• Prevention Quarter: Firearm Violence Perspective from the Injury Prevention Committee

    Dr. Thomas Duncan

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    Firearm Violence Perspective from the Injury Prevention Committee

    Our world has an unfortunately long history of violence. There have been countless wars and currently, there are multiple wars in the world. The war in Ukraine has caused 3,998 civilian deaths and 4,693 injuries to date, figures that continue to escalate daily.1 The wars in Myanmar, Pakistan, Afghanistan, Congo, Chad, Somalia, and Ethiopia are just as devasting, even if they do not get as much media coverage. Additionally, in communities across the globe, people suffer daily forms of violence. For example, many children need to carefully navigate a pathway from home to school and vice-versa in a manner that will lessen the risk of them becoming victims of community-based violence. Some children and families experience violence at home.

    Without diminishing the significance of the foregoing tragedies, there is an epidemic of gun violence that is specific to the United States (U.S.). In the U.S., firearms account for 38,000 deaths and up to 85,000 non-fatal injuries per year.2 In 2020, gun violence was the leading cause of death among children, teens, and young adults under 25 with black males being 20 times more likely to be a victim of gun homicide; there were 45,222 gun deaths in the U.S. (highest ever); firearm homicide rates increased by 35% from 2019 to 2020, and a child or teen was killed unintentionally by a gun injury every 2.5 days.3 On average, 50 women in the USA are killed with a firearm by intimate partners each month. Abused women are five times more likely to be killed if the person abusing the woman owns a firearm. 4

    A person contemplating suicide has an 85% chance of being successful if a firearm is present in the home.5 This statistically is particularly troubling since the pandemic brought about a rise in depression and suicide.6

    Our country is also suffering from a surge in mass shootings. A mass shooting is defined as three or more individuals killed in a single incident.7 There have been 229 mass shootings year-to-date in the U.S. The Buffalo, Orange County, and Uvalde massacres mark the 196th, 201st, and 212th mass shootings, respectively.8 These few examples are highlighted but should not take away from the other mass shootings that have occurred this year and in the past. Some of these preventable incidents are targeted and planned acts toward innocent individuals that were in places considered to be safe havens.

    Many healthcare professionals feel helpless because we are unable to intervene in these various catastrophes. This feeling of hopelessness has been worsened due to the complexities of patient management brought forth by the COVID-19 pandemic and the increase in violence due to the same disease. It goes without saying that our job will be less emotionally taxing if we do not have to speak to family members about the loss of their loved one to a preventable injury or suicide. Each life lost brings about a sense of failure in the healthcare professional’s mind. Compounded losses of multiple victims escalate the emotional impact that could eventually lead to burnout and post-traumatic stress disorder.

    Although we cannot stop the various wars happening across the world, there are several things we can and should do to reduce gun violence in our own communities.

     

    Renew Our Commitment to the Hippocratic Oath 

    As surgeons in the name of healing, we have a part to play in advocating for our patients especially as we took a Hippocratic oath to “do no harm.” As such, we are encouraged to care for all patients regardless of their skin color, socioeconomic background, sexual orientation, or religious background. Recognizing the difficulty that arises on occasion, we should acknowledge that the first point of contact with a patient may stir up unpleasant emotions if the individual happens to be the instigator of violence or an incident in which innocent lives are lost. It is important to remember our role regardless of the circumstance that saving lives comes first, and the rest will be handled by the appropriate authority.  

     

    Reduce Patient Recidivism and Increase Patient Empowerment

    Victims of violence have a long road to recovery not only from their physical injuries but their psychological trauma. At trauma centers, it behooves us to use the principles of Trauma-Informed Care (TIC) to approach our patients to avoid re-traumatization. TIC is defined as an approach to a patient’s care that acknowledges that health care organizations and care teams recognize a complete picture of a patient’s life situation, both past and present, to effectively provide health care services with a healing-oriented goal and avoid re-traumatization.9 A pilot program championed by the American College of Surgeons Committee on Trauma (ACS-COT) will be instituted soon. In the same respect, AAST’s Injury Prevention committee provided a soon-to-be-diversified survey on TIC to obtain meaningful information on how best to educate health care professionals on this important topic.

    Hospital-Based Violence Intervention Programs (HVIPs) which function under the auspices of Health Alliance for Violence Intervention (The HAVI) are multidisciplinary programs that combine the efforts of medical staff with trusted community-based partners to provide safety planning, services, and TIC to violently injured people by taking advantage of the “teachable moment” in providing bedside interventions and long-term follow up by trained culturally-competent front-line workers/violence prevention professionals. HVIPs elevate the issues of the revolving door of violence while integrating equity and building partnerships with communities and survivors of violence by addressing important social determinants of health.10 Look out for the following sessions planned for the upcoming AAST scientific meeting in Chicago, September 2022: (1) Lunch session on HVIPs – implementation, funding, and evaluation; (2) Short course on complex trauma follow up and discharge management: improving lives and preventing reinjury.

     

    Bolster Injury Prevention Efforts

    According to the American College of Surgeons (ACS), “the only thing more tragic than a death…is a death that could have been prevented.” This is a principle adopted by clinicians caring for injured patients and is highlighted in the Resources for Optimal Care of the Injured patient standards.11

    Injury prevention has been a staple of trauma centers across the world. Clinicians encouraged patients to use seatbelts, car seats and bicycle/motorcycle helmets long before they were required by law. These preventative tools have improved nationwide morbidity and mortality and diminished injury rates over the past several decades. For example, among drivers and front-seat passengers, seatbelts have reduced the risk of death by 45% and the risk of serious injury by 50%.12 In some trauma centers, every bicyclist/skateboarder involved in a crash that presents without donning a helmet or has a damaged one is gifted a helmet prior to discharge. Similarly, if a child is brought into a trauma center after falling through a window without a proper screen, it behooves the facility to do due diligence by providing the family with injury prevention counseling and home safety inspection services to avert a subsequent injury.

    This same injury prevention approach applies to gun violence. Without taking away Second Amendment rights, the ACS and American Association for the Surgery of Trauma (AAST) promote safety measures for firearms, including, but not limited to, gun locks, safe gun storage, gun safes, proper firearm training, mandatory background checks for firearm purchase, legislation banning civilian access to assault weapons and munition designed for law enforcement and military agencies, improving quality access for behavioral health services, supporting bleeding control training for the public and public access to bleeding control kits, and evidence-based research on firearm injury. These position statements can be accessed on the organizations’ websites.2,13,14,15,16

     

    Educate the Community about Hemorrhage Control

    It is well known in the trauma community that uncontrolled hemorrhage is the most common cause of preventable death in a traumatic situation. Due to the Boston bombing and Sandy Hook massacres, the Stop the Bleed course (also known as cardiopulmonary resuscitation (CPR) for trauma) was created by a group of stakeholders championed by the ACS and endorsed by the White House administration in 2015. The course instructs the public how to control bleeding by applying pressure from packing gauze and the use of a tourniquet. To date, there have been 1.9 million people trained to control hemorrhage. On May 19th, many trauma centers across the globe collaborated in bringing awareness of the Stop the Bleed course.17 As a result of ongoing mass shootings, surgeons, and other clinicians active in the care of injured patients have been placing warranted pressure on our congressional leadership on Assembly Bill (AB) 2260 which is awaiting the California Senate’s approval. AB 2260 will require presence of a Stop the Bleed kit next to a defibrillator in any new building in California.18

     

    Conclusion

    With each mass shooting or other act of gun violence that occurs, thoughts and prayers go out to victims and their families. In addition to these heartful sentiments, it is my sincere hope that meaningful collaboration from all sides can be made in the aim of making our nation safe. Here is a summary of things you can do to help in your role as a healthcare professional:

    1. Speak up if you notice anything unusual pertaining to any potential acts of violence.
    2. Advocate for your patients.
    3. Implore your congressional representative(s) to support bills pertaining to firearm safety and research.
    4. Recommend/seek mental health services for anyone with thoughts of disarray.
    5. Recommend and utilize the suicide hotline. 1-800-SUICIDE (1-800-784-2433), 1-800-273-TALK (8255) Suicide Prevention Lifeline; Suicide Prevention Guide.
    6. Refer to the soon-to-be-updated AAST Violence Prevention Internet Guide for a plethora of resources, available on the AAST website.
    7. Continue teaching Stop the Bleed courses.
    8. Direct patients and/or families to law enforcement to discard of unwanted firearms left by deceased family or friends.
    9. Promote safe handling of firearms, particularly in homes with children.
    10. Aim to establish and promote HVIPs in the appropriate setting.
    11. Do no harm.

     

    References

    1. Office of the United Nations High Commissioner for Human Rights (OHCHR).
    2. The American Association for the Surgery of Trauma (AAST) Board of Managers. AAST statement on firearm injury.TSACO 2018;3:e000204. doi:10.1136/tsaco-2018-000204.
    3. A year in review: 2020 Gun deaths in the U.S. Johns Hopkins Center for Gun Violence Solutions.
    4. Duncan, T, Stewart, R, Joseph, K, Kuhls, D, Dechert, T, Taghavi, S, Bonne, S, Matsushima, K. American Association for the Surgery of Trauma Prevention Committee Review: Family Justice Centers – A Not-So-Novel, But Unknown Gem. Trauma Surg. Acute Care Open. 2021 Jun 7;6(1):e000725. Doi:10.1136/tsaco-2021-000725. ecollection 2021.
    5. Pompili M. Can we expect a rise in suicide rates after the COVID-19 pandemic outbreak? Eur Neuropsychopharmacol.2021 Nov; 52: 1-2.doi: 10.1016/j.euroneuro.2021.05.011.
    6. Drexler M. Guns and suicides. Harvard public health. The hidden toll.
    7. Investigative assistance for violent crimes act of 2012. H.R. 2076 112 – 265.
    8. gunviolencearchive.org
    9. traumainformedcare.chcs.org
    10. thehavi.org
    11. Resources for the Optimal Care of the Injured Patient. March 2022 Standards.
    12. cdc.gov. Policy Impact: Seatbelts
    13. Gun Safety and Your Health; A Proactive Guide to Protect You and Those Around You. American College of Surgery Committee on Trauma and American College of Surgeons. facs.org.
    14. facs.org. Statement on firearm injuries.
    15. Duncan TK, Weaver JL, Zakrison TL, Bellal J, Campbell BT, Christmas AB, Stewart RM, Kuhls DA, Bulger EM. Domestic Violence and Safe Storage of Firearms in the COVID-19 Era. Ann Surg, Vol. 272, No 2, Aug 2020.
    16. Kuhls DA, Falcone Jr. F RA, Bonne S, et al. Prevention of firearm injuries: it all begins with a conversation. J Trauma Acute Care Surg. 2020;88(2):e77–e81. doi: 10.1097/TA.0000000000002452.
    17. stopthebleed.org
    18. California legislative information. AB-2260 Emergency response: trauma kits.

     

     

     

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