Understanding Blunt Force Trauma Lethality
An Interview with Dr. Robert Margulies
by Gila Hayes
The long-time standard for self defense allows use of force proportional to that used by the attacker. A common misunderstanding arising from this general guideline is the very real danger of crippling or even lethal outcomes from blunt force injury inflicted during a purely physical attack. Can the armed citizen justify defensive display of a firearm or shooting to stop a physical beating?
It is not hard to find reports of deaths from blunt force trauma. In 2011, a 25-year old man took a $5 bet to be punched in the face by a woman. The autopsy showed that an artery burst in his neck and that he died from brain hemorrhage caused by blunt force trauma. At 5’5”, 142 pounds, the woman was reportedly not a bodybuilder nor was she trained in martial arts nor did she possess any extraordinary fighting skills.
Another well-publicized case from 2011 tells of a tourist in Las Vegas who was punched, fell to a tile floor and hit the back of his head. At trial, a Clark County, NV forensic pathologist identified the cause of death as blunt-force trauma from hitting his head on the floor.
In 2013, a large, 17-year old player punched a soccer referee in Utah in the face. A week later the ref was dead, having gone into a coma with swelling in his brain.
North of Seattle, WA in 2014, two teens agreed to resolve a fight by allowing one to punch the other in the face; he died from blunt force trauma to his head, after being hit in the face with a closed fist.
These are only a fraction of the many anecdotal reports of death from an empty hand attack. Still, society and the criminal justice system are eager to prosecute those who use guns to defend against ostensibly unarmed assailants. To offer just two examples, in Wyoming, a murder conviction was overturned in late 2013.The Wyoming Supreme Court found that a Freemont County prosecutor’s closing statements to the jury were inaccurate, asserting in part, “In the state of Wyoming, there is a law against shooting an unarmed man.” (http://www.courts.state.wy.us/Documents/Opinions/2013WY118.pdf) Oregon courts also have sometimes failed to acknowledge fists as dangerous weapons. (http://law.justia.com/cases/oregon/court-of-appeals/1975/540-p-2d-394-2.html).
All across the country, armed citizens face punishment for justifiable use of countervailing deadly force, and they are jailed, often prosecuted, and face a very difficult, uphill fight to prove the necessity of their use of force against an assailant’s fists, feet, knees and elbows. A big part of defending use of force is being able to document knowledge of the danger prior to facing the threat.
With that in mind, we called on long-time emergency medicine physician and Network member Robert A. Margulies, MD, MPH, FACEP to explain blunt force trauma injuries in this first segment of a two-part study of defending against physical attack. In addition to a long career in emergency medicine, Dr. Margulies is a skilled lecturer whom I was privileged to question at length on this topic recently. We switch now to an interview format to share his words with readers.
eJournal: Cases in which people died after a single punch bring us to a surprising conclusion about the human body’s fragility! To get us started, could you identify areas of greatest vulnerability to blunt force trauma of the sort an empty-handed aggressor could inflict with such immediacy as to result in death or such disability that we would be unable to seek out and benefit from medical intervention?
Dr. Margulies: The real answer is, “It is anywhere.” The fact that a blow to the nose can produce tearing, as it almost always does, means that you can’t see what is coming and that puts you at a tremendous disadvantage for the rest of the attack. Once you are tearing, you don’t know whether the aggressor is reaching for a weapon of any kind, so a blow to the nose, certainly a blow to the eyes, would render one at a great disadvantage.
There are places that are more likely to produce devastation from the initial blow, and those would include again, that blow to the nose. If it is properly delivered, an aggressor can break the nose bone and drive it up into the brain.
A blow to the temple area where the skull is relatively thin can actually cause a fracture in that area and tear the underlying artery. This can produce permanent disability, and can cause death.
A blow to the back of the neck can dislocate the spine and cause paralysis or death. These are things that one does not really have to be a trained martial artist to do. Blows to the nose, to the back of the neck, to the throat are examples of “empty hands” that can produce disability or death.
Head and face trauma has an interesting aspect to it. It is not just that somebody has been hit in the face, but bleeding and swelling of tissues can also lead to airway blockages. Bleeding in the mouth can lead to swallowed blood, which is very irritating and can cause vomiting which puts somebody at a disadvantage, but also leads to the risk of aspiration. That is, the vomit is trying to come up and out, and you’re trying to breath in, and you suck some of this stuff down into your lungs. All of these things can become fatal, even though this was just a broken jaw and a little bleeding.
A blow to the ribs can cause injury to the liver or the spleen, both of which, in the vernacular, bleed like stink. Surgery is extremely difficult because the liver and the spleen are not like muscle where you can isolate a blood vessel and get control, they’re spongy and trying to suture is like trying to sew gelatin—it is difficult! It requires a highly trained team to be able to salvage somebody who has a shattered liver or spleen. Spleens can be removed and the patient can survive. Humans do not do well without a liver.
eJournal: Do we no longer have the luxury of using the word, “just” when discussing physical attack? We want to deny our vulnerabilities, so we use words like “only” when the domino effect you just described can kill. The direct damage, plus the potential for additional effects, is profound.
Dr. Margulies: Most people are mis-educated by what we see in the movies and on television. Just as a bullet from a handgun does not pick people up and throw them against the wall, in the real world, one does not sustain a blow to the head, the kick to the chest, and then stand up and produce his magic fight-ender. That’s fantasy! That’s not the real world. It doesn’t happen that way. You get hit in the head, you go to the ground, and you are badly hurt.
eJournal: Returning to something you said earlier, are these injuries that do not require training or any particular expertise to inflict?
Dr. Margulies: Unequivocally not. I consider hands and feet, knees, elbows and shoulders, to be deadly weapons. Once that first blow is delivered and once you go to the ground, the kick to the head, the knees in the chest, may produce permanent injuries and fatalities. I’m going to give you a reference to an article in the Journal of Head and Face Medicine, published in October 2005 (see http://www.head-face-med.com/content/1/1/7 - B10). One of the comments in it is that as of 2005, we in developed countries have a level of facial injuries caused by interpersonal violence exceeding those from motor vehicle crashes. This is not a new concept or a new problem.
eJournal: Some of the deaths I’ve read about appear to be caused by what you might call the secondary injury resulting from a blunt force attack, the head injury suffered when the victim falls down. What is the physical cause?
Dr. Margulies: The brain is gelatinous and is not a very strong structure, not like a muscle. This gelatinous structure rests inside the bony vault and it is bathed in fluid. Around the age of 40, the brain actually begins to shrink. The skull does not. We now have this gelatinous structure in more fluid. That means it can move and it displaces the fluid as it moves.
A blow produces an acceleration force and so if you’re struck–let’s just pick a spot–in the forehead, the skull begins to move backwards while the brain lags. It sits there and first, the forehead bone actually strikes the brain, then, in many cases, there is the secondary acceleration and the brain moves away and now strikes the back of the skull and there’s additional injury at the other end. The technical term is contra-coup. It is the secondary injury due to the brain’s movement within the skull.
If that initial blow to the forehead drives the head back into a wall or the head restraint of the car seat, the skull stops and the brain continues now to bang into the back of the skull, we have two points of injury.
If you fall and you have the gravity effect in addition to the impact effect, and the head now hits a hard surface–and by the way, that could be a grassy field–that secondary impact brings the skull to a sudden stop. There’s been the additional time and energy developed by the movement of the skull and brain between the initial impact and now when it hits the ground, the concrete, the post or the fence, that exacerbates the secondary injury.
The injury may not be something that we see with the naked eye. We know that a concussion, for example, which renders a football player, a boxer or any martial artist dizzy, light headed, having difficulty focusing–both with the eyes and the brain–frequently does not produce an injury that is seen on a CAT scan. The injury is within the blood supply and neurons themselves and they lose the ability to transfer information. That is what the nerve cells do: they move information from one place to another. So the concussion without a visible, anatomic injury is a disabling injury.
eJournal: What losses should we expect from injury to different parts of the brain?
Dr. Margulies: The lower portion of the back of the brain is where we see. The information is transmitted through what appears to be a fairly long channel from the eyes to the occipital lobe at the back of the brain where we have our visual cortex, the part that interprets the electrical and chemical impulses that are generated. It is not the eye that sees, it is the impulses from the eye that are interpreted in the visual cortex, so striking the back of the head can render someone temporarily unable to see clearly. That is a disabling injury.
As I mentioned earlier, other areas that are more easily damaged are the temporal areas just above and slightly forward of the ears. An injury there can produce an electrical storm in the sense that bony fragments penetrate the brain. Though there is no pain involved–the brain itself does not have sensory nerves–the impact and the fragmentation produce an electrical shock wave through the brain. That’s in addition to the bleeding if the temporal artery is torn. Again, that renders the individual disabled in terms of mounting a reasonable defense.
eJournal: Would a victim injured in that way by an attacker who didn’t stick around, be unable to seek medical assistance or provide self-care to mitigate the damage?
Dr. Margulies: The point that has been all too long ignored in the justice and legal system is the unprovoked attack puts one in a very dangerous situation. In a dark alleyway, or a subway station after the train has pulled out and very few people are there, that initial impact can produce injuries that without immediate care can be fatal.
eJournal: If victims realize they’ve suffered a head injury, what should they do?
Dr. Margulies: If the individual is awake, breathing and talking, there needs to be an evaluation. It is not the same urgency as a cardiac arrest or someone who is not breathing, but I go back to the concussion: we have raised a generation of athletes who have long term permanent disabilities as a result of repeated concussions. In the State of Washington, several neurosurgeons and others involved in this kind of thing were responsible for the passage of the Lystedt law. Zackery Lystedt was a young football player who was badly concussed, went back into the game and received a second injury, and now has permanent disability. Anybody who receives a head injury that, in the vernacular, “rings the bell” or “sees stars,” should be evaluated.
eJournal: Is there a “golden hour?” What’s the timeline?
Dr. Margulies: The brain itself does not have any ability to store oxygen or glucose, the energy fuel. The muscles, the liver and some other organs have the ability to store glucose at least as glycogen, and they can then maintain themselves even in the absence of blood flow for a certain amount of time. A little bit of a digression: we know that we can put a tourniquet on in the operating room for surgery and we have five to six hours before there’s permanent damage in skeletal muscle. That is not true in the brain! In the brain, 20 seconds without oxygen is about all we can get.
If there is bleeding into the brain, the bleeding–aside from the injury that resulted in the bleeding–produces pressure. That increased pressure causes a loss of circulation in the surrounding tissues and widens the injury. If a victim can be brought to a place where the diagnosis and then the surgery can be performed promptly by removing that blood or stopping the bleeding and reducing the internal pressure, the brain function can be preserved. So, yes, if there is an injury where there is bleeding, time is of the essence.
eJournal: And there are diagnostic tools to show the bleeding?
Dr. Margulies: Oh, yes! The CAT scan is remarkably sensitive for that, so we can see bleeding promptly, but you have to be someplace where a CAT scan is available, and then you have to have the surgeon and anesthesia and team to proceed to do what needs to be done. Receiving such an injury, and being left to lay in that subway station or a dark alley for an hour or two hours, may produce irreparable damage or death.
eJournal: That explains many of the anecdotal reports we study in an attempt to define the seriousness of a physical attack.
Dr. Margulies: The body is really quite fragile. Someone who has any training in the martial arts can break bones or dislocate joints rapidly. There are lots of places where the injury renders you unable to defend yourself. There are lots of places on the body where a blow produces that level of disability. If one is, in the vernacular, kicked in the nuts, that in and of itself produces a fair amount of pain and results in what most people would refer to as going into a defenseless posture. If the blow is delivered properly, and the testicle itself is actually shattered, not just bumped, the body’s response is a collapse to the knees and vomiting.
A blow to the mid back that strikes the kidney produces the same kind of response, perhaps not the vomiting, but a collapse to the knees and a defenseless position. The bare hand or the foot or a knee or an elbow, can produce that disability that leads to an inability to defend yourself. And it only takes one blow!
eJournal: Are these results physiological, or is the victim too weak to work through the pain or failing to “man up?”
Dr. Margulies: These are physiological responses. They are not a result of intellectual, emotional, psychological or physiological weakness. These are blows that produce an inability to defend oneself. You’re on your knees, you are trying to grasp the area that’s been hit, and your head and face and neck are defenseless.
eJournal: You mentioned blows to the chest in some of our initial discussions. You cited one case in which a young female athlete was struck in the chest. What happened?
Dr. Margulies: She had an enzyme and electro-cardiogram proven heart attack. We call that a cardiac contusion. Actually, it is more common in the elderly because we do not have the flexibility in our chest walls. The cartilage becomes calcified, the ribs become more rigid, things break more easily, and the sternum itself loses some of its flexibility at its joints. The sternum is not a single bone: it has three separate sections. A properly delivered blow to the sternum can shatter it and lacerate the heart.
eJournal: That echoes concerns over disparity of force for the elderly.
Dr. Margulies: As we get older, we lose our flexibility. Our joints aren’t as limber. There are very few 70 year olds who can do what a 30 year old can do. We lose muscle mass as we age; we have decreased responsiveness in our hearts and our lungs. Even our adrenaline reaction goes down as we grow older. There is a significant disparity of force between your 60 year old and your 30 year old, even if the 60 year old does not have a heart condition or lung condition or preexisting medical problems: a healthy 60 year old is at a disadvantage physiologically against a healthy 30 year old.
I think that from our mid-sixties, the average individual really has to appreciate that it is the rare individual who gets past their mid-sixties and does not have some physiological changes. All of those physiological changes in aggregate produce a greater risk of injury. There is also the psychological component: people don’t want to appreciate this!
eJournal: After a long career in emergency medicine, do you view the threat of empty handed assault differently than most citizens? How does that factor in to your decision making as an armed citizen?
Dr. Margulies: I think I do look at it differently than the average person. I am a little stranger than the average bear. I never go through a door without looking up and in all directions, including up. I don’t think about it anymore, but I know I do it.
I pay very, very close attention to people’s faces and hands. I think that people need to learn to read that clenching fist, that lifting eyebrow, that cold stare. I learned that lesson very, very young. I was a senior medical student doing a psych rotation at a VA hospital and I approached a drunk carelessly and he managed to clip me. Fortunately, there was an aide in the room who saw it coming, blocked some of it and was able to take care of the problem very effectively. I can honestly say I have been studying this since 1968.
I think people really do need to pay attention to what is going on, on the other side of the street as you are walking. I think you need to pay attention to the rear view mirror when you are driving. What is going on back there? Is traffic parting and cars speeding? I want to get out of there. Is it a couple of drunks racing or are the police chasing an armed perp? I do not want to be sitting in the middle lane at the speed limit when there’s high-speed stuff going on around me. I want out of there. You have got to watch your rear view mirror: look at it, pay attention!
The world is a beautiful place, but a cobra is beautiful, too! I think we need to be careful. I think we need to understand that if somebody is approaching you and they’ve got clenched fists, you need to be prepared. I think that Marc MacYoung is a wonderful resource. At my age, I need to be prepared to give them a “Don’t move!” I need to be prepared to present my firearm because if their fists are clenched, the question is “why” and I can’t wait until I get hit. I’m not prepared to let somebody use me as a punching bag.
My explanation? If I ever have to, I can and I will describe what I saw, what it was that triggered my response, and I have the benefit of being able to explain that I know how dangerous a fist or a foot is. It doesn’t even have to be a fist. There are open hand blows that are very dangerous. There is a whole vocabulary of strikes from fingertips to open hand to edged hand to forearm, to elbow, to shoulder, to knees to feet…and I know how dangerous they all are. My hope is that other people are motivated on the basis of what you’re going to write to do some study about this, so they are prepared to say they understood what this was. If you can’t explain it, you are going to get hung.
eJournal: You have given us an excellent foundation from which to pursue further study, and I promise we will do exactly that. Thank you so much for sharing your expertise and knowledge with us.
Dr. Robert Margulies and his wife Sara Baron, RN, MS teach firearms safety and use, personal safety in both armed and unarmed environments, as well as wilderness survival and other safety topics through International Emergency Consultants in Richland, WA. To learn more about their work see http://i-e-c.org/instructors/ or get to know them on Facebook at https://www.facebook.com/InternationalEmergencyConsultants/.
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