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Summary

Clinicians have a duty to care for patients whose injuries or illness may appear self-inflicted. However, in some cases, the self-inflicted element of these injuries makes this care especially difficult. Repeated self-inflicted injuries raise ethical dilemmas including issues of allocation of scarce resources, how to justly care for patients in the context that led them to self-injury, so-called "care contracts" with patients, and whether it is ever appropriate to violate a patient’s autonomy to protect them from further self-harm (either during acute recovery or long-term). They also raise issues of frustration for caregivers seeing patients at medical risk that feels avoidable, and caregivers who feel that by providing immediate medical care they are likely not addressing the root of the problem for the patient.

We examine these issues via a clinical ethics case study of a patient representing a case of Repeated Foreign Body Ingestion (RFBI). RFBI occurs among a small number of patients, but occurs frequently for those affected, and often requires emergency surgery to resolve. In many cases, RFBI is extremely dangerous for patients who experience it, and caregivers find themselves haunted by wondering what they could have done differently for patients when the RFBI does repeat.

Background:

Cadaveric and older radiographic studies suggest that concurrent cervical spine fractures are rare in gunshot wounds (GSWs) to the head. Despite this knowledge, patients with craniofacial GSWs often arrive with spinal motion restriction (SMR) in place. This study quantifies the incidence of cervical spine injuries in GSWs to the head, identified using computerized tomography (CT). Fracture frequency is hypothesized to be lower in self-inflicted (SI) injuries.

Methods:

Isolated craniofacial GSWs were queried from this Level I trauma center registry from 2013-2017 and the US National Trauma Data Bank (NTDB) from 2012–2016 (head or face abbreviated injury scale [AIS] >2). Datasets included age, gender, SI versus not, cervical spine injury, spinal surgery, and mortality. For this hospital’s data, prehospital factors, SMR, and CTs performed were assessed. Statistical evaluation was done with Stata software, with P <.05 significant.

Results:

Two-hundred forty-one patients from this hospital (mean age 39; 85% male; 66% SI) and 5,849 from the NTDB (mean age 38; 84% male; 53% SI) were included. For both cohorts, SI patients were older (P < .01) and had increased mortality (P < .01). Overall, cervical spine fractures occurred in 3.7%, with 5.4% requiring spinal surgery (0.2% of all patients). The frequency of fracture was five-fold greater in non-SI (P < .05). Locally, SMR was present in 121 (50.2%) prior to arrival with six collars (2.5%) placed in the trauma bay. Frequency of SMR was similar regardless of SI status (49.0% versus 51.0%; P = not significant) but less frequent in hypotensive patients and those receiving cardiopulmonary resuscitation (CPR). The presence of SMR was associated with an increased use of CT of the cervical spine (80.0% versus 33.0%; P < .01).

Conclusion:

Cervical spine fractures were identified in less than four percent of isolated GSWs to the head and face, more frequently in non-SI cases. Prehospital SMR should be avoided in cases consistent with SI injury, and for all others, SMR should be discontinued once CT imaging is completed with negative results.

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Chapter 26 - Doing It To Themselves

Summary

Cervical Spine Injury is Rare in Self-Inflicted Craniofacial Gunshot Wounds: An Institutional Review and Comparison to the US National Trauma Data Bank (NTDB)

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Chapter 26 - Doing It To Themselves

Summary

Cervical Spine Injury is Rare in Self-Inflicted Craniofacial Gunshot Wounds: An Institutional Review and Comparison to the US National Trauma Data Bank (NTDB)