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Tue Jul 31 12:24:57 BST 2007

personally, I would have the bullet removed.  That would be my choice to make, and I would make it IF it didn't pose a significant risk.  For me, a laparotomy or thoracotomy would be out of the question, and a procedure that would put arterial flow or nerve function would likewise be out of the question.  But an easily accessible bullet - that is a no-brainer.  And Sanjay, that has nothing to do with ethics...this is just plain evidentiary justice at work!

As far as my patients, I have to agree with all that was said as to the true indications for removal.  Having said that, I would always give them the same options that I would offer myself or my loved ones; if something is good enough for me 'n my kin, then it sure as hell is good enough for my patients!

Ron

>>> Sanjay Gupta MD <sanjaygupta99_91 at yahoo.com> 7/30/2007 7:13 PM >>>
Suppose that you (the physician) have been shot. 
There is no indication to remove that bullet for any
of the medical reasons listed in here.  The gun that
is supposed to be the one responsible is found, but
the only way to figure out if the bullet came from
this gun is to remove the bullet (and this would not
jeopardize your life), what would your ethics say. 
Remove the bullet and get the assailant his due
punishment (and maybe some reward to you) or leave the
bullet in your body and let the miscreant get away? 
What am I, as a physician to do in this situation, if
you (the victim) happens to be someone near and dear
to me?

Sanjay

--- caesar ursic <cmursic at gmail.com> wrote:

> 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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> > >
> >
> >
> >
> > --
> > '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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> >
> >
> >
> >
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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.
> --
> trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe visit:
> http://www.trauma.org/index.php?/community/ 
> 

Sanjay Gupta MD
Tel: 412 335 6304

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