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CE Article: Knife and Gun Injuries
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Knife and Gun Injuries
Penetrating trauma involves wounding instruments that penetrate the skin and directly injure body tissue. Although there are numerous examples of penetrating trauma — such as a child falling on a pencil that penetrates the globe of the eye or a piece of shrapnel from an explosive device tearing through a limb — two obvious causes of penetrating trauma are firearm wounds and stabbings. This module discusses the mechanism of injury involved in firearm injuries and stab wounds. The healthcare providers should have a baseline understanding of the mechanisms of injury surrounding this form of trauma.
The goal of this educational program is to provide nurses in acute care settings with an introduction to the biomechanical concepts of firearm and stabbing injuries and an explanation of how those concepts relate to the care of the patient with penetrating trauma.
Types of Trauma
Trauma is divided into two main categories: blunt and penetrating. Blunt trauma is caused by blunt forces external to the body. These blunt forces transmit energy through body tissues. Examples include motor vehicle collisions, falls, and sporting injuries. In contrast, penetrating trauma is caused by wounding instruments that penetrate the skin and directly injure body tissue. Penetrating trauma can take many forms and may be accidental or intentional. It may be the result of a mishap with an everyday object or a violent act with a weapon. Firearms and knives, or other sharp objects, can cause very serious penetrating injuries.
Gun violence is considered by many experts to be a public health crisis, and injury and death related to firearms continues to rise. Deaths attributed to guns increased 20% worldwide between 1990 and 2016 with more than half of those deaths occurring in the U.S. (DynaMed, 2018). One study found that every seven minutes someone is brought to a hospital in the U.S. for a gun-related injury (DiMaggio et al., 2017). This represents a 4% total increase and 30% increase among children less than 5 years of age.
Relias LLC guarantees this educational program free from bias. The planners and authors have declared no relevant conflicts of interest that relate to this educational activity. See Page 34 to learn how to earn CE credit for this module.
Goal and Objectives
After taking this course, you should be able to: • Calculate the kinetic energy of a moving mass. • List at least three factors that affect the severity of firearm injuries. • Describe common injuries associated with stab wounds to the trunk. • Discuss nursing care for penetrating trauma wounds.
Overview
Injuries related to firearms are the second-leading cause of traumatic death in the U.S., second only to motor vehicle crashes (Tasigiorgos et al., 2015). Even more patients survive
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firearm injuries. While close to 90 people die every day from firearms, an additional 160 nonfatal injuries are treated in hospitals around the U.S.
Often the visible wounds on a patient with a firearm injury do not reflect internal and less visible damage done by the bullet to underlying structures. If a practitioner has a base knowledge of firearms and ballistics, it may make it easier to anticipate the types of injuries that cannot be seen. Some factors that may help predict injury patterns and severity of injury when caring for the victim of a firearm injury include: • The type of firearm used • The distance from the firearm to the target • The type of projectile fired from the firearm • The type of tissue through which the projectile passed • The trajectory of the projectile through the body
Firearms can be divided into several major categories. Handguns, as the name implies, are small, light, and easy to conceal. For that reason, they are a popular choice for both personal protection and criminal activity in the U.S. Examples of handguns include revolvers and pistols.
Another classification of firearms is long guns, such as rifles and shotguns. Long guns tend to inflict greater injury than handguns simply because of the length of the barrel. If the barrel of the firearm is longer, the bullet moves faster through the air after it leaves the barrel. With shorter-barreled firearms, such as pistols and revolvers, the projectile has less speed moving forward (Klatt, n.d.). Shotgun injuries can differ from those caused by handguns and rifles when shot ammunition is used (DynaMed, 2018). With greater distance from the intended target, spread of shot pellets is increased; with shorter distance, lethality from this ammunition is greater.
Distance to the Target
Once the projectile leaves the barrel of the gun, there are no influences propelling it forward. In fact, at that point, the atmosphere, gravity, and friction will slow the projectile down. Gravity will also pull it toward the ground. The farther the projectile must travel between the barrel of the gun and the target, the slower it will go (Holzner, 2011; Klatt, n.d.).
These factors are important to consider because tissue injury is partially related to the velocity of the bullet as it hits the body. Tissue injury is related to the amount of energy exerted on the body. To determine the amount of kinetic energy, one must take the mass of the object involved, half it and then multiply it by the velocity that the object is moving (squared) (Klatt, n.d.; Powers & Delo, 2013):
Kinetic energy = ½ mass × velocity2
As this equation aptly demonstrates, velocity is a major factor in determining the energy and ultimately the wounding potential of a projectile. Knowing the type of firearm used as well as the distance the target was from the wounding instrument can help to predict the types and severity of injuries the patient may sustain.
The Type of Projectile
The kinetic energy formula introduced in the previous section familiarized you with the two components that may contribute to energy transfer between objects. The first was velocity, affected by the type of firearm used as well as the distance between the firearm and the target. The second part of the formula involves mass. The heavier an object is, the more kinetic energy it tends to transfer. Therefore, knowing the type of projectile that struck a patient in a firearm-related injury may help you better anticipate the injuries the patient may have.
A way that bullets are differentiated is by their size. A .22-caliber bullet (this may also be called a “22-gauge”) is a different size than a .45-caliber bullet. The caliber refers to the diameter of the bullet in inches; therefore, a .22-caliber bullet is 22/100 inches in diameter and a .45-caliber bullet is 45/100 of an inch in diameter (Klatt, n.d.; Powers & Delo, 2013). Since mass is part of the kinetic energy formula, the size of the bullet will influence tissue damage, with larger bullets tending to inflict greater damage.
The design of the bullet will also influence its wounding potential. Softer metals, such as lead, will travel farther and will maintain a higher speed over longer distances. However, soft metals will easily deform when they strike an object and may not penetrate. Heavier metals, such as copper, are less likely to deform but will slow down faster in the friction of the atmosphere. To compensate for this, some bullets are made of softer metals and then coated with a heavier metal. This combination reduces the weight of the bullet so it travels faster, but the tough outer coating minimizes its deformation on contact. This is called a “full metal jacket.” The tough outer layer allows it to keep its shape as it travels through tissue, and the bullet may pass right through the body (Klatt, n.d.).
Other bullets, sometimes called hollow points or soft points, may not have a heavy metal jacket around the entire outside, and the leading edge of the bullet will be a softer, lighter metal. When these bullets strike the body, the leading edge flattens out, and as the bullet goes through tissue, the larger, flattened leading edge will increase the surface area and significantly increase the tissue damage.
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This large, flat leading edge will also slow down more quickly in tissue, causing more energy to be transferred from the moving object to the body than a full metal jacket (Klatt, n.d.).
The Type of Tissue
As a projectile enters a person’s body, two types of injuries occur. The first is crush injuries directly caused by the path of the projectile through the body. This is referred to as the permanent cavity (Powers & Delo, 2013). The larger the projectile, the larger the permanent cavity will be. A .45-caliber projectile, for example, will leave a much larger permanent cavity than a .22-caliber projectile. Similarly, a hollow-point projectile whose leading edge flattens out will have a large diameter leading surface tearing through the body, creating a much larger permanent cavity (Peitzman et al., 2013).
Because of the speed of the projectile, tissue around the permanent cavity will be forced away from the projectile, creating a temporary cavity. The tissue in the temporary cavity is forced away from the moving projectile and essentially suffers the effects of blunt trauma. Although the tissue in the temporary cavity will generally return to its original state within milliseconds after passage of the projectile, the damage in the structures affected by the momentarily enlarged temporary cavity can be extensive. The size of the temporary cavity can be as much as 10 times the caliber of the bullet (Klatt, n.d.). The stretching can rupture blood vessels, leading to secondary edema and blood loss.
Injury patterns are affected to some extent by the type of tissue that is involved. Highly elastic tissue, such as skeletal muscle and lung, may be deformed by the temporary cavity; however, these tissues are designed to stretch, at least to a certain degree, and there may be minimal injury to them. Near-water-density tissues, such as the brain, liver, and spleen, are not designed to stretch, and the temporary cavitation may cause significant damage or even cause them to break apart. Similarly, fluid-filled organs, such as the heart, bladder, and intestine, are not designed to stretch and sustain greater damage or may even rupture if the temporary cavity is large enough. All tissue directly crushed by the projectile will be nonviable and will die regardless of the type of tissue (Klatt, n.d.; Peitzman et al., 2013)
The Path Through the Body
Multiple other factors can affect the wounding potential of a projectile. One is the stability of the bullet. If the bullet enters the body straight on, the size of the permanent cavity will be the same as its diameter. If, however, the projectile wobbles or tumbles before or after it hits the body, it will create a much larger permanent cavity. If, for example, the projectile ends up going through the body sideways (at a 90-degree angle) instead of with its pointed end forward, the amount of resulting crushed tissue can be three times greater (Powers & Delo, 2013).
Another factor that can alter tissue injury significantly is the fragmentation of the projectile. Softer metals are more likely to break apart, especially if they strike bone. The smaller pieces may continue to move throughout the body, resulting in multiple projectiles instead of a single projectile, each creating its own cavity of destruction (Peitzman et al., 2013).
Stab Wounds
Although gunshot wounds and stab wounds are both considered penetrating trauma, the injuries are very different. The velocity of a projectile in a firearm injury is responsible for much of the tissue damage that is imparted. In stab wounds, the velocity of the penetrating object (e.g., a knife or screwdriver) is usually much less; therefore, tissue damage may be less. But the surface area of some stabbing instruments, such as a large butcher knife, may be much greater than a firearm projectile, leading to increased size of wounds, both on the surface and in underlying structures. • Factors to consider when caring for the patient with a stab wound include: • The anatomic area involved • The depth of penetration • The blade length • The angle of penetration
Stab wounds to the abdominal area can be deceiving. One-third of these wounds do not even violate the peritoneum, leaving the vital organs and blood vessels intact. A further one-third do penetrate the peritoneum but do not affect the abdominal viscera. When the abdominal viscera is affected, the most common structures to be injured include the small bowel, liver, stomach, colon, and vascular structures (Cox, 2011).
Stab wounds are more common in the upper abdomen than the lower abdomen. Structures at risk in upper abdominal stab wounds include the liver, gall bladder, stomach, duodenum, pancreas, spleen, small/large bowel, omentum, aorta, inferior vena cava, portal vein, and mesenteric arteries. Stab wounds in the lower abdomen more often affect the small/large bowel, bladder, uterus, aorta, inferior vena cava, mesenteric vessels, and the femoral/ external iliac vessels (Corneille et al., 2008). Stab wounds to the abdomen are often not as serious initially as
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they are days or weeks later. If the stab wound involves disruption of a large blood vessel, the bleeding can be immediately serious. If it involves the underlying viscera, the symptoms of peritonitis and sepsis may be delayed (Corneille et al., 2008; Cox, 2011).
Stab wounds to the left chest are the most fatal because of the location of the heart and great vessels. Interestingly, victims of stab wounds involving the ventricles are more likely to survive for a longer time than those with stab wounds to the atria because the muscular contraction of the ventricles provides a temporary protective effect (Corneille et al., 2008). Other organs in the chest that can be affected by a stabbing instrument include the lungs, bronchi, diaphragm, and mediastinal structures. Stab wounds to the lungs often have positive outcomes provided the victim receives prompt emergency treatment. The more peripheral the stab wound is to the center of the chest, the less likely it will affect major blood vessels, and the less fatal the wound tends to be. Indications of lung involvement include hemoptysis, subcutaneous emphysema, and signs of a pneumothorax or hemothorax.
When caring for the patient with stab wounds to the trunk, remember that the diaphragm, which separates the abdomen from the thorax, is mobile. During exhalation, the diaphragm may elevate as high as the nipple line, but during inhalation, the diaphragm may extend to the lower rib cage. Therefore, stab wounds of the upper abdomen and lower chest should be evaluated for both abdominal and thoracic involvement. Generally, wounds below the fourth intercostal space on the anterior chest wall and below the scapular tip on the posterior chest wall should be worked up for possible abdominal involvement (Cox, 2011).
Retroperitoneal organs, such as the kidneys, ureters, pancreas, and duodenum, can be injured in up to 40% of stab wounds in the flank or back. It can be difficult to assess for damage to these structures. Therefore, diagnostic tests such as triple-contrast CT, local wound exploration, ultrasound, and diagnostic peritoneal lavage/laparoscopy may be carried out. Stab wounds to the back also raise the concern of spinal cord involvement, although this is rare because of the thick bony protection of the vertebrae. If the spinal cord is affected, the most common regions are the cervical and thoracic areas. This is because, if the person is stabbed from behind and he or she is bending forward at the time, the vertebrae in these areas separate further, providing greater exposure of the underlying spinal column (Corneille et al., 2008).
Although stab wounds to the neck are rare, they have a higher frequency of being fatal than stab wounds to other parts of the body. This is because structures such as large blood vessels, the trachea, and the larynx are all close to one another and are only 1/2 to 1 inch below the skin surface. Death is caused frequently by exsanguination, air emboli, or asphyxia due to aspiration of blood (Corneille et al., 2008). If stab wounds to the neck are deep, the spinal cord can also be affected (Savall et al., 2015).
Isolated stab wounds to the extremities are rarely life-threatening unless catastrophic hemorrhage occurs secondary to disrupted arteries. But extremity stab wounds can have long-term consequences for future functioning of the limb, including lacerations of nerves, tendons, and muscles. Compartment syndrome secondary to intrafascial bleeding is also a potential complication.
The Depth of Penetration and Blade Length
One factor that can make assessment of the stab wound challenging is that the external wound does not always equate to the underlying damage. If a screwdriver is used as a wounding instrument, the surface wound may be very small. But if the screwdriver is pushed deep into the body, this seemingly small wound may inflict fatal damage to underlying structures, such as blood vessels and organs. Most stab wounds are deeper than they are wide at the surface. The depth of a stab wound may be greater than the length of the stabbing instrument when the body surface “dents” from the thrust of the wounding instrument as it is pushed into the body. It is also important to note that because of the elasticity of skin, the shape and width of the wounding instrument does not always match the shape of the visible wound. The wound may be as much as 2-mm smaller than the instrument that caused the wound (Forensic Medicine for Medical Students [FMMS], n.d.).
The Angle of Penetration
When caring for a stab wound, remember that the surface trauma may not represent the underlying trauma. The assailant in a stabbing incident may insert the wounding instrument and then move it around, or the victim may move while the wounding instrument is in the body. In this case, the surface wound will be no larger than the wounding instrument, but the surface area of the underlying trauma may be significantly larger.
Generally, stab wounds to the back are delivered in a downward motion and stab wounds to the front are delivered in an upward motion. Stab wounds delivered in a downward motion, also known as an “overarm”
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assault (in which the knife is held in the ulnar aspect of the hand) tend to enter the body at a greater speed and cause deeper and more damage than stab wounds caused by an upward motion, also known as an “underarm” assault (in which the knife is held in the radial aspect of the hand) (Gilchrist et al., 2008).
Assessment and Management
A thorough patient and/or witness interview can provide valuable information about the nature of the patient’s injuries. In the case of firearm injuries, ask the patient or any witnesses to the incident how many shots were heard (DynaMed, 2018). If possible, ascertain specifics regarding the type of weapon and ammunition involved in the injury. The distance and position of the patient relative to the shooter are also important, as are the number and location of any known wounds and any treatment that was rendered. Depending on the situation, law enforcement or EMS may provide these details.
If it has not been completed by EMS, the patient’s clothing should be removed to assess injuries. (DynaMed, 2018). Highest priority should be given to injuries located on the head, neck, chest, and abdomen as these present the greatest risk to the life of the patient. Note that for unstable patients with penetrating gunshot or stab wound injuries, immediate surgical treatment may be required as guided by Focused Assessment with Sonography in Trauma (FAST) imaging (DynaMed, 2018a). Next, perform a primary survey based on the Advanced Trauma Life Support® (ATLS®) algorithm, starting with securing the patient’s airway and assisting ventilations if necessary. Chest movement should be evaluated for paradoxical motion and lungs auscultated for abnormal, decreased, or absent breath sounds (Kostiuk & Burns, 2020). Any external bleeding should be managed and intravenous (IV) access initiated (DynaMed, 2018). Crystalloid boluses or blood product transfusions should be administered if indicated for hypotension related to blood loss. If the patient has signs of pneumothorax due to penetrating chest wall injury, it should be addressed at this time by a physician or other Licensed Independent Practitioner (LIP) with thoracostomy (chest tube) placement. Nursing care includes setting up chest tube drainage systems and documenting output.
A secondary survey is performed after the requirements of the primary survey have been addressed and includes a head-to-toe exam to determine and/or confirm the number and location of all wounds (DynaMed, 2018). It is during and after this assessment that imaging should be performed to attain additional information about internal injuries. Imaging studies can also highlight bullet trajectory and help localize any bullets or bullet fragments still inside the body. Plain films (X-rays) are best suited for this, but CT may be ordered if the patient is stable. Ultrasound using Focused Assessment with Sonography in Trauma (FAST) may also be used. FAST has gained popularity in recent years due to its portability and lack of ionizing radiation exposure for the patient and can be used to detect peritoneal fluid, pneumo- and hemothorax, and hemopericardium. Lab tests often ordered in penetrating trauma cases include complete blood count (CBC), chemistry, blood type and crossmatch, and blood gases (DynaMed, 2018).
Medications
Depending on where they work, nurses may administer sedatives and paralytics to assist with establishment of an advanced airway (DynaMed, 2018). Pain control is important, especially in cases of penetrating chest trauma when pain may interfere with effective respirations and clearance of secretions (Jain & Burns, 2020). Short-acting narcotic analgesics (e.g., fentanyl [Sublimaze] and morphine [Duramorph®]) are typically ordered (DynaMed, 2018; Jain & Burns, 2020). Broad spectrum IV antibiotics (usually ampicillin/sulbactam [Unasyn®], piperacillin/tazobactam [Zosyn®], or Cefotetan [Cefotan®]) are given in the case of abdominal injuries with peritoneal penetration and tetanus vaccines should be updated if indicated (DynaMed, 2018).
Reporting
All gunshot wounds and most stab wounds are reportable conditions under federal and state laws (Smallwood, 2020). Gunshot injuries that are intentionally inflicted or injuries obtained during illegal acts such as robberies, must be reported to law enforcement authorities. Gunshot injuries that are considered unintentional must also be reported. Additionally, injuries caused by sharp instruments, like knives, must be reported if they were intentionally inflicted, whether or not they were other- or self-inflicted. Specifics regarding how to report incidents varies by state. Refer to your state’s laws and your institution’s protocols when reporting firearm or stabbing injuries or other criminal activity, such as sexual assault, abuse, and neglect.
Because many penetrating injuries are the result of violence, clinicians must apply the principles of forensics during care. Treat the patient and anything on the patient as a potential crime scene. Be familiar with evidence collection and help law enforcement carry out justice by carefully preserving evidence and documenting meticulously.
Summary
Now that you have finished viewing the course content, you should have learned the following: • How to calculate the kinetic energy of a moving mass. • At least three factors that affect the severity of firearm injuries. • Common injuries associated with stab wounds to the trunk. • Nursing care for penetrating trauma wounds.
Penetrating trauma from gunshot and stab wounds cause serious and often life-threatening injuries. Knowledge of the physical forces involved in generating these injuries and familiarity with guidelines for patient care and incident reporting will enable you to provide optimal care for your patients.
Course Contributor
The content for this course was revised by Carrie Furberg, BSN, RN, CRN. Carrie Furberg, BSN, RN, CRN, has over ten years’ experience in radiology nursing, in vascular and interventional radiology as well as all imaging modalities. She is a Certified Radiology Nurse with clinical expertise in procedural sedation, cardiac CT, and radiation safety, and prior experience in critical care, cardiac stepdown, and emergency care. She is a member of the Association for Radiologic and Imaging Nursing (ARIN) and RAD-AID International.
Editor’s note: Jeff Solheim, MSN, RN, CEN, TCRN, CFRN, FAEN was the previous author of this educational activity but has not influenced the content of the current version of this course.
Clinical Vignette
Dispatch calls a local trauma unit to indicate that two ambulances are en route, each transporting a patient with gunshot wounds. Ambulance 1 is transporting a law enforcement officer struck in the groin by a .22-caliber full metal jacket bullet fired from a small handgun during a firefight at a robbery scene. The bullet struck the muscles of the upper leg. The second ambulance is carrying the alleged perpetrator, who has three gunshot wounds: two to the anterior chest and one to the central abdominal area. Bullet 1 entered the right lung, bullet 2 struck the right ventricle, and bullet 3 struck the liver. The alleged perpetrator was shot by pistols firing .45-caliber hollow point bullets.
1. Based on the information given, which statement is most accurate?
A. Both patients are likely to have exit wounds.
B. Neither patient is likely to have an exit wound.
C. The alleged perpetrator is more likely to have exit wounds than the law enforcement officer.
D. The law enforcement officer is more likely to have an exit wound than the alleged perpetrator. Feedback: A heavier metal around a full metal jacket causes it to retain its shape and velocity as it passes through body tissue; therefore, exit wounds are more common with full metal jackets than hollow-point projectiles. Hollow-point projectiles deform when they hit the body, and this slows them down or even causes deformation; therefore, they are less likely to cause an exit wound.
2. Of the four wounds described, which one was most likely to cause the area it struck to break apart?
A. Bullet 1, which struck the alleged perpetrator in the right lung
B. Bullet 2, which struck the alleged perpetrator in the right ventricle
C. Bullet 3, which struck the alleged perpetrator in the liver
D. The bullet that struck the law enforce-
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ment officer in the muscles of the leg Feedback: The temporary cavity caused by a bullet moving through water-dense tissue, such as the liver, spleen, or brain, may cause them to break apart. Muscle tissue and lung tissue are elastic rather than water-dense and are less likely to “break apart.” The heart is a hollow organ and is less susceptible to “breaking apart.”
3. Of the four wounds, which one was most likely to cause the area it struck to rupture?
A. Bullet 1, which struck the alleged perpetrator in the right lung
B. Bullet 2, which struck the alleged perpetrator in the right ventricle
C. Bullet 3, which struck the alleged perpetrator in the liver
D. The bullet that struck the law enforcement officer in the muscles of the leg Feedback: The temporary cavity caused by the bullet moving through a hollow organ, such as the heart, bowel, or stomach, may cause them to rupture. Muscle tissue and lung tissue are elastic rather than hollow and will not rupture. The liver is a dense organ that may sustain significant damage but will not rupture.
4. If the four bullets in this scenario remain on a straight trajectory through body tissue, which one is MOST likely to cause the smallest permanent cavity?
A. Bullet 1, which struck the alleged perpetrator in the right lung
B. Bullet 2, which struck the alleged perpetrator in the right ventricle
C. Bullet 3, which struck the alleged perpetrator in the liver
D. The bullet that struck the law enforcement officer in the muscles of the leg Feedback: The larger the caliber of the bullet, the larger its diameter. The permanent cavity is caused by crushing of tissue as the bullet moves through tissue; therefore, if all the bullets stayed on a straight trajectory, the smallest bullet (the .22 caliber bullet) would create the smallest permanent cavity. A .45-caliber bullet is larger and will produce a larger permanent cavity.
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References
1. Corneille, M. G., Lopez, P. P., Cohn, S. M. (2008) Abdominal trauma. In: Irwin, R. S., & Rippe, J. M. (Eds.), Irwin & Rippe’s Intensive Care Medicine (6th ed., p. 1919). Lippincott Williams & Wilkins.
2. Cox, W. A. (2011). Sharp-edged and pointed instrument injuries. Forensic Medicine with Dr. Cox. http://forensicmd.files.wordpress.com/2011/07/ sharp-edged-and-pointed-instrument-injuries1.pdf
3. DiMaggio, C. J., Avraham, J. B., Lee, D. C., Frangos, S. G., & Wall, S. P. (2017). The epidemiology of emergency department trauma discharges in the United States. Academic Emergency Medicine, 24(10), 1244-1256. https://doi.org/10.1111/acem.13223
4. DynaMed. (2018). Gunshot Wounds - Emergency Management (Record No. T902781). EBSCO Information Services.
5. DynaMed. (2018a). Penetrating Thoracic Trauma in Adults (Record No. T921446). EBSCO Information Services.
6. Forensic Medicine for Medical Students (n.d.). Characteristics of stab wounds. Retrieved June 3, 2020 from http://www.forensicmed.co.uk/ wounds/sharp-force-trauma/stab-wounds/
7. Gilchrist, M. D., Keenan, S., Curtis, M., Cassidy, M., Byrne, G., & Destrade, M. (2008). Measuring knife stab penetration into skin simulant using a novel biaxial tension device. Forensic science international, 177(1), 52-65. https:// doi.org/10.1016/j.forsciint.2007.10.010
8. Holzner, S. (2011). Physics I for Dummies (2nd ed.). John Wiley & Sons, Inc.
9. Jain, A., & Burns, B. (2020). StatPearls: Penetrating Chest Trauma. U.S. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/ NBK535444/
10. Klatt, E. C. (n.d.). Firearms tutorial. University of Utah Spencer S. Eccles Health Sciences Library. Retrieved June 3, 2020 from http://library.med. utah.edu/WebPath/TUTORIAL/GUNS/GUNINTRO.html
11. Kostiuk, M., & Burns, B. (2020). StatPearls: Trauma Assessment. U.S. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/ NBK555913/
12. Peitzman, A. B., Schwab, C. W., Yealy, D. M., Rhodes, M., Fabian, T. C. (Eds.). (2013). The Trauma Manual: Trauma and Acute Care Surgery (4th ed.). Lippincott Williams & Wilkins.
13. Powers, D. B., & Delo, R. I. (2013). Characteristics of ballistic and blast injuries. Atlas of the oral and maxillofacial surgery clinics of North America, 21(1), 15-24. http://dx.doi.org/10.1016/j.cxom.2012.12.001
14. Savall, F., Dedouit, F., Mokrane, F. Z., Rougé, D., Saint-Martin, P., & Telmon, N. (2015). An unusual homicidal stab wound of the cervical spinal cord: A single case examined by post-mortem computed tomography angiography (PMCTA). Forensic Science International, 254, e18-e21. https://doi. org/10.1016/j.forsciint.2015.06.025
15. Smallwood, R. (2020). REL-ACU-0-REAMR21: Regulation express: Mandatory reporting [Relias module].
16. Tasigiorgos, S., Economopoulos, K. P., Winfield, R. D., & Sakran, J. V. (2015). Firearm injury in the United States: An overview of an evolving public health problem. Journal of the American College of Surgeons, 221(6), 1005-1014. doi: https://doi.org/10.1016/j.jamcollsurg.2015.08.430
Clinical VignettE ANSWERS
the law enforcement officer in the muscles of the leg.
Answer: D, The bullet that struck
4.
in the right ventricle. Answer: B, Bullet 2, which struck the alleged perpetrator
3.
C, Bullet 3, which struck the alleged perpetrator in the liver. Answer:
2.
have an exit wound than the alleged perpetrator.
Answer: D, The law enforcement officer is more likely to
1.
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ENDING INCIVILITY AND BULLYING
By DON SADLER
Few would disagree that society has seen growing levels of incivility and bullying in recent years. Unfortunately, this incivility has spread to many workplaces, including hospital operating rooms.
In fact, the health care industry experiences some of the highest levels of bullying across all industry sectors. Up to half of all nurses say they have been bullied in some manner in the workplace, according to the American Nurses Association (ANA).
Fifty percent of nurses say they have been bullied by a peer while 42% have been bullied by someone at a higher level of authority, according to ANA. Meanwhile, nearly one in four nurses (25 %) say they have been physically assaulted at work and one in 10 (10 %) say they are concerned about their physical safety at work.
A Dangerous Problem
“Incivility in health care has been investigated by researchers and we know it is a problem among nurses in a variety of settings, including the perioperative environment,” says Erin Kyle, DNP, RN, CNOR, NEA-BC, editor in chief, Guidelines for Perioperative Practice for the Association of peri-Operative Registered Nurses (AORN).
“Incivility and bullying in the operating room is a common but dangerous problem,” adds Ruth P. Shumaker, BSN, RN, CNOR, executive director, perioperative services, Regional One Health. She cites an AORN Journal article which notes that 88% of nurses have witnessed physician incivility and 48% of physicians have witnessed nurse incivility.
While serving on the 2021 Task Force for Civility in the Workforce, Shumaker and her colleagues conducted a comprehensive review of the literature.
“Unfortunately, this revealed that incivility is widespread in nursing,” she says. “While mistreatment in nursing was mentioned in the literature as early as 1980, it really started to surface in the early 2000s and has steadily increased since then.”
Deborah L. Spratt, MPA, BSN, RN, CNOR, CHL, independent perioperative consultant, says that bullying behavior can be physical, emotional, sexual, social, verbal or racial.
“When I first started in the OR almost 50 years ago, I would have attributed the behavior to the perceived difference in status of the various team members,” Spratt says.
“Back in those days, surgeons were held in much higher esteem than other perioperative team members and bad behavior was allowed because they were the money makers,” says Spratt. “To some extent this attitude continues, but there is also now a nurse-to-nurse component, as well as nurses to other team members.”
Based on her literature review, Maria Sullivan, MSN, MMHC, RN, CNOR, says that more than seven out of 10 nurses have experienced incivility.
“The problem of incivility began mainly with perioperative team members, but it has now extended to patients also being uncivil,” Sullivan says.
Defining Incivility and Bullying
The ANA defines incivility as “one or more rude, discourteous or disrespectful actions that may or may not have a negative intent behind them.” And it defines bullying as “repeated, unwanted harmful actions intended to humiliate, offend and cause distress in the recipient.”
Incivility is often a precursor to bullying. It can take many different forms, some of them subtle: Gossiping and rumor spreading • Eye-rolling and name-calling
- Deborah L. Spratt
• Using a condescending tone • Public criticism • Refusing to help a coworker • Withholding information and sabotage • Social exclusion • Hostile, snide and rude remarks • Passive-aggressive behavior • Scapegoating and backstabbing • Failure to respect privacy
Bullying takes incivility to the next level with actions such as: • Hostile remarks • Verbal attacks and threats • Taunts and intimidation • Withholding of support • Harmful actions intended to intimidate • Workplace “mobbing”
Kyle says that she has personally witnessed the consequences of incivility and bullying in the OR.
“These memories are some of the most vivid from early in my career,” she says. “On the other hand, I have also witnessed civil behaviors that can turn the situation around. The individuals who took the initiative to stop the patterns of incivility made all the difference in those moments.”
“During the span of my nursing career, I have witnessed and/or experienced verbal, and on a more intense level what verged on the threat of physical, harm,” says Shumaker. “Overt aggression, bullying and abusive behaviors are often purposely intended.”
Other personal observations of incivility in the perioperative environment Shumaker has witnessed include shouting, intimating body language, talking down to others, making demeaning remarks and not listening. “I have also observed abuse and misuse of power by leaders and supervisors,” she says.
Spratt tells of a Primary Service Nurse who was known for keeping an instrument in her locker that was always needed for a particular case so that when no one was able to find it, she did and looked like a hero. “I have also seen a scrub nurse send the circulator out of the room for an item later recognized to be on the back table,” she says.
“And once, many years ago, I saw a surgeon throw a knife in frustration,” says Spratt. “That never happened again.”
What Causes Incivility?
There are many different possible causes of incivility and bullying in the OR.
“It could just be the way someone’s day started,” says Sullivan. “Maybe they snapped at the person who came in to help them get their case ready, and that person feels hurt and decides not to bring in the tray that’s in the sterilizer. This can have a ripple effect and lead to compromises in patient care.”
Kyle cites issues that are common in the perioperative environment as potentially triggering incivility such as high stress, a hierarchical structure and a culture that tolerates incivility.
“I believe you can’t change people’s basic personalities,” says Spratt. “Once a bully, always a bully, and you find bullies in all professions. There’s also the stress of time pressure in the OR where time means money, so its push, push to get cases done and start the next case.”
“Incivility in the OR may be caused by a shortage of experienced personnel, extreme work demands, high patient acuity, a lack of teamwork and a lack of respect for coworkers,” says Shumaker. “Also, the pandemic exposed nurses to conditions they weren’t familiar with, causing more stress, burnout and problems with coworkers.”
- Maria Sullivan
Consequences of Incivility
It’s not surprising that incivility and bullying can have serious consequences on the well-being of health care workers and patients. “Incivility is probably the biggest threat to patient safety in the operating room today,” says Kyle. “This is because perioperative team members who do not feel secure and supported in the practice environment are not able to practice at their best.”
Sullivan also worries about the effects of incivility and bullying on patient safety. “If you are working with a surgeon or anesthesia team member who has been less than kind to you in the past, you might be reluctant to stop the line and speak up for patient safety,” she says.
“There are also the psychological effects on nurses who have been bullied by other team members,” Sullivan adds.
According to Kyle, perioperative team members who are subjected to incivility and bullying in the workplace report a wide range of physical, psychological and behavioral disturbances including: • Insomnia, dizziness and fatigue • Irritable bowel syndrome • Abdominal and back pain • Hypertension and headaches • Loss of appetite and self-confidence • Rage, aggression and irritability • Anxiety and panic attacks • Depression and PTSD • Inability to relax • Suicidal ideation
“In a 2018 study, researchers found that the suicide rate among nurses, especially female nurses, is significantly higher than the general population,” says Kyle. “I think it would be foolish to ignore the connection between the psychological consequences of incivility and the high rate of suicide among nurses.”
Spratt says that incivility and bullying can increase the risk of “never events” like wrong patient/wrong site surgery, retained foreign bodies, and specimen and medication errors.
“Nurses who are bullied are also more likely to leave the profession,” says Spratt. “Right now, older nurses are retiring and
younger nurses are leaving the bedside in droves. New nurses with a healthy self-esteem may just decide to go into another line of work.”
Supporting Civility
The topic of incivility in the OR is so important that AORN has partnered with the American Association of Nurse Anesthesiology (AANA) and the American Society of PeriAnesthesia Nurses (ASPAN) to create a position statement on workplace incivility.
“Every perioperative team should be aware of the position statement and integrate it into their practice,” says Kyle.
The position statement clarifies that it’s the responsibility of employers and all health care professionals to create an environment that’s free of distracting, disruptive or violent behavior. It also clarifies the difference between incivility and bullying.
Incivility is addressed by transforming culture, according to the position statement, while bullying is commonly addressed in workplace policy and the code of conduct. “The mission, values and code of conduct of a health care setting should address the importance of a healthy work culture,” says the statement.
“Everyone has a role in workplace civility,” says Kyle, who lists a number of steps that can be taken to improve civility in the perioperative environment. Those steps are: • Conduct a full workplace assessment of conflict and disruptive behaviors to inform a workplace violence prevention program as recommended by OSHA. • Make cultivating and maintaining a culture of safety a priority at all levels of the organization by adopting a zero-tolerance policy and providing employee support to address uncivil and bullying experiences. • Use an interdisciplinary approach when leading teams through education and implementation of workplace civility programs.
“Multidisciplinary team training is a great place to start,” says Spratt. “Team training in a casual setting, using round tables and with assigned projects, is a great way to break the ice between team members who may not even know each other’s names.”
Some universities are now putting medical and nursing students in the same classes so they can learn to work together right from the beginning, adds Spratt.
“Also be willing to stand up for yourself and your colleagues,” says Spratt. “Don’t participate in the behavior and don’t hesitate to report up the chain of command. If you can’t handle a situation, call for help. That’s what leadership is there for: to provide an atmosphere that lets you do your job in a safe manner.”
Sullivan concurs. “It starts with leadership laying the foundation for the type of workplace they want to foster and then holding all team members accountable for behavior that does not meet that expectation,” Sullivan says.
“Leaders are integral in establishing a respectful and positive workplace culture,” adds Shumaker. “Health care institutions must provide a system where employees can report incivility and bullying without fear of retaliation.”
Sullivan sums it up best. “Be kind and give grace,” she says. “And don’t accept bullying behaviors. Alert management if they occur so they can be resolved quickly.”
- Erin Kyle
• Conduct a full workplace assessment of conflict and disruptive behaviors to inform a workplace violence prevention program as recommended by OSHA. • Make cultivating and maintaining a culture of safety a priority at all levels of the organization by adopting a zero-tolerance policy and providing employee support to address uncivil and bullying experiences. • Use an interdisciplinary approach when leading teams through education and implementation of workplace civility programs.
