Check Up: Dealing with crueler bullets

As an orthopedic trauma surgeon at Temple University Hospital, Saqib Rehman sees gunshot injuries almost daily.

The problem is what he can't see. With the growing use of hollow-point bullets that expand inside the victim, entrance and exit wounds are no longer a reliable indicator of internal damage.

"It requires more careful evaluation of the wounds to make sure the patient doesn't require urgent surgery," Rehman said.

For the average person - perhaps even the average gun owner - the idea that handguns can cause dire wounds is about as surprising as a murder on Law & Order.

But in medicine, gun injuries were assumed to fall into two categories. High-powered guns, such as rifles and shotguns, cause "high energy" injuries that rip soft tissues and muscles as well as bones and organs that lie in the bullet's path. Emergency surgery is typically needed to remove dead, dying, and contaminated tissue, and make repairs.

In contrast, handguns cause "low energy" injuries that are generally treated with simple wound care, with or without antibiotics. Typically, the entrance wound is not stitched closed.

But now, Rehman said, "we feel this distinction between high- and low-velocity injuries may be blurred with hollow point bullets."

To verify that impression, he and three collaborators, including forensic scientist Michael Garvey of the Philadelphia Police Department, analyzed city ballistics data and gunshot cases from Temple's trauma center. With 1,615 gunshot victims in the city in 2010 (242 were murders), they had plenty of data.

On Saturday, Rehman presented their review at the annual meeting of the American Association of Orthopaedic Surgeons.

Newer ammunition, they found, has become "increasingly prevalent," resulting in grislier injuries than doctors expect. Still, doctors should not focus on figuring out the bullet type, caliber, or weapon because even with X-rays and other scans, this information is hard to determine.

Rather, they should look for signs of severe trauma, such as exposed bone or unusual swelling.

"The surgeon should individualize treatment on a case-by-case basis and pay close attention to how each patient presents," Rehman said.

And hope for less gun violence.

- Marie McCullough