Pediatric Gun Violence: Pediatric Trauma Series 2017

OK. Well, good evening. Um, it's a pleasure to join you, um, uh, and always, uh, enjoy, uh, educating a little bit about pediatric, uh, gun violence or firearm, uh, injuries. Um. And I'm gonna focus a bit on some uh epidemiology and advocacy efforts, uh, in terms of uh firearm injuries and pediatrics. And so everybody here, I'm, I'm assuming, um, understands the burden, um, that pediatric injury plays in the, uh, in our population. Um, we can take some solace in the fact that, uh, over the last 25 years or so, uh, the mortality from trauma has decreased, uh, by about 50%. Um, but we also have to realize that, uh, despite that fact, it's still the single most common cause of death in the pediatric population, uh, and more common than all other causes combined. So we still have a lot of work, um, to do. Um, when we look at pediatric injury death, uh, and the causes, um, the number one causes most know is motor vehicle-related, but, um, not far behind are both firearms and falls in this data, uh, that I'm, uh, showing you is from the National Trauma Data Bank, um, their benchmark report from 2016. So this is trauma center-related deaths. So this is gonna undercount all of the deaths because these are kids that make it to a trauma center to, uh, to receive care. Um, of those kids that, that die in a trauma center, the most common mechanism, um, or the most lethal, sorry, mechanism would be firearms. So if a kid gets to the, um, to the trauma bay, then the cause that would be most likely to result in a death is gonna be a firearm. So these are, uh, still important issues for us to, to be dealing with. And I showed the, uh, first slide and how we've had a reduction in In mortality from trauma overall. But if you focus just on the pediatric firearm injuries, we still have made little progress. So they're about the same number of firearm deaths in the pediatric population now as there were at the beginning of this century. And if we look specifically at the um intent, uh, homicides are the most common in this uh pediatric age range with suicide, a second followed by unintentional. We can um focus on a couple smaller groups and, and see the role of firearms. So this is, this is uh just the 10 leading causes of death in a very specific population. The ages 15 to 19. And you can see that uh unintentional injury is uh by far and away the most common cause of death followed by homicide and suicide. If you split those out a little bit further, uh, in the homicide group, you can see that firearms are by far the most uh common. Um, uh, mechanism, uh, responsible for 84% of homicides in the age group of 15 to 19. And similarly, in suicide, firearms play, uh, a major role and they're responsible for 46% of the suicides in this age group. So depending on the, on the population that you focus on, you can see how, how prominent a role firearms will play. Uh, and in this age group, 15 to 19, um, 25% of all deaths involve a firearm. So that's a pretty significant, um, subset and a pretty significant, uh, role that the firearms play. And so I thought, uh, this event, this is the headline from The New York Times two days after, um, Sandy Hook occurred. Uh, and we're about to have the 5th anniversary of Sandy Hook in just a couple of days, 2 days. Um, and I thought naively that this was an event that was going to change things. Um, I thought that the, the murder of 20, uh, elementary school children, uh, would, um, lead to meaningful change, uh, but unfortunately, hasn't, uh, been as meaningful as I would have liked to have seen. Um, but, but what has happened is a lot of the organizations that, that we're, uh, involved with, uh, such as the American Academy of Pediatrics or American College of Surgeons and for the pediatric surgeons, um, the American Pediatric Surgical Association did, uh, take this as an opportunity to review their policy statements and, um, and update those. Uh, interestingly, the American College of Emergency Physicians had just updated, uh, their policy statement on firearm, uh, safety and injury prevention just prior to Um, uh, Sandy Hook. And, uh, Uh, these were a, um, a resource for members of their organizations to use, um, for advocacy efforts, uh, and education. Uh, there were efforts by, uh, other organizations to join together to, uh, for a unified message, and this was a, a white paper that was published in the Annals of Internal Medicine. Uh, and it was 8 organizations that joined together to discuss. Um, uh, the role of firearms that included the American Academy of Pediatrics and American Academy of Family Physicians, surgeons, American Psychiatric Association, American Public Health. Uh, so a whole host. And finally, it also included, um, the American Bar Association. So one of the few times that doctors worked with lawyers. Um, and one of the highlights was, uh, their philosophy that we believe that multidisciplinary interprofessional collaboration is critical to bringing about meaningful change to reduce the burden of firearm-related injuries and deaths on persons, families, communities, and society in general. And so they, um, realized the role, uh, that the medical community, I think, uh, can play in trying to mitigate, uh, injury and firearm injury in particular. The American College of Surgeons uh had published their um policy statement on firearms and gotten a fair amount of um feedback from a vocal minority, I think, um, about the, the role that the Committee on Trauma and the role that, uh, the American College of Surgeons should take, uh, in this arena. And so the, the COT undertook a Uh, survey of its membership. So this is, uh, again, members of the Committee on Trauma of the American College of Surgeons, specifically, uh, about whether they agree with, um, some of these topics that are, that are on the screen, uh, as areas that the college should, uh, focus their advocacy efforts. And what they saw was that in the, in the Committee on trauma, Um, overwhelmingly, there was support for, um, advocacy in, um, firearm-related, uh, issues. Um, essentially, every single, uh, issue had over 50% support and then, uh, nearly half of them had over 90% support. And these included things like improving mental health screening, um, uh, including, uh, Uh, making funds available for research, um, and, and preserving the right for, uh, healthcare providers to counsel their patients on firearm safety. So some were very straightforward, um, issues, other were, uh, a little bit more controversial with restricting access to assault rifles and the like. Um, but the main point was that there was, uh, a consensus that, uh, the Committee on Trauma and the more, more broadly, the American College of Surgeons should take on. Um, some of these issues, uh, from an advocacy perspective. I'll, I'll look at uh, the efforts that the American Pediatric Surgical Association also undertook. Um, and after Sandy Hook, uh, the Committee on Trauma was asked to review the, the white paper, their policy statement on firearm injuries in children. And the, the board of governors for the American Pediatric Surgical Association realized that this would be, um, a very, uh, controversial, um, topic. And so rather than simply approving it and, and publishing it online, uh, They actually suggested that it be um reviewed by the entire um Membership and there be a period of review and then a discussion at the annual meeting. And what we saw was that there was overwhelming approval for the policy, the firearm injuries and children policy statement, uh, including the nine statements which are, you can see at the bottom of the screen. And I'll uh touch on several of the, of the policy statements. And, uh, the, the ones I'm choosing to look at, uh, I'm doing in Uh, for a reason. And, and these are, um, policy statements that really, uh, it's very easy to, to connect, uh, a medical organization, a surgical organization, and the reason for, um, supporting these policy statements. So they're not ones that, uh, should engender much controversy. That includes, uh, Addressing firearms as a public health problem, um, mental health services, funding, um, and the, um, physician-patient relationship. And I'll, I'll touch on those, uh, for just a second. And so, uh, firearm deaths is a, a public health issue. Uh, it's the first one. We, um, generally approach things and certainly in the public health, uh, world, they approach problems with the Hatton matrix and it's a way of breaking down a problem, um, into, um, understandable or perhaps manageable pieces that you can go after. And it, it looks at, uh, the event you're trying to address, um, things that happened before the event and things that happened after the event. And then it looks at the host. Um, the agent causing the problem and then the environment that the problem occurs in. And so the classic example of, of employing the Haddon matrix is, is, has been done with motor vehicle crashes quite successfully and um something that would fit in the box for a pre-event issue, uh, impacting the host would be education for motor vehicles. So it might be, uh, teen driver education. Um, the agent is the vehicle in this case, and there have been numerous modifications, uh, of vehicle design. In the pre-event, it's collision avoidance, so you don't have the accident. If the event occurs, it might be airbags to lessen the, the, um, impact and consequences of the crash. And for post-event, it might be something like OnStar. So if you roll your car into a ditch, there's a little voice that, uh, that comes over, uh, and helps you get help. Um, pre-event physical thing might be modification of the roads, the rumble strips if you're falling asleep to remind you to get back on the road. Um, a social, uh, pre-event thing might be a modification of, uh, some existing laws like DUI laws. Um, the event has occurred, it might be, uh, modifying behavior and using seatbelts. Um, The physical environmental change for the event might be energy dissipation. So those water barrels that usually occur at the corners of an off-ramp, um, to, uh, absorb energy. And then post-event, uh, might be things like improvements in trauma care and access to trauma care. I'll highlight this one because this is probably where, uh, most of us live. So if you're a healthcare provider, most of us, uh, work towards, uh, improving the outcome post-event. And then finally, um, uh, post-event, social, environmental issue might be, uh, resources for, uh, PTSD or the like. So there's, uh, all kinds of ways to approach this problem, break it down into manageable, um, pieces and try to have an impact. And, and this has been, uh, quite successful. So over the last Um, 30 to 40 years, uh, there's been a 17% reduction in motor vehicle-related deaths. During that same time frame, there's been a 15% increase in motor, motor vehicle-related, I'm sorry, 15% increase in firearm, uh, related deaths. Um, so I haven't made, uh, much progress. And it's even more, uh, impressive when you realize that at the same time interval, there's been a 77% increase in the vehicle miles traveled. So, Uh, while we're driving more, we're dying less. Um, and so in the last five decades, the mortality has declined from about 5 deaths per, uh, vehicle mile travel billion, um, to 1.14. So a pretty impressive, uh, reduction in mortality, um, and in part, uh, perhaps from addressing it as a public health, uh, uh, problem and figuring out solutions. Switching to firearms and, and mental health, um, The, a lot of these, uh, mass shootings, there's focus on mental health issues and a deranged shooter. Um, but what probably is, uh, more common, more important is, um, suicide. And I'll highlight several of the statistics about suicide, which hopefully will, will show how, um, there's a lot of room to improve and make an impact here. In the pediatric population, um, suicides are the 3rd leading cause of death, um, in our young adults. Um, it's estimated that there are 25 suicide attempts for every completed suicide. So, uh, one way of looking at it, there are 24 potential, um, saves every time that, that one kid will die from, uh, suicide. In youth suicides, the use of a firearm, however, is, is uh successful in 95% of cases. So, um, it's the firearms in particular that are, that are problematic when the kids have access. And firearms were realized in almost 50% of the successful completed suicides. Um, 90% of, of patients who survive a suicide do not ultimately die from suicide. So there's the common misconception that um you can take away firearms, but they'll just find a different way to kill themselves, and that's not actually true. Um, most adolescent suicides occur in the home, um, uh, with a firearm owned by the parent. And so, um, it highlights why it's, it's important to, um, to know where the weapon is. Um, it's important to educate families about the potential significance of having a firearm in their home, uh, and accessed by a child. Because many youth suicides are quite impulsive. Um, it happens, uh, in less than 5 minutes from the impulse to, to action. And so if there's a, a means such as a firearm, uh, it can be, uh, devastating. And suicide mortality is not reduced with trigger locker or a gun safe in some cases because in the teenage population, you may have um demonstrated where the firearm is or given them the combination to the lock so that they can protect themselves. So um you have to be careful. It's a double-edged sword, uh, letting the kids know where the firearm is. Um, firearms and research, uh, are a big issue. We, we practice evidence-based medicine all the time. We, we count on, um, research to help educate us on, uh, the appropriate ways to, to care for kids, um, to care for problems. Uh, and so we need research. Um, in 1992, the National Center for Injury Prevention and Control was established under the, um, guidance of the CDC. One of the Sentinel papers that came out from, uh, some of the early funding was one by Art Kellerman. In which he demonstrated that gun ownership is a risk factor for homicide in the home. And this, this paper in particular didn't go over well um with the NRA and, and immediately they became a target of the NRA. And in 1996, just a few later, a few years later, Jay Dickey um successfully added an amendment to an annual spending bill. Um, Uh, which essentially, uh, cut out fundings, uh, the specific amount to the CDC that was provided to the NC, National Center for Injury Prevention and Control. It was a clear shot over the bow, um, about not funding, uh, firearms research in the future. And so just to give you a, a perspective on how much is spent on firearms research, one common way to consider the impact of a particular disease is to look at it as the years of potential life lost. Uh, so for instance, if you were expected to live to 75 and you die of a gunshot wound when you're 25, that's 50 years of potential life lost. By the same token, if you are expected to live to 75 and you die when you're 70 of cancer, that's 5 years of potential life lost. And so, when you look at uh the funding for cancer and for uh for instance, um, based on the years of potential life lost and the amount of funding that's provided, um, we fund cancer at a rate of about $4200 per year of potential life lost. Down here at firearms-related deaths. And we fund firearms-related research with US sources uh at a rate of $2.70 per year potential life loss. So, a, a profound difference. And it's not to say that we don't need to fund cancer the way we fund cancer. It's just to highlight how little, um, the government funds firearms-related research. And then finally, um, the physician-patient relationship. Uh, this is, you know, something that, uh, is near and dear to us. Um, many of our organizations, uh, recommend that we counsel parents regarding the risks and benefits to keeping firearms in the home. Again, um, if you have a team that's going through, uh, troubles, you, you have to worry about whether it's, uh, how you store a firearm in the house. If you have a, a toddler, you have to worry about whether they have access to the firearm. Um, and in fact, the majority of gun owning parents feel that this counseling is appropriate. There have been several states, however, that have uh tried to pass laws and in the case of Florida, for instance, they did pass a law, um, uh, which restricts the physician from talking to their um patients about firearms. This is the uh Florida Firearm Owners Privacy Act and it says the healthcare provider or healthcare facility shall respect the patient's right to privacy and should refrain from making a written inquiry or asking questions concerning the ownership of a firearm or ammunition. And the penalty for violating this could be loss of your license and up to a $10,000 fine. Not surprisingly, this law was challenged in the state, um, Florida Supreme Court overturned the law, um, but the state then appealed to the 11th Circuit Court of Appeals, um, and the three-judge panel of the Court of Appeals overturned it again, uh, ruling in favor of the state, so putting it back into play. Um, fortunately, the 11th Circuit. The full en banc 11th Circuit overturned the docs and Glocks. This is named the Docks and Glocks law. So, currently, that is not uh in, in effect, but it's this insidious, um, uh, gun law or, or, uh, interfering with the, with the physician-patient relationship has to be, uh, I think, carefully watched. So, um, just to, to sort of summarize, I think we in the healthcare profession have a very unique and powerful perspective, something that most, um, don't have. We, we are the ones caring for these patients quite frequently. We're the ones that see, um, the issues that they have potentially for the rest of their lives. We see the impacts on the families, uh devastated by the firearms, uh, and we need to share that. Um, I think policy statements such as that from the American Pediatric Surgical Association or, uh, other organizations, the college, um, or American Academy of Pediatrics are, are good resources for practitioners to use and to start the process. Um, and I think we should work with others, uh, who share similar goals to try to enact change and I think there's a lot we can do, um, in the healthcare, uh, world, uh, to, to advocate for our patients. Uh, and I think that's all I have, uh, uh, for my part, and I'll, uh, stick around. I think we'll have a, um, Uh, question section at the end. So, so Mike, it's, uh, it was a great talk. Um, I have a couple of questions just to kind of get things started and some discussion. Uh, the funding differences, is clearly remarkable and, and, and devastating and, and I agree with you certainly that we as healthcare providers need to be the advocates, um, as much as we can. But how does our, our financing and advocacy compared to that of the NRA? And how do we work with the NRA, uh, perhaps as opposed to oppose them or or how do we get over that hurdle which is clearly a big hurdle. Um, I think one of the problems is that the NRA has a, a 40 or 50-year head start, uh, on the process and they've been around and they've been just profoundly successful at what they do. Um, and getting, uh, building their relationships with, uh, you know, legislators, both, uh, probably most importantly, to be honest, at the, um, at the state level. Uh, that's where a lot of the action is, is happening. Not much happens on the federal level. So, The, the problem with most of the uh firearms legislation and activity is it happens in fits and starts. And so we have an event like a Sandy Hook and everybody is uh outraged, but um that outrage sort of gradually dies down and so do the efforts. And so what needs to happen is, uh, just sustained efforts. So we need to continue, um, our efforts to, to reduce the burden. We need to have sustained efforts working with our, uh, congressmen, both at the, at the state and federal level to advocate for change. And I think we need to continue to point out, um, the issues. Uh, and so I think we just have to not let, uh, you know, not let up. And, and I hope that some of the efforts that have started up since, um, Sandy Hook, uh, have been more sustained. So, uh, hopefully we can continue. I think there's also a role for, for working with the NRA. It's, uh, I think it's mind-boggling to me, some of the stances that are taken, um, you know, uh, against common-sense measures, background checks, you know, some of the mental health issues, um, which Uh, their positions have changed a bit over time. Um, and I think there's some things that we should move forward on, things that really shouldn't impact, um, uh, or be controversial from the perspective of the Second Amendment, so. Great, great, and so one question I think I know the answer but you own a gun? I missed is a. I, I was, I was wondering if you own a gun. Oh, I do not. I'm, I'm afraid I would injure myself. Good, good.