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Patient Care Vignette

A 28-year-old male was transported to the emergency department of a Level-1 trauma center as a victim of gun violence. He is alert and oriented, with a blood pressure of 98/64 mmHg. He has multiple gunshot wounds to the abdomen, flank, and back. Hypotension (88/60 mmHg) and tachycardia (HR = 124 bpm) develop rapidly. Massive blood transfusion is started followed by emergency and hopefully life-saving operation. Injuries to his liver and small intestine were managed by stopping bleeding and removing the section of the small bowel that was injured by bullets. Due to difficulty clotting, and the inability to clear waste products that were acids, the operation was converted to a damage control procedure. His abdomen was left open and covered with a device that provided both a temporary closure and a negative pressure across his abdomen, which controlled fluid leakage and protected his organs.

After 48 hours of complex ICU care, the patient returned to the OR to remove the temporary closure device, put his bowel back together, and close his abdomen. During this time, he received continuous infusions of an opioid analgesic (fentanyl) and an intravenous general anesthetic (propofol) interrupted by brief sedation holidays to assess his brain. At no point was he aware of the family that visited, and no family member had a meaningful interaction with him.

This patient is typical of those who sustain firearm injury and survive long enough to get to a hospital. Motor vehicle crashes, falls, and blunt assault have different kinds of injuries. Nonetheless, life-threatening injury can occur with all mechanisms of injury. This chapter uses firearm injury and subsequent care to illustrate how life-saving care can impact future recovery.


Many of the ICU interventions required to rescue an injured patient who is at risk of death impact how patients perceive and interact with their care environment and those who provide care. The same concerns extend to how patients may interface with visitors including family members. Many of those interactions may be quite different from the patient’s usual behavior. Brain injury, low blood flow followed by normal blood flow (reperfusion injury), edema, problems with blood flow within different spaces that function as compartments (brain, chest, abdomen), exposure to anesthetics and other medications that the patient does not usually receive, inadequate sleep, and infection may make patients either very sedated or inappropriately agitated. Some medications and conditions may induce temporary delirium, and may present a danger to patients who require care devices to remain in place such as catheters for monitoring blood pressure, infusing certain medications, or providing mechanical ventilation.

These behaviors may be profoundly disturbing for visitors, as may be the interventions required for patient and staff safety. Therefore, direct clear communication about what is happening—and what is likely to occur—is key in ensuring understanding and trust. Moreover, such communication supports patient- ...

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