VIOLENCE
This includes regional referral centers, Emergency Medical Services( EMS), Emergency Department( ED) providers, nursing providers, respiratory therapists, operating room staff, therapists and rehabilitation specialists. This list is clearly not exhaustive. Abdominal and chest gunshot wounds( GSWs) are given, on average, six units of blood product during resuscitative efforts. From that standpoint( blood donation) and many others, the trauma system heavily relies upon community resources in order to provide optimal care.
From our perspective, these numbers clearly represent a significant public health issue. This sentiment has been viewed as controversial by many, likely due in part to the emotional and political attitudes implicit in discussions regarding gun violence. But, for perspective, the current Hepatitis A outbreak in Jefferson County has made national headlines with about 480 cases, and is associated with a less than one percent mortality. Of the nearly 600 patients who were seen at ULH following firearm injury last year, approximately 10 percent did not survive their injuries, and this does not include many of the over 100 homicides( most by firearm), people who were declared dead prior to arriving to the hospital. More than one in 10 patients who suffer a GSW, most in their second or third decade of life, will die from their injuries.
As is the case with many public health issues, familiarizing the public with the issue is a good place to start. The epidemiology, management and consequences of firearm injury are not typically considered common knowledge despite ample screen time in television, movies and popular culture. Common misconceptions persist. Mass casualty events( sometimes defined as four or more fatalities in a single incident) and shootings in public places are followed by extensive media coverage and ongoing debates regarding gun control and legislative initiatives. Although these tragedies are heartbreaking in nature, they represent a very small minority of all firearm fatalities, as do shootings involving law enforcement. Firearm injuries occur every day in America, and most days in Louisville. Violent crime and firearm injury can be included in the same discussion, or represent entirely different discussions, as many injuries are intentionally self-inflicted or occur as accidents. Over the last five years at ULH, accidental shootings comprised 15 percent of injuries, and 17 percent were the result of intentional self-inflicted injury. Representing one-third of all firearm injuries, these populations involve entirely different issues from those related to violent assault type injuries.
Although the retrieval of the bullet from the affected body cavity is often thought to be important by patients and families, this is never the primary objective during initial management. A stepwise approach including airway, breathing and circulation( A, B, C) is the dominant principle immediately following injury. The initial operative objectives include hemorrhage control and control of contamination, followed secondarily by the re-establishment of vascular, gastrointestinal and bone continuity. This is sometimes done over the course of staged operations, termed“ damage control surgery” with life-threatening issues addressed first. Many assume that all GSWs ultimately require operative intervention but many do not. This is illustrated best by noting that almost 40 percent of all GSWs are discharged home from the ED. This subgroup consists primarily of extremity wounds that don’ t involve nerve, bone or vascular structures. Location of injury is the major determinant here as almost 90 percent of abdominal GSWs and 40 percent of chest GSWs require operative intervention, whereas less than 20 percent of GSWs to the head require urgent operative intervention.
The caliber and type of weaponry are believed to be of paramount importance. Although these factors may play some small part in outcome, location of injury remains the primary determinant of survival and morbidity. Of those surviving to arrive at ULH, GSWs to the head carry the highest mortality( 60 percent), followed by injuries to the chest( 22), abdomen( 11), and extremities(< 1). Obviously, given 10 percent overall mortality, one can reason that injuries to the extremities are much more common than injuries to the head or torso. The circumstances surrounding the injury also demonstrate strong correlations with injury location. Intentional self-inflicted injuries predominately involve GSWs to the head, whereas accidental injuries most commonly involve extremities. Assault injuries are the most diverse group with a more even distribution across various anatomic locations.
Despite recent advancements in medicine, the post-injury management of firearm injury has changed very little. More balanced blood transfusion ratios, massive transfusion protocols, and damage control surgery have reduced mortality following injury. But the most dramatic impact is achievable through primary injury prevention. Given the scope of the issue and the innumerable factors that appear to contribute to a single injury, it can be difficult to identify successful prevention strategies. However, the issue is not insurmountable and there are clearly actions physicians, regardless of specialty or role within the health care system, can take to play a part in injury prevention strategies.
1. OPTIMIZE CARE FOLLOWING INJURY
Optimal care following injury to reduce morbidity is sometimes referred to as tertiary injury prevention and is the health care system’ s primary responsibility. The majority of acute care following firearm injury will continue, for the foreseeable future, to be in the hands of trauma centers across the country. However, regionalization of trauma care is dependent upon all centers being equipped to both stabilize patients and identify appropriate patients for transfer to trauma centers. This is true throughout rural Kentucky, but also applies to urban hospitals within our own community. The first few actions taken following a GSW will often determine outcome, long before the patient reaches a trauma center. Targeted towards providers, Advanced Trauma Life Support( ATLS) training is integral to achieving competence in these areas. By empowering all physicians and providers with these skills, there is potential for
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