Firearm Injury & Emergency Medicine: Was 2020 a Good Year After All?
By Corey Hazekamp MS4 University of Illinois College of Medicine
Despite being a turbulent year that everyone is eager to put behind them, there is something to celebrate in 2020: The National Center for Injury Prevention and Control (NCIPC), Division for Violence Prevention, committed $7,836,869 to funding sixteen research projects related to firearms research! Each project fell under one of two research objectives: (1) to help inform the development of innovative and promising opportunities to enhance safety and prevent firearm-related injuries, deaths and crimes or (2) to rigorously evaluate the effectiveness of innovative and promising strategies to keep individuals, families, school, and communities safe from firearm-related injuries, deaths, and crime. As I write this, I just came off a shift in which two victims of intentional firearm injuries walked into the Emergency Department (ED) and were rushed into trauma surgery. I sit here wondering, how will this event change their lives? Because it inevitably will. Will they retaliate and continue the spread of violence? Will they be physically disabled and unable to work? Will they survive? These are likely just a few thoughts that cross the minds of Emergency Medicine (EM) physicians nationwide as we face a firearm-related injury epidemic that is currently lurking in the shadow of the COVID-19 global pandemic.
In 2018, the second and third leading cause of death among all 15- to 34-year-olds in the United States (US) was suicide and homicide from firearms, respectively.[1] Between 2003 and 2013, it was estimated that firearm injuries cost over $622 million annually in hospital admissions, of which uninsured patients averaged $155 million.[2] Between 2006 and 2014 it is estimated that firearm-related injuries collectively cost $174 billion annually in lost work, health care costs, criminal justice claims, and decreased quality of life.[3] The cost per person presenting to the ED for fire-arm related injuries was $5,254 on average and inpatient charges averaged $95,887, leading to an annual burden of $2.8 billion per year in the US between 2006 and 2014.[4] Using WISQARS data, this study estimated the annual financial burden of firearm-related injures was $45.6 billion after combining medical costs ($1.1 billion) with work-related costs ($44.5 billion). [4] Despite these jarring statistics, until this year, the federal government had allocated 0$ to funding firearm research due to the Dicky Amendment which prevented national funding from being used for researching or preventing firearm use.
After the Sandy Hook Elementary School shooting in Newtown, CT in 2013, a group of EM physicians published a call to action providing the groundwork for progressing towards the development of evidence based research to prevent firearm-related injuries.[5] In 2016, 27 experts on firearm research, led by EM physicians, convened to help provide goal directed research for firearm prevention. Five categories were targeted: (1) self-directed violence (suicide and attempted suicide), (2) intimate partner violence, (3) peer (non-partner) violence, (4) mass violence, and (5) unintentional (“accidental”) injury.[6] Fifty-nine specific questions were developed to help reduce the medical and public health burden of firearm injuries in the US via high-quality firearm injury prevention research.[6] Despite this specialty consensus however, severe lack of funding for firearm violence research persisted. As a familiar comparison, in 2017, while firearms were responsible for the same number of deaths as sepsis, funding for firearm violence research was only 0.7% that of sepsis. For every 100 articles published on sepsis, there are approximately four published on firearm violence. [4]
Despite these previous funding limitations, EM physicians and epidemiologists have recognized the need for evidence-based solutions to prevent firearm-related injuries and have managed to produce baseline research to highlight the need for national funding. Implementing a public health focus, they have approached violence in the same manner as a contagious disease; there is a disease agent (firearm and bullet), a vector of transmission (exposure to violence) and high-risk environment (concentrated poverty).[7] Their completed and ongoing research has provided important perspective and stepping stones for future EM-based interventions to build upon. While getting government-funded research entities to finally support firearm-related research has not been easy, several of the sixteen awards from the NCIPC presented in 2020 were given to EM physicians or ED researchers across the country including Dr. Aimee Moulin (UC Davis), Dr. Megan Ranney (Brown University), and Dr. Patrick Carter (University of Michigan) among others.
Dr. Moulin will be investigating the synergistic impacts of firearm access and opioid-related harm on firearm suicide risk at an individual and population level. Dr. Ranney will be evaluating how Reframe, a bystander intervention, can change firearm injury prevention norms, attitudes, intentions, and behaviors among a sample of adults and youths belonging to the 4-H Shooting Club. Dr. Carter will be studying how a technology enhanced behavioral intervention will reduce the risk of firearm behavior, firearm carriage, and violence with co-occurring mental health and behavioral risks among youth who seek treatment in the ED. Two other researchers with the EM team at UC Davis were also provided funding. Dr. Nicole Kravitz-Wirtz will estimate the population prevalence and consequences of youths’ direct and indirect exposure to community gun violence to inform prevention efforts. Dr. Rose Kagawa will examine neighborhood-level exposures and how they work to impact firearm violence. In addition, Dr. Jason Goldstick, with University of Michigan EM, will study how machine learning methods can optimize the ability to assess youth risk for firearm violence so that prevention resources and emergency department interventions can be used efficiently. All of the funded projects and descriptions can be found at: https://www.cdc.gov/violenceprevention/firearms/funded-research.html . So perhaps, let’s actually ‘cheers’ to 2020 and its profound progress toward generating evidence-based research to prevent firearm-related injuries while humbly recognizing this is as only one of many steps needed to address and solve an ongoing epidemic of violence.
BIBLIOGRAPHY
1. Centers for Disease Control and Prevention. Web-based Injury Statistics Query and Reporting System (WISQARS) [Internet]. 2020. Available from: https://www.cdc.gov/injury/wisqars/index.html
2. Peek-Asa C, Butcher B, Cavanaugh JE. Cost of hospitalization for firearm injuries by firearm type, intent, and payer in the United States. Inj Epidemiol. 2017;
3. Spitzer SA, Staudenmayer KL, Tennakoon L, Spain DA, Weiser TG. Costs and financial burden of initial hospitalizations for firearm injuries in the United States, 2006-2014. Am J Public Health. 2017;
4. Gani F, Sakran J V., Canner JK. Emergency department visits for firearm-related injuries in the United States, 2006-14. Health Aff. 2017;
5. Ranney ML, Sankoff J, Newman DH, Fenton A, Mukau L, Durston WE, et al. A call to action: Firearms, public health, and emergency medicine. Ann. Emerg. Med. 2013.
6. Ranney ML, Fletcher J, Alter H, Barsotti CE, Bebarta VS, Betz ME, et al. A Consensus-Driven Agenda for Emergency Medicine Firearm Injury Prevention Research. Ann Emerg Med. 2017;
7. Hargarten SW, Lerner EB, Gorelick M, Brasel K, DeRoon-Cassini T, Kohlbeck S. Gun violence: A biopsychosocial disease. West J Emerg Med. 2018;