SIGNA VITAE 2016; 12(1): 106-110

Stray bullet injuries in a tertiary care center

NICHOLAS BATLEY, RINAD BAKHTI, RANA BACHIR, AFIF MUFARRIJ Department of Emergency Medicine, American University of Beirut Medical Center, Beirut,

Corresponding author: Aff Mufarrij Department of Emergency Medicine American University of Beirut Medical Center P.O.Box - 11-0236 Riad El Solh Beirut 1107 2020 Phone: +961-1-350000 Ext: 6636 E-mail: [email protected]

ABSTRACT and the region to document cases of stray will fall at its terminal or free fall velocity bullet injuries presenting to the ED. Bet- based on bullet characteristics like weight Background. A stray bullet injury is de- ter laws and educational policies need to and shape, its kinetic energy, and whether fned as an accidental frearm injury oc- be implemented to help discourage this it lands base or nose frst. (5) Te degree curring outdoors by an anonymous at- practice. of tissue damage also varies based on the tacker. Stray bullet injuries are rare, but not size of the organ or tissue and the resist- uncommon in certain parts of the world. Key words: stray bullets, emergency depart- ance of the tissue to strain. (6) A bullet that In , 165 patients with stray bullet ment, injured body part, consequences of hits ‘nose frst’ will have the highest termi- injuries were recorded between 2006 and stray bullets, hospital admissions, severity of nal velocity and might cause more damage. 2010. injury, surgical intervention, Lebanon (5) Tis can occur from both handguns and rifes. With an AK47 rife, the veloc- Objectives. In Lebanon, gunshots may oc- ity of a bullet is 2,330 feet per second (fps) cur during politicians’ speeches, funerals INTRODUCTION with a bullet weight of 7.9 grams, while an and afer exam results are published. No M16 has a velocity of 3,250 fps and a bul- studies to date have looked at the details A 38-year-old female presented to the let weight of 3.6 grams. (7) Te maximum and consequences of these gunshot inju- Emergency Department (ED) at the Amer- range of an AK47 and an M16 is 2300 ries. ican University of Beirut Medical Center meters and 2700 meters, respectively. (8) (AUBMC). She was having dinner on the Bullets with a caliber of 0.30 may have a Methods. A retrospective chart review of veranda of a seaside restaurant in Bei- terminal velocity of 300 fps, whereas larger patients presenting to an emergency de- rut when she developed a sudden, severe bullets of 0.50 caliber may have a velocity partment (ED) in Beirut, Lebanon, from right-sided headache and bleeding from of 500 fps. (9) 2010 to 2015, with clear stray bullet inju- a scalp wound. Te patient underwent a ries was conducted. Variables included: computed tomography (CT) scan of the Te trajectory of a bullet, called “horizon- demographics, injured body part, admis- brain, which revealed a bullet lodged in the tal projectile motion,” will continue to ac- sion to hospital, number of days in hospi- scalp with no skull fracture or intracranial celerate when shot in the air until it arrives tal, length of stay in the ED, mortality, past injury (fgure 1). Te bullet was removed at a point where its weight is equal to the medical history, emergency severity index, without complication, the scalp was su- resistance of the air. Although when fall- and consequences of injury including sur- tured and the patient discharged home in ing, these bullets are not at optimum veloc- gery. a stable condition. ity, they might still reach 600 fps while fall- ing down. A speed of 148 fps is sufcient Results. Out of 154 bullet injuries, 12 stray Te International Classifcation of Dis- for a bullet to penetrate the skin whereas bullet injuries were recorded. Injuries of eases defnes a stray bullet injury as an ac- a bullet at 200 fps can potentially pierce the lower extremity were most common, cidental frearm injury occurring outdoors through bone structures and enter the followed by the head, shoulder/thorax, by an anonymous attacker. (1) Although skull. (10) When a bullet is shot at a high abdomen/pelvis and upper extremity. Sur- stray bullet injuries are generally rare, but non-vertical angle, it is more likely to gery was needed in 7 patients (58.3%). Te they are not entirely uncommon in certain be potentially fatal on return. (5) With median length of stay was 3.08 hours in the parts of the world. (2) Falling bullets may most cases of stray bullet injuries, the bul- ED and 4.78 days in hospital. Tere were hit people, more commonly in populated let is stuck in subcutaneous regions with no recorded deaths. Consequences of each areas like cities, cause injury and in some no exit wounds. stray bullet injury are presented. cases, result in death. (3) In a sample of 284 cases, 81% of those injured were unaware In Lebanon, gunshots are frequently heard Conclusion. Stray bullet injuries are com- of the causes or events of the shooting. (4) during politicians’ speeches, funerals and monly reported on in news and media afer exam results are published. (11) No outlets. Tis is the frst study in Lebanon Generally, a bullet that is fred vertically studies to date have looked at the conse-

106 | SIGNA VITAE quences of these gunshots. Te purpose of Statistical analyses were carried out using and posterior chest (50%). Of the 2% of the current work is to better defne stray SPSS 23 (Statistical Package for Social Sci- bullets hitting the chest, only a fraction bullet-induced pathology and its conse- ences). In the univariate analyses, descrip- had injured the heart. Some consequences quences. tive statistics and frequency distributions included seizures, neurologic defcits and were presented whereas the continuous joint immobility. variables were analyzed as means, standard MATERIALS AND METHODS deviations, ranges and percentiles. Between 2006 and 2010, 165 patients with stray bullet injuries were detected in the Te present paper summarizes the data on Sind province of Pakistan. (14) Te ma- stray bullet injuries presenting to the ED of RESULTS jority (61.8%) presented with peritonitis, AUBMC in Beirut, Lebanon, from January followed by haemothorax/ pneumothorax 2010 to November 2015. Te study was ap- Out of a total of 154 bullet injuries, 12 in 11% of cases. Additionally, 55% un- proved by the Institutional Review Board cases were found to be stray bullet injuries. derwent laparotomy, whereas the rest had at AUBMC. AUBMC is the largest tertiary Socio-demographic and clinical character- chest tubes inserted and other procedures care center in Lebanon, receiving approxi- istics are presented in table 1 (Appendix done. In terms of consequences of injury, mately 49,000 patient visits per year. Te A). Te sample was composed of 5 males nine people sufered permanent disabili- ED is divided into three levels: a high acu- (41.7%) and 7 females (58.3%), with a me- ties and 13 died. In a similar study from ity section (ED1), low acuity section (ED2) dian age of 25.5 years. Four were married Pakistan, 144 injuries from stray bullets and a pediatrics section (ED3). Triage is (33.3%) and the remaining were single were assessed; marriage ceremony celebra- conducted according to the Emergency (66.7%). A total of 7 were self-paying pa- tions were the most common cause. (3) Of Severity Index (ESI) scoring system, as- tients (58.3%). Five patients (55.6%) had the 144 cases, 102 were considered a trivial signing severity scores to patients. (12) ESI received an ESI of 2 while four (44.4%) had injury, while the rest required surgical in- consists of fve levels used to assess patient an ESI of 3 at triage. Only two reported tervention. Te mean hospital stay was 13 acuity from level 1 (most urgent) to level 5 having any past medical history (16.7%). days and the surgical interventions con- (least resource intensive). During the study Almost all patients were admitted to the ducted were: chest intubation, wound tract period, 288,361 patients were admitted to hospital except for one (91.7%). Injuries exploration to retrieve the bullet, and lapa- the ED. Te ESI distribution of those seen of the lower extremity were most com- rotomy to manage intra-abdominal injury, was 0.4%, 7%, 67.7%, 22.7%, and 2.2% for mon with 5 cases (41.7%), followed by the with no recorded deaths. ESI 1, 2, 3, 4, and 5, respectively. Payment head with 3 cases (25%), shoulder/thorax, was covered though private insurance in 2 cases (16.7%), one case of abdominal/ According to the Centers for Disease Con- 72.5% of cases, 25% out-of-pocket and pelvic injury (8.3%) and one case of an trol and Prevention, 2 people die and 25 2.5% through governmental insurance. injured upper extremity (8.3%). Surgery people are injured annually on New Year’s was required for 7 patients (58.3%). Te Eve in . (15) Te most common A retrospective chart review of patients median length of stay during their visit site of injury is the head (36%), followed by of all ages presenting to the ED in Beirut, was found to be 3.08 hours in the ED and the foot (26%) and then shoulder (16%). Lebanon, in these fve years with clear stray 4.78 days in the hospital. Tere were no bullet injuries, was conducted. Stray bullet recorded deaths. Each case, along with the In some countries in the , gun- cases were defned as unintentional injuries consequences of injury, is presented in Ap- fre ofen occurs during weddings, gradu- resulting from an unknown shooter. Te pendix B. ations, (2) political speeches and clashes. diagnoses are categorized as per the Inter- (11) Tere are, however, few academic national Classifcation of Diseases, Ninth studies or case reports on the topic. In Lib- Revision, Clinical Modifcation (ICD-9- DISCUSSION ya, 23 cases of stray bullet injuries were CM), which assigns numeric codes to di- reported between 2011 to 2012, with 2 re- agnoses. Exclusion criteria included any In the US, between 2008 and 2009, 317 corded deaths. Te upper and lower limbs bullet injuries that were not explicitly listed people were injured by stray bullets, 65 were the most common injured body part as stray bullets by the attending physician of whom died. (4) In specif- followed by the chest and head/neck. (2) in the ED at the time of injury. cally, 118 cases of stray bullet injuries were recorded across a 7 year period, with 77% In the present study, the most common Data were extracted on: injured body part, resulting in an injury to the head, 12% to site of injury was the extremities, includ- admission to hospital, number of days the shoulder, 5% to the upper back, 2% to ing calf, thigh, and leg. Tis is in line with spent in hospital, length of stay in the ED, the posterior chest and neck and 1% to the the epidemiology of stray bullet injuries mortality, past medical history, ESI and upper arm, leg, and foot each, with a mor- found across the US,(4) revealing that in a consequences of injury, including whether tality rate of 32%. (13) In cases where the sample of 284 cases, extremities were the or not surgery was required. Additionally, source of the bullet was known, all were most injured body part, and similarly for demographic variables such as age, gender, found to be fred by handguns from within the Libyan sample.(2) In samples where marital status and type of insurance were a one mile radius. A high mortality rate the chest (3) and the head (11) were most collected. was found for those hit in the head (40%) commonly injured, a much higher mor-

SIGNA VITAE | 107 tality ratewas recorded. As with the Los CONCLUSION (3) Laws, educational policies and cam- Angeles sample, perforating injuries were paigns to inform the population should be rare. (11) Resulting admission to the hos- Although cases of stray bullet injuries are better implemented to avoid such injuries pital for further management, number of reported in news and media outlets, aca- and reduce the signifcant threat to public days spent in hospital and surgical inter- demic articles and case reports are com- health that stray bullets represent. Tis vention for the Libyan sample was also at a paratively few. Tis is the frst study in study aims to highlight the dangers of this similar rate as the present sample. (2) Lebanon to document cases of stray bul- practice with the aim of encouraging its Tis is a single-center, retrospective study let injuries presenting to an ED. Te act is prevention and limiting resulting injuries. with a low sample size. Tere are a total considered illegal and the government has of 164 hospitals in Lebanon. (16) As such, previously warned against it. Te majority the total number of stray bullet injuries in of people believe, however, that bullets shot Lebanon is projected to be much higher. in the sky vanish or disappear into space.

REFERENCES

1. World Health Organization. International statistical classifcation of diseases and related health problems. World Health Organiza- tion; 2004. 2. Al-Tarshihi MI, Al-Basheer M. Te falling bullets: post-Libyan revolution celebratory stray bullet injuries. Eur J Trauma Emerg Surg 2014 Feb;40(1):83-5. 3. Ali SA, Tahir SM, Makhdoom A, Shaikh AR, Siddique AJ. Aerial fring and stray bullet injuries: a rising tide. Iran Red Crescent Med J 2015;17(4):26179. 4. Wintemute GJ, Claire BE, McHenry VS, Wright MA. Epidemiology and clinical aspects of stray bullet shootings in the . J Trauma Acute Care Surg 2012 Jul;73(1):215-23. 5. Haag L. Shooting incident reconstruction. Academic press; 2006. 6. Maiden N. Ballistics reviews: mechanisms of bullet wound trauma. Forensic Sci Med Pathol 2009;5(3):204-9. 7. Hartink AE. Te complete encyclopedia of automatic army rifes. Hackberry Press; 2001. p. 119-20. 8. Kjellgren GLM. Te Practical Range of Small Arms. Te American Rifeman; 1970. 9. Shuker ST, Sadda R. Craniomaxillofacial falling bullet injuries and management. J Oral Maxillofac Surg 2010 Jul;68(7):1593-601. 10. Ordog GJ, Wasserberger J, Balasubramanium S. Wound ballistics: theory and practice. Ann Emerg Med 1984 Dec;13(12):1113-22. 11. El Hassan, J. Stray bullets are no cause for celebration [Online]. 2013 Sep 5. Available from: URL:http://www.dailystar.com.lb 12. Eitel DR, Travers DA, Rosenau AM, Gilboy N, Wuerz RC. Te emergency severity index triage algorithm version 2 is reliable and valid. Acad Emerg Med 2003 Oct;10(10):1070-80. 13. Ordog GJ, Dornhofer P, Ackroyd G, Wasserberger J, Bishop M, Shoemaker W, et al. Spent bullets and their injuries: the result of fr- ing weapons into the sky. J Trauma 1994 Dec;37(6):1003-6. 14. Malik AM, Alkadi A, Talpur KA, Qureshi JN. Te incidence, pattern and outcome of stray bullet injuries. A growing challenge for surgeons. Pak J Med Sci 2013 Sep;29(5):1178-81. 15. Centers for Disease Control and Prevention. New Year’s Eve injuries caused by celebratory gunfre—Puerto Rico, 2003. Morb Mortal Wkly Rep 2004;53:1174–5. 16. National Health Statistics Report in Lebanon [Online]. 2012. Available from: URL:http://www.igsps.usj.edu.lb/docs/recherche/re- cueil12en.pdf

APPENDIX A

Table 1. Descriptives. Variable Median Range 25% percentile 50% percentile 75% percentile Age 25.50 11 – 58 16.5 25.5 35 Length of stay in the 3.08 0.98 – 6.72 1.75 3.08 4.25 ED Length of stay in the 4.78 1 – 26.62 3.08 4.78 7.08 hospital

ED, emergency department.

108 | SIGNA VITAE Table 2. Frequencies. Variable Frequency Percent Gender Male 5 41.7% Female 7 58.3% Marital status Single 8 66.7% Married 4 33.3% Payment Insurance company 5 41.7% Self-payer 7 58.3% ESI 2 5 55.6% 3 4 44.4% Past medical history No 10 83.3% Yes 2 16.7% Admitted to the hospital No 1 8.3% Yes 11 91.7% Injured body part Lower extremity 5 41.7% Shoulder/Torax 2 16.7% Upper extremity 1 8.3% Head 3 25.0% Abdomen/Pelvis 1 8.3% Surgery No 5 41.7% Yes 7 58.3%

APPENDIX B

Table 3. Stray bullet injuries. Age Gender Injured body part Classifcation of Admitted to Days in Consequences of injury Surgery Injury hospital hospital 24 Female Right leg Lower extremity Yes 7 Open fracture of distal tibia fbula Yes 16 Male Lef shoulder, lef poste- Shoulder/Torax Yes 1 No bleeding, no loss of conscious- No rior thoracic wall, bullet ness, no weakness, no paresthesia, projecting over frst lef no exit site, no evidence of major rib (did not enter chest vascular injuries cavity). 28 Female Right thigh Lower extremity No 0 Right thigh superfcial abrasion No 58 Female Lef arm, bullet in Upper extremity Yes 2 Bullet in the palmar aspect of the Yes palmar aspect of forearm forearm with associated overlying (middle third and sof tissue swelling distal third of posterior forearm). 11 Male Lef eye Head Yes 2 Shrapnel injury leading to eye No redness, headache, and blurry vision. Abrasion at limbus, corneal laceration 6mm.

SIGNA VITAE | 109 36 Male Lef mid-thigh Lower extremity Yes 1 Exploration and removal of bullet No 32 Male Lef side of pelvis (ante- Abdomen/Pelvis Yes 1 Exploration and removal of bullet Yes rior entry through right thigh). 37 Female Lef shoulder Shoulder/Torax Yes 4 Apical pneumothorax, hemo- Yes thorax, bullet lodged in lef lung. Comminuted minimally displaced fracture involving the lef clavicle. Required thoracotomy, removal of bullet, bilateral chest tubes. 27 Male Frontal lobe of brain Head Yes 2 Lef craniotomy for removal of Yes bullet 20 Male Face, eyes, and neck (5 Head Yes 23 Scleral repair of laceration, pars Yes shrapnels to face). plana vitrectomy 18 Female Lef thigh Lower extremity Yes 1 Fracture of the anterior cortex of Yes the lef femur 11 Male Right calf Lower extremity Yes 1 Mild swelling, sof tissue injury, no No bleeding, slight oozing

Figure 1. Stray bullet lodged in right side of head (1), computed tomography (CT) scan with bul- let (2), CT scan afer bullet removal (3), image of bullet (4).

110 | SIGNA VITAE