Shot in the Calf. Bummer.

A few years ago, I had a paramedic student riding with me when we ran a dude in the southeast corner of the city who was shot through and through his calf.  I knew it was through and through, because I could see through it (science!).  I bet it hurt, but it wasn’t bleeding especially badly and didn’t seem life threatening.  I lifted his shirt to check his chest and back, but found no other wounds.  We were pretty close to a lower-level trauma center (Level III or IV), but since I wasn’t worried about the patient’s condition, I felt confident they could handle things.  More immediately, I was confident that the paramedic student could handle this call – there was nothing to screw up.

As we were about to leave, the patient told my student that his testicles hurt more than his calf.  My unvoiced thought was that it's a pretty bad day when you get shot, but it's a worse day when you get shot and have nut pain.  The paramedic student, though, got the patient’s pants off and took a look at the area of complaint.  He found nothing out of the ordinary.  Since that student was conveniently nearby, I told him that he was going to have to more thoroughly examine the patient: “Cup and lift, Junior.”

The patient was shot in the taint.  (On a side note, I still don’t understand how a person gets shot in the perineum.  One would assume that it is a pretty rare location to suffer a gunshot wound.)

I looked up 'perineum' on Creative Commons for photos that I could share.  It was… a mistake.  Don't do it.  Instead of a perineum, here is a picture of a calf. (Photo by Galia^)

All I can say is that I was really glad I had a paramedic student that day.  If I am being completely honest, it would be an especially rare situation to find me cupping and lifting.  But finding that wound was a game changer in a clinical sense.  The Level IV trauma center was out – the patient had a torso GSW.  Level I trauma center it is.  A torso wound is the difference between a macro for pain control and two large bore blood pumps.  The patient acuity completely changed.

Secondary exams are important.  I can’t stress this enough.  I can’t describe how many times in my career this lesson has been brutally taught to me by the EMS Fairy when I was being lazy, nor can I describe how uncomfortable each lesson was as I relearned it.  As paramedics and EMTs, we only have two ways to get information: ask questions and touch/view things.   History and physical.  The newer you are, the more important a detailed, thorough secondary exam is – from head to toe and everywhere in between, in order, all at once – because you have less experience to tell you what is important.  Secondary exams are critical skills for every provider on most every call, however.

Focused exams should be pretty rare.  Even a “simple” focused exam usually involves several body systems.  For example, picture a healthy adolescent who has twisted her ankle, breaking it, and fell down.  Do you just look at the ankle, or do you check if she hurt other body parts in the fall, as well?  How about the same ankle situation in a nursing home patient?  You would do a more complete exam then, right?

Going back to the guy shot in the taint, the really weird part of the story is that he had a third bullet wound.  It was dead center in his right butt cheek.  Equidistant between crack and hip, centered between his waist and thigh.

Dead.  Center.  Damn.

That wound track did not communicate with the taint wound, so I still don’t understand how dude was shot in the perineum.  I never knew about the butt wound because I hadn’t specifically looked.  EMS Rule #2 (Look cool) was unmet on this call.  Not that finding the wound would have made much difference – torso shot is torso shot.  But I hate not finding all the holes…

Doing a half-assed (yeah, pun intended) secondary is half-assing half your potential information.  Don’t skimp.