Gun Violence More Health Problem Than Criminal Justice Issue

Ingrid Hein

November 20, 2019

Last year during hunting season, a patient with depression presented to the emergency department at the Berkshire Medical Center in Pittsfield, Massachusetts. Members of the hospital staff "were worried about him hurting himself. I knew he owned a bunch of guns," said attending emergency physician Christopher Barsotti, MD.

As a Vermont rifle instructor for the 4H Club, Barsotti is at ease talking to patients about guns. "To me, firearms safety is a natural conversation," he told Medscape Medical News. "I just asked our patient, Are your guns inside the house?"

The patient said yes, and agreed with Barsotti that it was appropriate to have the guns "out of the house for the time being." A conversation with the family followed, and the guns were temporarily removed.

Barsotti is the chief executive officer of the American Foundation for Firearms Injury Reduction in Medicine (AFFIRM), a nonprofit organization made up of researchers and physicians who raise money to help curb the epidemic of gun violence. AFFIRM is focused on funding research that informs protocols for emergency departments and others on the frontlines of medicine.

We need to stop dealing with guns as a criminal justice problem; that's not going to solve it, said Barsotti. We can't legislate the end of violence. "The gun-control versus right-to-bear-arms conversation is not changing anything."

Instead, "we have to solve this as a health problem, by mitigating risk and reducing harm," he told Medscape Medical News.

"I have patients who have had ideas about emulating Columbine," he added. "What do I do if this person in front of me is considering an act of public violence?"

"We have a protocol for almost every single thing — for example, for when elderly people fall or when people go through alcohol withdrawal — but there's no clinical guidance for this huge problem, no algorithm to evaluate people who may harm themselves or others," he said.

We have to solve this as a health problem, by mitigating risk and reducing harm.

"Gun violence is a public health issue that has a large impact on society and the healthcare system, emergency medicine in particular," said David Callaway, MD, from the Carolinas Medical Center in Charlotte, North Carolina.

"Our goal should be to identify risk factors associated with gun injuries, then put policies in place to mitigate those risks," he told the audience during his keynote lecture on gun violence at the American College of Emergency Physicians 2019 Scientific Assembly in Denver.

When approached in this way, "you can take the emotion out of the conversation and focus on the goal, which is to reduce injury and death," he explained.

In the emergency department, alcohol and substance abuse, a mental health crisis, or events that lead to a crisis or trauma are all risk factors for gun violence, said Callaway.

"We see all of that on a daily basis," he pointed out. "And when we do, we have to ask ourselves: Are we just going to take care of the problems when they are acute, like putting our fingers in the holes of a dyke? Or are we going to say, we've seen the consequences, we have some understanding of these problems. Let's apply the principles of prevention."

After the Sandy Hook shooting in Newtown, Connecticut, Megan Ranney, MD, from the Rhode Island Hospital in Providence, said she was compelled to step up and support a change in medicine on gun violence. "I've got two kids; it could have been one of them," she told Medscape Medical News. "That was the moment for me when I thought, we have to change our approach to gun violence and look at it as a medical problem."

"We've decreased the number of car crashes by 70% since the 1960s, not by taking away cars," Ranney said. "We have to offer education, do research, and figure out where the risks are and how they can be mitigated."

Before Sandy Hook, the topic of gun violence was off the table for physicians. "We were all scared to talk about it; it was too political," she explained.

But after Sandy Hook, Ranney went to the chair of her hospital and told him she did not want to be silent. He gave her permission to go and talk about it. "I'm a permission person," she said.

"We're changing the discourse around the firearm problem, standing together for the public health," she said. "As a mother, it matters immensely to me. As a physician, not a day goes by in most of our emergency departments when it doesn't matter."

Principles of Prevention

To decrease the risk, we have to get specific, said Callaway. For example, "we can tell parents they can decrease risk by simply locking their guns and storing them separately from ammunition."

Having nonjudgmental conversations, asking parents if they have devices to lock their guns, and offering education are all ways to "be preventive," he said.

"If a weapon is stored away from ammunition, you can decrease the risk of child suicide or injury tenfold," he reported, citing a report published in Pediatrics.

Currently in the United States, fewer than half the states have "red flag laws" — also known as extreme risk protection orders, gun violence restraining orders, risk warrants, and proceedings for the seizure and retention of a firearm — that permit police or family members to petition the court to temporarily remove firearms from people who might be a danger to themselves or others.

Although these laws have "the potential to reduce suicide, intimate-partner violence, and mass shootings," the challenge is that they are different in every state and there are no ground data on risk, said Callaway.

Where should doctors fall in all this? What should clinicians do in a state that has a red flag law? Do they petition the courts? These laws "need to be studied to a greater degree," he said.

This is not about gun control; it's about how we keep one another safe, both as clinicians and members of the community.

Emmy Betz, MD, from the Colorado School of Public Health in Aurora, started the Patient-Centered Injury Prevention initiative not only as a way to keep guns away from people with risk factors that might put them in harm's way, but also to help clinicians make decisions on when older people should stop driving.

"This is not about gun control; it's about how we keep one another safe, both as clinicians and members of the community," she said.

The focus of the initiative is to find solutions that make it easier for people to see risks and take preventive actions, she told Medscape Medical News.

"Even as a parent myself, I realized I rarely asked my patient's parents if there are unlocked guns in the home," she said. "Why don't I do that?"

Betz is also a cofounder of the Colorado Firearms Safety Coalition, alongside Dick Abramson, chief executive officer and general manager of the Centennial Gun Club, and officials from several suicide-prevention groups. The coalition focuses on forging partnerships with gun shops that can store guns for people whose firearms are removed from the house temporarily, especially those at risk for suicide.

A dynamic online map on the coalition website shows gun owners where they can find gun shops and law enforcement agencies that will consider requests for temporary voluntary gun storage. The project was inspired by the New Hampshire Firearms Safety Coalition, said Betz.

In a recent overview, Betz and her colleagues discuss strategies to help clinicians assess risk and intervene in emergency situations.

"These activities generally involve a patient who already owns or has access to firearms, but much of what we present is applicable to counseling a patient who does not have a firearm and is considering whether to acquire one," the team writes.

"We know that violence does not happen in a vacuum," said Barsotti. Some of the common risk factors are previous violence, substance abuse, and abuse as a child, and we know that at a certain point in people's lives, more risks can be added."

"When people go through a crisis, you want to make violence as logistically difficult as possible. Keeping firearms secure is part of that," he told Medscape Medical News.

American College of Emergency Physicians (ACEP) 2019 Scientific Assembly. Presented October 27, 2019.

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