Special considerations for gunshot wounds and shrapnel wounds

The basic principles of open/puncture wound care apply, even though of course these wounds are especially sinister versions of punctures. Don't forget that the basics still apply. If they're all you remember, you will do a good job. That said, I've learned a bit about this stuff, so I'll offer some advice.

The most commonly used Israeli rifle is the M16A2. They fire the notoriously small and brittle 5.56mm round, which shatters and distorts when it hits bone. (This is not the same as dum-dum bullets, which flatten on impact to create a wider path of "cavitation" through the body, though the effects can be just as bad.)

Thorough assessment
You have to be VERY thorough in assessing gunshot wounds from M16s (no, you probably won't know the difference during treatment). I once had a patient near Jenin with 8 holes from 2 bullets (or possibly just one) in his legs. I had another patient near Ramallah who was shot directly in the chest, but the bullet bounced off his ribs, never even penetrated his chest cavity (that's called luck, it isn't the norm). The unlucky part is, after the bullet BOUNCED OFF his chest, it went THROUGH his humorous (!) near the shoulder. I'm not shitting you -- there were 3 holes on the outside of the kid's shoulder, one hole on the underside of his upper arm, and one tiny spot and a broken rib on his chest. My point is, M16 rounds are unpredictable as hell. You need to assess the WHOLE BODY visually and by palpation. The more painful punctures/exits are likely to distract your patient from the less painful ones, but the latter might be more serious.

Leg and arm wounds
There have been many cases where an untrained international had to stand by while a man was bleeding having been shot several times in the legs. One man died in an ambulance a few days later after being held at a couple of checkpoints for several hours on his way to Nablus hospital.

GSWs to the legs are pretty common in the Territories. Fighters/defenders will have GSWs to the arms because they were holding up a rifle when they were fired on and their arms may save their lives.

Shrapnel wounds
As for shrapnel wounds, the basic principles apply. They're essentially just punctures with impaled objects. Don't remove the shrapnel. If the shrapnel is still piping hot (it will be if you're on-scene when the injury occurs), DO NOT REMOVE IT. You will want to pull it out. DON'T EVEN TOUCH IT. It's going to be too hot to grab, even if you're wearing a latex glove. But don't use pliers or tweezers, either. IRRIGATE THE SITE.

Infection is almost guaranteed with shrapnel wounds. Irrigate and cool them (same procedure) immediately, and get the patient to advanced care even if thewound is not immediately life-threatening.

Don't use direct pressure on shrapnel wounds. Most shrapnel wounds won't bleed all that much. So loose, sterile dressing is the way to go.

Indirect pressure points
Remember the indirect pressure points (femoral and brachial). Use them if you can't stop bleeding. You need to be careful with direct pressure on bullet wounds same as shrapnel wounds. If they've hit an artery and are hanging around, you might cause more damage with direct pressure. Even if there is a clear exit wound, with an M16 round you can't be sure the whole bullet exited. Sometimes it splinters. Indirect pressure would in that case be the way to go.

Eventually (I know this sounds dismal) after you treat a few bullet wounds you'll start to recognize how big the exit wounds should be for different sized fragments on different parts of the body. Even then, you cannot be sure there are no fragments left at the wound site.

Tournequet
Also, you should find out if the surgeons at the hospitals closest to you know what to do with a tournequet. If you can talk to the local medics about this, whether they have used TQs and what their success rate has been, you'll get a better idea of whether you want to implement one ever. I can't give advice on protracted care scenarios (1 hour + to advanced care). Maybe others will feel more comfortable advising. It's much more complicated, as goes without saying...

However, I can say you should go straight to a TQ anytime there's an amputation or an extreme avulsion involved. As I'm sure you are aware, amputations are pretty common with explosives. Strapping up the stump will be part of your C step during your initial assessment.