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Case

A young male is brought to the emergency department (ED) via EMS after sustaining a gunshot wound. The trauma team is activated. The patient is hemodynamically stable and has an intact primary survey. On secondary survey, there is a perforating wound. Across from the wound is a bulge in the skin with a palpable foreign body, presumably a bullet. Radiographic imaging shows no serious vascular or bony injury, and confirms the presence of a superficial, bullet-shaped radiopaque foreign body as noted on exam. Given its position, the trauma team decides to remove the bullet at the bedside. You then hear the surgical resident tell the nurse, “Get me a scalpel, tray, and a metal basin. I love hearing the bullet drop into the basin.” How do you respond to this request?

Discussion

Firearm injuries are increasingly common in the United States. In 2020, there were over 45,222 firearm-related deaths. Many more Americans were injured by firearms with more than 70 percent of them were firearm-related assaults.¹ Following a gunshot wound, there are a few possible outcomes: the patient dies at the scene, the patient is transported to the hospital and dies either in the ED, operating room, or at some point after hospital admission. For patients who do not survive, their forensic needs are met by the coroner or medical examiner. Other patients following a gunshot would arrive to the ED and undergo treatment and evaluation, and are either admitted to the hospital or discharged. Ultimately, those who make it to the hospital and survive rely on emergency physicians and ED personnel to help meet their forensic needs. Our primary goal remains resuscitation and stabilization, however, we should be cognizant of the forensic needs.

FIGURE A: Because bullets are soft and malleable, use of metallic surgical

instruments like forceps to grasp the bullet can impart marks from the instrument

into the bullet. (Click to enlarge.)

One aspect to consider is how to handle evidence. Ammunition, or a cartridge, is the object that is loaded into a firearm. It consists of a cartridge case which holds the bullet, a primer, and powder. Upon firing the weapon, the bullet becomes the projectile. Cartridges are commonly made of brass (copper and zinc). Bullets come in a variety of shapes, sizes, and compositions. Bullets are often made of copper, steel, and lead (though lead is becoming less common). Copper and lead are soft and malleable so they can conform to the barrel of the weapon, which has spiral impressions called lands and grooves. Traveling along the barrel imparts ballistic markings onto the bullet that experts can use to match it to the weapon and other possible casings.^2,3