How Emergency Physicians Are Working to Prevent Firearm Injury

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As emergency physicians, we are the first and often the only physicians to see victims of firearm injury. We are the docs who are the first to manage the aftermath of a mass shooting. We are the ones most at risk of active shooters in our own hospitals, and we are the ones who have to handle the legal questions that come with a patient with violent tendencies who has been dropped off at our door by the police. We see both the immediate and long-term effects of these injuries, and of course, many

of us came to emergency medicine from prehospital or military backgrounds, where we had more immediate firsthand experience. Firearm injury is an issue that impacts all of us.

We see how it’s getting worse. More and more of us are joining the awful club of having had to treat a mass shooting. More and more of us have had family members or friends who have been injured. More and more emergency physicians are being hurt or killed, most tragically and notably with the shooting death of Tamara O’Neal, MD, outside her emergency department at Mercy Hospital in Chicago.

However, we also know that we don’t have to accept injury or disease outbreaks as a fait accompli. We have a long history of mobilizing, as emergency physicians, to identify and then reduce patterns of injury. Doing this work is nonpartisan; it’s based on science and great research. Through this public health approach, emergency medicine has been a critical leader in national and local efforts to reduce car crash deaths and child abuse, plus is leading the charge against opioid overdose deaths, human trafficking, and more.

Emergency medicine is also a leader in developing a public health approach to reduce firearm injuries. Through this approach, we can make a difference in the prevalence, severity, and long-term consequences of gunshot wounds across the country.

A short list of actions by ACEP includes:

• Six years of work by the ACEP Trauma & Injury Prevention Section to highlight the importance of addressing firearm injury as a public health problem
• Lectures on firearm injury prevention at ACEP17 and ACEP18
• A firearm injury prevention policy that was rewritten in 2013 and is currently being reevaluated by the Public Health & Injury Prevention Committee in addition to the original task force
• Completion of a Technical Advisory Group on emergency medicine–relevant firearm injury research, culminating in a publication in Annals of Emergency Medicine in 2016¹
• Active advocacy for federal funding and universal background checks, in accordance with ACEP’s firearm injury prevention policy
• Completion of two surveys of emergency physicians’ firearm injury prevention practices and beliefs through the EM-PRN network
• Donating $20,000 to the American Foundation for Firearm Injury Reduction in Medicine (AFFIRM), a not-for-profit organization founded and led by emergency physicians

Additionally, emergency physicians have led national non-ACEP-affiliated efforts to change the trajectory of this epidemic. A short and incomplete list includes:

• Development of the “What You Can Do” video series on screening and counseling by Garen J. Wintemute, MD, MPH, at UC-Davis Health in Sacramento, California
• Development of the National Institutes of Health–funded Firearm Safety Among Children and Teens consortium, led by Rebecca Cunningham, MD, FACEP, and Patrick Carter, MD, at the University of Michigan in Ann Arbor, with the collaboration of numerous emergency physicians across the country
• Leadership of the National Network of Hospital-Based Violence Intervention Programs by Kyle Fischer, MD, MPH, of the University of Maryland in College Park; Robert Gore, MD, of Kings County Hospital in Brooklyn, New York; and many more
• Development of novel coalitions between gun shop owners and firearm injury prevention researchers led by Marian (Emmy) Betz, MD, MPH, at the University of Colorado-Denver
• Promotion of the #StopTheBleed training by Eric Goralnick, MD, FACEP, at Brigham and Women’s Hospital in Boston
• Development of a scholarship fund in honor of Dr. O’Neal by the University of Illinois-Chicago residency and a memorial research fund in her name by the AFFIRM and FemInEM
• The #ThisIsOurLane movement, covered in The New England Journal of Medicine with a piece by myself, Dr. Betz, and Cedric Dark, MD, MPH, of Baylor College of Medicine in Houston²

Individual emergency physicians have written numerous publications and led local movements as well. There simply isn’t space to list them all.

Lastly, emergency physicians have led the charge to develop new sources of research funding. Firearm injury prevention research is currently funded at about 2 percent of what would be predicted, and the Centers for Disease Control and Prevention still has $0 for this public health issue.

In 2017, AFFIRM was founded under the leadership of Christopher Barsotti, MD, FACEP, FAAEM, in response to this continued lack of substantive federal funding for firearm injury prevention research. Its underlying concept is that the public’s health is our job and that we cannot solve the firearm injury epidemic by treating patients who have already been shot. Instead, we need a full-scale collaborative effort, the collective will of medicine, to bend the curve on firearm injuries and deaths.

The mission of AFFIRM is to reduce firearm injury deaths through research, innovation, and evidence-based practice. AFFIRM knows that through clinically relevant research and dissemination of best practices, we can stop many shooters before they shoot. AFFIRM has the partnership of almost 20 medical societies, including ACEP, the Emergency Medicine Residents’ Association (EMRA), and the Emergency Nurses Association. It represents physicians and health care professionals along the political spectrum who are united in the belief that we need to find a new way forward; the old ways of fighting this epidemic aren’t working. Examples of AFFIRM’s work include:

• Under the leadership of Dr. Betz, the chair of the Research Council, AFFIRM is co-funding research grants with the Emergency Medicine Foundation and EMRA, as well as with the Firearm Safety Among Children and Teens consortium, based off of ACEP’s published research agenda, to spur innovative, clinically relevant approaches to reducing the firearm injury epidemic.
• AFFIRM developed the Dr. Tamara O’Neal Memorial Research Fund last November, in collaboration with Dr. O’Neal’s friends, co-residents, and family. This fund honors Dr. O’Neal’s memory. Its goal is to create meaningful change in her name by funding research that addresses the issues she most cared about, including sponsorship of people of color and development of youth mentorship programs.
• AFFIRM is developing infographics, blog posts, podcasts, and educational slide decks under the leadership of Nikita Joshi, MD, AFFIRM’s director of education and outreach, along with numerous other members of AFFIRM’s advisory board and research council, to help disseminate all of this awesome work.
• Finally, AFFIRM is organizing a series of events across the country this fall, “AFFIRM Across America,” to highlight the personal stories of all of us who have treated or been personally affected by gun violence—and to create hope. Emergency physician Charlotte Lawson, MD, is leading this initiative.

Emergency medicine is once again at the forefront of change. We are creating a path forward that isn’t “us versus them.” It’s all of us together, speaking out on behalf of our patients and communities, to tackle firearm injury the same way we’ve addressed every public health epidemic in history, through nonpartisan research, evidence-based practice, and community-oriented solutions.

To learn more about AFFIRM, please visit AFFIRM Search.

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Dr. Ranney is director of emergency digital health innovation and special projects and associate professor in the department of emergency medicine and department of health services, policy and practice at Brown University and the Injury Prevention Center of Rhode Island Hospital in Providence. Disclosure: She serves as AFFIRM’s chief research officer, a volunteer position.

References

1. Ranney ML, Fletcher J, Alter H, et al. A consensus-driven agenda for emergency medicine firearm injury prevention research. Ann Emerg Med. 2017;69(2):227-240.
2. Ranney ML, Betz ME, Dark C. #ThisIsOurLane – firearm safety as health care’s highway. N Engl J Med. 2019;380(5):405-407.