EXTREMITY GUNSHOT WOUNDS .1. IDENTIFICATION AND TREATMENT OF PATIENTSAT HIGHRISK OF VASCULAR INJURY

Cost containment is important in this time of inner-city economic and health-care crisis. This paper examines patients who were treated for gunshot wounds (GSWs) of the extremities. During the study period 1978 through 1992, 16,316 patients (18,349 extremities) were treated for e xtremity GSWs. Nine patients with asymptomatic injuries in proximity t o vascular structures who were treated before the use of duplex Dopple r ultrasonography (DDU) were later found to have surgically treatable vascular injuries. These were identified and treated onan outpatient b asis with no long-term morbidity or mortality. With the adventof DDU, asymptomatic vascular injuries were no longer missed. A conservative e stimate of the cost savings from this study is more than $47,000,000.0 0. The use of DDU and the enclosed protocols for treating asymptomatic extremity wounds prevented 16,450 needless angiograms, with an additi onal savings of $32,900,000.00, for a total savings of more than $79,9 00,000.00. With a more liberal use of DDU and angiography to eliminate the rare missed vascular injuries (0.09%), and the use of protocols t o analyze patients with asymptomatic injuries, many extremity GSW vict ims (79% in this study) can be safely treated as outpatients, eliminat ing the need for expensive in-hospital observation.