Firearm Injury Prevention in Medicine
By William Dewspelaere
The following article is adapted from a series of lectures given at the Society for Academic Emergency Medicine 2019 national meeting. The purpose of this meeting was to educate national leaders in emergency medicine about the state of firearms injury prevention. The author would like to acknowledge Dr. Megan Ranney, Dr. Lauren Hudak, Dr. Emmy Betz, Dr. Patrick Carter, and Dr. Jeremy Ackerman for their contributions.
When the majority of people think about firearm violence, media images of the medical team rushing a gunshot victim into a large room, doing procedures to stop bleeding and performing CPR come to mind. While certainly dramatic and entertaining for TV, what is not often seen is what the medical system attempts to prevent shooting and injuries from happening in the first place.
The field of firearm injury prevention is growing rapidly. After the National Rifle Association shared their now infamous “stay in your lane” tweet in November 2018, healthcare providers were thrust into the national spotlight. Medical societies are also getting more engaged, as an example, the American College of Physicians now urges medical providers to counsel at-risk patients about firearms[1]. Here, we will present a brief overview of some important aspects of firearm injury prevention to help both providers and patients better understand what is being done and how far there is to go.
A National Epidemic that Affects Us All
The scope of the issue cannot be understated. In 2017, 39,773 people in the United States were killed by a firearm. 60% of these deaths were suicides, 38% were homicides, and the remaining 2% were accidental deaths and mass shooting[2]. In the USA, firearm violence is the second-leading cause of death among young people, and accounts for one out of every five deaths[3].
The magnitude is indisputable. And while this epidemic affects us all, gun violence touches each of us in different ways. Among white men, firearm deaths peak in those in their 50s due to high rates of suicide. Among Black and Hispanic men, deaths peak in the 20s, driven by high rates of interpersonal violence.
Because this epidemic is so complex, solutions require input from all angles. This includes voices of the medical team who care for its victims -- including doctors, nurses, EMS, and allied health professionals.
Where are the research dollars?
Physicians are leading the way on developing and testing ways to reduce firearm violence. Unfortunately, the magnitude of research funding is not proportional to the magnitude of the problem. In the USA between 1973 and 2012, there were 2068 cases of cholera, diphtheria, polio, and rabies combined. These 4 diseases received 486 National Institute of Health (NIH) grants. In that same time period there were 4 million firearm-related injuries. Firearm research received only 3 NIH grants[4].
But the trend is quickly changing! As public concern about firearm violence increases, research groups such as AFFIRM (a non-profit foundation) and Firearm Safety Among Children and Teens (FACTS) (an NIH-funded consortium) are developing new research in the area. Examples of cutting-edge projects include emergency department-based counseling for teens, mobile apps to engage at-risk youth in preventing violence, and educating physicians about firearm safety.
The Many Settings for Change
Intervention to prevent firearm violence can happen whenever and wherever it is appropriate. This means that doctors must meet patients where they are, whether that is in the clinic, the hospital, or the emergency department (ED). Almost half of all people who commit suicide visit their primary care provider within the preceding month. Clinic visits, therefore, are an important time to screen for risky firearm ownership, especially in the older male population who is at higher risk.
On the other hand, interpersonal violence accounts for most firearm deaths in adolescents and young adults. Unfortunately, at-risk youth overwhelmingly do not have any other source of healthcare, leaving counseling in the hands of providers in the ED.
The ED also sees adults who are at risk of suicide. As part of the routine ED suicide risk assessment, it is imperative for providers to ask about firearm ownership. Those who screen positive should be counseled about the need for temporary change in firearm access, whether that be placing the gun in a safe in the home, transferring the firearm to a friend or family member, or finding a gun range that can assist with storage outside the home. A newly design, patient-centered decision aid can be used to help inform this choice[7].
All providers in all settings should educate themselves about methods of intervention to prevent recurrence and escalation, and make it as routine as counseling about medication adherence and smoking cessation.
Where Can I Learn More?
This write up is only an introduction to firearm injury prevention. A variety of national groups are tackling this issue at a deeper level. A few are listed below.
Sources
Laine C, Taichman DB. The Health Care Professional's Pledge: Protecting Our Patients From Firearm Injury. Ann Intern Med. [Epub ahead of print 17 October 2017]167:892–893. doi: 10.7326/M17-2714
WISQARS, www.cdc.gov/injury/wisqars
Stark DE, Shah NH. Funding and Publication of Research on Gun Violence and Other Leading Causes of Death. JAMA. 2017;317(1):84–85. doi:10.1001/jama.2016.16215
Patrick M. Carter, Maureen A. Walton, Douglas R. Roehler, Jason Goldstick, Marc A. Zimmerman, Frederic C. Blow, Rebecca M. Cunningham. Firearm Violence Among High-Risk Emergency Department Youth After an Assault Injury. Pediatrics May 2015, 135 (5) 805-815; 10.1542/peds.2014-3572
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