Everybody who gets shot wants to know if you got the bullet out.
Well, let me back up. “Everybody” is probably too strong a word, because gunshot wounds come in many flavors and sometimes the bullets simply get themselves out.
There are graze wounds, for example, where the bullet barely brushes up against someone, and flesh wounds, which are increasingly common as the obesity epidemic makes folks more fleshy. Bullets aimed at the abdomen zip through bulging “love handles” instead and we find the spent missile in patients’ clothes as we undress them in the emergency room.
Often, though, people come to the ER with bullets still inside them, and if the bullet broke a bone or pierced the bowel or a blood vessel, the patient is admitted and goes straight to the operating room. They’re the ones that wake up asking if we got the bullet out.
Mostly the answer is no. We didn’t get the bullet out. And mostly I get the same response: raised eyebrows and disbelief. “Really?” folks want to know. “You didn’t get the bullet out? Why not?”
It turns out that removing bullets happens more in movies than in real life. Taking out bullets leads to bleeding and doesn’t fix what the bullet injured. Only in Westerns does the mythic bullet removal actually cure someone.
After real-life gunshots, I tell patients, we operate to stop internal bleeding, to set the bones in a broken leg or to stop injured intestines from leaking into the abdominal cavity. If we find the bullet as we do those things, we’re happy to pluck it out. Otherwise, though, it’s like looking for a needle in a haystack – we find ourselves probing deep into the liver or teasing apart strands of bruised muscle. Then suddenly we’re in a deep hole and we’ve stirred up bleeding that had stopped itself before we poked it like the proverbial skunk.
Still, people are skeptical, and who can blame them? Bullets aren’t supposed to be in us. People worry that they’ll ache in the winter or ding the metal detector at the airport. A bullet outside of us shows that we can triumph over adversity. It’s a talisman, physical evidence that healing has begun. A bullet inside reminds us of our vulnerability and leaves people feeling unwell, even if they really aren’t.
A couple of years ago I had a patient who was shot in the back. His colon, small intestine and bladder were all injured. We operated for a couple of hours in the middle of the night.
As we were washing him off at the end of the case, I felt a lump in his upper thigh, like a little pebble just beneath the skin. It was a bullet. Of course.
The patient was still asleep. I had a medical student who should have been asleep too, but instead he was on call, holding retractors and pushing the intestines around so that we surgeons could see as we cut and sewed.
“Here,” I said. I handed him the scalpel. “Take this bullet out.”
He swallowed, then gripped the knife and tentatively made a half-inch cut over the peanut-size lump. A drop of blood welled up and I wiped it away. The metal gleamed as the student pulled the bullet out of the wound, and it clanked as he dropped it into a sterile steel basin. Then the nurse called hospital police so they could come to the operating room and claim the evidence. We finished washing the patient off and took him to the recovery room.
The bullet removal was a tiny part of the patient’s operation, but it was my student’s first opportunity to use a scalpel on a fellow human. In the recovery room, we pulled our masks off. Underneath his mask, the student was beaming.
Later he wrote to me about how much it meant to him to take the bullet out. It was the first time, he said, that he really believed he’d become a doctor.
I remember that night, which was long and busy, because it contained all the elements of a life spent in surgery. There was drama, blood and guts, a big operation and the saving of life. All of that, of course, was exciting and satisfying. Still, the moments of human connection all centered around the smallest surgery, the least dramatic moment, which was the removal of the bullet by our student.
Finding the bullet was a gift for everyone involved. It enabled me to slow down, to spend a quiet moment being a generous and patient teacher. It gave my student an opportunity to feel the deep satisfaction of wielding a scalpel in a way that helped someone.
Finally, of course, it enabled us to say yes to the predictable bullet question and to launch the patient on recovery with a sense that his gunshot wound was really over and that truly the worst was behind him.