From my very first clinical experience as a patient advocate volunteer in a Philadelphia emergency room, I was drawn to injured patients and their families, all of whom had awakened that morning thinking it would be a normal day. The events, however, which brought them to the emergency room that evening were anything but “normal” events. The patients were in pain — physically and emotionally traumatized, and their families were incredulous of what had happened to their loved ones.
Even though I had no medical training at that time, I clearly understood that their lives had changed forever, and I helped to facilitate communication between the busy medical team and their patients and families.
Fast forward 14 years to 2000, when I arrived in Las Vegas after completing my medical education and training as a trauma/critical care surgeon in Philadelphia, NYC (Bronx), and Baltimore. I joined Dr. John Fildes, University Medical Center Southern Nevada (UMC)’s trauma medical director at Nevada’s only Level I Trauma Center and Nevada’s only Pediatric Trauma Center. I have always felt privileged to treat our community’s injured patients, and as medical director of the Trauma ICU for over 20 years, I have cared for some of the most injured, many of whom did not survive despite our best medical care. I can tell you that it is beyond excruciating to have to tell a family that one or more of their loved ones has died.
Traumatic injuries are highly associated with behaviors that increase the risk of injury. Trauma centers are required to hire an injury prevention specialist, and very early in my career, I had a strong desire to try to prevent the devastating injuries that took my patients’ lives or left them forever changed. I participated in the injury prevention committees of all my professional organizations.
By looking at the epidemiologic data, I learned that injury — not cancer, heart disease, stroke, or other diseases — is the number one cause of death for Americans for the first 44 years of life! Motor vehicular crashes were the leading cause of injury deaths for decades and with safety innovations, road engineering, and policy-mandated behaviors like speed limits, seat belts, and other injury prevention initiatives, vehicular crash-related deaths gradually decreased until the COVID-19 pandemic, and since that time they have increased as a result of human behavior.
I also treated many patients with gunshot wounds, but I didn’t initially realize that firearm-related deaths were approaching the number of vehicular deaths in our country. I hadn’t understood the true magnitude of this public health problem.
I was appointed chair of the American College of Surgeons’ Committee on Trauma’s Injury Prevention and Control Committee (COT IPCC) about six weeks before the Sandy Hook Elementary School shooting on Dec. 14, 2012. Updating a statement on firearm injury prevention was one of my first tasks. Understanding firearm injuries and deaths and working on how we can prevent these horrific injuries has been a focus of my injury prevention efforts and research ever since.
In 2014, only 4 percent of patients treated at U.S. trauma centers sustained firearm injuries, yet Centers for Disease Control and Prevention (CDC) Health Statistics data indicated that firearm-related deaths were essentially the same as vehicular deaths, with mortality rates of 10.5 per 100,000 population for firearms and 10.6 per 100,000 population for vehicular deaths. Firearm injuries are so lethal that many victims are pronounced dead at the scene and are transported directly to the coroner’s office.
Actions needed
The American College of Surgeon's Committee on Trauma and its injury-prevention coordinator course embarked upon a consensus-based approach to address this very common injury and cause of death. We surveyed multiple surgery professional organizations, including the entire membership of the American College of Surgeons, and found that although members had very different views on whether firearm ownership is beneficial, harmful, both, or neither, there was agreement that 16 of 25 proposed policy and advocacy initiatives were high priority, including preventing people with serious mental illness from purchasing firearms, enhancing the National Instant Criminal Background Check System (NICS), mandatory background checks for all firearm purchases, temporarily removing firearms from high-risk individuals, federal firearm injury prevention research budget, mandatory safety training, preserving the right of health care providers to counsel patients and other initiatives. We engaged avid firearm-owning surgeons, which we called the FAST Group and they also agreed on many policy changes and advocacy initiatives.
The American College of Surgeons Committee on Trauma held a Medical Summit on Firearm Injury Prevention in 2019, attended by 44 medical organizations (virtually all specialties) as well as the American Public Health Association (APHA) and American Bar Association (ABA), and, again, these organizations agreed on nine action steps, paraphrased:
- Firearm injury is a U.S. public health crisis
- Combined public health and medical approach is required
- Research is needed to better understand root causes of violence
- Federal funding must match the burden of disease (Injury research is poorly funded)
- Important to engage firearm owners and populations at risk
- Health care providers should counsel patients about firearm safety and safe storage
- Screening for risk of depression, suicide, intimate partner violence, and interpersonal violence should be conducted across all health care settings
- Hospitals and health care systems must engage communities in addressing social determinants of disease and injury, which contribute to structural violence
- All 44 organizations committed to working together on constructive action
While I was very involved through professional organizations in addressing possible legislation and policy initiatives, a major mass shooting occurred in my hometown of Las Vegas. While mass shooting deaths represent a small percentage of firearm-related deaths in the U.S., they represent much of the horror of firearm-related injuries and deaths and are an important call to action to address this growing public health crisis. They also underscore the need to understand and address the root causes of violence.
We in Southern Nevada know the horror of mass shootings, as well as the physical and emotional toll on the injured victims, families, health care workers, and our entire community. On the night of Oct. 1, 2017, the Las Vegas shooting occurred — Dr. Syed Saquib and I were the two trauma surgeons in-house at UMC when the patients started to arrive “en masse.” We stayed all night and well into the next day, along with many residents, attendings, and other health care professionals who were in-house, called in, or voluntarily came to help.
I feel an obligation to continue to work on policy, best practices and research to prevent these injuries and deaths, both in recognition of the suffering and deaths that have occurred and to prevent the same in the future.
So, I have been active in my professional organizations to address what are important consensus-based initiatives, several of which have been introduced to Congress — at the time I am writing this article, many are stalled at various stages of the legislative process. Several recent successes include: for the first time since the 1980s, beginning in 2020, there has been an appropriation of $25 million annually, divided between the National Institutes of Health (NIH) and CDC, to study firearm injury prevention. Several trauma surgery and emergency medicine organizations have committed the money to fund a two-year Firearm Injury Prevention Scholar, dedicated to firearm injury prevention research.
As I finish this article, several newsflashes came across my desk, including that the U.S. Senate, then the House, passed the Bipartisan Safer Communities Act, aimed at keeping firearms out of the hands of dangerous people and funding several measures to increase resources and safety. As the final details of the legislation President Biden signed become better known, we know there is still so much more that needs to be done to address this very complex medical-public health problem.
What else can we do? Action can include: talking with our patients about securing any firearms in their home, inquiring about firearms with our patients who may be at risk of harm to self or others, and discussing a firearms plan when a member of the household develops dementia. Many resources are being developed, including a digital and printable brochure on how to keep our families safe, health care provider webinar training and other resources to help health care providers learn how to speak with their patients about firearm safety.
We also can teach our students, residents, and fellows about this public health problem that affects people of all ages. Recent research publications have established priorities for firearm injury education and have developed educational priorities and curricula to teach residents to talk with patients about firearm injuries. We have an opportunity to develop interprofessional, culturally competent educational curricula and programs, and to engage in research to decrease injury and death in our community.
Startling statistics
Firearm-related deaths continue to rise at an alarming rate. Since 2017, the mortality rate for firearm injuries surpassed that of vehicular injuries and has continued to climb to a mortality rate of 13.7 per 100,000 population (2020). That translates to 45,222 firearm deaths in 2020, or 124 deaths per day.
Here is the breakdown of firearm deaths in 2020:
- 24,292 (53.7 percent) were suicide
- 19,384 (42.8 percent) were homicide
- 611 (1.4 percent) as a result of legal intervention
- 535 (1.2 percent) as a result of unintentional discharge of a firearm
- 400 (0.9 percent) unknown intent
Firearm deaths have also surpassed vehicular deaths for children and adolescents. By comparison, U.S. vehicular deaths totaled 40,698 in 2020 (12.4 per 100,000 population). Deaths are just the “tip of the iceberg” and several organizations are currently working on improved approximations for total firearm-related injuries in the U.S.
We must decrease firearm injuries and deaths, but it will require a multi-pronged approach. Legislation, policy changes, and financial resources are important to address this medical-public health problem. There are also important opportunities to learn to talk with our patients about keeping their families safe, to develop and implement curricula to educate our learners, as well as to engage in research to better understand and address the root causes of this complex medical-public health problem, and to develop evidence-based, effective prevention and intervention programs that can be implemented in our community.
