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Keep Your Head in the Fight

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From the archives: RECOIL Magazine Issue 14, September/October 2014
Illustration by Joe Oesterle


Writing about the newest guns and latest training is great, and we love reading about them. That’s a beautiful relationship, and most times our knowledge begins and ends with those topics. But for the thousands of people who serve in the military or law enforcement, work in armed protection, or simply choose to use firearms in their daily lives to protect person and property, the quest for knowledge should reach beyond gadgets and gear.

Unfortunately, sometimes we don’t know what we don’t know. Or worse, we think we know what we need to when we actually don’t. Movies, television, and video games have long been the primary source of our preconceived notions when it comes to gunshot wounds. Pop-culture portrayals of how human bodies react to bullets are widely varied — and rarely accurate. And of all the different types of shootings played out in Hollywood, none is more misconstrued than the headshot.

This is not a condemnation of action cinema. I love a little on-screen fun as much as the next guy, but for a lot of gun owners and armed professionals these are the only images they have to relate to. Those stereotypes, reinforced over hundreds of movies, TV episodes, and hours behind a game controller, create an expectation of what we’ll see if we encounter a headshot in the real world. Hopefully, this article will help dispel some of the commonly held misconceptions about gunshot wounds to the head and explain how treatment of these wounds has advanced in recent years — because the statistics are improving greatly.

It’s important to note that this article is not medical training, nor is it a discussion of tactics. Many places teach the head as a primary target for close-quarters engagements. I don’t take any issue with that philosophy. This article simply provides some accurate information about what happens if and when you press the trigger. Also, with all this talk about headshots, I swear to you I will only use the word zombie one time. And that was it.

The University of Arizona Medical Center recently concluded a five-year study on aggressive management of gunshot wounds to the brain. The study’s senior author, Dr. Peter Rhee, sat down with us to discuss some of the details. Dr. Rhee is currently Chief of Trauma, Critical Care, Burns and Emergency Surgery at the University of Arizona, where he’s also a professor. He retired from the U.S. Navy as a Captain with 24 years of service, including tours in Iraq and Afghanistan. He is also a founding member of the Tactical Combat Casualty Care Committee.

The historically accepted survival rate for gunshot wounds to the brain is about 10 percent. Furthermore, it has long been thought that any wound where a bullet crosses the mid-line of the brain is 100 percent fatal. These snapshots are important because they played a large part in deciding what efforts were made to treat the patient. In the past, if a patient were brought to the hospital with a bullet in the brain, they may have been deemed untreatable and simply allowed to expire.

Aggressive management techniques were reserved for patients who scored well on certain medical field assessments, like the Glasgow Coma Scale (GCS). In short, it’s a three-part check of basic eye, verbal, and motor skills. In recent years, however, it’s been found that “function checks” like the GCS are not accurate or reliable indicators of a headshot patient’s potential for recovery. We’ll come back to this in a minute.


So what actually happens when a bullet hits the skull? The one thing that Hollywood may have gotten right is that bullet strikes to the head produce a wide array of different outcomes. There is no “typical” wound pattern associated with headshots. Factors like trajectory, angle of impact, deflection caused by the skull, and bullet velocity all affect what the wound looks like once the bullet has come to rest or exited the skull. However, there are a couple things worth noting. One is that bullets don’t bounce. Over the years, we’ve probably all heard a lot of “gun store wisdom” or so-called anecdotal evidence about how small, light bullets will enter the body and just sort of rattle around, tearing up everything in their path. This is inaccurate. Bullets can deflect if they hit the inside of the skull after entry, but the idea of a bullet bouncing back and forth like a ping-pong ball is pure, unadulterated bullshit. It’s also possible for a bullet to strike the head, but miss the brain entirely. This is especially relevant in the context of a frontal shot to the face. The orbital bones of the eyes, nose, teeth, and jaw bone may deflect a bullet or even stop it completely from entering the brain.

If a bullet does actually penetrate the skull and enter the brain, what happens then? There are three primary mechanisms that can kill a person who has sustained a gunshot wound to the brain. The leading cause of death in these cases is blood loss. There are a number of large blood vessels located in the brain. The internal carotid artery provides blood to parts of the cerebrum, and the vertebrobasilar arteries supply part of the cerebrum, part of the cerebellum, and the brainstem. These two arteries are joined at the base of the brain, forming a large blood vessel known as the Circle of Willis. Then there are smaller, penetrating arteries deep inside the brain, known as lenticulostriate arteries. These are all thick, pumping vessels filled with oxygen-rich blood that the brain needs to function. Damage to any of these caused by the physical impact of a slug, or by cavitation, will cause rapid, severe hemorrhaging. Since you cannot employ a tourniquet, surgical intervention is the only way to treat this.

The second leading cause of death is physical destruction of the brain itself. Specifically, any type of damage to the brainstem is considered catastrophic. This is the part of your brain that controls basic life support functions like breathing, blood pressure, and heartbeat. Gunshot wounds that result in damage to the brainstem are effectively 100 percent fatal, with death often occurring at the scene. This is the closest thing to that “magic light switch” we see on the big screen.

The third major mortality factor in headshot patients is increased cranial pressure. This over-pressure may be caused by swelling of the brain itself or by the presence of a hematoma (blood clot) inside the skull. Though its effects are not immediate, increased pressure can lead to oxygen starvation, which will cause permanent brain damage. It can also cause brain herniation, where the brain actually squeezes out through openings in the skull. Part of the brain may swell out through an entry or exit wound, or through natural openings in the brain like the foramen magnum — the opening in the base of the skull where the spinal cord connects to the brain.


So what exactly does “aggressive management” mean and what specific treatments fall into this category? The use of neurosurgery to repair damaged blood vessels or drain a hematoma is one. Another is the use of hypertonic saline. This is a high-sodium IV fluid that draws water out of swollen brain tissue to relieve pressure. In other cases, parts of the skull may be removed to relieve pressure or manage a herniation. Giving a patient multiple blood transfusions to counteract rapid hemorrhaging has also been used to good effect.

What makes the Arizona study unique is that they used these techniques on every single patient in the study, regardless of how they scored on traditional assessments like the GCS. The results are impressive. That historical 10 percent survival rate increased for each year of the study, all the way up to 46 percent, with the blanket use of aggressive management techniques. Wounds where a bullet crossed the midline of the brain — previously deemed to be 100 percent fatal — showed a 10 percent survival rate. Perhaps as importantly, in cases where patients did not survive, the percentage of organs retrieved from donor bodies increased from 1.3 percent to 2.8 percent, giving life to several additional people.

What does all this mean for us? There are a couple of relevant takeaways. If you or your loved one/patrol partner/battle buddy ever suffers a gunshot wound to the brain, never give up the fight. The results of the Arizona study show great promise in the treatment of wounds that once meant being left for dead. These odds will only get better as medical technology and medical knowledge continue to advance.

If you are on the giving end, it’s critical to understand that, as in any defensive encounter, don’t assume that just because you hit what you’re aiming at, the fight is over. Headshots are survivable and, barring that golden BB to the brainstem, your adversary may still be capable of doing you harm. If you do incapacitate an adversary and subsequently render aid to them, this information applies equally in that situation.

Speaking of rendering aid, there are some things to remember if you encounter a headshot patient as a first responder, good Samaritan, or bystander. One of the most widely known medical maxims is to apply direct pressure to severe bleeding. However, in the case of a gunshot to the brain — where the integrity of the skull may be compromised — this can do more harm than good. You may wind up applying pressure to the brain itself, which can cause permanent damage or death. The two best things you can do for a headshot victim are to ensure breathing and move quickly. This latter point was best summed up by Dr. Rhee: “The most important fluid for a headshot patient is diesel.” Quick transport to the nearest Level 1 trauma facility is by far the best hope for survival, so know where yours is. Even if you happen to have a trauma surgeon on scene when the shooting occurs, without access to proper equipment and a surgical support environment, there’s very little they can do.

The prospect of total rehabilitation for those who do survive a gunshot to the brain is uncertain. There’s no definitive long-term data to date. The best odds at returning to normal will depend largely on the amount of money and resources available to each patient. For military members and LEOs, access to long-term treatment will likely come from your parent organization. For PMSCs, find a good DBA lawyer and keep them on speed dial. For private citizens, get in touch with your life and health insurance providers to review details about your coverage in the event of this type of injury. Consider it part of your exit strategy. Remember, don’t just plan on surviving, plan for it.

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