Diagnosis in the heat of battle
|Diagnosis in the heat of battle
By Dr. Marc Siegel
November 6, 2007
The premise: The unit's rangers are in Beirut. As they rescue a kidnapped
journalist from Hezbollah terrorists, ranger Charles Grey (Michael Irby) is
shot. The rescue chopper crashes. Team leader Jonas Blane (Dennis Haysbert)
and marksman-medic Hector Williams (Demore Barnes) are compelled to
commandeer a family's apartment and perform emergency surgery on Grey, who
is losing a lot of blood, coughing and having trouble breathing.
Although Williams doesn't have a stethoscope, he states that Grey has a
collapsed lung. He lays Grey on the family's dining room table and inserts
an intravenous line, placing the bag of solution under the man's head for
pressure. He makes an incision in Grey's chest without administering a
painkiller, widens it and inserts a chest tube. As Williams tells Grey to
breathe deeply, bloody fluid drains from his lung into the tube, down into a
jar of water. There is a slight hissing as the chest lung reinflates and
Grey breathes more easily.
But he is losing a lot of blood and his heart rate is increasing. Blane
thinks Grey is OK because his chest is not distended and there are no
discolorations, but Williams believes a second bullet must be responsible
for the continued bleeding. He turns Grey on his stomach and finds the
entrance wound. Fearing that the sharp bullet has severed an artery and
could do more damage, Williams reaches into the wound with his finger,
locates the bullet and pulls it out. He then clamps the artery with a
Medical questions: Can a medic diagnose that a wounded soldier has a
collapsed lung without benefit of a stethoscope? Do field kits not contain
painkillers, stethoscopes, sterile gloves, antiseptic or forceps? Shouldn't
the IV bag be hung from a lamp or door rather than put under the soldier's
head? Once a chest tube is inserted, is it possible to have the patient
breathe in order to reinflate the lung, with gravity causing bloody drainage
to siphon down into a pitcher of water?
Is Blane correct that the lack of chest distention or discoloration is a
good sign, or is Williams right that the rapid heart rate and apparent
continued blood loss is the sign of a second bullet? Would a field medic
reach into a wound to remove a bullet and then blindly clamp an artery?
The reality: The clinical diagnosis of a "dropped lung" can be made without
a stethoscope, by observing distended veins in the neck, difficulty
breathing and absence of the movement of breathing on one side of the chest,
says Cmdr. D. J. Green, an assistant professor of trauma surgery at Keck
School of Medicine of USC and Naval Trauma Training Center. The description
of the chest tube insertion and lung re-expansion are likewise accurate, he
"The patient breathes, the lung expands, the blood/air are expelled through
the tube as a one-way valve," Green says. But, he points out, field kits
routinely include the painkiller lidocaine, sterile gloves, the antiseptic
Betadine, forceps and stethoscopes. He says hanging the IV bag from 4 feet
above the patient would provide a much better infusion rate of fluid.
The continued rapid heart rate and probable associated blood loss wouldn't
necessarily imply a second gunshot wound, Green says, adding that Grey could
still be bleeding from the first wound. And Dr. H. Leon Pachter, chief of
surgery at New York University School of Medicine and former trauma chief at
Bellevue Hospital Center, adds that the lack of discoloration and chest
distention doesn't mean the first wound is doing well.
As for the handling of that second bullet, Pachter says: "Pulling out a
bullet or any penetrating object is counter to accepted trauma principles,
as the penetrating object may be tamponading [putting pressure on] the
injury. With its extraction, massive bleeding could ensue." In any case,
this bullet seems to be too superficial to be causing massive bleeding. The
finger method and blind clamp, according to Pachter are "right out of H.G.
Dr. Marc Siegel is an internist and an associate professor of medicine at
New York University's School of Medicine. He is also the author of "False
Alarm: The Truth About the Epidemic of Fear." In The Unreal World, he
explains the medical facts behind the media fiction. He can be reached at
Please consider a tax-deductible contribution to CMPI. Your support is appreciated.