The following case study is of an Afghan civilian woman who was medically evacuated to a Forward Surgical Team in regional Afghanistan having sustained a through-and-through gunshot wound to her right upper chest. The exact circumstance of the wounding was never made completely clear, but it was understood that the women was injured in crossfire during a firefight between two feuding Afghan tribes. The likely weapon that the bullet came from was an AK-47, and history from the woman suggested that the range she was shot from was likely between 300-400 metres, meaning that the bullet would have lost a significant amount of velocity before it struck her.
The casualty had been taken to a regional military base where her wounds were covered with occlusive dressings by the treating medic and an AME was organised to the FST that I was working at on the day. The following image shows the primary survey of the casualty in the resuscitation bay of the FST with myself assessing her wounds and one of the trauma surgeons listening to her chest to assess for breath sounds.

Gunshot wound chest initial resus

The images below are of the wounds being assessed once the occlusive dressings had been removed.

Gunshot wound chest entrance woundGunshot wound chest 4Gunshot wound chest exit wound

The bullet had entered the casualty’s chest cavity through her right shoulder region at the back, and exited through her right upper chest at the front. It can be seen that the exit wound is a little jagged, suggesting that the bullet had destabilized as it decelerated in the casualty’s chest tissues, causing it to yaw, or turn sideward at the time it exited. For a detailed explanation of how a bullet behaves once it enters human tissue please see my previous article “Why I’d rather be shot by an AK47 than an M4”.

Initial review of the casualty revealed her to have a stable blood pressure, suggesting that she hadn’t lost a critical amount of blood into her chest, with a slightly elevated pulse and breathing rate, and slightly reduced oxygen saturations. Supplemental oxygen was used accordingly.

On removal of the occlusive dressing covering the casualty’s wounds, the exit wound on the front of her chest was noted to be a “sucking chest wound”, or an open pneumothorax, which will be discussed in detail below. X-ray showed that her right lung was deflated, and there was a small amount of blood collected in the right side of her chest, which has the effect of clouding out the effected side of the chest cavity on X-ray seen below. This is commonly seen following penetrating wounds to the chest, and is referred to as a haemo-pneumothorax (a combination of blood and air in the chest cavity). The other feature on the X-ray of note is the gross distortion of the soft tissues surrounding her right chest wall. This is due to air leaking out of her damaged lung accumulating in the soft tissues of her chest wall and neck in a condition known as surgical emphysema. This is detectable clinically by pushing over the tissues of the chest and feeling a sensation like rice bubbles, or bubble wrap under the skin, and is an indicator that the casualty has a pneumothorax or other damage to their airway.

Gunshot wound chest X-ray