Mark Lister talks to emergency doctors in London and Chicago about the implications gun shot wounds have on health professionals and health services

In the flash of a bullet, a gun wound can destroy vital organs, unleash pints of blood, produce serious systemic infection, and cause widespread bodily chaos. The reality of such images is increasing in the bitter shootings of youths that confront staff in emergency departments. In the United Kingdom, the phrase gun culture is used widely, more so since the fatal shootings of two girls in Birmingham who were caught in the crossfire of a gangland shoot out.

Certain states in the United States consider the rise in gun culture a public health emergency, which is threatening to break emergency services. Consequently, doctors have had to rapidly evolve in the way they work to handle the demands of injuries that guns can cause. About 39 000 shootings present to emergency rooms throughout the United States every year.1

Cai Glushak, medical director of the emergency medical services, at the University of Chicago Hospital, Illinois, says Chicago is still "leader of the pack in terms of homicide rates." Shootings are normally associated with young male gang members, and as such present security worries to healthcare professionals who need to give treatment. Glushak says, "There have been significant violent episodes. There is increased attention to hospital emergency room workers because of violent patients or visitors. Most now have armed security guards and better response protocols. It's not uncommon to see police at bedsides."

Although gun wounds to emergency workers are still exceptionally rare, Glushak points out that "paramedics who operate in high risk areas have some sort of bullet proof vest protection. It's not issued to them, it's their own decision whether they want to buy (at a cost of several hundred dollars) proving invaluable to some paramedics. In Chicago it's a small number of incidents but it's regularly reported and there are also threats at gunpoint. They tend to come from people picked up by paramedics who are intoxicated or who have some kind of altered mental status, not intentionally aiming for paramedics."

Illinois boasts one of the oldest and most refined trauma systems. Specific criteria have developed for trauma care. Hospitals are categorised, in a unique scheme, into different levels depending on the trauma service provided. According to Glushak, "Any wound from neck to abdomen gets routed directly to a high level trauma centre." This evolution of trauma care, in response to the problem, has "vastly improved outcome. There has been a decrease in mortality. It has been speculated it's a function of effective trauma care--not fewer injuries." Advocates of the US system argue emergency care of patients with gunshot wounds has reached such a high level of skill that little more can be achieved in increasing survival rates.

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The realisation that people were being shot faster than they could be repaired has cultivated a new breed of doctors eager to exploit their position and experience to help mould public policy. "Five or six years ago there was a strong physician movement to tackle the issue. Latest efforts are to tackle gun manufacturers. Something needs to be done but no one's found a solution." Glushak estimates that about 40% of inner city admissions are penetrating injuries (knife and gun).

Across the pond, the United Kingdom does not have such an epidemic of gunshot wounds, despite what the media say. Dr Lemen, emergency physician at St Thomas's Hospital, London, says only one or two admissions a month are gun related. "There is an increase in gun related crime, particularly in London," he says. "Despite the great media concern the vast majority of injuries are stabbings (20 per week) and other blunt assaults (100 per week)--such penetrating injuries are more common and a greater cause of morbidity. More people die from being stabbed than shot because there are more people being stabbed. The trouble with guns is the fatality rate of an assault is around 30%-50% whereas the mortality rate of being stabbed is probably only 1% or 2%. Stabbing is a far more common crime."

Yet the rise in gun culture has still required health workers to embrace a new environment and new ways of working. The United Kingdom has not adopted the injury specific code of the United States for dealing with trauma patients. "The structure in an emergency department allows for sufficient training to deal with it." Mirroring the United States, such injuries are mainly non-domestic. Lemen says, "Staff work in close cooperation with the police. If police accompany the patient in, they may retain and seal their clothing. This is the police's responsibility. They also ask for access to blood samples. We treat under the same code of ethics as for all other patients. There is no need for us to know the details of the incident."

As the use of firearms to cause injuries has tightened its grip, emergency services across the world have to evolve and rise to the problem. The United Kingdom still has other causes of trauma topping the list of emergency admissions, but gun violence and everything associated with it is a growing concern for those on the front line. Some people may fear that what the United States has today, the United Kingdom will have tomorrow.