Offered by the PTS Education Committee
Case Report Topic:
Prepared by: Stephen Murphy, MD, FACS
Follow up: The patient was doing well physically a month post hospital discharge. An appointment with PTSD counselors was arranged. The ureteral stent was removed 2 months later as an outpatient procedure. Five months following his index admission, the patient stole a motor vehicle and was tackled as he fled the scene, sustaining a concussion. He was admitted overnight for Rehabilitation Medicine consult. He was discharged to a detention center.
2. ATLS principles apply. Life threatening tension pneumothorax is addressed in the primary survey. In a patient in NO respiratory distress with a small pneumothorax, the surgical relief may safely occur a bit later in the course of resuscitation.
3. The patient described above requires a surgical intervention. Hemodynamically unstable patients should be moved expeditiously to the OR where resuscitation and operative intervention may occur. The trauma surgeon may need to proceed with a minimum of investigation in a dire situation. In the hemodynamically stable patient, imaging can be helpful in planning the surgical procedure.
4. Though a laparoscopic approach is possible, laparotomy via midline incision remains the gold standard. The bullet trajectory was considered and CT results were not available at the start of the case. A bullet passing from the right posterior back to the left chest may traverse critical abdominal organs including Vena Cava, liver, spinal cord, duodenum, pancreas, kidneys, spleen, stomach, small bowel, colon, diaphragm, as well as critical thoracic structures. Midline laparotomy was felt to be the most prudent approach. 4 quadrants were packed with lap packs. Bleeding was controlled. The injured structures were identified and debrided. Primary repair of the diaphragm and Grade 2 gastric injury was possible but may not be. The trauma surgeon must be ready for a damage control procedure with temporary abdominal closure and subsequent planned return to OR.
5. Violent intentional injury is the most poorly addressed public health problem in the U.S. according to American College of Surgeons-Committee on Trauma. Teen males of color are disproportionately represented. Males account for 85 % of firearm related mortality. Firearm injury constitutes the second leading cause of death in the pediatric population, trailing only motor vehicle collisions. The presence of a firearm in the household is associated with an increased risk of injury and death. Recidivism rates are as high as 40 %. A 20 % 5 year mortality is a sobering statistic. Increased exposure to Adverse Childhood Events (ACE) increases the risk for perpetration of violence. Social determinants of health factor heavily into the risk for firearm injury.
6. Hospital Performance Improvement: The Trauma Tertiary Performance Improvement review addressed the issue of lack of real time access to critical imaging in this scenario. This sentinel event could potentially have negatively impacted patient outcome. Through the Trauma PI Program, Trauma system concerns were moved forward to the Hospital PI forum. The Medical Imaging Department implemented solutions on an educational and institutional level to ensure the communication of crucial radiology findings to the clinician in a time critical situation.
1. Westreich M. The Odd or Even Bullet. Injury 1986; 17: 45-6
2. American College of Surgeons. Advanced Trauma Life Support Course Manual, 10th ed. Chicago: American College of Surgeons, 2018
3. Yanchar NL, Woo K, Brennan M, et al. Chest X-Ray as a screening tool for blunt thoracic trauma in children. J Trauma Acute Care Surgery. 2013; 75(4); 613-9
4. Fair KA, Gordon NT, Barbosa RR, et al. Traumatic diaphragmatic injury in the American College of Surgeons National Trauma Data Bank: a new examination of a rare diagnosis: Am J Surgery. 2015; 209(5): 864-8
5. Petty JK, Henry MCW, Nance M, Ford H, APSA Board of Governors. Firearm Injuries and Children: Position Statement of the American Pediatric Surgical Association. Pediatrics. 2019; 144(1) e20183058
6. Fowler K, Dahlberg L, Haileyesus T, et al. Childhood Firearm Injuries in the United States. Pediatrics. 2017, e20163486
Mass Shooters and Murderers: Motives and Paths. Educational overview of mass shootings, including school shootings. The offering delves into public health concern associated with mass shootings. Continuing education credit is offered for multiple disciplines.