Opinion | Treating the Trauma of Bullet-Related Injuries

In part 2 of this exclusive interview, Jeremy Faust, MD, editor-in-chief of MedPage Today, and LJ Punch, MD, trauma surgeon and director of the Bullet Related Injury Clinic (BRIC) in St. Louis, discuss how the dogmatic practice of leaving bullets in patients can be harmful to the mind and body.

The BRIC is a community-based clinic that helps people heal after they have been injured by a bullet. Part 1 can be watched here.

The following is a transcript of their remarks:

Faust: What’s the first encounter like when someone is recovering or they’re a victim and they come to your clinic?

Punch: So again, the numbers, let’s level set. Around a little over 40,000 people lost their lives to a bullet last year, 85,000 were injured non-fatally, and 70% nationwide — different ERs [emergency rooms] might have different practices — go home from the ER.

So let’s think about that body of people. The overwhelming majority of people who have bullet injuries are managing that on their own, wherever they live, wherever they work, wherever they play. Now, within that group there might be a wide range of injuries, but generally we think of bullet injuries that can be managed by people on their own as “minor,” and they’re sent to follow-up in 2 weeks as needed with their primary care doctor or perhaps in a trauma clinic.

Here’s the thing: In the days after a bullet injury due to the blast effect of the bullet moving through the tissue, depending on the depth of that bullet’s track, there is a profound inflammatory response. The blast effect can even cause tissue necrosis, such that what I have found is that bullet injuries tend to get worse and be more symptomatic in the days after.

The way this engagement begins, therefore, in the idea of the BRIC, is to invite someone to an aftercare experience that begins with them right there in the emergency room through the presentation of a BRIC box. A BRIC box has all the supplies that somebody needs to get started on reducing that inflammation, managing that wound, getting that body moving again, and starting to deal with the emotional and psychological impact of what it is to have your life threatened.

That idea then moves people into the opportunity to follow-up with us in a clinic appointment soon, not waiting 2 weeks while that pain and that inflammation and that trauma is getting deeply entrenched.

Faust: Thank you for that amazing introduction to what you do.

And I also want to make sure that people understand who may not be in medicine, something that’s different from the movies. In the movies, someone is shot and, oh we got to get the bullet out, we got to get the bullet out. And very often that’s not the case acutely, right? Because there are considerations about whether it needs to come out — it could cause more harm than good.

But where BRIC comes in is that sometimes downstream this is a physical reminder of something really both literally traumatic and psychologically traumatic.

So at some point, I was reading in your work, that that discussion happens: Do bullets come out, and how does that benefit people? How do you have those discussions, and what kind of outcomes do you see?

Punch: This is important. Let me start right here, right here: Tell me the longitudinal study that shows that retaining bullets or leaving bullets inside someone’s body is a safe practice.

Faust: I mean, it’s dogma. That’s all I could tell you is that that’s dogma.

Punch: It’s dogma. OK, where’d that dogma come from? Let’s go back. We have to go back to the 1700s to figure out where this came from.

So if you think about it, before aseptic technique, before hand washing, and way before antibiotics, people would obsess with getting missiles out of people’s bodies because it was thought that if the missile was in there, the bullet, it would cause harm. In not using clean technique and not preventing infection, digging into bullet tracks or making incisions, lo and behold, people could get sick.

And a doctor — I believe it was a British doctor in the 1700s, I think it was a Dr. Hunter — observed four soldiers who were shot who went and hid in a barn for 4 days, who emerged from the barn not infected and healing their bullet injuries just fine. And from that moment it was decided, the dogma was born: Bullets should be left inside people’s bodies.

I’m sorry, but I don’t know too many techniques that we base our care on that come from the 1700s, and yet it remains unchallenged.

Now, why, why, why would it remain unchallenged? What on earth would keep this practice so understudied and under-understood? There have been structural realities in our academic approach, but to me the bigger issue is our language, because we haven’t named and identified what the injury actually is. This is why it’s so important.

So for us, by talking about bullet-related injuries, we do a few things. One, we stage them. Typically in a medical record, if someone has a bullet injury we call it a “gunshot wound.” But how big it is, what length of tissue it goes through, how deep it goes — the orthopedic surgeons have a little bit of language around this and there’s a little bit of language from the military in terms of triaging people to surgery or not — but otherwise, there’s nothing. People know if they have stage 4 pancreatic cancer. We talk about a level 4 BRI [bullet related injury]; it gives us a way of helping people begin to understand the impact.

And from there, if they have a retained bullet or not, we can have rich conversations about their options for getting the bullet out. These conversations need to be backed by scholarship. So we’re studying as best as we can the impact of early bullet removal. And there are researchers across the country, such as Dr. Randi Smith at Emory, who have been saying for a long time, “Leaving bullets in is not benign,” showing higher rates of depression, and other studies recently showing even lead toxicity that can come, especially if a fracture is associated and the bullet is sitting in the bone.

There is a lot of science that needs to be done around what it means to have a bullet inside your body. We need to catch up, and that needs to begin with people having academic pathways and funding to study it. For now, we’re doing the best we can in the community environment to get those questions answered.

Faust: Can you tell me a little bit about examples of where this made a huge difference for a patient? Because I don’t think I know that story.

Punch: Here’s an example. A 15-year-old who was shot literally getting off a bus during the afternoon release from school. The bullet ended up in his foot. He went to two local emergency departments to get evaluated and was sent out both times without being admitted with no dedicated aftercare except for he finally got referred to us.

I saw him, and his foot was horribly swollen and had signs of infection. I put him on a couple-day course of antibiotics and then did a procedure — 1-inch incision, lidocaine, 15 minutes. Not only had I pulled out a very easy-to-get bullet, but I had pulled out a piece of his shoe as it had been driven in by the bullet.

Now his story, many people would be like, “Oh, well of course it was infected. You had to do something, and I would’ve done the same.” But the thing is he is one of hundreds of patients that we have seen over the last 3 and a half years who have bullets left in their bodies who are not appropriately advised of their options and their choice. They are not supported in their ability to make decisions; there’s no shared decision-making. It’s just literally patients being told, “This isn’t the movies. We don’t take bullets out. You’ll be fine. Go home.” I’m not saying this theoretically, [I’m] quoting my patients who are telling me how tragic this is.

Another 19-year-old that I had who sat in the emergency room and said, “I feel the bullet in my belly right here.” And was told that instead she would need a 12-inch incision and a major laparotomy to get it out, and that wasn’t needed because she didn’t have any other indication for surgery.

Twenty minutes later, a bedside ultrasound on my iPhone, and some lidocaine, and the bullet’s out of the kid’s body, because she knew it was not supposed to be there. Actually not 19 — [she was] 17, that’s why I’m saying child. Two children who knew something wasn’t right, who could not get appropriate care in a hospital setting, and weren’t admitted for further care.

These are the kinds of stories I’m seeing day after day at the BRIC. It tells me we’ve got something really wrong in the way we’re not just managing the injuries, but even how we’re talking to patients about what the injuries mean.

Faust: Yeah. I think about some work that I saw that you had done about this idea of the stigma, and it’s not even necessarily external, that people even know about it, because a lot of it they are literally internal, literally walking around carrying physical evidence of something that occurred that wasn’t your fault. That’s a big thing that you talk about, I think in your TED St. Louis talk. About this idea that this is this constant, literal reminder of something and the blame that happens. I was really moved.

You talked about that very famous scene in “Fresh Prince of Bel-Air,” and then a similar one in “Good Will Hunting,” where it really hit home this idea that people who walk around with injuries — whether they’re psychological injuries or literal bullet injuries — eventually a lot of them, not all of them, but a lot of them start to blame themselves and it’s not appropriate. That’s not their fault.

So, two things. One, please talk about that and expand on that. And second, is it your theory that when you get that literal physical reminder out of there that maybe they’re less likely to blame themselves for something that really wasn’t their fault?

Punch: I’ll say that I am not the moral police. I had to really let go, seriously, I had to relinquish my thoughts of judgment about my patients and the conditions or the circumstances of their injuries, because that did not allow me to be in a good position to be their doctor. So that is really important, whether it’s their attitudes about gun ownership or their relationship to the bullet that’s in their body. I’m not here for that.

I’m here for people. I love people. I’m in love with humanity. I want to help people’s bodies get well and I want to help them live their best lives. So that was a really important commitment for me in building the BRIC.

In terms of what a bullet means, when a half-inch piece of metal moves at the speed of sound and it ends up lodged in your body, regardless of how it gets there, it creates a constant message to your body that you are not safe, regardless.

That creates trauma and keeps people in a fight or flight response, which is excruciating. They can’t eat, they can’t sleep, they can’t move their bodies, they can’t think, and that puts everyone at risk for more trauma.

Now let’s look at the numbers. Adolescent and young men who have bullet injuries 25% of the time will have a recurrent bullet injury and maybe even have a fatal bullet injury in 10 years. Anyone who’s hospitalized for a bullet injury is 30 times more likely to have a recurrent bullet injury in the next 5 years, or seven times as likely to die in the next 5 years.

What do I mean? Bullet-related injury is its own worst risk factor. One of the most common risks for fatal BRI is non-fatal BRI. And so I think it’s really, really important to do everything we can to heal BRI.

Retained bullets are one of the most malignant forms of BRI. See? If I use that language, it kind of makes sense because the bullet is the virulence. Think of it like you’re having a really high viral load if the bullet’s still inside your body. So yes, I think early removal that is reasonable is important. And I think quite honestly the surgical risk for a huge amount of bullets is extremely low.

Again, further scholarship is necessary, but minor procedures should not be delayed in getting that under control and helping people take steps in their healing.

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