Rep. Steve Scalise (R-LA) is back in intensive care after progressing from last month's shooting on a baseball field. Why do traumas, like gunshot wounds, require such comprehensive interventions? And why do thery carry infection risks?
Rep. Steve Scalise (R-LA) is back in intensive care. He had been progressing after being shot last month by a lone gunman—having initially arrived at MedStar Washington Hospital Center in critical condition in shock and at “imminent risk of death.” The hospital released the following statement:
July 5, 2017, 10 p.m.
Congressman Steve Scalise has been readmitted to the Intensive Care Unit at MedStar Washington Hospital Center due to new concerns for infection. His condition is listed as serious. We will provide another update tomorrow, July 6.
During a press briefing held on June 16, 2017, the Director of Trauma Dr. Jack Sava revealed “Congressman Steve Scalise sustained a single wound from a rifle, entering in the area of his left hip. The bullet traveled straight across toward the other hip, in what we call a transpelvic gunshot wound. The round fragmented, and caused significant damage to bones, internal organs and blood vessels.”
The abdomen and pelvis are very highly vascularized regions with a lot of anatomical structures.
Dr. Sava went on to discuss the complexities of such traumas, the multiple stages of surgeries and procedures, the seriousness of these types of injuries and the common practice of not always removing fragments or bullets as risks can outweigh benefits. In this video, he describes the fractured pieces to be in the hundreds and the immediate concerns after penetrating traumas of bleeding and infection control. His full statement is here.
In addition, Dr. Sava names a number of staff members engaged in the highly coordinated, multidisciplinary team involved in Congressman Scalise’s care. Among them include nurses and doctors from intensive care to interventional radiology to anesthesia and orthopedic surgery.
Now, we will shift gears to address why traumas like gunshot wounds— in general— require such comprehensive interventions and carry infection risks.
What are the main concepts to understand with penetrating traumas?
Unlike a host of other conditions, penetrating traumas like gunshot wounds take on unique trajectories that are erratic, asymmetrical and variable in depth and extent. In the grand scheme, real estate matters most in terms of what high value locations were damaged by the primary insult as well as its reverberating effects.
Damage control tends to be the priority in staging of surgeries to stop massive hemorrhaging and its deleterious, destabilizing impact. All is not necessarily repaired at once depending on the scope of injury and status of the patient, so multiple surgeries and procedures can take place with repair well-choreographed after life-saving interventions.
Why are infections common?
Infections are not uncommon and an emphasis on prevention is standard from the start, but not always achievable despite the most pristine surgery, treatments and hospital course. The bullet itself captures and carries debris it acquires throughout its high velocity journey as it is also a foreign body that is not sterile. Tetanus prevention is important. Due to the chaotic nature of response in the field after a person has been shot and the environment itself, open wounds and transected blood vessels can pose many risks. These forms of traumatic injuries tend to be dirty and contaminated-- with issues compounded by exposed blood vessels, tissue and organ destruction along with many challenges for repair.
The protracted hospitalization of those suffering from such traumas includes placement of intravenous lines, drains, catheters and so forth which can add to the exposures along with risks for hospital-acquired infections. The injury itself if, for example, it involves significant fecal contamination from perforated bowel poses another source of infection. A compromised and bedridden patient can be prone to pneumonias. Wound infections and devitalized tissue can play a role.
To review basic concerns during any post-operative period trauma-related or otherwise, see Bill Paxton Dies of Surgical Complications.
The take home message…
Trauma teams appreciate all these and more possibilities of where this unpredictable road can lead. They are keenly aware from the outset which is why they closely monitor for the slightest changes and act aggressively to stave off worsening events. Penetrating traumas can create quite a windy path to recovery replete with alternating cycles of forward and backward momentum. But, modern medicine at a level 1 trauma center can provide the most optimal of chances for a good outcome along with preservation of personal and organ function-- given the wide array of well-trained staff, equipment and the ability to harness thorough teams.