A significant obstacle facing us in our medical planning and preparation is the ongoing problem of erroneous knowledge when it comes to what we believe in terms of providing care in the Post-Apocalyptic World (PAW). We covered this briefly with the What You Think You Know article of a few weeks past.  This time we are going to delve deeper into select issues in order to discern some of the reasons behind them, why they are wrong, and the actual truth behind the errors.

The reason I term these ‘obstacles’ is because by accepting them as valid we shut ourselves off to the recognition that by erring in our thinking we also tend to err in our preps. If we don’t recognize a threat as such we do not prepare for it. Likewise if we act on misperceptions and erroneous information we can easily fail to properly prepare and find ourselves wanting when the time comes.

There is a concept in psychology termed ‘normalcy bias.’ In simple terms we tend to disregard anything that falls outside our normal comfortable thinking pattern. It is a form of habitual thinking. Said bias can be arrived at as a matter of practice, or it can be induced. Somewhere along the line we seem to have collectively picked up certain aspects of such thinking and made it part and parcel with our everyday routine.

Much the same sort of thinking surrounds PAW medicine. Myths about what is or not become rooted in the general wisdom and over time become widely accepted as fact. Hopefully we can dispel some of those myths and get you back on track to being better prepared.

We are going to tackle a series of myths in successive articles in this series and try to give them the serious attention they deserve. We’ll only address one or two myths per segment though. In that way each can be given the scrutiny it requires to hopefully lay it to rest. The intent is to increase the critical thinking of the followers of this series, leading to improved medical readiness levels.

Myth #1: Shoulder wounds aren’t serious.

This is one of the favorites in the fictional PAW as well as a staple with Hollywood. It isn’t realistic to believe our heroes will come through 47 gun battles and never suffer so much as a hole in their hat, so they usually end up shot in the shoulder at some point. And the non-dominant side to boot. It isn’t life-threatening (so the thinking seems to go), and isn’t likely to be permanently disabling (same thinking) and the wounded hero will only need a couple weeks rest with an arm sling before they recover (and so it goes). After all, it’s just a hole, right? They might even be able to use that arm later in the episode to finish the battle before they stand down. Or so Hollywood likes to think.

The reasoning behind this seems to be that the shoulder area does not contain any critical organs (true), that movement restriction of same due to the injury will not inhibit mobility (not universal but likely not), and it isn’t likely to be fatal (also true, the key word being “likely”). Barbara Scriptwriter and Bob Novelist are both under the impression that shoulder wounds are akin to so-called flesh wounds. If we have the bullet strike our hero there they’ll be fine and still be around for the next installment.

The Reality: They are more serious than you have been led to believe.

According to an article sourced from EB Medicine only 9% of cases out of all upper extremity wounds involve the shoulder itself. By contrast the forearms account for up to 20% of ALL gunshot wounds, not just those to the upper extremities. (1)

It is true that wounds to the shoulder are statistically not immediately or even quickly fatal. But it is also false to assume that situation is more or less universal. One study referenced for this article showed a mortality rate of 3.8% for shoulder-only firearms wounds. (1) Even in a world with a functioning modern medical care system that includes EMS, hospitals and specialty surgeons – never mind third generation antibiotics – people still die from shoulder wounds, usually due to exsanguination (bleeding out), though sepsis is also a distinct possibility. So, a roughly 4% mortality rate – you can live with those odds, right? Unfortunately that doesn’t mean that the other 96% of the time you are going to be fine.

What the article did not detail was the percentage of instances of orthopedic, nerve or significant vascular damage and the long-term effects of same.

More Than Just Muscle

The shoulder is not merely a mass of soft tissue through which various and sundry hostile projectiles may pass without injury aside from a small hole that will eventually fill itself in. We have in that relatively compact area bones, muscles, ligaments and tendons. And those are just the major structures. Add in veins, arteries and nerves. And there is more after that – enough to make this a 3-page article on the anatomy alone. For now let’s use the video found at this link as a quick review. It is only 1 minute 50 seconds in length.

As you can see there is little area for a projectile to pass through without striking something significant. If not bone then an artery. Or perhaps the connective tissues (tendons, ligaments). Let’s also not forget the major nerve pathways, and more. In other words we aren’t talking ‘just’ soft tissue in there.

A Hole Is Not Just a Hole

Let’s focus on the nerves in the arm for a moment point and look at some real world facts.  Injury to the nerves in the shoulder/arm region due to gunshot wounding is most often due to the concussive effects of a high velocity (approximately the 2,000 FPS range) projectile such as from a military or hunting rifle. Less frequently is such injury due to direct contact with a penetrating projectile. Low velocity projectiles (up to 1,200 FPS) such as from a .22 rifle round, or 9mm or .45 caliber, etc. handguns can also cause damage to the local nerve pathways, but the instances are statistically fewer and the damage usually less. Nevertheless the damage can be significant in terms of rates of occurrence, which can reach up to 50% of cases where an artery is also involved (directly or indirectly).  The good news is that for a contusion-type injury to the nerves, vs. actual direct impact of same, the overall recovery rate is around 70% with enough time, though complete recovery is often appreciably less than that.

Bearing this in mind you might be better understand that there are actually 3 separate injury zones from the passage of an errant missile. PAW fiction tends to focus only on the primary zone, the ‘permanent’ cavity caused by the passage of the projectile. Next we have the ‘contusion zone,’ the temporary cavity caused within the surrounding muscle tissue. Note that when we refer to a cavity – even temporary – everything in that region is briefly pushed aside before it snaps back to more of less its original form. In effect, you have a momentary ‘hole’ much larger than the projectile. Granted, it only lasts bare fractions of a second but it is there nevertheless.

Finally we have the ‘concussion zone” where we find secondary injury caused by the shockwave set up by a high-speed projectile passing through. The ‘wave’ extends beyond the temporary cavity. Think of it like a ripple passing through water. These same principles apply regardless of whether the subject is shot through the shoulder, the thigh, or even the abdomen.

More Than Just Nerves

Unfortunately involvement of the nerves also means that there is very likely involvement of the major veins and arteries, and that both vessels and nerves were affected by the concussive effects rather than the actual projectile or fragments thereof. Again referring to the same education lesson just referenced we see that statistically up to 15% of shoulder wounds have vascular (veins and arteries) damage associated with them, and that of those up to 25% involve injury to the subclavian and (or?) axillary arteries. (3) Remember what was said above about fatal wounds to the shoulder?

No Bones About It

Remember our little video up above, and the bones that make up the shoulder? They take up more space than you might think, and when they are hit by objects like bullets they tend to get really messed up. Think well beyond an arm sling. Think “I need to find a surgeon or Ralph here is going to finish his life with his arm hanging limply at his side for the rest of his life.”

Unfortunately when bones are shot they don’t just get holes poked in them. Depending on the velocity of the projectile they tend to either break into more than a couple of pieces, or even shatter. Either way there won’t be two bone ends to realign using muscle, sweat and a leather piece to bite on.

So, What Does It All Mean?

First, rifle or handgun – it’s going to leave a mark. And not just on the surface. Absent some serious physical therapy work there is more than an even chance that the injured party will always have some limitations to that joint by way of pain or decreased range of motion, assuming they suffered more than only a literal surface graze leaving a bar-fly impressing scar. How much will of course depend on what was damaged and the care provided afterwards. Not everyone is going to have the Matt Bracken’s Victor as part of their team. And even the good Doctor Victor would have been hard pressed to elicit a decent outcome from a 9mm through the ball joint, much less a rifle round.

The Take Away

Even a ‘mere’ deep graze through the fleshy outer aspect of the shoulder will require more than a couple of week’s rest with a sling. A through-and-through wound is not always desirable either. Exit wounds can be – but are not universally – appreciably larger than the entrance wound.

Plan on needing regular dressing changes, having suitable antibiotics on hand, and if bone is involved, starting them sooner rather than later, and rigging up some basic physical therapy devices involving pulleys and weights at a minimum.

And remember, neither Hollywood nor your favorite PAW writer should be considered as reliable sources of real-world information. Recognize the errors, adjust your thinking, and prepare accordingly.

About the Author

Reasonable Rascal has been plaguing the internet since 1997 and refuses to go away despite years of jeers. He began his medical career using all the skills the Boy Scouts could teach him and eventually found his way into a more formal career as a Paramedic and Registered Nurse. He is one of the authors of Survival and Austere Medicine, 3rd Edition.

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