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Myths and Misinformation About Gunshot Wounds may Adversely Affect Proper Treatment

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Abstract

Background

Poorly designed experiments and popular media have led to multiple myths about wound ballistics. Some of these myths have been incorporated into the trauma literature as fact and are included in Advanced Trauma Life Support (ATLS). We hypothesized that these erroneous beliefs would be prevalent, even among those providing care for patients with gunshot wounds (GSWs), but could be addressed through education.

Methods

ATLS course content was reviewed. Several myths involving wound ballistics were identified. Clinically relevant myths were chosen including wounding mechanism, lead poisoning, debridement, and antibiotic use. Subsequently, surgery and emergency medicine services at three different trauma centers were studied. All three sites were busy, urban trauma centers with a significant amount of penetrating trauma. A pre-test was administered prior to a lecture on wound ballistics followed by a post-test. Pre- and post-test scores were compared and correlated with demographic data including ATLS course completion, firearm/ballistics experience, and years of post-graduate medical experience (PGME).

Results

One-hundred and fifteen clinicians participated in the study. A mean pre-test score of 34 % improved to 78 % on the post-test with associated improvements in all areas of knowledge (p < 0.001). Years of PGME correlated with higher pre-test score (p = 0.021); however, ATLS status did not (p = 0.774).

Conclusions

Erroneous beliefs involving wound ballistics are prevalent even among clinicians who frequently treat victims of GSWs and could lead to inappropriate treatment. Focused education markedly improved knowledge. The ATLS course and manual promulgate some of these myths and should be revised.

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Acknowledgment

IRB approval was obtained from the UCSF Fresno/Community Medical Centers Institutional Review Board; this study qualified for waiver of consent.

Conflict of interest

None.

Author information

Authors and Affiliations

  1. Department of Surgery, Fresno Medical Education Program University of California San Francisco, 1st Floor, 2823 Fresno Street, Fresno, CA, 93721, USA

    Stephen C. Hafertepen, James W. Davis, Ricard N. Townsend, Lawrence P. Sue, Krista L. Kaups & Kathleen M. Cagle

Authors
  1. Stephen C. Hafertepen
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  2. James W. Davis
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  3. Ricard N. Townsend
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  4. Lawrence P. Sue
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  5. Krista L. Kaups
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  6. Kathleen M. Cagle
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Corresponding authors

Correspondence to Stephen C. Hafertepen or Krista L. Kaups.

Appendix

Appendix

Ballistics in Medicine

Pretest

  1. 1.

    Have you taken ATLS (Advanced Trauma Life Support) and if so within how many years

    1. (a)

      No, I have not taken ATLS.

    2. (b)

      Yes, I have had ATLS within the last 1–4 years.

    3. (c)

      Yes, but was more than 4 years ago.

  2. 2.

    Please rate your firearms/ballistics experience

    1. (a)

      None (never used a firearm).

    2. (b)

      Minimal experience (limited experience with firearms).

    3. (c)

      Some experience (understand and feel comfortable using a firearm).

    4. (d)

      Expert (performed research with firearms or on wound ballistics).

  3. 3.

    Please chose answer that corresponds to your years of post-graduate medical experience

    1. (a)

      1 year

    2. (b)

      2–3 years

    3. (c)

      4–5 years

    4. (d)

      5–10 years

    5. (e)

      10+ years

  4. 4.

    Shotguns are typically only lethal at a range of

    1. (a)

      20 yards or less.

    2. (b)

      40 yards or less.

    3. (c)

      60 yards or less.

    4. (d)

      Can be lethal over 100 yards.

  5. 5.

    A 24-year-old male presents to the ED with a gunshot to his right thigh from an assault rifle. Last tetanus shot was 7 years ago. After a primary and secondary surveys which demonstrate intact sensation, movement, and pulses to the affected extremity, initial management should consist of

    1. (a)

      Tetanus booster alone.

    2. (b)

      X-ray of the thigh and arterial pressure indices.

    3. (c)

      X-ray of the thigh, arterial pressure indices, and tetanus booster.

    4. (d)

      X-ray of the thigh, arterial pressure indices, tetanus booster, and IV antibiotics.

    5. (e)

      CT angiogram of the thigh and tetanus booster.

  6. 6.

    You see a police officer fires a gun at an assailant; the bullet hits him in the chest

    1. (a)

      When the bullet hits him in the chest, it will knock him off his feet.

    2. (b)

      He will immediately collapse to the ground.

    3. (c)

      Blood with spurt from the chest.

    4. (d)

      There will be little to no outward sign that he has been shot.

  7. 7.

    A 16-year-old male is dropped off at the emergency department after sustaining a gunshot wound to the right chest. The police say it was from a high-velocity assault rifle. Which of the following statement is most correct

    1. (a)

      The patient will likely need extensive debridement beyond the edges of the wound because cavitation can stretch the tissue up to 100 times the diameter of the bullet.

    2. (b)

      Cavitation can be up to 30–40 times the diameter of the bullet and can cause injury far from the bullet tract.

    3. (c)

      Cavitation type injury to the lung will be more significant than the liver because it is mostly full of air.

    4. (d)

      The majority of penetrating chest trauma does not require operative intervention.

  8. 8.

    A 23-year-old male is shot with a gun. Of the following which is the greatest determinant of damage from a ballistic missile

    1. (a)

      Kinetic energy transferred to the tissue.

    2. (b)

      Type of missile (i.e., hollow point vs. full metal jacket vs. shotgun).

    3. (c)

      Bullet caliber.

    4. (d)

      None of the above.

  9. 9.

    A 35-year-old female sustains a high-velocity gunshot wound to her right thigh. Debridement is

    1. (a)

      Not important.

    2. (b)

      Important to remove obviously non-viable tissue.

    3. (c)

      Important to remove obviously non-viable tissue and then close the wound to prevent contamination.

    4. (d)

      Important to remove tissue beyond areas of obviously non-viable tissue because microscopic cell death occurs far from the edge bullet hole.

  10. 10.

    A 4-year-old female was shot in the thigh. Of the following statement is most correct

    1. (a)

      The majority of bullets made today are not made of lead, hence there is little need to worry about lead poisoning.

    2. (b)

      The lead bullet should be removed to prevent lead poisoning because the bullet is large compared to the size of the child.

    3. (c)

      Dimercaprol (BAL) should be given as chelation therapy because of the large-sized lead bullet.

    4. (d)

      Unless the bullet is in contact with a joint space, there is no need to worry about lead poisoning.

Ballistics in Medicine

Posttest

  1. 1.

    I have a better understanding of wound ballistics

    1. (a)

      Strongly disagree.

    2. (b)

      Disagree.

    3. (c)

      Neutral.

    4. (d)

      Agree.

    5. (e)

      Strongly agree.

  2. 2.

    This lecture will alter my management of gunshot wounds?

    1. (a)

      Strongly disagree.

    2. (b)

      Disagree.

    3. (c)

      Neutral.

    4. (d)

      Agree.

    5. (e)

      Strongly agree.

  3. 3.

    A 28-year-old female sustains a gunshot wound to her torso from a 12 gage shotgun firing OO buckshot. There are 5 wounds each about 5–7 inches apart.

    1. (a)

      There should be little concern about deep penetration because the pellets are so far apart, and it would be a shotgun wound from a long range.

    2. (b)

      Regardless of how far apart the wounds are, they should be treated as separate gunshot wounds (i.e., being shot with a pistol multiple times).

    3. (c)

      OO buckshot is a very small projectile unlikely to cause much harm.

    4. (d)

      Treatment should consist of antibiotics and tetanus prophylaxis alone.

  4. 4.

    A 34-year-old female presents to the ED with a gunshot to her left upper arm from an assault rifle. Last tetanus shot was 7 years ago. After a primary and secondary surveys which demonstrate intact sensation, movement, and pulses to the affected extremity, initial management should consist of:

    1. (a)

      Tetanus booster alone.

    2. (b)

      CT angiogram of the thigh and tetanus booster.

    3. (c)

      X-ray of the arm and arterial pressure indices.

    4. (d)

      X-ray of the arm, arterial pressure indices, and tetanus booster.

    5. (e)

      X-ray of the arm, arterial pressure indices, tetanus booster, and IV antibiotics.

  5. 5.

    You witness a shooting in the ED parking lot, a woman is shot in the back. She will most likely

    1. (a)

      be knocked off her feet when the bullet strikes her

    2. (b)

      immediately collapse to the ground

    3. (c)

      have blood spurting from the wound

    4. (d)

      continue to stand there with little to no outward sign that she has been shot

  6. 6.

    A 27-year-old male is dropped off at the emergency department after sustaining a gunshot wound to the back. The police say it was from a high-velocity assault rifle with a full metal jacket bullet. Which of the following statement is most correct

    1. (a)

      Cavitation should not be considered because it does not occur with full metal jacket bullets.

    2. (b)

      Cavitation type injury to the lung will be more significant than the liver because it is mostly full of air.

    3. (c)

      Cavitation can be up to 30-40 times the diameter of the bullet and can cause injury far from the bullet tract.

    4. (d)

      Temporary cavitation is a phenomenon that occurs with both low- and high-velocity projectiles.

  7. 7.

    A 33-year-old male is brought in by ambulance after being shot with a 357 magnum. Of the following which is the greatest determinant of damage from a ballistic missile

    1. (a)

      Muzzle velocity (how fast the bullet is traveling when it leaves the gun).

    2. (b)

      Type of missile (i.e., hollow point vs full metal jacket vs. shotgun).

    3. (c)

      Kinetic energy transferred to the tissue.

    4. (d)

      The fact is was a magnum round.

    5. (e)

      None of the above.

  8. 8.

    A 25-year-old male sustains a high-velocity gunshot wound to his left thigh. In regards to the patients care

    1. (a)

      Debridement is not important.

    2. (b)

      Debridement should be performed if there is obviously non-viable tissue.

    3. (c)

      Debridement should be performed if there is obviously non-viable tissue followed by immediate closure of wound to prevent contamination.

    4. (d)

      Debridement should be performed to remove tissue beyond areas of obviously non-viable tissue because microscopic cell death occurs far from the edge bullet hole with high-velocity wounds.

  9. 9.

    A 35-year-old female was shot in the right thigh with a civil war era musket firing a 50 caliber lead slug. Of the following statement is most correct

    1. (a)

      The majority of bullets made today are not made of lead, hence there is little need to worry about lead poisoning.

    2. (b)

      The lead bullet should be removed to prevent lead poisoning.

    3. (c)

      Unless the bullet is in contact with a joint space, there is no need to worry about lead poisoning.

    4. (d)

      dimercaprol (BAL) should be given as chelation therapy because of the large-sized lead bullet.

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Hafertepen, S.C., Davis, J.W., Townsend, R.N. et al. Myths and Misinformation About Gunshot Wounds may Adversely Affect Proper Treatment. World J Surg 39, 1840–1847 (2015). https://doi.org/10.1007/s00268-015-3004-x

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