What is the prognosis for Rep. Gabrielle Giffords?

I worked as an ER doctor in both Detroit and Flint when those Michigan cities were vying for the right to be called the Murder Capital of the World, so I've seen many patients with gunshot wounds to the head. Some patients are immediately killed, while others go on to lead relatively normal lives. What is the prognosis for Rep. Giffords?

The bullet entered the back of her skull (see updates), exiting the front, near the left eye. This trajectory suggests that her left frontal, parietal, and possibly occipital lobes were damaged. The extent of the injury depends on the bullet size (reportedly 9 mm), velocity, and type: some bullets create catastrophic devastation, while others pass through and deposit much less energy into the brain.

9 mm pistol rounds create significantly less injury than high-velocity rifle bullets that damage more tissue distal to the wound channel. The latter create a shock wave that can destroy areas they never directly touch. In some cases that shock wave can split the skull or even cause it to explode, leaving nothing north of the cranial vault except for a few tattered flaps of skin.

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pumpkin shot by 9 mm bullet

A pumpkin shot by a 9 mm pistol. The after photo shows the exit channel, which is obviously larger than 9 mm. Many bullets mushroom (expand in diameter) to some extent upon impact and create other effects that contribute to a wound channel much larger than the bullet diameter.

NOTE: No good pumpkins were harmed in the production of this demonstration, which used a pumpkin inadvertently left in my garden too long. Incidentally, I previously donated surplus vegetables that I carefully grew using organic techniques, but after Congress passed legislation that partially revokes one of our fundamental freedoms, I don't have enough money to hire a team of lawyers to pore over thousands of pages of legislation to see if I might inadvertently be subjected to a draconian fine for giving my food to people who need it, so I do the legally safe thing and discard vegetables (and eggs) that I cannot eat. Thanks, Congress! I don't want a SWAT team raiding my home (as they've done several times to other small food producers), nor do I want the Supreme Court saying that I am engaging in interstate commerce by not engaging in interstate commerce, as they found in Wickard v. Filburn, in which a farmer, Roscoe Filburn, grew wheat to feed his chickens, not to sell. Although his wheat was solely intended for his chickens, the federal government ordered him to destroy his crops and pay a fine, thus establishing a precedent that the Constitution means whatever the tyrants in Washington can twist it to mean.

Why everyone should fear a SWAT raid: The government sometimes uses SWAT raids to get rid of people, hoping they will respond in a way that gives police an excuse to shoot. Don't think so? Try asking Donald Scott. Oh, that's right—you can't ask him, because he is dead. Scott, a 62-year-old multimillionaire and heir to the Scott Paper fortune, lived adjacent to federal park lands on 250 acres of breathtakingly beautiful property that the government wanted. He refused to sell it, so the government concocted an excuse to raid his home, using weapons to threaten his wife. He heard her screaming, “Don't shoot me, don't kill me!” and rushed to defend her. He was shot three times and killed.

To get an idea of what problems Rep. Giffords (or Gabby as she is affectionately known to her many friends) might experience, let's look at other cases.

Phineas P. Gage was a handsome 19th century American railroad construction foreman who survived an accident in which a large iron rod was driven through his head, damaging his left frontal lobe and personality so much that friends saw him as “no longer Gage.” His name was the same, but he was a very different man. Initially diligent, hard-working, reliable, responsible, and good-humored, he reportedly became lazy, unreliable, irresponsible, humorless, profane and substituted his prior interest in going to church with gambling, alcohol, whoring about, and possibly even sexually molesting young children. These changes are not surprising since the frontal lobes help sustain attention and inhibit socially unacceptable behavior. He developed amaurosis secondary to optic nerve damage, ptosis, partial facial paralysis, seizures, and “a queer feeling which he is not able to describe.” He died at age 37.

James Brady was permanently disabled from an assassination attempt on President Reagan in which a “devastator” bullet injured his left frontal and right parietal lobes, producing partial paralysis and cognitive deficits such as impaired short-term memory and time perception that prevented him from returning to his job as White House Press Secretary, although he was given small tasks to help ease a deep depression resulting from an awareness that he would not fully recover in spite of his valiant efforts. Brady was reportedly abandoned by some friends and colleagues who were “unable to cope with his physical difficulties and his shaky voice, not to mention the emotional unsteadiness that is a frequent side effect of the kind of brain damage that Brady suffered.”

Mary Jo Buttafuoco was shot by Amy Fisher, a.k.a. the “Long Island Lolita,” who was then sexually involved with Mary Jo's husband Joey, whom she belatedly realized was a sociopath with a charming veneer, as is often the case (learn how to spot a sociopath). That realization prompted her to write a book, Getting it Through My Thick Skull: Why I Stayed, What I Learned And What Millions Of People Involved With Sociopaths Need To Know. The fact that Mary Jo is now an author who does savvy and polished media appearances attests to the fact that some people with severe head injuries can make remarkable recoveries. In fact, she seems to be doing much better than Fisher, who is now reportedly a pornographic actress.

It isn't possible to reliably predict the extent of recovery, but based on initial reports that Gabby was able to follow simple commands, her doctors are “cautiously optimistic” about her prognosis, but she will almost certainly suffer permanent disability that will prevent her from returning to Congress except in a symbolic way. Just as Gage “was no longer Gage,” Gabby will likely not be the person she was before the shooting.

Overly optimistic assessment

On January 10th 2011, Fox News broadcast the words of someone they identified as Dr. Jeffrey Brown, who said, “The energy—it's just physics—the energy of the bullet was dissipated in fracturing the skull. We heard they had to operate on the orbit—fractured skull—so I pray that what we're hearing is that the skull took the hit, not the brain.”

Martha MacCallum responded, “We agree, and we pray that, too.”

MacCallum isn't a doctor, so I'll excuse her opinion. While we all wish the best for Gabby, what Dr. Brown said is so unscientific that I wonder if he is a doctor or, if so, how much experience he has treating patients with gunshot wounds to the head.

In my vast experience treating gunshot victims, I know that bullets can do seemingly inexplicable things once they enter the body. Logic might tell you that if a bullet enters at Point A and exits (or almost exits) at Point B, the path it took was a straight line connecting A to B. Not always; sometimes bullets strike objects (principally bone) that cause them to ricochet (deviate off course), but ricochets inside the skull invariably (because of mathematical laws) increase the path length from A to B and hence the probability of more brain destruction in almost every case.

One of the strangest cases I saw was a man with a gunshot wound to the chest but no exit wound. When I and the other docs on the Trauma Team did not see a bullet in his chest x-ray, I used a scanner I made that detects ferrous (iron, steel) and nonferrous (lead, copper, aluminum, etc.) metal in the body and found the bullet embedded in a flank. How did it get there without puncturing the diaphragm? It struck a rib and followed a circular path to the flank, thanks to skin elasticity. If you're familiar with fiber optic cables, you will recognize this as being analogous to total internal reflection in which photons reflect back into (rather than exiting) the cable if they approach its boundary at a sufficiently shallow angle.

I've also seen this total internal reflection phenomenon apply to people shot in the head at Point A, with the bullet almost exiting at Point B, without the bullet entering the cranial vault (where the brain is) even though a straight line from A to B suggests the brain was in the obvious path between those points. What happened in these cases is the bullet struck the skull at an oblique angle, causing it to ricochet, striking the elastic scalp at an angle less than its total internal reflection angle (so to speak), which pushed it along a circular course. Such profound alterations in course are more likely with relatively low velocity ammunition; high velocity rounds tend to blast through rather than bounce off. Nevertheless, ricochets can affect any bullet or other projectile, which is why tanks commonly have sloped armor.

With this as a preface, I am fully aware that bullets do seemingly inexplicable things, but one thing they don't do is pierce the skull, vanish, and then reappear to exit the skull—near the orbit, in Gabby's case. I haven't yet heard an exact description of where the bullet entered, but from the general description of it entering the back of the head and exiting near the eye, and from the description of her neurosurgery, it is clear that she suffered a brain injury. Gabby does not have rocks in her head, so unless the bullet entered at an angle so it immediately reflected off the inner surface of the skull before exiting (which is highly unlikely), a lot of brain tissue was damaged between the entrance and exit wounds. In the one-in-a-million best-case scenario, it is still impossible for a 9 mm bullet to enter the back and exit the front without damaging the brain.

A bullet cannot pass through anything (including air but especially bone) without transferring energy to it, so when a skull is hit, it does dissipate some of the bullet's energy. However, the fact that the bullet exited proves that it had plenty of energy before that to damage the brain, so Dr. Brown's speculation about “the skull took the hit, not the brain” is unscientific and cruelly misleading to her family. It's as absurd as saying Chuck Norris kicked a hole through one of my exterior walls, piercing the drywall and siding, but not the insulation in between.

I haven't heard Dr. Brown on Fox News before, so I'll give him the benefit of the doubt and assume his newbie jitters caused him to misspeak. His somewhat disjointed sentence (quoted above) suggests that he was indeed nervous. Let's hope that Fox News corrects this error before left-wing media outlets claim they recruited an “expert” who graduated from the National Enquirer School of Medicine.

FYI: Sociopaths

Even trained professionals may have difficulty detecting sociopaths. Learn how to spot one, and save yourself a lot of grief. Given the prevalence of sociopathy, it is inevitable that you will meet—and likely vote for!—at least a few of them in your life.

Incidentally, based on Jared Loughner's bizarre online rants, Gabby's shooter appears to be schizophrenic, not a sociopath, which I pointed out 30 seconds after reading his words that are classic symptoms of that disorder.

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Dr. Peter Rhee later said that Giffords was probably shot in the front of her head, with the bullet exiting the back, although they are not certain.

The views expressed on this page may or may not reflect my current opinions, nor do they necessarily represent my past ones. After reading a slice of what I wrote in my various websites and books, you may conclude that I am a liberal Democrat or a conservative Republican. Wrong; there is a better alternative. Just as the primary benefit from debate classes results when students present and defend opinions contrary to their own, I use a similar strategy as a creative writing tool to expand my brainpower—and yours. Mystified? Stay tuned for an explanation. PS: The wheels in your head are already turning a bit faster, aren't they?

“The test of a first-rate intelligence is the ability to hold two opposed ideas in mind at the same time and still retain the ability to function.”
F. Scott Fitzgerald

Reference: Imagining dialogue can boost critical thinking: Excerpt: “Examining an issue as a debate or dialogue between two sides helps people apply deeper, more sophisticated reasoning …”

Comments (3)

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Comment #99 by Nelson
January 10 2011 08:10:23 PM

Chuck Norris

I think Chuck Norris has actually kicked a hole in someone's house before without piercing the insulation.

I know for a fact that he's counted to infinity ... twice.

Editor's note: If anyone doesn't get this humor, see http://www.chucknorrisfacts.com/chuck-norris-top-50-facts

Comment #98 by Anonymous
Contact the commenter via MySpamSponge: iyq Contact this person via MySpamSponge
January 9 2011 11:46:54 PM

I Feel Better

We here at PETP feel better knowing that no pumpkins were harmed in the demonstration.

—People for the Ethical Treatment of Pumpkins

Comment #97 by karenena
January 9 2011 05:45:19 PM

Thanks for the analysis of the prognosis for Rep. Giffords.
It's a terrible event for her and the others who were hurt and killed.

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