As I instruct young doctors and medical students, I help them to visualize trajectories – whether it be the location of the end of a needle inside the patient while doing an aspiration, understanding the best path for placing a catheter or thinking though the path of a bullet in a patient who has suffered a gunshot wound.
A young man was shot in the left midback by an armed robber. He presented to BMC with severe abdominal pain and bloody urine. He only had one bullet wound on his back with no apparent exit wound, although he was tender along the anterior left rib margin.
I took him to the operating room for an abdominal exploration. I found that the bullet had emerged into the abdominal cavity through the mesentery of the descending colon after forcing its way through the top of the left kidney. Other holes were found in the transverse colon, the sigmoid colon and in a portion of the small intestines. Finally, a laceration in the muscles of the anterior abdominal wall was found without an external wound.
With the abdominal cavity open, these injuries can be laid out and separated one from the other. However, with some imagination, I can visualize all of these structures having been lined up at the time of the shooting to allow the bullet to pass straight through them creating injuries in seemingly unrelated organs. For this reason, it is imperative to inspect all structures of the abdomen during an exploratory surgery for trauma, because injuries may be found where least expected.