June 2022- Special Edition Firearm Injury Prevention

This issue was prepared by EAST Injury Control and Violence Prevention Committee Members Linda Dultz MD, MPH, Anna Goldenberg MD, Hee Soo Jung MD, and Leah Tatebe MD.

As we are continuously reminded, tragedy after tragedy, firearm violence is the leading cause of death in young people in the United States. Every day in 2020, an average of over 123 people (45,222 people a year) died from firearm-related injuries.
 
In the context of recent events and the ongoing public health crisis, the Eastern Association for the Surgery of Trauma, the Manuscript and Literature Review Committee, and the Injury Control and Violence Prevention Committee has prepared this Special Edition Literature Review as an affirmation of our commitment as trauma care providers to reduce firearm-related injuries. In this edition, we highlight some important findings, statements, and recommendations regarding firearm injury prevention from trauma care societies.

EAST Statement on Firearm Injury Prevention

Released in December 2018 and published in 2019, EAST stated its support for the following evidence-based strategies to address the public health crisis of firearm injuries:

1. Federal funding of firearm-related research to inform solutions.
2. Violence and injury prevention programs that address conflict resolution.
3. Programs that teach nonviolent conflict resolution, coping strategies, and anger management.
4. Improved access and quality of mental health services.
5. Recognition of the other factors that affect these issues including structural violence, domestic violence, and mental health.
6. Limited access to firearms through mandatory safe storage (keeping guns unloaded in a safe with ammunition stored in a separate locked device), gun locks, trigger locks, and other safe storage practices.
7. Expanded universal background checks to include all firearms sales in any venue.
8. Mandatory waiting periods and universal background checks for acquisition of firearms.
9. Limited civilian access to highly lethal firearms and firearm accessories, such as high velocity rifles, high-capacity magazines, trigger cranks, and bump stocks.
10. Limited dissemination of technology to enhance lethality or bypass standard safety and/or screening (e.g., 3D printing firearms).

EAST continues to call for evidence-based solutions for firearm-related injury.
 

American College of Surgeons: Accelerating Our Response to America's Firearm Public Health Crisis

American Association for the Surgery of Trauma Statement on Firearm Injury
 

As a literature review, the views expressed in these highlighted publications are those of the authors and their expressed affiliated professional societies. They do not necessarily reflect the views and opinions of EAST, the EAST Board of Directors, or the EAST membership.
 
Hee Soo Jung, MD FACS FCCM
Chair, EAST Injury Control & Violence Prevention Committee

In This Issue: Injury Prevention 

Article 1
Recommendations from the American College of Surgeons Committee on Trauma's Firearm Strategy Team (FAST) Workgroup: Chicago Consensus I. Talley CL, Campbell BT, Jenkins DH, Barnes SL, Sidwell RA, Timmerman G, Gross RI, Coburn M, Bailey JA, Eastman A, Ficke J, Kuncir E, Letton RW, Eastridge BJ, Liepert AE, Wilson A, Robinette D, Davis JW, Shalgian C, Michaels H, Weissler MC, Kuhls DA, Bulger EM, Stewart RM. J Am Coll Surg. 2019 Feb;228(2):198-206.

Firearm related injury and death continue to be an ongoing epidemic in the United States. Various medical organizations have worked on development of effective tools to not only reduce firearm injury but also to educate and engage the community on safe firearm practices. The American College of Surgeons Committee on Trauma (ACS COT) has created a dialogue that incorporates an all-inclusive approach to opinions on firearm safety and injury.  The Firearm Strategy Team (FAST) Workgroup specifically wanted to look at firearm owners in the US, particularly surgical leaders in the trauma community who were passionate about firearm ownership and had an extensive knowledge base about firearm safety and regulation.
 
For five years the ACS COT FAST group worked on a consensus strategy on how to best reduce firearm related injury, disability and death. The focus was to get input from passionate gun owners on how to make firearm ownership safer, decrease the risk of intentional mass shootings, and start to address the culture of violence in the US. All members of the group needed to agree with the recommendation. When it came to obtaining ownership, it was supported that robust backroad checks be conducted before any purchase or exchange of firearms. In addition, it was recommended that firearm reporting systems be kept up to date and should be standardized. It was also agreed upon that all firearms be registered with the ability to be tracked. When it came to licensure, there was no consensus on all firearm ownership but did recommend state licensure in the form of concealed carry permits by state that should be applied for.
 
When discussing education, the workgroup recommended that formal fun safety and training should be mandatory for new gun owners. In addition, it was recommended that there should be adult supervision for anyone younger than 12 years and indirect supervision of anyone between 12 and 18 years of age. All owners should practice safe and controlled firearms storage. Any owner show is deemed a risk to themselves, or others should have a temporary or permanent restriction of their ownership. All mass shootings should be treated as an act of terrorism and involvement of law enforcement professionals is paramount in decreasing injury. The committee extensively discussed research and concluded that research should be federally funded and should always have a broad agenda which would include the root cause of violence, effects of media, effective forms of storage, safety and training classes, effectiveness of restricting access, epidemiology of the high-risk populations, and the effects of firearms lethality differences.
 
Furthermore, although the committee preferred more research for gun violence, a recommendation was made to not highlight mass killings but rather take steps to eliminate any attention to such events to reduce notoriety and copy-cat events. Increased mental health screening were highlighted and focused on early recognition by any individuals that are known to the person who is of concern with immediate reporting to local and national law enforcement.
 
In conclusion, members of the FAST workgroup set forth the recommendation as a guide to reduce firearm related injury and death and empower the public. The problem is in fact complex with no immediate and fast solution, but the goal is to keep firearms out of the hands of people who pose a danger to themselves and others as well as provide safe practice guidelines for the general gun owner.

Article 2
Strategies for Trauma Centers to Address the Root Causes of Violence: Recommendations from the Improving Social Determinants to Attenuate Violence (ISAVE) Workgroup of the American College of Surgeons Committee on Trauma. Dicker RA, Thomas A, Bulger EM, Stewart RM, Bonne S, Dechert TA, Smith R, Love-Craighead A, Dreier F, Kotagal M, Kozyckyj T, Michaels H; ISAVE Workgroup; Members of the ISAVE Workgroup. J Am Coll Surg. 2021 Sep;233(3):471-478.

As surgeons, it is all too easy to relegate our services to mere plumbing and carpentry while ignoring the humanity behind the injuries. Truly comprehensive trauma care, however, requires that we understand the environments from which our patients come to us and what they face upon their return. The authors state that we have to actively and thoughtfully recognize and address the effects of social determinants of health and structural racism in order to exercise effective injury prevention strategies.
 
The social determinants of health cross 5 domains: economic security, social and community context, neighborhood and built environment, healthcare and quality, and education access and quality. It is felt that healthcare itself only contributes to about 20% of an individual’s health and wellness, while socioeconomic factors contribute to >40%. The long history in America of sequestering racial and ethnic groups into areas with lower quality education, security, healthcare, etc. has created significant structural factors that have worsened racial disparities in health. The authors state that injury prevention has to work to repair these systemic inequities.
 
The authors present an elegantly written overview of the efforts thus far from the ISAVE (Improving Social Determinates to Attenuate Violence) workgroup, a priority of the American College of Surgeons (ACS) Committee on Trauma. In order to be inclusive of all primary stakeholders, ISAVE was built to have members from multiple areas of medicine (surgery, emergency medicine, internal medicine, psychiatry, and pediatrics), hospital and community-based violence intervention programs, community-based organizations, and law enforcement.
 
Those of us dedicated to injury prevention have watched expectantly over the last few years, awaiting these initial recommendations. The enumerated four strategies highlighted by the ISAVE workgroup should be set as a new standard all trauma centers should strive to meet.
 

1. TIC can not only assist us in providing empathic and compassionate medical care, but it can also address the factors that contribute to reinjury. The TIC curriculum now in development could be used to augment medical education. Some hospitals have begun to train all patient-forward employees in TIC. This initiative could be used to allow the ACS to lead the nation in the promotion of TIC education. TIC is injury prevention.
2. Consideration should be made for hospital-based violence intervention programs (HVIPs) to be made a verification requirement for Level 1 trauma centers. Physicians should further be encouraged to incorporate social care into part of the acute trauma resuscitation and response team.
3. The call for trauma centers to invest in their own at-risk communities is admirable, but would likely be met with economic feasibility concerns from already underfunded urban centers. As the authors point out, hospitals can start by building local vendor relationships to feed targeted economic growth.
4. We are fierce advocates for our patients’ health, and we need to be just as committed to advocating for the resources they need to thrive through civic engagement. This should include meaningful and sustainable grant funding for evidence-based injury prevention research and HVIPs.