On my first trauma shift as a fourth-year medical student, a young, disheveled man with blood-soaked pants hobbled into the emergency department. Wincing in pain, he offered me a bizarre history of being shot in the leg by a nail gun that went off after he dropped it on some stairs while helping a friend move. He lifted his right pant leg and removed the bloody, tattered bandana wrapped around his lower leg to reveal a pea-sized hole in his shin.
After giving the patient some pain medications and briefly examining his wound with my attending, we sent him to radiology to determine the location of the nail and assess the damage it had caused in its trajectory through his leg. His X-ray, however, did not show a nail, but rather a bullet which had somewhat miraculously passed through the interosseous space between his tibia and fibula before coming to rest just under the skin overlying his calf.
Back at the bedside, my attending gently pointed out the discrepancy. “You can tell the difference from an X-ray?” our patient asked, looking both surprised and alarmed. Before we had a chance to answer, the young man sprang up in his hospital bed and defiantly stated, “If I have to talk to a social worker about this, I’ll just leave right now!”
Despite his naivety regarding the capabilities of modern X-ray technology, our patient was well aware that, by Washington State law, we were obligated to report his gunshot wound to local law enforcement, and that our social work team would be the ones to gather and provide the relevant information to the police. Our patient made it clear that if this was to be the case, he was fully intent on leaving the hospital against medical advice with a dirty, untreated gunshot wound rather than getting involved with the cops.
Fortunately, after much reassurance and a fair degree of diplomacy, we were able to convince our patient to stay and let us clean out his wound on condition that, although we would ultimately need to report his case to the authorities, we promised not to do so until after his immediate medical needs were attended to. After controlling his pain, we washed out, evaluated, and bandaged up the hole in his leg. We provided him with a prescription for antibiotics, a couple of days worth of wound care supplies, a cane, and instructions for follow-up. Moments later, he eloped before social work had the opportunity to speak with him.
Laws requiring hospitals to report gunshot wounds and provide the victim’s identifying information to law enforcement authorities are intended to aid in the investigation of violent crimes, protect victims and the public at large from perpetrators of such crimes and facilitate surveillance of gun-related violence — which itself constitutes a major public health problem in this country.
However, as illustrated by our patient’s bogus nail-gun story and his willingness to leave against medical advice with an untreated bullet hole in his leg, such laws erode trust in patient-physician confidentiality, blur lines between health care and law enforcement, and can deter victims of violence from seeking emergency medical care.
I can only speculate as to why our patient did not want to speak with our social worker or have his shooting investigated by the police, as he refused to discuss the matter further. He did share with me that he was homeless, regularly used heroin and admitted to shooting up just before coming to the hospital in an attempt to relieve the excruciating pain in his leg. It’s possible that he was just paranoid about being high in our busy inner-city emergency department where local police officers are a near constant presence. Perhaps he had a warrant for his arrest, was engaged in criminal activity at the time of the shooting, or was fearful of retaliation from the individual who shot him. It is just as likely that he, like many of the patients struggling with homelessness and drug addiction who we serve in our busy safety-net hospital, simply lives in fear of the police, viewing law enforcement as an entity to be avoided at all costs rather than a haven of protection, safety and justice. Again, I can only speculate as this was an issue our patient did not feel comfortable discussing with me or anyone else on his care team.
In the end, while I’m relieved that we were able to address our patient’s most pressing medical needs, I can’t help but ponder how his care might have been improved if we had not been obligated to report his injury to the police in the first place. While mandatory gunshot wound reporting laws may be well-intentioned, it certainly seems that we, as a society, could have better served this young man by not forcing him to weigh his need for urgent medical care against the potential legal ramifications of being treated for a gunshot wound in the emergency department.
Shane Collins is a medical student.
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