“I just want you all to think about that for a second,” said Dr. Joseph V. Sakran, director of emergency general surgery, associate professor of surgery and vice chair of clinical operations at The Johns Hopkins Hospital in Maryland. “It’s not car crashes. It’s not cancer. It’s not poisonings. It’s gun-related injury.”
Sakran, a panelist for a recent webinar on the pediatric health threat of gun violence hosted by U.S. News and World Report, was in fact inspired to become a trauma surgeon after he was a victim himself. In 1994, he was shot in the throat as a bystander at a Burke, Virginia, playground outside Washington, D.C. “I left that morning as a healthy high school student, and then I was collateral damage after nearly being killed,” he said during the webinar.
Firearm-related accidents and suicides, as well as shootings among young people, have only increased since then. The devastating toll this is taking on families, schools and society at large is also presenting challenges for the hospitals and trauma centers treating these young patients, many of whom will need not just lifesaving but lifelong care.
In response, hospitals and health systems are taking concrete actions to reduce the toll in their communities by implementing public awareness programs, promoting gun safety, ramping up mental health services and more. Sakran, a board member with the Brady Campaign that works to reduce gun violence, noted that eight children and teens are unintentionally shot every day “in instances of what we call family fire, which is a term essentially to describe a shooting that involves an improperly stored or misused gun found in the home.” That doesn’t include the victims of mass school shootings, street shootings and other tragedies, Sakran noted. “People always ask what’s the one solution. And the reality is, there is no one solution,” he said. “It requires a multifaceted approach.”
At Le Bonheur Children’s Hospital in Memphis, Tennessee, researchers tracked 15 years of gun-related injuries and found that about half were related to unsafe firearm storage and half to community violence, with an increase in the latter during the pandemic. “How can we teach families and communities to store their guns safely?” said Dr. Regan Williams, medical director of trauma and associate chief of staff at Le Bonheur. “We’re really shifting to look more into community violence because that’s the largest driver [of gun violence] in our community right now.”
Dr. Sandra McKay, director of population health and advocacy, associate professor of pediatrics with the McGovern Medical School at UTHealth Houston and a pediatrician with Children’s Memorial Hermann Hospital, said that, in Texas, “we have a different relationship and culture around firearm ownership.” Physicians are generally trusted by patients for “what to do with a cold,” as an example, she said, but for questions on safely storing firearms, “we were not the top-ranked person they would go to.” Instead, it was “law enforcement, family and friends, and firearm retailers. And so, what we’ve done is we’ve taken a little bit of a different approach, partnering with our firearms retailing community” on messaging, particularly regarding suicide prevention and safe storage counseling.
They “really do want to partner with us because when it comes to safety,” she said, “they see themselves as the experts. And they are.” At the same time, sellers say, “ ‘We would love to get some training from you and health care to learn about what are the red flags when someone’s struggling that we should be looking for in that point of sale.’ ”
One idea is having more retailers offer temporary out-of-home, voluntary firearm storage for a small fee. That can be an option, say, for firearms owners who are having grandkids over for the week or who have someone in the home who is struggling. Her team is trying to contact every firearm retailer in Texas to engage them, because when patients were surveyed, 40% of people said they would not know what to do if they had to remove a firearm for safety reasons, “and that’s a huge concern for us as pediatricians,” McKay said.
Sakran emphasized the need to expand training of future clinicians. “A lot of us here and across the country believe that we have a role in firearm injury prevention that cuts across the focus of clinical care,” he said, and includes educational, research and community engagement components.
McKay, who is also Huffington Fellow with the Baker Institute for Public Policy at Rice University, agreed noting the value of workshops for pediatric physicians who are often uncomfortable having conversations around firearms with patients. More than 80% aren’t firearm owners themselves, and so she focuses on helping them feel empowered to ask key questions in a culturally sensitive way and then to work on a harm-reduction strategy.
Northwell Health similarly has added firearms questions to its universal patient screening. “Every single patient who comes into our [emergency department is asked] questions about firearm injury, risk, including access-related risk and violence-related risk,” said Sathya, who is also assistant professor of surgery and pediatrics at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell. By “integrating screening and intervention into your clinical workflows” and taking “a comprehensive, team-based approach, not only does it improve your successive implementation because you have multiple folks involved,” he noted, but it ensures the entire team is educated and engaged.
Sakran also emphasized nonmedical interventions to address the root causes of gun violence, including the social determinants of health that involve the conditions in which people live and grow, like economic and housing stability and access to quality health and trauma care. He also stressed the need for the medical community to advocate for change. “I think for a long time, we looked at advocacy as a dirty word, but really, it’s not. As individuals that are at the center of taking care of these patients, we have both the opportunity and the responsibility to advocate for evidence-based policies that we think are going to not just impact the outcomes of our patients but prevent them from ever becoming our patients.”
Another source of concern is that children and teens aren’t just victims; they are also perpetrators of gun violence. “I don’t think we totally know what works” in addressing this critical dynamic, Williams said. But one factor is getting help to kids before their teen years,” she said. “I really think that by [age] 14” because their scars and their adverse childhood experiences are so severe, “it’s really hard to rehabilitate them,” she noted, “so we really want to focus on [ages] 8 to 12” and figuring out how to support children in disenfranchised communities “to keep them out of that cycle of violence.”
McKay agreed on the need for early intervention: “We’ve implemented a universal screening process for social determinants of health for all children at all well-child visits” starting when they are 12 and 18 months old, she noted. During screening, families are asked if they are struggling financially, or with housing or transportation security. If they are, pediatricians are encouraged to connect them with community-based resources. “That is where pediatrics needs to continue to move to, so that we can help support children and families,” she said.
Sathya noted another screening tool called SaFETy Score “that has been shown to predict gun violence in at-risk, substance-using youth.” It includes questions about frequency of hearing gunshots and having a gun pulled. “These are questions that are highly predictive of future gun violence” and provide the opportunity, he said, to offer resources before a patient comes in with a gun injury.
Sathya emphasized the need for more centers for gun violence prevention to be established similar to those for cancer or heart disease prevention so not just frontline workers are engaged but the entire culture of the institution.
“It definitely takes a community,” added Williams, who is also president-elect of the medical staff at Le Bonheur Children’s and associate professor of surgery at the University of Tennessee Health Science Center. She sees hospitals as a gathering place. “We actually had a community summit where we brought everyone together,” she said. “Everybody learned a lot about each other, which was really important,” particularly in developing the most effective programs targeting members of the community. “I don’t know the best way to teach them about firearms safety, and I don’t know how to treat all their social determinants of health and to support them. But the people that live in the community, they do.”
This commonality of purpose “often doesn’t get seen, because you see all the kind of divisiveness that’s happening on social media or on the evening news,” Sakran said, but most Americans don’t want to see children being shot and killed. No one wants to see these school shootings or the urban violence. It’s not just about the right idea, but it’s also about having the right strategy and approach.”
Williams compared firearm safety with car safety. “In the 1970s, death was really common for motor vehicles. We didn’t take cars away,” she noted. “We started collecting data on why people were getting killed and injured … then we worked systematically to make them safer.” Now, guns are the No, 1 cause of death in children, “but we haven’t done the same thing,” she said. Yet by looking at “why people get shot, how they get shot, and then also ways to make guns safer, we really can make the community and the world safer for our children.”