Review of Statutory Obligations for Reporting Ballistic Injuries

Background:

Traumatic ballistic injury is an unfortunate and commonly encountered problem seen by surgeons. An estimated 85,694 nonfatal ballistic injuries occur annually, and in 2020 there were 45,222 firearm-related deaths in the United States. Surgeons of all subspecialties may provide necessary care. Acute care injuries are generally reported to authorities immediately; however, delayed presentation of ballistic injuries may go unreported despite regulations to do so. We present a case of a delayed ballistic injury and a comparative review of individual states’ reporting requirements to highlight statutory obligations and penalties as an educational reference for surgeons treating ballistic injuries.

Methods:

Google and PubMed searches were performed utilizing keywords “ballistic,” “gunshot,” “physician,” and “reporting” as terms. Inclusion criteria included the English language, official state statute sites, legal and scientific articles, and websites. Exclusion criteria included nongovernmental sites and information sources. Data collected were analyzed to include statute numbers, time to report, infraction consequences, and monetary fines. The resultant data are reported by state and region.

Results:

All but two state jurisdictions mandate healthcare providers to report knowledge and/or treatment of ballistic injuries, regardless of the timeline of injury. Violations of mandatory reporting may lead to fines or imprisonment, depending on the specific state. The timeline for reporting, fines, and subsequent legal action varies by state and region.

Conclusions:

Requirements for reporting injuries exist in 48 of 50 states. The treating physician/surgeon should thoughtfully question patients with a chronic ballistic injury history and provide reports to local law enforcement.

Takeaways

Question: Are there statutory obligations and penalties in the United States for surgeons who do not report ballistic injury, even if being treated in a delayed fashion?

Findings: This review catalogues that 48 of 50 states have laws requiring mandatory ballistic injury reporting whether the injury is acute, or the presentation is delayed.

Meaning: Physicians and surgeons caring for patients with ballistic injuries should be aware of state guidelines for mandatory reporting, as most states require reporting of ballistic injuries.

INTRODUCTION

Ballistic injuries are commonly encountered traumatic wounds in the United States. There are an estimated over 85,000 injuries seen yearly.^1–6 These problems are cared for by physicians and surgeons across multiple subspecialties. Acute injuries are frequently immediately reported to legal authorities, for an investigation into the circumstances and etiology of the injury.⁷ Unreported, initially delayed, or untreated injuries can present in a delayed fashion. Complaints of symptomatic foreign body and removal requests are not uncommon.⁸ In these instances, the legal requisite for reporting remains.⁹ It can be difficult, and sometimes burdensome, to ascertain whether a previous investigation had been completed. Patients may not provide a truthful or accurate report concerning the facts surrounding the initial injury, or whether a proper legal investigation had previously been undertaken. Therefore, the treating physician/surgeon should be aware of the legal/ethical requisites and considerations upon encountering delayed (or acute) ballistic injuries and should contact legal authorities to assure proper documentation of and compliance with the requisite investigation.

METHODS

An analysis was performed using open-sourced legal databases on an individual state level. Google and PubMed search engines were utilized from September 2019 to March 2022. Database search was guided utilizing keywords “ballistic,” “gunshot,” “physician,” “ballistic injury reporting,” and “gunshot reporting.” Inclusion criteria included English language websites, with documented state-affiliated legislation, and legal or scientific publications. Exclusion criteria included websites that were not affiliated with state government entities or referencing nonstate mandated legislation. Statute reference numbers and specifications regarding time to report, possible infraction charges, and monetary fines were recorded. Statutes on reporting ballistic injuries were further examined by region (Fig. 1). (See figure, Supplemental Digital Content 1, which shows a report of ballistics on the state level. http://links.lww.com/PRSGO/C420.) PubMed search/review was utilized for background information.

Fig. 1.

Map of the United States illustrating states containing legislature that holds potential legal conviction, monetary fines, and defined time to report ballistic injuries. Statutes on reporting ballistic injuries can be further evaluated in the West, Midwest, Northeast, and Southern regions.

CASE REPORT

We encountered a case of a 56-year-old right-hand–dominant man who presented to the clinic with request for foreign body removal of the left upper extremity after a ballistic injury occurring a decade ago. Radiographs obtained at initial evaluation appeared to be consistent with a retained bullet fragment of the mid-volar forearm, without any underlying osseous disruption. The patient claimed the ballistic injury was sustained during a prior accidental discharge of a firearm and was seeking removal due to discomfort encountered with pronation of the extremity. He underwent an uncomplicated surgical exploration and removal of the foreign body, consistent in nature with a retained bullet, which was subsequently sent for surgical pathology. After surgery, the patient requested the release of the bullet fragment for his personal possession.

The patient’s request to obtain his bullet fragment prompted the surgical team to reach out to local legal and law enforcement agencies for elucidation on physician reporting of gunshot wound injuries. According to Florida statute 790.24, failure of a surgical team to report a gunshot wound to local law enforcement could result in penalties, including a first-degree misdemeanor. Based on this statute, a physician remains obligated to report a ballistic injury, regardless of whether intervention is performed, and irrespective of the mechanism, characteristics, or timing of the injury.¹⁰ Our physician’s obligation to disclose the ballistic injury and provide the bullet fragment for analysis with the local sheriff’s department was disclosed with the patient, albeit after the surgical intervention. The bullet fragment underwent forensic analysis by the sheriff’s department after retrieval from pathology with the intent to determine any evidence of criminal activity associated with the original injury.

This specific patient encounter prompted a systematic review of the state legislature across the United States to further determine physician obligation when reporting ballistic injuries, as consultations for foreign body removal are frequently encountered in surgical clinical practice.^9,10

In retrospect, if the surgical team had been aware of the statutory duty to report the retrieval of the foreign body, the patient’s confidences may have been more safeguarded. Although documentation is very important for both medical and legal purposes, documentation should not compromise patient care or interrupt resuscitation efforts. However, the extent of disclosure may impact a patient’s mental state or well-being, and therefore, it is relevant to consider the clinical importance of informed discussion prior to intervention.

RESULTS

The review revealed that regulatory requirements for reporting ballistic injuries exist in 48 of 50 states^11–58 (Fig. 1). Oklahoma and New Mexico have no such statutes. Approximately 18% of states (9/50) subject physicians to monetary fines, whereas other state statutes cite criminal action of misdemeanor offense with potential imprisonment if the physician is found to be in violation of mandatory reporting legislation (Supplemental Digital Content 1, http://links.lww.com/PRSGO/C420). Specifications with regard to failure to report were then further stratified at the regional level. It was found that Northeastern states have the greatest number of statutes implicating monetary fines with failure to report (3/9, 33%). Midwestern states contain statutes with the highest potential for misdemeanor infarction (4/12, 33%), followed by the South (3/16, 19%). Western states demonstrated the greatest trend in detailing a specific time limit in which the physician is required to report a ballistic injury (3/13, 23%), with Hawaii requiring physician reporting within the first 24 hours (Supplemental Digital Content 1, http://links.lww.com/PRSGO/C420).

DISCUSSION

Patient–physician confidentiality is a core tenet of medical ethics; however, this duty is subject to certain exceptions. The American Medical Association’s Code of Medical Ethic states a “physician shall safeguard patient confidences and privacy within the constraints of the law.” This code of medical ethics mandates a physician’s disclosure of confidential information if a crime may have or did occur.¹⁰ Physicians and surgeons caring for patients with ballistic injuries should be aware of state guidelines for mandatory reporting, as most states require reporting of ballistic injuries. Not only should acute injury be reported, but any questionable delayed ballistic injury as well, regardless of the actual treatment rendered. It was found that 48 of 50 states have laws requiring mandatory ballistic injury reporting whether the injury is acute, or the presentation is delayed.^11–58 The injury/incident necessitates careful investigation to determine criminal activity, whether acute or delayed. The surgeon can help support investigations by providing information to law enforcement, from reported history, physical examination findings, imaging examination, and pertinent observation. A proper chain of custody, should operational removal of a projectile be performed, is necessary to maintain a legal record for any possible prosecution. This may necessitate coordination of operative scheduling with the presence of law enforcement for immediate evidence retrieval. The surgeon may be subpoenaed to be deposed or testify to their role and action in the case.⁵⁹

Reporting ballistic injuries remains a delicate balance of safeguarding a patient’s confidentially while upholding a physicians’ inherent duty to society. This review outlines the reference guide for violation of reporting requirements at the state level, as well as elucidating nuances with regard to additional risk of monetary fines or criminal action. The duty to report suspicious ballistic injury situations may seem to place physicians between the ethics of patient confidentiality and the law; however, legal statutory obligations directed at public safety provide the proper ethical principles of action in these situations.⁶⁰