Editors: Nikita Joshi MD, and Utsha Khatri MD
Many physicians are first exposed to the devastation of firearm injuries in their work practice. My first experience came much earlier, when I was just 13 years old. I grew up living a very normal American life, complete with loving-parents, a brother, dog, sports, and school, all within a small midwestern community. My childhood was devoid of worry, fear or danger.
This all changed on a day that was unusually sunny for a fall Minnesota day. As the sun began to set, my mom and I were excitedly preparing for my dad and brother to return from a weekend of hunting. Amidst our preparations, the phone rang loudly. I listened intently as my mom answered, as if I knew this call was not a normal call.
“Dad, I don’t understand.”
My mom’s voice called to me.
“There’s been an accident, and it’s very bad. But I don’t know the details.”
My mom stared forward as she drove, praying at times. She was hyperaware of everything around her yet completing unsuspecting of how her life was about to change. We drove in silence for 20 minutes until we arrived to the hunting area. It was dark and the world seemed to be on hold. When we arrived, we noticed the ambulance parked nearby. Its lights and sirens were silent, as if they were waiting for us in disbelief. My mom was instructed to follow the ambulance. I remember driving behind the ambulance in our car, not understanding why the end destination was the nearest funeral home. As I walked in and walked by the EMS crew, they looked empty. Lost. Shocked. Avoiding eye conflict. Silent.
We walked into a large frigid room. In the center of this room there was a gurney that was holding a body bag.
“We need to see him,” my mom commanded.
The funeral home director shook his head side to side but then conceded to her request.
He unzipped the body bag starting at the head, but could only make it to his chest before turning away.
We stared. We cried. We stared some more. Small splatters of blood remained on my brother’s face although the EMS crew did their best to clean him up. His freshly adjusted braces glistened. I thought I detected a smile as the corner of his lips turned upward. He was pale, lifeless and part of his frontal and parietal skull were gone. Gone was the cranium and meninges that protected him for his 15 years of life.
I touched him. He was cold.
I have no idea how long we stared.
I do remember the creeping silence, too easily recalled when I think about that horrific day.
The details of my brother’s death are still unclear. Weeks after the horrific event, we learned the safety of the gun was malfunctioning. But he was by himself with a gunshot wound to his head. We questioned after the fact if we had missed something. Had he taken his own life? Or was this an accident? He showed no obvious signs of depression or suicidality. He took the required certification courses to operate a gun. It took us years of agonizing over the cause of his death before we accepted we would never know for sure.
I would never know how my brother died but I never stopped wondering why this happened. I continued to wonder this as I muddled through courses in college, medical school, and residency. Until residency, I thought my experience was unique. Certainly this was a freak accident. A case study. It seemed unimaginable that other 15 year olds would be fatally wounded by a firearm injury. My clinical experience in Emergency Medicine, first in Philadelphia and now in Kentucky, quickly taught me that this was not true. The gun violence was different but the loss the same. In West Philadelphia, there is an astounding number of young adults who were victims of homicide. In Philadelphia in 2015 when I was a resident, the number of firearm homicides were nearly double the number of firearm suicides . The homicide rate in Philadelphia is now one of the highest in the United States and has only increased since 2015 . When I moved to Kentucky, I was relieved to witness less victims of homicide but appalled at the number of young adults who were victims of firearm assisted suicide. In 2016, Kentucky ranked number ten in the nation for number of firearm suicides [3,4].
Death by firearm knows no boundaries based on age, race, gender or geography. I suppressed my grief to get through training. But when firearm injury became publicly rampant and a dedicated group of activists took action, I remembered. I remembered the silence. But it’s time to end the silence with knowledge, data and targeted interventions.
In 1999, the year my brother died, unintentional injury was the number one cause of death for his age group, 15-19 years of age. Suicide was the number three cause of death for his age group, with fatal firearm injuries as the number one all cause of suicide deaths. In 1999, 233 teenagers died from unintentional firearm injury and 1,872 teenagers died from intentional firearm injuries. 2,105 other families experienced the same horror as us, the life changing loss . Fifteen years later, the data look shockingly similar.
A few studies exist that have compared firearm injuries in rural and urban areas. The results indicate that both locations are high risk for teenagers. In rural areas, suicides, usually among males, account for the majority of gun deaths [6,7]. In urban settings, male teenagers are at a greater risk of firearm fatalities and injuries secondary to assault but suicide still accounts for a high percentage of gun deaths .
In rural areas, there are additional barriers of prolonged discovery time and transport time to trauma centers. In general, rural areas have high injury mortality rates, meaning those living in rural areas are more likely to die from traumatic injuries . Not surprisingly, prehospital deaths from trauma increases, as distance to a hospital increases .
These statistics support my experience working in both rural and urban settings. What my experience has also taught me is that there are not enough directed interventions in either setting. Doctors who care for these patients are devastated by the loss. They are tired of resuscitating teenagers who are victims of homicide or suicide. They wonder why it appears that it is easier for depressed teenage boys to access firearms than to access mental health care.
Studies have shown that those who own or have access to firearms are more likely to experience firearm injuries and fatalities. A study by Grossman and colleagues found that “more than 75% of the guns used in suicide attempts and unintentional injuries were stored in the residence of the victim, a relative, or a friend” . Another study by Johnson and colleagues evaluating adolescent suicide in four states supports this data. Their study revealed that 80% of adolescent suicides involved firearms and most adolescents committed suicide at their home using guns owned by their parents .
My brother was approximately 100 miles from a level one trauma center and the gun he was using belonged to our family and was typically locked in a gun safe. He followed all of the statistics.
Regardless of where they reside, teenagers with access to a firearm are at risk for harm and death. Since my brother died, few interventions have been implemented that could have prevented his death. In fact, in Minnesota, a 12 year old can still receive a Firearms Safety Certificate after required training, which allows them to operate a gun with supervision. While some may argue that early training and exposure is critical, do we have data to support this? My brother was responsible, certified, and with knowledgeable friends and family. While I am not anti-gun or anti-hunting, I am pro-safety. It is imperative that we support research that allows us to better understand the data surrounding firearm injuries and their complex relationships. Only with data can we implement successful, outcomes based prevention strategies that are tailored to the individual, community and environment.
As a physician, I am anti-silence. As a sister, I am anti-silence. Too many years of my life have been plagued by grief and anger, in silence. His loss is an incurable sadness but my anger has changed to action, and I have come to respect and value the opinions of those who use guns. I understand that hating guns will not bring my brother back. But I owe it to him to change the statistics. To advocate for data-driven policy. To be anti-silence.
- Philadelphia Department of Public Health. Deaths and Injuries from Firearms in Philadelphia. CHART 2017;2(10):1–6. Accessed at https://medium.com/@PHLPublicHealth/deaths-and-injuries-from-firearms-in-philadelphia-e4d8e00c4aae
- Philadelphia Police Department. Annual Murder and Shooting Victim Report. 2016. Accessed at https://www.phillypolice.com/assets/crime-maps-stats/2016-Homicide-Report.pdf.
- Violence Policy Center. State Firearm Suicide Rates. 2016. Accessed at http://vpc.org/press/state-firearm-suicide-rates-2016/.
- Centers for Disease Control and Prevention. Fatal Injury Data. Accessed at https://www.cdc.gov/injury/wisqars/fatal.html
- Centers for Disease Control and Prevention Injury Prevention and Control. Fatal Injury Data. Accessed at https://www.cdc.gov/injury/wisqars/fatal.html
- Branas CC, Nance ML, Elliott MR, Richmond TS, Schwab CW. Urban-rural shifts in intentional firearm death: different causes, same results. Am J Public Health. 2004;94(10):1750-5.
- Dressang LT. Gun deaths in rural and urban settings: recommendations for prevention. Journal of American Board of Family Practice. 2001;14(2): 107-115
- Herrin BR, Gaither JR, Leventhal JM, Dodington J. Rural versus urban hospitalizations for firearm injuries in children and adolescents. Pediatrics. 2018;152(2):1-9.
- Peek-Asa C, Zwerling C, Stallones L. Acute traumatic injuries in rural populations. American Journal of Public Health. 2004;94:1689-1693.
- Gomez D, Berube M, Xiong W, Ahmed N, Hass B, Schuurman N, Nathens AB. Identifying targets for potential interventions to reduce rural trauma deaths: a population-based analysis. The Journal of Trauma – Injury, Infection and Critical Care. 2010;69(3):633-639.
- Grossman DC, Reay DT, Baker SA. Self-inflicted and unintentional firearm injuries among children and adolescents: the source of the firearm. Arch Pediatr Adolesc Med. 1999;153(8):875–878.
- Johnson RM, Barber C, Azrael D, Clark DE, Hemenway D. Who are the owners of firearms used in adolescent suicides? Suicide Life Threat Behav. 2010;40(6):609-11.