IF SYMPTOMS PERSIST By DR. JOSE PUJALTE JR.

“You never know what’s hit you. A gunshot is the perfect way.”

— John F. Kennedy (1917-1963), US President “The Kennedys” Peter Collier & David Horowitz (1984)

Ch. 3 (responding to the question how he would choose to die)

  Dr. Jose Pujalte Jr. In the past three weeks, I’ve operated on three male patients who had one thing in common: they all shot themselves while cleaning their guns. The first one was the luckiest. He shot himself in the hand and while I had to scoop out the .22 caliber bullet, he only chipped the edge of a small bone. The second guy wasn’t so lucky. His .45 automatic was pointed straight at his thigh when it fired. His femur (thigh bone) was a jigsaw puzzle which my resident and I had to piece together in the operating room. Now the third patient didn’t exactly shoot himself. His 9mm Glock unloaded, and the bullet ricocheted from the floor then entered/exited his leg. His tibia (leg bone) shattered like windshield glass. Why they were cleaning loaded guns is another matter. I didn’t ask. It’s like asking a sideswiped pedestrian why he was crossing NLEX where cars can average 120 kph. Wound Ballistics. The FBI website article “Handgun Wounding Factors and Effectiveness,” explains quite plainly the mechanics of projectile wounding. Incapacitation by any handgun round is a result of the bullet’s ability to penetrate tissue, to create a permanent cavity (the bullet hole), to create a temporary cavity (the bullet’s passage) and fragmentation. The “crush mechanism” is the result of penetration and permanent cavity and it the “only handgun wounding mechanism which damages tissue.” Tell me about it.  Better yet, tell my patients about it because they’ll be feeling the damage in their bones for a long time. The Open Fracture. A Filipino-American orthopedic surgeon (and one of my blessed mentors) Dr. Ramon B. Gustilo, is credited with having classified the open fracture in the 1970s.  The open fracture is a true orthopedic emergency because not only is there a break in the bone, it is also exposed to the elements. The moment this happens, bone is contaminated. IF left untreated within eight hours, the fracture is considered infected. A gunshot to the extremity that strikes bone is an example of an open fracture.  Other open fractures result from vehicular crashes, falls, natural disasters, and occupational accidents. Diagnosis and Treatment. Obviously, if the bone is jutting out of the skin it’s a no-brainer. But an open fracture wound can be as little as a blood-tinged puncture. Remember that once bone is broken its sharp fracture ends can pierce through tissue. This is still an open fracture and can be treacherous if the penetrating germ is gas-forming (such as the organism in tetanus). The mainstays of treatment are still debridement (meticulous removal of necrotic or dead tissue), antibiotic coverage, delayed wound closure and internal fixation (the application of hardware such as nails, screws, plates and wires). Gun Safety. The US National Rifle Association (NRA) has three fundamental rules for safe gun handling. They are:

1. Always keep the gun pointed in a safe direction (not in the direction of your mother in law).
2. Always keep your finger off the trigger until ready to shoot.
3. (And for my patients) Always keep the gun unloaded until ready for use.

Also in bold letters, “before cleaning your gun, make absolutely sure it is unloaded.” Bullet wounds to other parts of the body will of course be lethal. Immediate incapacitation in a human target occurs from hits to the brain and the spinal cord, preferably in the region of the neck. Trauma surgeons have their hands full in the emergency and operating rooms when the bullets are in the chest or abdominal cavity. Bullet wounds to the extremities are easily more compatible with life, and later, an eagerness to memorize gun safety rules. E-mail: [email protected]