Retained bullets after firearm injury: A survey on surgeon practice patterns

Author(s): 
Smith, R.N., Tracy, B.M., Smith, S., Johnson, S., Martin, N.D., & Seamon, M.J. (2020)
Source: 

Journal of Interpersonal Violence, 1 – 21

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Summary: 

This study explored the practice of retaining bullets during/following surgery. Researchers found that a minority of surgeons are likely to remove bullets and that psychological conditions are rare indications for bulletectomy. Pain (88.1%) and a palpable bullet (71.2%) were the most frequent indications for removal.

Expanded Abstract: 

Firearm trauma has remained a major cause of injury related deaths in the United States, with more than 39,000 firearm fatalities estimated in 2017 (Centers for Disease Control and Prevention, 2018). In addition, for the annual 95,000 patients who survive a firearm injury (Centers for Disease Control and Prevention, 2018), recovery is often complex and can require medical, legal, and psychological intervention (Greenspan & Kellermann, 2002). A wealth of data exists on managing firearm trauma, but less focus has been given to the bullet itself. Most research on retained bullets entails associated adverse medical conditions like infection, pain, and lead intoxication (Apte et al., 2019; Jakoi et al., 2015; Najibi et al., 2006). Other small series have concluded that removal is indicated only when the projectile rests in close proximity to neurovascular structures, intra-articular spaces, or weight-bearing regions (Eylon et al.,2005; McQuirter et al., 2001; Riehl et al., 2013, 2015).

Retained bullets are common after firearm injuries, yet their management remains poorly defined. Surgeon members of the Eastern Association for the Surgery of Trauma (n = 427) were surveyed using an anonymous, web-based questionnaire during Spring 2016. Indications for bullet removal and practice patterns surrounding this theme were queried. Also, habits around screening and diagnosing psychological illness in victims of firearm injury were asked. Most respondents were male (76.5%, n = 327) and practiced at urban, academic, and Level 1 trauma centers.

Findings from the survey showed that only 14.5% of surgeons had institutional policies for bullet removal and 5.6% were likely to remove bullets. Half of the surgeons (52.0%) preferred to remove bullets after the index hospitalization and pain (88.1%) and a palpable bullet (71.2%) were the most frequent indications for removal. Having the opportunity to follow-up with patients to discuss bullet removal was significantly predictive of removal. Furthermore, routinely asking about retained bullets during outpatient follow-up was predictive of new psychological illness screening and diagnosis in victims of firearm injury. For all surgeon respondents, the most frequently provided indications for bullet removal were pain (88.1%), a palpable bullet (71.2%), and infection (40%). Less common reasons for bullet retrieval were patient anxiety (12.9%) and PTSD.

In sum, researchers found that a minority of surgeons are likely to remove bullets and that psychological conditions are rare indications for bulletectomy. However, it was noted that having the opportunity for follow-up was predictive of bullet removal and asking about retained bullets during outpatient follow-up was associated with psychological illness screening and diagnosis. Regardless of the clinical setting, surgeons should be encouraged to allot time for conversations with their patients, particularly concerning retained bullets, so that the management decision can be a shared effort.

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