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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