Firearm Injury: An Escalating Health CrisisFREE

An estimated 50 000 people in the United States lost their lives to guns in 2021 (1). An infectious organism responsible for that many deaths would clearly be considered a public health threat, and that is why the American College of Physicians sees gun injury as a public health issue (2). Reducing the negative impact of guns on the health of the U.S. public requires multidisciplinary efforts involving government, law enforcement, gun manufacturers, and others—health care professionals also have an important role. Physicians encounter patients who suffer the adverse consequences of firearm injury personally, via injury to a loved one or neighbor or because the ubiquity of guns makes them feel unsafe in their communities. Firearm injury in the United States highlights deep-seated inequities: The firearm homicide rate among Black individuals is consistently and substantially greater than that among White individuals (3). Gun injury is very much in our lane.

On 11 January 2023, Annals of Internal Medicine and the American College of Physicians gathered a panel of experts to discuss what health care professionals can do to reduce the adverse impact of guns on the health of their patients. Dr. Sue Bornstein, a general internal medicine physician and Chair of the Board of Regents of the American College of Physicians, moderated the discussion. Panelists were Marian (Emmy) Betz, MD, MPH; Scott P. Charles, MAPP; and Thea L. James, MD, MPH, MBA. Dr. Betz is an emergency medicine physician at University of Colorado who conducts research in injury epidemiology and prevention. She co-founded and leads the Colorado Firearm Safety Coalition. Mr. Charles is the Trauma Outreach Manager for Temple University Hospital and is Director of Temple's Cradle to Grave Program, an award-winning hospital-based initiative on violence prevention that educates public school students and adjudicated youth about the medical realities of firearm injury. He also coordinates the hospital's Trauma Victims Support Advocates program. Dr. James is Vice President of Mission and Associate Chief Medical Officer at Boston Medical Center. She is an Associate Professor of Emergency Medicine and Director of the Violence Intervention Advocacy Program at Boston Medical Center. Dr. James is a founding member of the National Network of Hospital-Based Violence Intervention Advocacy Programs.

After Dr. Bornstein introduced the panelists, attendees had an opportunity to respond to 3 clinical vignettes about patients affected by or at risk for firearm injury before the panelists discussed their approaches. The panelists then addressed questions that had been submitted by attendees when they registered for the program.

The panelists all emphasized the importance of listening to patients, acknowledging their situation, and establishing a relationship before raising the topic of guns in a nonjudgmental manner focused on the safety of the patients and those they care about. The panelists emphasized that no U.S. state currently has laws that prohibit physicians from talking about guns with their patients. Dr. Betz provided a very pragmatic approach to use in situations where a physician is hesitant to ask a patient whether they have access to guns---don't ask. Instead, provide advice about safe gun storage along with reducing household hazards for vulnerable persons, safely storing medications, or keeping car keys away from household members for whom driving is unsafe.

Mass shootings and firearm-related homicides tend to get more attention than suicides, but half of firearm deaths are from suicides and half of suicides involve firearms. Impulsive behavior characterizes many suicides. Thus, when suicide risk is a concern, discussion of access to guns warrants a direct approach. The panelists thought it was preferable to engage the patient in voluntary means to reduce risk, such as storing the guns outside the home, before invoking extreme risk protection orders (“red flag laws”), which in some locales must be initiated by family members or law enforcement rather than health care professionals. When risk is very high, such action, which not only removes currently accessible guns but prevents the at-risk person from purchasing new guns, may be justified.

The program also covered the care of victims, including not only the person directly injured but also their family members and others who become caregivers in the face of nonfatal injury or suffer grief when the injury is fatal. The panelists highlighted resources available to victims in many locales that physicians practicing outside emergency department settings may not be aware of, such as through the Health Alliance for Violence Intervention (www.thehavi.org). The services provided range from counseling and mentoring to housing and employment support. This discussion raised the critical need to address the many social determinants involved in the risk for and consequences of firearm injury in the United States.

To date, infectious disease outbreaks—COVID-19 and mpox---have been the focus of these virtual forums. Here we shifted focus to another public health crisis: firearm injury. Currently, more Americans lose their lives to firearm injury than to motor vehicle crashes. Firearms are now the leading cause of death for children in the United States (4). In a nation that has come to have more guns than people (5), every day people are killed or injured in firearm-related accidents, homicides, and suicides. Physicians and other health care professionals have a responsibility to take action both to prevent these injuries and deaths and to care for those who suffer their sequelae. We encourage you to watch the Video of this program.