Psychological Impacts of Retained Bullets From the Perspective of Survivors

Abstract

Introduction:

Despite a high prevalence of retained bullet fragments (RBFs) after firearm related injury (FRI) there is limited data on the full spectrum of their consequences, particularly the psychological impacts on those injured. Further, the experiences of FRI survivors with RBFs are missing from existing literature. The objective of this study was to explore the psychological impacts of RBFs on individuals who have experienced recent FRI.

Methods:

Adult (18–65 years) survivors of FRI with radiographically confirmed RBFs were purposively selected from an urban Level 1 trauma center in Atlanta, Georgia, to participate in an in-depth interview. Interviews were conducted between March 2019 and February 2020. Thematic analysis was used to identify a range of psychological effects from RBFs.

Results:

Interviews from 24 FRI survivors were analyzed: the majority of participants were Black males (N = 22, 92%) with a mean age of 32 years whose FRI occurred ∼8.6 months prior to data collection. The psychological effects of RBFs were grouped into four categories: physical health (eg, pain, limited mobility), emotional well-being (eg, anger, fear), social isolation, and occupational welfare (eg, disability leading to inability to work). A range of coping mechanisms were also identified.

Conclusion:

Survivors of FRI with RBFs experience a range of psychological impacts that are far-reaching and affect daily activities, mobility, pain and emotional wellbeing. Study results indicate a need for enhanced resources to support those with RBFs. Further, changes to clinical protocols are warranted on removal of RBFs and communication about the effects of leaving RBFs in situ.

Introduction

While the incidence of firearm-related deaths in the United States has risen exponentially to over 45,000 annually, the number of survivors exceeds deaths by nearly 3:1, with approximately 120,000 firearm-related injuries (FRIs) each year.¹ There are short- and long-term consequences of FRI, which have direct and indirect costs to survivors.² Survivors and their family networks experience more mental illness, substance abuse, chronic pain, and health care utilization following FRI.²

A large number of survivors have retained bullet fragments (RBFs) after FRI. An RBF is a metallic fragment left in the body after a gunshot wound is sustained. Retained bullet fragments are often seen on radiographic imaging (ie, X-rays, computed tomography,) or discovered on physical examination. Contemporary trends reveal up to 75 percent of civilian FRI survivors have RBFs, the consequences of which remain largely ill-defined.^3,4

Prior studies have demonstrated that RBFs are not always benign. They may cause complications such as infection, pain, increased blood lead levels, and disruption of normal mobility secondary to bullets lodged in joint spaces or from those that prevent non-union of bone fractures.^5–15 In addition to the physical and toxicological ramifications, RBFs have been linked to psychological consequences, such as depression; however, the full array of these psychological effects is unknown.¹⁶

The purpose of this study was to assess the psychological impact of FRI from survivor’s perspectives. Our objectives were to (1) identify the effects of RBFs on psychosocial health of survivors and (2) determine survivor’s desire for bullet extraction. Our results can be used to inform new clinical practice management guidelines for RBFs, and to identify appropriate social and mental health resources needed for this vulnerable population.

Methods

The study was conducted at Grady Health System in Atlanta, Georgia. This is Atlanta’s only level 1 trauma center and is one of the busiest centers in the country.¹⁷ Nearly a quarter of annual trauma admissions are due to penetrating injury.

Eligible study participants were survivors of an FRI occurring within 2 years of data collection, aged 18–65 years, with clinically or radiographically confirmed RBFs in their body. We excluded those who were pregnant and/or incarcerated. Due to the acute vulnerability of our study subjects around the time of traumatic injury, we recruited participants at least one month following their hospital discharge from initial injury. Eligible study participants were referred to the study team by clinicians during their index hospital visit or during their subsequent clinic follow-up and invited to participate in the study by phone.

Data Collection

Data were collected between March 2019 and February 2020. Qualitative in-depth interviews were conducted by trained researchers and held in a private office at the hospital. A semi-structured interview guide was used, including questions on the circumstance of the injury, information provided by doctors, emotional and psychological impact of the retained bullet fragments on the participant’s daily life, feelings toward living with a bullet fragment in situ, desire for RBF removal, and the extent of disclosure of RBFs to social networks. All interviews were audio recorded and lasted approximately one hour.

Data Analysis

Interview recordings were de-identified and transcribed verbatim by an independent agency. The transcriptions were reviewed for accuracy and completeness by the study team. Thematic analysis was carried out in six steps (see Figure 1) which were conducted in a circular way whereby some steps were repeated or occurred concurrently: (1) Reviewing data to develop a code book, (2) assessing inter-coder agreement, (3) coding data, (4) descriptive analysis, (5) comparative analysis, and (6) categorizing issues into themes.

Figure 1.

Thematic analysis steps.

Ethical approval was received from the IRB at Emory University and the Research Oversight Committee at Grady Memorial Hospital. Study participants received monetary compensation of $25 for their participation. Participants were advised that agreeing to be interviewed would not impact their treatment and that they were free to withdraw from the study at any time.

Results

Sample

Twenty-four interviews were conducted. 92% (n = 22) of participants were black, and 88% (n = 21) were male. Their median age was 28 years [IQR 21–38.5], and the median duration of exposure (time from ballistic injury to interview) was 8.6 months [IQR 2–12] (see Table 1).

Table 1.

Demographic Characteristics of Study Participants.

Participant	Age	Gender	Race	Location of retained bullet	Duration of exposure
Interview 1	38	Male	Black	Arm	11 months
Interview 2	26	Male	Black	Proximal lower leg	10 months
Interview 3	27	Male	Black	Sacrum	3 months
Interview 4	58	Male	Black	Lower leg	8 months
Interview 5	34	Male	Black	Lower leg	8 months
Interview 6	24	Male	Black	Arm	10 months
Interview 7	30	Male	Black	Head and Axilla	10 months
Interview 8	39	Male	Black	Chest	8 months
Interview 9	28	Male	Black	Pelvis	11 months
Interview 10	22	Female	Black	Pelvis	9 months
Interview 11a	19	Male	Black	Abdomen	3 months
Interview 12	20	Male	Black	Back	2 months
Interview 13	18	Male	Black	Upper leg	2 months
Interview 14	32	Male	Black	Abdomen	1 month
Interview 15	19	Male	White	Chest	12 months
Interview 16	59	Male	Black	Chest	1 month
Interview 17	51	Male	Black	Lower leg	18 months
Interview 18	45	Male	Black	Upper leg	Unknown
Interview 19	32	Male	Black	Lower leg	Unknown
Interview 20	40	Male	Black	Knee	20 months
Interview 21	24	Male	Black	Upper leg	15 months
Interview 22	29	Male	Black	Pelvis	2 months
Interview 23	28	Male	Black	Arm	2 months
Interview 24	20	Female	Black	Lower leg	12 months
Interview 25	19	Female	White	Head	15 months

^aDiscarded due to incomplete records.

Themes

Four areas of participants’ lives were influenced by living with an RBF: (1) physical health, (2) emotional well-being, (3) social isolation, and (4) occupational welfare. Participants also described an array of coping mechanisms for living with an RBF (see Table 2 for exemplary quotations and full responses are available through the corresponding author, see Figure 2 for coping mechanisms).

Table 2.

Exemplar Quotations of Each Theme.

Theme	Category	Quotation(s)
Physical health	Pain	“I really don’t sleep. If I roll the wrong way or move my arm wrong, I’m coming out of my sleep instantly. I’m in pain so I just sit up most nights. I don’t really sleep that much” “Sometimes it feels like it’s burning. Sometimes it feels like I’m getting stabbed in my foot. Other times it feels like somebody done took a hammer and hit the heel of my foot”
Emotional well-being	PTSD/flashbacks	“The other day I had a nightmare; I dreamed that I got shot in the head, type of thing, and I died in the dream” “It’s like a reminder. It’s like a trophy. Like somebody got their trophy in me”
	Vulnerability	“Man, I was this big person. Couldn’t nobody tell me nothing [but when I was shot] I couldn’t protect myself” “You can’t trust anybody”
	Shame/embarrassment	“For a minute there, I kind of balance that. […] I kind of lost a little of self-confidence” Having a RBF made him feel: “Shameful. That was the first time in my life I ever get a bullet. That made me really, really being down”
	Pride	“If I can get past this, like I said, there’s nothing else that I can’t overcome” “But [the retained bullet][…] kind of makes me feel a little badass just for kind of getting through what I did against the odds. Because all the doctors were like you shouldn’t have survived”
Social isolation	Relying on friends/family	“All my friends still, they’re trying to treat me like - like, if we go out, they be like guarding me” ‘For the next two months [my friends] were in the house together basically playing house. They made sure my daughter was okay, he took care of the company, she cooked”
	Distrust of strangers	“Sometimes, I can be scared of people sometimes. Or like the guy I seen earlier. LIke, man. I think, is he going to kill me again? People, they’re serious, what the hell is going on. People are, we cannot trust everybody in this world. You cannot be friends with everybody”
	Isolation	“Nobody else got [a retained bullet] but me. Everybody who I know, personally, who either got shot - they don’t have a bullet. I’m the only one, like, who got the bullet in their body. I think that is so horrible. I think that’s bad. I think - because nobody can relate to it”
Occupational welfare		“I really want to quit my job now ‘cause it hurts. It hurts to do anything. But I can’t. I have to keep working” “I used to do security too, so I used to have to stand on my feet for a long period of time at a strip club or whatnot and I can’t – I stopped. I had to stop the job or whatever the case because it was too much for me to stand up for a long period of time and break up physical altercations and stuff like that”
Coping mechanisms	Processing	“Even at night here lately I find myself when I go to sleep I just hold my hand there to kind of like make sure it’s still there and it hasn’t moved. I know that eventually through therapy I’ll be able to work that worry away from me”
	Distractions	“When you drink like that – I mean [the pain and traume] go away for a while ‘cause you’re drunk. But when that drunkenness go, your highness go, the matter is still right there”
	Problem solving	“I can’t live with this in my arm for the rest of my life […] I’m always gonna think about this” “they told me if I wanna get better, I had to go to – they sent me to like a [physical] therapist, and I went every appointment, and it got better. And they told me every time I went for my appointment I had to do different stuff, move my arm around and loosen it up for my arm to get better. But it’s a lot better than it was at first’

Figure 2.

Coping mechanisms.

Theme 1: Physical Health

Physical consequences of living with RBFs impacted the psychological well-being of participants, with all participants experiencing pain following their injury. While the severity of participant’s pain did fluctuate over time, participants described the pain as “burning,” “sharp or shooting,” and causing them to feel “irritation” or “agitation.” Those with palpable RBFs associated their pain with the location of fragments, while those who had internal fragments said they could usually not make a direct association. Retained bullet fragment-associated pain caused sleep disturbances in the form of insomnia, frequent need to adjust sleeping position, or repeated awakenings.

Additional physical health ailments reported by participants included limited mobility and inability to exercise or complete activities of daily living (ADLs). Retained bullet fragments in the upper extremities were associated with difficulty bathing and dressing oneself, while RBFs in the lower extremities presented as persistent challenges with mobility, walking, going up and down stairs, and running. These limitations impacted the quality of life for many participants, who were not able to function as they previously had or carry out physical activities they had previously enjoyed.

Theme 2: Emotional Well-being

The emotional effects experienced by those with RBFs were diverse and included anger, fear, shame, regret, pride, and vulnerability, unpredictable mood changes, flashbacks, nightmares, paranoia, hypervigilance, and clinical diagnoses of post-traumatic stress disorder (PTSD).

Anger was one of the most commonly described emotions experienced by participants. It was typically related to pain, with one individual describing that “pain creates anger.” Others noted that anger brought on arguments within their personal and occupational lives. When asked about triggers and/or solutions for anger management, some participants felt their anger could be improved with removal of the bullet. Hypervigilance, paranoia, and fear were also described but took on different forms in different individuals. For example, a participant illustrated angst by stating, “[the bullet] would also make me just kind of paranoid because I felt like it wasn’t fully fixed.” Shame and regret were also described. Some participants felt shameful living with a retained bullet in their bodies, concerned about scars, the fragments’ visibility, and how others may perceive this and judge them.

Conversely, some participants felt pride in surviving, commenting that it made them stronger and viewing their retained bullet as a reminder of their resilience. One participant referred to himself feeling “like superman,” one said she felt likea “badass,” and another stated, “ifI can get past this, like I said, there’s nothing else that I can’t overcome.”

Theme 3: Social Isolation

Participants described the impact their RBF had on their social well-being, which encompassed interactions with family, friends, other survivors, and strangers.

Participants described relying more on family and friends after their FRI, which was especially true for those with limited mobility due to their injury. A few participants also noted how their RBF reminded them of the fragility of life, and as a result, took more time to protect the relationships valuable to them in their lives.

Participants typically felt their injury created distance between themselves and their families or peers as they felt others could not relate; “It’s […] like you had a picnic and you got that bee, you know what I mean? And it seemed like you the only person in the room it’s bothering. That’s what a bullet in your leg feel like.” These individuals found deep social connection in speaking with survivors who had endured similar trauma. Conversely, those participants who did not have anyone with a shared experience to talk to felt more isolated. One female participant explained “Nobody else got [a retained bullet] but me. Everybody who I know, personally, who either got shot – they don’t have a bullet. I’m the only one, like, who got the bullet in their body. I think that is so horrible. I think that’s bad. I think – because nobody can relate to it.”

In addition to the social disconnect with family, friends, and fellow survivors, participants also described a lack of trust in strangers and acquaintances. They described feeling concerned and hypervigilant in public.

Theme 4: Occupational Welfare

All participants in this study were unable to work for a period of time following their injury, which led to a profound impact on their occupational lives. They discussed how challenging this was, as their occupations were important not only from a financial stand-point but also in bringing meaning and purpose to their lives.

Some participants described how their RBF became an inspiration to work harder, go back to school, or set higher goals for themselves. They described their injury as a catalyst and the bullet as a constant reminder that they wanted more out of life. In contrast, others described the bullet as a constant reminder of the professional limitations they now experienced. They described the emotions of anger and paranoia discussed in theme 2 permeating their work lives and leading to irritability, trust issues, and relationship problems with co-workers and supervisors.

Coping Mechanisms for Living With an RBF

We asked participants how they coped with the various effects of the RBF on their daily lives. Three types of coping mechanisms were reported: (1) processing, (2) distractions and redirection, and (3) problem-solving (see Figure 1).

One coping strategy described by participants involved focusing on processing their trauma through use of their family, friends, religious groups, and other survivors. While a few participated in formal therapy, most described social networks as more beneficial. Much of their healing process was also self-reliant, and independently making sense of what had happened and how it made them stronger. One individual stated: “Why do you have such confidence?’ Because I’ve been through so much that this is not gonna tear me down. This is not gonna keep me down. This is not gonna do anything to me.”

Another coping strategy involved choosing not to dwell on the past but rather distracting themselves with other things. For example, some participants tried to redirect negative emotions into positive thoughts or actions, such as singing, being outdoors, or working on household projects. Others found themselves turning to unhealthy outlets and distracting themselves with alcohol or marijuana.

Lastly, some participants focused on the physical impact of the bullet on their lives and sought to solve this problem by focusing on having it removed. These participants felt having the bullet was “unnatural” and that having it removed may alleviate their psychological burden. They sought both medical counsel regarding this and some acknowledged that if they did not have it done professionally, they worried they may do it themselves. One participant actually did dig the bullet out himself in the days immediately after the injury after the medical professionals refused to believe he had an RBF. Another participant who still had his RBF commented, “I can’t live with this in my arm for the rest of my life […] I’m always gonna think about this.”

Discussion

Nationally, there has been an evolution of civilian firearms and ammunition design, which is likely increasing the number of RBFs. For example, the use of hollow-tip bullets is rising; hollow-tips deform and “mushroom,” increasing the amount of tissue destruction and decreasing the chance of exiting the body. Given these trends and the pervasiveness of firearm-related injuries (FRI), it is imperative to understand the impact of RBFs.

Our study demonstrates that patients with RBFs after FRI experience both physical and psychological effects that are intertwined and continue far after the initial injury. There are currently no widely utilized guidelines regarding the management of RBFs, making removal a case-by-case decision and usually only if causing direct physical complications.¹⁸ However, our study illustrates that having RBFs leads to a multitude of sequelae influencing the overall psychological well-being of those affected. These findings align with previous literature by Smith et al who first proposed a potential linkage between RBFs and patients’ mental health.¹⁶ In their retrospective subgroup analysis of African American men with FRI, individuals with RBFs had higher depression scores on the QIDS-SR 16 screen when surveyed 3 months after injury as than individuals without RBFs. The authors concluded that while RBFs themselves may not be physiologically detrimental to a patient, they may serve as a constant reminder of the traumatic event and may precipitate adverse psychological effects such as PTSD, anxiety, or major depression.¹⁶

Building on the concept of a constant reminder of trauma, RBFs can be likened to scars in burn survivors. It is well-studied that in addition to pain, burn survivors with visible and/or hidden scars suffer from “psychological agony.”¹⁹ Much like burn survivors, recovery from FRIs requires intentional intervention that provides holistic care and promotes resilience.^19,20 Our study participants acknowledged feelings of shame of having a foreign object lingering in their body, sometimes visible and sometimes not. Perhaps complete removal of the fragment may serve as a permanent fix that allows the external and internal scarring to heal.

Conversely, some participants likened their RBFs to a badge of honor or recovery. With reflection on personal transformation from the woes of injury, not every sentiment regarding RBFs was negative. Clinicians should, therefore, seek to understand how RBFs affect the health, lives, and psychosocial well-being of their individual patients on an individual basis and allow this to guide appropriate treatment options.

To our knowledge, this is the first qualitative study on the psychological impacts of RBFs from the perspective of FRI survivors. The themes that emerged from our study—physical health, emotional well-being, social isolation, and occupational welfare—illustrate that the impacts of RBFs permeate all aspects of daily life. The high prevalence and documented long-term effects after FRI should consider RBFs not an isolated medical condition but a chronic public health issue that should be treated, funded, and researched as such.

Limitations

The study sample comprised predominantly young black males; thus, study results largely reflect the views of this demographic. Furthermore, study participants were recruited from a single institution, which may have certain care practices for RBF. Finally, at times, it was difficult to tease apart sentiments related to the RBF or the FRI, in general. Skilled researchers used probing and other techniques to overcome this limitation.

Conclusion

This study highlights the importance of considering the psychological consequences of RBF in those who survive FRI. Given the high number of gunshot wound survivors with RBF in the US, it is prudent that clinicians understand the full extent of adverse consequences of RBF, including psychological impacts, in order to appropriately counsel patients on holistic and RBF management.