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Tue Sep 2 15:50:24 BST 2008

Please remove me from your trauma list. I have unsubscribed.

Thank you.

-----Original Message-----
From: Robert F. Smith <rfsmithmd at comcast.net>
To: 'Trauma &amp; Critical Care mailing list' <trauma-list at trauma.org>
Sent: Tue, 2 Sep 2008 9:57 am
Subject: RE: question about projectile composition

Richard,
I don't think anyone was saying it never happens or can't happen. Of the 119 
rticles listed in the world literature in Pub Med, it looked to me that around 
0 may have been dealing with lead toxicity in humans as a result of GSW. It's a 
ittle hard to tell from the titles. A lot of the other articles dealt with 
ullet emboli or appendicitis etc. By far, most of the articles were case 
eports though some had multiple cases. It looked like the articles went back to 
969. 
I think everyone is saying it can happen but it appears to be a pretty uncommon 
omplication of a retained lead missiles in civilian GSW.
Rob Smith
-----Original Message-----
rom: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] On 
ehalf Of Richard Wigle MD FACS
ent: Monday, September 01, 2008 10:37 PM
o: Trauma & Critical Care mailing list
ubject: RE: question about projectile composition
I must disagree. While it is undoubtedly rare I think that lead toxicity from 
etained particulate lead does occur although, as noted previously, usually when 
t lies within some liquid or gelid area. While I am still living out of a 
uitcase and don't have access to my files, a quick search produces numerous 
ase=2
0reports where lead toxicity was found and resolved after removal of the 
ragments. Granted, an elevated lead level in someone who lives in the less 
avory parts of our cities and happens to be carrying a bullet in their person 
s hardly conclusive, I think that a little time searching the literature will 
roduce enough evidence to negate being able to say that it never occurs. A few 
amples:
Bolanos AA, Demizio JP Jr, Vigorita VJ, Bryk E. Lead poisoning from an 
ntra-articular shotgun pellet in the knee treated with arthroscopic extraction 
nd chelation therapy: a case report. J Bone Joint Surg. 1996;78 :422 –426
S. T. Mahan, M. M. Murray, A. D. Woolf, and J. R. Kasser
ncreased Blood Lead Levels in an Adolescent Girl from a Retained Bullet. A Case 
eport J. Bone Joint Surg. Am., December 1, 2006; 88(12): 2726 – 2729
Farrell SE, Vandevander P, Schoffstall JM, Lee DC. Blood lead levels in 
mergency department patients with retained lead bullets and shrapnel. Acad 
merg Med. 1999;6 :208 –212
McQuirter JL, Rothenberg SJ, Dinkins GA, Kondrashov V, Manalo M, Todd AC. Change 
n blood lead concentration up to 1 year after a gunshot wound with a retained 
ullet. Am J Epidemiol. 2004;159 :683 –692
John BE, Boatright D. Lead toxicity from gunshot wound. South Med J. 1999;92 
223 –224
I know - they are all case reports and as such anecdotal but there are plenty 
ore.
R Wigle MD FACS
SU Shreveport

-- On Mon, 9/1/08, Robert F. Smith <rfsmithmd at comcast.net> wr
ote:
> From: Robert F. Smith <rfsmithmd at comcast.net>
 Subject: RE: question about projectile composition
 To: "'Trauma & Critical Care mailing list'" <trauma-list at trauma.org>
 Date: Monday, September 1, 2008, 5:47 PM
 I realize I'm really going out on a limb here, but I
 agree with Drs. Mattox
 and Stein. I trained in Occ Med back in the day and we
 tried to look for
 evidence of the effect of lead exposure through bullets.
 Sort of an overlap
 thing at Cook County Hospital. Everything was pretty
 equivocal at best.
 Sometimes you could find elevated serum Pb levels but the
 exposure to a
 variety of non-gunshot lead sources for patients from the
 South Side of
 Chicago was pretty high. But not necessarily uniform, you
 know. So it was
 hard to figure out to what we were or should be comparing
 the GSW victims
 to. I definitely don't ever remember a pt. with
 "poisoning" from a bullet.
 The worst possible scenario I could imagine would have been
 a lead bullet
 left exactly in the spinal canal. And how often would that
 happen??

 Rob Smith

 -----Original Message-----
 From: trauma-list-bounces at trauma.org
 [mailto:trauma-list-bounces at trauma.org]
 On Behalf Of KMATTOX at aol.com
 Sent: Monday, September 01, 2008 4:51 PM
 To: trauma-list at trauma.org
 Subject: Re: question about projectile composition

 Mickey's skepticism regarding "lead or metal"
 poisoning from metal  
 projectiles is several quantum less than mine.     I have 
 read some
 laboratory issues 
 regarding
 this subject, but have never seen either  in
 street fighters, war 
 wounds, referred patients, or any others any problems  that
 I was smart
 enough 
 to identify.    I was taught and  continue to leave
 missiles stay where they

 are, unless they have caused bleeding  problems.      I am
 aware of the 
 literature that real  LEAD bullets exposed to a synovial
 joint can result in
 lead 
 absorption, but have  never seen any good evidence for
 such.      Many of
 the  
 projectiles we see are really not LEAD.    I do believe
 that  there is a
 great 
 deal of urban legend here and a great deal of old wives
 tales  and retold 
 culture which either needs to be killed or have some
 science behind  it.

 But what do I know after being involved in and or
 supervising more than  
 70,000 injured patients during my clinical career as a
 medical student,
 resident, 
 soldier, and faculty since 1960.     

 k

 In a message dated 9/1/2008 3:39:32 P.M. Central Daylight
 Time,  
 mgstein at bezeqint.net writes:

 Hello  all,

 I am a bit perplexed!!

 I began Med School  in 1972.  Served as a Medic (1973) and
 Doctor
 (1982,1991,2006) in four  wars. Seen thousands of war
 casualties and
 personally treated hundreds of  shrapnel/projectile victims
 of explosives
 and
 firearms.  Treated  hundreds of suicide bombing victims
 (and have data on

 some 8000 others from  other med. centers around the
 country) from all sorts
 of stuff that the  terrorists' twisted minds try to add
 to the explosives.

 In all  these years (1973-2008) I have never never never
 seen a metal
 substance  poisoning from these projectiles.  Oh, we did
 see these particles
 to  cause severe problems.  However, all were mechanical or
  infectious
 complications.  Those (infectious complications) were seen 
 more commonly
 with the non-metalic projectiles or if traversed through 
 contaminated
 organs
 (i.e. hollow viscus etc.).  More so, I have never  heard of
 anyone who saw
 these types of complications (including the 2 years  I
 spent at STC in
 Baltimore MD 1993-5).

 Personal experience  is Level 6 :-) or less evidence but.

 Am I blind?

 Am I  deaf?

 Is it such a scarce issue?

 Are my patients just  LUCKY?

 Do they use different "Metals" in the Middle
 East?

 Are we  divinely protected from this type of complication
 in the
 "Holy-Land"?

 Is the King Naked?

 All or some of the  above?

 Your humble devils  advocate.

 Mickey

 *******************************************************************

 Michael  Stein MD

 Chairman, Israel Trauma Society

 Director of Trauma,  Attending Surgeon

 Department of Surgery,

 Rabin Medical Center -  Beilinson Hospital,

 Petach-Tikva,  49100

 ISRAE
L

 ******************************************************************

 -----Original  Message-----
 From: trauma-list-bounces at trauma.org
 [mailto:trauma-list-bounces at trauma.org]
 On Behalf Of listasmsd
 Sent:  Monday, September 01, 2008 1:28 PM
 To: Trauma & Critical Care  mailing list
 Subject: Re: question about projectile  composition

 old data

 Am J Forensic Med Pathol. 1983  Jun;4(2):165-9. Links

 A fatal case of lead poisoning due to a retained  bullet.

 DiMaio VJ, DiMaio SM, Garriott JC, Simpson P.

 Lead  poisoning from a retained bullet or missile is rare
 and is usually  

 dependent on the location of the missile in a bone or
 immediately  adjacent 

 to a joint. A review of the literature revealed only 14
 cases  in which
 there

 was adequate laboratory documentation of plumbism  caused
 by a retained 

 bullet or missile. Only one of these previously  reported
 cases resulted in 

 death. We report a second death due to lead  poisoning from
 a retained
 bullet

 with elevated blood lead levels  documented by toxicologic
 analysis.>

 > 

 > 

 >  Hello again all, In the news today I saw that the
 army is studying  the

 > longterm effects of shrapnel left in the bodies of
 soldiers.  It made me

 > think of all the GSW fragments I have seen left in 
 patients over the

 > years. The standard missile composition I  understand
 to be20copper
 jacketed

 > lead. Also common hollow point  and softpoint
 projectiles have no covering

 > at all. Does anyone  know of the longterm health
 effects of tihs either in

 > civillian  studies or anecdotes? What about
 projectiles with tungsten?
 Does

 >  location in the body have an effect on outcome? Look
 forward to the
 input

 > from the list. thanks again,Mike

 > 

 >  

 > 

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