Gun Violence: A Biopsychosocial Disease

Patterns of firearm related injury in the elderly: A single institution analysis

BACKGROUND

Firearm-related violence (FRV) is a public health crisis in the United States that impacts individuals across the lifespan. This study sought to investigate patterns of injury and outcomes of firearm-related injury (FRI) in elderly victims and the impact of social determinants of health on this age demographic.

METHODS

A retrospective review of the trauma registry at a large Level I center was performed from 2016-2021. Patients over age 18 were included and FRI was defined by ICD 9 and 10 codes. Comparisons were then made between elderly (age > 65 years) and non-elderly (age 18-64 years) victims. The primary outcome was mortality. Secondary outcomes included hospital and intensive care unit length of stay, in-hospital complications and the impact of distressed community index (DCI) and insurance status on discharge disposition.

RESULTS

23,975 patients were admitted for traumatic injury and 4,133 (6 %) were elderly. Of these, 134 had penetrating injuries and 72 (54 %) were FRI. The elderly patients had a median age of 69y and they were predominantly black (50 %) males (85%). Over 75 % had some form of government insurance compared to less than 20% in non-elderly (p<0.001). 33 % of elderly FRIs were self-inflicted compared to only 4 % in the non-elderly cohort and their overall mortality rate was 25 % versus 15 % in non-elderly with FRI (p = 0.038). The median DCI for the non-elderly victims was 72.3 [IQR 53.7-93.1] compared to 63.7 [IQR 33.2-83.6] in the elderly (p < 0.001), however, over 50 % of elderly victims were living in "at risk" or "distressed" communities.

CONCLUSION

FRV is a public health crisis across the lifespan and elderly individuals represent a vulnerable subset of patients with unique needs and public health considerations. While many interventions target youth and young adults, it is imperative to not overlook the elderly in injury prevention efforts, particularly self-directed violence. Additionally, given most elderly victims were on government funded insurance and had a higher likelihood of requiring more costly discharge dispositions, new policies should take into consideration the potential financial burden of FRV in the elderly.

Investigating the 2016 surge in firearm violence in Illinois, USA, through community-based organisations: a qualitative study

BACKGROUND

Illinois experienced a historic firearm violence surge in 2016 with a decline to baseline rates in 2018. This study aimed to understand this 2016 surge through the direct accounts of violence prevention community-based organisations (CBOs) in Illinois.

METHODS

We conducted semistructured interviews with 20 representatives from 13 CBOs from the south and west sides of greater Chicago metropolitan area. Interviews were audio recorded, coded and analysed thematically.

RESULTS

We identified lack of government-derived infrastructure and systemic poverty as the central themes of Illinois's 2016 firearm violence surge. Participants highlighted the Illinois Budget Impasse halted funding for violence prevention efforts, leading to 2016's violence. This occurred in the context of a strained relationship with the criminal justice system, where disengagement from police and mistrust in the justice system led victims and families to seek justice outside of the judicial system. Participants emphasised that systemic poverty and the obliteration of community support structures led to overwhelming desperation, which, in turn, increased risky behaviours perceived as necessary for survival. Participants disproportionately identified that this impacted the young people in their communities.

CONCLUSIONS

Lack of government-derived infrastructure and systemic poverty were the central themes of the 2016 firearm violence surge. The insights gained from the 2016 surge are applicable to understanding both current and future surges. CBOs focused on violence prevention offer insights into the context and conditions fuelling surges in the epidemic of violence.

The biopsychosocial model: Its use and abuse

The biopsychosocial model (BPSM) is increasingly influential in medical research and practice. Several philosophers and scholars of health have criticized the BPSM for lacking meaningful scientific content. This article extends those critiques by showing how the BPSM's epistemic weaknesses have led to certain problems in medical discourse. Despite its lack of content, many researchers have mistaken the BPSM for a scientific model with explanatory power. This misapprehension has placed researchers in an implicit bind. There is an expectation that applications of the BPSM will deliver insights about disease; yet the model offers no tools for producing valid (or probabilistically true) knowledge claims. I argue that many researchers have, unwittingly, responded to this predicament by developing certain patterns of specious argumentation I call "wayward BPSM discourse." The arguments of wayward discourse share a common form: They appear to deliver insights about disease gleaned through applications of the BPSM; on closer inspection, however, we find that the putative conclusions presented are actually assertions resting on question-begging arguments, appeals to authority, and conceptual errors. Through several case studies of BPSM articles and literatures, this article describes wayward discourse and its effects. Wayward discourse has introduced into medicine forms of conceptual instability that threaten to undermine various lines of research. It has also created a potentially potent vector of medicalization. Fixing these problems will likely require reimposing conceptual rigor on BPSM discourse.

Firearm Violence in the United States: An Issue of the Highest Moral Order

Firearm violence in the United States produces over 36,000 deaths and 74,000 sustained firearm-related injuries yearly. The paper describes the burden of firearm violence with emphasis on the disproportionate burden on children, racial/ethnic minorities, women and the healthcare system. Second, this paper identifies factors that could mitigate the burden of firearm violence by applying a blend of key ethical theories to support population level interventions and recommendations that may restrict individual rights. Such recommendations can further support targeted research to inform and implement interventions, policies and laws related to firearm access and use, in order to significantly reduce the burden of firearm violence on individuals, health care systems, vulnerable populations and society-at-large. By incorporating a blended public health ethics to address firearm violence, we propose a balance between societal obligations and individual rights and privileges.

Emergence of Gun Violence as a Patient Priority

PURPOSE

Gun violence is a growing public health epidemic that disproportionately affects underserved and minority communities. Our study sought to document patient experiences of community gun violence as a theme that emerged in the context of interviews exploring community-level factors influencing patients' engagement in primary care within the context of a larger study on cardiovascular health.

METHODS

We completed semistructured qualitative interviews of individuals with uncontrolled hypertension recruited from primary care practices serving underserved communities in metro Richmond, Virginia that were participating in a larger study on improving cardiovascular health.

RESULTS

Of 19 individuals interviewed, 11 discussed without prompting the negative effects of gun violence in their community. Themes that emerged included both the acute and chronic traumatic experience, the physiologic and cognitive effects of gun violence and the negative effects on ability to manage heart health.

CONCLUSIONS

The effects of gun violence on not only cardiovascular health but also all aspects of health emerged unprompted in qualitative interviews about community level factors influencing management of cardiovascular health. Given the widespread negative effects of experiencing gun violence on health, family physicians could play an important role in identifying and managing the effects of gun violence. Future studies on how primary care clinicians can address gun violence in the caring for their patients comprehensively are needed.

Gun Violence Education in Medical School: A Call to Action

ISSUE

Gun violence is a major public health burden, adversely affecting patients, families, and communities across the United States (U.S.) and the world. To manage the burden of injury from gun violence and identify primary, secondary, and tertiary prevention strategies, physician leaders must understand the biological and psychosocial aspects of this complex problem. However, gun violence and its complexities are not widely taught in medical schools. This Observation article details why gun violence education is not being included in medical education, offers an informed, science-based model for the disease of gun violence, and suggests methods to integrate gun violence education into medical school curricula.

EVIDENCE

We surveyed the literature for articles addressing this topic and for studies on medical school education and curriculum changes. We also examined some of the resources commonly used in medical school for mention of gun violence. Finally, we conducted a query of the AAMC Curriculum Inventory to further see if gun violence is currently incorporated into participating U.S. medical schools' curricula and found that gun violence is not a topic discussed in any significant capacity at most U.S. medical schools. Only 13-18% of schools that participated in the AAMC Curriculum Inventory during the years 2015-2018 documented gun and firearm content in their curriculum. Any other disease with similar number of deaths and injuries would be considered worthy of inclusion into medical education curricula.

IMPLICATIONS

Medical school curricula commonly adjust with the ebb and flow of disease. Although gun violence meets the classic definition of a disease and is a major cause of harm and death, it is not taught to medical students. We assert that gun violence should be taught and framed as a biopsychosocial disease, highlighting many opportunities for interventions across a team of health care providers and physician leaders. We strongly urge medical schools to evaluate their curricula, address this teaching gap, and train the next generation of physician leaders to address all aspects of gun violence.

Increases in Violence and Changes in Trauma Admissions During the COVID Quarantine

BACKGROUND

The COVID-19 pandemic caused an abrupt change to societal norms. We anecdotally noticed an increase in penetrating and violent trauma during the period of stay-at-home orders. Studying these changes will allow trauma centers to better prepare for future waves of COVID-19 or other global catastrophes.

METHODS

We queried our institutional database for all level 1 and 2 trauma activations presenting from the scene within our local county from March 18 to May 21, 2020 and matched time periods from 2016 to 2019. Primary outcomes were overall trauma volume, rates of penetrating trauma, rates of violent trauma, and transfusion requirements.

RESULTS

The number of penetrating and violent traumas at our trauma center during the period of societal quarantine for the COVID-19 pandemic was more than any historical total. During the COVID-19 time period, we saw 39 penetrating traumas, while the mean value for the same time period from 2016 to 2019 was 26 (P = .03). We saw 45 violent traumas during COVID; the mean value from 2016 to 2019 was 32 (P = .05). There was also a higher rate of trauma patients requiring transfusion in the COVID cohort (6.7% vs 12.2%).

DISCUSSION

Societal quarantine increased the number of penetrating and violent traumas, with a concurrent increased percentage of patients transfused. Despite this, there was no change in outcomes. Given the continuation of the COVID-19 pandemic, quarantine measures could be re-implemented. Data from this study can help guide expectations and utilization of hospital resources in the future.

Shook Ones: Understanding the Intersection of Nonfatal Violent Firearm Injury, Incarceration, and Traumatic Stress Among Young Black Men

Violent injury is a leading cause of death and disability among young Black men, with the highest rates occurring in low-income urban populations. Hospital-based violence intervention programs (HVIPs) offer a promising opportunity to address the biopsychosocial factors that adversely affect this population. However, there are major gaps between the needs of young Black male survivors of violent injury and the forms of care provided by HVIPs. Patient-centered outcomes research provides a useful mode of inquiry to develop strategies to decrease these differences. Care for survivors, including treatment for traumatic stress disorders, must be reconceptualized to center the lived experiences of young Black men. This paper qualitatively explores how these survivors of gun violence express symptoms of traumatic stress and the ways in which their narratives can inform the implementation of the biopsychosocial model in HVIPs. A phenomenological variant ecological systems theory framework was used to analyze participant narratives to aid in understanding their symptoms of traumatic stress and post-injury affective changes as both psychologically and socially important experiences. Such insight may inform changes to HVIP practice to address persistent health disparities related to violence.

Gun Violence and Firearm Injuries in West Michigan: Targeting Prevention

INTRODUCTION

Firearm-related deaths and injuries are ongoing public health issues in the United States. We reviewed a series of gun violence- and firearm-related injuries treated at a multi-campus community healthcare system in West Michigan to better understand the demographic and clinical characteristics of these injuries. We also studied hospital charges, and payers responsible, in an effort to identify stakeholders and opportunities for community- and hospital-based prevention.

METHODS

We performed a retrospective review of firearm injuries treated at Mercy Health Muskegon (MHM) between May 1, 2015 and June 30, 2019. Demographic data, injury type, Injury Severity Score (ISS), anatomic location and organ systems involved, length of stay (LOS), mortality, time of year, and ZIP code in which the injury occurred were reviewed, as were hospital charges and payers responsible.

RESULTS

Of those reviewed, 307 firearm-related injuries met inclusion criteria for the study. In 69.4% of cases the injury type was attempted murder or intent to do bodily harm. Accidental and self-inflicted injuries accounted for 25% of cases. There was a statistically significant difference in the mechanism of injury between Black and White patients with a higher proportion of Black men injured due to gun violence (P < 0.001). Median ISS was 8 and the most commonly injured organ system was musculoskeletal. Median LOS was one day. Self-inflicted firearm injuries had the highest rate of mortality (50%) followed by attempted murder (7%) and accidental discharge (3.1%; P < 0.001). Median hospital charge was $8,008. In 68% of cases, Medicaid was the payer. MHM received $4.98 million dollars in reimbursement from Medicaid; however, when direct and indirect costs were taken into account, a loss of $12,648 was observed.

CONCLUSION

Findings from this study reveal that young, Black men are the primary victims of gun violence-related injuries in our West Michigan service area. Hospital care of firearm-related injuries at MHM was predominantly paid for by Medicaid. Multiple stakeholders stand to benefit from funding and supporting community- and hospital-based prevention programs designed to reduce gun violence and firearm-related injuries in our service area.