Addressing the Growing Issue of Firearm Injuries

ACS Awarded Grant to Identify Risk Factors

It's hard to stop what you don't understand.

To address the growing issue of firearm-related trauma, the American College of Surgeons Committee on Trauma (ACS COT) is launching a multi-center prospective study on individual and community risk factors for non-lethal gunshot injuries in the United States. The new study is made possible by a two-year, $711,218 grant from the National Collaborative for Gun Violence Research.

"In the last two years of data available from the CDC, firearm-related deaths exceed vehicular deaths," said Deborah Kuhls, MD, FACS, FCCM. "And for all-cause trauma, it is the leading cause of death up through the first 44 years of age."

Kuhls, who is the immediate past chair of the ACS COT Injury Prevention and Control Subcommittee, has been an integral part of the national leadership team defining a public health approach to firearm injury prevention. A professor of Trauma and Critical Care in the Department of Surgery at the University of Nevada, Las Vegas, Kuhls is also medical director of University Medical Center's Trauma Intensive Care Unit. She was one of the surgeons on duty when casualties started arriving in October 2017 in the wake of the mass shooting during a country music concert that left nearly 900 injured and 58 dead.

Kuhls said gunshot trauma - both intentional and unintentional - has been increasing dramatically for several years. She stressed the need to move the dial on research in order to create evidence-based interventions that might turn the tide on injuries ... and ultimately fatalities.

"When you look at the amount of research allocated proportionately to cause of death, firearm injury prevention research is very underfunded compared to funding allocated to other causes of death," she noted. Gun violence is one of the five leading causes of death for Americans up to age 64, yet research dollars have lagged far behind allocations to heart disease, stroke and cancer. However, she continued, research funding is beginning to open up with renewed efforts to better understand best practices for prevention, treatment and recovery.

"This particular grant is private, but some very exciting things are happening on the federal level, too," she said. "For the first time since the 1980s, there were federal funds appropriated to study firearm-related injuries and deaths."

Utilizing the ACS Trauma Quality Improvement Program (TQIP) network, the new research project looks to engage current participants by having them collect and input additional data surrounding firearm injuries being seen in trauma centers across the country. "We are expanding the data collected to include information that we don't currently have in the U.S.," Kuhls said, adding information on the type of weapon, comorbidities, mental health issues and other data points will help expand the body of knowledge. She added much of the new information that will be requested is commonly found in the medical record so it isn't anticipated to add significant burden to busy trauma centers.

While statistics on firearm deaths are reported, there is currently a gap in understanding about the scope and burden of non-lethal injuries. "We want to understand the circumstances of the shooting better than we do now," she explained. By improving contextual information, the hope is to create effective upstream interventions.

"The end game is we hope the data we get from this study can inform injury prevention and be targeted to those most at risk of injury," said Kuhls.

She added the two-pronged approach of public education and effective policy that helped decrease motor vehicle injury and death also could be applied to firearms. "We didn't outlaw motor vehicles, but we worked with the industry on a lot of meaningful federal standards for safety," Kuhls pointed out. "We're optimistic we can start to gain some insight into how we can prevent injuries from happening when people are around firearms, as well."

The ACS COT study is among $7.5 million in grants recently announced by the National Collaborative for Gun Violence Research to help fund 15 research projects. The latest round of support by the Collaborative follows $9.8 million in grants last year to fund 17 research projects.

ACS Study Documents Cost of Gunshot Wounds Requiring Surgery

Days after winning a grant to study firearm trauma, the American College of Surgeons released information from a large national study of the increasing frequency, cost and severity of gunshot wounds that require surgical intervention. The study, which appeared as an "article in press" in the Journal of the American College of Surgeons website in August ahead of print, outlines an annual cost to the U.S. health system of $170 billion for gun violence overall, with $16 billion for operations alone.

The researchers used the National Inpatient Sample (NIS) to identify all hospital admissions for gunshot wounds (GSW) from 2005 through 2016. The researchers did not look at all adult GSW victims admitted to the hospital, estimated at 322,599, but only at the 262,098 victims who required at least one major operation.

"We're now seeing a lot more on the impact of gun violence," said lead study author Peyman Benharash, MD, MS, and an associate professor-in-residence of Surgery and Bioengineering at the David Geffen School of Medicine at the University of California Los Angeles. "In the past, gun violence was never really discussed in the open; it was thought to only affect a certain population. However, now we know that it affects everyone. In the hopes of trying to reduce it at a systemic level from top to bottom, we're reporting, as surgeons, how gun violence in the patients that we treat has changed over the last decade."

Improved survival of GSW patients is a function of improvements in trauma transport from the field, better prehospital resuscitation, and improved techniques, patient management and adjunct therapies once they get to the hospital, Benharash said. "It appears that patients are reaching surgery more often because of reduced mortality before they get to the hospital," he added.

The study also attributed improvements in survival to efforts by the ACS Committee on Trauma, including the Advanced Trauma Life Support curriculum and Stop the Bleed^® campaign. The latter trains the public in techniques to stop life-threatening bleeding in everyday emergencies.

However, Benharash noted those improvements don't obviate the need for addressing the underlying problem "We hope that our findings are able to better inform policy in terms of violence prevention, as well as reimbursement to hospitals, which are often in underserved regions, that care for these patients."

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