I am sitting in the emergency room with a co-worker who just got shot in the neck and upper arm by a random shooter. It was a bloody mess. This may seem weird, but I’ve never been in an emergency room or a hospital since I was born. What will happen to her?

Patients who come to the emergency department with gunshot or bullet wounds are treated first for blood loss and shock. Once the bleeding is stopped and she is stabilized, surgery will probably be done. The first thing the surgeon does when a patient arrives with an injury of this kind is get a good history of what happened, how it happened, and when it happened.

Then a physical exam is performed including all sorts of special tests designed to figure out what got injured, where, and how bad is it. Nerve injuries are common with open wounds like this. The group of nerves in the neck and upper arm coming from the spinal cord and going all the way down to the hand is called the brachial plexus.

Imaging studies starting with an X-ray of the head, neck, spine, and upper arm may be followed up with CT scans, MRIs, and electrodiagnostic studies. There are even some specific tests that can be done to look for bone fractures and damage to the muscles, tendons, and nearby blood vessels. Injury to the blood vessels is common with some brachial plexus injuries.

Identifying specifics about injury to the brachial plexus help provide the prognosis and treatment plan. For example knowing that there is an avulsion injury (nerve is pulled right off the spinal cord) requires immediate surgery. A less severe injury with damage or stretch to the nerve but no rupture or tear to the nerve fibers has the potential for spontaneous recovery.

Surgical procedures to reconstruct nerves that have been damaged can include nerve transfers, muscle or tendon transfers, nerve grafting, and arthrodesis or fusion of the affected joint(s). The surgeon must work with both the sensory and the motor sides of nerve function. Without proper sensation, the patient can be at risk for other injuries or even burns because of a loss of sensation. Surgery isn’t the end of treatment. After surgery there can be weeks and months of rehab to restore arm and hand function.

No two injuries of this type are alike. The hospital and surgical teams will do everything they can to care for your coworker. Your friendship, support, and encouragement in the months ahead are going to be just as important.