Mirror Image
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Copyright 2015 Phil Wheeler
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0234 City Community Hospital ER
“OK, people, let's go!”
“Jennie, what do we have?” The question came from a slender woman with auburn hair and green eyes, and was directed at the nurse who had just spoken. The woman was dressed in blue scrubs and had a cloth cap, tied at the back, on her head. The cap was pink, with ribbons printed all around. She wore iridescent green running shoes, and her name was Doctor Alex Conner. She was nearing the end of a 12-hour shift, she was tired, and she wanted to go home. That wasn't going to happen anytime soon.
“Multiple gunshots to the heart. Looks like it was at pretty close range.”
Doctor Conner bent over the man lying on the operating table. “Three shots to the heart, 9 mm would be my guess. Looks like the gun was held directly to the body. Look at the soot and stippling at the sight, and you can see the outline of the muzzle; there is also laceration of the skin from effects of gases. How is this guy even still alive?”
Jennie, head Triage Nurse, couldn't answer that question. The victim, a John Doe, had been found in an alley, hands tied behind his back, barely alive. His Blood Pressure had been 60 over 43, and his pulse 31. He'd lost a lot of blood. “The paramedics did a hell of a job on this guy, they got him here alive.”
“Yeah”, said Conner, “But I don't see how we can do much for him. It's hard to believe that his heart is still capable of pumping. Still, we need to do something. Let's take a look.”
“Doctor!”
“Yes, Deanna, what is it?” Alex turned to her right to observe the X-ray technician walking towards her, an X-ray in hand.
“You really need to see this.” said Deanna.
Doctor Conner took the preferred X-ray, and held it up to the overhead light. A single “Damn!” escaped her lips. She walked over to wall of the ER, where she could use the light device to review the X-ray in a more clear manner, and held it up to the light. A single “Damn!” again escaped her lips.
One year later – The National Forensic Academy quarterly conference
“A gunshot to the body involves transfer of energy to that body. The amount of damage is directly proportional to the amount of energy exchanged between the bullet and what it strikes, as related to the bullet's mass and velocity. Other factors which influence damage are the density of tissue, and distance from the target. As the bullet strikes the body,” said the speaker, “the tissue is crushed. The forward motion of the bullet creates a temporary tunneling affect, which expands as it travels along; creating a cavitation wave – air bubbles created in the passing tissue. Since the shock waves formed by collapse of the voids are strong enough to cause significant damage to moving parts, cavitation is an undesirable phenomenon. Are there any more questions?”
“Yes, Doctor Conner, is the design of the bullet significant?” asked a member of the audience.
Doctor Alex Conner, forensic expert on gunshot wounds, contemplated the question before speaking. “That is a very good question. Yes, design varies, from hard, copper jacketed, which prevents deformation of the lead, to bullets that deform or fragment upon entry – these cause tremendous damage to tissue and organs.”
“Doctor Conner, I understand that you have collected quite a lot of Triage data as it pertains to gunshot wounds. Can you share some on your findings with us?”
Alex had been invited to speak at this conference as an expert on gunshot wounds, and as the head of the traumatic wounds center at City Community Hospital in Magnum City, there was no denying that she had seen more then her share. It had become her specialty, and almost an obsession. The fact that people would use a gun to bring harm to another was abhorrent to her, but the damage that was done by the projectile was fascinating.
“The difference in diameter, expansion, and penetration greatly effects the blood pressure of the victim, and the amount of shock that accompanies the wound. Systolic blood pressures were compared between penetrating large and small bullet groups and with perforating wounds. Response times and demographics were compared. Wounds caused by large bullet penetration resulted in lower initial systolic blood pressures than wounds caused by small bullet penetration, which, I think, is what you would expect. The age of the victim, transport time, and wound length were similar among the bullet groups. The most important factors in causing significant injury or death are their placement and projectile path; with the head and upper torso being the most vulnerable to damage. The extent of tissue and organ trauma will depend on terminal ballistics, which are influenced by the type of bullet, its velocity and mass as well as the physical characteristics of the penetrated tissue.”
“Doctor, please describe scene response” asked another voice in the crowd.
“Certainly, scene response is vital to the survival of the victim of a gunshot wound. The first personnel on the scene will need to start triage. This can be difficult even for veteran providers due to access and the availability of resources. Accuracy is vital. In the triage of gunshot wound victims, quick patient assessment to identify life-threatening injuries is essential. Some areas of importance are airway management, pleural decompression, pressure for external hemorrhage and avoiding on-scene delays before transport. The acronym ABCDE is very useful for rapid assessment. Please turn your attention to the screen behind me.”
A projection appeared behind her, showing the acronym ABCDE, and its explanation:
“Airway: If the patient's airway is unstable or at risk, intervention is critical.
Breathing: As the patient's airway is opened, evaluate breathing and respiratory effort simultaneously.
Circulation: Circulation should be quickly assessed; evaluate for presence, rate, regularity, strength and quality.
Disability: What is the level of consciousness?
Exposure: any clues to explain the patient’s condition? Signs of trauma, bleeding, skin reactions, needle marks, etc, must be observed. Body temperature can be estimated by feeling the skin or using a thermometer when available.
***
Alex was glad the conference was over for the night, she felt her work to be important, but was always hesitant to speak before a crowd, it always wore her out and took a few days to recover. She was looking forward to a quick meal, a hot shower, and a comfortable bed tonight. Tomorrow, she would be speaking again; this time about some of the more bizarre gunshot wounds she had seen over the years.
“Doctor Conner?”
The voice startled her and, as she turned towards it, she was startled again – this time, by the face attached to the voice.
“You - you're John Doe!”
The man smiled, “Is that what you called me?”
“Yes,” said Alex, “we didn't know your name – never did – and when you disappeared out of your hospital room we could never trace you. You survived!”
“You seem surprised, Doctor. You saved my life, and I want to thank you.”
The man turned to walk away. “No, wait!” cried Alex.
He stopped, turned back, and stood smiling at her.
“Please, your case was unique, I have never known anyone like you. Are – are you doing OK?”
“Yes, I am. You did a good job, doc.” With that, the man turned and walked into the night, and Alex was left standing, and wondering.
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***
He kept in the shadows, moving silently, slowly to the window. The light coming from inside revealed a man sitting at an ornate desk; he was seated in a high-backed, expensive-looking chair, facing away from the window; unaware of the man outside. The man in the shadows moved to a set of French doors and tested the doors handle, it was unlocked. He turned the handle, opened the door, and stepped into the room. The man at the desk looked up in surprise, then his face paled.
“You! It can't be, I shot you in the heart!”
“Your aim was off.”
“It's not possible, nobody could have survived that.”
The man walked over to a chair in front of the desk, and sat down. For a while, he just sat there, smiling, saying nothing. Finally, he spoke, “I survived. Answer me one question, why?”
The man at the desk looked scared. “I had to, you where getting too big and I was afraid for my life. What was to stop you from taking me out? It was self-defense.”
The man in the chair smiled grimly. “I loved you like a father, I would never had done that.”
“In this business,” replied the man behind the desk, “you can't trust anyone, you can't let them close. Eventually, you would have turned on me.”
“No!”
“Yes.”
“Well, I guess that's a reason. Now, it's time for you to die.” He pulled a gun out from under his jacket, and trained it at the man behind the desk.
“Please, first tell me one thing. How could you possibly have survived?”
“Sorry to disappoint you,” said the man with the gun, “but you will never know the answer to that question.”
An explosion rocked the room, the man behind the desk looked suddenly startled, and a tiny trickle of blood rolled down his nose to fall in a puddle on the desk.
***
The National Forensic Academy quarterly conference
“I have seen a lot of strange gunshot wounds. One gentleman, I will call him Mr. X, was attending his bachelor party when officers entered the club. In the confrontation that followed, five officers opened fire, killing one man and wounding Mr. X. I stabilized him with an air tube for his breathing, and began a head-to-toe inspection. I found that he had been shot 19 times; including several in his legs, his abdomen, at least one in his chest and one to his cheek bone, which was superficial. Miraculously, he survived.
The most incredible case, though, was a Joe Doe last year. He came in with three gunshots to the heart, or at least that was what we thought. My x-ray tech approached me with the mans x-ray, and I was so shocked at what I found that I was speechless. He had Situs inversus.”
“Doctor Conner,” asked a man in the front row, “I am not sure that I have ever heard that term. Can you please explain?”
“I am not surprised. It is a condition that occurs in only 1 out of 10,000 – only .01% of the population. It is is a congenital condition in which the major visceral organs are reversed or mirrored from their normal positions; the normal arrangement is known as situs solitus. The condition affects all major structures within the thorax and abdomen. Generally, the organs are simply transposed through the sagittal plane. The heart is located on the right side of the thorax, the stomach and spleen on the right side of the abdomen and the liver and gall bladder on the left side. The left lung is trilobed and the right lung bilobed, and blood vessels, nerves, lymphatics and the intestines are also transposed. ”
Murmurs of “amazing” could be heard throughout the auditorium.
“Yes, it truly is. In the absence of congenital heart defects, individuals with situs inversus are phenotypically normal, and can lead normal healthy lives, without any complications related to their medical condition. Many people with situs inversus totalis are unaware of their unusual anatomy until they seek medical attention for an unrelated condition.
Since the bullets penetrated the chest wall and damaged the lung, he was coughing up blood, very short of breath, and basically drowning in his own blood. But we have two lungs and the victim was able to breathe and speak.
Once he was found, the paramedics placed an endotracheal tube into his lungs to help with breathing, started an IV, and transported him to the hospital immediately. Once his condition was discovered, I treated the damaged lung, and he was stable.
After surgery, he was placed on a ventilator overnight. We always try to remove ET tubes as quickly as possible since there are many complications if they remain in place for several days. Most commonly – pneumonia.”
“Doctor, did he survive?” came another question.
“Not only did he survive,” answered Alex, “he left the hospital the next day. I came in to check on him, and he had disappeared – just walked out. I never saw him again – at least, not until last night. Strangest thing, after I spoke, I was stopped in the hall by him. I hadn't seen or heard from him in a year, and he suddenly appears. He said he was doing fine, and then he just walked away.”