An Interview with Robert A. Margulies, M.D.
Interview by Gila Hayes
Who better than a recently retired emergency room physician to teach about the seriousness of severe injury or death from ostensibly unarmed attackers? Recently, I had a long talk about injuries sustained in empty-hand attacks with Robert A. Margulies, MD, MPH, FACPM, FACEP (L), FACFE (L) who combines 50 years as a physician in emergency medicine, certification as an aircraft accident investigator, and a depth of experience from his first career in the Medical Corps of the US Navy where he doctored in austere environments and earned “dolphins and wings,” submarine warfare and senior parachutist and flight surgeon insignia. He headed several air medical programs after retiring from the Navy and continued his work in emergency medicine, while also making time for volunteer policing, teaching self defense and survival classes and practicing martial arts.
Over the years, I’ve referred people asking questions about head injury lethality to Dr. Margulies’ interview archive in our December 2015 journal. The dangers, however, go beyond brain injury. Increases in violent crime and large-scale release of violent offenders to America’s streets, suggest continued if not greater risk from empty-hand attack. Unfortunately, there’s a lot of misinformation about the seriousness of bodily harm an aggressor can cause with empty hands. Let’s switch now to Q & A and get a reality check from Dr. Margulies.
eJournal: Sometimes the news suggests that there’s little to fear from “just a beating,” and pundits rail against police when a violent aggressor is shot. The outcry makes people question whether a deadly force response is ever appropriate against physical attack because, having no first-hand experience with purely physical violence, many fail to grasp its risks.
Dr. Margulies: I do not think that people understand the dangers of the open hand. According to national statistics from 2021, more people died from hands and feet – and that includes boots, of course – than from all the rifles combined. Our “devastating” MSRs (modern sporting rifles) and hunting rifles and .22s were used to kill fewer people than hands and feet. (See https://ucr.fbi.gov/crime-in-the-u.s/2019/crime-in-the-u.s.-2019/tables/expanded-homicide-data-table-8.xls ) That does not include the falls that come from things like the knockout and pushover games.
There are some other interesting statistics. The Northeast and the West have a higher percentage of people who die as a result of hands and feet than the Midwest and the South. 5.9 and 6.0% of homicides are by hands and feet in the Northeast and in the West. The highest is the 6.0 in the West. Blunt-object weapons – hammers, golf clubs, two by fours, tire irons, fire extinguishers – are not included in the 5.9 and 6.0% of homicides by hands and feet! It is really a pretty phenomenal number because even more people die from those injuries. Now, that statistic does not include handguns. In criminal homicide, handguns are still far and away the most reported means.
eJournal: Still, we focus on handguns and ignore the danger to personal survival from empty hands.
Dr. Margulies: The risk of death or permanent disability or disfigurement is really quite high when you think about all the ways that it can happen. Let’s start with something simple: a finger in the eye.
eJournal: That’s one I hadn’t considered. Can that result in blindness?
Dr. Margulies: Yes, if you are caught by surprise or temporarily disabled and somebody pokes you in the eye, you can be permanently disabled. In martial arts, we learn to make people move their heads because it takes their eyes off the target. It is a simple thing. Have somebody stand in front of you and rapidly, and without warning, just bring your hand up towards their face [mimes pulling his head back abruptly]. It is a natural reaction. They can’t see you and you are now at liberty to do whatever you want. How much worse is it if somebody punches you in the eye?
The open hand slap to the side of the head, to the ear, can, first of all, if it is done properly, rupture the eardrum which causes immediate nausea. Frequently, it causes vomiting and that leaves you pretty defenseless. If it is done properly, an open hand slap to the side of the head also transmits that force to the balance organ, which is the inner ear, and not very far in, but if you rattle the balance organ, people become unstable.
Dr. Margulies: If someone knows what they are doing, they can inflict devastating damage with an open hand. Literally. It depends on where you strike somebody. A strike to the neck? That can crush the larynx. There are major blood vessels on both sides of the neck, and from a martial arts perspective, there are well known pressure points which can have a devastating effect. We learn these things, but we do not practice because they can be fatal, instantly.
Any blow to the head – it does not have to get to the ear – just any blow to the head, or rapid turning of the head, stimulates the balance organs, changes the eye position, and in many cases, is stunning depending on how strongly it was delivered. How long? 2 to 3 seconds. How much damage you can do in 2 to 3 seconds?
When we did the 2015 interview, we talked about the knockout game. Remember, it is not just the initial blow that does the damage. When the skull hits the concrete, the brain keeps moving. Well, the same thing occurs when you slap the head. The head turns, the brain starts to spin, and then the brain doesn’t stop until it hits the other side. If that is done fast enough, the injury is the same. It may not be as extensive as when the brain smashes into the skull from a 6-foot fall. While 6 or 8 inches is proportionally less, it is still damaging.
eJournal: As bad as traumatic brain injury is, what about blows that shatter bone? I knew an officer who changed careers after suffering an orbital fracture during a fight with a suspect. What other injuries result from blows to the head?
Dr. Margulies: When the nose gets hit, three things happen. The eyes close, the eyes begin to tear, and the head moves back. A blow to the nose by a martial artist can be fatal because you can literally push the bone up into the brain. I am not sure that most of our teen-aged thugs know that, but that does not mean that it cannot happen accidentally.
Bad things can happen when we are dealing with blows to the small, thin bones of the sinuses and the nose, because the lower portion of the skull above the nose behind the forehead [indicates brow ridge] is a fragile area. It is called cribriform plate because it is perforated. It is very thin, and it is perforated because that is where the nerves from the nose go. That is why it is so easy, if one knows what one is doing, to push that bone right up into the brain. That’s the brain on the other side of the cribriform plate!
Draw a line between your ears and see where it goes. [Demonstrates drawing index fingers forward from ears to under eyes across the bridge of the nose.] Think about anything on that line, front and back. On the back, the spinal cord exits the skull on that line. A sudden movement can jar the base of the brain which has the breathing and circulatory centers.
In mixed martial arts and in cage fighting there are rules. You cannot hit anybody in the back of the neck just like you can’t strike somebody in the eyes or kick someone in the testicles. There are no referees and rules on the street.
eJournal: Vulnerability in the back of the head and the back of the neck reminds me of recently talking with a man who suffered several surprise attacks from behind. He couldn’t see them coming, so could not deflect or get out of the way. Your explanation about the vulnerability of spinal cord, nerves, and more below the occipital ridge, shows how serious those assaults were.
Dr. Margulies: Put your finger on the nuchal ridge and then run your finger down until you feel a little bump. That bump is the spine of the first cervical vertebrae and where is it? It is right on that line I had you draw, so I am more worried about the area on the line.
eJournal: At the risk of saying, “But wait there’s more!” we should explore the risks of strangulation or of being choked.
Dr. Margulies: Aside from stunning somebody and probably putting them on the ground, a blow to the carotids has two implications.
Because there are pressure points along with the carotid artery that will literally collapse the nervous system, what if a blow to the carotids puts you on the ground and somebody kicks you?
Trauma to the carotid artery is also associated with an increased incidence of carotid aneurysms. An aneurysm is an area of the artery that is weakened and expands. We hear about aortic aneurysms a lot. People die because the aneurysm bursts. Well, you don’t do well if the carotid artery bursts. Somebody who gets struck in the carotid artery, may, six months later, literally fall over dead, and we later learn that they got hit there six months, a year or two years earlier. We have to protect these areas.
You asked about strangulation. Normally, the brain runs out of oxygen in roughly 20 seconds, but if choking occurs during an altercation, you have 4 to 6 seconds because during an altercation, there is already increased blood flow and increased consumption of oxygen. The brain is working harder; it consumes oxygen during physical activity as well as mental activity. Choking shuts off blood flow up and blood flow down. Oxygen is consumed. The brain does not have storage of oxygen like in the muscle cells, so without oxygen, brain cells start dying.
Some of this has never been tested. There have not been functional MRIs done while someone is being choked to see what the brain is actually doing. What we know of these time frames is by inference, from what we see in martial arts, combat and police work. The shorter 4 to 6 second times are an inferential number based on observations, and statements by people who a) have had it done to them, and b) who learn how to do it properly and recognize that the individual has gone limp.
Air chokes or strangulation occurs when breathing is restricted, as seems to have been the case in the George Floyd situation; but can occur in many mechanisms.
eJournal: There are ways to get out of choke holds that use leverage, not size or strength, but that’s a lesson for a physical skills class. Moving down to bigger targets, what concerns exist if we’re hit in the torso?
Dr. Margulies: Here’s one: A punch to the chest. The youngest one I ever had was a 12-year-old girl who ended up in the ICU from a punch to the chest by another 12-year-old girl on the basketball court. It caused a cardiac contusion, bruising of the heart muscle, and she had a heart attack. We still don’t know what happened to Damar Hamlin, the football player. My personal opinion? His collapse fits a guy who gets hit by a knee to the chest. If you take a knee to the chest, how long do you have? Well, you have 8 to 20 seconds because although your heart has stopped, your brain is still dealing with oxygen that is already there. You stand up and then your brain runs out of oxygen, and you fall over. Is that what happened to Hamlin? I don’t know. Is it plausible? Yes, it’s definitely plausible.
Take a kick or blow to the front, and there is risk to the heart. If it is down a little lower, we have spleen and liver and, in the back, we have the kidneys. The kidneys are right at the level of the lower ribs which are, effectively, unsupported. A properly placed smack to the 12th rib can dislocated it and cut a kidney.
I know martial artists who can crack ribs with their open hand – no weapon. Once bone breaks it has sharp edges and depending on where it is, can puncture a lung and cause a pneumothorax. A pneumothorax, in and of itself is uncomfortable, but if we are young and healthy, we can breathe just fine on one lung – for a while. It is still a serious injury. On the other hand, if it becomes a tension pneumothorax, it can be rapidly fatal.
A tension pneumothorax occurs when the air can get in, but it can’t get out. You get what we call a flap valve. You breathe in, the air comes in; you breathe out, the air can’t get out. Every time you breathe in, you are increasing the air pressure and it starts to push the heart to the other side. You can actually see the trachea being displaced but it is not the airway that gets shut off. The displacement kinks the blood vessels and shuts off blood flow.
eJournal: Before mentioning damage to lungs from ribs, you talked about laceration of spleen, kidneys, or the liver. How much time is there to get medical help?
Dr. Margulies: It depends on what part is injured. Liver, spleen, and kidneys will all bleed internally, the question is whether it actually involves a major artery. If the injury involves a major artery, it is very rapid. I had a colleague who was doing a lockout from a submarine with a SEAL team. After about 70 minutes in the water, he came back in and started feeling something was wrong. He took his pulse. He was tachycardic: his heart rate was too fast. He had bumped his left side on the hatch getting out of the submarine and the blunt force injury lacerated his spleen. He put two IVs into himself, called for an air lift, and had his spleen removed in the military hospital in Seoul, South Korea.
eJournal: How quickly might he have died if he had ignored that he did not feel right?
Dr. Margulies: About four hours later he would have been dead. My young doctor friend was very fortunate. His injury was to the lower part of the spleen, and it did not involve a major branch of the splenic artery. Had it been a major branch, he would not have survived an air evac.
Are these dangerous? Yes, they are. The question becomes, how dangerous? They are more often longer-term problems, meaning hours, not minutes. They are not fight stoppers. We have cases of people who have been shot in the liver and continue to fight.
There is that infamous case of a patrol officer who was shot in the back with a 7.62 x 39 at about 60 yards. He felt it hit his soft body armor, but he solved the problem, then when everybody else arrived, he said, “I’m fine; I will go to the hospital later.” He refused to allow himself to be stripped and examined although he’d been in a gun fight. About 20 minutes later, everybody is getting ready to go back to their cars, and he falls over dead. That is really a tragic case. He did not want to admit that he could have been hurt. That happened because of the adrenaline.
eJournal: Even though that was a penetrating injury it gives an especially important lesson about blunt force injuries that can be fatal several hours after they happen. Like the officer, the temptation is to say, “I am unharmed; there are no marks on me. I do not need to be checked out by a doctor.” Get medical attention after a fight! Let’s see, we were at the spleen, liver, and kidneys. What other vulnerabilities to blunt force do we need to acknowledge?
Dr. Margulies: As we move down the body, sticking with the torso, I want to make it clear that there’s still a whole lot to be aware of. A punch to the abdomen, whether delivered intentionally or accidentally, will cause you distress. It is going to make you unable to immediately defend yourself. That’s why, if it ever happens in the ring, the ref stops the fight immediately. Out there, there is no ref. On the same line, is the spine. Somebody who hits you or elbows or knees you on the spine can cause significant damage. There are lots of strong ligaments that hold us up. The ligaments don’t give. If you get a blow that rips a ligament, the entire spine is now unstable. If the cord is cut, you may be paralyzed.
Moving down the body, we get to the genitals, it does not take much for people to understand that a kick is going to cause some problems. That is not the end of the story, though, somebody who kicks you in the knee and dislocates your kneecap, is going to put you on the ground and that is not a good place. If somebody stomps on your foot – think about what happens if you stub your toe and take that up a magnitude – it is very, very disconcerting.
What about the arm? It is easy to dislocate the elbow if somebody catches your arm while you’re trying to defend yourself. Dislocating the shoulder is a little more difficult, but it happens. Injury to the elbow, to the wrist, fingers breaking, these are things that are not uncommon in the emergency department. It is unusual if you don’t see boxer’s fractures – injury to the fifth metacarpal – one every Friday night, two on Saturday and two on Sunday! The point is it is not hard for a boxer’s fracture to happen. Even if you are defending yourself, if you hit wrong, you can disable yourself.
There are little things that are not taught in Phys Ed that people should be taught about stabilizing joints or how to take a fall. This is not martial arts! This is just how to safely go to the ground, just how to deal with some of the day-to-day occurrences. You stumble and you put your hand out to catch yourself on a wall. Do you know how to minimize damage to your joints?
I am not talking about martial arts; a physical therapist could teach things like balance exercises. We are willing to spend so much money on our cars, we are willing to spend lots of money on our houses, we spend lots of money on our guns and ammunition, but what about us? The house, the car, the guns are not worth anything if we cannot use them.
eJournal: Several times, you’ve referenced the abilities of a skilled martial artist, but what about risks from empty hand attack by an emaciated, drug-addicted gang member? To inflict the kinds of injuries we have talked about today, what kind of physical size, strength or prowess is required? Can a small assailant do the same?
Dr. Margulies: Yes. It has more to do with angles and force than it has to do with size. Now, can force be correlated to size? Sure. Your 250-pound lineman can certainly push harder than your 105-pound 5’ 1’’ tall female. On the other hand, that 5’ 1’’ inch tall female has smaller knuckles, so that whatever force she generates is more pounds per square inch. If he generates 150 pounds over 1 1/4 inch and she generates 50 pounds over half an inch, she can bust your rib.
I’m relatively small. I’m 5’ 9’’, about 160 pounds, so the people I work out with are all bigger than me. I learned that I can’t take that first punch; I have got to get inside. When I get inside, I can do damage with knees and elbows and fists in close. That is on people wearing pads of course, I am not hurting anybody – but that is how we train. The 6’ 3’’ guy with 8 inches more reach, can stand off and pick me off. I can’t let that happen. I have to get inside. People have to know what their limits are. I am too old to get on the ground and roll around anymore and I don’t want to. I try to keep my awareness level really high, so I don’t have to.
eJournal: There’s another danger from physical attacks. Everyone uses the phrase that they were fearful of losing their lives, but have we weighed the long-term implications of permanent disability? How do you get along if you can’t take care of yourself any longer? You spoke of the danger of abdominal injury. If an organ is irreparably damaged, do we ever regain our health after that?
Dr. Margulies: The law says justification for self defense is fear of death or permanent disfigurement or disability. How happy would you be if instead of your knee being temporarily dislocated, all of your ligaments were shattered? Maybe it can be repaired, maybe you will have a permanent limp, maybe you will always have a stiff leg or an artificial leg. It changes your life. Can other injuries kill you or cause you permanent disability? Absolutely. Cardiac injuries, spine injuries, liver injuries – no question. If you lose your liver, you’re dead, so you will need an artificial liver or a liver transplant. You can live without a spleen. A kidney? You’ve got two; you can give one up, but you only have one brain.
We have to protect our brains. The most devastating injury is an injury to the head. Unquestionably. When I teach survival, I ask people what is your most important survival tool? They whip out their lighters and their knives, but no, this is it [pointing at his forehead]. The brain is what we have to protect because the brain is the only thing that separates us from the Void. We don’t have the claws of the tiger, we don’t have the fangs of the wolf, we don’t have the hide of the elk. They live differently than we do, but we can live in all of their environments because of our brain.
eJournal: When we talk about defense against physical attack, our minds race forward to countervailing force, be that defensive tactics or firearms. You mentioned awareness when you commented that sparring practice taught you to act quickly to avoid taking the first hit. We, too, need ways to be faster to react to avoid threatened danger. When we come back next month, I would like to apply what you’ve taught us about the risks of blunt force trauma from empty or open hands, so we don’t miss how many solutions precede a decision to use deadly force.