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Recovery process from a gunshot to the hip
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silver_ryu wrote in little_details
Hi all. I need some help with a gun shot wound recovery process. I have a tentative time-line, but I would appreciate if someone who actually knows something of trauma injuries to confirm me it is plausible. This is the central point of my story, therefore I need to plan everything, time-wise, around it.

Summary
When: Present day.
Where: Las Vegas.
What: Is my time-line of a gunshot recovery plausible?
Previous research: Google, this comm, ScienceDirect



I got a 26-year-old male who gets shot on the upper hip (ilium bone, here you got an anatomy-correct image (read nsfw) of where). The bullet hit a metal plate first, so that took away some of the inertia, which is the reason the bone does not crack (might get hairline-fractured, but I don't require him to be too badly hurt.)

The character is male, 26, of Japanese origin. He is in good physical form due to regular exercise (gym addict), but is a heavy passive-smoker due to his job (he is a card dealer in a contemporary-day Las Vegas-like city casino).

Right now, my first tentative time-line goes like:

Shot to the hip
Shooting goes on for ~3 minutes before pressure is applied. Ambulance call
Ambulance coming: in ~4.5 min
EMT and Ambulance ride: ~7 minutes
Surgery: about an hour
Anesthesia → first wake-up: ~50 min
Anesthesia → actual consciousness: overnight (~8 hours)
Hospital discharge: after one week, needing wheelchair
Using wheelchair for 2 weeks after the shooting.
On painkillers for 3 weeks after the shooting
Using crutches for about 3 weeks more (5 after the shooting)
Full Recovery: 8 weeks after the shooting


I've put together the time-line using info from google (gunshot recovery time, gunshot to the hip, hip surgery and assorted related searches), and mostly used this bunch of documents. As mentioned, I just need to plan and set all the on-goings around the event, and this is the best I can do. So, is it reasonable, or am I yanking the laws of physics' chain?

Thank you~

ETA: So no, it does not work. Good to know when it's not too late yet xD Thanks, everyone!


And how does physical therapy fit into your timeline? I had very minor hand surgery and I have had 6 weeks of physical therapy to help restore full motion. My mother broke her hip and had PT for months. I'm sure that your character wouldn't be undergoing anything as intense, but a few weeks of lying around can do interesting things to the muscles and tendons. You might want to consider that in your timeline, 8 weeks for *full* recovery is mighty optimistic. You could be Pollyanna and decide all things go perfect and well, but... you may want to look at physical therapy as well.

The idea was to threw physical therapy on a daily basis from the point he's off the wheelchair (he is a very stubborn guy who will not enjoy the bed rest) till the end of the 8th week based on a figure I got from one of the articles that put an average recovery time of 86 days. But I will look into it and push it back if it sounds so unlikely. Thanks

Actually, with the diagram that you've referenced? If that's where the gunshot is and the only injur is to soft tissue and maybe a chip fracture to bone, here's where I'd have issue:
- there likely wouldn't be any surgery. Majority of the time we don't operate just to remove bullets - we usually do more harm then good. We usually leave bullets in place unless there's a good reason to go after them - and in that location, with no signs of intra-abdominal injury, there aren't.
- so there wouldn't be a prolonged hospital stay. Overnight, maybe, just to watch and make sure that signs of intraabdominal injury don't develop (abdominal pain, guarding, rebound tenderness) - and that's a real possibility with the anatomic location you've circled. But 8-12 hours of observation would be it.
- so the wheelchair/crutches/PT, etc. thing would be out of play.

He could potentially be back to his usual activites within a week or so.

Most of the things you read about 'gunshot to the hip' are almost certainly referencing the femoral neck, and that's a whole different animal from the iliac crest (which is roughly what you seem to be referencing with your diagram).

That's really interesting. I did find a webpage that had a bullet on that location, but technical terms lost me, I have to admit. I had read about the not-removing the bullet, but I understood that if the bone was nicked the bullet would be removed to prevent infection (though most of the articles were a bit old, so maybe policies have changed).

I would not want him to get hurt close to the femoral since that probably could just get him to bleed to death on the floor of the casino, but is there any likable complication that could have him under for about month or something? Because I need to make a little bit of a fuss since he is suing the casino for damages; the person whose bullet hits him is the security guard.

Thanks for your help ^^

Nah, if there's an actual fracture, then you might operated to clean out the fracture - but not necessarily to remove the bullet. You'd remove the bullet if it's sort of there in the vicinity and easy to grab, but otherwise, you'd leave it alone. Most of the time, the bullet itself is actually sterilized by the heat generated by being fired out of a gun. And femoral neck vs. femoral artery are again two ver different animals. The femoral neck is the bit of bone that connects the long bone going down your thigh to the 'ball' part of the ball and socket joint that comprises the hip (and the 'ball' part is the femoral head, the 'socket' part is the acetabulum). It's reasonably far lateral in the thigh. The femoral artery and vein, which are what might cause you to bleed out - those are way closer to the midline. You've got a pulse in your groin - that's the femoral artery, and the femoral vein sits just medial (toward the midline of the body) to that.

There are blood vessels in the vicinity of the femoral neck, but their main purpose is to carry blood to the femoral head - if they're 'nicked,' they won't make you bleed out. They'll bleed a bit, and then clot off, and then you may end up with the femoral head dying due to lack of blood flow (avascular necrosis).

So you'd leave the bullet even on a joint? okay, I'll take note of that.

Thank you so much for all your info (and the free anatomy lesson!). I'll give the whole scenario a thorough once over with all this new information. I think I was so worried about not giving him "super-fast healing" that I went overboard taking all the worst-case scenarios ^^ Thanks again~

You probably wouldn't leave a bullet in a joint - but what you're indicating on your diagram is nowhere even close to the actual hip joint.

No, up there is not a joint, it was a random thought. Since most of my "knowledge" about bullet wounds came originally from movies & crime shows and there they always want the bullet out for whatever analysis they want to do on it, I guess that shatters part of brain's preconceived ideas (yes, I know that you should not trust tv-shows, but in my pre-living-in-a-city-with-public-library-and-Internet times they were my main source of info XD).

Oh, the cops would almost always like the bullet retrieved - it's up to the surgeon to exercise his/her judgment in the matter and to do what's best for the patient, which is not always what's best for the police investigation.

So the surgeon could say no way in hell and that would be it? I mean, I guess the cops would make a scene and demand the bullet, but the surgeon's word prevails?

At least in the US, a surgeon can't be compelled to operate on a patient solely for the purposes of gathering evidence for the police - so, yes, the surgeon can tell the cops, 'Sorry, not doing it.'

I've honestly never seen a cop try to force the issue, though - I've had them remind us that if we're operating and happen to remove the bullet, there are things that need to be done to preserve the chain of custody, and there are things that should be done to avoid damaging evidence - like the fact that they really never, ever want the bullet put into a metal container - that movie-theater 'clink' of the bullet hitting a metal container can alter the shape of the bullet just enough to screw up ballistics.

But in over ten years? Not once has a cop tried to say, 'You must remove this bullet.'

Makes sense. Where I live the surgeon must do what the cop tells them, via Warrant, and yeah, they can and push the issue, that I know. It is rare, but can happen. My father was once forced to remove some pellets from a patient (hm... yes. My father is a surgeon. And he heavily frowns upon my writing, so I cannot cross-check stuff with him ^^;;; So here I am annoying you).

Most of the time, the bullet itself is actually sterilized by the heat generated by being fired out of a gun.

In the days of slow .50 caliber round shot the bullets (supposedly) tended to drag bacteria-laden clothing into the wound; I suspect that rifled bullets have made this phenomenon pretty rare (if it was ever that common to begin with) and GSW infections from the late 19th century onward tend to be from GI penetration or lack of sterile conditions for proper wound care.

Is it at all common to find additional foreign material (e.g. clothing fibers) when a bullet is surgically removed, and if this material were present, is it likely to generate serious infection?

I can't recall ever seeing obvious clothing fibers when I was operating on a gunshot victim - but then, I'm a general surgeon. If I'm operating for a gunshot wound, it's usually involving the belly and there's blood and intestinal contents everywhere that have to be washed out. If there were clothing fibers, they'd likely be washed out along with all the blood and stool. Intraabdominal infections after gunshot wounds are caused by intestinal flora (E. coli, B. fragilis, E. faecalis, etc), not skin flora (S. aureus, S. pyogenes, etc) - so clothing fibers causing infection is pretty much of a non-issue in the abdomen, anyway.

My vague memories of rotating on the ortho service as a resident include more senior residents being berated by one senior attending for using inappriopriate antibiotic coverage - for using coverage that was too broad spectrum. The ER textbooks say that when it's actually been looked at in a randomized, controlled fashion, the infection rates for gunshot wounds to a bone are no different whether it's a high speed or a low speed missile - so I suspect that 'low velocity bullets = more infection' is one of those things like 'patients with diverticulosis shouldn't eat nuts or seeds' that sounded like it made sense, but actually doesn't pan out when you do the research. The orthopedists operating for an open fracture caused by a gunshot to a bone or joint are usually picking antibiotics to cover soil flora - what they're most worried about is that when you hit the ground after the gunshot, Clostridia from the dirt on the ground might get into the wound. I don't remember anyone every picking out clothing fibers from a gunshot to a bone, either, but it's been a while.

Which is a long way of saying no, it's not at all common, and no, it wouldn't be my biggest worry, infection wise.

This is a really fascinating response, thank you.

I suppose the answer then is that *if* bullets draw foreign material into the wound, that material still doesn't represent enough bacterial load to warrant removal. Which of course wouldn't stop the average 19th century physician from trying.

What they're meaning by a broken hip vs. what your mother had are likely two very different things - when most orthopedists say that they're fixing someone's 'broken hip' they mean a femoral neck fracture. Completely different from what they're referencing with the anatomic diagram.

It's not a trauma injury, but I had surgery at my hip. A bit of bone material was removed to use it as an implant. On the very next day, I was supposed to get up from my bed and walk around a bit. I used two crutches and then one crutch for a few days, but a wheelchair never came into it.

I realise it's not the same, but somehow I just don't see why he would use a wheelchair in your scenario. Also, the time for using crutches and pain killers seems very long to me.

I would agree with the eight weeks until he's fully recovered, but that's mostly because I had to realise that the flesh wound healed much faster than the damage to the bone did.

Actually, from the diagram the OP posted, your surgery's very close to what the OP's character would go through.

surgicalsteel made that point too. Thank you for the first-hand info, it seems I have to re-plan the whole scenario (trying not to make him recover ultra-fast, it seems I went overboard on the other direction XD).