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When I was a resident at a Philadelphia University Hospital, a patient came to the E.R. with a complaint of a headache. He was seen by another resident, a friend of mine. He denied any history of trauma, but had a few minor abnormalities on his neurologic exam. My friend decided to order a skull x-ray, as many of our E.R. patients' stories were not entirely reliable. The radiologist called back to the E.R. and said the patient had a bullet, estimated to be .45 caliber, almost in the exact center of his brain. He was questioned again about head injuries and then recalled that several days before he had been in a card game where one of the players claimed he had been cheated, left the game, and later returned with a handgun that he began firing as soon as he re-entered the room. The patient stated that he dove out of a first-floor window and thought he struck his head on the windowsill on his way out. Apparently not so. A careful examination of his scalp revealed a small scab over a laceration on the side of his head. A consulting neurosurgeon was of the opinion that antibiotics should be given to prevent possible meningitis, but that surgery was inadvisable as it was likely to make him neurologically worse. The x-ray made the cover of the next Medical Center newsmagazine. My conclusion was that as far as gunshot effects are concerned almost anything was possible.
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