[Aspects relevant for abdominal surgery of attempted suicide]

In this retrospective study of 24 patients who were treated at our clinic during the last 22 years after having attempted suicide, we evaluated aspects concerning abdominal- and transplantation surgery. There was a predominance of "hard" (70%) versus "soft" (30%) methods for suicide attempt. Intra-abdominal injuries resulting from attempted suicide by stabbing or shooting should lead to laparotomy-the prognosis is then good. Surgical treatment after intoxication, especially caustic ingestion, depends on endoscopic and clinical findings. The highly increased rates of suicide in patients with end-stage renal disease can be reduced significantly by kidney transplantation. The risk of suicide after transplantation is further diminished with improved immunosuppressive treatment. Only in a few cases there is an indication for liver transplantation-in some cases of fulminant hepatic failure caused by self-administered paracetamol overdose. Auxiliary liver transplantation may then be considered.

After the shooting stops: follow-up on victims of an assault rifle attack

OBJECTIVE

To determine long-term medical, social, and psychological outcome of survivors of a multiple-shooting mass casualty disaster.

DESIGN

A case-study review was performed 42 months after injury involving chart reviews and patient interviews.

PARTICIPANTS

Survivors of a multiple shooting.

MAIN OUTCOME MEASURES

The need for primary operative treatment, subsequent operations, and medical treatment related to the injuries, current work status, and psychological impact of injury was determined.

RESULTS

Thirteen patients required operation initially; 12 are long-term survivors. Eight have returned to work. Most of the victims reported experiencing psychological and emotional problems.

CONCLUSIONS

Despite a well-functioning trauma system that maximized survival from devastating injury, considerable long-term morbidity and disability persists. Efforts at prevention of mass casualties seem to be the only potential solution.

Challenges in patient and family care following an unsuccessful suicide attempt

According to the dictionary, challenge is a stimulating or interesting task or problem. But neuroscience nurses can offer a more comprehensive definition, especially in the context of caring for a patient and their family after an unsuccessful suicide attempt. This situation stimulates our thinking about why individuals try to take their lives, how suicide is attempted and what we, as nurses, can do to turn a hopeless situation into one of hope.

A firearm safety program for children: they just can't say no

The purpose of this study was to compare children's play and aggressive behavior with firearms before and after an information-based intervention. Correlates of aggression and gun play were also analyzed. Subjects were 24 pairs of preschool children videotaped for 10 minutes in a structured play setting, in which they had access to a variety of toys and to real and toy guns. One child from each dyad was then exposed to an information-based intervention and told not to play with guns. The children were again videotaped in the same setting approximately 1 week later. Results indicated that the intervention was ineffective in modifying the behavior of the children. Regression analyses revealed that access to a parent's firearm was correlated with gun play and that gun play and handling of firearms in the home were correlated with aggressive behavior. The findings in this study represent the first systematic attempt to decrease gun play in children and suggest that information provision alone is an insufficient intervention.

Sociodemographic predictors of firearm suicide among older white males

Compared to women, younger males, and other racial/ethnic groups in the United States, white males 65 and over have the highest suicide rates. Using the Mortality Detail Files (1989-1991), this study examined the sociodemographic factors associated with late life firearm (vs other methods) suicide among white males. White males aged 65-84 residing in nonmetropolitan areas who were married, divorced, or widowed and with less than a high school education were significantly more likely to have killed themselves with a firearm than with other methods. Policy initiatives and community interventions should incorporate knowledge of those demographic subgroups most at risk for firearm suicide.

Dissociable contributions of the two cerebral hemispheres to judgments of line orientation

A previous study of the performance of men with chronic unilateral focal brain lesions (due to wartime missile injury) on a standard test of line orientation suggested a left hemisphere (LH) as well as a right hemisphere (RH) contribution to visuospatial processing. The present study was designed to fractionate the variables that could underlie this unexpected finding and thereby to tease out the mechanisms involved in LH as compared with RH processing. A simpler ("purer") version of the standard line orientation task was used, as were two other versions in which matching in an array and matching with distractors were measured. The findings confirmed the hypothesis of RH involvement in the purer task of metric measurement and suggested that the LH has an important role in keeping track decisions and updating decisions in more complex aspects of line orientation judgment.

Jumping the gun: firearms and the mental health of Australians

OBJECTIVES

The aims of this study were to (i) survey mental health-related correlates of firearms ownership and availability in Australia, and (ii) assess possible causal relationships between civilian gun deaths, gun availability and mental disorders.

METHOD

Available data regarding firearms ownership, injuries and deaths were reviewed as well as studies of (i) gun ownership, suicide and homicide, and (ii) gun control laws and suicide.

RESULTS

Findings indicated that 85% of firearm deaths are triggered by distress, as opposed to crime. Most firearm homicides are intrafamilial or involve familiar persons. Firearm suicide rates, although tapering off in recent years, continue to rise among certain groups. It was also found that: (1) Beyond reasonable doubt, a causal relationship exists between gun ownership and firearm suicides and homicides. The role of method substitution is controversial, but is probably less important among the young. (2) Outside the United States, legislation may be useful in reducing firearm and possibly overall suicide rates. (3) If firearm owners are representative of the community, then 15-20% suffer from a psychiatric disorder at any time. While a modest increase in risk of firearms misuse exists for this group, especially those with a history of substance abuse or violence, concern also arises regarding those with mental disorders who access firearms because owners have not secured them. No uniform definition or way of verifying self-reports exists for gun licence applicants regarding these issues.

CONCLUSIONS

Further regulation of firearm safety and availability is warranted. Public health measures include improved surveillance regarding firearm events, advocacy for appropriate firearm legislation, and better education and communication about firearms.

Use of ECT after brain injury

Electroconvulsive therapy (ECT) was administered to a man with a history of a gunshot wound to the head with persisting skull defect and intracranial metallic foreign bodies. It appears that ECT is a safe and effective treatment for depression in this setting. Electrode placement is selected to avoid the skull defect and anticonvulsant therapy may be continued if the patient was previously receiving it.

Defensive and affective-emotional reactions to war: the Abkhazian war as reflected in people's subjective reactions

Differences in defensive and affective-emotional reactions of 108 male Georgian subjects who had been confronted with the consequences of the Abkhazian war in different ways (nonwounded soldiers, wounded soldiers, and civilian controls) were significant between groups on all defense scales and four of the 12 Gottschalk-Gleser scales. The results are discussed from a perspective with war forming for all three groups an important life event which differentially determined their psychological reactions.

Managing elder suicide: a profile of American and Canadian Crisis Prevention Centers

Suicides among older adults in the United States and Canada in the last decade have accounted for an increasing share of all suicides. In both countries the use of firearms among older adults has steadily increased. Despite these trends, little is known about the extent to which crisis centers are prepared to prevent elder suicide. A survey of AAS-listed crisis prevention centers examined the training, knowledge, and current practices relevant to elder suicide among personnel in 321 crisis prevention centers in both countries. Results revealed insufficient training, a lack of familiarity with recent suicide trends, and limited outreach to older adults.

Youth suicide trends in California: an examination of immigrant and ethnic group risk

Although immigrants are in better health than the U.S.-born population according to a variety of indicators, little research has investigated current foreign-born/U.S.-born differentials in suicide. A review of 32,928 California death certificates from 1970 to 1992 indicates that although foreign-born persons are consistently underrepresented in the suicide deaths of 15- to 34-year-olds (risk ratio = 0.60), any foreign-versus U.S.-born difference by ethnicity appears to be decreasing. Specifically, although Hispanics born outside the United States consistently are at significantly lower risk of suicide than U.S.-born Hispanics, the discrepancy between the two groups has diminished over time. And, in a comparable trend, non-Hispanic white persons born outside the United States were at higher risk of suicide than their U.S.-born counterparts until 1990, when their risk became similar. Black and Asian/other foreign- and U.S.-born persons have been at statistically similar risk since 1970. A man using a firearm at home was the typical pattern for both the foreign- and U.S.-born.

[The mental health of surgical patients with combat wounds]

Under analysis were results of examination of 119 servicemen who had got wounds of different degree during military operations. The authors come to a conclusion that mental disorders are a component in semiology of traumatic disease in the wounded. Clinical manifestations were found to correlate with the view of the injuring factor, localization, degree of the injuries combination as well as with specific personal reactions to stress.

Morbidity and injury recurrence in victims of firearm injuries

Civilian violence has become an increasing problem in the industrial world. Gunshot wounds, fatal or non-fatal, are often considered as acute trauma episodes. However, our previous study, based on 820 firearm injuries, showed that this group of patients was characterized by a high mortality rate and a pronounced involvement in criminality when compared to a control group. The aim of this study was to determine the general morbidity in the same group of firearm victims. Our hypotheses were that these patients consume a considerable amount of hospital care due to recurring trauma episodes and that their general morbidity is raised. Information was collected concerning all episodes of in-patient care for victims of firearm injuries from 1972-1992 in Stockholm, Sweden. The victims were compared with a sex- and age-matched control group. During the study period, 69.9% of the 820 firearm victims were treated for other reasons than gunshot injuries, compared to 45.5% of the 820 controls. The former group was hospitalized 3,703 times and the latter on 1,512 occasions. The firearm injury group showed an higher morbidity in almost all diagnostic subgroups according to ICD-9. The trauma recurrence rate was high and suicide, homicide and assault were relatively more common in this group. We suggest that the gunshot episode may be regarded as one expression of a "chronic trauma syndrome'. Patients exhibiting this "syndrome' are characterized by recurrent episodes of trauma, a risk-taking and destructive behavior, high morbidity and mortality as well as anti-social traits. Medical, social and legal complications are common making these patients extremely costly for society and their identification a matter of concern. It is probable that this "syndrome' also exists in other groups of trauma patients. Since hospitalization affords a unique opportunity of reaching patients who have a "chronic trauma syndrome' risk profile, we believe, that these patients should not only be treated for their acute injuries, but that they should be offered help in order to change their destructive life-style. Research should be undertaken to evaluate whether an intervention program, such as counseling, could have an effect on morbidity and injury recurrence for these patients.

Penetrating injuries in the Vietnam war. Traumatic unconsciousness, epilepsy, and psychosocial outcome

The WF Caveness Vietnam Head Injury Study includes over a thousand men who survived penetrating head injuries during the Vietnam War and on whom detailed medical and follow-up data are available. This population offers unique opportunities for the study of recovery from brain injury and of brain structure-function relationships. The authors briefly review long-term outcome in this cohort with respect to traumatic unconsciousness, post-traumatic epilepsy, and elements of psychologic and psychosocial function, including returning to work.

Comparing neuropsychological and psychiatric evaluation of competency in rehabilitation: a case example

This report describes the case of a 20-year-old man who sustained a gunshot wound to the forehead, resulting in traumatic brain injury and C2 ventilator-dependent quadriplegia. Issues of personal control and autonomy typified his psychological adjustment. The question of competency to refuse medical treatment arose when he disallowed intervention for a suspected ear infection not confirmed by culture. Subsequently, the patient was alternately described as incompetent by a psychiatrist and competent by a medical ethics review panel. These decisions are interpreted within the context of existing medical-legal literature and historical precedent of competency in civil law. Central to competency evaluation is the patient's ability to recognize that a decision-making process is required, to review the pros and cons of various options, and to communicate a decision. Importantly, this decision need not be in accordance with the opinion of family or the health care team. Neuropsychological screening indicated the patient's cognitive abilities were within functional limits, and he subsequently agreed to treatment after experiencing pain and fever, and learning of a positive culture. It is concluded that a two-pronged neuropsychological evaluation of competency based on the patient's information processing capabilities is most appropriate in medical rehabilitation settings.

Treatment of coexisting substance dependence and posttramatic stress disorder

This paper describes the treatment of a physician who developed posttraumatic stress disorder (PTSD) and a polysubstance use disorder after he was shot and held hostage by a patient. Inpatient treatment combined pharmacological and behavioral approaches, including systematic re-exposure via talking about the event in therapy groups. Standard methods for achieving and maintaining abstinence were used, such as asking for and accepting peer support and discussing painful feelings. Cognitive aspects of treatment included education about interactions between the two conditions. After 12 weeks the physician was free of symptoms and had minimal anxiety when exposed to salient cues of the traumatic event.

Verbal learning and memory impairment in adult civilians following penetrating missile wounds

Verbal memory and learning patterns, as measured by the California Verbal Learning Test (CVLT), following penetrating head injury (PHI) from gunshot wound were studied in 10 acutely injured patients (mean age 25.3 years) at a mean of 2.1 months post-injury. Primary impairment was found on measures of free recall of new verbal information which appeared to be related to deficits in organisational and retrieval functions: (1) the group's learning characteristics were marked by disorganization and an underutilization of active learning strategies; (2) rate of acquisition also appeared to be mildly decreased; (3) nevertheless, the PHI group did not show severe disruption in all aspects of learning and memory. In fact, the group showed a relatively intact capacity to store new information in memory.

Community re-entry of long-term institutionalized brain-injured persons

Although evidence exists for delayed recovery after traumatic brain injury, patients who do not receive rehabilitation early after their injuries often remain permanently in long-term care facilities. Case reports of five severely brain-injured persons who were discharged into long-term nursing care facilities for at least 1 year before initial rehabilitation admission are discussed. After prescreening for evidence of functional improvement, these patients were admitted to a rehabilitation unit with the goal of community discharge. Functional improvement was evaluated using the Functional Independence Measure (FIM) and additional categories of function. Community discharge was successfully achieved in all five patients, who demonstrated particular improvement in bathing, transfers, memory, bowel management, problem solving and independence during waking hours. Further efforts should be made to identify patients in long-term care facilities who might benefit from rehabilitation services, and to identify those factors which contribute to successful community discharge.

Prior nonfatal firearm injuries in detainees of a large urban jail

Detainees of large urban jails have may health risks including injuries related to violence and firearms. A survey of 582 randomly selected detainees entering the Cook County Department of Corrections during the summer of 1994 found that 51 percent had previously entered hospitals for violence-related injuries, and 26 percent survived prior gunshot wounds. Patterns of firearm injuries were different from patterns of violence affecting the general population. Factors common to those with prior firearm injuries included witnessing a shooting at an early age, tattoos, previous sexually transmitted diseases, easy access to a semiautomatic weapon, and prior incarceration. Implications and prevention strategies are discussed.

[Are there predictors for impulsive, homicidal-suicidal acts of violence]

Patient's statements or fears that they may "go crazy" and harm themselves or persons around them are rare, but extremely difficult for all participants to deal with. On the basis of the existing, unsatisfactory literature as well as an analysis of 196 incidents of homicidal-suicidal violence designated by German media as "running amok" and fulfilling defined criteria, we examined whether or not there are predictors for the degree of potential danger inherent in such threats. Impulsive, homicidal-suicidal acts of violence among patients with psychiatric disorders often occur in environments characterised by chronic psychosocial estrangement and isolation. Extremely distressing situations may trigger the course of violence, but the actual act is often planned during a seemingly peaceful interval. Personalities with a high affinity to weapons and a tendency toward acting out seem to increase the potential risks. Such events should be treated analogous to suicidal crises, with a strategy that takes the individual disorder into consideration. The parameters investigated in this paper are not sufficient, even in different combinations, to offer a satisfactory explanation or predict the occurrence of this extremely rare behaviour; further research is necessary.

A shooting incident in an elementary school: effects of worker stress on public safety, mental health, and medical personnel

The effects of impact of event and five categories of worker stress were studied with 140 police, fire, medical, and mental health personnel who were involved in emergency service work following a shooting in an elementary school. A questionnaire distributed 6 months after the incident was utilized. Public safety personnel reported a recollection of significantly fewer intrusive thoughts than medical and mental health professionals immediately following the incident. Groups did not differ in intrusive or avoidance scores on the Impact of Event Scale 6 months after the event and all groups showed a significant decrease in both scores over time. Stepwise linear regression showed that a self-reported qualitatively heavy work load predicted intrusiveness and avoidance of thoughts both immediately after and at the 6-month anniversary of the incident. Additionally, time pressure and quantitatively heavy work load also predicted avoidance score at the time of the incident. Results are discussed in terms of control models of anxiety and as foci for debriefing with affected personnel.