Case of the Week: Gunshot wound to the abdomen

A volunteer group has just arrived at the BMC to do hernia surgeries over the next week.  They were asking me about what cases I have been doing over the last year.  One question in particular was about penetrating trauma and I told them that I have been very lucky this year with not having much penetrating trauma.  In a low resource hospital a critical patient with a penetrating trauma can be very hard to manage. 

I told them about the tribal war earlier in the year when I had gotten 9 gunshot wounds (GSW)  in one night, but luckily 6 were extremity wounds, one was a GSW to the chest that only needed a chest tube, one was through and through the 1 cm of fat the patient had on his abdominal wall (a few millimeters the other way he would have been getting surgery), and the final one was a patient that was shot through the face, who I quickly stabilized and sent south to a larger teaching hospital.  Other than that one night the only other penetrating trauma I had seen was bull horns to the abdomen and in those patients although I did surgery to make sure everything was fine, I never found an injury.

About two hours after that conversation, I received a phone call from the physician on call that a young girl had shot herself in the abdomen by accident.  I rushed to the hospital to find Abena in the males ward because when they brought her the nurses had mistaken her for a boy.  She was alert and talking and when I peeked under the large bandage on her abdomen to see the wound my heart sank because the entrance wound was in her upper abdomen right under where her breast bone ends.  Many important  structures live right below that area and I was just praying we would be able to do something to help this little girl. 

Abena on post-operative day six . . . It drives me nuts because
Ghanaians will not smile for a camera and she has a
great smile.  Just before this picture she was smiling and laughing
with me and then I went to snap the photo and she got all serious,
which makes it look like she is sad and not well.

Everything at the BMC seemed to work perfectly that afternoon.  I ran to the lab were they happened to already have a unit of blood in the blood bank that matched Abena.  The anesthesiologist arrived quickly and the staff readied the OR and Abena.  We were able to get started in the OR in less than thirty minutes, which is record time.  One of the visiting surgeons with the hernia team first assisted me in the OR, which in a traumatic case like this is so important to have a good skilled first assistant.

The bullet had passed through Abena’s abdominal wall and blew off a crescent shape wound on the edge of her left lobe of her liver.  It then traveled through and through her stomach leaving about 5 cm defects on each wall.  The bullet tickled the distal end of her pancreas before lodging itself into her spleen.  During surgery I did a quick splenectomy and packed her liver to control bleeding.  I then repaired the holes in her stomach and explored the rest of the abdomen for injuries.  After packing, her liver injury was not bleeding so I left it alone and placed a drain into her abdomen to watch for pancreatic enzymes leaking from her pancreatic injury or bile leaking from her liver.

Abena has done remarkable well and on post-operative day one she was sitting up begging me for food!  I held off feeding her for several days because of the extensive injury to her stomach and the small pancreatic injury.  Today on post-operative day six she is walking, eating, only taking Tylenol for pain, and most likely heading home tomorrow!  This was a great save and a great case to end my year in Ghana!