INTRODUCTION

Background

Military medical personnel must be well-versed in the management of gunshot injuries, as such cases can arise at any time in various military contexts. While numerous reports have detailed injuries caused by live ammunition, knowledge regarding the effects of blank cartridge shots (BCS) is limited [1–3]. Research has indicated that BCS can cause a spectrum of injuries, from superficial to potentially fatal [4–6]. However, in the South Korean military context, understanding is limited due to the small number of cases and the variability in factors such as patient demographics, the types of firearms used, and the nuances of the country’s medical system, all of which can influence the outcomes of BCS incidents.

In 2022, a total of 93 deaths occurred within the South Korean military, 70 of which were attributed to suicide [7]. Within this organization, injuries resulting from BCS have also predominantly occurred due to suicide attempts. Thus, affected individuals require comprehensive care that includes both physical treatment by trauma teams and emotional support from psychiatrists.

Objectives

In April 2022, South Korea opened its first military trauma center, dedicated to providing specialized treatment for service members with serious injuries. The purpose of this study was to document a series of cases involving patients who sustained injuries from BCS during suicide attempts within the South Korean military after this center was established.

METHODS

Ethics statement

The study was approved by the Institutional Review Board of Armed Forces Capital Hospital (No. AFCH 2024-05-001). The requirement for informed consent was waived due to the retrospective nature of the study.

Gun and blank cartridge involved

The K2 assault rifle is the standard service rifle used by the South Korean military. It is chambered for the 5.56×45-mm NATO (North Atlantic Treaty Organization) blank cartridge, specifically employing the M200 variant. This cartridge features a crimped design sealed with violet lacquer (Fig. 1).

Study design and patients

From April 2022 to April 2024, four patients in the South Korean military sustained injuries from BCS trauma due to suicide attempts. These individuals received treatment at a military trauma center that was established in April 2022. A retrospective analysis was performed by examining the patients’ medical records. Information was collected regarding their general characteristics, such as sex, age, injury site, surgical intervention if required, length of hospitalization prior to transfer to the psychiatry department, duration of psychiatric management, and treatment outcomes.

RESULTS

Table 1 presents the general characteristics of the patients. All were male, with a mean age of 20.8±0.87 years (range, 19–20 years), and were conscripted soldiers. Each patient had sustained injuries from attempted suicide during the study period. No instances of BCS injury resulted from other causes. Four patients were airlifted to the trauma center by a military helicopter directly from the scene of the incident, while one patient (case 4) was transported by military ambulance due to inclement weather. Upon arrival at the emergency room, all patients exhibited stable vital signs and were alert, with no abnormal laboratory findings (Table 2). Most injuries were to the submandibular area (Fig. 2), except for case 2, which involved the temporal area (Fig. 3). Computed tomography (CT) scans were performed to confirm injuries caused by projectile gas and gunpowder (Figs. 2, 3).

Both cases 1 and 2 necessitated emergency surgery. The patient in case 1 underwent a surgical procedure to evaluate major structural injuries and to remove foreign bodies, including gunpowder. Case 2 involved surgery to treat tissues with burn injuries and to remove foreign bodies such as soot and gunpowder. Cases 3, 4, and 5 were managed consecutively without surgical intervention.

The average length of hospitalization was 35.2±12.11 days. Initially, patients were admitted to the trauma surgery department for the management of injuries sustained from BCS. They were later transferred to the psychiatry department to address any emotional issues. One patient vehemently opposed transfer to the psychiatric isolation ward and was consequently managed in the trauma surgery ward, with regular consultations from psychiatric specialists. The average duration of hospitalization was 15.6±15.87 days in the trauma surgery department and 19.6±14.99 days in the psychiatric ward.

DISCUSSION

Characteristics of individuals who attempt suicide using firearms

Individuals attempting suicide by gunshot often seek a swift, painless, and certain death. Consequently, they typically aim for the heart, head, and oral cavity. In cases involving head injuries, the temporal area—particularly the pterion—is commonly targeted. When rifles are used, the submandibular area and forehead are frequent points of impact. Wounds from gunshot injuries are usually the result of close-range shots (contact or near contact), based on the shooting distance. Shooters often assume a stable position to minimize discomfort [8]. BCS resulting from suicide attempts exhibit similar features. In this study, all patients sustained wounds caused by close-range rifle shots. Among these cases, four patients had submandibular injuries, while the remaining individual sustained a temporal injury.

Transportation of patients

In South Korea, a variety of options are available to transport patients injured in the military to a hospital. These include military helicopters, public helicopters, military ambulances, and public ambulances [9]. Patients with BCS injuries receive the same expedited transfer care as those with live ammunition gunshot wounds. Helicopters are the preferred mode of transport when weather conditions permit.

Clinical features and treatment

The severity of injuries caused by BCS varies depending on the site of injury. Oral cavity injuries from BCS, which are frequently inflicted during suicide attempts with firearms, can have serious consequences. In one instance, a patient who sustained a BCS injury to the oral cavity using a K2 rifle necessitated immediate intubation to secure an airway due to profuse bleeding [10]. A tracheostomy was subsequently performed to facilitate further examination and treatment of the oral cavity. The patient had sustained a severe injury to the soft palate and underwent emergency surgery to manage the hemorrhage. During recovery, the patient was required to retain the tracheostomy tube.

A blank cartridge is designed to simulate gunfire and produce a gas flare without discharging a bullet. Nevertheless, the propellant gases and gunpowder from these cartridges can still cause bodily harm [4]. Subcutaneous emphysema in the face and neck may indicate injuries to the airway, oropharynx, or esophagus. In cases of blunt trauma or penetrating stab wounds, clinicians should promptly consider the need for emergency exploration [11]. Notably, however, the propellant gases from BCS can cause subcutaneous emphysema without inflicting other significant structural injury [6]. Caution is advised against overestimation of injuries. When considering exploratory procedures, careful decision-making is crucial to avoid unnecessary interventions that could cause harm. Conversely, underestimation also poses serious risks. Although external wounds from shootings may appear similar, the extent of internal injuries can differ greatly from case to case. If the patient’s vital signs are stable, further diagnostic tests, especially CT scans, are recommended [12,13]. For patients presenting without critical signs or abnormal imaging findings, close observation is typically adequate. Additionally, due to the potential for infection from gunpowder and small fragments, prophylactic antibiotics and close monitoring are necessary [6]. Criteria for the removal of residual foreign bodies include the following [14]: (1) proximity to the airway or gastrointestinal tract; (2) location within vital organs such as the eyeball, central nervous system, or heart; and (3) size exceeding 15 mm if located in the thorax or abdominal cavity. Clinicians should also carefully monitor patients for signs of lead poisoning, although cases resulting from retained bullets are rarely reported [14,15].

Psychiatric management

Suicide represents the leading cause of death in the South Korean military, comprising 44.9% of all fatalities. In comparison, diseases and accidents account for 36.7% and 18.4% of deaths, respectively [7]. Many psychiatrists contend that all individuals who have attempted suicide should be admitted to a psychiatric facility, regardless of the method used [16]. We propose that the psychiatry department at this military hospital should specialize in treating military-related psychiatric disorders, including suicide attempts, and offer care for psychiatric inpatients within the military context.

Strengths and limitations

This study appears unique in its focus on BCS injuries resulting from suicide attempts in the South Korean military. However, our report of five cases may not sufficiently illustrate the full spectrum of BCS injuries.

Conclusions

This study highlights the consequences of BCS resulting from suicide attempts within the South Korean military, offering crucial insights for medical personnel who may encounter patients with BCS injuries.

ARTICLE INFORMATION

Author contributions

Conceptualization: JIJ, KL; Data curation: all authors; Formal analysis: all authors; Investigation: KL; Methodology: JIJ, KL; Project administration: KL; Visualization: KL; Writing–original draft: all authors; Writing–review & editing: all authors. All authors read and approved the final manuscript.

Conflicts of interest

The authors have no conflicts of interest to declare.

Funding

The authors received no financial support for this study.

Data availability

Data analyzed in this study are available from the corresponding author upon reasonable request.

Fig. 1.

(A) A K2 rifle. (B) Live ammunition (5.56 mm, KM193) and blank cartridge (5.56 mm, KM200). The bullet is indicated with a circle. Provided by the Armed Forces Capital Hospital (Seongnam, Korea), with permission for reproduction.

Fig. 2.

Submandibular injuries resulting from a blank cartridge shot. (A–D) External wounds. Computed tomography scans showing (E–H) the external wound and gunpowder (circles) and (I–K) the subcutaneous emphysema. (A, E, I) Case 1. (B, F, J) Case 3. (C, G, K) Case 4. (D, H) Case 5.

Fig. 3.

Right temporal injury resulting from a blank cartridge shot (case 2). The wound was superficial without bone and brain injuries. (A) External wound. (B) Computed tomography scan.

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Figure & Data

References

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