Gunshot Wounds – From Lebanon, via Syria, to the Streets of Your City!

The index article by Zgheib and Colleagues from Lebanon, published in JETS, details the 83 cases of gunshot wounds from their 6-year retrospective chart review.[1] They dissect the underlying intent of the injury and relate the relative mortality of these 83 patients, the spectrum of injury, and the pathway to receiving care at their institution. This aspect is a relatively under-researched area of trauma care, particularly from the perspective of countries where the highest trauma burden exists, namely the lower- and middle-income countries (LMICs).

In addition, they highlight the “stray bullet” concept, which appears to have a higher incidence in Middle Eastern countries due to certain “cultural” activities. These are usually perpetrated by males yet seem to injure child and female victims commonly, often at a distinct distance from the shooter. The other group mentioned is those injured unintentionally, from bystanders to untrained weapon handlers/gun cleaners. They further highlight over 10% mortality and almost 20% morbidity in the patients reviewed, despite the many late presentations to their facility, while for the latter two groups, the injuries appeared generally less severe. Al-Tarshihi and Al-Basheer highlight the often confusing clinical picture of the stray bullet due to lack of an audible gunshot.[2]

Despite the 60% intentional injuries, with many multiple gunshot wounds, the mortality was reasonably low, suggesting that many had “self-triage,” and more severe injuries, especially from the conflict zones, had demised on route to the study site. Almost 9% of their patient population were from the conflict zones of Syria and Iraq with mainly intentional injuries.

The two interesting issues are the stray bullet and the intentional war zone/automatic weapon shootings, common to many LMICs and recently under scrutiny in the USA after several mass shootings in the civilian scenario. The resulting “#thisismylane” threads on social media in the USA bear testimony to the need for rational gun control and better education of gun owners to reduce the trend of gun-related injury.[3]

The conflict in Syria was recently reviewed from other countries where the victims present as cross-border transfers.[4,5] While war is terrible and causes untold misery, the fact that many of the victims are women and children (noncombatants), as well as the associated humanitarian crisis related to access to care, along with “collateral damage” should inspire all health practitioners to be peace loving and antiwar. Iflazoǧlu et al. emphasized the potential for nonoperative management in these late-presentation gunshot wounds presenting to their facility in Turkey. They found that around 10% of such cases had successful management nonoperatively. Salamon et al. mention the effect of the delay to definitive vascular surgery from such war victims with a 25% limb loss in the cohort. Hardcastle and David, in a recent editorial, emphasized that resource constraints in conflict zones are not unlike LMIC settings, so by auditing and reviewing the provision of trauma care in conflict zones, the innovations, lessons learned, and strategies to provide timely care are essential to improve outcomes in trauma care in LMICs.[6]

The issue of the general escalation in gunshots, especially unintentional and particularly mass shootings, raises the social issue around gun control, which leads to heated debates. While the majority of legal gun owners and particularly sports shooters will correctly store and manage their weapons, the concerns exist around the easy access to weapons and poor storage techniques in many cases where injury occurs. In particular, this relates to semi-automatic weapons, where the consequences of multiple wounds are higher given the opportunity to fire multiple rounds, especially during intentional shooting incidents, such as during conflicts and recent civilian shootings in the USA. The cases of stray bullets in the “cultural shootings” additionally bear testimony to this fact. The steady increase in mass shootings facing civilian populations, particularly in the USA, or parts of Africa, bears testimony to the need for multidisciplinary action, while this has declined with good gun laws in Australia.[7] Lin et al. also noted the risk of so-called “copycat” events in their review.[7] The debates around the legality of “bump” stocks in the USA further add impetus to this point, along with other measures to reduce the amount of potential bullet energy, by limiting magazine capacity, for example. Background checks, safe storage, and a requirement for basic ownership training are also mooted as prevention techniques. Without urgent intervention, we will be limited to post hoc education of our patients.[3,6,7,8]

It therefore behooves us as clinicians to carefully take heed of the challenges facing surgeons dealing with conflict medicine and apply the learning points to our civilian practice and aim to reduce death and disability through prevention and reasonable legislation, rather than facing the need for reactive patient care once the injury has already occurred.