A 54-year-old woman collapsed behind the counter
of a small neighborhood market. She was discovered a few minutes
later by a customer, who immediately called 911. On arrival,
paramedics found the patient unresponsive, with poor respiratory
effort and a barely palpable pulse. Initial treatment included
fluid resuscitation and external pacing for a heart rate in the
40s. The patient was transported to the nearest emergency
department (ED), where an initial chest x-ray suggested congestive
heart failure. Rather acutely, the patient became pulseless, and
CPR was initiated as the patient's cardiac rhythm went from
bradycardia to ventricular fibrillation, and then asystole. The
patient was pronounced dead after an hour of failed resuscitative
paramedics later returned to the ED, which, of note, was not a
trauma center. The ED physician informed the paramedic team of the
patient's death and reported that the patient had a tiny amount of
blood on her left nipple, which he attributed to chest
compressions. Together, the paramedics and the ED physician
examined the patient's clothing and discovered a drop of blood
inside her bra and a small hole in the bra itself. Further review
of the admitting chest x-ray indicated the presence of a small
caliber bullet in the area of the left ventricle, which was
initially thought to be a cardiac monitoring electrode. The medical
examiner was notified of the possible homicide, and an autopsy
confirmed that a bullet likely lacerated the patient's left
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