Socioeconomic aspects of stab and gunshot wounds

ORIGINAL CONTRIBUTION

Socioeconomic Aspects of Stab and Gunshot Wounds R. Edward Wase, Jr, MD Harold F. Hamit, MD Charlotte, North Carofina

Records of 294 patients with gunshot, stab, or shotgun wounds admitted to Charlotte Memorial Hospital and Medical Center between July 1, 1976 and June 30, 1977 were reviewed. Data were gathered on 24 clinical, social, and economic aspects to discover any patterns in these areas. Eighty-three percent of the patients were male; 71%, black; 70%, unmarried; and 56%, between 16 and 30 years of age. Fifty-five percent came to the hospital between 10 pm and 3 am; 57% on Friday, Saturday, or Sunday; 31% came in June, July, or August. Sixtyfour percent were gunshot wounds, 80% of which were by small caliber weapons.Ninety-four percent of all patients survived. The patients "consumed" 3,260 hospital days, 526 intensive care unit days, 533 units of blood, and 261 operations, totaling 595 hours of operating room time. Hospital charges totaled $668,000, of which 1.1% was paid from private funds and nearly 65% from the taxpayers and other private paying patients. Wase RE Jr, Hamit HF: Socioeconomic aspects of stab and gunshot wounds. JACEP 8:353-356, September 1979.

injury, gunshot; stabbing; socioeconomic factors, gunshot, stabbing

INTRODUCTION A socioeconomic profile of victims of gunshot, stab or shotgun wounds is of interest to emergency department personnel, the medical profession as a group, legislative and law enforcement agencies~ sociologists, and especially to the taxpayers, who involuntarily subsidize the cost of treatment. For this reason we undertook a study of 294 patients who sustained such wounds. These statistics are compared with a study by Jett et al of 254 similar injuries at Charlotte Memorial Hospital and Medical Center in 1969.1 MATERIALS AND METHODS The clinical records of all inpatients treated for gunshot, stab or shotgun wounds from July 1, 1976 to June 30, 1977 were reviewed. Two hundred ninetyfour charts were studied, with data gathered in 24 areas: age, sex, race, marital status, date of admission, day of week, week of month, time of day, type of injury (weapon used), site of injury, discharge status (alive or dead), major operations, minor operations, operating room time, units of blood, hospital days, intensive care unit (ICU) days, hospital charges, amount paid, source of payment, admitting service, alcohol or drug involvement, nature of incident (accidental, suicide, altercation, alleged crime involved), and any previous or later hospital visits for these injuries. Most demographic and financial data on inpatients is stored on computer records, and patients were selected from these computer records by From the Department of Emergency Medicine, C-CharlotteMemorial Hospital, Charlotte, North Carolina. Address for reprints: R. Edward Wase, Jr, MD, Charlotte Memorial Hospital, Box 32861, Charlotte, North Carolina 28232. 8:9 (September) 1979

JACEP

353/21

diagnosis (primary or secondary) of gunshot, stab or shotgun wounds. Clinical review and data gathering was accomplished manually. Outpatient records were not computerized and manual review of 80,000 emergency department visits was impossible. Thus those t r e a t e d .and released, or those DOA or expired in the emergency department are not included in this study.

40. PATIENT~ 32

301--20i

13

13 1 3 ~

~

3

RESULTS

Eight-three percent of the patients were male. T h i r t y percent were married (Table 1). Fifty-six percent of the patients were between 16 and 30 years of age (Figure 1). The population of Charlotte is approximately 75% white and 25% nonwhite (telephone conversation, Charlotte Chamber of Commerce). The patients in our study were 71% black and .28% white and, therefore, significantly different from the general population• Gunshot wounds ac-

Percent

245 49

83 17

~ 133 88 44 21 7

45 30 15 7 2

Male Female Single Married Separated Divorced Widowed

t t ! , I I I I i I= I I I I I I I /

60 PATIENTS

59 45

] | i

[ i

Fig. 2. Distribution of patients by time of day. counted for 64% of the injuries, while 32% were admitted for stab wounds and 5% for shotgun wounds. Thirtynine weapons were documented for caliber in the charts, and 80% of these were .22 and .32 caliber. Of the stab wounds, two were by ice pick, one by butcher knife, one by razor, and the r e m a i n d e r unclear in the charts. Two h u n d r e d seventy-six (94%) patients were discharged alive, while 18 (6%) died. Of those with fatal injuries, five had abdominal gunshot wounds, one had an abdominal stab wound, two received g u n s h o t wounds to the chest, two h a d stab wounds to the chest, one a shotgun wound to

Table 1 SEX A N D M A R I T A L STATUS n = 294 No

Oil

58

the chest, and one a shotgun wound to the abdomen. Five patients with gunshot wounds of the head died, and one p a t i e n t with g u n s h o t wounds to the chest and abdomen died. This is in contrast to Jett's findings 1 in 1969 of head injuries in 8 of 11 fatalities, and a total survival rate of 95.5%. Time and Date of Admission

The exact time and date of admission were recorded by time clock on all charts. Fifty-five percent arrived at the hospital between 10 pm and 3 am (Figure 2). Seventeen percent of the emergency department's average daily census (all visits) for June 1977 were between 10 pm and 3 am. Over 57% came on Friday, Saturday, and Sunday (Table 2). Approximately 30% were admitted during June, July, and August (Table 3).

49

3"/

Table 2 CENSUS BY DAY OF WEEK n -- 294

34

15

Age:Un~15 16-20 21-25 26-30 31-35 36-40

41-45 46-50 51-55 56"60 Over60

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

No

Percent

32 25 38 32 49 76 42

1i 8 13 11 17 26 14

Fig. 1. Distribution of patients by age. 22/354

JACEP

8:9 (September) 1979

Table 5 A D M I T T I N G SERVICES n = 294

Table 3 C E N S U S BY M O N T H OF Y E A R n = 294

No

July August September October November December Jan uary February March April May June

31 31 17 32 17 24 23 11 25 26 25 32

Percent

10 10 6 11 6 8 8 4 8 9 8 11

Table 4 L O C A T I O N O F INJURY n = 294

Abdomen Chest Extremities Head Neck Back Face Genitals Rectum

No

Percent

82 77 77 27 14 12 9 3 1

28 26 26 9 5 4 3 1 <1

Housestaff general surgery Thoracic and vascular surgery Orthopedics Neurosurgery Private general surgery Plastic surgery Urology Ear nose throat Ophthalmology Psychiatry

g u n s h o t wounds, stab wounds, or shotgun wounds for 76 of the 294 patients. Previous or subsequent incidents and complications of the wounds in this study were counted. Visits to neighboring hospitals were not studied. The first week of each month accounted for only 22% (the last week only 24%), indicating that "welfare weekend" (welfare checks were dist r i b u t e d the first week of each month) had no higher proportion t h a n statistically expected. There were 13 full moons during the 12 m o n t h s of our study (3.6% of the total days) and 12 patients were admitted on those dates (4.1% of total patients). Therefore we could not support the allegation that the full moon influenced an increase in these incidents.

Location of Injuries The chest and abdomen were most commonly involved and several patients were injured at several sites (Table 4).

Use of Hospital Facilities and Resources

The 294 patients spent a total of 3,260 days in the hospital (averaging

Admitting Services

The services admitting from the emergency d e p a r t m e n t were most often general and thoracic surgery. Two p a t i e n t s were a d m i t t e d to psychiatry after minor self-inflicted stab wounds (Table 5).

Private Funds

Social Aspects

The nature of the incident was documented in 124 patients: altercation, 76 (61%); suicide, 19 (15%); accident, 16 (13%); and crime in progress, 13 (10%). One hundred ten patients (37%) were noted to be intoxicated, and six more had drug use documented. Medical record review revealed an additional 114 visits to this hospital for 8:9 (September) 1979

No

Percent

106 72 55 35 8 7 4 3 2 2

36 24 19 12 3 2 1 1 1 1

11.1 days per patient). Of these, 131 patients spent 526 days in the intensive care unit (averaging four days per patient), ranging from 1 to 100 days. Two h u n d r e d t w e n t y - f o u r patients underwent surgery, 215 major procedures and 46 minor, with a total o p e r a t i n g room time of 595 hours. A total of 533 units of blood were given to 97 patients (averaging 5.5 units per patient). The patients in Jett's study z spent 3,090 days in the hospital (12.5 per patient), 331 days in ICU (average 2.6 per patient), and had 433.5 hours of operating room time. Cost of Hospital Care

Hospital charges, including room charges, laboratory, pharmacy, blood bank and operating room charges and excluding professional fees for private patients, totaled $667,922, a v e r a g i n g $2,272 per p a t i e n t and r a n g i n g from $199 to $30,775. In

~

S

Insurance Balances

Fig. 3. Sources of payment of hospital charges.

JACEP

355/23

contrast, the hospital costs totaled $265,816 in the 1969 study. 1 The injured patients paid only 1.1% of these costs from private funds (paid by cash, check or credit card), while g o v e r n m e n t sources (Medicare, Medicaid, Mecklenburg County) paid 31% (Figure 3). Third party insurance paid 33.3%. Unpaid balances out on a trial basis account for 18% and may be found uncollectable, while 16% has already been written off as bad debts. As in Jett's study, 1 paying patients of the hospital, who help assume the hospital's bad debts, and taxpayers appear to have borne the financial burden of about two thirds of the hospital expenses of these 294 patients. Combined with those who purchase health insurance, they will probably subsidize more than 90% of the hospital costs for these injuries, depending on accounts outstanding on a trial basis that may be paid.

DISCUSSION The c h a r a c t e r i s t i c victim of these injuries was a nonwhite male between 16 and 30 years old who came to the emergency department between 10 pm and 3 am on Friday, S a t u r d a y or S u n d a y , f r e q u e n t l y under the influence of alcohol or

24/356

drugs. Most of these patients were unable or unwilling to pay the cost of their treatment. While some were non-participating bystanders or innocent victims of c i r c u m s t a n c e s beyond their control, the majority of injuries apparently were not accidental, and many were not the first such injury for these patients. The number of patients, cost of care, and m o r t a l i t y r a t e has increased in this community compared with figures from 1969, with hospital costs alone up more than 100%. Obviously, t h e r e are n u m e r o u s and complex factors involved in these patterns of behavior, including the ready availability of weapons and the acceptability of violence to terminate differences of opinion. Factors not studied here include population changes, unemployment rates, and general incidence of alcohol and drug abuse. Only the initial costs of the medical care for these patients are presented in our paper. The possibly far g r e a t e r costs to society are, for example: follow-up medical costs, law enforcement, legal costs (taxpayers support prosecution, defense, and judges in many cases), prison facilities, loss of income, and loss of potential working force.

JACEP

CONCLUSION In these times of emphasis on preventive medicine and the control of medical costs, it appears that we desperately need assistance and attention from police, lawmakers, and sociologists in combating these apparently preventable illnesses of patients and of society in general. To date, society has been unable or unwilling to p6~trol the factors generating these problems and behaviors, not only in this c o m m u n i t y , but perhaps throughout the country. Our statistics reveal the incidence of injuries from stabbings, g u n s h o t wounds, and s h o t g u n wounds to be increasing compared to figures from 1969.1 We do not offer any conclusions or answers to the complex factors and sociological questions involved, but hope that this study will encourage those with expertise to seek effective solutions. The authors thank Ms. Ann McNeely for her assistance in chart reviews and preparation of this manuscript.

REFERENCES 1. Jett HH, Van Hoy JM, Hamit HF: Clinical and socioeconomicaspects of 254 admissions for stab and gunshot wounds. J Trauma 12:577-580, !972.

8:9 (September) 1979