Abstract

This article aims to identify the profile of police officers who underwent surgery due to gunshot wounds to the face, to survey the anatomical distribution of injuries and the repercussions on their health, work and family relationships. We conducted a retrospective epidemiological study based on secondary data of police officers who underwent surgery at the Central Military Police Hospital of the state of Rio de Janeiro due to gunshot wounds to the face from June 2003 to December 2020 (N=87). We also adopted a qualitative approach by applying a questionnaire with open and closed questions (N=37) to survey repercussions of the violent event on police officers’ work, families and health. The profile of police officers who underwent surgery showed that they were exclusively males, aged 34.9 years on average, privates, and injured in the line of duty. Fractures of the mandibular region were the most frequent injuries. After the accident, physical health conditions of police officers deteriorated, including an increase in cases of hypertension, a high frequency of insomnia (59.4%), and headache (51.3%). Damaged family relationship included an increasing trend of self-isolation and a feeling of fear experienced by police officers’ family members.

Key words:
Police officers; Gunshot wound; Occupational health

Introduction

Brazil has been historically marked by violence¹1 Da Matta R. As raízes da violência no Brasil: reflexões de um antropólogo social. In: Pinheiro PS. Violência Brasileira. São Paulo: Brasiliense; 1982. p. 12-43.. According to the Brazilian Public Safety Yearbook²2 Lima RS, Bueno S. Anuário brasileiro de segurança pública. São Paulo: Anuário brasileiro de segurança pública; 2020., 47,773 people suffered intentional violent deaths in Brazil in 2020, 72.5% of which were caused by guns. Firearms are the main cause of injury among police officers in the line of duty worldwide³3 Maia ABP, Assis SG, Ribeiro FML. Ferimentos por arma de fogo em profissionais de segurança pública e militares das forças armadas: revisão integrativa. Rev Bras Saude Ocup 2019; 44:e9.. In the state of Rio de Janeiro (RJ), high crime levels, armed clashes between police and drug trafficking groups and a large quantity of firearms in circulation have resulted in a high number of police officers hit by gun bullets, producing fatal and/or disabling injuries, increasing health risks of this population⁴4 Minayo MCS, Souza ER, Constantino P. Riscos percebidos e vitimização de policiais civis e militares na (in) segurança pública. Cad Saude Publica 2007; 23:2767-2779..

It is known that the risks of their profession and the violence police officers experience on a daily basis have seriously impacted their mental and physical health⁵5 Hall AB, Qureshi I, Wilson RL, Glasser JJ. Timeline of Psychological and Physiological Effects Occurring During Military Deployment on a Medical Team. J Spec Oper Med 2021; 21:118-122.

6 Guerrero-Barona E, Guerrero-Molina M, Chambel MJ, Moreno-Manso JM, Bueso-Izquierdo N, Barbosa-Torres C. Suicidal Ideation and Mental Health: The Moderating Effect of Coping Strategies in the Police Force. Int J Environ Res Public Health 2021; 18(15):8149.^-77 Maia ABP, Assis SG, Ribeiro FML, Wernersbach L. Non-fatal gunshot wounds among military police in Rio de Janeiro: health as a field of emergency against the naturalization of violence. Cien Saude Colet 2021; 26(5):1911-1922.. According to Dejours⁸8 Dejours C. Subjetividade, trabalho e ação. Production 2004; 14:27-34., work interferes in the construction of subjectivity, puts it to the test and may result in either constructive and/or destructive aspects in the subjectivity of workers. Working is not merely about producing, it is rather about transforming oneself. Studies have emphasized that these impacts on the health of police officers result from insalubrious working conditions, such as poor nutrition, work overload, a constant environment of violence that includes armed clashes and cause a high rate of victims. Work organization often clashes with the relations of police officers with their peers and superiors, they live in constant fear for their safety and society hardly recognizes police work⁷7 Maia ABP, Assis SG, Ribeiro FML, Wernersbach L. Non-fatal gunshot wounds among military police in Rio de Janeiro: health as a field of emergency against the naturalization of violence. Cien Saude Colet 2021; 26(5):1911-1922.^,99 Bezerra CDM, Assis SGD, Constantino P, Pires TO. Fatores associados ao sofrimento psíquico de agentes penitenciários do estado do Rio de Janeiro, Brasil. Rev Bras Saude Ocup 2021;46:e17.. Consequences of this working method also interfere with the mental health of their relatives¹⁰10 Paixão CC. Transtornos psiquiátricos em crianças e adolescentes filhos de policiais militares do estado do Rio de Janeiro [dissertação]. Rio de Janeiro: Escola Nacional de Saúde Pública Sergio Arouca; 2013. and impact their social relationships¹¹11 Oliveira TS, Faiman CJS. Ser policial militar: reflexos na vida pessoal e nos relacionamentos. Rev Psicol Organiz Trab 2019; 19:607-615..

Despite an increase in studies in the last decade that analyze the work relationships of military police officers and their impacts on health¹²12 Brito HPP. Sofrimento psíquico em policiais militares: um estudo de revisão [dissertação]. Rio de Janeiro: Escola Nacional de Saúde Pública Sergio Arouca; 2020., and despite the fact that we know that the occurrence of morbidity by firearm among military police officers (PM) in the state of RJ is high, few studies discuss the consequences of the occurrence of this type of morbidity on work, health and family relationships, which is, in turn, a research gap¹³13 Maia ABP, Assis SG, Minayo C. Systematic review on firearm injuries in the face: state of the art and existing gaps. J Braz Oral Maxillofacial Surgery 2021; 7(1):15-22..

Therefore, the present article conducted a survey on patients who underwent surgery due to non-fatal gunshot wounds (GSWs) to the face, i.e., active military police officers of the state of Rio de Janeiro. It further presents the repercussions of this type of injury on their life, focusing on aspects related to their health, police work and their family relationships.

Materials and methods

We adopted both a quantitative and a qualitative approach to achieve the goals of the present study¹⁴14 Deslandes SF, Assis SG. Abordagens quantitativa e qualitativa em saúde: o diálogo das diferenças. Caminhos Pensam Epistemol Metodo 2002; 2:195-223.. Analyses were performed based on two instruments obtained from the Oral and Maxillofacial Surgery and Traumatology Clinic (CTBMF) of the Central Military Police Hospital (HCPM). The first of them (Instrument 1) contains information we obtained from patient progress charts of 87 active duty police officers who were injured by firearms to the face and were admitted to the clinic between June 2003 and December 2020, i.e., 16.1% of the total number of police officers treated at the hospital for all causes. Civilian patients and retired military personnel were excluded. Epidemiological information included: age, gender, race/color, date of trauma, position or military rank at the time of injury. Maxillofacial injuries were classified according to their location, if the injuries had resulted in face bone fractures and their location, distributed by region: mandibular, maxillary, zygomatic-orbital, nasal and frontal. We also took into account patients’ general health condition before the injury, the number of surgeries performed after the trauma, the most frequent complications and sequels found and the health specialties involved in rehabilitation. Data were entered in a standardized form based on the variables of the document made available by the clinic and typed into a database (Epidata 3.0 software program). This analysis stage included only police officers with facial GSWs who did not immediately die as a result of their injuries and thus required oral and maxillofacial care.

The second instrument is based on a questionnaire introduced at the clinic in 2019 to survey the repercussions of facial GSWs. It was applied to 37 face-wounded police officers at the HCPM between December 2019 and September 2021 and contains open and closed questions. The mean time between facial GSWs and filling out of instrument 2 was 7.1 years. All 87 police officers were invited to the clinic for treatment, i.e., a 42.5% response rate in relation to the total number of facial GSW patients admitted to the hospital during the investigated period. That low response rate was mainly due to poor contact information, since many phone numbers found in the medical records were outdated. Phone numbers of 20 police officers were missing, 4 had been dismissed due to discipline issues, 6 had died, 1 was on ex officio leave, 1 refused due to health restrictions and 18 did not answer our calls. Those non-interviewed police officers (N=50) were male military privates (100%), aged 33.7 years on average and 89% of them had been wounded in the line of duty. The longer ago the injuries had occurred, the lesser they would answer. From 2003 to 2007, our losses were 68%, from 2008 to 2012 they were 66.7%, from 2013 to 2017 they were 57% and from 2018 to 2020, they were 35.8%.

Instrument 2 contains questions related to: a) identification of the patient’s profile; (b) health care received; c) general and oral health impacts after GSWs, diseases acquired after the injury, body mass index (BMI / weight, divided by height squared, considering obesity ≥30 kg/m²), frequency of physical activity practiced, habits such as smoking; d) impacts on social and family relationships; e) impacts on work performance and resulting issues; f) functional and/or aesthetic limitations resulting from trauma. Data were processed using a database (Microsoft Office Excel 2019 software program). We used the SPSS Statistics version 19.0. software program to process and analyze all information by performing a descriptive analysis that includes the presentation of frequencies and percentages.

A content analysis was performed to obtain a qualitative analysis, i.e., the modality of thematic analysis, which required performing the following steps¹⁵15 Minayo MCS, Assis SG, Oliveira RVC. Impacto das atividades profissionais na saúde física e mental dos policiais civis e militares do Rio de Janeiro. Cien Saude Colet 2011; 16(4):2199-2209.: (1) digitize interview notes; (2) assign thematic blocks; (3) comprehensive reading of digitized texts to detect particularities and coincidences among reports; (4) group excerpts of most illustrative reports; (5) identify main ideas; (6) identify meanings attributed to ideas; (7) elaborate interpretative syntheses. Analyzes were performed to understand, interpret and synthesize the impacts experienced by police officers at work, in their family, in their way of being and they were also asked what they feel is the best and the worst of being a police officer after they had been injured.

The research was submitted to and authorized by the Fiocruz Research Ethics Committee (CAAE 31541320.8.0000.5240).

Results

From June 2003 to December 2020, 196 facial GSW surgeries were performed on 87 active duty police officers, i.e., an average of 2.2 surgeries per patient injured by firearms. In our analysis, all patients were male (N=87), between 24 and 49 years old (34.9 years old on average). Regarding skin color, 51.5% were identified as white, 28.5% as black and 20% as brown.

Professional profile of police officers included predominantly privates (97.7%), especially soldiers (40.1%), who were injured in the line of duty (73.5%). Among the circumstances of accidents that happened off duty, mugging or attempted robbery ranked first (73.2%), followed by suicide attempt (9.6%).

Regarding analyzed oral and maxillofacial injuries, 82.7% suffered facial fractures. Considering wound size, 72 patients presented 122 fractured facial regions, among which the mandible region was the most affected one (Table 1).

Due to the severity of gunshot wounds, 18.4% of the patients had to be submitted to tracheostomy. Medical records of the 87 patients of our sample show 282 occurrences of sequels and complications caused by trauma, as seen in Table 2.

Regarding “health impacts”, anamnesis of Instrument 1 (N=87) reported on the first consultation showed that 6.9% of the patients suffered from hypertension and 1.1% from gastritis, joint pain and diabetes. Analysis of the questionnaire answers on the repercussions of injuries (Instrument 2, N=37) showed that health conditions of patients had worsened further (Table 3).

“Impacts on work” ranged from full-time leave from work to changes in their way of working or in their functions. According to the Medical Health Board of the State Department of Military Police¹⁶16 Rio de Janeiro. Polícia Militar do Estado do Rio de Janeiro. Portaria nº 346, de 12 de maio de 2010. Aprova as novas Instruções Reguladoras das Inspeções de Saúde e das Juntas de Inspeção de Saúde no âmbito da Polícia Militar do Estado do Rio de Janeiro e dá outras providências. Diário Oficial do Estado do Rio de Janeiro; 2010., 20 police officers were classified as fit for work and 17 as unfit for work. Accident leaves lasted 15.4 months on average (N=29). This figure excludes eight police officers who were still on accident leave on the day of the survey interview.

Regarding their way of working, only two interviewees did not mention any changes after their accident. Reported changes showed behavior marked by either greater caution or greater work exposure to seek revenge, both of which were permeated by a feeling of fear. Some injured police officers had performed tactical functions of conducting operations but were no longer able to perform them after their accident:

Police officers frequently reported that soon after returning to work, some of them had a more impulsive and reactive behavior. Most of them (N=34) answered that work posed a constant threat. As for working conditions over the long run, 21 police officers reported improved working conditions, especially better vehicles (N=10), weapons and bulletproof vests (N=11). Police officers who reported worsened conditions complained about the lack of camaraderie among peers at work and the lack of respect by society towards police officers.

When asked what they considered the worst thing about being a military police officer, the central ideas of open answers showed a strong dissatisfaction regarding the form of relationship with superiors (N=17) and how poorly SEPM recognizes the work of privates (N=13). We would like to emphasize that the lack of recognition by society (N=6) and the professional risks (N=6) were less often cited:

When asked what they considered the best of being a police officer, they stated that they felt a great satisfaction in being able to help people and serve society (N=15). Interviewees also stated to enjoy the fact that they were financially stable (N=6) and that their career as police officers allowed them to build friendly relationships (N=4):

Regarding “repercussions on their families”, police officers pointed out changes in social life, financial losses and health issues by family members. As for the family context, 30 were married and 7 were single. They had an average of 1.6 children, they lived either in their own and fully paid home (N=14), their own financed home (N=9), in a rented home (N=12) or in granted home for free (N=2). Police officers also reported the lack of security in their neighborhoods and two of them had even to leave their home due to orders given by local traffickers. Despite those issues, the 29 police officers mentioned that their family was the main support network to overcome their difficulties:

Regarding married police officers (N=30), 22 stated that their accident had an impact on the life of their spouses. Increased irritability and impatient behavior towards spouses or partners were reported more often. Three police officers got divorced, others reported that their wives became increasingly fearful and anxious, as well as more concerned for the safety of their families. Some started to suffer from depression and hypertension after the accident of their husbands. However, some also reported that the quality of their relationship improved after the accident (N=2) given the feeling of solidarity that resulted from their suffering. Fear was most often mentioned to describe the impacts on their children after the accident, as well as depression and the need for psychological help for some children.

Reports that mentioned “changes in the way of being” (N=32) stated a decrease in social life that resulted in self-isolating behavior:

Changes occurred due to limitations in physical and emotional health, fear of getting injured again and worsened financial conditions of the families. Physical difficulties involved dissatisfaction with facial aesthetics and acquired functional limitations, such as loss of visual and auditory acuity, as well as chewing limitations. Financial impacts resulted from the fact that police officers were unable to perform extra jobs in their free time or vacation to increase their income, from extra health care expenses, loss of bonuses due to their different health status, and from the fact that their wives lost their salary as they had to stop working to take care of their husband’s health.

Discussion

Facial GSWs result in blunt penetrating injuries of maxillofacial segments, which usually result in wounds associated with serious risks to the physical and emotional health of patients due to frequent aesthetic and functional impairment that challenge surgeons¹⁷17 Maia ABP, Assis SG, Ribeiro FML, Pinto LW. The marks of gunshot wounds to the face. Braz J Otorhinolaryngol 2019; 87:145-151.. Professional profiles of facial gunshot wound patients included military privates, especially male soldiers aged 34.9 years on average who had been shot in the line of duty. The average age of facial GSW patients was found to be higher among military police officers when compared to civilian patients¹⁸18 Lima CHR, Ranúzia I, Pereira IF, Vasconcelos BCE. Lesão por arma de fogo no rosto: revisão da literatura e relato de caso. Acta Sci Dental Sci 2018; 2:37-40.^,1919 Liu FC, Halsey JN, Hoppe IC, Ciminello FS, Lee ES, Granic MS. Uma revisão unicêntrica de fraturas faciais como resultado de lesões por projéteis de alta velocidade. Eplasty 2018; 9:18-20.. The fact that wounded patients are only male may be explained by the low number of female police officers in the State Department of Military Police and that most privates who take part in confrontational operations are male, which exposes them to higher degree of violence due to the effects of the distribution of corporate work and of permanent social conflicts.

GSW surgeries performed on police officers made up 16.2% of those performed at the CBMF clinic of the HCPM, which is a very high rate when compared to the civilian population that varies from 1%²⁰20 Scannavino FLF, Santos FDSAD, Novo Neto JP, Novo LP. Análise epidemiológica dos traumas bucomaxilofaciais de um serviço de emergência. Rev Cirurg Traumatol Buco-maxilo-facial 2013; 13:95-100., 2%²¹21 Santos CML, Oliveira MJ, Silva CI, Nascimento MTM. Estudo epidemiológico dos traumas bucomaxilofaciais em um hospital público de Feira de Santana, Bahia de 2008 a 2009. Rev Baiana Saude Publica 2012; 36:502. to 6%²²22 Pereira C, Boyd JB, Dickenson B, Putnam B. Gunshot Wounds to the Face. Ann Plastic Surgery 2012; 68:378-381. of operable maxillofacial trauma. Despite the fact that the police officers surveyed by this study do not represent the totality of the police force’s occurrences, the HCPM is the main hospital for police officers statewide, i.e., it accounts for 35% of the emergency care provided to GSW patients⁷7 Maia ABP, Assis SG, Ribeiro FML, Wernersbach L. Non-fatal gunshot wounds among military police in Rio de Janeiro: health as a field of emergency against the naturalization of violence. Cien Saude Colet 2021; 26(5):1911-1922.. It is common knowledge that public safety professionals are exposed to a higher danger to life compared to other professions²³23 Blair JM, Fowler KA, Betz CJ, Baumgardner JL. Occupational homicides of law enforcement officers, 2003-2013: data from the National Violent Death Reporting System. Am J Prev Med 2016; 51(5 Supl. 3):S188-S196.

24 Violanti JM, Hartley TA, Gu JK, Fekedulegn D, Andrew ME, Burchfiel CM. Life expectancy in police officers: a comparison with the US general population. Int J Emerg Ment Health 2013; 15(4):217-228.^-2525 Swedler DI, Kercher C, Simmons MM, Pollack KM. Occupational homicide of law enforcement officers in the US, 1996-2010. Inj Prev 2013; 20(10):35-40., which is due to the nature and tasks of their occupation. Even if we take into account those circumstances, rates found among police officers in Rio de Janeiro are unusually high⁷7 Maia ABP, Assis SG, Ribeiro FML, Wernersbach L. Non-fatal gunshot wounds among military police in Rio de Janeiro: health as a field of emergency against the naturalization of violence. Cien Saude Colet 2021; 26(5):1911-1922.^,1616 Rio de Janeiro. Polícia Militar do Estado do Rio de Janeiro. Portaria nº 346, de 12 de maio de 2010. Aprova as novas Instruções Reguladoras das Inspeções de Saúde e das Juntas de Inspeção de Saúde no âmbito da Polícia Militar do Estado do Rio de Janeiro e dá outras providências. Diário Oficial do Estado do Rio de Janeiro; 2010.. Mandibular fractures were the most frequent type of GSWs, as reported by the literature¹³13 Maia ABP, Assis SG, Minayo C. Systematic review on firearm injuries in the face: state of the art and existing gaps. J Braz Oral Maxillofacial Surgery 2021; 7(1):15-22.^,1717 Maia ABP, Assis SG, Ribeiro FML, Pinto LW. The marks of gunshot wounds to the face. Braz J Otorhinolaryngol 2019; 87:145-151.^,2121 Santos CML, Oliveira MJ, Silva CI, Nascimento MTM. Estudo epidemiológico dos traumas bucomaxilofaciais em um hospital público de Feira de Santana, Bahia de 2008 a 2009. Rev Baiana Saude Publica 2012; 36:502., followed by fractures in the maxillary region and in the zygomatic-orbital region. On average, every patient presented 1.4 regions with maxillofacial fractures. These fractures were accompanied by extensive losses of teeth, bone segments and dysesthesias, which can be explained by the high avulsion and destructive potential of firearm bullets.

Over the past two decades, studies have reported a wide range of health issues of public security professionals in Brazil²⁶26 Ferreira DKS, Augusto LGS, Silva JM. Condições de trabalho e percepção da saúde de policiais militares. Cad Saude Colet 2008; 16(3):403-420.

27 Pinto LW, Figueiredo AEB, Souza ER. Sofrimento psíquico em policiais civis do Estado do Rio de Janeiro. Cien Saude Colet 2013; 18(3):633-644.

28 Minayo MCS, Adorno S. Risco e (in)segurança na missão policial. Cien Saude Colet 2013; 18(3):585-593.

29 Minayo MCS, Souza ER, Constantino P. Missão prevenir e proteger: condições de vida, trabalho e saúde dos policiais militares do Rio de Janeiro. Rio de Janeiro: Editora Fiocruz; 2008.^-3030 Minayo MCS, Souza ER. Missão investigar: entre o ideal e a realidade de ser policial. Rio de Janeiro: Garamond; 2003.. This especially corroborates that issue, as it shows that after the occurrence of GSWs, the health condition of analyzed police officers got worse. We found a large number of cardiovascular and gastrointestinal diseases, joint/spine issues, an increase in diabetes and a high occurrence of insomnia, headache and chronic pain. A high rate of obesity and overweight, in addition to a sedentary lifestyle rate above average of the Brazilian population³¹31 Brasil. Ministério da Saúde (MS). Plano Nacional de Saúde 2020-2023. Brasília: MS; 2020. are additional risk factors of concern.

Factors associated to harmful facial GSW impacts on family and work relationships point to three causal aspects: a) complaints regarding facial aesthetics and visibility of injuries, as well as a contemporary perspective that takes into account the high representativeness of the face; b) a high perception of risk and the fear felt by the injured police officers and their families, and c) their working conditions and division of labor.

Regarding the high representativeness and visibility of the human face, we need to consider that it performs not only physical functions, i.e., speech, chewing, breathing, taste, vision, but that it also participates in the construction and development of our subjectivity and relationships³²32 Elias N. A sociedade dos indivíduos. São Paulo: Zahar; 1994.^,3333 Le Breton D. A Sociologia do corpo. Petrópolis: Editora Vozes; 2012.. The increasingly destructive power of firearms makes treatment of injuries more difficult and worsens sequels, hampering not only functional recovery, but also facial aesthetics of these patients. Opposed to and unaware of this difficulty, Elijah³²32 Elias N. A sociedade dos indivíduos. São Paulo: Zahar; 1994. and Le Breton³³33 Le Breton D. A Sociologia do corpo. Petrópolis: Editora Vozes; 2012. show how increasingly important the representation of the face has become for individuals over time since the fifteenth century while De Vihena³⁴34 De Vilhena NJ. O intolerável peso da feiúra: sobre as mulheres e seus corpos. Rio de Janeiro: Garamond; 2006. describes the growing social demand for facial aesthetics. Hence, despite advances in reconstructive techniques, reports on impaired facial aesthetics were the most common occurrence found in medical records, as they resulted in psychological issues and in problems related to sociability, which have been described by Goffman³⁵35 Goffman E. Estigma: notas sobre a manipulação da identidade. 4ª ed. Trad. Márcia Bandeira de Mello Leite Nunes. Rio de Janeiro: LTC; 2017. in his studies on social stigma as a derogatory attribute and its impacts on spoiling the identity of subjects.

The treatment of this type of morbidity requires multidisciplinary teams, multiple reconstructive surgeries, extensive recovery periods and it still results in physical limitations that invariably impact patients’ life socially and emotionally. Other studies mention a long recovery period marked by chronic pain that affects patients’ mood negatively and destabilizes them emotionally, worsening their quality of life¹⁷17 Maia ABP, Assis SG, Ribeiro FML, Pinto LW. The marks of gunshot wounds to the face. Braz J Otorhinolaryngol 2019; 87:145-151..

To analyze the effects of facial GSWs on the ability to perform work, we adopted a theoretical construction proposed by Dejours³⁶36 Dejours C. A loucura do trabalho: estudo de psicopatologia do trabalho. 6ª ed. São Paulo: Cortez Editora; 2015. to define working conditions and division of labor, as well as how patients dealt with their suffering at work. According to Dejours³⁶36 Dejours C. A loucura do trabalho: estudo de psicopatologia do trabalho. 6ª ed. São Paulo: Cortez Editora; 2015., working conditions are related to the issues that affect the worker’s body, which exclusively affect his physical condition. In this study, we found that armed clashes in the line of duty produced violent accidents that worsened the health conditions of these public security professionals in Rio de Janeiro, which is a consequence of adverse working conditions.

As for division of labor, Dejours³⁶36 Dejours C. A loucura do trabalho: estudo de psicopatologia do trabalho. 6ª ed. São Paulo: Cortez Editora; 2015. defines it as follows:

Work organization may conflict with the psychic functioning of workers in such a way as to neutralize both collective and individual defensive strategies and produce pathological suffering. Antunes³⁷37 Antunes EJF. Hierarquia na Polícia Militar do Estado do Rio de Janeiro: uma análise crítica de seus impactos na saúde [dissertação] Rio de Janeiro: Escola Nacional de Saúde Pública Sergio Arouca; 2019., in a literature review on that topic concluded that hierarchy defines work organization of military police and is considered a factor that contributes to suffering and health issues. The high frequency of non-psychotic symptoms found in this article, such as insomnia, irritability, headache and gastritis may be manifestations or answers to a type of psychological distress as described by Bezerra et al.⁹9 Bezerra CDM, Assis SGD, Constantino P, Pires TO. Fatores associados ao sofrimento psíquico de agentes penitenciários do estado do Rio de Janeiro, Brasil. Rev Bras Saude Ocup 2021;46:e17.. The recurrent narratives by interviewees who state that the problematical functioning of the institution’s hierarchy is one of the worst aspects of being a police officer highlight the fact that the institution’s work organization is a risk factor for the psychological suffering of injured police officers. On the other hand, camaraderie and the satisfaction that results from helping people may function as strategies that reduce their suffering.

Both the Brazilian and the international literature mention that work performed by public security professional poses a high risk of physical and psychological diseases²³23 Blair JM, Fowler KA, Betz CJ, Baumgardner JL. Occupational homicides of law enforcement officers, 2003-2013: data from the National Violent Death Reporting System. Am J Prev Med 2016; 51(5 Supl. 3):S188-S196.

24 Violanti JM, Hartley TA, Gu JK, Fekedulegn D, Andrew ME, Burchfiel CM. Life expectancy in police officers: a comparison with the US general population. Int J Emerg Ment Health 2013; 15(4):217-228.^-2525 Swedler DI, Kercher C, Simmons MM, Pollack KM. Occupational homicide of law enforcement officers in the US, 1996-2010. Inj Prev 2013; 20(10):35-40.^,3838 Sherwood L, Hegarty S, Vallières F, Hyland P, Murphy J, Fitzgerald G, Reid T. Identificando os principais fatores de risco para resultados psicológicos adversos entre policiais: uma revisão sistemática da literatura. J Traumatic Stress 2019; 32(5):688-700.^,3939 Stevelink SAM. Provável PTSD, depressão e ansiedade em 40.299 policiais e funcionários do Reino Unido: prevalência, fatores de risco e associações com a pressão arterial. PloS One 2020; 15:e0240902.. Due to high rates of armed clashes in the city of Rio de Janeiro - which occur based on the logic that war against drugs is the main public security strategy -, police officers also show higher rates of losses in physical and mental health quality⁷7 Maia ABP, Assis SG, Ribeiro FML, Wernersbach L. Non-fatal gunshot wounds among military police in Rio de Janeiro: health as a field of emergency against the naturalization of violence. Cien Saude Colet 2021; 26(5):1911-1922.^,1515 Minayo MCS, Assis SG, Oliveira RVC. Impacto das atividades profissionais na saúde física e mental dos policiais civis e militares do Rio de Janeiro. Cien Saude Colet 2011; 16(4):2199-2209.^,2828 Minayo MCS, Adorno S. Risco e (in)segurança na missão policial. Cien Saude Colet 2013; 18(3):585-593.. Analysis of facial GSW impacts on work performance shows that they resulted in long periods of accident leave for health treatments and a high percentage of withdrawal from ostensible policing activities. Thus, consequences arising from the work organization model of the military police added to the violent event and catalyzed the existing risk factors, deteriorating mental health condition of police officers who underwent surgery.

The present article shows that this type of injury frequently prevented police officers (75.7%) to resume ostensible policing activities. Azevedo⁴⁰40 Azevedo CRN. Vocações violadas? A identidade e a motivação dos policiais militares afastados das ruas [dissertação] Rio de Janeiro: Escola Brasileira de Administração Pública e de Empresas; 2021., in a study conducted with police officers on accident leave emphasizes that most of their frustration and dissatisfaction is due to the violation of their vocation, since they wish to preserve their police identity and to resume their initial condition, expressing their dissatisfaction with the restrictions and limitations. That high rate of withdrawal from work activities requires increased attention from health professionals who deal with these patients to help them cope with the changes in their way of life. Even police officers who were able to resume ostensible policing work had to rethink their careers and change their way of working.

The narratives about the impacts on relationships and work show that a feeling of fear and an increased perception of risk are directly linked and are the main perceptions that result from changes that occurred in their relations, way of living and working. Oliveira et al.¹¹11 Oliveira TS, Faiman CJS. Ser policial militar: reflexos na vida pessoal e nos relacionamentos. Rev Psicol Organiz Trab 2019; 19:607-615. found that the feeling of fear lasts longer than the police officers’ active duty time period and that the need for constant caution impacts the way they establish and maintain social relationships. Minayo et al.¹⁵15 Minayo MCS, Assis SG, Oliveira RVC. Impacto das atividades profissionais na saúde física e mental dos policiais civis e militares do Rio de Janeiro. Cien Saude Colet 2011; 16(4):2199-2209.^,2828 Minayo MCS, Adorno S. Risco e (in)segurança na missão policial. Cien Saude Colet 2013; 18(3):585-593. found that police officers with a high perception of professional risk are among those who most often experience violence, such as the kind that results from firearms. This explains the extremely high risk awareness found among interviewed police officers who suffered facial GSWs. According to them, fear of getting injured is not a remote possibility, but daily reality which interferes by producing types of behavior that are either more aggressive or more self-protective during ostensible policing work.

Regarding impacts on police officers’ families, there is no doubt about the impacts on health, quality of life and marital relationship of their wives given the nature of their husbands’ work⁴¹41 Derenusson FC, Jablonski B. Sob fogo cruzado: o impacto do trabalho policial militar sobre a família do policial. Aletheia 2010; 32:22-37.^,4242 Soares K, Souza R, Melo SMV. Experiência de ser esposa de policial militar: um estudo fenomenológico. Phenomenological Stud 2020; 26:242-252.. Family relations are already often affected by the daily impacts of that kind of profession and after a violent accident such as GSWs, the family needs to find means and the strength to overcome difficulties. Detrimental consequences that affect family members of police officers include, as stated above, financial losses caused by a reduced family income, changes in the way of being of police officers, i.e., changes in routine and in the family’s way of living, as well as mental health issues that may affect not only police officers, but also their family members. Such developments may sometimes cause couples to break up permanently.

Paixão¹⁰10 Paixão CC. Transtornos psiquiátricos em crianças e adolescentes filhos de policiais militares do estado do Rio de Janeiro [dissertação]. Rio de Janeiro: Escola Nacional de Saúde Pública Sergio Arouca; 2013. found a high prevalence of disorders among children of police officers in the state of Rio de Janeiro. Families that had experienced violence showed a higher degree of fear related to professional risks¹⁰10 Paixão CC. Transtornos psiquiátricos em crianças e adolescentes filhos de policiais militares do estado do Rio de Janeiro [dissertação]. Rio de Janeiro: Escola Nacional de Saúde Pública Sergio Arouca; 2013.. Police officers with facial GSWs mostly mentioned fear to describe the impacts on their spouses and children. That feeling of fear was related to their own insecurity and the fact that death had become very present in the life of their family members. Wound marks, which remain visible to patients and their relatives, remind them every day of the reality of death and the high risks police officers are exposed to in the state of Rio de Janeiro.

Results presented in this study emphasize the need to promote public policies that ensure better working conditions and support to injured police officers. Regarding health professionals who deal with them, however limited their scope of action may be from the anatomical point of view, it is inevitably related to issues that exceed the limits of health and physical disease. Hence, those professionals need to be attentive and prepared to deal with psychosocial issues involved and try to detect, at an early stage, a possible need for mental health care of facial GSW patients and their families. Considering the scope of impacts on the family, which is the main support network to tackle difficulties, we urgently need to develop measures that ensure more adequate and effective support during the recovery period of police officers. In addition, from the perspective of workers’ health, we need to clarify the reasons behind the high morbidity by firearms and the current working conditions that expose police officers to such a high rate of injuries.

This article is limited insofar as it does not provide a representative sample of the total number of police officers affected by facial GSWs in the state of Rio de Janeiro. This is due to the fact that some police officers may have been treated in other hospitals and due to the reduced number (42.5%) of subjects who were ready to answer the questionnaire on the impacts of facial GSWs. Despite these limitations, data point to a health issue that may be considered relevant for that professional category, but there is no information on either size or extent of the impacts of this kind of morbidity on work performance and family relationships.

Conclusion

Profile of police officers who underwent surgery due facial GSWs included male privates who were 34.9 years old on average. Injuries and fractures in the mandibular region were the most common ones found. Facial GSWs resulted in long accident leaves for health treatment, high rates of definitive severance from work and limited work performance by those who resumed their position as police officers.

Changes in both their way of life and in social life resulted from their greater perception of police work risk and an increased visibility of their injuries. The feeling of fear that appeared after their violent accident produced impacts that included a greater tendency to self-isolation. Regarding family relationships, we found reduced physical and mental health and a decrease in family incomes of police officers and their family members.

The high occurrence of this type of morbidity among police officers of Rio de Janeiro has drawn attention to the need to discuss and rethink the way public security professionals perform their work, as well as their working conditions. Since this area is characterized by intersectoriality, studies that address the impacts on the health of police officers may contribute to developing measures aimed at improving the way these professionals work by focusing on a preventive approach that involves intelligence work, rather than on the current logic based on armed clashes.

References

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