This study describes the epidemiology of firearm injuries managed at the Cayenne General Hospital. This is the first study on the topic in French Guiana and one of the largest cohorts of civilian ballistic trauma victims in France. The population was predominantly young, male, and victim of assaults with a long-barreled gun. The population at risk found in our work but also circumstances are close to those found in the worldwide epidemiology of ballistic trauma [1]. This is all the more interesting given that 51% of the world’s firearm civilian deaths occur in six American countries, including some of French Guiana neighbors.

One of the points of this study was to describe the management of these patients. First of all, pre-hospital care by emergency medical service appears to be lower than in the USA (47% vs. 68%) [19]. Contrary to the Anglo-Saxon paramedics organization, in France, out-of-hospital emergency teams are organized on duty 24/7 and include doctors. For less severe injuries, teams of first rescuers not considered emergency medical service but with basic life support knowledge are mobilized. Regarding surgery, the proportion of surgical managements in our series is twice than in a US cohort study in 2021 [20]. This is probably due to our method including all patients needing emergency surgery compared to other studies excluding patients directly transferred to the emergency surgery room. We also note that the American studies mention a more frequent hospitalization rate (65% vs. 60%) as well as hospitalization in the intensive care unit (31% vs. 12%) [20]. In view of these results, it might seem that our population suffered less severe ballistic trauma than those reported in the literature. However, the mean length of stay in the intensive care unit is four times shorter in the USA (5 days vs. 20 days) than in our study.

Regarding mortality, the intra-hospital mortality rate was 4.8%, lower than in several American countries [1, 20]. The overall mortality (6.3/100,000 inhabitants/year) is significantly lower than results reported in the neighboring countries: 19.4/100,000 in Brazil and 10.6/100,000 in the USA but two to three times higher than the French national rate (2.7/100,000 inhabitants/year) [1]. These rates follow the overall crime rates and gun laws in the different countries. As found in previous works, our study identifies factors associated with an increased risk of death such as male gender or suicide context [1, 21]. In our results, deaths are associated with assaults in 80% and suicides in 11% of cases. Comparatively, in mainland France, suicide is the main cause of firearm-related deaths (79%) and concerns an older population [5]. In the USA, suicide accounts for 60% of firearm deaths [22]. The low suicide rate in our population could explain part of the difference about global mortality.

As described in the work of Maiden in 2009, who studied ballistics in firearm injuries, the study of wound sites and induced injuries finds a major impact on lethality [22]. In our series, head and/or neck and thorax injuries are associated with increased mortality. As found in a previous study, central neurological, respiratory, and vascular injuries are also associated with an increased risk of death [22, 23]. This finding is particularly interesting in terms of assessing the Cayenne Hospital’s technical facilities. Although these lesions can be very damaging and even life-threatening, requiring emergency surgery, stomatology, neurosurgery, and cardiothoracic surgery is under-represented or even absent in French Guiana [24, 25]. Induced mortality could be the direct cause of the absence of these specialties in our territory. In support of this hypothesis, abdominal-pelvic lesions, although frequently reported as fatal in the literature, are not so in our work, our hospital being adequately staffed with digestive surgeons [26].

Several areas for improvement emerge from this work in line to implement research on this topic insufficiently studied [27]. The most important issues accessible to primary prevention are violence and crime control, and gun laws: the population at risk being mainly young male victims of assault. According to Santaella-Tenorio’s study in 2016, gun ownership legislation as well as the number of weapons circulating is correlated with the number of related deaths [28]. Since 2017, the French Guiana Police Commissioner started to regulate the use and possession of firearms [16]. Despite its implementation in 2017, our work did not show a decrease in the number of firearm trauma victims during the study period. The high incidence of deaths from 2017 to 2019 follows the trend of violence and delinquency markers over the same period [12]. However, the continuous monitoring is necessary to evaluate the results of this new regulation in the medium and long term. This observation, as well as multiple proposals to fight violence, gold panning, and drug trafficking, is reported in the French Senate report in February 2020 [12].

CGH does not fill the characteristics of a “trauma center” due to a lack of some technical skills and facilities. There is also a large deficit in terms of intensive care capacity [29]. This aspect is responsible for long, costly, and often risky medical evacuations to specialized hospital centers in the French Caribbean islands or in mainland France [29]. The availability of interventional radiology techniques since 2020, the implementation of an observational database (TraumaBase®) in 2021, and the training of remote health center teams (university degrees: “severe trauma and life-threatening emergencies” and “initiation to emergency medicine”) since 2022 are the first responses for improving management of these patients [30,31,32,33].

Our study presents several limitations. First, this is a monocentric study. However, CGH is the referral and the main hospital in French Guiana with the majority of specialties, intensive care unit, and mobile emergency medical service. Second, this is a retrospective study with numerous missing data which leads to the classic biases of this methodology. The implementation of the TraumaBase® registry will allow a complete prospective data collection and a correct outcome evaluation of these traumas [31, 34]. Nevertheless, this study reports interesting results to understand the burden of firearm injuries in French Guiana. This work is a first step to adapt legislative texts according to the department context as it is discussed in the USA but also to improve medical care according to the national and international guidelines [35, 36].