entertain temptations to dump the 9 in favor of the .45 or .40 for an extra edge, it’s worth considering that he only sees the ones who weren’t hit in terribly vital places and were alive to make it into the ER. Still an interesting take and worth a bit more than you paid for it though.

 

[earlthegoat2]

There is an old piece of Internet gun forum history out there somewhere that was written supposedly by an ER doctor or a coroner in a bigger city that apparently had a bit of violent crime. It was likely from the 2000s because I remember folks a few years ago dismissing it a bit because we have “modern bullets” now.

So the jist of it is this guy, because of what he had seen in his occupation, insisted in carrying a 40 or 45 because 9mm, for whatever reason, didn’t cause enough damage.

Maybe someone can come up with a link. I know it was making the rounds at the Defensive Carry forum back in the day.

 

[Double Naught Spy]

There is an old piece of Internet gun forum history out there somewhere that was written supposedly by an ER doctor or a coroner in a bigger city that apparently had a bit of violent crime. It was likely from the 2000s because I remember folks a few years ago dismissing it a bit because we have “modern bullets” now.

Not this bit of history...?
https://www.thehighroad.org/index.php?threads/caliber-question-tales-from-the-morgue-part-1.367877/ (first post)

And was highly debated and debunked here (but don't click the link in the first post, it triggered my anti-virus protection)

Ex cop/currently works in morgue

Something for all you 9mm fans. So much for more capacity. This guy works in the morgue in Atlanta, and he says that bullets act much differently in the body as opposed to in gel. It's a long read, but worth it. The following post is from Curtis on concealed carry forum. Posted -...

www.thehighroad.org

 

[230RN]

Oh, every time this stuff comes up I end up posting the Coroner's remarks on the Jack Ruby - Lee Harvey Oswald shooting.
Ruby fatally wounded Oswald with a close range single shot to the abdomen from a .38-caliber Colt Cobra snubnosed revolver. This model had various chamberings but IIRC plus Ps had not come about at that time.

---------------
Coroner's report from Jack Ruby's .38 snubby into Lee Harvey Oswald:

QUOTE
"There was a gunshot wound entrance over the left lower lateral (lower left rids) chest wall and the bullet could be felt in the subcutaneous tissue (beneath the skin) on the opposite side of the body, over the right lower lateral chest cage.

"It was probable, from his condition, that the bullet had injured the major blood vessels, aorta (main artery from the heart) and vena cava below the diaphragm. Consequently, he was taken immediately to the operating room and through a mid-line abdominal incision, the abdomen was exposed.

"Several liters (a liter is 1.057 quarts) of blood were immediately encountered. Exploration revealed that the bullet had gone from the left to right, injuring the spleen, pancreas, aorta, vena cava, right kidney and right lobe of the liver. The bullet then came to rest in the right chest wall.
CLOSE QUOTE

https://www.upi.com/Archives/1963/1...lly-injured-by-time-he-arrived/8181204553842/

I was amazed when I read about all that damage. Close range, but hey, you're only talking, what, 800-900 f/s? Hey, that's Official Record, no "caressing" the truth.

FWIW,

Terry, 230RN
-------------------------------
Sooner or later, the law output rate will become greater than the Court input rate. Won't we be in a pretty pickle when the lawmakers discover they can pass any law they want to without danger of any Constitutional review?

 

[earlthegoat2]

This model had various chamberings but IIRC plus Ps had not come about at that time.

Some would argue that standard 38 special ammo from back then was in fact loaded up to and exceeding modern day +P. I don’t think what pressure the ammo was loaded to is significant however as the end result would likely have been the same regardless.

Not this bit of history...?

That was likely the one.

 

[Mike J]

There is an old piece of Internet gun forum history out there somewhere that was written supposedly by an ER doctor or a coroner in a bigger city that apparently had a bit of violent crime. It was likely from the 2000s because I remember folks a few years ago dismissing it a bit because we have “modern bullets” now.

So the jist of it is this guy, because of what he had seen in his occupation, insisted in carrying a 40 or 45 because 9mm, for whatever reason, didn’t cause enough damage.

Maybe someone can come up with a link. I know it was making the rounds at the Defensive Carry forum back in the day.

I remember that thread. For whatever it is worth, while I wouldn't disparage .40 or .45 I believe just about anything can work. Some rounds will penetrate deeper & expand more than others but shot placement is critical.

 

[entropy]

Pure anecdote of course, but… chatting with a new acquaintance this evening, we were talking about carry/keeping a gun. He’s a trauma surgeon. He confessed to us that he’s stitched up so many gunshot victims, at the present time he’s not comfortable carrying, would rather de-escalate, etc. (I think he will come around on this one honestly. He spoke like he was trying to convince himself and asked to go to the range with me.)

So I asked for his perspective on caliber and stopping power. He said “I like the idea of carrying a 9mm because most of the time the wounds are easy to stitch up, there’s not a lot of tissue damage, the bullets usually stay in the body…” “I see more gunshot victims with 9mm than anything else and they usually survive.” In other words, as someone not quite comfortable with armed self defense, he likes the idea that 9mm probably won’t hurt the bad guy too much.

My friend interjected “what about hollowpoints?” and pulled out his spare magazine to demonstrate. “Hollowpoints don’t make much of a difference, it’s still not a lot of tearing and easy to stitch up usually.”

“Now those .22 cal bullets from an AR15? Those are nasty. 9 times out of 10 there’s nothing I can do to help them. There’s so much destroyed tissue, the wound channel is massive and repairing it usually isn’t possible.”

Of course, before we entertain temptations to dump the 9 in favor of the .45 or .40 for an extra edge, it’s worth considering that he only sees the ones who weren’t hit in terribly vital places and were alive to make it into the ER. Still an interesting take and worth a bit more than you paid for it though.

I shoot Trap with a young lady who is an ME tech- the person who actually cuts open the dead body. Her takeaway in calibers is that any of them will kill if it gets to a place that will disrupt major bodily functions.
She really hates .380 ACP, says she has had to dig them out from behind bones nowhere near where they went in. So like M193 ball, I guess.
Ironically, she works for the county I work at a gun shop in. I carry a .380 at a minimum, sometimes a 9 as well. Hopefully we'll never have to compare notes.
Your ER doctor friend has some bias conditioning, he sees them come in alive, and almost all the time, out alive. I suspect luck and adrenaline (on the part of the patient) and poor aim and adrenaline (on the part of the shooter), have a lot to do with the outcomes he sees. My ME tech friend knows shot placement is critical, but also that it isn't a bad idea to have some oomph to the round.

 

[fxvr5]

Some would argue that standard 38 special ammo from back then was in fact loaded up to and exceeding modern day +P.

Evidence? There is misunderstanding about this topic, as with 357 ammo, about the old time ballistics. What most don't realize is that around 1976/1977 ammo makers changed the barrel length of the test guns. Before that time a lot of 38 ammo was shot from a 6" barrel. After that it was shot from a 4" vented barrel. (The 357 was shot from 8.38" barrels, then down to 4" barrels.) The ballistics changed because of the shorter barrel, but the ammo did not. Remington made this very clear in their 1976/1977 catalogs.

 

[fxvr5]

Oh, every time this stuff comes up I end up posting the Coroner's remarks on the Jack Ruby - Lee Harvey Oswald shooting.
Ruby fatally wounded Oswald with a close range single shot to the abdomen from a .38-caliber Colt Cobra snubnosed revolver. This model had various chamberings but IIRC plus Ps had not come about at that time.

There were some high speed loads around at that time. Remington lists in their 1963 catalog a high speed 110 load at 1320 fps from a 6" barrel, and a 158 grain load at 1090 fps from a 6" barrel. Some of these were intended for use only in the 38/44 type heavy duty 38 Special revolvers.

 

[bangswitch]

Pure anecdote of course, but… chatting with a new acquaintance this evening, we were talking about carry/keeping a gun. He’s a trauma surgeon. He confessed to us that he’s stitched up so many gunshot victims, at the present time he’s not comfortable carrying, would rather de-escalate, etc. (I think he will come around on this one honestly. He spoke like he was trying to convince himself and asked to go to the range with me.)

So I asked for his perspective on caliber and stopping power. He said “I like the idea of carrying a 9mm because most of the time the wounds are easy to stitch up, there’s not a lot of tissue damage, the bullets usually stay in the body…” “I see more gunshot victims with 9mm than anything else and they usually survive.” In other words, as someone not quite comfortable with armed self defense, he likes the idea that 9mm probably won’t hurt the bad guy too much.

My friend interjected “what about hollowpoints?” and pulled out his spare magazine to demonstrate. “Hollowpoints don’t make much of a difference, it’s still not a lot of tearing and easy to stitch up usually.”

“Now those .22 cal bullets from an AR15? Those are nasty. 9 times out of 10 there’s nothing I can do to help them. There’s so much destroyed tissue, the wound channel is massive and repairing it usually isn’t possible.”

Of course, before we entertain temptations to dump the 9 in favor of the .45 or .40 for an extra edge, it’s worth considering that he only sees the ones who weren’t hit in terribly vital places and were alive to make it into the ER. Still an interesting take and worth a bit more than you paid for it though.

He's talking about the differences in velocity between handgun rounds and rifle rounds. The shock effect from a rifle bullet at high velocity will make a larger wound channel than a low velocity handgun round pretty much regardless of the caliber. Then you factor in what type of bullet it is, FMJ or hollow point, etc.

He may be a surgeon but it doesn't make him an expert in ballistics. He assesses a wound and treats it accordingly, and what he's saying is basically a rifle does more damage than a handgun.

I'm not a surgeon, but was an O.R Nurse in a trauma center and saw plenty of GSW's that went far above just sewing up a hole.

 

[Dave DeLaurant]

Pure anecdote of course, but… chatting with a new acquaintance this evening, we were talking about carry/keeping a gun. He’s a trauma surgeon. He confessed to us that he’s stitched up so many gunshot victims, at the present time he’s not comfortable carrying, would rather de-escalate, etc. (I think he will come around on this one honestly. He spoke like he was trying to convince himself and asked to go to the range with me.)

I can certainly sympathize. Any sane person would prefer de-escalating a situation before matters come to blows, let along gunfire.

The thing is, there are unilateral situations that start and end with a weapon: robbery, rape, kidnap, homicidal mania, terrorism. The participants' (or more accurately, victims') comfort isn't a consideration.

I hope your new acquaintance never discovers this first-hand. America needs good surgeons!

 

[trackskippy]

I would say Oswald's autopsy shows that when important things are hit the desired result comes about more quickly.

The other thing that stands out here, to me anyway is, people seem to have it in their heads that all they have to do is "hit them somewhere" and the magic bullets they use, will make up for their shortcomings.

The moral of the story.... learn and understand human anatomy and regularly practice shooting quickly and repetitively, so you have a better chance at hitting those "important spots", and load them up when you do.

 

[rabid wombat]

He may be a surgeon but it doesn't make him an expert in ballistics. He assesses a wound and treats it accordingly, and what he's saying is basically a rifle does more damage than a handgun.

Read ML Fackler… he did a LOT around the understanding of wounds. An example: https://thinlineweapons.com/IWBA/2000-Vol4No3.pdf

 

[earlthegoat2]

Evidence?

Nope. Don’t have any. Just links to threads ad nauseum from Google searches.

Just some internet gun lore to go along with this stopping power thread which is itself more lore than fact so I don’t feel too bad about not providing any evidence or any other factual information pertaining to this thread since it is based on anecdote and A much debated topic that usually winds up with shot placement being the answer.

 

[kmw1954]

A little different perspective. I personally do not want to be shot by any caliber, at any time to any body part.

The human body is delicate and the human body is resistant. Have seen instances where a minor injury has caused death while at the same time where massive trauma has been survived with very little disability caused.

Next living between Chicago and Milwaukee I see the nightly news reports with the numbers of shooting and many times the woundings highly out number the deaths.

 

[230RN]

There were some high speed loads around at that time. Remington lists in their 1963 catalog a high speed 110 load at 1320 fps from a 6" barrel, and a 158 grain load at 1090 fps from a 6" barrel. Some of these were intended for use only in the 38/44 type heavy duty 38 Special revolvers.

Thanks for the additional insights. It's difficult to find true nitty-gritty details on the ammunition used. I assumed, properly, from the gun model, it was straightforward "stop at Walmart and get a box of thirty-eights" ammunition. It seems most contributors to the details are not gun folks, and a "thirty-eight" is a .38, and that's that. But regardless of the exact velocity and the exact bullet weight, style, and range, that's a heck of a lot of damage to Oswald's internals from this gun:

http://murderpedia.org/male.R/images/ruby_jack_leon/ruby_revolver.jpg

And I'm not saying that shot placement isn't critical, but according to the Oswald surgeon, this wasn't even a COM shot; "There was a gunshot wound entrance over the left lower lateral (lower left rids) chest wall." (Sic on the "rids." Typo was in my original source.)

And has been noted so often, the mere presence of a firearm, without a shot being fired, has prevented many crimes.

"Watch it! He's got a gun!"

"What brand and caliber?"

"Can't tell from here, but it looks like it goes bang!"

Jeeze. <rolleyes>

Terry, 230RN

 

[CDW4ME]

But, but but, this chart shows 32 acp has better incapacitation than 45 acp ... Sure it does.

And "modern" 9mm HP is "just as good" as 45 acp. Sure it is.



ETA: In before anyone posted the nonsensical term "caliber war"

 

[General Geoff]

“Now those .22 cal bullets from an AR15? Those are nasty. 9 times out of 10 there’s nothing I can do to help them. There’s so much destroyed tissue, the wound channel is massive and repairing it usually isn’t possible.”

It cannot be overstated just how much more damaging and lethal intermediate and full power rifle rounds are, compared to typical pistol rounds.

I respect a trauma surgeon's perspective of wanting to carry a caliber that he has personally seen to have the least likelihood of actually killing the recipient. Would be interesting to see how that thought process plays over with a jury of his peers.

 

[fxvr5]

Nope. Don’t have any. Just links to threads ad nauseum from Google searches.

Just some internet gun lore to go along with this stopping power thread which is itself more lore than fact so I don’t feel too bad about not providing any evidence or any other factual information pertaining to this thread since it is based on anecdote and A much debated topic that usually winds up with shot placement being the answer.

Ah. So you don't have any qualms about spreading BS on the internet. That's all we need to know.

 

[Double Naught Spy]

Oh, every time this stuff comes up I end up posting the Coroner's remarks on the Jack Ruby - Lee Harvey Oswald shooting.
Ruby fatally wounded Oswald with a close range single shot to the abdomen from a .38-caliber Colt Cobra snubnosed revolver. This model had various chamberings but IIRC plus Ps had not come about at that time.

---------------
Coroner's report from Jack Ruby's .38 snubby into Lee Harvey Oswald:

QUOTE
"There was a gunshot wound entrance over the left lower lateral (lower left rids) chest wall and the bullet could be felt in the subcutaneous tissue (beneath the skin) on the opposite side of the body, over the right lower lateral chest cage.

"It was probable, from his condition, that the bullet had injured the major blood vessels, aorta (main artery from the heart) and vena cava below the diaphragm. Consequently, he was taken immediately to the operating room and through a mid-line abdominal incision, the abdomen was exposed.

"Several liters (a liter is 1.057 quarts) of blood were immediately encountered. Exploration revealed that the bullet had gone from the left to right, injuring the spleen, pancreas, aorta, vena cava, right kidney and right lobe of the liver. The bullet then came to rest in the right chest wall.
CLOSE QUOTE

https://www.upi.com/Archives/1963/1...lly-injured-by-time-he-arrived/8181204553842/

I was amazed when I read about all that damage. Close range, but hey, you're only talking, what, 800-900 f/s? Hey, that's Official Record, no "caressing" the truth.

FWIW,

Terry, 230RN
-------------------------------
Sooner or later, the law output rate will become greater than the Court input rate. Won't we be in a pretty pickle when the lawmakers discover they can pass any law they want to without danger of any Constitutional review?

But it really wasn't that impressive in terms of damage. On a guy as small as Oswald, that would probably be less than 10" of total travel. At the time of death, Oswald only weighed 135 lbs. The bullet probably only needed about 6-8" of penetration to do its job of hitting those structures. The blood loss isn't unusual for having hit the spleen and two major blood vessels damaged, both a vein and an artery, and these were peripheral or minor blood vessels either. People with a aortic tear (aneurysm) can present with similar amounts of blood in the abdomen when the tear is below the diaphragm. Even a small tear in the aorta is life threatening.

I would say Oswald's autopsy shows that when important things are hit the desired result comes about more quickly.

RIGHT! Miss the spleen, aorta, and vena cava and you got some liver and kidney damage, probably stomach and intestinal damage, but otherwise much more survivable with medical help.

Ruby got lucky. It wasn't like he was aiming for the lower aorta and nailed it. I doubt nightclub owner with just 1 year of high school education knew much about anatomy, LOL.

 

[CapnMac]

The ER docs are generally pretty consistent, anecdotally, the 5 out of 6 [handgun] GSW victims brought in survive.

Some significant portion of that is in how good modern medicine is, especially given the medical support available during transportation, and the reliability of transport in "the golden hour."
Some other portion of that is in the paucity of "good" (in context) shot placement. Which is going to be {better} seen in whether or not the GSW victim arrives alive to the ER.

We ought exclude rifle fire from all this as rifles are an entire order of magnitude more energy than handguns.
(Pointless "caliber war" comparison: 45acp 900fsp MV 350fp ME vs "half the size" 223 rem 2500fps MV 1550 fp ME)

Human tissue is incredibly elastic, this is particularly handy if one is putting sutures into it, and this extends right down to the vascular level where anastamosis is more about can you see to get the needle in to make the connection. So, the difference between a millimeter or two in diameter of an injury (insult is the term-of-art the medicos use) is often of no consequence, not nearly so much as the "where" the insult is.

We, in the "gun community" see our firearms in engineering terms, this is only natural. The engineering details are measured in engineering values, millimeters and grams. A 100 grams is 3.5 ounces, about a fifth of a pound--that matters for something we cant to carry around every day. Where that's important to "us" ought to be in whether your group size is an inch or half inch smaller, your shot placement as equally precise.

A 9mm bullet you can reliably deliver into a 30-40 mm circle is far better than a 10mm into a 50 or 60mm one. How much of the talk about the 9x17 round in the first couple of posts is down to being able to not flinch when firing those 380s?

All this wants a grain of salt.

 

[trackskippy]

But it really wasn't that impressive in terms of damage. On a guy as small as Oswald, that would probably be less than 10" of total travel. At the time of death, Oswald only weighed 135 lbs. The bullet probably only needed about 6-8" of penetration to do its job of hitting those structures. The blood loss isn't unusual for having hit the spleen and two major blood vessels damaged, both a vein and an artery, and these were peripheral or minor blood vessels either. People with a aortic tear (aneurysm) can present with similar amounts of blood in the abdomen when the tear is below the diaphragm. Even a small tear in the aorta is life threatening.



RIGHT! Miss the spleen, aorta, and vena cava and you got some liver and kidney damage, probably stomach and intestinal damage, but otherwise much more survivable with medical help.

Ruby got lucky. It wasn't like he was aiming for the lower aorta and nailed it. I doubt nightclub owner with just 1 year of high school education knew much about anatomy, LOL.

It doesn't take much damage if you hit the right things. In fact, some things are literally a shutdown switch, if youre lucky enough to hit them. Knowing what youre trying to hit and why makes that a lot easier, and allows you to try and direct your rounds into that general vicinity too.

And I know hitting specific things in the middle of a gun fight isn't anywhere as simple as it sounds, and that working on doing that in regular practice, that is as realistic as possible, and why shooting quickly, repetitively, and as accurately as possible, increases your chances of making things work considerably. But of course, that will take some work from you to be able to shoot like that, without having to think about shooting like that.

Regardless of caliber, handgun rounds suck as man-stoppers. The only way to increase your odds of making "any" of them work, is to understand that you have to shoot them where they need to be shot, as best you can, and keep doing so until they no longer have to be.

Of course, there's always hope, faith, and luck, and that seems to be the most popular and easiest way to go.

Aint the marketing behind just having a gun, loaded with "magical killer bullets" grand?

 

[benEzra]

“Now those .22 cal bullets from an AR15? Those are nasty. 9 times out of 10 there’s nothing I can do to help them. There’s so much destroyed tissue, the wound channel is massive and repairing it usually isn’t possible.”

I assume that because rifle wounds are rare (less than 4% of homicides involve any type of rifle), and .223 is by far the most common rifle caliber in the United States, the quoted surgeon friend has probably never seen wounds by fragile bullets fired from actual full-power rifle calibers.

He might be surprised to learn that .223 lies at the low end of the centerfire rifle power spectrum, and its velocity is respectable but not THAT high (just high compared to common pistol rounds), especially out of typical 16” barrels. I wouldn’t want to get shot with one, but .243 or .308 with varmint bullets would be worse.

243 Win 58 gr V-MAX® Superformance® - Hornady Manufacturing, Inc

...

www.hornady.com

308 Winchester 110gr FB Tipped Varmgeddon Ammunition

308 Winchester 110gr FB Tipped Varmgeddon Ammunition

www.nosler.com

 

[fastbolt]

... Your ER doctor friend has some bias conditioning, he sees them come in alive, and almost all the time, out alive. I suspect luck and adrenaline (on the part of the patient) and poor aim and adrenaline (on the part of the shooter), have a lot to do with the outcomes he sees. My ME tech friend knows shot placement is critical, but also that it isn't a bad idea to have some oomph to the round.

Pretty much.

Even when larger caliber (and expanded) JHP's are removed from survivors of shootings, the patients are alive not only because of advances in trauma treatment since the 70's, but also because of the bullets not hitting critical tissues, structures and organs.

It's not hard to hear how surgeons still estimate that between 70%-80% of persons suffering handgun GSW's - who aren't deceased at the scene - can survive. The question ER doctors and nurses aren't usually able to answer is whether the nature and extent of GSW's were able to stop someone's continuing volitional violent actions at the scene once they were shot.

The old saying is that 80% of people shot with handguns survive, but only 20% of people shot with rifles survive.

 

[rabid wombat]

Regardless of caliber, handgun rounds suck as man-stoppers.

This^

As many have said - it is about getting the bad guy to stop doing what caused you to shoot in the first place….