Case of the Month
August 2007

34-year-old male – suicidal behavior

Dispatch
"Aid 31, stage for police – 34-year-old male, suicidal behavior”

En route your crew discusses the following considerations:  

• Scene safety and adequate staging distance
• Probability of weapons on the scene
• Medical reasons for depression/altered LOC

While en route the dispatcher alerts you that there have been shots fired and the call is being up graded to include an ALS unit and an engine company for manpower.

Further update from dispatch advises you that the scene is secure and there is a police officer down with gun shot wounds.

Scene Size-up
As you roll up to the scene you see several police cars in the area of the dispatch address. You see two officers leading a man in hand cuffs away from the house; at the same time you are urgently motioned into the front of the house. Inside the front door there is a police officer lying on the ground conscious and wincing with pain. There is a small amount of blood around his right upper leg. Two other officers are working to get his ballistics vest off while a third holds pressure on his leg. His weapon has already been secured by another officer at the scene. One of the officers states the patient was shot in the leg and in the chest by a 9mm handgun…he believes the officer’s armored vest stopped the round to the chest.

Initial Assessment
The officer appears to be in a great deal of pain. He is conscious and his skin is cool and clammy. As his vest and t-shirt come off you see a red bruise the size of a golf ball just below his left nipple. You can also see that he is having difficultly breathing. His pulse is weak and 132. A quick “blood pat down” finds no other obvious sources of blood other than his right upper leg.

Initial Treatment
Your partner immediately begins high flow oxygen with an oxygen mask while you expose the wounded leg. The entrance wound is small and is bleeding lightly; however, the surrounding tissue is very swollen. You update the incoming units and send your partner to get a backboard and straps so that you can package the patient for rapid transport. As you are waiting you obtain a palpated blood pressure of 92 and a respiratory rate of 36.

Vital Signs
Blood pressure                  92/palp
Heart rate                        132/min
Respirations                      36/min
Level of consciousness       Fully alert

Event and Recent History
The other officers tell you that the injured officer was talking to a suicidal, but calm individual who was holding a knife. The officer asked the individual to hand him the knife and the individual said ‘I’ll give you this instead” pulled out a 9mm hand gun and shot the officer twice. Two other officers immediately subdued the suspect. Another officer held pressure on the leg wound while the suspect was handcuffed and removed from the area.

Further Evaluation and Treatment
Your partner returns with the backboard as the engine company arrives at scene. The crew quickly moves the officer onto the backboard and moves him into the aid unit. You will rendezvous with the ALS unit.

During this rapid transport the patient is stripped and full physical exam is performed. You find no other trauma. The officer’s weapons are collected for accountability, including a .38 caliber back up gun and 9mm ammo clips. The ALS crew transfers the patient to their rig and continues the transport to the local trauma center. The officer’s condition remains stable, but not improved, for the transport.

At the hospital the officer is found to have two broken ribs where the vest was struck by the 9mm round with a corresponding pulmonary contusion, which was causing shortness of breath. The swelling around his leg wound led to compartment syndrome and the fascia of that area has to be surgically opened to accommodate the swelling.

Gun Shot Wounds: 
The damage from wounds inflicted from firearms varies greatly. It is most imperative to treat the signs and symptoms with which the patient presents, concentrating less on the caliber and distance of the weapon. Often the entry point you see is a small slit or hole with little blood loss and no exit wound; however, the internal damage can be significant.

Regardless of what you initially see, be sure to perform a complete examination including a full visualization of the body. A bullet that enters the shoulder or hip can be deflected by bone and spin through the torso. In fact many rounds are not designed to stay intact and pass through the target, but to wreak havoc by tumbling around inside the body.

The soft body armor that most police agencies use offer limited protection from penetrating gun shot wounds. Even when body armor stops a round, blunt force trauma can occur to the tissue underneath. Appreciate the significant mechanism of injury the patient has encountered and assess for both penetrating and blunt trauma.

View more information on ballistic vests
Wikipedia (external link)

View more information on body armor
How Stuff Works (external link)

View more information on compartment syndrome
Wikipedia (external link)