Prevent the Bleed: A Step Toward the Firearm Endgame June 20, 2018 Guest Blog firearms, gun violence 0 [Article appeared in General Surgery News on June 13, 2018] By John Maa, MD, FACS, and Peter Masiakos, MD, FACS The recent tragedies in Florida, Nevada and Texas galvanized a national youth-led movement aimed at ending gun violence. State legislatures in Florida, Illinois, Massachusetts, New York, Tennessee and Washington enacted firearm safety laws that disarm dangerous or suicidal individuals, raise the minimum purchase age to 21, and strengthen background checks. Congress passed a spending package that incentivizes state and regional reporting into the national background check system, and the National Institutes of Health awarded $5 million to gun violence researchers. In a General Surgery News editorial [May 2018, page 3], Frederick Greene, MD, recognized that a “tipping point” of the national firearm debate has been reached and that the American College of Surgeons strategy of “stopping the bleed” cannot stand alone, and must be joined by the equally important concept of “preventing the bleed.” Some surgeons have become vocal advocates for firearm violence prevention. In March, Ara Darzi, MD, shared the British perspective into the American gun debate in the Annals of Surgery (2018;267[3]:430-431), urging a harm reduction approach and the adoption of a forward-thinking prevention strategy. In the Annals of Surgery in May (2018;267[6]:1009-1010), Natalie Yanchar, MD, MSc, and Suzanne Beno, MD, FRCPC, DABP, highlighted our professional responsibility to work within all levels of government to advocate for surveillance and funding of translatable research to help implement evidence-informed firearm policies. Joe Sakran, MD, a trauma surgeon and gunshot survivor, has worked to expand universal background checks, prevent straw purchases, and expand mental health treatment, and was featured by CNN in April. Andre Campbell, MD, a trauma surgeon at San Francisco General Hospital, refocused the world’s attention when speaking to the media after the April YouTube shooting. His words redirected the discussion away from impersonal statistics in treating the victims to the frustration that gun violence ravages our country and almost seems unpreventable. Immediately afterward, social media and a worldwide media response confirmed that many surgical colleagues and the public shared his sentiment. Additionally, professional surgical societies added their voice through policy statements and productive discussions. The American Pediatric Surgical Association reaffirmed its 2013 position statement emphasizing the need to discuss gun safety and safe storage in households with children. The Society of American Gastrointestinal and Endoscopic Surgeons called for enhanced safety technology to minimize accidental and mass shooting events, while the Western Trauma Association called for a ban on assault weapons and bump stocks. Ronny Stewart, MD, FACS, and Deborah Kuhls, MD, FACS, of the ACS Committee on Trauma (COT) identified areas of consensus through a survey of COT members and ACS Governors, which empowered the ACS Board of Regents in February 2018 to approve a nine-point action plan including gun control. In addition, the ACS joined other medical organizations to produce a position statement to reduce preventable injuries from firearm violence, and signed onto a 75-member coalition letter spearheaded by the American Academy of Pediatrics to urge Congress to provide $50 million for CDC firearm research. One of the nine ACS Regent action items emphasized overturning the Dickey Amendment, which restricts funding for gun violence research. Soon after the ACS statement was made public, Health and Human Services Secretary Alex Azar II surprisingly announced that CDC funding for gun violence research would be permissible. What more can we as surgeons do to further affect this public health crisis? Just as former Surgeons General Luther Terry and C. Everett Koop held Big Tobacco accountable for the deaths of 20 million Americans, the next steps could include a U.S. surgeon general’s report on the magnitude of firearm injuries across America. The ACS could assist in initiating and expediting the completion of that report, which over the long term, could reframe the conversation about the U.S. firearm problem into one focused on public health. Academic surgery programs can also play a key role in this campaign. Every department of surgery should feature a grand rounds on firearm injury prevention to educate surgeons how to discuss safe firearm storage with patients, and how to recognize mental health illness that may be a precursor to firearm violence. The ACS should partner with the American Medical Association and all other specialties that treat gunshot victims to publish joint statements on firearm violence prevention in their subspecialty journals. JAMA Surgery, Surgery, Annals of Surgery, and Journal of the American College of Surgeons should consider publishing theme issues about the treatment of firearm injuries, along with solutions to bring an end to the suffering and lives lost. In tobacco control, after decades of public health efforts to end the epidemic of death and disability from cigarette smoking, the final overarching strategy to permanently end the smoking-related health harms has become known as the Tobacco Endgame. A key to success in tobacco control was the Tobacco Master Settlement Agreement of 1998. To accelerate the path toward a firearm endgame, a collaborative effort by attorneys general across multiple states could focus on recouping a portion of the direct health care expenses for gun-related injuries (estimated between $7 and $9 billion) from firearm manufacturers. If control of the House of Representatives is flipped in the November elections, a Democratic majority could convene congressional hearings about new legislation in 2019. The ACS could then support Capitol Hill efforts to enforce the bump stock ban proposed by the Bureau of Alcohol, Tobacco, and Firearms and Explosives and the Department of Justice, and repeal the Protection of Lawful Commerce in Arms Act that grants immunity to the gun industry from lawsuits. In 1992, Dr. Koop argued in his editorial “Time to Bite the Bullet Back” (JAMA 1992;267[22]:3075-3076) that violence is a public health issue that can be more effectively addressed by an interdisciplinary approach. We have now seen remarkable forward progress within the ACS on the topic of firearm violence prevention, which has evolved to a balance between individual rights and public health. It is important for the ACS to continue to lead this important discussion. A “Prevent the Bleed” campaign operationalizing the regents’ plan should join the ACS “Stop the Bleed” program, which is providing important training shown to save lives. This double-pronged strategy to both prevent and treat firearm injuries could move our country toward a safer society, and end the epidemic of preventable firearm morbidity and mortality in America. Dr. Maa is the president of the San Francisco Marin Medical Society, and chief of the Division of General and Acute Care Surgery at Marin General Hospital; Dr. Masiakos is an associate professor at Harvard Medical School, and a pediatric general and thoracic surgeon at Massachusetts General Hospital, in Boston. Comments are closed.
