The Firearm Violence Epidemic

September 2019


You’re working yet another busy Saturday night in TCC, taking care of an array of
traumatic and non-traumatic injuries. After intubating a patient for respiratory
failure, you get a page for another level 1 trauma with a GSW to the chest. The
patient arrives in extremis with a hypotension and an obtunded mental status.
After prolonged and exhaustive resuscitative efforts (including intubation, bil
finger thoracostomies, large volume MTP blood transfusion, and ultimately a
thoracotomy), the patient is declared dead.

You care for three more GSWs throughout the night, though thankfully all of
these patients survive to hospital admission. At the end of your shift you feel
emotionally exhausted. You begin speaking with Dr. Laurie Punch about your
feelings, having previously seen her TEDx talk, “How Bullets Go Deep,” and ask
her to send you any articles she can to help you put our local crisis in
perspective. You then go home and, after a fitful day’s sleep, do your own
literature search, diving deep into the topic…


Article 1: Choi PM, Hong C, Bansal S, Lumba-Brown A, Fitzpatric CM, Keller MS.  Firearm injuries in the pediatric population: A tale of one city.  J Trau,a Acute Care Surg.  2016 Jan;80(1):64-9

Article 2: Rattan R, Parreco J, Namias N. Pust GD, Yeh DD, Zakrison TL.  Hidden Costs of Hospitalization After Firearm Injury:  National Analysis of Different Hospital Readmission.  Ann Surg. 2018 May;267(5):810-815

Article 3: Olson EJ, Hoofnagle M, Kaufman EJ, Scwab CW, Reilly PM, Seamon MJ.  American firearm homicides:  The impact of your neighbors.  J Trau,a Acute Care Surg. 2019 May;86(5):797-802.

Article 4: Goyal MK, Badolato GM, Patel SJ, Iqbal SF, Parikh K. McCarter R.  state Gun Laws and Pediatric Firearm-Related Mortality.  Pediatrics.  2019 Aug:144(2).

Brief Bottom Line

After declining during the 1990s, gun murder and suicide rates in the United
States have been on the rise over the last several years. Locally, a retrospective
cohort study among pediatric patients in St. Louis identified 398 children under
16 years of age who suffered firearm injuries over a 5-year period from 2008 to
2013. The overall mortality rate was 5% and a disproportionate number of
shootings occurred among blacks and in areas with lower median household
incomes. Among victims of accidental shootings, only around half were black and the median age (12.5 years) was lower tan among intentional shootings (15 years).

While the overall burden of firearm injuries is difficult to quantify, particularly given
the associated psychological effects, some have attempted to at least evaluate
costs associated with this epidemic. Rattan et al looked at the costs specifically
associated with readmission following hospitalization for a firearm injury. While
the overall cost of initial admission for a firearm-related injury was $1.45 billion,
the total cost of 30-day readmission was $54.2 million and the total cost at one
year was $131 million. The overall societal cost is likely much higher, as this does
not include the costs of rehabilitation, follow-up, and lost work associated with
these injuries.

Given the high burden of disease and high costs, some studies have attempted
to look at the effects of state gun control laws on the incidence of injuries and
homicide. Among patients 21 years of age or less, more restrictive gun control
laws (measured by the Brady Campaign to Prevent Gun Violence) were
associated with a decreased risk of firearm-related mortality (incident rate ratio
[IRR] of 0.92; 95% CI 0.89 to 0.96). This decreased risk persisted after
adjustment for racial and ethnic proportions, education, poverty, and gun
ownership rates (IRR 0.96; 95% CI 0.93 to 0.99). Taking this further, Olson et al
attempted to look at the effects not only of each state’s gun laws, but of the gun
laws of neighboring states. While the model used in this study was far from
perfect, there was an association between the calculated “Border Adjustment
Score” and firearm mortality and firearm homicide rates.