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Mon Jul 30 16:13:22 BST 2007

I the USA there is no way that any court, judge, police agency or other
official can legally oblige any physician to remove any bullet from any
patient.  Period.  The bullet might eventually get removed, but only by a
doctor who agreed to do so williingly - not because of any legal pressure.

Those of you who believe otherwise please provide specific citations of
specific cases.

CM Ursic, MD
Santa Fe
USA

On 7/30/07, Hardcastle, Tim, Dr <tch at sun.ac.za> <tch at sun.ac.za> wrote:
>
> Pret
>
> The way the law and ethics combine here are site specific: In South Africa
> the doctor would be issued with a subpoena to undertake the bullet removal;
> refusal is contempt of court. You therefore comply stating in your notes
> that this is undertaken "against scientific evidence and under duress"
> (legal-speech, not mine!) and the court response is usually (at the time of
> the trial) "so-noted and thank you for compliance with the higher
> authority". The doctor is covered for any action by the patient who will
> have to prove that the action of the doctor violated his right to either a
> fair trial (unlikely, since most bullets we remove are in victims rather
> than perpetrators) or appropriate health-care!
>
> Also remember we use Roman-Dutch law without a jury system - the judge
> makes the call based on the law rather than the feelings of a mini-mob. :-)
>
> Tim
> Dr T C Hardcastle
> M.B.,Ch.B.(Stell); M.Med(Chir); FCS(SA)
> Senior Surgeon / Senior Lecturer: Surgery (Trauma and ICU)
> ATLS  instructor and DSTC Cape Town Course Director
> Intern program Coordinator: Surgery
> M.Med (Emergency Medicine) Executive Committee member
> Clinical Head (Director): Diana Princess of Wales Trauma Unit
> Division of Surgery (General) Room 4064
> Department of Surgical Sciences
> Tygerberg Hospital / University of Stellenbosch
> PO Box 19063
> Tygerberg 7505
> Western Cape
> South Africa
> e-mail: tch at sun.ac.za
> Cell: +27824681615
> Office: +27219389281 or 4911 pager 0302
>
>
>
> -----Original Message-----
> From: trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org]On Behalf Of Bjorn, Pret
> Sent: Monday, July 30, 2007 2:35 PM
> To: Trauma &amp; Critical Care mailing list
> Subject: RE: Bullet removal
>
>
> Okay, I'm here to learn:
>
> The court can order it; but must a doctor violate his or her oath in the
> process of compliance?  Seems to me that even if the State gives proxy
> consent, you still have to get past the medical necessity condition
> before this passes the ethical straight-face test...
>
> Pret
>
> -----Original Message-----
> From: trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org] On Behalf Of Hardcastle, Tim, Dr
> <tch at sun.ac.za>
> Sent: Monday, July 30, 2007 6:33 AM
> To: Trauma &amp; Critical Care mailing list
> Subject: RE: Bullet removal
>
> Unless he is "under arrest"
>
> In most places then the court may order such a step!
>
> On the topic: our five indications for bullet removal:
> -You see it in the wound
> -You feel it under the skin / in the soft tissue
> -It communicates with CSF or joint space fluid = risk of electrolysis
> and lead poisoning long term
> -In or near a vascular injury - embolisation risk and sepsis of graft /
> repair
> -The justice system orders the removal of an awaiting trial prisoner's
> bullet.
>
> In my mind these are the only sound reasons for removing bullets
> anymore, this is our day to day practice and we see anything from 5 to
> 20 GSW's per week!
>
> Tim
> Dr T C Hardcastle
> M.B.,Ch.B.(Stell); M.Med(Chir); FCS(SA)
> Senior Surgeon / Senior Lecturer: Surgery (Trauma and ICU)
> ATLS  instructor and DSTC Cape Town Course Director
> Intern program Coordinator: Surgery
> M.Med (Emergency Medicine) Executive Committee member
> Clinical Head (Director): Diana Princess of Wales Trauma Unit
> Division of Surgery (General) Room 4064
> Department of Surgical Sciences
> Tygerberg Hospital / University of Stellenbosch
> PO Box 19063
> Tygerberg 7505
> Western Cape
> South Africa
> e-mail: tch at sun.ac.za
> Cell: +27824681615
> Office: +27219389281 or 4911 pager 0302
>
>
>
> -----Original Message-----
> From: trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org]On Behalf Of Pret Bjorn
> Sent: Monday, July 30, 2007 11:18 AM
> To: 'Trauma &amp; Critical Care mailing list'
> Subject: RE: Bullet removal
>
>
> You comply with such an order only after the patient's consent, I
> presume.
> Otherwise it sounds like a good case for your ethics committee: you're
> both
> committing assault and violating his Fifth Amendment rights.  That is,
> if
> America still has a Bill of Rights.
>
> Wait.  We still have amendment number two, don't we?  Hence the missile
> of
> interest...
>
> Pret Bjorn, RN
> Bangor, ME USA
>
>
> -----Original Message-----
> From: trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org]
> On Behalf Of Hall, John R
> Sent: Sunday, July 29, 2007 11:31 PM
> To: Trauma &amp; Critical Care mailing list
> Subject: RE: Bullet removal
>
> CM
> We once had a "court order" to remove the bullet for evidence.
> j
>
>
> -----Original Message-----
> From: trauma-list-bounces at trauma.org on behalf of caesar ursic
> Sent: Mon 7/16/2007 12:37 PM
> To: Trauma &amp, Critical Care mailing list
> Subject: Re: Bullet removal
>
> Consensus?  What's that?
>
> I do know one thing: failure to remove all bullets will severely
> compromise
> your credibility as a trauma surgeon with the family.  In their eyes,
> the
> primary purpose of emergency surgery is to get the bullets out.
>
> However, I was indoctrinated to believe that only bullets in the
> following
> areas actually require removal:
>
> 1. when in contact with synovial fluid (i.e. joints): because they
> compromise joint integrity and mobility and, if unjacketed, may lead to
> lead
> intoxication;
>
> 2. when in a vessel lumen, to avoid distal missile embolus and vascular
> occlusion;
>
> 3. when inside the heart, because, well... because loose objects within
> heart chambers will only cause mischief.
>
> 4. when under the skin on weight-bearing surfaces (eg: the buttocks) or
> surfaces subject to contact with clothing (eg: belt line) that produce
> discomfort or pain.
>
> 5. when visibly bulging beneath the skin and causing cosmetic distress.
>
> I've never heard that the indications are different in women versus men.
>
> Once in a while a law-enforcement type will tell me that I need to
> remove a
> bullet for 'evidence.'  I've never done that nor think that one can be
> forced to do so, at least in this country (USA).
>
> CM Ursic, MD
> Santa Fe
>
>
>
> On 7/16/07, William Bromberg <brombwi1 at memorialhealth.com> wrote:
> >
> > Hey there,
> >
> > Is there any consensus on indications for bullet removal in:
> >
> > asymptomatic men (I vote leave it)
> > asymptomatic child-bearing age women - this is where I'm uncertain
> >
> > Symptomatic, in joints/blood vessels, impinging on the SC I figure
> need
> > to come out.
> >
> > Any advice appreciated.
> >
> > Bill Bromberg
> >
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>
>
>
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-- 
'Twas brillig, and the slithy toves
Did gyre and gimble in the wabe:
All mimsy were the borogoves,
And the mome raths outgrabe.

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