Firearm Injury in the United States: Effective Management Must Address Biophysical and Biopsychosocial Factors
Authors: Stephen Hargarten
Journal: Annals of Internal Medicine (2016)

Editorials20 December 2016Firearm Injury in the United States: Effective Management Must Address Biophysical and Biopsychosocial FactorsFREEStephen Hargarten, MD, MPHStephen Hargarten, MD, MPHFrom Medical College of Wisconsin, Milwaukee, Wisconsin.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M16-2244 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Every hour of every day in the United States, a bullet kills or injures someone. People affected by firearm violence represent a spectrum of races and reside in both urban and rural areas (1). The mass and velocity of a bullet—its kinetic energy—is the cause of mortality, morbidity, and significant lifelong physical and psychological sequelae. Although a bullet's kinetic energy is the immediate agent of injury, biopsychosocial factors are important contributors to the public health problem of firearm violence (2, 3).Firearm injury requires emergency and often operative and intensive care for a bullet's adverse biophysical effects. Level 1 and 2 trauma centers, especially those in U.S. cities, manage these biophysical aspects of firearm injury daily. When people are injured by bullets, a team of caregivers provide vital resuscitation and operative interventions that save lives and reduce morbidity and disability. Trauma centers across America excel at treating acute injuries, especially those from bullets (4). However, treating only the biophysical effects of bullets on the human body is not enough. We need to probe about patients' behavioral and social history. Only by understanding the biopsychosocial factors that contribute to firearm violence can we develop informed prevention strategies.We have made progress in acute care settings to begin to ask good questions about what happened to patients injured by firearms and use the answers to inform strategies to reduce subsequent harm. Some hospitals have organized the National Network of Hospital-based Violence Intervention Programs (5); participants develop and implement prevention strategies dedicated to reducing violent injury and death.To successfully tackle firearm violence, we need a vigorous approach similar to that used to combat HIV and other public health problems that affect our cities. We require rigorous, adequately funded research to advance knowledge and inform implementation of evidence-based programs and policies. Rowhani-Rahbar and colleagues (6) report such research. Their well-constructed case–control study and retrospective cohort study examined violence perpetration before and after hospitalization for firearm injury according to whether the injury was categorized as intentional (assault) or unintentional (accident). Patients with unintentional firearm injury had a higher rate of prior violence-related arrests than hospitalized control patients. These observations suggest that patients with firearm injuries—whether intentional or accidental—might benefit from interventions aimed at reducing the risk for future violence and treating biophysical wounds.Rowhani-Rahbar and colleagues linked hospitalization records from the Washington State Department of Health Comprehensive Hospital Abstract Reporting System and Washington State Patrol in their analyses. Other settings with similar data sources can also perform similar analyses of linked databases to confirm their findings. Firearm injury seems to warrant comprehensive biopsychosocial intervention regardless of intent. The authors show that the cumulative incidence of violence-related arrest over the follow-up period (after hospitalization) was 10% for patients with accidental firearm injuries, 15% for those with assault-related firearm injuries, and 1% for those without injuries.Politics complicate and impede funding for research about firearm injury. Of note, Rowhani-Rahbar and colleagues' work was funded by the City of Seattle, which is a local government seeking to better understand the scope and nature of firearm-related injury and death in its community. In a heartening development, the State of California recently approved and awarded $5 million for gun violence research (7). We need research that advances our understanding of the public health problem of firearm violence and incrementally informs our efforts for reducing its burden on communities across the United States.References1. Wintemute GJ. The epidemiology of firearm violence in the twenty-first century United States. Annu Rev Public Health. 2015;36:5-19. [PMID: 25533263] doi:10.1146/annurev-publhealth-031914-122535 CrossrefMedlineGoogle Scholar2. Greenspan AI, Kellermann AL. Physical and psychological outcomes 8 months after serious gunshot injury. J Trauma. 2002;53:709-16. [PMID: 12394871] CrossrefMedlineGoogle Scholar3. Kumar V, Abbas AK, Aster JC. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Philadelphia: Elsevier; 2015. Google Scholar4. MacKenzie EJ, Rivara FP, Jurkovich GJ, Nathens AB, Frey KP, Egleston BL, et al. A national evaluation of the effect of trauma-center care on mortality. N Engl J Med. 2006;354:366-78. [PMID: 16436768] CrossrefMedlineGoogle Scholar5. National Network of Hospital-based Violence Intervention Programs. Home: history: the emergence of a network. Accessed at http://nnhvip.org/mission on 12 October 2016. Google Scholar6. Rowhani-Rahbar A, Fan MD, Simonetti JA, Lyons VH, Wang J, Zatzick D, et al. Violence perpetration among patients hospitalized for unintentional and assault-related firearm injury. A case–control study and a cohort study. Ann Intern Med. 2016;165:841-7. doi:10.7326/M16-1596 LinkGoogle Scholar7. California approves firearm violence research to fill gap left by Congressional restrictions [news release]. Sacramento: California State Senate, 3rd District; 16 June 2016. Accessed at http://sd03.senate.ca.gov/news/2016-06-16-california-approves-firearm-violence-research-fill-gap-left-congressional on 5 October 2016. Google Scholar Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: From Medical College of Wisconsin, Milwaukee, Wisconsin.Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M16-2244.Corresponding Author: Stephen Hargarten, MD, MPH, Medical College of Wisconsin, 8701 West Watertown Plank Road, Milwaukee, WI 53226; e-mail, [email protected]edu.This article was published at www.annals.org on 18 October 2016. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoViolence Perpetration Among Patients Hospitalized for Unintentional and Assault-Related Firearm Injury Ali Rowhani-Rahbar , Mary D. Fan , Joseph A. Simonetti , Vivian H. Lyons , Jin Wang , Douglas Zatzick , and Frederick P. Rivara Metrics Cited byThe Health Care Professional's Pledge: Protecting Our Patients From Firearm InjuryChristine Laine, MD, MPH and Darren B. Taichman, MD, PhD 20 December 2016Volume 165, Issue 12Page: 882-883KeywordsCohort studiesDisclosureFirearm injuriesForecastingHospitalizationsMorbidityPrevention, policy, and public healthRetrospective studiesRural areasViolent crime ePublished: 18 October 2016 Issue Published: 20 December 2016 Copyright & PermissionsCopyright © 2016 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...