Mystery: A bullet with no entry wound, in a paper with no spell check?

“The Patient, a 60-years old Caucasian male found unconscious in a trailer park of gypsies…”

So begins a strange — and apparently not copyedited — new case report in the World Journal of Emergency Surgery. The paper concerns a patient — perhaps we should call him Rasputin — who showed up with a bullet in his left lung but no entry wound that would explain its presence.

Naturally, the authors draw the obvious conclusions:

The possibility of gunshot fired throughout natural orifices, such as anus, should be always taken into account in case of retained bullet without clear entry hole and, more important, the members of the trauma team should always keep in mind that a digital rectal exploration is mandatory in cases of abdominal gunshots wounds with unclear dynamics.

As if the poor gunshot victims haven’t suffered enough — now they may get rectal exams to see if a bullet made its way into their butts?

We’re adopting a somewhat glib tone here because the patient thankfully survived this awful ordeal. And there’s so much to note about this paper, which appears to not have been copyedited. Look no further than the title: “Gunshot wound without entrance hole: where is the trick? – a case report and review of the literaturer.”

There are many holes that a simple edit would have filled in:

Obviously a quite different problem arises when entry and/or exit holes of the bullets are not clearly detectable, as highlighted by the reported singular case of unrecognized gunshot entrance hole, due to the fact that the patient was shot through his anus. To our best knowledge in scientific Literature there is any case of undetected entrance hole due to trans-anal gunshot, even if we found out 2 rare cases of unrecognized gastrointestinal bullet embolism.

And:

The only possible explanation for the trajectory of the bullet was that it was shot through the anus; evidently, after the blow on the head, the patient had fallen face down and the assailant shot him throughout the anus. This interpretation was later confirmed by aggressor interrogation by the Police.

(An aside: We sincerely hope we are never shot “throughout the anus.” It sounds much, much worse than being simply shot in the anus, and even that does not sound like a picnic.)

We asked blogger Skeptical Scalpel (a retired surgeon) to take a look at the paper for us. He told us the author’s “only possible explanation” for what happened seems highly impossible:

In most people, the anus cannot be seen unless the buttocks are spread, and the anus is normally closed unless defecation is in progress. In order for a bullet to have done what the authors describe without injuring the buttocks and the anus itself, the gun’s barrel would have to have been placed directly into the anus.

If the victim had been shot after falling down, a few things would have occurred. Unless he was naked, there would have been bullet holes in his pants and his underwear.

The alleged angle of the bullet’s trajectory does not compute. If the victim was in the prone [face down] position, a bullet entering through the anus would have exited the rectum anteriorly injuring the urinary bladder and probably exiting the skin through the lower anterior abdominal wall.

Otherwise the assailant would had to have fired while prone, and the victim’s legs, and buttocks would had to have been spread. Even if this highly unlikely scenario had occurred, the anus could not have been unscathed.

I do not believe that this patient’s injury could have possibly occurred in the manner described in the case report.

He added that the American College of Surgeons used to recommend digital rectal examinations for all trauma victims, but studies have found it is “almost always useless and is unpleasant for a patient who has already suffered an injury.”

A spokesperson for publisher BioMed Central told us this journal doesn’t perform language editing:

We can confirm the article was peer reviewed. Editorial decisions are made solely based on the quality of the scientific content of the manuscript. If editors and/or referees cannot follow the rationale for, or the experimental design of, a study [they] are free to recommend the use of a language-editing service during the peer review process. BioMed Central journals receive varying levels of copyediting agreed by the journal’s Editor-in-Chief. This particular journal opts to provide formal mark-up without any language editing. It ensures that the manuscript is complete and puts the material in the correct sequence.

We’ve also reached out to first author Silvia Ministrini at University of Brescia in Italy.

Update 11/23/15 1:12 p.m. eastern: We’ve heard again from the BMC spokesperson, who told us the title was the result of a “production error:”

Our Production Team are looking into having this corrected as soon as possible.

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