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In comparison to many nations in the developed world, the United States has more cases of civilian ballistic injuries. Both low and high velocity firearm injuries are frequently encountered in American urban trauma centers, and physicians become familiar with these traumatic injury patterns. Physicians from other nations may rarely encounter such injuries. With an increase in international conflict, there is an increased need for clinicians to participate in international medical aid which may include patients with ballistic injuries. Clinicians with limited familiarity of such injuries may result in under-triage and delayed recognition of injury severity, resulting in increased morbidity and mortality of patients. This study aims to show that a course on ballistic injuries will improve clinician recognition of injury patterns and comfort levels managing these patients.
Clinicians participated in a course which was designed to introduce ballistic injury patterns. The course was reviewed and supported by emergency medicine physicians who work in a large level I trauma center in the Southeastern United States and serve in clinical roles with EMS and community law enforcement. Course content included demonstrations of firearm injuries by discharging weapons into gels and models designed to replicate human body tissue. Participants were surveyed prior to and after completing the course regarding their comfort with firearms and firearm related injuries.
Participants reported increased comfort level with the management of ballistic injuries. The course requires a full day of expert physician time, approximately US$600 in supplies if performing live demonstrations, and the cost of designated space for safe firearm discharge and use.
This course or a similar course with pre-fired demonstration rounds proved to be feasible and beneficial for those who will likely encounter firearm injuries in their clinical environment. There are both quantifiable and perceived benefits for physicians.
This chapter provides some insights into the book's recommendations for safe and effective practice of pain management in day-to-day emergency department (ED) practice. Pain is a cultural phenomenon as well as a physical one. Certain kinds of patients obtain more attention from their relatives or immediate companions and friends, and seem always to overreact to pain. There appear to be many patients (e.g. some with sickle cell crisis) who prefer meperidine to morphine for pain relief. It is wise to remember the three missions of medicine:to cure disease, to relieve ongoing ravages of disease, and to provide comfort. As an overarching guide, remember that because pain is subjective to the patient, it is also subjective to the physician. We have the training, the experience, and the expertise to interact in a way that provides comfort. It never hurts to lean to the side of providing that comfort.
Acute care providers need to be familiar with phantom limb pain (PLP) as the complaint occurs in up to 80% of patients after amputation and it is important to institute early and effective intervention. Opioids are commonly recommended for acute treatment of PLP. Oral opioids, usually in combination with another agent (e.g. calcitonin), form the mainstay of PLP therapy. The benzodiazepines, which potentiate the spinal neuronal inhibitory effects of gamma-aminobutyric acid (GABA), may ameliorate pain from acute PLP flares. In contradistinction to their utility in other forms of neuropathic pain, antidepressants have only a limited role for acute PLP. The anticonvulsants have been investigated for PLP, with mixed results. Carbamazepine is postulated to be of utility, but supporting evidence for its use in PLP is anecdotal. There is stronger evidence for gabapentin prescription in PLP.