Bite the Bullet

Graham Elder

November 15, 2020 – 6 min read

The recent Netflix action movie 6 Underground features an opening high speed car chase scene where a “doctor” is attempting to remove a bullet from a co-conspirator’s abdomen in the backseat of an Alfa Romeo Giulia Quadrifoglio sports sedan. 

https://www.imdb.com/title/tt8106534/?ref_=fn_al_tt_1

Wait. Why does she have to remove the bullet with such urgency?

Does the bullet really even have to come out? 

The presence of the bullet itself doesn’t necessarily kill you in the short term. It’s the damage the bullet causes on its way to being lodged somewhere in your body that potentially ends your life – primarily by causing you to bleed to death. Orthopedic surgeons implant metals into patients (plates/screws/rods/hip prostheses, etc.) on a regular basis with little concern for the effects the metals will have because the materials are considered biocompatible. That is, the body doesn’t react to the hardware, and the hardware doesn’t react to the body. The metals that make up these implants are most commonly a mixture of many types of metals (stainless steel, titanium and cobalt, to name a few) and are considered inert. Lead does not fall into this category; it’s quite the opposite of inert and quite toxic. 

Is that why the bullet has to come out? Because of lead poisoning?

Not necessarily. Over the long term, the body quickly forms a protective fibrous tissue (scar tissue) envelope around the bullet, isolating it, like a little island, from the rest of the body. This is why the leaching of potentially toxic lead is a non-issue. The exception to this scenario is if the bullet is sitting in fluid that is acidic (low pH) such as synovial fluid in any joint or within an organ involved with digestion (stomach). The acidic fluid prevents the protective scar tissue envelope from forming and accelerates the breakdown of the lead into potentially toxic substances leading to lead poisoning.

Shouldn’t the bullet be removed anyway because it will cause an infection?

Once again, there are a number of variables here that include the location of the bullet wound, the presence of a fracture (broken bone), and the muzzle velocity of the weapon (high vs low). It’s also important to note whether the bullet carried along contaminated materials when it entered the body, such as clothing fibers. In general, most gunshot wounds require some period of IV antibiotics, the exception being a low velocity wound to a non-vital soft tissue area (arm, leg, buttock). In these cases, studies have shown no important decrease in infection by using antibiotics. All of this is independent of whether or not the bullet remains in the body. 

While infection and plumbism (lead) poisoning are potential problems in the longer term, it’s the short term we are concerned with. Once a bullet penetrates the human body, through cavitation and other fancy physics explanations, the damage is done. There’s only one urgency, and that is to stop the bleeding. But removing the bullet does the exact opposite. It increases the bleeding and, thus, the chances of death. 

So, when does a bullet have to come out? The simplest answer to this question harkens back to Hippocrates and primum non nocere or “first, do no harm.” If bleeding is controlled and removal of the bullet is going to cause more harm than good, leave it in. At least for now. It’s that simple. Deal with the possibility of infection and plumbism later. 

So, back to the movie 6 Underground. Why does she have to remove the bullet? The answer is because it makes for a tense and visually entertaining cinematic experience. Nothing more. 

Although that is a pretty good reason if you’re stringing along a big budget Hollywood yarn. 

Still, don’t try this at home!

Note, the above is strictly an overview of this topic. For more in depth information, the following websites offer good reviews:

https://www.orthobullets.com/trauma/1059/gun-shot-wounds

http://www.wheelessonline.com/ortho/gun_shot_wounds

https://medlineplus.gov/ency/patientinstructions/000737.htm