Before handguns became readily available it was comparatively common to see patients in inner-city casualty departments who had been hit by a blast of shot from a sawn-off gun. It made a terrible mess of the patient.

In rural areas the injuries inflicted by shotguns, unless the intent was suicidal, were in most cases confined to pellets being embedded in the skin and subcutaneous tissue.

However, there must be many rural doctors who have seen more serious injuries, including, for example, the loss of an eye and sometimes worse, even fatal, injuries. Most people who spent their youth in the country will have been brought up to respect the famous lines from A Father’s Advice to His Son. The last words of this, that the American Vice-President, Dick Cheney, may have forgotten, sum up dad’s teaching:

“All the pheasants ever bred
Won’t repay for one man dead”

Doctors have been puzzling over the injuries suffered by Harry Whittington, Cheney’s 78-year-old shooting companion. It seems unlikely, as it is being suggested, that the shot moved around Whittington’s body, rather as shrapnel does after a war injury, and somehow managed to work its way into a coronary artery.

Whittington, so we were assured, had suffered a typical shooting accident. He had been peppered by the Vice-President, who had followed a quail around as it flew behind him, and had fired without realising that it was Whittington, not the quail, that was in his line of fire.

Whittington suffered the classic widespread peppering of head, chest and neck, but had immediate first-aid treatment from the Vice-President’s medical team, which is always in attendance. The shot was presumably of fairly small size, probably the American equivalent of British size seven. The general impression was that Whittington had suffered only classic superficial wounds with pellets embedded in his skin and subcutaneous tissue.

A day or two later he showed the classic signs and symptoms of a heart attack. Shot wounds that have reached the heart muscle usually do damage in one of two ways. If shot lodges in the muscle of the heart, provided that there has been no bleeding into the pericardial sac, to begin with it may not produce any trouble.

Once the bruising becomes established, muscle damage gives rise to symptoms hard to distinguish from those of an ordinary heart attack. Whether a pellet wound or heart attack, the myocardium, the muscle of the heart, is damaged and some of it even destroyed.

If the heart muscle damage has been the result of an injury by a pellet, the cause is obvious. However, if it is after a myocardial infarction (a heart attack), the muscle damage follows obstruction to the coronary artery so that the muscle is no longer supplied with the necessary oxygen and other nutrients, and dies.

Even though the heart muscle damage after a shot wound may not always be as severe as it would have been after a heart attack, the patient’s blood pressure, blood enzyme tests and his ECG looks almost identical to those recorded after a coronary. All is well provided that a close eye is kept on the patient and he doesn’t develop a serious arrhythmia. Fortunately, Whittington was carefully monitored in a high-dependency ward because he developed just such an abnormal rhythm of his heart and this could be immediately corrected. Just as an arrhythmia can be caused by known coronary arterial disease with consequent heart muscle damage so can the damage from a pellet induce an abnormal heart rhythm.

Another possibility after being peppered with shot penetrating the heart is that one of the pellets damages a coronary artery before it comes to rest, and thereby cuts off the circulation to that section of the heart muscle.

The signs and symptoms of this, and the sequel to them, is exactly the same as if the shot man had had a myocardial infarction. Whittington has had cardiac catheterisation so that any residual damage to the circulation in his heart can have been checked out and the site of the pellet clearly defined.

If all goes well, Whittington should be home again within a week to ten days. It should not prevent his enjoying many more days shooting quail with the Vice-President. But he must be hoping that next time he won’t be mistaken for a potential dinner.