But even a single penetrating wound to the pelvic region, which is densely packed with blood vessels, organs and other structures, is extremely dangerous, according to trauma surgeons and emergency medical personnel.
According to MedStar Washington Hospital Center, the rifle shot to the Louisiana congressman's left hip “traveled across his pelvis, fracturing bones, injuring internal organs, and causing severe bleeding.” He went into shock and within hours received many units of blood via transfusion and underwent two operations.
In an update Thursday evening, the hospital said Scalise had undergone additional surgery "related to his internal injuries and a broken bone in his leg. He remains in critical condition, but has improved in the last 24 hours." The statement also said further surgery will be required and that Scalise "will be in the hospital for some time."
Such details reflect the complexity of the pelvic area, which is home to the iliac blood vessels that include major arteries branching off the aorta — the main route that carries oxygenated blood to all parts of the body. Wounds to those vessels, large and small, cause fast, severe blood loss, which can set off a cascade of problems for surgeons trying to save a patient's life.
In fact, 30 percent to 50 percent of injuries to the main iliac vessels result in death, said Joseph V. Sakran, director of emergency general surgery at Johns Hopkins Hospital, who was himself shot in the throat after a football game about two decades ago when a fight broke out and someone fired into the crowd.
“When you look at the main cause of death in trauma, it’s hemorrhagic shock,” he said. In other words, rapid blood loss deprives vital organs of oxygen and nourishment and affects the normal balance of bodily systems. The kidneys can shut down. Body temperature declines. The level of acid in the blood rises. Other systems begin to work poorly.
Even if doctors are able to quickly replace all the lost blood, the effect is not the same as having healthy circulation. Blood clotting — which is critical to stanching internal blood loss — simply doesn't work as well, explained Lynne McCullough, medical director for the emergency department of Ronald Reagan UCLA hospital in Los Angeles.
“The more you bleed, the more blood we give you. The more blood we give you, it affects your ability to clot,” she said.
Survival, McCullough said, generally depends on numerous factors: the position of the body when it was struck and its distance from the weapon; the velocity of the bullet and the type used; the location of the entry wound and the path the bullet follows before it exits, if it exits at all.
Scalise appears unlucky for any number of reasons. Perhaps because of how he was standing when hit, the bullet traversed his pelvis, doing considerable damage along the way, according to MedStar's statement.
Bullets can ricochet off bone and change direction inside the abdomen, but it's not just the missile itself that causes trauma, said Faran Bokhari, chairman of the department of trauma and burn surgery at Cook County Health and Hospital System in Chicago, which sees 1,000 gunshot victims a year.
“There is a shock wave that accompanies that metal fragment,” Bokhari said. “It makes a track where it cuts through. … Everything above or below it is destroyed.” That track can be five to 10 times wider than the bullet, he added. High-powered rifles put vastly more energy behind a bullet than handguns do, increasing the damage, he said.
A patient with a wound like Scalise's probably could not survive the amount of repair needed all at once, Bokhari said, emphasizing that he did not have enough information to speak specifically about the lawmaker's injuries. Between procedures, he would be ventilated to provide oxygen, warmed and given fluids. Doctors would administer clotting agents and try to bring down the acidity of his blood.
In addition to blood loss, Scalise also suffered injury to “internal organs,” MedStar said, without specifying which ones. But they could include his intestines, liver and genitourinary structures, any of which may require repair after he is stabilized. There was no indication of nerve damage in MedStar's statement.
“The bottom line,” Bokhari said, “is that there are a lot of very, very important structures in the pelvis, and they’re all packed very close to one another.”
On Thursday, Scalise's condition had not deteriorated, according to other lawmakers. "Nothing’s gotten worse,” said Rep. Cedric Richmond (D-La.), whose congressional district abuts Scalise’s in New Orleans. Richmond, the star pitcher for the Democrats, visited the hospital twice Wednesday and planned another trip Thursday afternoon before the congressional baseball game.
Paul Kane contributed to this report.