22 gunshot wounds and still alive

This morning at 3am they wheeled a guy in that had 22 gunshot wounds.  This guy puts 50 cent to shame.  When he came in, he was still able to tell me his name, but he really wasn't in the mood to tell me how it all happened.  All I knew was that he had lost about 2 liters of blood from his left chest and we had to move fast.  With that many gunshot wounds, it was tough to figure out the trajectory of all the bullets (which is important when you're planning an operation).  Luckily, we have a Lodox machine that can x-ray the entire body in about 13 seconds.  The Lodox was originally developed by South African diamond miners so that they could tell if any of the miners were stealing diamonds as they left the mines, but that's another story.

Here's a small piece of the Lodox:

After the Lodox, we still had a couple of mystery bullets.  There were 3 in the abdomen, and it looked like some had crossed the mediastinum (center of the chest) and diaphragm.  Any time you have bleeding in 2 body cavities, it can be BIG TROUBLE.  Opening the wrong body cavity first can be a fatal mistake.  We didn't have time to do a CT scan because he was too unstable.  He kept bleeding out of his chest and his oxygen saturation was falling.

We rushed him to the OR and opened the Left chest via an anterolateral thoracotomy.  Turns out it was the right move.  Two bullets had zinged through both lobes of his lungs, and he was pumping blood out of the holes.  One bullet was on it's way up to the neck and the other on it's way past the diaphragm and through the liver.  The bullet tracts in the lungs were too deep to staple off so we had to open up the tracts using a cool technique called a tractotomy.  You fire a stapler THROUGH the bullet hole and then deal with the leaks head on.  It worked like a charm.

Once we had the chest under control, we opened his abdomen and found a big gash in the liver, 14 holes in the small bowel, 2 at the terminal ileum and one in the pelvis right next to the rectum.  He had a  bullet lodged right next to his SMA (a very big and important artery for your intestines).  It was miraculous that no bullets hit any major vascular structures.  This guy must have taken some serious notes while watching the Matrix.

After anesthesia caught up and he stabilized, we had time to fix him properly.  We did 2 small bowel resections and an ileocecectomy (taking the terminal ileum and cecum), which took care of all the holes in the bowel.  We stopped the bleeding from the liver and we tied of his right Vas deferens that had been taken out by the pelvic bullet.  Don't worry, he still has an intact Vas on the left so he will be able to reproduce fine offspring one of these days.

The case took a little over 5 hours and we were able to close him up at the end.  It was amazing that he pulled through.  One bullet taking a 3 millimeter detour in the wrong direction would have been game over for this guy.  At the end of the case, he definitely looked worse for the wear, but he was still alive and in stable condition.  Once we stopped the bleeding in the chest, his hemodynamics improved like magic!  That's one of the things I love the most about trauma.  Healthy people in the wrong place at the wrong time.  You fix the holes in time, and they get better.  We left 2 chest tubes and 3 abdominal drains:

All in all, a pretty lucky dude.

...so am I.