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Be ready for gunshot wounds in your ED
ED nurses 'play a pivotal role' in outcome
Five or six gunshot wounds in one night. "Drive-bys" in which a person's body is dumped by the ED entrance. These are not unusual occurrences for ED nurses at Grady Memorial Hospital in Atlanta, as the only Level 1 Trauma Center in the area, says Julie McInnis, RN, BSN, ED nurse.
"We admitted 3,500 traumas last year, and 22% of those were gunshot wounds," she reports. "We are used to seeing a lot of gang violence and drug crime shootings."
In a single month, ED nurses at George Washington University Hospital in Washington, DC, participated in two successful trauma codes requiring open-chest resuscitation, reports Regina J. Hymer, RN, BSN, director of emergency services. "Both patients left the ED with a sustaining blood pressure and were delivered to the operating room safely," she says.
Even if your ED hasn't seen a gunshot wound in 10 years, you have to be prepared for triage and treatment of this injury, says Sydney Vail, MD, director of trauma at Carilion Roanoke (VA) Memorial Hospital. "For a guy with chest pain, you move at a certain pace. For a code, you move at a faster pace, and when it comes to penetrating wounds, you go at the fastest pace possible. If it's life-threatening, things can change in front of your eyes very quickly,"
To improve care of gunshot wounds, here are key areas to consider:
• Get information from emergency medical services (EMS).
"We look really hard at what EMS tells us the vital signs are, and we set up our trauma bays accordingly," says McInnis. "If nurses can get a heads-up on what type of patient they are getting, they can get ready for the type of injuries that person might have and think about what to look for when the patient hits the doors of their ED."
Always ask where and when the patient was shot, she says. If the patient was shot 24 hours ago and their vital signs are fine, different interventions are needed than if a patient was shot five minutes ago and already is losing their blood pressure, says McInnis. "If a patient is doing badly before they even get to the hospital, they don't even stop in our trauma bay," she says. "They go straight to the OR."
• Preserve evidence.
When you cut off a patient's clothing, handle it as minimally as possible, and never cut through bullet holes, says Vail. "Collect it all and bag it and tag it appropriately, or the chain of evidence is broken," he says.
If you happen to find what caused the injury, such as a bullet or casing, become the "guardian" of that item, advises Vail. "Typically, physicians will step on those things and contaminate the evidence, so I really encourage nurses to be the champion of that," he says.
• Stick to the facts when documenting.
Don't specify whether a wound is entrance or exit even if you feel sure, says Vail. "You are not a forensic pathologist. It is simply a wound," he says. During one court case, Vail was asked by defense attorneys where he got his certification in forensic pathology to decide where the bullet entered. "I really got hammered," he says. "Don't get involved in that — simply document "wound on the front side" or "wound on the back side."
You may assume that the larger wound is the exit wound, but this is not always true, says Hymer. "The patient's positioning and other factors may account for a larger entrance wound," she says.
• Stay one step ahead of the team.
At Carilion Roanoke, the gunshot wound is marked with a paper clip and X-ray taken to delineate the bullet's trajectory, says Vail. Before the X-ray comes back, staff members are asked to make an educated guess of "Where is the bullet?" based on the history and physical examination, he says.
"The nurses can figure it out before my residents some of the time, or the doctors are so engrossed in the acute resuscitation, the nurse picks up the phone to the OR and says: "GSW to the chest, and they'll likely be in the abdomen also,'" says Vail.
Likewise, a chest entry tray can be pulled off the shelf so it's ready to open, and nurses can reposition the retractor if it was put back backward by the person who cleaned it, says Vail. "ED nurses should be very familiar with the tools we use, because they end up playing OR nurse," he says.
• Do a thorough assessment.
Always examine the patient's entire body, says McInnis. "Even though the patient may think they were only shot in the arm, we look everywhere to make sure there isn't something we are missing," she says.
A patient once walked into Carilion's ED telling the triage nurse his arm hurt but refused to give more specifics. "If she had done a neurovascular check she would have found no pulse, because the guy had been shot in the arm," says Vail, who had to reconstruct the patient's artery when the gunshot wound was discovered. The patient had some nerve damage but could use his hand, he says.
"Never assume a patient doesn't have a worse injury than they are advertising," says Vail. "That could be a gunshot wound or crush victim who now has no pulse, and the guy's going to lose his arm because he sits in the waiting room for six hours."
For more information about treatment of gunshot wounds in the ED, contact: