Stray bullet shooting are unique subset of firearm related injury events. Most are unintended consequences of intention violence. “Collateral damage” is the term applied to death resulting from such act of terrorism. Stray bullet injuries by falling bullets are defined as gun fire injuries inflicted usually outdoors by an unidentified shooter (
2, 3). In certain Middle East countries stray bullet injuries are seen at the wedding ceremonies, on the arrival of spring season and graduations ( 2, 4). In Pakistan, the phenomena is continues to rise for last two decades due to wide spread availability of automatic fire arms and ammunition. In the province of Sindh, the incidences of aerial firing due to dirty politics is increasing compared to other provinces, especially in the cities of Karachi and Hyderabad as different political, and ethnic groups show their power probably to impress other group. In these cities, low-educated and jobless youth is particularly more active. Unfortunately our educational institutes are also not exempted from such incidences as the main political parties have their active student wings. In Pakistan the practice is most commonly observed during the marriage season in the Islamic month of Shawal, friends of the bridegroom open celebratory aerial firing at the time of arrival at the marriage halls. Print and electronic media have reported that these bullets can cause disastrous consequences to bridegroom or any invited guests in the marriage ceremony or any other unknown victim remote from the site of marriage ceremony. There are plenty of literature and news reports available on the Internet and print media about stray bullet injuries; however, there are very few case reports and original articles in medical literature ( 9- 14). We found chest as the most common site of the stray bullet injury (35.71%), followed by head and neck region (23.80%) with no mortality, which is in sharp contrast to the finding of Al-Tarshihi who reported most (77%) stray bullet injuries are sustained to the head. He also reported 32% mortality rate which is significantly higher than all other type of gunshot injuries. He suggests that there is a need to educate the public and law enforcement is required to prevent these serious but preventable injuries ( 12). The Center for Disease Control (CDC) in United States of America has also reported that 80% of these stray bullet injuries are to the head, followed by feet and shoulder ( 13). Celebratory gunshots are often seen in big cities of Pakistan and densely populated areas. Shooters are single or multiple usually on a street. Victims are more commonly a male; however, it is not rare for children and women to be a victim as observed in our study ( 15, 16). Celebratory gun fire near an airport can be dangerous to landing air craft ( 17, 18). There are case report studies reported a bullet entering a gravid uterus of a pregnant women and resulting in the death of her fetus and a bullet entering directly into pericardium resulting in sudden death ( 19, 20). Moreover, CDC report from Puerto Rico showed that on average 2 died and 25 got injured annually as a result of celebratory firing on the occasion of New Year. Some media also reported that 68% stray bullet injuries victims on the New Year night with victims with the age range between 4 months and 82 years, 63% males and 37% females and 21% victims were hospitalized. Out of 68%, 21% were children with head (38%) the most frequent area hit by the stray bullet, followed by foot (26%) and shoulder (16%). Forty-two percent of injuries took place during late evening and night and 48% from mid-night till early morning next day ( 4, 21). The aerial firings and stray bullets injured innocent citizens, sometime fatally and the documented mortality of these victims is about 32% compared to 2% - 6% normally associated with other type of fire arm injuries ( 22). Sometimes, these stray bullets are fired from a distance to far for the short to be heard but had a sufficient energy and velocity of more than 200 feet per seconds to penetrate the victim's body ( 5, 6). Wintemute et al. reported that 59.2% of the events of areal firing are due to violence on streets. He reported that among all incidence of aerial firing, 59.2% times it is the result of interpersonal violence. He also reported that age group most commonly affected is between 15 - 34 years with 50.2% male and 44% female. In his study, the victim wound location was frequently the extremities (35%), followed by abdomen (30%) and head and neck (20.5%) ( 23). Media reports such aerial firing and stray bullets leading to fatal injuries and death are punishable with the detention, imprisonment with variable period and heavy fine in various States of America ( 24). In addition to the homicidal, suicidal and accidental cases of fire arm injuries, aerial firing resulting in stray bullet injuries is a new tide rising in our country. Most of the people think that aerial bullets vanish in the air/space like explosives and fire work, but this is not true in fact these bullets make a projectile or vertical motion and come back to surface to hit anything which comes in their way. Stray bullet injury is usually by a single bullet with wound of entry and most of the time they lodge in the subcutaneous areas and consequently there was no exit wound. Many of the victims are unaware of the fire arm event and hence a healthy number of them seek medical advice few days later ( 25). The incidence of stray bullet injuries are more common during the night hours as most of the victims at the time of incidence were sleeping on the roof of their houses during the summer. In tribal areas of Khyber Pakhtunkhwa (KPK) Province, birth of a male child is usually traditionally celebrated by aerial firing. However, these tribal areas are mountainary area not thickly populated; hence, the chances of injury are less compared to densely populated areas in cities. Almost all age group irrespective of sex are victims of aerial firing, but male adults are the usual victims. Stray bullet injuries are usually single and nonfatal then other type of bullet injuries as they usually lodge in subcutaneous tissues with less mortality and morbidity. Our youngest victim was a one-year old baby girl with a stray bullet impacted firmly to right femoral area through her pamper. Few of the patients with superficial palpable bullets causing discomfort were removed under local or short general anesthesia. The usual history narrated by the patients is injury by stone with sudden feeling of a wetness on the cloths, which reveals fresh blood. Some patient who received bullet while sleeping and unaware of the event report they have a rat bite last night and causing pain. Victims with abdominal or chest stray bullet injuries usually attend A and E departments soon after the event due to bleeding. Some of the patients of stray bullet injuries were picked up by radiographs. There are cases where the stray bullets after entering the body wanders to nearby area or remote areas like stray bullet hitting the cheek lodge into submandibular area, stray bullet hitting chest wall was wandering in abdominal cavity, bullet entering in the jejunum was drag down by peristalsis movements to the terminal ileum, intracranial migration and intra venous migration ( 9, 13, 14). Some of the patients had no knowledge as to how and when they had sustained bullet injury. Children are usually presented with a swelling or small wound for which no cause could be found in such cases, stray bullet should be suspected and radiological evidence can be helpful ( 25). Having said this, one cannot measure the psychological trauma associated with stray bullet injury, imagine a person relaxing at roof of the house and inflict fire arm injury for none. The house is even not safe place to avoid stray bullet injury. In Pakistan, section 144 of the law is imposed to prevent aerial firing during celebration if harm is caused, and an first investigation report (FIR) may be registered against a person who does so. However, many cases go unreported ( 3). As aerial firing is preventable; hence, existing laws should be actively enforced and secondarily community leaders of public housing areas should develop a campaign focused on changing attitudes and behaviors towards celebrating firearm in these areas. A concerted effort should be taken at preventing progression of firearm use. Future research might combine active surveillance, with follow-up, interviews of victims to identify all cases and obtain more complete data. We conclude that prevalence of aerial firing resulting in stray bullet injuries is alarmingly on rise in our country. Above all, those doing aerial firing do not considered it as crime, instead taken it as they are privilege to do anything when celebrating. Awareness of the consequences must be propagated by every means to condemn this social crime.