Life on Both Sides of the Gun: a Surgeon General’s Call to Action
Disparities in Firearm Injury: Consequences of Structural Violence
Abstract Purpose of Review This review focuses on disparities in firearm injuries and deaths in the United States (US), specifically looking at imbalances between different races/ethnicities, socioeconomic statuses, genders, sexual orientations, geographic locations, firearm ownership, laws, and intents. Recent Findings There are regional differences within the US between firearm deaths, firearm legislation, gun ownership rates, and Black-White disparities. Firearm injury intent varies by race/ethnicity, age, and gender. Data remain limited due to continued restrictions on funding for firearm research. Summary The studies highlighted in this review show that firearm injuries and deaths remain a public health crisis in the US, and that certain populations are affected more than others. By identifying and targeting these inequities with specific interventions, we can work toward lessening preventable firearm deaths and disabilities.
Plasma: a Brief History, the Evidence, and Current Recommendations
Abstract Purpose of Review The purpose of this chapter is to provide a brief history of the use of plasma, as well as to provide a review of currently available products, indications for usage, and benefits of transfusion. Recent Findings The Prospective Observational Multicenter Major Trauma Transfusion (PROMMTT) trial, an observational study from ten level-one trauma centers, aimed to define the principles of Damage Control Resuscitation (DCR) and a balanced transfusion strategy. The Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial was the first randomized controlled trial to address the question of transfusion ratios. Together these studies, along with the remainder of body of plasma literature, have led to current transfusion recommendations. Summary The current cornerstones of therapy for the management of a trauma patient in hemorrhagic shock include early hemorrhage control, permissive hypotension, and damage control resuscitation. The American College of Surgeons’ Trauma Quality Improvement Program (TQIP) recommends a target balance between 1:1 and 1:2 for plasma to red blood cell ratio and one single donor apheresis or random donor platelet pool for each six units of RBC.
Law Enforcement: a Vital Partnership in the Public Health Approach to Gun Violence
Abstract Purpose of Review To discuss the concerns, motivations, and accomplishments of the law enforcement community with respect to gun violence. To raise awareness of the scope of the problem of gun violence from the law enforcement perspective. Recent Findings Gun violence impacts civilians and the law enforcement community in different ways, with similar outcomes. A multidisciplinary approach of education, legislation, and enforcement may best impact trending US gun violence. Summary The law enforcement community can help to define gun violence as a public health crisis. Working relationships between the police, health care providers, legislators, and community leaders are extremely important in the national conversation about gun violence prevention.
A Worldwide Perspective Provides Insights into why a US Surgeon General Annual Report on Firearm Injuries Is Needed in America
Abstract Purpose of Review The review aims to empower the USA to better understand the myriad reasons that contribute to nearly 40,000 firearm deaths and over 100,000 gun injuries estimated annually. By examining global insights and preventive approaches utilized around the world for tackling this growing public health threat, it aims to highlight why a US Surgeon General Annual Report on firearm injuries is needed. Recent Findings The review summarizes themes in the worldwide experience with firearm injuries and explores the challenge from the perspective of Japan, Honduras, Brazil, India, and Germany. Summary A US Surgeon General’s report and overview of lessons from around the globe will deepen the understanding of the American problem and reveal new solutions. By exploring initiatives and reforms that countries have undertaken to reduce the threat of firearms, this report highlights the opportunity of the US collaboration with neighboring countries who share similarities in the level of injury and disability.
Developing Data-Driven Solutions to Firearm Violence
Abstract Purpose of Review Firearm-related injuries remain a major public health crisis in the USA with significant impact on society. Communities nationwide have a growing need for solutions to mitigate the public health impact through data-driven innovative solutions built on the collective expertise of multiple stakeholders. Recent Findings There is an overall increasing incidence of firearm-related injuries over the past couple of years with more severe injuries and a higher mortality rate. The best available data clearly shows that restrictive legislation, non-liberal licensing, comprehensive background checks, and responsible firearm ownership are associated with lower firearm injury rates. A nationwide firearm research infrastructure is also needed to verify the potential role of these solutions. Summary Firearm-related injuries remain a multifaceted national public health crisis that imposes a significant burden on many medical and social systems. Multiple data-driven targeted interventions can address different dimensions of the problem.
Hospital-Based Violence Intervention Programs to Address Social Determinants of Health and Violence
Abstract Purpose of Review This review seeks to help the reader understand the current state of hospital-based violence intervention programs (HVIPs) and discuss the next steps in creating a widely adaptable public health model for violence intervention. Recent Findings HVIPs are an emerging practice in hospitals and trauma centers. These programs employ public health principles to reduce the impact of social determinants of health on at-risk populations. To date, evaluation of these programs demonstrates increased positive intermediate outcomes and decreased recidivism. Summary Interest in HVIPs is growing due largely to a surge in the trauma community’s engagement in solutions to the epidemic of community violence and due to the development of a best practices HVIP model. National partnerships and organizations have become key to the dissemination of this public health model. With increased interest and positive outcomes, key stakeholders, including cities and states, are investing in the dissemination of these programs as a strategy to decrease violence, including firearm injury, in their populations.
Modern Management of Bleeding, Clotting, and Coagulopathy in Trauma Patients: What Is the Role of Viscoelastic Assays?
Abstract Purpose of Review The purpose of this review is to briefly outline the current state of hemorrhage control and resuscitation in trauma patients with a specific focus on the role viscoelastic assays have in this complex management to include indications for use across all phases of care in the injured patient. Recent Findings Viscoelastic assay use to guide blood-product resuscitation in bleeding trauma patients can reduce mortality by up to 50%. Viscoelastic assays also reduce total blood products transfused, reduce ICU length of stay, and reduce costs. There are a large number of observational and retrospective studies evaluating viscoelastic assay use in the initial trauma resuscitation, but only one randomized control trial. There is a paucity of data evaluating use of viscoelastic assays in the operating room, post-operatively, and during ICU management in trauma patients, rendering their use in these settings extrapolative/speculative based on theory and data from other surgical disciplines and settings. Summary Both hypocoagulable and hypercoagulable states exist in trauma patients, and viscoelastic assays are better at diagnosing both relative to standard coagulation testing and can better indicate what therapy may be most appropriate. Further study is needed, particularly in the operating room and post-operative/ICU settings in trauma patients.
Turning Experience into Action: This Is Our Lane
Abstract Purpose of Review To discuss the origins, motivations, and accomplishments of the social media inspired movement @This
Lane, a grassroots action intended to raise awareness of the scope of the problem of gun violence and to provide examples of successful past clinician lead social media and grassroots legislative advocacy. Recent Findings In 1 year, conversations to address the issue of gun violence in America have been moved from trauma rooms and societal meetings, into lecture halls, state, and federal legislatures. Social media played a large role in disseminating our message, and as a result, the number of research projects has increased, and an endgame to gun violence has been better defined. Summary Healthcare providers have helped to define gun violence as a public health crisis and, because of our presence, have become important stakeholders in the national conversation about gun violence prevention.
Building Consensus to Decrease Firearm Injuries and Death in the USA: Engaging Medical and Public Health Organizations to Find Common Ground
Abstract Purpose of Review Firearm injury deaths are rising and as of 2017 exceed motor vehicle crash deaths in the USA. We as healthcare professionals treat many of the injured, including those cared for in the network of over 560 ACS-verified trauma centers. In order to address this public health crisis that affects us all, we need to develop a multifaceted public health strategy to decrease and prevent firearm injuries and deaths. Recent Findings While personal opinions about firearm ownership vary significantly across the USA, an inclusive, consensus-based, public health approach to reducing firearm deaths is possible. This article reviews recent literature on this approach, first building consensus among surgeons and then extending across the entire healthcare professional community. Summary There is broad support for a public health approach which focuses on the understanding and addressing the underlying causes of violence while also making firearm ownership as safe as possible. This approach requires the expertise and committed support of healthcare and public health providers, along with their professional organizations, healthcare systems, and public health networks which they lead. To achieve the goals of eliminating preventable firearm-related death and disability also requires engaging firearm owners and members from vulnerable communities as key stakeholders in the public health solution. In order to achieve the goals of the public health approach, increased federal and philanthropic research funding is required to identify and evaluate the most effective injury prevention initiatives.
The Scope of the Problem: Gun Violence in the USA
Abstract Purpose of Review To update current understanding of the extent and impact of firearm violence in the USA. Recent Findings In the past decade, rates of firearm injury have increased in the USA, both absolutely and in comparison to other high-income countries. Firearm homicides, firearm suicides, and public mass shootings have all been increasing. Firearm homicide rates remain highest for young non-White males in urban areas, and firearm suicide rates remain highest for older White males in rural areas. The burden of all these shootings falls not only directly on the victims themselves but also can impact their families, friends, and communities. These more indirect costs include medical care, grief, fear, hopelessness, and PTSD. The negative effects of exposure to firearm violence have been highlighted in the literature. Individual and community efforts to prepare for and prevent the shootings entail additional costs and burdens. Summary The scope of the US gun problem in 2019 is far greater than is indicated merely by medical costs and body counts.
A Review of Gun Buybacks
Abstract Purpose of Review This reviews the history of gun buybacks and the literature to determine their impact and efficacy, as well as highlighting salient critiques. Finally, we discuss potential avenues that would enhance our understanding of buybacks and methods to address gun violence. Recent Findings Gun buybacks have become more prominent since their inception in the 1970s and often come in response to a tragic local event. The largest scale buyback was in the mid-1990s in Australia, which collected over 650,000 guns. Buybacks are a cost-effective method of reducing the number of weapons in the general public. Summary Gun buybacks are a cost-effective means to reduce the number of unwanted firearms in the general public and also provide a means for education regarding injury prevention. Buybacks in conjunction with other methods have been shown to be successful in reducing the number of firearms that could lead to injury and death.
A Review of Whole Blood: Current Trauma Reports
Abstract Purpose of Review Interest in whole blood transfusion, particularly in trauma resuscitations, has been growing over the last decade. This has led to more data from civilian trauma centers on the efficacy of whole blood compared to component therapy, the safety profile, and the hemostatic effects of cold-storage. Recent Findings The summation of recent data suggests that whole blood is at least as effective as component therapy in trauma resuscitation although data is limited to relatively small volumes (< 6 units). The effect of leukoreduction on platelet function and other hemostatic markers appears to be small in vitro, but clinical data is lacking. There is virtually no data on massive resuscitation with whole blood (> 10 units) except for case reports. Summary Resuscitation with whole blood appears to be safe and offers some advantages over component therapy. More clinical data is needed on the safety of whole blood in massive resuscitation and the potential hemostatic effects of whole blood transfusion.
Platelet Contributions to Trauma-Induced Coagulopathy: Updates in Post-injury Platelet Biology, Platelet Transfusions, and Emerging Platelet-Based Hemostatic Agents
Abstract Purpose The purpose of this review is to summarize the current understanding of the role of aberrant platelet biology in trauma-induced coagulopathy (TIC), discuss the evidence for platelet transfusions in the management of hemorrhaging trauma patients, and review emerging platelet-based hemostatic adjuncts. Recent Findings Advances in the study of post-injury platelet biology have led to the discovery of pathways associated with altered platelet activation and aggregation observed in the context of TIC. Impaired platelet aggregation after injury has recently been associated with histone driven modifications in platelet structureand function, alterations in calcium signaling, and alterations in von Willebrand factor (v
WF) platelet interactions. Furthermore, studies have identified several soluble factors in plasma which may play a role in inhibiting platelets after injury. Lastly, loss of the normal regulatory and bidirectional relationships of platelets with the endothelium and with fibrinolytic pathways may additionally play key roles in TIC. Importantly, the use of platelet transfusions as a treatment for hemorrhage control is not “one size fits all”—the benefit in several circumstances may be outweighed by risks, and there is a lack of demonstrated effectiveness for certain populations. Therefore, current efforts are underway to develop platelet based and platelet mimetic hemostatic agents, and to improve the effectiveness of platelet transfusions while mitigating the risks. Summary Our understanding of how injury leads to altered platelet behavior contributing to TIC has grown substantially but remains incomplete. Decoding the complex biologic interface of platelets with the endothelium, fibrinolysis, and inflammatory pathways will lead to a more complete understanding of platelets and of TIC. Platelet transfusions remain the mainstay of treatment as part of balanced and goal-directed resuscitation, but through advancing knowledge of the underlying biology, safer, targeted, and more effective therapies may emerge.
School Nurses Share Their Voices, Trauma, and Solutions by Sounding the Alarm on Gun Violence
Abstract Purpose of Review The purpose of this review is to discuss the impact of gun violence within schools from the perspective of school nurses. School nurses are first responders whose skills are crucial to ensuring the health and safety of students, staff, and faculty within schools and the surrounding community. Recent Findings In the USA, fear has long dictated how schools invest their resources in response to gun violence. In the wake of a series of school shootings that began in the 1990s, school safety is now a multi-billion-dollar industry. Although school shootings remain rare events, the response to potential gun violence has been an implementation of active shooter drills in 95% of US schools. School districts are faced with difficult choices that balance the safety concerns of school communities and the plethora of industry vendors who claim they have the most effective method to take action and keep their students safe. Summary There is a critical need for research that guides the selection of evidence-based safety programs that consider the developmental and the mental health needs of school communities. School nurses are healthcare providers embedded in schools whose expertise and collaboration is critical to the design and implementation of these programs that keep students safe and ready to learn.
#ThisIsOurLane: Incorporating Gun Violence Prevention into Clinical Care
Abstract Purpose of Review This article reviews the medical community’s evolving perspective on its role in gun violence prevention efforts, particularly evaluating the evidence for and potential impact of patient education and firearm safety counseling. Recent Findings Growing numbers of physicians and professional medical societies recognize gun violence as a public health crisis and are increasingly supporting a more active role for the profession to address it. In spite of this urging, relatively few physicians routinely address firearm safety with their patients, in part driven by a lack of standardized education about how to incorporate gun violence prevention into clinical care. Summary Clinicians have a unique opportunity to prevent firearm-related injuries and death by performing firearm safety screening and violence prevention counseling at the bedside. With growing evidence for the effectiveness of such counseling and increasing number of widely available resources, clinicians across medical disciplines are well positioned to address this unmet need.
Combat Casualty Care Statistics as Outcome Measures for Medical Treatment on the Battlefield: A Review and Reconsideration of the Data
Abstract Purpose of Review This review focuses on the use of the case fatality rate (CFR), the killed in action percentage (%KIA) and died of wounds (%DOW) as battlefield medical outcome measures and reports the current statistical data for recent conflicts. Further, the review defines each statistic, and identifies their usefulness and limitations in medical research. Recent Findings The CFR, %KIA, and %DOW have been used by many authors since the beginning of the conflicts in Afghanistan and Iraq in 2001. However, these statistics are primarily derived from administrative databases maintained by the Defense Casualty Analysis System, and their primary purpose is not to evaluate the effectiveness of medical treatment. We believe both the magnitude of the improvements in CFR and %KIA and impact of medical treatment on these statistics have been in some cases overstated. Summary Battlefield lethality is significantly impacted by non-medical factors. Some medical researchers, likely unknowingly, continue to use these statistics, especially the CFR, without taking all battlefield confounders into account. The Department of Defense Trauma Registry provides opportunity for improved data collection, performance improvement, and standardization of the combat casualty care statistics thereby allowing for meaningful comparisons and a better understanding of battlefield trauma care.
Mechanisms of Traumatic Hyperfibrinolysis and Implications for Antifibrinolytic Therapy
Abstract Purpose of the Review To provide an update on the current knowledge of mechanisms that regulate hyperfibrinolysis and implications of recent findings for use of antifibrinolytics. Recent Findings New data demonstrate a role for both platelet and endothelial dysfunction, as well as novel mechanisms for activated protein C in the pathophysiology of hyperfibrinolysis. Although randomized clinical trial data in mature trauma centers is lacking, most analyses support the early use of tranexamic acid in the treatment of all severely injured patients experiencing hemorrhagic shock. Summary Hyperfibrinolysis is a devastating complication of trauma and hemorrhagic shock. Currently available antifibrinolytics are largely considered safe and effective and further research is needed before restricting antifibrinolytic use in the sub-population of patients with fibrinolytic shutdown. Future development of novel therapeutics to reverse hyperfibrinolysis could improve treatment of this hemostatic disorder.
Alone and Sometimes Unafraid : Military Perspective on Forward Damage Control Resuscitation on the Modern Battlefield
Abstract Purpose of Review The objective of this review is to describe the military experience and utilization of damage control resuscitation as well as explore future developments to push the best medicine far forward in the austere environment. Recent Findings The Global War on Terror has transitioned from mature combat theaters staged with rapid medical evacuation and robust medical facilities to more austere environments. Due to this transition, the military medical force has adopted the practice of sending providers and surgeons into forward deployed environments to provide Damage Control Resuscitation closer to the point of injury. Summary This review focuses on the key tenets of Damage Control Resuscitation and its development. It also describes how various military units have adopted damage control resuscitation principles.
Prehospital Hemorrhage Control and REBOA
Abstract Purpose of Review Review the current state of the art in prehospital hemorrhage control and the role of resuscitative endovascular balloon occlusion of the aorta (REBOA). Recent Findings Prehospital data demonstrate improved hemorrhage control and decreased blood product transfusions with tourniquet use. Minimal complications have been noted (temporary nerve palsy) and no tourniquet-related amputations have been reported in modern series. Junctional tourniquets are effective in stopping arterial flow and controlling bleeding in preclinical trials. Clinical data is lacking. Hemostatic bandages have been shown in animal studies to improve time to hemorrhage control and survival. Limited clinical data supports improved hemorrhage control and no morbidity. The REBOA catheter is a promising technology with a clear role in severe pelvic fractures. The role of REBOA in the prehospital setting remains undefined. Summary Preclinical and clinical data are supportive of both prehospital tourniquet and hemostatic bandages. Junctional tourniquets are promising but lack clinical data. The REBOA catheter is an effective bleeding control adjunct for which prehospital indications are still being defined.