GSW TO HEAD: To save or not to save

First let me explain why I even got this call. My lieutenant was having me meet him at our dispatch center, way out of our zone, so he could fix my key ring. Our narc keys are on a special ring which was damaged, and they have a special tool to fix it. So I was subject to calls out of our zone while on the way.

Medic 8 respond to possible suicide attempt.

Dispatch Notes
65 y/o male unconscious, breathing. GSW(gunshot wound) to the head.

We wait for the scene to be secured by law enforcement and head in. Of coarse the address we have is a little off, but we eventually locate the patient indicator lights (cop cars).

Scene Size Up
The patient is located supine, on the ground, just outside the driver-side door of his pickup truck. The police officer stated that he found a 0.22 caliber rifle about 5 feet away from the patient. The patient was found by a friend of his, and by our arrival the patient's adult son and daughter were both on scene. This road is on the patient's property.

Obvious hemorrhaging from the patient's head; unsure exactly where from. The patient was breathing about 8 to 10 times per minute with blood in his oropharynx. My first impression was to control the patient's airway. I have heard of the calls where the bullet misses the brain somehow. I do, however inspect for brain matter. The patient had an obvious skull fracture indicated by bilateral periorbital ecchymosis. The patient had a good radial pulse and HR of about 70. I called trauma alert.

Control the bleeding, get the patient packaged and into the ambulance. We needed room to work, and I didn't want to work this patient right in front of his family. As we are placing the patient on to a backboard I notice it, the wound was proximal to his frontal lobe, dead center of the forehead. We were assisting ventilations at the time via bag-valve mask. I noticed what appeared to be brain matter oozing from the wound. I had never seen brain matter before, and always thought it to be grey, but this was yellow. It was like slime, what else could it be?

At this point I had made the decision that this patient was obviously not going to make it. Our protocol states that if a patient has injuries incompatible with life, resuscitation is unnecessary. In addition, as we were rolling the stretcher towards our truck, the daughter stated that the patient has a DNR. I told her to get it, because we were going to need it.

This patient subsided rather quickly, leaving me with an uneasy feeling as I watched him die. I know the patient's outcome wasn't going to change. I took into consideration that the patient obviously didn't want to live, and this helped me cope with my decision.


By moving the patient to my ambulance, I successfully turned my rig into a crime scene. We had to await the medical examiner's arrival. Once there, he did in fact confirm the presence of brain matter.

Here's the unusual part. He identified the wound on the forehead as an entrance wound. I presumed that the blood in the mouth possibly indicated an entrance wound with the exit wound on the forehead. This meant possible homicide. Fortunately, with further examination, this was a confirmed suicide.

When the ME checked the patient's wallet, he identified the label "organ donor" on the patient's driver's license. This thought never entered my head. He was an old guy, and I didn't think anything would be viable. The ME explained how his kidneys and liver could have been used.

I will never forget this call. I think I did the right thing. I believe this is what the patient wanted, and I don't feel organ harvesting would have been appropriate. Guess that is a matter of opinion. What do you think?

*****Update May 4, 2009*****

A related study by American Surgery, Mar 2009
Gunshot wounds to the head are associated with poor outcome. We reviewed data to identify prognostic factors. We performed a retrospective study of all patients admitted to a Level 1 trauma center with isolated gunshot injury to the head during 6 1/2 years. Data collected included demographics, mechanism of injury, prehospital and resuscitation room data, and initial CT scan characteristics. The primary outcome measure was the Glasgow Outcome Scale. Seventy-two patients with isolated gunshot wounds to the head were admitted. Overall mortality was 58 per cent. The mortality for patients with an initial Glasgow Coma Scale score of < or =" 8"> 8 (P < or =" 0.0001)." p =" 0.06).">
*****End Update*****


NYCMedic said...

Totally agree w/you

Adam Thompson, EMT-P said...

Thanks NYCMedic, this call is one of those you never forget. Those judgement calls are some of the hardest things for us to deal with as medics.