Gunshot Wounds and You
April 26, 2014 at 3:01 pm #91493
Note: This is not Max’s response/content. Just a glitch from the transition to subscription.
Gunshot Wounds And You…
A mini-analysis about the rate of mortality from gunshot wounds:
Article author: Bill Prudden
A fellow shooter recently found an interesting article about the rate of survival from gunshot wounds, which she and I then followed up on by looking at some of the more interesting references. I have summarized the combined results below and pointed out their possible implications for our future training; they are quite interesting to say the least.
I spend a lot of time commenting on rates of mortality and how I, as a shooter, can increase them. A quick word about motives though, I am not in the “killing” business, but instead in the “stopping the attack” business. However, the data regarding “stopping” just doesn’t exist in any meaningful way, and so instead we are forced to use the next best thing – mortality. Further, the implications to us as possible gunshot wound victims are obvious. My hope is that this article will inspire some to look at the use of medical data to help our training methods evolve and increase our odds of survival when it counts the most.
Lethality of Firearm-Related Injuries in the United States Population Beaman, et al, Annals of Emergency Medicine 35:3 March 2000
This is a nation-wide analysis based on 132k individual patients with gunshot wounds (GSWs).
• Of those who died from their wounds, only 30% made it to the ER for treatment, the other 70% were not alive long enough to be transported.
• Of the total number of patients with GSWs who survived, 43% were treated in the ER and then released, 52% were treated and held at the hospital, and 6% were treated and transferred to an acute care facility.
• Of those shot in an assault, the overall mortality rate was 20%
• Of those shot in the head in an assault, the mortality rate was 40%.
• Of those shot anywhere other than the head in an assault, the mortality rate was 16%.
What these data points mean to me:
a. If you are shot you have an 80% chance to survive.
b. If you are going to die, you are probably going to die on-scene.
c. If you make it to the ER alive there is a good chance (43%) you’ll even sleep in your own bed that night.
d. Head shots appear to have more than twice the lethality of non-head shots.
Outcomes Related to the Number and Anatomic Placement of Gunshot Wounds Carr, et al, The Journal of Trauma 64:1 2008
This is an analysis of 111 patients treated at an ER in Philadelphia in 2004. There was a lot of interesting data, and I’ll comment as we work through it:
• The range of number of GSW’s per patient was from a single hit to a dozen, but the mean was 2.6 wounds and the median was 2.
• They broke the body into six anatomic sections – head & neck, upper torso, lower torso, butt & pelvis, proximal extremities, and distal extremities. The number of regions hit per victim was a mean of 1.6 and a median of 1.
So much for all of that crap in the ’80s about how Glock pistols and other high-capacity semi-autos were going to change the face of shooting… Median patient receives two hits to one region…
• Of those who arrived to the ER alive; 13% died while being treated in the ER, 27% were treated and went home (all survived long-term), and 60% were treated and held at the hospital.
• Of the 60% who were treated and held, 65% survived long-term and 35% died.
• Of that 35% who died, 100% did so within the first 24 hours.
These figures, combined with the data from the above study about those who die on-scene vs. make it to the ER, indicate to me that we, as potential GSW victims, need to focus on fighting through the wounds and the shock and the fear and LIVE long enough to make it to the hospital and then LIVE for the first 24 hours. If we can do that, we are in the clear.
• The regions most frequently hit were the proximal and distal extremities.
Just like our experiences with simunitions and other dynamic force on force training, in real life arms and hands and legs and feet get hit a lot. Training implications: We must know how to fight with only one hand, and from the ground, and we should practice our first aid procedures impaired as well.
• Mortality rates by region were 38.5% head and neck, 28.6% upper torso, 23.1% lower torso, and ZERO for butt and pelvis and the extremities!
Many of us were trained that pelvic shots, perhaps as an alternative to chest shots against someone wearing body armor, would likely result in femoral artery bleeders and bullets fragmenting off of the pelvic bone and creating carnage which would be incapacitating. Many of us, perhaps influenced by the death of one of the infamous Miami bank robbers from a brachial artery bleeder, have thought that certain types of hits to the arms could be lethal. The above data challenge both of those assumptions.
• Patients who were hit in two or more regions had their mortality rates go up anywhere from 8 – 20%, depending on the combination of regions.
This makes perfect sense but it is nice to have the data confirm some of our long-held beliefs!
• They also used length of stay in the hospital as a measure of the severity of wounds. Not a perfect method, of course, because people who had the most severe wounds (dead on scene) had zero days in the hospital, and lots of other factors would affect the length of stay of survivors, but the results were interesting none the less:
1. People with 1 – 4 hits averaged a length of stay of 3 days. Say that again: People shot four times who lived spent as much time in the hospital as people shot just once.
2. However, people hit in just one region averaged one day in the hospital, two regions yielded three days, and three regions meant a stay of eight days.
Does this mean that we need to train to slide our point of aim across the body as we fire a string into him while waiting for him to stop or drop? Does a “tight” string or series of rounds into the same area have much less effect than a well-distributed series? I’d love a study about just this point, because this directly impacts our training.
The Number of Gunshot Wounds Does Not Predict Injury Severity and Mortality Cripps, et al, The American Surgeon 75:1
This is an analysis of 531 patients treated at an Oakland, CA hospital from 2004 to 2006. As their title indicates, these guys appear to have supported their null hypothesis; imagine their horror!
• Of those who arrived to the ER alive, only 13.2% went on to die.
• Mortality rate from single head shots was 50%, multiple hits was 38%
• The rate for a single GSW anywhere but the head was only 9%, multiple hits was 8%.
• The mortality rate for a hit to the thoracoabdominal cavity was 13.6%, for multiples 12.9%.
• The mortality rate for a hit to an extremity only was 1.5%, multiples 0%.
• Their overall mortality rate for a single hit anywhere was 16%, for somebody hit more than once 11%.
In all cases, when there were multiple hits the mortality rate went down. What the hell does that indicate? If we had two communities of shooters, ones who took careful aim and delivered good head shots or solid cardio-pulmonary or CNS shots with a single hit, and then a second community of shooters who sprayed and prayed and got multiple hits but few “good” ones, then we could plausibly explain these results. But I strongly suspect there is, in fact, a single community of shooters on the streets of Oakland with shared levels of training and technique responsible for these 531 patients. What the hell indeed…
Factors Affecting Mortality and Morbidity in Patients with Abdominal Gunshot Wounds Adesanya, et al, Injury, International Journal for the Care of the Injured 31 2000
This study was conducted in a hospital in Lagos, Nigeria, and only considered 82 patients, all of whom were shot in the abdomen between 1992 and 1998. I include it in this discussion for one reason – the point their data make about “spreading the wealth”:
• Overall, their patients had an 18% mortality rate
• Patients with a single organ injured had a 4% mortality rate
• Patients with two injured organs died at a 19% rate
• Three organs injured jumped to 35% mortality
• Four organs injured meant 37% mortality
• And five organs injured resulted in 100% fatalities
For the record, these wounds were likely more powerful than what we will see on our streets: 38% were caused by a handgun, 33% by a shotgun, and 21% by a rifle, almost certainly a .30 caliber one.
So, what does all of this mean? My conclusions for training:
As a shooter:
1. If headshots are an option, take them. If we compare the highest head shot mortality rate versus the lowest non-head shot figures, it appears as though a single head shot can mean as high as 50% mortality, while even multiple non-head hits can result in only 8% mortality. Even if I admit that using the best-case data vs. the worst-case data from multiple studies is invalid and unfair, it is still very interesting…
2. Spread the wealth. Even if we take the head shot option off the table, hitting more regions and organs results in higher mortality, in most of the studies at least.
3. No longer train to go to the pelvis as an alternate point of aim vs. body armor or failure to stop. Go to the head exclusively.
4. To whatever extent possible, protect my head and also limit the number of regions in which I get shot (I know, easier said than done).
As a GSW victim:
1. Recognize that I am likely to survive.
2. Do everything in my power, from first aid to proper mindset to screaming the loudest when the ambulance arrives, to make sure I receive care and am alive when I reach the ER.
3. Spend all of my faith and reserve and courage to live through the first 24 hours.
April 26, 2014 at 3:59 pm #91494HiDesertRatParticipant
i worked in that Oakland hospital (Highland Hospital) in the operating room for 3 years as an anesthetist, so my priority was to
resuscitate the patient during surgery. i saw my share of folks expiring in front of me. of course, blood loss was usually the cause.
holes in vital organs too big, too numerous to fix in a short amount of time. it was where the holes were that mattered, and how many large vessels were destroyed beyond repair, ie shot placement. few years earlier worked in Martland Hospital in Newark, NJ in the ER. interestingly, i saw more deaths from knives than GSW, on the order of 2X. also what mattered was location of the injury. the knives were usually kitchen variety (think chefs’knife), most of the bullets i ever saw were pistol .32-.38-9mm. occasional .22 or .45. rarely rifle. my takeaway, like the real estate biz… location,location,location.
April 27, 2014 at 6:27 am #91495
I’m at a CRCD weekend but I saw this, skimmed it, and was moved to quickly comment:
Let’s make sure we assess the veracity and relevance of things that we post before we draw conclusions such as “Hips and heads don’t work.”
This study does not chime with TC3 teaching and studies in combat. Probably because it is based on hospital data from small caliber handgun wounding?
Take a TC3 class – maybe even mine? View the TC3 post I have up on the blog?
About 80% of combat wounds are not survivable. High velocity rifle wounds, blast, shrapnel, etc.
3 main PREVENTABLE causes of death: extremity bleeding (massive hemorrhage), tension pneumothorax (sucking chest wound), airway obstruction.
Check source and relevance before making conclusions!
April 27, 2014 at 3:17 pm #91496
Note: This is not Max’s response/content. Just a glitch from the transition to subscription.
Max, I did not write the article. The author was identified at the beginning.
Let me add some clarification. The authors conclusions are not my own. While I may not have worded my own conclusions exactly like that, or came to different conclusions myself – most passed the general common sense test.
With that said, I do not agree with #3 which states….” No longer train to go to the pelvis as an alternate point of aim vs. body armor or failure to stop. Go to the head exclusively”
It’s common sense to take the best available target, sometimes that is the pelvic region. Pelvic hits can be devastating, especially in multiples and if done with a rifle. Pistols probably don’t feel good either and may stop the fight long enough to allow you to pursue other options – even if they are statistically survivable for the victim.
As far as the relevance of the authors data. It is both absolutely relevant and statistically robust. He cites several studies of different sizes from different locations and sources. One was 132K patients – in research, quantity has a quality all of its own. Most of his data comes from CONUS. One set comes from Nigeria. In the CONUS data sets there is no specifics given as to weapons used. You are probably accurate that they were mostly smaller handgun calibers. However, there is no doubt they also included rife and shotgun to some degree. While it may have been a smaller % than pistol, even a small % of 132K can be a substantial sample. The Nigerian study does divide the types of small arms used into percentages.
The journals he derived the data from are all well respected and peer reviewed.
In regards to the TC3 data. I am familiar with its common conclusions and quoting’s. I cannot say I have ever been provided with much information in regards to sample size and other specific variables in the data – just the general catch phrases. Big Army data is simply data. It is usually well presented and robust. However, it is not an all encompassing and definitive final word on any topic -nor is it always above reproach. The “80% of combat wounds are not survivable” quote looks at combat wounds as a multiple source group as opposed to looking at small arms wounds alone. This will change the % survival rate seen in the data outcome. Additionally, I agree with you that the increase % of rifle gunshots compared to handgun will also change the survivability rate in the data outcome – a fact that has been borne out in other data.
So, in the end, it is simply an additional data source with which to increase one’s frame of reference for gunshot lethality considerations. Neither the author’s emergency room data or the TC3 data alone paint the picture with the degree of accuracy that they do when considered together. And together, they are still incomplete as other data sets that have been done or will be done in the future will continue to add value and increase frame of reference.
TC3 conclusions look at what MAY be the case in the CONUS – one day. It draws on conclusions from what IS the case in protracted wars of insurgents vs a technologically advanced multinational force overseas.
The multi-year emergency room data looks at what IS the case regarding gunshots in the CONUS – right now.
The data findings are not competing with each other.
The data that the author references does not act to delegitimize the TC3 data or techniques.
I think it would be smart to consider them both together.
I appreciate your concern for applicability of data and accuracy of conclusions. I agree that in this case, and in every case, we should be very careful to analyze any conclusion that we or others draw from the data.
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