This is a case study of a casualty that I was involved with a number of years ago in Afghanistan. I feel it is worth sharing due to the fact that it was initially a bit of a perplexing case, however, applying common advanced life-support principles allowed us to identify the life-threatening injury and deal with it appropriately.

The backstory to the case is a bit of a mystery. The details of the gunfight in which the casualty sustained his wounds were never revealed to us, but the information we did receive was that he was brought to a remote U.S. base in Afghanistan after suffering multiple gunshot wounds to his legs. On first medical review, he was haemodynamically stable, and it was initially thought that his wounds were relatively minor through-and-through gunshots to the thighs.

While being medically reviewed at the remote base, the casualty began to show increasing signs of shock, prompting an aeromedical evacuation to the forward surgical team (FST) that I happened to be working with on that day. The medic at the remote base had inserted an intraosseous cannula into the casualty’s left tibia and infused one litre of saline before the AME arrived.

Intraosseous GSW casualty

(If anyone’s interested in a more detailed look at intraosseous devices, please see my previous blog post, “Drilling shins to save skins: Demystifying intraosseous cannulation.”)

The casualty received two units of O-type packed red cells in flight, and despite the fluids and blood, was deeply shocked on arrival at the FST. On first review, he appeared to have two separate through-and-through gunshot wounds to his left thigh, and what appeared to be an exit wound on his right lateral thigh. He had clearly been shot multiple times, but had no obvious wounds above his upper thigh. He didn’t have any signs of arterial bleeding from any of his wounds, and his pulse was present, but faint, in both of his feet, implying that his femoral arteries were intact.

Gunshot wound leg 3 Gunshot wound leg 2 Gunshot wound leg 1

It appeared on initial assessment that one of the bullets had passed through the casualty’s left leg first, and then through his right leg, to account for the apparent exit wound on his right lateral thigh. A closer examination of the casualty’s inner right thigh revealed no entrance wound to support this theory, leading us to explore the possibility that the right thigh wound was, in fact, an entrance wound and that the bullet was still within the casualty.