Firearm Injury Prevention
Authors: Michael U. Antonucci
Journal: Annals of Internal Medicine (2019)

Letters20 August 2019Firearm Injury PreventionFREEMichael U. Antonucci, MDMichael U. Antonucci, MDMedical University of South Carolina, Charleston, South Carolina (M.U.A.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/L19-0210 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail TO THE EDITOR:With the recent mass shootings in Thousand Oaks, California, and the Pittsburgh Tree of Life Synagogue adding to the increasing number of gun-related deaths in the United States, physicians promoting guidelines to reduce firearm-related violence (1) have been instructed by the National Rifle Association to “stay in their lane.” Taichman and colleagues' editorial (2) reflects a powerful refusal to be silenced and counters the National Rifle Association's tweet with both strong evidence and common sense. Data released since the publication of this editorial reveal that a record number of school shootings took place in 2018 (3), which further highlights the urgency of this issue. Against this backdrop, and contrary to its initial goal, the National Rifle Association's suggestion has motivated physicians across specialties to examine their lane and identify ways to combat escalating gun violence.As a neuroradiologist, my lane traverses behind the scenes. I am spatially removed from patients and indirectly evaluate them through images. Clinical colleagues (who directly interact with patients) typically have a more complete overview of specific issues, but the extent of damage from a bullet is a notable exception. Although I am spared such emotional tasks as conveying prognostic information to the families of victims, I have a more vivid first look at the pathologic characteristics of ballistic trajectories. On clinical examination, superficial skin laceration and hematoma around a scalp entry wound (and, if present, exit wound) belie the more substantial intracranial findings seen on medical imaging. These can include skull and metallic fragments within brain tissue, resultant hemorrhage in and damage to eloquent cortex and white-matter tracts, edema, and herniation.In my lane, the prevalence of gun violence is alarmingly apparent. For example, over a particularly taxing call weekend in which gunshot victims are treated by multiple clinical teams, the neuroradiologist interprets imaging of every head, face, and spine affected by a firearm. Individually, these are not pretty pictures; the collective catalog is devastating.I do not envy my clinical colleagues who deal with this directly—those with literally blood-soaked hands who invoke the ire of the National Rifle Association. Nevertheless, my lane affords me an opportunity and responsibility to share what I see. The Figure includes imaging from 3 victims of gun violence. These are only a fraction of the many images that are now indelible in my memory and stored in our institution's imaging archive. They are an objective, unfiltered look at the reality of gun violence in modern medicine and underscore our frustration as we attempt to bandage the wounds of the unfortunate victims who enter our lane.Figure. Computed tomography images from 3 victims of gun violence.Left. A young patient shot in the right temple. Noncontrast computed tomography shows minimal skin swelling near the entry site (A; arrow) with extensive ballistic and skull fragments in the underlying right temporal lobe. No exit wound was seen on examination, and the bullet stopped along the contralateral inner table (B; arrowhead), with resultant parenchymal hematoma as well as subarachnoid and large left subdural hemorrhages (B; arrow). Three-dimensional reconstruction shows a small hole near the skull entry site (C; arrow), and 3-dimensional oblique reconstruction (D) highlights the trajectory across both cerebral hemispheres. Center. A young patient fatally shot in the right parietal region. There are extensive metal and bone fragments in the right cerebral hemisphere with surrounding hemorrhage (E; arrow), midline shift, and a partially visualized right subdural hematoma (E; arrowhead). Three-dimensional reconstruction shows an extensively comminuted skull fracture with a small residual bullet fragment demarcating the calvarial entry site (F; arrow). Right. A young patient with extensive ballistic injury to the bilateral frontal lobes with bone and metal fragments, hemorrhage, and edema (G; arrow). The force of the gunshot also produced a large and severely comminuted bilateral frontal skull fracture with sinus involvement visible on 3-dimensional reconstruction (H; arrow). Download figure Download PowerPoint References1. Butkus R, Doherty R, Bornstein SS; Health and Public Policy Committee of the American College of Physicians. Reducing firearm injuries and deaths in the United States: a position paper from the American College of Physicians. Ann Intern Med. 2018;169:704-7. [PMID: 30383132]. doi:10.7326/M18-1530 LinkGoogle Scholar2. Taichman D, Bornstein SS, Laine C. Firearm injury prevention: AFFIRMing that doctors are in our lane. Ann Intern Med. 2018;169:885-6. [PMID: 30458522]. doi:10.7326/M18-3207 LinkGoogle Scholar3. Riedman D, O'Neill D. K-12 school shooting database. Center for Homeland Defense and Security. 2018. Accessed at www.chds.us/ssdb on 16 December 2018. Google Scholar Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: Medical University of South Carolina, Charleston, South Carolina (M.U.A.)Disclosures: The author has disclosed no conflicts of interest. The form can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=L19-0210. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoFirearm Injury Prevention: AFFIRMing That Doctors Are in Our Lane Darren Taichman , Sue S. Bornstein , and Christine Laine Firearm Injury Prevention Sarabeth Spitzer , Vishnu Muppala , and Abigail Solomon Metrics Cited byGuns, scalpels, and sutures: The cost of gunshot wounds in children and adolescents 20 August 2019Volume 171, Issue 4Page: 304-305KeywordsBoneComputed axial tomographyEdemaFirearm injuriesHemorrhagePatient advocacySkullSubarachnoid hemorrhageTemporal lobeViolent crime ePublished: 20 August 2019 Issue Published: 20 August 2019 Copyright & PermissionsCopyright © 2019 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...