Bullet-Related Injuries: 'The Problem Is Our Relationship to Lethal Force'

— Injuries will make one person cling to guns and another renounce them, says LJ Punch, MD

  • author['full_name']

    Jeremy Faust is editor-in-chief of app, an emergency medicine physician at Brigham and Women's Hospital in Boston, and a public health researcher. He is author of the Substack column Inside Medicine.

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    Emily Hutto is an Associate Video Producer & Editor for app. She is based in Manhattan.

In part 3 of this exclusive interview, Jeremy Faust, MD, editor-in-chief of app, and LJ Punch, MD, trauma surgeon and director of the Bullet Related Injury Clinic (BRIC) in St. Louis, discuss the complex issues of gun control and gun ownership in the context of bullet-related injuries (BRIs).

is a community-based clinic that helps people heal after they have been injured by a bullet. Click here for part 1 and part 2 of this interview.

Faust: Richard Kensinger and Nancy Kraus ask about this in the chat about the difference between a single bullet wound, or maybe two, versus automatic weapons, many, many bullet wounds and the psychosocial and biological differences that people face with that.

And then my related question is: We live in a country with the Second Amendment, we're not going to ban guns, but do you feel that efforts looking at magazine capacity limitations are something that we should be looking at more?

Punch: In our approach to bullet injury, there is a robust staging system. And it really helps, because if someone, for instance, has four bullet injuries but seven external wounds, we want to describe the path, the trajectory, the depth of invasion, the size of the wound, and whether or not there's a retained bullet for each injury.

This is taking an appropriate, rigorous approach to understanding and helping and then advising people on what they can expect in the recovery for each bullet injury. Just like we would give an expectancy for the outcome of a diagnosis of diabetes or cancer, right?

So first of all, no matter how many bullet injuries there are, each one needs to be staged, described, and there's some sort of prognosis associated with it. But yes, high-caliber, high-energy, and multiple injuries create a fundamentally different experience.

Now, what does that have to do with the conversation around firearm control and firearm ownership?

I'm going to really push just for one second. First of all, I feel like the arguments that hover around the issue of gun ownership, hover around the right to own, that are based on similarly dehumanizing concepts as the concepts that go around criminality that's associated with gun violence. In other words, if you say that somebody is a criminal or is insane or is unworthy of owning a gun, or you say someone is a criminal or insane, mentally unwell, and that's why they got shot, you're saying the same thing, which is people are the problem.

People are not the problem, and I refuse to live in a world that makes people be the problem. The problem is our relationship to lethal force and our relationships with each other and the fact that all of this unhealed trauma is out there. So for me, I just refuse to get into a political war that would have me dehumanize anyone, because I'm not here for that. I recognize everyone's sovereign humanity and I'm here to protect it.

This is not to say I opt out of saying that bullets are a problem. They are, but I'm going to tell you, bullet-related injury will make one person cling to their gun ownership and make another person renounce guns altogether. What are we going to do? We have to respect and deal with that, and that's the conversation I'm here for.

I think that physicians, healthcare professionals, and systems of care have a beautiful, unifying opportunity to say, "Here's the thing I know we all agree about: We don't want holes in people's bodies. What can we do to heal those injuries so they don't come back?" It's simple, but the work is hard. I'm not opting out and saying that I just want the easy way out. I'm digging in and I'm trying to figure out where is the place that I, with the tools of the healer and the tools of allopathic medicine and the tools of trauma systems of care, invest in healing people.

Gun sales go up after mass shootings because everybody has BRI. I say the whole world had BRI the day that Martin Luther King's life was ended by a bullet. What would happen if instead of demonizing that behavior, we recognize what was going on and we help people heal. These are the kinds of things.

I'll end by saying that I work, collaborate with a couple that runs a firearm training program as well as a gun shop in the St. Louis region. I have learned so much from them. In their training, they say that the best gunfight is the one that doesn't happen, but they also say that much of the injustice that has come in this country has been around disproportionate power around gun ownership, going all the way back to the roots of chattel slavery.

This stuff is deep, and I think it's an important conversation for leaders, but I think physicians have to at least get the part of it that we can get right right, by dealing with the impact of bullets in people's bodies. Because if BRI is its own worst risk factor, what would happen if we just started identifying and treating it holistically? That's the conversation that I'm here for.

Faust: For somebody like me, an ER [emergency room] doctor, if someone comes in, chief complaint foreign body and they have a splinter, if I can see it, I'll remove it. So if someone comes in and they have a retained fragment or whatever, somewhere that I feel comfortable going, can I as an ER doc get my point of care ultrasound, remove this thing, and then refer them to some outpatient resources such as BRIC? If so, if I can do that, are there any textbooks or guidelines or what kind of training can I do as an ER doc to get involved in this?

Punch: I think that if someone is under anesthesia and not in shock, due diligence should happen to get the lead out. Because if there's a bullet in the muscle, the subcutaneous fat, or just underneath the skin, that bullet is going to be symptomatic. If it's embedded in a bone, you and the orthopedic surgeons have to duke it out. But the bottom line is, if they're under anesthesia and they're not in shock, the question at least should be asked.

There are a lot of surgeons who take these bullets out and they do it in their clinics and they try their best, but we don't have a standard. That's where my most exciting body of work is right now. It's called BRIC Institute.

It's putting together all of our best practices from the staging, to the conversations, to being trauma-responsive, to the pain protocols, to lead level surveillance, to actual techniques and taking bullets out. All of that we're amassing into a so that we can democratize this knowledge and get these practices into the hands of people directly affected as well as practitioners.

We're going to be doing an in-person convening in St. Louis, November 7 to 9, and we really, really want to do everything we can to create virtually-accessible resources around what we call BRIC Care, which is the expression of BRIC medicine.

Each one of us is going to have to work out what it means to practice BRIC medicine in these different environments. I'm just here to share and to show up, and I really appreciate the chance to share some of this narrative-shifting work with you all today.