Big T Retained Bullet
===

Speaker: [00:00:00] you've got a single ballistic wound to the thigh with a retained bullet. There's no bleeding, no fracture, and no deficits on exam. You tell the patient, "You're definitely lucky."

You discharge them home, advise them to follow up as needed, and you rush back to your case in the OR. As trauma surgeons, this is definitely a regular occurrence. The patient was in fact lucky, but it doesn't change the fact that they still have a bullet in them, a bullet that can cause pain, psychological distress, and in rare instances, serious lead poisoning.

So welcome back to Behind the Knife. I'm Patrick Georgoff, and today we're tackling a topic every trauma surgeon encounters, but almost none of us are formally taught, and that's retained ballistic fragments. So we'll cover the epidemiology, when to remove and when to leave them alone, how to handle bullets as forensic evidence, the underappreciated psychologic toll on our patients, and lead toxicity that can show up decades later.

So joining me are Dr. Teddy Puzio from UT Houston, Dr. Madhu Subramanian, a colleague of mine at Duke and a gun violence survivor, and our [00:01:00] beloved Duke ACS fellow, Dr. Tyler Simpson. Tyler, set the stage for us. Why should trauma providers care about this topic?

Speaker 3: Thanks, Dr. Georgoff. So as we all know, firearm injuries are still a significant public health concern in the United States, and the CDC estimates that about 161,000 non-fatal firearm injuries occur annually in the US.

And in fact, one study found that about 76% of patients with non-fatal GSWs had retained ballistic fragments.

Speaker 2: Yeah, that, that leaves a lot of trauma survivors walking around with retained fragments. That's why that's kind of the, the crux of this episode.

Speaker: It's remarkable how high that number is.

Speaker 4: Yeah, and you know, I don't wanna dive too deep into my own personal life, but, I made the choice when I got shot to, um, have my bullet removed 'cause I didn't wanna live with the complications associated with having a retained bullet.

The more we study this, the more that we learn that there are consequences of retained bullets [00:02:00] that don't necessarily manifest immediately. Often the clinical impacts and even the psychological impacts associated with these, uh, manifest months or years later. This is especially true when people develop lead toxicity.

The crazy thing is that these patients could present to a different provider than us, um, with symptoms that seem unrelated to the GSW, but are actually, um, due to the lead toxicity or other manifestations of their bullet injury. Yeah.

Speaker 2: Yeah, that, that's exactly why we're talking about that in this episode, so hopefully we can give our listeners kind of a mental framework for managing these retained ballistic fragments, uh, both during their index hospitalization and then through long-term follow-up.

Stuff that we don't really, as we said before, we don't really teach or think about.

Speaker: Yeah. Tyler, you mentioned , the no removal rate. Let's dig deeper into the epidemiology.

Speaker 3: Sure. So a few more numbers. Another recent study looked at about 298 patients, all with non-fatal GSWs, and about three-fourths of [00:03:00] them had at least one retained bullet, and then of those, another three-fourth had absolutely no attempt at bullet removal during their index admission.

And in fact, only 10% of all, all comers had complete fragment removal. And making matters worse, these patients actually had significantly higher rates of return to the emergency department within six months of their

Speaker 4: injury. It's important to highlight that this study we're talking about only considers non-fatal GSWs in patients that were admitted. This does not take into consideration the countless number of patients with non-fatal GSWs with retained bullets that are routinely discharged.

Retained bullets aren't just a physical artifact, they're a marker of ongoing community level vulnerability. These patients carry real downstream, burden of pain, infection, migration, lead toxicity, and then the psychological distress associated with these retained bullets.

Speaker: Sure. So with that , Teddy, , when do we remove these bullets?

What are you guys doing in [00:04:00] Houston?

Speaker 2: So generally we remove the bullet if it's easily accessible intraoperatively, if it's kinda in the field, or if it's something that is superficial, if it's palpable. If we have a patient that comes back to clinic and they have persistent pain, infection, if it's kinda nagging.

Some people complain that they can't sleep on a certain side because it wakes them up. But we don't really have a formal protocol, and it's patient and provider specific.

Speaker: Yeah. I think that's common. At Duke, we just recently created a retained bullet guideline, with the goal of increasing awareness, to get our team thinking about bullet removal early and to educate about these rare events, but serious events of lead toxicity.

And in general, I think I'm more aggressive about removing retained bullets during the initial hospitalization if it's safe to do so. So Tyler, walk us through, the framework, when it comes to the decision to remove bullets or bullet fragments, both acutely and in delayed fashion.

Of course.

Speaker 3: So at their index hospitalization, some strong indications that have [00:05:00] been cited previously include if it's superficial, if the bullet's palpable, or if it's, has fragments that are easily accessible. Also, if the fragments are encountered during operative debridement or exploration, if the fragments have an intra-articular location or if they're on a weight-bearing surface, and then if there's nerve root impingement with a progressive neurological deficit.

And lastly, if there's vascular embolization, which most would agree is probably a relatively rare phenomenon.

Speaker 4: Yeah, and there's also softer indications that we should consider when these patients are initially hospitalized. These include progressive pain clearly attributable to the fragment, pediatric patients with a long lifetime exposure of lead ahead of them, and patients with multiple retained fragments where the aggregate lead burden adds up.

Speaker: Yeah. You know, what irks me and part of the reason, we created that protocol is if we have folks that come in, to the ED, whether they're admitted or not, and, soft tissue injury, no big deal, and the bullet's just sitting there.

You can [00:06:00] feel it. It's underneath the skin, and we just leave it there. -- We should be taking those out, e-especially when it's easy enough, some local at the bedside, making an incision, pulling the bullet out. , That should be done during that admission in the ED, in-house, whatever it may be.

So Tyler, what about delayed removal patients coming back to clinic with issues.

Speaker 3: Yeah. So for delayed removal, some of the indications for re-- or bananas. When patients return to the clinic or the ED with persistent pain at the fragment site, infection, fragment migration, psychological distress, or if they have evidence of lead toxicity, those are all indications in which we should reconsider removal

Speaker 4: I like that you said reconsider.

There's always a risk-benefit calculation that we need to make with these. So we have to think about the fragment depth. Is there any proximity to neurovascular structures? Their overall patient status. This patient may be, deathly ill from all their injuries, so we gotta really take those things into consideration before we remo-remove [00:07:00] these bullets.

, Many times, the risk may actually exceed , the reward of trying to take one of these bullets out. Yeah. You

Speaker: know, often the morbidity of excising that bullet is way too great. You can go digging through a bunch of important structures deep in the tissue. And when removal isn't the right move, the approach should be watchful waiting with a structured surveillance plan and an explicit shared decision-making conversation, which is probably one of the main things we're missing in trauma, is to acknowledge the fact that there's a bullet there.

Talk about what that could mean in the future. Talk about how we would take care of it and it's probably good to document that, too. Say, "Hey, there's a retained bullet," and the SOAP and, , it was discussed with the patient, and we talked about a surveillance plan which includes XYZ.

About three sentences in the chart. And, uh, importantly, to share with those patients, especially at the time of discharge, what symptoms should prompt them, to return.

And the next part is really important, too. This comes up all the time, when it comes to removal, what do we do with this forensic evidence? Uh, it's something that's [00:08:00] genuinely under-taught

Speaker 2: yeah. I think that's something that we don't really discuss enough in surgical training.

Uh, especially if you're not at, like, a high volume penetrating center is, how do you remove the bullets, and what is the kinda chain of command once you remove them?

Speaker 4: When I was in training, I removed a number of bullets and didn't really understand this whole process. You know, the key is to preserve forensic integrity.

These bullets are potential criminal evidence. Um, so if you scratch, clean, damage the bullet, you may destroy the, , microstriations on the bullet that these forensic examiners use to match the bullet to a specific firearm. Tyler, what are some operative considerations to preserve the forensic integrity?

Speaker 3: So when you're in the OR or if you're in clinic,, and you're removing a bullet fragment, the instrument you're using matters. We wanna avoid using any metal forceps or metal clamps on the bullet surface. And ideally, we should use plastic forceps or forceps with rubber tips or rubber-tipped Kelly clamps.

Oftentimes, [00:09:00] these may not be available, and you can improvise by cutting a piece of a red rubber catheter and then just place it over the tips of the instrument you're using. You can also manually retrieve it with a gloved finger if that's possible But each ballistic fragment should be placed in a separate plastic container.

And I know we all love, , the sound of dropping that metal bullet onto the, , onto the mayo or into a, , metal container, but this, this needs to be avoided.

Speaker 2: It's really hard not to

Speaker 3: do that.

Speaker 2: Yeah. Drop its bullets. That's one of my f- yeah, it's one of my, I don't wanna say one of my favorite things to do, but it's a guilty pleasure, I gotta admit.

Now I don't wanna do it as much after all this- It's stripped away from you, Teddy ... this education. Yeah. Like all, like all good things in

Speaker: life, it's gone. I know.

Speaker 2: There it goes.

Speaker 3: But along, along those lines, you wanna keep the bullets in separate containers, that way they, they also don't damage each other when they're transported.

You should place a label on each container and include the anatomic location of retrieval, and then the ballistic fragment should always follow your [00:10:00] institution's chain of custody procedures.

Speaker 4: Yeah, I think the chain of custody is non-negotiable.

This is one thing that I think a lot of surgeons are not familiar with, and it's really important to confirm the process with your institution, um, your OR leadership, and the hospital police. Generally, when this occurs, the first thing you do is have the OR circulator contact hospital police or public safety to retrieve the evidence.

And then remember, the only person who can accept that bullet is a designated officer that's permitted to take the specimen. The transfer should include the officer's name when available, and that should be documented in the chart. All you really have to do is put a one-liner in your op report or in a note so that we can follow up on it and make sure that we're following the chain of custody.

Yeah.

Speaker: I checked this after we'd, , looked into this episode and the last one we had removed, , the OR nurse did a great job. She walked the bullet in a plastic cup, out to the OR front desk where Duke Police were waiting for her. She handed it off to them , and a note documenting Officer So-and-so, badge number so-and-so, [00:11:00] retrieved the bullet at such and such time and, took it back to their, storage facility.

Where, , I learned the vast majority, at least for us in Durham those bullets are, , sent back out to their respective counties in which those police,, departments reside. And so those bullets, do, at least locally, get, sent back to the right place for o- ongoing investigation.

Speaker 4: I think one thing that I would add is that, , if you are not familiar with this it's probably a good idea if you're taking somebody to the operating room to do this.

Um, you can always contact your hospital administrator on call, and they should hopefully have an answer for you as to how to address this if no one really is familiar in the operating room.

Speaker: Yeah. And sometimes it, these things happen late at night too, and that's when it may break down. So let's talk about lead poisoning, Tyler.

Give us a, bit of background here.

Speaker 3: All right. So lead toxicity, it's historically called plumbism, and it's, it's an underdiagnosed complication of non-fatal GSWs. Just a quick note on bullet composition. Most of modern handgun rounds are now jacketed, [00:12:00] so they have a copper alloy shell that's over a lead core.

And this jacketing slows leaching of lead, but it doesn't necessarily prevent it, especially when projectiles deform or fragment on impact and expose the core. So even jacketed ammunition can be a lead source once it's in tissues, and the rate at which lead leaches from ballistic fragments isn't uniform.

It depends critically on the local tissue environment around the fragment.

Speaker: Yeah. It, it's important to recognize lead toxicity is rare. You know, overall, you step back, it is rare. But one of the known causes are retained bullets. If that retained bullet's in the soft tissue, it's less likely to be an issue, but the location really does matter, , Tyler, so what types of locations or exposure to certain types of tissue, lead to greater risk of lead poisoning?

Speaker 3: The highest risk locations are those that have continuous body fluid contact.

These are the intra-articular spaces that are bathed in synovial fluid, [00:13:00] fragments that are in contact with cerebrospinal fluid, fragments in bone marrow, and fragments that are in highly vascularized tissue. Uh, a systematic review in two thousand and nineteen showed that intra-articular locations, bone fractures or trauma at the fragment site, multiple fragments, hypermetabolic states, and longer retention duration all independently increase the risk of lead toxicity.

The synovial fluid environment is particularly corrosive to lead as it contains hyaluronic acid, and it has continuous joint motion, both of which accelerate dissolution

Speaker 4: Yeah. And I think it's worth adding, you know, the old assumption that soft tissue fragments are safe because they're get encapsulated isn't entirely true.

There's a published case of a man who had retained soft tissue fragments who presented 10 years out with blood levels over 200 micrograms per deciliter.

This was confirmed at the source by isotope ratio analysis. So encapsulation does reduce the [00:14:00] risk, but it doesn't completely eliminate it.

Speaker: Tyler, what happens then after lead leaches from retained bullet fragments and is absorbed into the bloodstream?

Speaker 3: Well, lead distributes among the blood, the soft tissue, and the bone.

It actually behaves like calcium, entering cells through the calcium channels and other metal ion transporters. The blood half-life is about 28 to 36 days, but this is a little bit misleading because the kinetics are biphasic. So about 94% of total body lead in adults and about 73% in children is actually sequestered in bone, and the half-life of lead that is in bone is somewhere in between 10 and 30 years.

Speaker: Yeah. And that matters clinically because anything that increases bone turnover, so stuff like hyperthyroidism, even pregnancy, can lead to remobilization of stored lead back into the circulation, even years after the source fragment is, removed , or after that , GSW.

Speaker 2: No, I think that's an important point. We mentioned it earlier about education, [00:15:00] right? We see a lot of people who are shot, and we just send them out. And I think part of, uh, the message that we are giving today is that we should be educating these people on, you know- Yeah

what they should look for, right? So with that, Tyler, we see these patients with, uh, retained ballistic fragments for follow-up in trauma clinic All the time. Every day we see them. What are some of the clinical manifestations that we should be looking for of lead toxicity so we can identify them?

Speaker 3: Oh, man. Unfortunately, the symptoms are frustratingly non-specific, and that's why it gets missed. Lead affects virtually every organ system. Uh, the so-called classic constellation is fatigue, abdominal pain, constipation, and peripheral neuropathy. But you can also see anemia from the inhibition of heme synthesis, renal dysfunction from tubular injury, cognitive changes and memory impairment, irritability, mood changes.

The presenting complaint of [00:16:00] abdominal pain and anemia in a young guy or a young girl who had a history of a GSW should be enough to prompt obtaining a blood lead level, though.

Speaker 2: Yeah. It's an easy diagnosis to miss given how vague the presentation is, right? And I think a lot of these people end up seeing their PCP, uh, with these symptoms, and it, it sometimes takes a while.

I know the patients that we've seen in our clinic with this problem, it's been, they've bounced around from place to place until they get this diagnosis, 'cause it's really not often thought of until they can- The importance, the importance,

Speaker: like you said, of education, Teddy, right? Getting patients the knowledge so they can show back up to you, someone who, may have the sense to, to check for lead levels even if the symptoms are non-specific.

Speaker 2: Yeah. And, and like we talked about, some of these patients are at higher risk depending on the location and the number of retained fragments. When we've had patients, I think the, the, the, the few times that I can remember seeing this are patients with shotgun wounds that have multiple, multiple fragments.

So if you, [00:17:00] in your mind, you're gonna discharge them from your clinic, you should educate them on the, they're at risk for this kind of stuff.

Speaker: So what are blood lead levels that we need to worry about, Tyler?

Speaker 3: Yeah. So blood lead levels, they're measured in micrograms per deciliter, and the CDC classifies a lead level of greater than three point five micrograms per deciliter as elevated.

But in clinical terms, levels at or below this reference value of three point five warrant observation only. And then levels that are above the reference level and get into single digits warrant a little bit closer monitoring with attention to risk factors. And then once you get to lead levels of 10 micrograms per deciliter and above, that's a clinically significant elevation, and surgical removal, again, should be reconsidered if it's feasible.

And once blood lead levels reach 50 and above, you're entering a point of severe toxicity territory requiring urgent specialist-directed [00:18:00] chelation.

Speaker: Mm-hmm. So how often are we checking blood lead levels for patients with retained bullets?

Speaker 3: There's not really a formal consensus that I'm aware of.

As we mentioned at Duke, we've recently got a new retained ballistic fragment protocol, and our protocol calls for us to get lead levels within a few weeks of injury, then every six months for at least two years.

Speaker 4: Yeah. And, uh, you know, some centers now have risk-stratified blood lead level monitoring. So, for high-risk patients, which include those that have intra-articular involvement, CSF contact, bone involvement, multiple fragments or pe-pediatric patients, they would all fall into that category.

Low-risk patients are those that are asymptomatic with subcutaneous or intramuscular retained bullet fragments. Low-risk patients require a baseline blood lead level and less frequent monitoring.

Speaker 2: Yeah, I think, I think one of the key distinctions here that we should really take [00:19:00] a moment to focus on is the pediatric patients, and that across the board, they're considered high risk inherently.

You know, at Houston, we have a distinction between adults and pediatrics in this when we-- when it kinda comes to blood, uh, lead level testing. We don't really have a protocol in the adult world yet. But in kids, we, we are very aggressive with checking blood lead levels. And we know because kids are at more risk due to high GI absorption of lead, they have ongoing CNS development, high bone turnover, and that can remobilize the stored lead, as we talked about.

So the accepted position in pediatric toxicology is that no blood level is safe in children. So in pediatric patients with these retained ballistic fragments, they should have more frequent surveillance.

Speaker: Okay. So let's say we check blood lead levels on a patient, starts off at three. Next check, six months later, it's, it's seven. What are we doing for them? [00:20:00]

Speaker 3: Yeah. So we've, got rising blood lead levels in this patient.

And, uh, two big things here. First and foremost, we should again reconsider removing the ballistic fragment if it's surgically feasible And then secondly, we should consider specialist consultation. So this may be institutional specific, but it may be a hematology consultation or medical toxicology. And we can consult them if lead levels are greater than ten micrograms per deciliter, or if the lead levels are rising on serial labs, or if patients are symptomatic, have high risk ballistic fragment locations, like we mentioned, intraarticular, in the CSF, in the bone marrow.

And then, uh, chelation therapy really should be directed by a sp-specialist, and it's reserved for patients with significant toxicity, often when lead levels reach fifty micrograms per deciliter or higher.

Speaker 4: Just to clarify, you know, chelation alone is not the answer. It, it just is a temporizing [00:21:00] measure, right?

The lead will continue to keep leaching out of that bullet. So in the ideal situation, we should be focusing on trying to remove the fragment because that is the definitive step.

Speaker: Yeah. We, , uh, actually implementing the protocol, found one person with a slightly elevated, , blood lead level and went ahead and talked with hematology, and they were absolutely geeked about this.

It was awesome. The patients can be looked after very closely. These are folks who have a genuine interest in this and an expertise. So that's pretty cool to see. So Madhu, a-as a gun violence survivor, can you speak to the psychological impacts of retained bullets?

Speaker 4: Just from my experience, I, I wanted to learn more about it. And, and so one of the people that is doing a ton of work on this is Randi Smith and her group, . First at Penn, now at Emory. Um, they did a study in twenty eighteen where they prospectively followed a hundred and thirty-nine male firearm injury survivors at a level one trauma center.

They used a validated instrument three months post-injury to kinda follow these [00:22:00] patients and assess their, psychological symptoms. , They didn't see a difference between PTSD symptoms in those who had a retained bullet versus those that did not, but depression was a completely different story.

When they did a multivariable regression controlling for injury severity, number of wounds, education, marital status, they noticed that the presence of a retained bullet fragment was , independently associated with about a three-point-five point increase in depression scores. Patients with retained bullet fragments were also less likely to return to work.

Smith and her group followed this up with a qualitative study that they published in twenty twenty-three. In that study, they did in-depth interviews with about twenty-four survivors. What was interesting was the language that these patients used. They described the shame of having a foreign body in their body.

Many of them likened it to having a permanent scar that they couldn't remove, and they explicitly wanted the fragment out, not because they were told it was dangerous Or because of any [00:23:00] other real reason, they just thought it prevented them from having psychological closure. The authors compare this to burn survivors, where this bullet fragment is kind of a reminder of the trauma, um, that they've undergone.

Speaker 2: That definitely, , reframes the risk-benefit calculation. You know, something that we don't put into the risk of leaving the fragment. So psychological distress is definitely real. And these patients may not have lead toxicity, but the, but if the patient is in our clinic coming back and telling us that they think about this bullet every day and they're persevering on it, then that should weigh into that, decision to remove it.

Speaker 3: There's a couple caveats here that are worth mentioning, and one is probably the study population consisted almost entirely of young males at urban level one trauma centers, and the short follow-up is worth mentioning as well. And no one has truly tested whether removal actually improves depression scores.[00:24:00]

The signal is real, but I think the evidence base is still maturing. But the practical takeaway is that psychological distress definitely belongs on our list of relative indications for delayed removal, and we should probably be screening for depression at trauma clinic in our, our GSW survivors, not just asking about pain and wound healing.

Speaker: Yeah. I think that's a whole nother topic when it comes to comprehensive trauma-informed care in our follow-up clinics, which can lack. So with that, we'll wrap up our conversation here on retained bullets. Remember the following key points. Number one, most retained bullets stay retained, and most patients come back with issues related to that.

Number two, we should all have a clear framework for removal that may look different at different institutions, uh, but having a framework is important. Number three, treat every bullet as forensic evidence. We provided the tips and tricks for effective removal. [00:25:00] Number four, while rare, lead toxicity is real, it's delayed, and it can easily be missed.

And five, the psychological burden of retained bullets should absolutely not be dismissed.

Speaker 3: All right. Well, thanks for listening to this episode of Behind the Knife. As always, dominate the day.