Shot in The Dark

“There is a sniper out there,” the paramedics stated matter of factly as they wheeled our patient into the trauma bay. “This is Jose, he is 25 years old, he was walking to the store this evening when he heard a loud ‘pop’, and felt a sting on the left side of his neck. He is bleeding from a small puncture wound over the lateral portion of his neck, and there is noted swelling. He denies any airway compromise, his vital signs are stable, we have an IV established …we think he was struck by a pellet gun…this is the sniper’s 5th victim.” A pellet gun? Sniper? What is going on here? Apparently there is a vigilante perched in a window overlooking a busy San Francisco street corner. His targets? Drug dealers. He has taken matters into his own hands: shooting dubious drug dealers on the street corner in front of his apartment. He has shot 5 people so far, most have walked away-or walked to jail-with only welts, after the shooter alerted Police of their illegal business activities. The problem is, no one has any idea where he is, or when he will strike again. He remains elusive…investigators are waiting patiently for the next shooting. We have begun our own investigation in the Emergency Department: Jose’s healthy appearance and small wound may be concealing significant damage to large vessels in the neck.

Our first order of business is to ensure that Jose has no compromise of his airway. He had swelling over his neck, but he was able to speak clearly, and was breathing comfortably. We undressed him to locate any additional wounds-just the neck. We had no idea how close the shooter was to Jose: “I heard the shot come from above, a few seconds later I felt a sting,” Jose said. Below Jose’s left ear was a small puncture wound, no bigger than an eraser head, a small amount of blood oozed from the wound, surrounded by about 2 inches of swelling. “There is no way there is a pellet in there,” one of my colleagues stated…”most of these wounds are just tissue damage, you would be able to feel the pellet…look feel.” I felt the wound…he was right, no pellet. I just was not convinced. The investigation continues. Outside, “pop,” a sixth victim, a SFPD patrol car near the corner hears the shot, and notices a figure duck from a 3rd story window…

We need to find this pellet. Using my best sleuth hat, I set off to make certain that my colleague was right, or wrong, about that pellet. I had just the trick to find it.…like a detective searching for hidden clues, I turn to my most powerful instrument…behold, the mighty Ultrasound. Ultrasound, in its simplest terms is a device which emits sound waves, like sonar, into tissue. These waves are bounced back to the machine, and based on whether it is bone, blood, fat etc, an image is created. The machines are now smaller, more portable (about the size of a small brief case), more powerful, and are an essential piece of every Emergency Department physicians arsenal.

Just as a stethoscope gives us insight into the inner workings of the human body, the ultrasound machine is the “ultimate stethoscope for the 21st century, and has become our best investigative tool. We use it for every trauma victim in the Emergency Room, looking for any evidence of bleeding within the abdomen, collapsed lungs, or injury to solid organs. We use it to look for gallstones, for evidence of damage to the Aorta, and to evaluate pregnancies. We can look to see how well the heart is squeezing, or if it is surrounded by fluid. We have used it to diagnose pieces of glass and metal in the eye, to look for abscesses in the arm in order to drain them, and to find large blood vessels buried beneath the skin in order to start intra-venous fluids.

I place the ultrasound probe on Jose’s neck over the wound. I notice the tissue of the neck, and the great blood vessels pulsating beneath…no pellet. I think to myself, “he was shot from above…the pellet, if fired from a high powered gun would have traveled downward…and inch, an inch and a half?” I move the probe down….Eureka! Sitting less than 1 millimeter on top of Jose’s carotid artery is a bright shiny round pellet!

All trauma victims are “guilty until proven innocent of injuries.” Once again our ultrasound machine puts the questionable injury to the test. Jose had a Computed Tomography Angiography of his neck to ensure no damage to his Carotid artery. Luckily there was none. Unluckily for Jose, a father of 2, he just happened to be at the wrong place at the wrong time. He left the ER with a small souvenir of his visit with us. Meanwhile…the police knock on the third story window apartment door, a man answers, smoking a cigarette, in his boxer shorts….it is the “vigilante shooter.” He unexpectedly runs, and jumps out his third story window. Our next trauma victim is on his way.

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