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Volume 1 Issue 4 June 1996 Contents:
Introduction: Welcome to the fourth edition of the Trauma Grapevine The Trauma Department is very grateful to Hoechst Marion Roussel for their help in generating a more professional approach to the Trauma Grapevine. We hope that you will enjoy it's more professional format and we would welcome any suggestions, letters to the Editor or any other topics that you may wish us to cover. It has been a very exciting time for us all in Trauma at Liverpool Hospital and we would like to welcome Dr. Khaqan Jahangir Janjua, his wife Saira N.Afridi and children to Liverpool Hospital as the new Trauma Fellow. Dr. Janjua has broad orthopaedic and general surgical training and has just completed his Masters in Medical Science on Trauma at the University of Birmingham.
Royal Australasian College of Surgeons NSW State Trauma Committee Martin McGee-Collett FRACS March 1996 MORBIDITY AND MORTALITY Morbidity and mortality relating to firearms is identified as a significant health (trauma) issue in NSW. The Royal Australasian College of Surgeons has a brief to educate the medical community with regard to the facts pertaining to firearms and also a responsibility to the community at large in terms of championing public awareness and preventative health education. HISTORICAL PERSPECTIVE As early as 1795 the fledgling colony of NSW it was realised that the uncontrolled entry and dispersal of several hundred fireamms had occurred. In an attempt to create the first firearms registry in the colony a disappointing identification of less than 25 percent of the known fireamms was achieved. This set a precedent for the continued lack of prospective gun control in NSW and, later, Australia. A Gun Licence Bill was introduced into the NSW Parliament in 1914 in an attempt to reduce the number of accidents and deaths from the (careless) use of firearms. Further firearms legislation modification occurred through various select committees, various acts and amendments. A significant body of work was produced in the Report of the Joint Select Committee upon Gun Law Reform in 1991. It is notable that no medical practitioner was a member of that particular committee. it is also notable that many select committees and acts of legislation have been stimulated by newsworthy acts of violence which have appalled the community. There are no uniform gun licensing regulations and laws across the Australian States and Territories. LEGISLATION In NSW the regulation of firearms licensing and the application of firearms law occurs through and under the direction of the NSW Police Service. The relevant legislation includes:- Summary Offences Act (1988). Crimes Act (1900) Firearms Regulation (1990). Firearms Act (1989). Prohibited Weapons Act (1989). Prohibited Weapons Regulations (1990). The law and the penalties for transgressing the laws are specific and substantial. It should not be the policy of the RACS to make any recommendations with regard to the interpretation of the law or its application other than to make the comment that the various maximum penalties would seem to the lay person to act as sufficient deterrent. Long arms are not required to be registered in New South Wales. The New South Wales Police Service Firearms Registry relies upon the combination of pistol and shooter's licences to identify fireamms owners. Certain weapons are prohibited in NSW and a gun and knife amnesty currently exists in NSW. GUN OWNERSHIP In NSW approximately 60,000 pistols are licensed to 10,000 owners. There are approximately 180,000 shooters licences (1995). Overall several categories of shooter's licences exist and good reason has to be shown in order to permit the successful application of a shooter's licence for firearms ownership. There has always been (from the earliest days of NSW as a colony) a large number of unidentified or unflaggable weapons and this will almost certainly remain the case irrespective of current or future legislation. Socioeconomic profiles would indicate that there is very little difference if any between the profile of shooters and non shooters. NSW has statistically the least number of fireamms when compared to other states in Australia and other countries in the world. Approximately 80 percent of households have no firearms. Firearms are more frequently found in rural areas and Newcastle and Wollongong whereas Sydney has the lowest rate of domestic fireamms with firearms being present in only 6 percent of households. The NSW Police Service monitors firearms ownership and shooters licences through a state wide computerised network. Firearms offences and offences which may make firearms access and ownership unlawful are flagged and identified on a daily review of the computeRsed network perfommed by the NSW Police Service Firearms Registry. Appropriate action is then possible on the part of the police. Obviously firearms possession and potential offences may occur outside the surveillance of the Firearms Registry and the Police Service believes certain "fringe groups" are particularly notorious, such as "out-law" motorcycle gangs. From a practical point of view it would seem that a ban on firearms usage or even more restricted access would not be feasible. Certain lobby groups within the community exist such as the Coalition for Gun Control and the Shooters' Party. The college has no role in aligning itself with orendorsing any of such groups. FIREARMS TRAUMA Suicides: In 1990 the NSW Coroners Courts statistics indicated
that 105 (16.7 percent) of a total of 630 suicides occurred by shooting.
This was compared to 157 (24.9 percent) by hanging, 122 (19.4 percent) by
gassing in motor vehicles, 89 (14.1 percent) by drug and/or alcohol overdoses,
46 (7.3 percent) by falling and jumping and 25 (4.0 percent) killed by trains. Homicides: With regard to homicides 20 (16.8 percent) of a total of 119 murders occurred by shooting in comparison to 39 (32.8 percent) by beatings and assault and 27 (22.7 percent) by knife attacks. The murder rate in Australia has remained constant over the last 100 years at approximately 2 per 100,000 population per year Murder rates and the use of firearms are not necessarily able to be extrapolated between countries and notably the United States has wider access to firearms than Australia and a much higher rate of homicide by shooting. Alternatively the United Kingdom has a very low rate of murder by shooting but data analysis would indicate that there is no evidence that firearms registration has had any effect on the homicide or accident rate by shooting in the latter country. With regard to homicide approximately 43 percent of victims are shot by a family member, 20 percent are shot by a friend or acquaintance and only 18 percent are shot by a stranger. Accidental Shooting: With regard to accidents it is notable that over 2,000 air rifle accidents occurred in 1991/1992. With regard to fireamms the most recent analyses are 15 to 20 years old and of the approximately 150 yearly firearms accidents analysed at the time 96 percent were incurred by males, 60 percent were incurred by persons less than 20 years of age and 25 percent of.those under 15 years of age. Forty two percent shot themselves and 30 percent had had less than 12 month's experience with a firearm. The rate of accidental shootings in Newcastle and rural areas was five times that of the rate in Sydney and the rate in the Wollongong area was in between. Sixty nine percent of weapons involved in accidental shootings were rifles (most often .22 calibre). Overall, 82 percent of accidents related to a lack of basic gun knowledge or the ignoring of the use of the safety catch. Comparative Date: The overall homicide rate, as stated above, has remained static in Australia over the last 100 years or so at 2.2 per 100,000 population per year. In comparison, the current rate of fatal road traffic accidents is approximately 10 per 100,000 population per year. Suicide occurs at the rate of 10.0 per 100,000 population per year and industrial accidents produce 5.0 fatalities per 100,000 population per year. DISCUSSION
Fundamentally morbidity and mortality from firearms trauma must be placed by the Royal Australasian College of Surgeons into the perspective of other and more frequent, and perhaps therefore more significant causes of morbidity and mortality such as road traffic accidents and industrial accidents, knife attacks, beatings and assaults and suicide by motor vehicle gassing and hanging. it would appear that absolute gun control and prevention of shooting trauma by legislation is and will continue to be impossible. Certainly any legislative move which could reasonably reduce the likelihood of accidental or fatal shooting would be welcomed by the RACS. Taking the practicalities of the situation into consideration it would therefore seem that the key to reducing accidents and fatalities would be by education of the public to ensure responsible storage and use of guns and education of shooters to ensure that basic training in the handling of firearms is a precondition of ownership. There has recently been a media campaign both on television and radio with regard to domestic access to firearms and hopefully this has alerted the local the local population to some of the problems of children having access to fireamms. With regard to the surgical community all who treat victims of shooting incidents should be well informed with regard to ballistics and wound management and the contemporaneous work of Martin L. Fackler should be brought to the attention of surgeons involved in the management of gunshot wounds. To date the issue of gun control has been a vexatious issue in our community. The evidence would indicate that a significant proportion of firearms-related injuries occur in the context of domestic violence. it may well be that the RACS would have a more productive role in applying its energies to the issue of domestic violence rather than the extremely complex issues around gun control which would seem to defy simplification. CONCLUSION The fundamental aims of firearms registration and regulation ought hopefully to be the reduction of the number of domestic households with access to a firearm and hopefully this will be achieved by the prevention of legally or medically (psychiatrically) unfit persons access to firearms in addition to a community health prevention/education program intended to highlight the major areas of concern which include access of the young and inexperienced to firearms and the involvement of firearms in the situation of domestic violence. Differential rates of firearm morbidity and mortality on a geographic basis should result in targeting of particular areas for public education programmes. With regard to the surgical management of firearms injuries the contemporaneous work of Martin L. Fackler should be brought to the attention of surgeons involved in the management of gunshot wounds. MARTIN McGEE-COLLETT Points from this month's Trauma Audit Intubation in the Emergency Department pre-surgery in trauma patients. During the past couple of months a number of patients have been intubated in the Emergency Department Resuscitation Room on the basis that they were having urgent surgery and would need intubation in the Operating Theatre. Generally trauma patients should not be intubated in the Emergency Department unless they have a problem with their airway breathing or to facilitate CT scan of the head or an absolute emergency haemostatic procedure in the Emergency Department. The reason for this is that vascular tone may collapse on induction of anaesthetic and in a hypovolaemic patient this may lead to an arrest situation. While this can occur similarly in the Operating Theatre at least the staff are in an immediate situation to cope with the blood loss.
There is a need to scoop and run from the Emergency Department after an initial, if appropriate chest x-ray so that the patients can get early control of haemorrhage. Team Approach to Trauma Care: There is a need to co-ordinate the early radiology of patients especially seriously injured patients. Pre-arrival of chest x-ray plates, for example, may help reduce time. Avoiding Hypothermia Well done to the Trauma Teams who recently prevented hypothermia in a young man receiving 25 units of blood with an injury severity score approaching 75. This is one of the first such cases in Liverpool Hospital where hypothermia has been averted through fine attention to detail.
Damage Control: Consideration should be given with serious intra-abdominal injuries of limiting surgery to arrest of haemorrhage and returning at a later stage to perform definitive surgery. BACKCHAT:
Dr. Ulvi Budak has been working very hard on the development of a Trauma Radiology Library. Photo-Elite have been kind to provide their services free of charge in what is a large undertaking copying prints of radiology films. Cyril Huggins has again been most helpful in producing slides of x-rays.
Dr. Jon Ryan is developing a Web Page fro the Trauma Department on the Intemet and shortly the Trauma Grapevine will be on the Intemet with a "Case of the Month". Congratulations to the successful Emergency Registrars in their recent specialist Emergency Examination. Keith Edwards and Sue Johanson.
Gill Bishop has just joined the College of Surgeons Trauma Committee of New South Wales as a member representing Intensive Care. Gill is Director of Intensive Care at Liverpool Hospital. ANSWERS TO THE MAY ISSUE'S CASE OF THE MONTH: (to refresh your memory click here) The questions were: Should the patient have been transferred to another hospital with
a functioning head CT scan before or after the popliteal fossa is explored? Comment: this depends upon how long the retrieval team is going to take to bring the patient to another trauma service with a functioning head CT scanner. In the scenario presented to us this time was going to be approximately 50 minutes. Based upon that it was felt that the warm ischaemia time of the leg would have been approximately three and a half hours and therefore a decision was made to explore and repair the damage in our Operating Theatre and transfer the patient. As it transpired the patient was waiting in recovery for twenty minutes after repair of the damaged popliteal veins and an on-table angiogram before the retrieval team came to take the patient to another major trauma service Does the patient need intubation? Faced with a patient with a GTS of 13 initially falling to 11 there may be a need to protect the airway with a view to CT scanning. Secondly as the patient is going to the Operating Theatre this may be another indication to intubate the patient, however, great care must be taken in intubating and paralysing patients who are hypotensive in the Resuscitation Room as this may precipitate vaso-motor collapse and cardiac arrest. Ideally these patients should be intubated in the Operating Theatre after instrument preparation and sterile preparations are made to allow rapid access to the vascular tree under a sterile environment. Should the patient of had an angiogram prior to surgery? Certainly if the patient was to have had an angiogram this should have been done on table in the Operating Theatre. It is essential that patients with a tourniquet in place, especially ones who are bleeding or who are hypotensive should not attend the Radiology Department for pre-operative arteriography. On table arteriography is very reliable, outlines the vessels in detail and can be done using image intensification or plain radiology. It is, however, essential that you notify the radiographer of your requirements before the patient goes to the Operating Theatre. In this patient's case the radiographer was in place prior to the patient arriving in the Operating Theatre and had a cassette for a tib and fib view for control film in place as the patient was being positioned on the operating table confirming the correct exposure for a subsequent film. Patient outcome: The patient was transferred to Westmead Hospital where a CT scan revealed
a mild cerebral contusion and the patient made an excellent recovery, required
a secondary closure of his leg and was discharged from hospital. CASE OF THE MONTH: A 32 year old female Security Guard was stabbed in the epigastrium by a long bladed knife. At scene: Airway: intact Breathing: RR 24/m Circulation: BP was initially unrecordable, but after five minutes BP 100/- , P130. There was no significant external blood loss. Treatment at the scene: Oxygen re breathing mask l.V. cannulas were placed and 500mls Haemaccel commenced. She received Morphine 2mg At Liverpool Paramedics scoop & run allowing the patient to arrive in the Resuscitation Room 22 minutes later. When a primary survey revealed that her Airway was O.K. Breathing was 24 andequal. Circulation: her BP was 140/80 pulse 120 There was no evidence of external bleeding and her abdomen looked soft. Disability: She was responding to verbal commands and was fully alert. TREATMENT: A second IV line was inserted and the patient was seated upright for an erect x-ray as the stab wound was high in the epigastrium. The patient collapsed with an unrecordable blood pressure- and was quite pale. Airway was intact, up to this point there was no evidence of pneumothorax or haemothorax and no evidence of cardiac tamponade. WHAT WOULD YOU DO NOW? Should the patient have a thoracotomy? Should the patient have a major blood transfusion in the Emergency Department to bring up the blood pressure? The Trauma Department would like to acknowledge the support of Hoechst Marion Roussel in the publication of the Trauma Grapevine Photographic services to the Trauma Department has been provided for 3 years by Elite Heathcote Road 98212522 Copyright 1996 Trauma Department Liverpool Letters to Dr Michael Sugrue Trauma Department Liverpool Hospital Elizabeth
Street 2170 or Fax 98285305
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