Epidemiology of firearm injuries in Saudi Arabia
A population in different countries, regardless of their continental location, have various availability to acquire firearms, which reflect the number of firearm-related deaths and disabling injuries.
According to the University of Sydney international research on Gun Policy, the annual rate of all gun-related deaths in Saudi Arabia is 0.35 per 100,000 of population. This is a relatively small number, compare to the USA (11.96), South Africa (9.39), Argentina (6.73), Austria (2.9), France (2.65), Turkey (2.63), Egypt (1.61), Sweden (1.6), and Australia (1.04). However, it is exceeding the numbers in such countries as Malaysia (0.3), UK (0.17), Japan (0.02), and Morocco (0.01), where access to the firearm is very limited (www.GunPolicy.org, The University of Sydney international research on Gun Policy Facts). Availability of small firearms has been compared to a cancer spreading across the developed countries. Although firearm injuries periodically have been reported from Saudi Arabia, these injuries are mostly accidental and mortality and morbidity are low compare to many developed countries.
The incidence of firearm injuries in the Al Kharj region was estimated as 3.13 per 100,000 of the population. This is approximately 2.5 times lower compare to the results demonstrated by a study performed in the Abha region of Saudi Arabia, which can be explained by differences in demographic proportions on nationalities living in these regions (Softah et al. 2002).
Unfortunately, there was no data available to compare the incidence of firearm injuries with largely populated urban places such as Riyadh or Jeddah. According to the Menoufiya University Hospital study, firearm injuries were found more common in rural regions (72.41%) compare to urban areas (27.59%). This could be explained by the facts that rural population has easier access to small firearms to protect their livestock and less gun regulations than urban areas (Badawy et al. 2009).
For the period of this study from 2013 to 2017 inclusive, there were 102 firearm and air gun offenses recorded by submission to the major local public hospital. Based on the data collected by the Trauma Audit, this represents 23.4% of all trauma cases recorded over this period, which included road traffic accidents, burns, industrial and domestic injuries, and stabbing.
The evaluation of these injuries requires specialized training and expertise.
The human factor remains to be the major, if not the only, when the trauma injury is related to firearms. A study conducted in 2015 showed that firearms were the leading cause of trauma deaths and long-term disabling injuries in the Abha region of Saudi Arabia (Softah et al. 2002). The highest numbers of firearm victims were in the 20–30-year-old age group. This study also concluded that the head and torso were the most vulnerable areas due to organ destruction and hemorrhage.
In this study, 18 patients (17.7%) were identified as children (age below 16 years old). All episodes of injured children were related to unintentional fire due to careless handling of firearms or air guns.
The majority of Saudi population would consider an air gun as a toy rather than a dangerous weapon. This attitude of population more likely is due to the lack of education about air guns as weapons, which can cause severe injuries although rarely fatal.
Initial assessment of presented injuries
According to the Trauma Assessment rules and algorithms, doctors in the emergency department were inquiring about the type of weapon used if the victim or witnesses are able to answer.
It was mandatory to examine the entry wound and the exit wound where applicable.
All patients underwent full blood examination and X-ray or CT scan investigations depending on GCS score on presentation for bullet/pellet localization and ultrasound study in search of hematoma and estimation of the volume of blood loss, and the degree of hemorrhagic shock.
All patients were checked for tetanus up-to-date cover and received primary vaccination or buster injection.
Management
All patients with gunshot injuries had cross matching of 1 to 4 units of blood and two large-bore IV cannulae for fluid replacement. Systolic blood pressure maintenance was aimed as 100 mmHg to avoid exacerbation of blood loss. X-rays (AP and lateral) of affected body region above and below the entry wound were performed to search for an embedded bullet or pellet. The vital signs, arterial blood gases, and ECG monitoring were used after the initial primary and secondary assessments, as per universal trauma protocol. The decision to take patient to operating theater immediately, to the intensive care unit, or to a high-dependency unit was made depending on the patient’s hemodynamic stability and ISS. In order to reduce the risk of infection, debridement of damaged tissue followed by delayed closure of wounds and use of prolonged broad-spectrum antibiotics were implemented.
Chest injuries
Although 6 patients sustained rib fractures from the un-established type of weapon or projectile caliber, there were only 2 chest-penetrating injuries, which required insertion of the chest drain for moderate pneumothorax.
Abdominal injuries
Twelve of abdominal injuries were associated with bowel injuries of various localizations and required emergency laparotomies for damage control and bowel repair or partial bowel resection with primary anastomosis. Superficial non-penetrating wounds of the abdomen required bullet/pellet extraction, wound wash out, and further close observation in high-dependency unit for occult bleeding. In case of doubts in patients who were hemodynamically stable, diagnostic laparoscopies were performed to exclude hollow organ injuries and internal bleeding. Early administration of broad-spectrum antibiotics took place with any abdominal injury.
Limb injuries
Large vessels, peripheral nerves, and tendons were endangered in 46 cases, including 6 injuries of femoral arteries, causing significant blood loss and requiring urgent revision of the arteries with primary repair, which was followed by a close monitoring of the limb circulation. Injuries to the peripheral nerves and tendon injuries (14 out of 102, %) were referred after patient stabilization to the appropriate specialized center for further management.
Wound closure
Where soft tissue damage occurred with low-velocity bullets, gunshot wounds were managed by bullet/pellet extraction from the soft tissue followed by wound care and further outpatient review. Wide excision or fasciotomy was required to clean from foreign material (normally clothing) and dead tissue. In these cases, the primary wound closure was delayed for 3–7 days.
Forensic aspects in gunshot reporting
The Saudi Arabian law implements guidance concerning the reporting of all firearm-related injuries. The local police authorities were quickly informed upon gunshot injuries presented to the hospital. This information is important statistical crime/event investigation information and gun injury statistics. The disclosure of personal information of the injured person by medical personnel to the public without consent from the patients or their family was avoided.
Forensic evidences
Healthcare professionals preserved the potential forensic evidences, as a rule. These included the patient’s belongings and bullet/pellet fragments extracted from the body. The recovered forensic evidences were labeled and kept in a secure place until transferred to the police.
The cost of hospitalization due to firearm injuries
Researchers from Boston University School of Medicine through the analysis of more than 17,000 men and 2200 women admitted after a firearm injury demonstrated that the cost of acute and longer term medical care and recovery in this category of patients has increased greatly during the last decade. They concluded that many, almost certainly, face a long, painful recovery reflected in high medical bills (DiGravio 2018). This study was supported by multiple centers, such as Stanford University School of Medicine and Iowa University School of Medicine, which estimated the initial hospitalization cost of firearm injuries ranging from US$622 million to US$735 million per year (Peek-Asa et al. 2017).
Our findings, in agreement with the US studies, demonstrate the high healthcare cost burden of firearm injuries, in proportion to much larger scale of research. It is also showing high impact on young population by firearms.