Lifesaving expertise
MHB students explore complexity of gunshot wounds
Christoph Buchholtz (35) and Dennis Lander (32), 5th-semester medical students at the MHB, published a highly interesting paper with the title “Schussverletzungen: Wundballistik und Verwundetenversorgung fallspezifisch erklärt“ in the journal “Rettungsdienst”. They address a topic of vital importance in prehospital emergency medicine, although of only marginal significance in Germany: gunshot wounds. In the interview below, the two prospective physicians explain their focus on this complex and sensitive subject and report findings from their studies.
What motivated you to choose bullet wounds as the topic of your article? Was it a specific event, or personal interest?
Christoph Buchholtz: Before I took up medical studies I was employed as an emergency paramedic by the Federal Armed Forces. In the context of a special training they offer to emergency responders I attended the Trauma Fellowship Program at the Chris Hani Baragwanath Hospital in Johannisburg. This international teaching hospital has an exceptionally high rate of bullet and knife wounds, and my experience there definitely left its mark on me. Gunshot wounds are comparatively rare in Germany, but nevertheless very challenging due to their complexity. Starting out at the MHB, I met Dennis, a former assistant in forensic medicine from Saarbrücken. Building on his experience in that field he worked on the theoretical aspects of kinematics in bullet wounds while I focused on the perspective of clinical and emergency treatment and wound ballistics. Our article is based on two exemplary cases – involving a handgun and a rifle respectively – and illustrates the respective injury patterns as well as the challenges for diagnostics and treatment.
How did you go about collecting information for your article?
Dennis Lander: The decision to specialize in forensic medicine after graduation has much to do with my interest in research activities. A publication in a journal is not only a good opportunity for in-depth studies but also a significant step in the direction of my intended future career. Knowhow won from practical experience is certainly not enough for a scientifically sound publication. Many details – specifically on weaponry, ammunition and ballistic energy – had to be thoroughly researched. I concentrated on forensic literature whereas Christoph primarily studied sources related to emergency medicine and wound ballistics. He had acquired fundamental expertise in emergency medicine during his employment with the armed forces, mainly during his time in Johannisburg with the Trauma Fellowship Program. This is where the photos and patient documents stem from which we used as case examples in the article.
Dennis Lander (left) and Christoph Buchholtz. Private photo
Can you briefly explain the principal differences between various types of guns and the resulting injury patterns?
Dennis Lander: There are two basic categories of shotguns: rifles and handguns. “Long” weapons such as rifles have longer barrels and stronger propellants and therefore a notably higher muzzle energy. Frequently this results in serious, large-scale injuries with deep tissue penetration and in many cases an exit wound. Handguns such as pistols and revolvers have less muzzle energy, so that the wounds they produce are mostly small in scale, and exit wounds are rare. The caliber plays an important role: large-caliber projectiles generally produce larger injuries with stronger tissue destruction. Small-caliber projectiles are less destructive but by no means harmless – they can be just as lethal, depending on angle of entry, bullet trajectory and wound ballistics. Another decisive factor is the type of projectile. Full metal jackets mostly penetrate the body and leave relatively smooth wound canals, whereas soft point bullets or expanding bullets are designed to expand on impact and produce larger diameter wounds. These projectiles depose their energy within the body and often remain there, so that exit wounds are less frequent. All these parameters mean that no bullet wound resembles another, and this is what makes their medical and forensic assessment highly complex and interesting.
Who is your article intended for?
Christoph Buchholtz: Our intention was to make the topic of wound ballistics – that is, the effect of projectiles on the human body – more understandable and of practical use primarily to paramedics and emergency staff in rescue crews, police forces or the military. The article also targets emergency physicians and medical students. Bullet wounds are an interdisciplinary topic: they combine physical fundamentals like kinematics and internal ballistics with medical aspects of prehospital treatment and clinical care. This is why the article touches on a variety of different disciplines – from physics and emergency medicine to forensic medicine. All of these aspects contribute to a better understanding of gunshot wounds and facilitate an appropriate response in emergency situations. Our intention was to set up this complex topic in a way that would make it easier to understand and manage for all disciplines involved.
Which are the primary points of initial treatment of a patient with gunshot injuries?
Christoph Buchholtz: First aid for gunshot wounds depends first of all on the situation or the environment, since self-protection is of utmost priority. Activities should be guided by the SICK scheme, which stands for Scene assessment and safety, Impression, Critical bleeding, and Kinematics. The first step is Scene assessment and safety; rescue staff need to identify potential dangers and, if necessary, withdraw or initiate a crash rescue. Assessment is followed by a first impression of potentially life-threatening injuries and vitally endangered persons. Critical bleeding will then have to be stopped, for example by means of a tourniquet. The last step is to assess the kinematics, a core topic of our article, i.e. the underlying injury mechanism. Here the focus is on the sequence of events, on the possible trajectory of the projectile and potential concomitant injuries such as organ, tissue or skeletal damage. It is moreover essential to identify the weapon and the caliber. Initial medical care of gunshot wounds follows the standardized “cABCDE scheme”, according to the principle of “treat first what kills first”.
Here is the link to the article.