Tuesday, March 3, 2009

Extracting the Bull*&*^* (Marin IJ)

Dr. Dustin Ballard: Even gunshot wounds go glam in TV, movies
Posted: 02/13/2009

Dr. Dustin Ballard
Several weeks ago, I joined legions of other fans in watching the season premier of ABC's "Lost." This hit series, about plane crash survivors stranded on a mysterious island, has become progressively fantastical with each passing episode. Once again, I was happily suspending disbelief as the "Lost" characters began to bounce haphazardly across a time-space continuum.

But while I find time travel to be a pleasant fictional diversion, I soon saw something that propelled me back to reality. One of my favorite "Lost" characters, John Locke, a survivalist with a messiah-complex, takes a rifle shot to the thigh. Moments later, out of the darkness appears Richard - Locke's ageless island guardian - to save the day. After informing Locke, "You are bleeding to death," and warning him, "This is going to hurt," Richard plunges a pair of forceps into the wound. With a simple turn and tug, he extracts the bullet from Locke's thigh. The next time we see Locke, he is emerging from the jungle with a slight limp, having just single-handedly disabled three hostiles.

This is fun television, but I must take issue with the medical care depicted. I know some of you are thinking "Who cares, it's just a silly TV show," or, "I see this sort of thing in movies all the time," and of course you are right. But keep in mind, even a fantasy like "Lost" (which receives about 10 million to 15 million viewers a week) can shape the viewing public's perception of what constitutes effective medicine. And,
with that concern in mind, let me extract the bull--- from how Hollywood often portrays the treatment of gunshot wounds.

First, bullet extraction is nowhere near as simple as shown on TV. If a bullet does not pass directly through human tissue (exiting out the other side) it is either because the bullet hit the body at extremely low velocity or because it hit something (such as bone) on its way through and was shunted in a different direction. If the bullet has lodged in an extremely superficial location (as in if it's practically sticking out of the skin), it can usually be easily removed, but any meatier location makes extraction exceedingly difficult - and messy.

During my emergency medicine training, a supervising physician and I attempted to remove a bullet from a man's shoulder so that we could hand it over to the police as evidence. On X-ray, the bullet appeared to be just below the skin, but dissecting down to and removing it from the man's shoulder took well over an hour and caused him substantial discomfort.

Another, historically significant example, involves President Garfield who, in 1881, was shot in the back by a disgruntled office-seeker. For the next 80 days, Garfield suffered through doctors' attempts to discern the .44 bullet's resting place. Numerous physicians probed the wound (without using sterile technique) and Alexander Graham Bell even tried to locate the bullet using his new invention, the metal detector. To no avail, the presidential bullet was not found, and Garfield's bungled medical care turned a 3-inch wound into a 20-inch tunnel, massively infected and oozing pus. Who knows - if those doctors had left the wound alone, Garfield may have lived, and avoided the unfortunate distinction of the President with the second shortest tenure in office.

And this brings me to my second point; in most situations, removing bullets does more harm than good. "Removing a bullet embedded in tissue can be a very unsatisfying, bloody experience," says Joseph Galante, assistant professor and trauma surgeon at UC Davis Medical Center. The process, he says Galante "cutting out a lot of healthy tissue, usually muscle" and carries with it "a high risk of infection."

Of course, living with a retained bullet isn't always advisable. There are rare cases of bullets lodged near major veins that loosen and migrate to the heart and several reports of retained bullets degrading (over a very long time) and causing lead poisoning. A bullet trapped in a joint can be extremely painful and I personally wouldn't want a metallic fragment floating around in my bladder and worrying that it might try to sneak out in a very painful manner. But, in the vast majority of cases, bullets cause their damage during their initial passage through the body and not by how they rest afterwards.

For example, a patient with a gunshot wound to the belly requires surgery - not because the bullet needs to be removed (although it usually is), but because it probably caused blood vessel and/or bowel injuries during its travels. Bullets embedded in arms, legs, muscles and superficial tissues, however, rarely need to be extracted. In a study of 28,150 patients with noncritical gunshot wounds (those not penetrating the head, neck, chest or belly) evaluated at a Los Angeles Trauma Center between 1977 and 1991, 60 percent were successfully treated without hospitalization, with a very low (less than 2 percent) complication rate. Of these, 39 percent had bullet parts seen on X-ray; and these were removed less than 1 percent of the time. The majority of these gunshot wounds were successfully treated by observing the famous surgical dictum: "treat the wound, not the weapon."

Thus, in the case of John Locke's gunshot wound, the appropriate treatment should have been to control the bleeding with direct pressure at the site of the wound (and not with the silly tourniquet Locke tries to fashion) and to let the sleeping bullet lie. (Avid "Lost" fans will recognize that it didn't really matter how Locke's wound was treated, because the island has magical healing properties that would have saved him regardless.)

So, is it too much to ask Hollywood to stop propagating the myth of the magical bullet extraction? Or, for that matter, the practice of sucking the venom out of snakebites? Relocating dislocated shoulders by slamming them against walls? Rendering someone instantly and lastingly unconscious with a simple blow to the head? The alternative depictions might not be quite so glamorous, but they would be real, and that would make them refreshingly original.

Dr. Dustin W. Ballard is an emergency physician at Kaiser Permanente San Rafael and the author of "The Bullet's Yaw: Reflections on Violence, Healing and an Unforgettable Stranger." His Medically Clear column appears every other Monday.