Feature Article, September 2002

Warning!!!

This article is not for the faint-of-heart as it is very graphic!

If you are the least bit uneasy seeing blood, bodies, or internal body parts do not read this article.  (see full warning)


This month's feature article comes from Brandon Bertolli, who is researching gunshot wounds in South Africa.  Most of this research will be conducted in the adult trauma unit of the Johannesburg Hospital, Johannesburg, South Africa.  This is Mr. Bertolli's third submission and I would like to thank him for taking the time to submit these interesting case studies to firearmID.com!

Adult Trauma Unit-Case Studies
Johannesburg, South Africa                    

The following gunshot cases were encountered by Brandon Bertolli at the Johannesburg Hospital Trauma unit in 2002.

Case 1

A 14 month old baby sustained a gunshot wound to the right shoulder and head. A single bullet perforated the shoulder and went on to penetrate the head. The baby was transferred from a small clinic to the Johannesburg Hospital. The circumstances of the shooting were unknown as no parent accompanied the baby. The baby was intubated.

Three wounds were evident: two on the shoulder and one in the right occipital area of the head. The trajectory of the bullet, based on review of the wounds and the radiological evidence, is only valid if the baby's neck was flexed at the time of the shooting. The position of the wounds can be seen in this photograph taken after the shoulder wounds were dressed and the head wound was sutured.

baby shoulder

Please note that it is not standard procedure to suture a bullet wound at our hospital (they are usually dressed like the shoulder wounds), but in this case the wound was bleeding excessively and had to be sutured. The shoulder X-ray proved that there was no fracture and the skin breaches were marked with paperclips as usual.

x-ray shoulder

The baby then went for immediate CT scan of the brain.

baby CT 1

The CT findings were: sub-arachnoid hemorrhage, brain contusion, pneumocephalus (abnormal pocket of air in the brain signaling a breach of the skull vault, seen on slice B) and a fracture of the occipital bone on the right, bordering on the base of the skull (seen on slice A). The bullet track was probably alongside the inner table of the skull, starting from the right occipital area, leading all the way up to its final resting position at the skull vertex (slice C). The radiological appearance of the bullet is consistent with that of a full metal jacket bullet. Unfortunately the bleeding and damage to the brain caused raised intracranial pressure and the baby "coned." Coning is when the pressure inside the skull due to hematoma or other abnormal collection pressing on the brain, becomes so great that the patient's brain is forced inferiorly so that the brain stem is trapped in the foramen magnum. The brain stem is vital for controlling all the impulses to vital organs such as the heart and lungs. If the stem sustains sufficient damage, these impulses are disrupted and the patient dies. Evidence of raised intracranial pressure can be seen on slice D where the ventricles are compressed on the right. This baby died within 24 hours of being shot.

 

Case 2

We were all shocked by the arrival of another baby with a gunshot wound to the head, just four days after the arrival of the case above. This infant was 20 months old and was being held in his mother's arms at the time he was shot. It is unclear whether the mother was the target or the infant was the target, because the mother sustained a minor shoulder wound from a second bullet. She was very vague about the circumstances of the shooting. Even by South African standards, it is a very grim situation if you have to deal with two pediatric gunshot heads within 4 days of each other.

This baby arrived at the hospital with his mother and was intubated. There was a wound on the left vertex area of the head, but no exit. Brain matter was seen to ooze from the wound.

There was a struggle to maintain the infant's vital signs and a CT scan of the brain was performed. Findings: raised intracranial pressure, bullet crossed the midline and was lodged in the right temporal lobe behind the right orbital wall. Bullet fragments were shed along the bullet track.


The entrance puncture of the skull can be seen in slice A, with fragment deposition in slice B and the parent fragment rest site in the right temporal lobe, bordering on the right orbit in slice C. There is evidence of intracranial hemorrhage and raised intracranial pressure on slice D. There is also a bullet fragment evident on slice D.  Unfortunately this infant also died within 24 hours.

Case 3

A middle-aged man was hijacked and sustained multiple gunshot wounds to the abdomen after being pulled out of his vehicle. He was brought to hospital by helicopter, had a single X-ray in the resuscitation bay and was rushed to theatre for a laparotomy. There were multiple perforating wounds and one penetrating wound with an expanded intact hollow point bullet lodged in the abdomen. The characteristic shape of the expanded hollow point bullet can be seen on X-ray. Note that there is another metallic artifact in the area: an ECG electrode.

The laparotomy findings were: extensively damaged inferior vena cava, holes in the stomach, spleen, small and large bowel and a massive cavitating hole in the liver which almost cut the liver in half. The liver had stellate tears in it from the cavitating rupturing effect of the projectile injury. The I.V.C was so badly damaged that a shunt had to be put in to return the venous blood from the liver directly to the right atrium of the heart. To this end, a thoracotomy was performed.

The surgeons battled for two hours to try to save the man, and despite employing high tech cell-saving machinery and having a spare anesthetist to handle fluids and pressures, the damage was too great and the patient did not survive. He had sustained too many injuries at the same time, each one bleeding profusely. The hollow point was retrieved and the surgeon took care not to handle the bullet with any metal instrument so as not to add tool marks to the surface. It could be any one of a number of widely available hollow points such as the Winchester JHP. Only detailed analysis will reveal the type of ammunition and the weapon used to fire it. Preliminary analysis indicates that the bullet is of the 9mm Parabellum variety. Handgun projectiles can cause cavitating injuries of inelastic organs such as the spleen, kidneys and liver.

It is obvious from the stipple on the patient's right flank that he was shot at close range. There were multiple breaches on the left flank and on the back.

The incidence of non-accidental gunshot wounds in Johannesburg has risen sharply since 1994. The average gunshot victim attendance at the Johannesburg Hospital was 150 per month in 1999. It has now risen to 160 per month (as of statistics available for 2001.)


If anyone has any questions about X-Rays, you can contact me at bbertolli@yahoo.com. 

All images seen on this page are copyright 2002 Brandon Bertolli.  All rights reserved.


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