Gunshot Victims Research Articles

Pro patria et spes gentis: military medicine, paediatric surgery and those who care for children

Children and military medicine have many links. On humanitarian and disaster deployments, the surgery of war has increasingly seen children as the focus of clinical salvage. When Romans spoke of children, they used the phrase 'spes gentis'-'the hope of the race'. In modern times, there developed a synergy, in the context of defensive war, that its prosecution depended not only on the defence of territory but also on its hopes for continuation of people and culture, into the future. In the 19th century, in Australia, several regiments had the motto 'Pro Aris et Focis'-'For the Defence of Hearth and Home'. Hearth implies the family and that implies children. From the point of view of an attending military clinician, the centrum of all medical care is the patient himself, and that centrality is reflected equally in the helplessness of a bomb-blast or gunshot victim as it is in the vulnerability of a sick or injured infant or child. The life and service of Major General Rupert Downes (1885-1945), whom the Downes Memorial Lecture commemorates, reflected this nexus. His career was that of a national leader in military medicine and that of paediatric surgery. The 2011 Rupert Downes Lecture explores and documents the extraordinary corpus of service of Australian paediatric surgeons and their contributions to military medicine from the 19th to the 21st centuries.

Social Networks and the Risk of Gunshot Injury

Objectives: This study investigates the relationship between an individual’s position in a social network and the probability of being a victim of a fatal or non-fatal gunshot wound.Methods: This study combines detailed observational data from the police with records of fatal and non-fatal gunshot injuries among 763 individuals in Boston’s Cape Verdean community. After creating the social networks of these high-risk individuals, logistic regression is used to uncover the relationship between the odds of being a victim of a gunshot injury and various network characteristics. Results: The probability of gunshot victimization is directly related to one’s network distance to other gunshot victims - i.e., the closer someone is to a gunshot victim, the more likely that person is to also be a gunshot victim. This social distance to gunshot victims operates above and beyond other types of exposure to gun violence. Younger individuals, gang members, and individuals with a high density of gang members in their interpersonal networks are also at increased risk of being a gunshot victim. Conclusions: Risk of gunshot injuries in urban areas is more greatly concentrated than previously thought. While individual and neighborhood level risk factors contribute to the aggregate rates of violence, this study suggests that most of the actual risk of gun violence is concentrated in a small social network of identifiable individuals.

Reply

We appreciate the reviewer's comments. We present our review of a large cohort of trauma patients in a single institutional study over 12 years, with all the limitations entailed in a retrospective trauma registry database review. We agree that it would be interesting to stratify the immediate versus the delayed from the overlooked injuries that subsequently declare themselves. However, we are not able to stratify these diverse injuries with the currently available dataset in a meaningful manner. We appreciate this limitation of trauma registry databases after our experience with this review. In many urban trauma centers throughout the United States and the world, there is poor clinical follow-up in trauma patients in general, and in gunshot victims in particular. As such, detailed treatment outcomes and follow-up data are often not available. This is a limitation of trauma series throughout the contemporary literature and is ,unfortunately, all too frequent with trauma registry databases. Many trauma centers have their own trauma team, and Urology may be involved and involved early. However, sometimes the fact is that Urology becomes involved late or not at all. Whether trauma center teams engage their Urology service directly and early contributes to variability in treatment protocols and clinical outcomes between trauma centers. This further makes prospective investigation of the evaluation, management, and outcomes of this heterogeneous and complex population with gunshot wound injuries trauma very challenging. A comprehensive multidisciplinary approach involving the Urology service in the evaluation and management of gunshot victims is highly recommended. Editorial CommentUrologyVol. 76Issue 4PreviewThis is a well written, comprehensive review of one institution's experience with civilian gunshot wounds to the genitourinary (GU) tract and genitalia. The authors demonstrate a correlation of associated injuries to other organs, both urological and nonurological, thus demonstrating how a ‘magic bullet’ can cause more damage than one initially might think. Full-Text PDF

The elusive slug: bullet intestinal “embolism”

Bullet retrieval from the body of a gunshot victim is one of many tasks in post-mortem forensic examination. Rarely, it is complicated by the migration of the missile away from the entry point by vessel embolism. Abdominal firearm injuries, in which the bullet enters the intestines and moves inside the lumen away from the point of penetration, are even less common. We present a case of postmortem recovery of a bullet from the intestines of a gunshot victim who died 18days after being shot in the trunk by three low velocity bullets. A missile had moved within the colon during hospitalization and postmortem handling of the body and was recovered from the sigmoid colon. This case demonstrates an extremely rare type of bullet "embolism" and emphasizes the usefulness of CT scanning in the location of projectiles.

Insurance Coverage Is Associated with Mortality after Gunshot Trauma

Poor access to adequate health care coverage is associated with poor outcomes for many chronic medical conditions. We hypothesized that insurance coverage is also associated with mortality after gunshot trauma. The trauma records for gunshot victims and their insurance status were reviewed at our center from January 1998 to December 2007. Patient demographics (age, gender, race, and insurance coverage), injury severity, hospital care (operations and radiographic studies), and in-hospital mortality were analyzed. There were 2,164 gunshot trauma activations reviewed during the study period. One-quarter (n = 544) of these patients had insurance and three-quarters (n = 1,620) were uninsured. The in-hospital mortality rate was significantly higher for uninsured patients than for insured patients (9% vs 6%, p = 0.02). After controlling for age, gender, race, and injury severity by logistic regression analysis, the odds ratio for death of uninsured patients was 2.2 (95% CI 1.1 to 4.5). Insured patients did not differ from uninsured patients with respect to mean Injury Severity Score ([ISS] 12.2 +/- 10.7 vs 12.6 +/- 12.4, p = 0.56); similar percentages of patients were severely injured (ISS 16 to 24, 17% vs 15%, p = 0.19) and most severely injured (ISS > 24, 15% vs 16%, p = 0.68). Insured patients did not differ from uninsured patients with respect to use of radiographic imaging (53% vs 50%, p = 0.15) or operative intervention (37% vs 35%, p = 0.35). Despite similar injury severity, uninsured trauma patients were more likely to die after gunshot injury than insured patients. This difference could not be attributed to demographics or hospital resource use. Insurance coverage may reflect the many social determinants of health. Improving the social determinants of health in patients affected by violent trauma may be a step toward improving outcomes after trauma.

Body & brain: Gunshot victims have need for speed: Delay for spine stabilization doubles death risk, study finds

Body & brain: Gunshot victims have need for speed: Delay for spine stabilization doubles death risk, study finds

Where Do We Go From Here? Interim Analysis to Forge Ahead in Violence Prevention

The severity and disparity of interpersonal violent injury is staggering. Fifty-three per 100,000 African Americans (AA) die of homicide yearly, 20 per 100,000 in Latinos, whereas the rate is 3 per 100,000 in Caucasians. With the ultimate goal of reducing injury recidivism, which now stands at 35% to 50%, we have designed and implemented a hospital-based, case-managed violence prevention program uniquely applicable to trauma centers. The Wraparound Project (WP) seizes the "teachable moment" after injury to implement culturally competent case management (CM) and shepherd clients through risk reduction resources with city and community partners. The purpose of this study was to perform a detailed intermediate evaluation of this multi-modal violence prevention program. We hypothesized that this evaluation would demonstrate feasibility and early programmatic efficacy. We looked to identify areas of programmatic weakness that, if corrected, could strengthen the project and enhance its effectiveness. We performed intermediate evaluation on the 18-month-old program. We selected the Centers for Disease Control and Prevention-recommended instrument used for unintentional injury prevention programs and applied it to the WP. The four sequential stages in this methodology are formative, process, impact, and outcome. To test feasibility of WP, we used process evaluation. To evaluate intermediate goals of risk reduction and early efficacy, we used impact evaluation. Four hundred thirty-five people met screening criteria. The two case managers were able to make contact and screen 73% of gun shot victims, and 57% of stab wound victims. Of those not seen, 48% were in the hospital for <or=2 days. Fifty-four percent of those screened had identified needs and received CM services. Thirteen percent refused services. Of the high-risk clients receiving full services (N = 45), 60% were AA and 30% were Latino. Sixty percent of the AA had no contact with their fathers. CM "dose": In the first 3 weeks of enrollment, 40% of the time, case managers spent >6 h/wk with the client. Forty-one percent of the time, they spent 3 hours to 6 hours. Seventeen of 18 people who required >6 hours had two to three needs. Attrition rate is only 4%. The table demonstrates percent success thus far in providing risk reduction resources. WP case managers served high-risk clients by developing trust, credibility, and a risk reduction plan. Cultural competency has been vital. Six of seven major needs were successfully addressed at least 50% of the time. The value of reporting these results has led WP to gain credibility with municipal stakeholders, who have now agreed to fund a third CM position. Intermediate evaluation provided a framework in our effort to achieve the ultimate goal of reducing recidivism through culturally competent CM and risk factor modification.

An analysis of inner-city students’ attitudes towards violence before and after participation in the “Cradle to Grave” programme

Background Cradle to Grave (C2G), a hospital-based violence prevention programme, brings inner-city youth into an urban Level I trauma centre to follow the path of an adolescent gunshot victim from trauma bay to morgue. We hypothesised that C2G alters student attitudes towards gun violence. Methods Eighty-eight adolescents were prospectively enrolled. With parental and student consent, students completed the Attitudes Towards Guns and Violence Questionnaire (AGVQ), a previously validated and reliable social science assessment tool. Two weeks later, the students participated in C2G. The survey was re-administered four weeks after C2G participation. AGVQ results are reported both as a total score and as a breakdown of the four component subscales. Higher AGVQ scores indicate proclivity towards violence. ANOVA compared scores with respect to demographics and type of school (public vs. charter). Results C2G altered student's attitudes towards guns and violence. Of 43 public school students, total scores decreased following C2G ( p = 0.02). The greatest attitudinal change occurred in subscale 1, “Aggressive Response to Shame” ( p < 0.01). C2G failed to produce significant changes AGVQ scores in the 45 students attending a city charter school. The two groups were found to have baseline differences, with public school students showing higher baseline tendencies towards violence. Conclusions Our hospital-based programme is capable of positively impacting adolescents’ attitudes towards guns and violence. This effect is most pronounced in subjects who already display increased tendencies towards violence. These results suggest that hospitals offer a unique opportunity to address the public health crisis posed by inner-city firearm violence.

Injury Patterns of Female Homicide Victims in South Africa

Injury patterns and interpretation of injuries in homicidal deaths are important components of medicolegal autopsies. The objective of this article is to describe the incidence of female homicides and their related injury patterns with reference to autopsy practices in South Africa. A national retrospective mortuary-based study of homicides in women of 14 years and older in 1999 was conducted. Data were gathered from medical legal laboratory records, autopsy reports, and police interviews from a stratified multistage sample of 25 mortuaries. The most common cause of homicide was a gunshot wound injury, with a firearm mortality rate of 7.5/100,000 women, 14 years and older, in 1999, followed by sharp force injury (6.8/100,000) and blunt force injury (6.1/100,000). Gunshot victims were more likely to be African, and those killed by sharp force injury were more likely colored. Significantly, blunt force injury deaths occurred predominantly in intimate partner homicides. A full autopsy was performed only in 70% of cases. An assessment of postmortem reports revealed poor descriptions of the anatomic location of injuries and the specifications of wound dimensions. South Africa has a high female homicide rate that exceeds reported rates with the cause of homicide varying by social group. Assessment of injury description suggests weaknesses in the documentation of injuries at autopsy. This weakens the forensic investigation and undermines the strength of evidence presented in court. Further measures are needed to strengthen forensic pathology services in South Africa.

The Number of Gunshot Wounds Does Not Predict Injury Severity and Mortality

It is presumed that as the number of gunshot wounds (GSWs) increases, so do the Injury Severity Score (ISS) and mortality risk. We hypothesized that the number of bullet wounds relates to ISS and death; however, a single GSW to the head is ominous. We reviewed the charts of all GSW patients admitted to a trauma center from 2004 to 2006 (n = 531). We analyzed patient demographics, ISS, and mortality. There was no correlation with the number of GSWs with either ISS or mortality. There was only a 0.3 per cent increased risk of death for each additional GSW (r2 = 0.12). Patients with a single GSW versus multiple GSWs had no difference in mortality (9.1 vs 8.4%, P = 0.8). A single GSW to the head carried a 50 per cent mortality risk. For those who sustained both head and body GSWs, each additional GSW did not increase mortality (r2 = 0.007). Our study shows that the number of GSWs has no affect on mortality or ISS. Internal triage and management of gunshot victims should not be affected by the categorization of patients as having a single versus multiple GSWs.

Endovascular Neurosurgery: A History of Electricity, Balloons, Wires and Glue

Physicians may have first known what an aneurysm was as far back as the 14th Century BC in Egypt1, but by the early 19th century they were still trying to find satisfactory options for treating large or surgically inaccessible aneurysms.4,5 One of the techniques being considered was inserting a needle to provoke formation of a clot that would close off the aneurysm. The proof that this technique could work was discovered by C. H. Moore in 1864, during an autopsy of a gunshot victim. The bullet, lodged in the ascending aorta, was embedded in fibrin. Based on this, Moore speculated that a wire could be introduced into the body through a small wound, but then passed up to the aneurysm where it would coil and attract fibrin to block the aneurysm. Moore used 26 yards of coil to treat a thoracic aorta aneurysm; the patient died of sepsis, but the aneurysm had decreased in pulsation and size before that, and autopsy confirmed that the coils had promoted fibrin clotting as predicted. Later efforts trying a variety of materials, ranging from iron wire to gold-plated watch springs, also had poor outcomes. Attempts using electrical current to provoke clots during this period did not produce a consistent benefit either.5,6

Identity and violent death

During the Freedman's Cemetery Project of the 1990s, evidence of lethal gun violence was recovered archaeologically from several early twentieth century burials. Although lying in unmarked graves, those who died violently still have the chance of being identified through the very bullets that robbed them of their lives. Forensic identification of the bullets and other archaeological criteria are compared to descriptions of gunshot victims in newspaper accounts and other archival records, and individual as well as group identity is examined in the process. These moments of violence also provide a unique window into exploring the extent and underlying causes of violence perpetrated within and against the African American community of Dallas, Texas, in the first decade of the twentieth century,

19 A Novel Approach to Residency Education in EMS: The MD‐PM Ambulance

Challenge: Indiana University EM residents have actively provided prehospital care as crew members on a hospital‐based air ambulance service. This service functions as a secondary responder for high acuity patients who have already had first tier evaluation and care. First response, ground EMS experiences have been observational only as residents have ridden along with a two‐paramedic team on an urban ambulance service for 24 hours during their residency careers. Resident understanding of first response care and challenges faced by initial EMS providers has been limited to that gleaned during their observational period.Solution: Most EM residencies do not provide opportunities for residents to function as first response providers. Therefore, we developed a Physician‐Paramedic team to provide first response care within a busy metropolitan area. This two‐member team operates within a “geozone” that includes a diverse patient population with both medical and trauma complaints. Unlike other residency ground EMS programs, the MD‐PM truck responds primarily to all ambulance requests within their designated geozone and assists outside their designated geozone for multi‐patient casualties in which a physician response would benefit patient care (fires, motor vehicle accidents, multiple gunshot victims). Residents on the MD‐PM truck not only provide care equivalent to that expected of a nationally certified paramedic (IVs, drug administration, splinting, packaging), but also perform advanced skills such as RSI which is outside the scope of a traditional two‐paramedic team. Immersion into the first response ground EMS system will provide valuable insight into the challenges of providing care outside of the hospital.

Videotoracoscopia para remoção de corpo estranho da cavidade pleural

Video-assisted thoracoscopy is a minimally invasive surgical technique. It is the procedure of choice for the treatment of certain lung and pleural diseases. It has been increasingly used in the acute phase of thoracic trauma. Another indication for its use, which is rarely described in the literature, is for the removal of retained intrathoracic foreign bodies. We report the cases of two hemodynamically stable gunshot victims in whom the bullet was removed from the pleural cavity through video-assisted thoracoscopy, thereby avoiding the need for thoracotomy.

Early gunshot victim uncovered

Early gunshot victim uncovered

General Management of the Gunshot Victim With Musculoskeletal Injury

General Management of the Gunshot Victim With Musculoskeletal Injury

Importance of radiological diagnosis applied to necroscopy

The authors evaluate the consequences of incomplete necroscopic examinations wherein it was impossible to apply radiological resources to locate firearm projectiles. The study includes 8185 reports from the Instituto Médico-Legal Afrânio Peixoto in Rio de Janeiro, Brazil, representing the totality of corpses processed from January to December 2001; of these, 3122 were gunshot victims, 309 of which were buried with unremoved projectiles, being liable to future judicial reappraisal. During the same period, there were 23 exhumation requests by police authorities, 12 of them querying the existence of projectiles. The authors looked into the formal reasons assumed by the medico legal experts to conclude their reports from incomplete examinations, and suggest that gunshot necroscopic examinations should follow specific protocols, as incomplete autopsies will require further exhumations, at unnecessary additional costs.

Participação da radiologia nas perícias necroscópicas de baleados realizadas no Instituto Médico-Legal do Rio de Janeiro

OBJETIVO: Este trabalho aborda as conseqüências de laudos necroscópicos incompletos de baleados, nos casos em que não foi possível o uso de recursos radiológicos para localizar os projéteis de arma de fogo. MATERIAIS E MÉTODOS: Foram analisados 8.185 laudos necroscópicos do Instituto Médico-Legal Afrânio Peixoto, Rio de Janeiro, RJ, referentes à demanda total de cadáveres no período de 1º de janeiro a 31 de dezembro de 2001, dos quais 3.122 casos corresponderam a necropsias de baleados. RESULTADOS: Desses casos, 309 corpos foram sepultados contendo ainda, no seu interior, projéteis de arma de fogo, podendo suscitar futuras indagações judiciais. No mesmo período foram solicitadas 23 exumações, 12 delas com a finalidade de recolher projéteis. Foram calculados os gastos relacionados à realização de necropsias de baleados - R$ 996,85 - e custos alusivos à realização de exumações com a finalidade de recolher projéteis de arma de fogo - R$ 1.155,40, visando a estabelecer o montante financeiro que poderia ser poupado pelos cofres públicos, a ser alocado para finalidades outras, se a perícia médico-legal de baleados, no exame inicial, obtivesse sucesso. CONCLUSÃO: Os resultados permitiram concluir que todos os atos necroscópicos de baleados devem seguir protocolos específicos, uma vez que perícias incompletas exigem exumação posterior, com gastos adicionais desnecessários.

Physical Forms of Contemporary Small-Arms Propellants and Their Forensic Value

Intermediate gunshot wounds typically produce powder tattooing and/or stippling of the skin. The size and density of such powder-induced injuries around an entry wound are used to estimate the separation distance between the muzzle of the responsible firearm and the entry site through test firings at selected muzzle-to-target distances, with ammunition comparable to the injury-producing round and the evidence firearm. The foregoing is well known to forensic pathologists who document and describe such powder patterns in gunshot victims and firearm examiners who customarily produce the test-fired powder patterns for subsequent range-of-fire determinations. Less known, particularly to pathologists, is the considerable variety in forms of modern nitrocellulose propellants, their effects on powder-induced injuries to human skin, and the value of these varied physical forms in the reconstruction of shooting incidents. These factors are the subject of this article.

Privacy versus public safety: reporting of gunshot wounds

Alberta politicians want to amend the Health Information Act to force doctors to tell police when they are treating a gunshot victim and to disclose that patient's health status. ![Figure][1] Figure. Alberta may require emergency staff to report gunshot wounds. Photo by: Corbis/Magma