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John Breeze · Jowan G. Penn-Barwell
Damian Keene · David O’Reilly
Jeyasankar Jeyanathan · Peter F. Mahoney
Editors

Ballistic Trauma

A Practical Guide

Fourth Edition

123
Ballistic Trauma
John Breeze
Jowan G. Penn-Barwell
Damian Keene • David O'Reilly
Jeyasankar Jeyanathan • Peter F. Mahoney
Editors

Ballistic Trauma
A Practical Guide

Fourth Edition
Editors
John Breeze Jowan G. Penn-Barwell
Queen Elizabeth Hospital Birmingham Royal Victoria Infirmary
Edgbaston, Birmingham, United Kingdom Newcastle, United Kingdom

Damian Keene David O’Reilly

Department Military Anaesthesia University Hospital of Wales
Royal Centre for Defence Medicine Cardiff, United Kingdom
Institute Research & Development
Edgbaston, Birmingham, United Kingdom Peter F. Mahoney
Department Military Anaesthesia
Jeyasankar Jeyanathan Royal Centre for Defence Medicine
Academic Department of Anaesthesia Institute Research & Development
and Intensive Care Medicine Edgbaston, Birmingham, United Kingdom
Royal Centre for Defence Medicine
Birmingham Research Park
Birmingham, United Kingdom

Department of Anaesthesia and Intensive

Care Medicine
Queen Victoria Hospital
East Grinstead, United Kingdom

ISBN 978-3-319-61363-5    ISBN 978-3-319-61364-2 (eBook)

https://doi.org/10.1007/978-3-319-61364-2

Library of Congress Control Number: 2017953016

© Springer International Publishing AG 2017

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of
the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation,
broadcasting, reproduction on microfilms or in any other physical way, and transmission or information
storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology
now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication
does not imply, even in the absence of a specific statement, that such names are exempt from the relevant
protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this book
are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the
editors give a warranty, express or implied, with respect to the material contained herein or for any errors
or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims
in published maps and institutional affiliations.

Printed on acid-free paper

This Springer imprint is published by Springer Nature

The registered company is Springer International Publishing AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
I would like to dedicate this book to my wife
Cristina and my parents Michael and Pauline
for their love and support.

To my friends and family—thank you for

your support and understanding. To the
medics over the world who care for those
injured from bullets and blast: your efforts
are seldom recognised but you stand
against the violence and darkness.
Thank you.
Contents

1 A Personal Experience. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Benoît Vivien
2 Firearms and Bullets. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Jowan G. Penn-Barwell and Aimee E. Helliker
3 Fragmenting Munitions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
John Breeze and Arul Ramasamy
4 Suicide Bombs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Piers Page and Johno Breeze
5 The Effect of Projectiles on Tissues. . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Jowan G. Penn-Barwell and Tom Stevenson
6 Personal Armour Used by UK Armed Forces and UK
Police Forces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Eluned A. Lewis, Johno Breeze, Chris Malbon, and Debra J. Carr
7 Triage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Ed Barnard and Jamie Vassallo
8 Prehospital Management of Ballistic Injury . . . . . . . . . . . . . . . . . . . . 75
Ravi Chauhan and Damian Keene
9 Emergency Department Management . . . . . . . . . . . . . . . . . . . . . . . . . 87
Jason Smith
10 Radiology and Ballistic Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
David Gay and Iain Gibb
11 Damage Control Resuscitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
Damian Keene
12 Anaesthesia and Analgesia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
Mark Davies and Jeyasankar Jeyanathan

vii
viii Contents

13 Damage Control Surgery and Ballistic Injury to the Trunk. . . . . . . . 151

David O’Reilly
14 Management of Ballistic Trauma to the Head. . . . . . . . . . . . . . . . . . . 175
Stuart A.G. Roberts
15 Penetrating Ballistic Spinal Injury. . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
Stuart Harrisson
16 Ophthalmic Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
Richard J. Blanch
17 Ballistic Maxillofacial Trauma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
Johno Breeze, Darryl Tong, and Andrew Gibbons
18 Penetrating Neck Injury. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257
Johno Breeze and David Powers
19 Management of Vascular Trauma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275
Claire Webster and Thomas C. König
20 Ballistic Genitourinary Trauma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
Angus Campbell and Davendra Sharma
21 Ballistic Wound Management and Infection Prevention. . . . . . . . . . . 337
Jowan G. Penn-Barwell, C. Anton Fries, and R.F. Rickard
22 Human Factors in Ballistic Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . 347
Simon J. Mercer
23 Management of Paediatric Trauma in an Austere Environment. . . . 357
William Tremlett, Johno Breeze, and G. Suren Arul
24 Ballistic Trauma in Pregnancy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 373
Tracy-Louise Appleyard
25 Managing Ballistic Injury in the NGO Environment.
A Personal View. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 391
David Nott
26 Forensic Aspects of Ballistic Injury. . . . . . . . . . . . . . . . . . . . . . . . . . . . 409
Jeanine Vellema and Hendrik Scholtz
27 Critical Care for Ballistic Trauma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 437
Andrew McDonald Johnston
28 Transfer and Evacuation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 445
Ian Ewington
29 Soft Tissue Reconstruction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 463
C.A. Fries, M.R. Davis, and R.F. Rickard
Contents ix

30 Skeletal Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 473

Daniel J. Stinner and David J. Tennent
31 Amputation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 491
Jowan G. Penn-Barwell, Jon Kendrew, and Ian D. Sargeant
32 Conflict Rehabilitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 505
Alex Scott and John Etherington

Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 525
A Personal Experience
1
Benoît Vivien

1.1 Background

On Thursday, the Twelfth of November 2015, I had been scheduled for a night duty
as coordinator physician in the call center of the prehospital emergency department
“SAMU de Paris”. I knew for several weeks that I had to take part in an important
mass casualty exercise the following day, Friday the Thirteenth of November, this
was not a concern after a normal night duty. Indeed, since 2 coordinator physicians
are on duty in the call center, we usually split the night from midnight to 8:00 AM,
so that each of us could have a short sleep of about 3–4 h.
Unfortunately, the activity during the night was very intense, with several road
accidents and a building fire in Paris, consecutively each of us only had 2 h of rest.
Nevertheless, on Friday the Thirteenth of November, at 8:30 AM, after the daily
staff handover and a short shower, I was ready for the planned morning tabletop
mass casualty exercise, and the following practical simulation session that after-
noon. That morning we opened the crisis room where the tabletop was to take place,
and welcomed the physicians who were to be the players for the morning session.
The scenario that we had envisaged for Friday Thirteenth, classically considered as
an unlucky day in western superstition, was 13 simultaneous terrorist attacks in
Paris and its suburbs. After several bombings in Paris in 1995–96, Pr Pierre Carli,
chairman of SAMU of Paris, created a specific plan to organize prehospital emer-
gency care for several simultaneous attacks. This plan was called “plan Camembert”,
since it splits Paris in different sectors like a cheese, prehospital care in each sector
being managed by local pre-hospital and in hospital teams independently from other
sectors. This plan had been tested several times during tabletop exercises, but never
really implemented. However, following the Charlie Hebdo attack in January 2015,
and according to confidential information from the authorities, we were advised that

B. Vivien, MD, PhD

SAMU de Paris, Anaesthesiology, Intensive Care and Prehospital Emergency Department,
Necker-Enfants Malades Hospital, 149 Rue de Sèvres, Paris 75015, France
e-mail: [email protected]

© Springer International Publishing AG 2017 1

J. Breeze et al. (eds.), Ballistic Trauma, https://doi.org/10.1007/978-3-319-61364-2_1
2 B. Vivien

major terrorist attacks would probably occur in Paris, sooner rather than later.
Therefore, we decided to organize the tabletop exercise with 13 different attack
locations, a much larger number than the previous maximum of 3.
The players involved were physicians from SAMU of Paris and from other
SAMU departments surrounding Paris, as well as representatives from the Fire
Department. For the first time, we invited physicians from major trauma centers
to take part. Indeed, there is frequently a gap between pre-hospital emergency
physicians and in hospital anesthesiologists or intensivists working in trauma cen-
ters. Since I had spent the first part of my career in the trauma center Pitié-
Salpêtrière (1997–2007), before becoming the deputy chairman of the SAMU of
Paris in 2007, I had experience of both environments but this crossover is rare in
France. Therefore, for this tabletop exercise, several trauma center physicians
were invited to play the role of pre-hospital coordinator physician, a “live my life
experience”, enabling them to better understand the difficulty of pre-hospital
emergency care during a mass casualty event. Finally, due to the high risk situa-
tion in Paris, we had invited representatives from the regional health agency and
police authorities.
The exercise started at 9:00 AM. According to the scenario defined a few weeks
previously, four groups of two terrorists heavily armed with automatic weapons
began simultaneously shooting in different areas of Paris and its suburbs.
Notifications arrived successively to the crisis room, with a number of victims
around 0–10 dead, 0–10 absolute emergencies (AE) and 0–10 relative emergencies
(RE), for each one of the 13 sites of terrorist attack. Overall the terrorist attacks
lasted about 2 h, with a final count of 66 dead, 74 AU and 48 RE. Applying the
principle of the “plan Camembert” adapted to this high number of sites, all of the
victims could have been virtually cared for by the different teams, first in the pre-
hospital fields, and thereafter in the different trauma centers. However, at the end of
the debriefing, one of the emergency physicians involved as a player in the crisis
room said and I quote “OK guys, this exercise was interesting, but largely too
much… This incredible scenario will never occur in Paris !”.
The second part of the day was dedicated to a practical exercise in an old unused
building in Necker-Enfants Malades Hospital. The scenario was focused on a mass
casualty event due to a terrorist attack occurring in an office building. Victims were
simulated using forty-five medical students, while first aid providers were also
played by other medical students from our SAMU department. Pre-hospital emer-
gency physicians and nurses had to apply the principles of damage control on site as
well as perform triage and categorization using electronic devices allowing trace-
ability of the victims until hospital admission. This practical exercise, lasting 3 h,
was considered as very instructive for all of the players, allowing them good work-
ing knowledge of the principles of caring for many victims from a mass shooting.
After an internal debrief with the other organizers of the mass casualty exercise I
went back home at 7:30 PM thinking that my work day was finished, and hoping for
a deserved rest after 36 h working in the hospital.
1 A Personal Experience 3

1.2 The Attacks

After having a short dinner, I sat on the couch, and started to watch the football on
TV. I’m not usually a fan of football, but tonight the French national team were
playing, so it was possibly interesting. However, after 36 h spent in the hospital, I
decided to switch channels and watch the continuous news. A few minutes after the
first explosion at 9:20 PM near the Stade de France, I saw the alert message on the
TV, notifying of an explosion of unknown origin. I found this strange, but was too
tired to reflect, and switched the TV back to the football match which rapidly
resulted in sleep! However, about 15 min later, my mobile phone and home phone
rang simultaneously and I heard the recorded message “This is not an exercise. The
mass casualty plan is activated. Please return immediately to the SAMU”. I switched
the TV back to the continuous news channel and saw with horror the news of 3 suc-
cessive bombings near Stade de France and simultaneously of several shootings in
Paris. I’ll always remember the first words I then said to my family “This is exactly
what we have played out this morning”. I quickly drank two double coffees, and
took my car back to the SAMU. During the journey, I made many phone calls to
exchange information with colleagues from trauma centers and other SAMU units,
some of them having participated in the morning exercise.
After arriving in the crisis room in the SAMU for Paris, I saw the physician who
had generated the scenario for the morning exercise and said to him “It’s incredible,
there have been some leaks !” The investigations since have shown that this was
fully unfounded, but this was a really troubling coincidence.
Many physicians, nurses, drivers, providers, phone dispatchers and secretaries
came back to the SAMU during the evening, spontaneously or after having received
the automatic phone call. We organized the crisis room as for the morning exercise,
splitting the room for each of the different events. Simultaneously, we had to manage
a fourfold increase in phone calls to the “15”, which is the medical emergency num-
ber in France. Conversely, the numbers of calls received for current medical emer-
gencies was dramatically reduced, it appeared that people refrained from calling for
minor emergencies. However, the world does not stop because of terrorists attacks, for
example that night we had to manage three patients presenting with acute coronary
syndrome, who were cared for by a Mobile Intensive Care Unit (MICU) team and
taken directly to the cath lab.
The high number of staff that came back to the SAMU enabled us to create new
MICU teams, who were sent on to the different locations of the terrorists attacks.
We also sent a trained emergency physician to each site to perform medical triage
and categorization. I should have been one of them, but after just 2 h rest during the
previous night, my colleagues refrained me by convincing me that it was not reason-
able. So I took the position in the crisis room of supervising the affect of the rein-
forcement teams.
During the evening the situation after the bombings near Stade de France and the
shooting in the terraces and restaurants in Paris was mainly controlled, the Bataclan
4 B. Vivien

hostage taking however remained a crucial and uncertain point. Indeed, before the
police assault, we had obtained some information suggesting the possibility of
approximately one hundred supplementary absolute emergencies. If this situation
had occurred, this would have clearly led to saturation of all the trauma centers in
Paris. Therefore we had to respond to this possibility early requesting reinforcement
from teams on a national scale. I directly called the other SAMU as far up to 500 km
from Paris, who were equipped with a helicopter, to ask them first for supplemen-
tary pre-hospital teams and to check local availability in their trauma centers to care
for AE and RE.
The strategy at this time was to station the maximum number of pre-hospital
teams near the Bataclan at the time of the assault, as well as having as many heli-
copters as possible ready to transfer casualties to trauma centers far from Paris. We
finally gained access to 9 SAMU helicopters, each one capable of transporting one
patient at a time. Additionally, we obtained 2 military helicopters, each allowing
transport of 4–6 patients simultaneously. Unfortunately, after the police assault, the
patients that we were supposed to care for had been killed by the terrorists, and the
number of new AE and RE patients was relatively limited.
The end of the night was a source of fear and major uncertainty. Our scenario for
the exercise during the morning was based on 13 terrorist attacks, while the sad real-
ity of the evening had shown “only” 9 attacks in Paris and its suburbs. We had to
face several false alerts of terrorist attacks, mainly due to people seeing military
police with weapons in the street of Paris and fearing they were terrorists.
Finally, at 4:00 AM on Saturday, the Fourteenth of November I went back home
for a short sleep, having been scheduled for a 24 h duty in the call center beginning
at 8:00 AM. Thankfully, some colleagues not involved in the Thirteenth evening
shared these duties between them. Given it is usually difficult to find a colleague to
cover a Friday, weekend duty, or during national holidays, this spontaneous solidar-
ity was greatly reassuring! The remaining weekend for the SAMU teams was pretty
quiet, although we had to face to two other false alerts, one on Saturday and one on
Sunday. One of them being very strange and worrying, it was interpreted by some
as a trap to test for a potential new terrorist attack against pre-hospital teams.
Unfortunately, the days following this sad Friday, the Thirteenth of November
made us realize that many of us, either in our personal or professional field, knew or
were closed to one or several victims or there relatives. One of the SAMU of Paris
staff a young emergency physician, less than 30 years old, who was working as a GP
in our call center was killed on the terrace of the restaurant “Le Petit Cambodge”.
The English teacher of the daughter of one of the secretaries of the SAMU of Paris
lost 5 of her friends during a shooting in a terrace restaurant, and survived only
because she was too tired that evening and left early after having a drink with her
friends. The girlfriend of the nephew of the wife of a SAMU physician was killed
as well as the son of the physician who had helped with the childbirth of another
colleague, 42 years ago.
1 A Personal Experience 5

1.3 Summary

Terrorist attacks are unfortunately a tragic event for which we have to be prepared.
For emergency teams, regular training is a necessity, both with tabletop and field
exercises. The major key points of medical care are the implementation of damage
control, and triage and categorization of the victims. Coordination between all the
parties involved from first aid providers, firemen and police forces to prehospital
emergency and trauma center teams, is the corner stone of the organization. Multi
partner exercises, and to greater extent “live my life experience” could contribute to
this all with the aim of improving the prognosis of the victims of these dramatic
attacks.
Firearms and Bullets
2
Jowan G. Penn-Barwell and Aimee E. Helliker

2.1 Introduction

Weapon development throughout history has focused on overmatch of the enemy’s

capability by increasing the range and lethality of weapons. This process in the
fourteenth Century meant the introduction of early firearms in Europe [1].
The Firearm, as defined by the UK Firearms Act 1968 is “a lethal barrelled
weapon of any description from which any shot, bullet or other missile can be dis-
charged.” Firearms are often referred to as guns by the general public: technically a
gun is any machine that converts stored energy to kinetic energy to accelerate a
projectile out of a barrel. Therefore the term gun may encompass everything from
small handguns to large artillery pieces. This book will use the term firearm to
describe guns that using that are carried by hand and use a propellant as a source of
stored energy, commonly also referred to as small arms.
This chapter provides the clinician with an overview of the terminology specific
to the firearms and ammunition field, ammunition types and constructions and types
of firearms by introducing firearms and then examining the ammunition used in
these weapons.

J.G. Penn-Barwell (*)

Institute of Naval Medicine, Gosport, Hampshire PO12 2DL, UK
e-mail: [email protected]
A.E. Helliker
Centre for Defence Engineering, Cranfield University, Defence Academy of the United
Kingdom, Shrivenham, Wiltshire SN68LA, UK
e-mail: [email protected]

© Springer International Publishing AG 2017 7

J. Breeze et al. (eds.), Ballistic Trauma, https://doi.org/10.1007/978-3-319-61364-2_2
8 J.G. Penn-Barwell and A.E. Helliker

2.2 History

The first chemical propellant used in firearms was black powder a mixture of potas-
sium nitrate, sulphur and carbon known as gunpowder. It was first described in
China, and knowledge of its composition spread to Europe around the end of the
first millennium CE [1]. Firearms were believed to be first used in combat by the
English Army in Europe when Edward III deployed Cannon at the Battle of Crećy
in 1346 against the French. Interestingly, these firearms were regarded as far less
decisive within the battle than the large numbers of longbows, also used for the first
time in war on the continent [2]. A well-trained archer with a long bow was signifi-
cantly more lethal in terms of range and rate of fire than a soldier with a musket.
Training an archer however took months whereas a soldier could be taught how to
operate a musket in a day.
The capability of firearms dramatically increased over the nineteenth Century
with the development of rifling, breech-loading, cartridged ammunition and maga-
zines. Bullets fired from early, un-rifled weapons were initially spherical, and to
ensure the maximum mass for a given size, the densest metals were chosen: lead.
This had the added advantage of being very soft, this meant that it could conform to
the shape of the barrel and when it struck the target it would deform and flatten.
In the late nineteenth Century, smokeless and more powerful explosives e.g.
Cordite, replaced black powder as a propellant for rifle ammunition. The higher
velocities generated by these propellants meant that soft-lead bullets deformed
within the barrel leaving deposits. To combat this, bullets were ‘jacketed’ or coated
with a harder metal such as a copper alloy. When full metal jacket rounds were first
used by the British Army in action, it was noted that the bullets imparted much less
energy and therefore caused far less tissue destruction [3].
In order to achieve the benefits of jacketed rounds with the wounding effect of
soft, expanding rounds, the superintendent of the ammunition factory at Dum Dum
in India, Capt Bertie-Clay developed a partially jacketed round with an exposed
soft-nose which deformed or expanded upon striking the target [4]. However the
wounding potential of high-velocity, expanding rifle rounds was regarded as exces-
sive, and their use in warfare inhumane. Ammunition designed to expand in the
human body was specifically outlawed by the 1899 Hague convention:
“It is prohibited to use in international armed conflicts, bullets which expand or
flatten easily in the human body, such as bullets with a hard envelope which does not
entirely cover the core or is pierced with incisions” [5].
Despite latter ratifying this part of the treaty, the initial UK negotiating position
at The Hague convention was that this type of ammunition was necessary for use in
Africa and India, though accepting that it was inappropriate for use in Europe [6].
The advent of body armour, particularly helmets led to the development military
ammunition with increased ability to penetrate. This is typically achieved by the
inclusion of a core of a harder metal e.g. steel, within the bullet. This is seen in the
design of most modern military ammunition including the standard NATO
5.56 × 45 mm round and the Russian 5.45 × 39 mm used in the AK-74 family of
weapons.
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