Treating gun violence before the 911 call.

Treating gunshot wounds is an important skill for emergency physicians. It is therefore fitting that our specialty’s premier journal devotes space to this topic. Over the past several years, Annals has published important studies, reports, and editorials on the terminal ballistics of projectiles,1 out-of-hospital trauma care,2,3 fluid resuscitation of shock,4 ultrasonographic examinations in the setting of penetrating abdominal trauma5 and exploding bullets,6 and clinical evaluation of penetrating extremity trauma.7,8 But no matter how vigorously we treat firearm injuries, we cannot fully reverse the damage wrought by bullets. A population-based study of fatal and nonfatal shootings in 3 US cities served by Level I trauma centers and advanced life support emergency medical services (EMS) systems determined that 56% of gunshot fatalities were pronounced dead on the scene. Another 23% died before or shortly after arrival in the emergency department. Fully 97% of those who died succumbed within 24 hours of the shooting.9 Gunshot victims who survive the initial insult often face a difficult, costly, and uncertain road to recovery.10-12 Hospitalized victims of serious firearm injury may experience months, if not a lifetime, of physical and/or psychological disability.13 Facts like these suggest that we may be reaching the limit on what can be accomplished with postevent care. This does not mean that firearm-related deaths and injuries are inevitable. Much more may be accomplished by directing our attention upstream, to the chain of events that takes place before the 911 call.14,15 Many firearm assaults are preceded by a sequence of discrete decisions and actions, many of which are already illegal under our nation’s existing gun laws (Figure). For example, adult felons and juvenile offenders are not legally entitled to purchase or carry a firearm; however, many choose to do so anyway. The reason is that they have concluded, rightfully or wrongfully, that the risks associated with being caught with a gun are outweighed by the anticipated benefits of having one for crime or self-defense.16-20 To feed this illegal demand, offenders require various sources of supply. Burglary or theft from legal owners provides approximately one half million guns per year. A few scofflaw firearms dealers knowingly sell large numbers of guns to criminals. Others unwittingly sell to legally proscribed individuals who “lie and buy” using a false ID or some other subterfuge. A common way criminals obtain new guns is to find a “straw purchaser”—someone who is willing to legally purchase the gun and hand it over for a fee. In strict gun control states, felons and juvenile offenders sometimes turn to interstate traffickers, who purchase quantities of firearms in lax gun control states, then drive across state lines to resell them on the street.21-24 Once a criminal acquires a gun, he must choose to carry it. Again, the calculus of benefits and risk applies. If the perceived benefits of carrying the gun are perceived to outweigh the risks and legal consequences of being caught, the deterrent value of laws that prohibit carrying by felons will be low. Once the decision to carry is made, it is largely a matter of time before it will be used. Whether that moment arrives during a crime of opportunity or an altercation with a rival, the likelihood that serious injury or death will result is greater when a gun is involved.25-27 The result is another 911 call. It doesn’t have to be this way. A growing body of evidence suggests that it is possible to block this chain of events through strategic enforcement of the nation’s existing gun laws.28,29 In the same way that certain antibiotics block the metabolic pathway of pathogenic bacteria, strategic firearms I N J U R Y P R E V E N T I O N / E D I T O R I A L