Stemming the tide of violence

The recent rise in mass shootings and firearm violence across the U.S. has taken an emotional toll on all Americans, but we as surgeons witness firsthand the devastating effects of firearm injuries. To help effect change, the American College of Surgeons (ACS) issued a letter on violence, its impact on health care, and how surgeons can take the lead in finding solutions by addressing this crisis as a public health issue.¹

ACS perspective on violence prevention

“We understand that not all of our Fellows agree on firearms, but the College is dedicated to improving care for the surgical patient, and as frontline caregivers for survivors of these tragedies, we must convene and lead where these issues are concerned,” the letter to all ACS Fellows reads.

In February, a gunman took the lives of 17 people—14 of whom were students—at a high school in Parkland, FL. An additional 17 people were wounded. But firearm violence doesn’t only involve mass casualty events. Indeed, the Gun Violence Archive website shows that, as of March 15, 2018, 2,867 people in the U.S. died as a result of firearm violence.² An estimated 4,880 were injured as a result of firearm violence in the U.S. during the same time period, according to the website.²

The ACS first issued a Statement on Firearm Injuries in 1991.³ The statement was later revised and updated in both 2000 and 2013—the latter in response to the mass casualty event at Sandy Hook Elementary School in Newtown, CT.³

According to the 2013 ACS Statement on Firearm Injuries, the College supports the following initiatives:

• Enacting laws that would ban civilians from accessing assault weapons, high-capacity clips, and munitions intended for use by the military or law enforcement
• Strengthening and requiring background checks for individuals seeking to purchase a gun, including at gun shows and auctions
• Creating programs that educate and improve safe gun storage practices, as well as teach nonviolent conflict resolution
• Researching firearm injuries and creating a database on these types of injuries to inform federal health policies

After the Sandy Hook mass shooting event—during which a gunman shot and killed 20 first-graders and six adults—ACS Regent Lenworth M. Jacobs Jr., MD, MPH, FACS, convened a number of experts, and they developed the Hartford Consensus.⁴ This consensus of recommendations dealt primarily with the issue of how health care providers and law enforcement could work together to provide medical service to injured victims. The consensus led later to the development of the Stop the Bleed^® program, which trains laypeople in first-response measures to help individuals who are experiencing blood loss. To date, the program has trained more than 100,000 people.

In addition, the ACS Committee on Trauma (COT) is working to create an action plan to reduce firearm violence. Nine recommendations—which are still being fine-tuned—have been developed and include the following:

• Continuing to support the development of trauma systems and the Stop the Bleed program, as well as access to bleeding control kits in public places, across the country
• Gathering gun-owning Fellows to discuss violence prevention strategies, as well as surveying ACS members to better understand their views on firearm ownership and injury prevention strategies
• Supporting programs that aim to counsel patients on safe firearm storage practices and injury prevention methods in order to reduce violence-related injuries
• Conducting research and supporting efforts to strengthen background checks and enforcement of laws designed to keep firearms out of the hands of criminals

Active shooter situation in health care facilities

The Joint Commission also is acutely aware of the issue of firearm violence and its impact on health care institutions. A Quick Safety advisory on preparing for active shooter situations updated as of February 2017 provides additional resources and safety actions to consider for health care workers who are involved in an “active shooter” situation. An active shooter is defined as an individual who is actively engaged in killing or attempting to kill people, most commonly in confined and populated areas.⁵

These safety actions include the following:

• Involving local law enforcement in emergency plans
• Developing a communication plan for these types of events
• Establishing processes and procedures to ensure patient and employee safety
• Training and drilling employees on these procedures and for these types of events
• Planning how to handle the event after it ends

Additional resources from The Joint Commission include the following:

• Quick Safety, Issue 5: Preventing violent and criminal events⁶
• Sentinel Event Alert, Issue 45: Preventing violence in the health care setting⁷
• A Workplace Violence Prevention web portal that includes emergency management resources for security, violence, and active shooter situations

A challenge that must be addressed

In a study published in the March 2016 issue of the American Journal of Medicine, the authors found that the homicide rate involving firearms was 25.2 times higher in the U.S. than in other high-income countries.⁸ The results of the study also showed that the gun homicide rate among 15- to 24-year-olds was 49 times higher in the U.S. than in other high-income countries.⁸

These data demonstrate that a clear problem exists in this nation, which is why the ACS and The Joint Commission have taken action to try to better manage these emergencies and, hopefully, minimize injuries and deaths.

These actions are important, but more involvement from the surgical community is needed. The ACS and The Joint Commission join our nation’s students, parents, teachers, patients, nurses, and physicians in asking Congress to act. Americans need our leaders to adopt the mantra that gained traction hours after the tragedy at Marjory Stoneman Douglas High School: “No more.”

Disclaimer

The thoughts and opinions expressed in this column are solely those of Dr. Pellegrini and do not necessarily reflect those of The Joint Commission or the American College of Surgeons.

References

1. American College of Surgeons. Violence prevention. Available at: facs.org/quality-programs/trauma/violence-prevention. Accessed March 26, 2018.
2. Gun Violence Archive. Available at: www.gunviolencearchive.org/. Accessed March 15, 2018.
3. American College of Surgeons. Statement on Firearm Injuries.  Available at: facs.org/about-acs/statements/12-firearm-injuries. Accessed March 26, 2018.
4. American College of Surgeons. The Hartford Consensus. Available at: www.facs.org/about-acs/hartford-consensus. Accessed March 26, 2018.
5. The Joint Commission. Quick Safety, Issue 4. Available at: www.jointcommission.org/issues/article.aspx?Article=h1wY0qOAjXjKMD9Np15aXCoh6JDFt4iaFxb%2f%2fTKfNWE%3d. Accessed March 26, 2018.
6. The Joint Commission. Quick Safety, Issue 5: Preventing violent and criminal events. Available at: www.jointcommission.org/issues/article.aspx?Article=kPXQxso3Rvf%2by4zxRHf0Tbsma%2bstHA5lm6nrsN3mnm8%3d. Accessed March 26, 2018.
7. The Joint Commission. Sentinel Event Alert, Issue 45: Preventing violence in the health care setting. Available at: www.jointcommission.org/sentinel_event_alert_issue_45_preventing_violence_in_the_health_care_setting_/. Accessed March 26, 2018.
8. Grinshteyn E, Hemenway D.  Violent death rates: The U.S. compared with other high-income OECD countries, 2010. Am J Med. 2016;129(3):266-273.