Prof. Stephen Hargarten from Medical College of Wisconsin discusses his experience of working in Emergency Room care, his research into harm reduction, social models to reduce the incidence, and risk and damage of violence in America.
This podcast details why violence is not being included in medical education and offers an informed, science-based model, suggesting methods to integrate social training and resources into medical school curricula.
Read his original article at: https://doi.org/10.1080/10401334.2021.1906254
Image credit: Vilevi/Shutterstock
Hello, I’m Will. Welcome to Researchpod.
This episode deals with gun violence. As a research communications platform, I don’t often feel the need to add content warnings to our episodes. However, between the recording and release of this episode, there has been a school shooting in America. As it stands today, gun violence has now become the leading cause of child death in the US.
Today I’m talking with Doctor Stephen Hargarten from Medical College of Wisconsin, about his research and his perspectives from the emergency room in treating the immediate damage, social collateral and root causes of gun violence.
And joining me today, Doctor Stephen Hargarten. Hello there.
Hello Will, I’m delighted to be with you today to talk about gun violence.
If we could start with a little bit about yourself, what’s brought you through medical school to talking about the violence epidemic?
Sure, I’m an emergency physician, background. I’ve been practicing emergency medicine since 1977, and when I joined the faculty at the Medical College of Wisconsin in 1989, my practice of emergency medicine was related to supporting a Level 1 trauma center, and the Level 1 trauma center was the Regional Hospital for all seriously injured patients, whether it be a car crash or someone suffering from a bullet injury. And it was at that point that we had a rise in gunshot wounds that started to occur in the early 1990s, and that became my, the start of my involvement in examining gunshot wounds. The patterns of, of these deaths and injuries, and it’s further informed my activities, since I’ve been on the faculty since that time. And we, unfortunately, amongst the level and trauma centers across the United States are suffering from now another increase in deaths and injuries.
Was there ever a time in your career, in your journey, that you thought of stepping away from this? Or has it always just been dedicated to the work?
Well, my clinical practice has ended, actually, I left clinical practice three years ago, but I practiced emergency medicine for 37 years. I greatly enjoyed the opportunity to help patients and their families, to work with medical students and residents to educate them at the bedside for helping patients who are injured. It really informed my efforts and continues to inform my efforts whether it be for research, or education and advocacy.
Well, to kind of talk about the numbers that you’ve seen over your career from the 1990s to today. To break gun violence down into a few different aspects in terms of the sociological aspect, but also the statistics and the medical aspect. If we could start with maybe just some raw data, what does gun violence look like on a page?
Sure, or actually your question is quite timely for us to be looking at 2020 data here in the United States where over 45,000 people died from bullets that were carried by guns. And of those 45,000, the majority them are actually suicides, and in my practice of emergency medicine, I rarely treated a patient who attempted suicide by using a gun and firing a bullet. It’s mostly non-fatal events, assaults with a gun, and with homicide, homicide victims that we’ve tried to resuscitate who subsequently died at our trauma center and emergency department. And then there’s another third subset of patients that we see who – a child who’s playing with a gun and discharges the gun, and the bullet injures a friend, injures themselves. So you’ve got three major categories of gun deaths: suicides, homicides and unintended events. And then you flip that to non-fatal events – the majority of non-fatal gun injuries in the United States are related to assaults – ah, one person seeking to injure another. And then there’s that category of unintentional events.
And when it comes to gun violence off the page and in the lived experience, kind of the social burden, I mean you can imagine lots of people around the world don’t have to imagine the impact that gun violence has on not just the patient, but the people around them, the carers, the family of the society that it exists in.
Well, certainly it’s not only a problem of the United States, it’s a global problem. Over 250,000 people are dying each year from bullets carried by guns, and of those 250,000, according to a recent study about half, a little over half, are in the Americas; United States, Mexico, Guatemala, Colombia, Venezuela and Brazil. And actually Brazil and I don’t have the 2020 data, but as far as I know, they remain the leading country in the world overall for gun violent deaths. Higher rates occur in such countries like El Salvador and Honduras, so it is a problem that the United States has had for many years continues to be challenged by examining opportunities to prevent them to reduce the the toll. But it’s a global problem as well. And the need to expand our research efforts across nations is going to be extremely important as we enter further into the 21st century.
And you’ve talked about the cases that you’ve seen across your career. Is it something that you see as unavoidable? Is it something that you think any doctor should be briefed for even if they’re not in emergency medicine? How likely is it, do you think, in any medical career in America that you’ll have to deal with some kind of gun trauma?
Well, actually most specialties are encountering a patient who needs initial care for their injury: surgeon, emergency physician, anesthesiologist, orthopedist, neurosurgeon.
But I think in terms of following up, other disciplines also encounter patients who’ve been injured, whether it be a general internist, a health psychologist, social worker – it crosses many disciplines, not only for the acute injury in its management, but also the behavioral issues that are part and parcel of gun violent event and the social issues.
And so it does permeate across disciplines, it permeates across health systems, and it does tend to be dominated for the homicides and the assaults, to be in urban centers, whether it be large urban centers or even medium sized cities. And so as you get into rural areas, you have unintentional events – somebody cleaning a gun and they get injured. And then there’s the suicides which do occur largely in rural areas. Many states in the United States, by far and away the majority of gun deaths are suicide related, and so we never see them.
There’s never an impact, and so addressing that problem requires us to be more vigilant – pre-event.
So pre-event screening of depression, prevent screening for job changes, marital changes. Those kinds of stressors, uh, carry with it a certain risks for someone considering to end their life, and it’s that screening element that I think is so important for us to be considering to address firearm related suicides.
You mentioned the primary care. The initial contact team who would be dealing with the immediacy of a bullet wound, and is there anything like a typical bullet wound?
I wouldn’t say there’s a typical wound. It does change with the caliber of the handgun or the usage of a rifle or shotgun. Those do elicit different kinds of bullet wounds, and the higher the velocity, the greater extent of damaged tissue occurs. The other element of that kinetic energy exchange is also the location of the injury – where the bullet penetrates. Certain tissues are more elastic; lung tissue, muscle tissue, so that energy exchange is relatively less of an issue compared to the energy exchange that occurs with a bullet entering a liver, where that tissue tearing is more pronounced, leading to hemorrhage, and that risks one to lose enough blood to die.
Other energy exchanges occurring in a closed system – the brain with the skull encapsulating the brain. That energy exchange is significant because it’s in a closed system, and the energy doesn’t dissipate as much, but rather gets focused and concentrated, further damaging the brain tissue.
So that’s going to be variable, depending on the kind of bullet used; there’s hollow point bullets, there’s bullets that fragment… And all those can contribute further to the injury of an organ or bone.
Is it even possible to be prepared to deal with a bullet wound?
Yes it is, and in fact that’s a great question, Will, because when we have a trauma alert, meaning that the paramedics now are taking care of a patient who’s been injured by a bullet, the location of the bullet wound is critically important to note quickly – it’s it is a chest, in the neck, in the abdomen, that carries with it significant risk of bleeding, and that elevates the response team to be a level one response, which includes then emergency physicians, surgeons, immediately gathering around this patient doing pre assigned tasks, quickly assessing the biology of this disease, the blood pressure, the pulse, the patient’s responsiveness, the need to help, help, the patient breathe whatever that is that’s immediately assessed within a minute and the decision about what to do next in terms of stabilizing the patient further.
Or quickly going to the operating room to expose unnecessary tissue to stop the bleeding, which is one of the paramount priorities, and the other is of course helping the patient breathe, if they’re not able to do so on their own. So, there’s pre-assigned responsibilities, it is multi-disciplined with again, physicians from a variety of disciplines immediately there; nursing staff, there’s blood, blood bank support. It’s all a comprehensive response. And that has paid positive dividends too, increased survival with patients who are injured by bullets.
Kind of addressing as much of the Physiology of an impact when it comes to the upset to the gunshot wound victim and to anyone else who’s come in with them. Is there any kind of provision of care for the emotional psychological needs? ’cause I imagine they’re going to be in a very heightened state on admission as well.
And that’s exactly how we are comprehensively caring for these patients. Not only do they need immediate biological care, surgeon takes care of those bleeding sites, they may take them quickly to the operating room, but there is a health psychologist. There is a 414 life team that responds also to the patient, to their families, about this event that carries with it behavioral injury, that results, or ‘price’ is the patient at risk for agitation, depression, post-traumatic stress and that intervention is as simultaneous as one can have it, in the in the face of someone who is seriously injured or mortally injured by a bullet. And so there’s priorities, the biological response has its priority, but the behavioral response to the patient and to their families is critically important to be done in real time, to care for the patient once they leave the operating room that are in the floor or when they’re discharged to follow up in a clinic that meets the needs of the patient’s biological issues, their behavioral care, and their social care.
And on behalf of the doctors and the nurses, and everyone that you’ve mentioned to is on hand to deal with that immediate emergency. The kind of stress that that is on a professional level to deal with day in, day out for all those hundreds and thousands of cases that can build up over the course of the year. Do they receive a similar amount of training to deal with their own wellbeing, and is there any kind of provision for care for them as well?
That’s a good question, Will, that is increasingly being attended to with attention to the wellness of providers to be able to talk about a case that is particularly challenging, to review cases, to look at ways in which we can strengthen care, not only for patients who are injured from bullets, but also patients who are injured in car crashes, falls from heights. The injured patient comes in very different, many different ways and the care and dedication that we bring, particularly with level 1 trauma centers is the dedication we bring to our patients who are acutely in, in need, and as a team we support each other during this, these challenging times like we would support each other in other challenging cases that occur in our practice.
And when it comes to the hopeful survival and recovery of anyone affected by those, directly or indirectly. A whole school of speciality in terms of the rehabilitation, the training that you mentioned, some of the emotional stuff there. How integrated is that aftercare into the training for medical staff.
It’s increasingly being integrated as I mentioned, when a patient is discharged now from our hospital, they are followed up in a clinic specifically designed specifically set up with multiple disciplines to assure a comprehensive recovery as much as can be possible. There may be permanent disabilities, because of a spinal cord injury, a fracture that devastated the upper extremity or lower extremity, but these behavioral issues with social care issues are managed simultaneously with the biological physical recovery from the bullet, injuring intestines, or a bone, and so that comprehensive approach is really becoming more and more common across, at least in I can state this clearly for the United States, not really well versed about other countries and other trauma centers, but we’re seeing that this is increasingly being done in a comprehensive way across disciplines to assure and maximize the recovery of the patient.
The best gunshot wound is the one that you don’t have that you don’t have to treat. Can I just maybe get your broad thoughts on that before we drill down into some details.
Well, I think in the general reference will this is related to suicides when there is an intent to harm oneself, the bullet is directed to either the head or the chest and that release of energy which is so quick which is so immediate, precludes active intervention that we see then when a bullet enters the abdomen, for instance, during an assault, and so the opportunity for intervention once the bullet is released is virtually nil, so the primary effort is to prevent the release of the bullet. And that means primary prevention of addressing suicidal ideations looking at, means restriction, trying to have the home safer without having this product- a gun with the bullets in the home – we know that a lot of suicidal events are rather impulsive, particularly amongst the young, so removing lethal means, be either permanently or temporarily, is an important strategy for primary prevention screening, assuring that these individuals get a timely behavioral health care helps to prevent the escalation of the depression, which leads to further likelihood or further risk of completing it with a gun or some other means.
But I think that’s where the area that is really important for primary prevention will obviously it’s part of the primary prevention of of homicides and unintended events that have different levels of strategy, so it’s it really is an important area that’s in in need of continued and thoughtful research.
And I’ve touched on some of it there, but the duties of care from kind of the immediate doctor in the treatment room, working backwards from the victim to the owner of the weapon, if it is not the victim, to whoever it is that gave the training for their firearm license, to the retailer that sold the weapon to the manufacturer who has produced the weapon to the bullet. How can any one of those stages any one of those people involved in the chain that leads up to a gunshot when presenting in an emergency room be encouraged to stop that from happening?
Sure, it’s a good and somewhat complicated question, Will, but there is that going upstream is what we commonly refer to, this is that, certainly an individual who buys a gun from a firearm dealer, the firearm dealer has a responsibility, increasingly to note whether or not this is someone who appears to be despondent.
Increasingly firearm dealers are being pulled into strategies to address firearm related suicides.
There are programs being initiated and evaluated where temporary storage of a gun, let’s say a veteran, who is despondent, and has guns in the home. Those guns are temporarily removed, stored by a gun dealer who agrees to be partnering with the community to address firearm related suicides.
So there’s responsibilities that are emerging with gun dealers. Responsibility for the gun manufacturers rests with making their product un-accessible to vulnerable, at risk users. Despondent youth, inquisitive children. Much like the car industry changed and there was a paradigm shift for safety in their design, with seatbelts and airbags and other elements that helped to reduce the toll of car crash deaths, I think that the gun companies have an opportunity, and an obligation, to design their products in a way that reduces unauthorized access, whether it be again, an inquisitive youth, a despondent teenager, or a criminal who seeks to steal a gun.
And the technologies that can make guns, what we call smart guns, um, is at the edge of, of design, and can be and should be examined carefully and thoughtfully introduced into the marketplace for those who choose to have a gun in their home. And so there is a cascade of some responsibilities, Will, that I view, that are important, just like there’s responsibilities all along the pathway to address car crash deaths and we’ve done successfully that with car crash deaths over the decades. We have, uh, a need and an opportunity to do this with gun violence.
Do you or have you ever owned a gun?
Yes, I own a shotgun. I own a couple of cars too. (laughs) I own a Polaris. It’s a electric vehicle that I get around in my place in western Wisconsin, so I own a lot of different products that help me do stuff, or protect me.
What we’ve discussed here sounds a lot like the Cardiff model of injury in a social context and I wonder if I could get a brief summary of what that is and how we can use it as a way to medicate against injury.
Well, the Cardiff model started in Cardiff, Wales, and it was spearheaded by a, um, oral-facial surgeon, Jonathan Shepherd, who was repeatedly coming to the emergency department treating injuries and he started to ask the question, well where did they get injured, meaning not anatomical location but where in the community?
And what has resulted from these, the simple question of going upstream if you will, resulted in what is again described as a Cardiff model, which is a comprehensive analysis of all of the police-informed assaults, and all of the assaults that are treated in emergency departments. Not all those events are reported by the police, so that combination of information – police-related assault information, emergency department assault information, de-identified and placed geo-spatially onto the map of Cardiff, or on the map of Milwaukee, which is what we’re doing as we speak.
That identifies place-based areas of assaults, but it also identifies opportunities led by the community. The community drives this, as what are some of the place-based opportunities to reduce violence, to reduce these assaults by improved lighting, by making the park safer with removing bushes that people hide behind.
A lot of differing place-based strategies can be informed and developed and then evaluated by the usage of this model of combining information to make it comprehensive. Major proportion of assaults are not known to the police, and so it strengthens their job to be proactive in preventing future assaults that may even further escalate into a homicide event.
So we’re attempting to replicate this in cities across the United States, notably Atlanta and Milwaukee, are the two furthest along, but there’s other cities in the United States and there are cities across the globe that are advancing this, not only in Great Britain but beyond, in countries like Australia and so forth.
So, this is a good example of a place-based strategy using linked information, geo-spatially presented on a map, and the rigorous analysis of Cardiff has demonstrated a reduction in violence, to, er, 30 or 40%.
Can gun violence be separated from its social-political context? There is a lot of personal, political involvement in the choice to own a gun, and whether there is any way to unpick the incidence of gun violence from the phenomena of gun ownership, and gun’s role in society, be they North America, the Americas, or globally?
Well, that’s a complicated question Will, that deserves much more cultural analysis if you will, than I can provide. We do know that the United States is the most, shall we say, heavily-armed society in the world, and we are challenged by that… need to, to look at the cultural issues of why people choose to have this product in their home. Whether it be for hunting, sporting, personal protection while also balancing the needs of our communities to be safe and healthy.
And I think that these research issues, these educational issues have to always be studied in the context of the culture that we live in. Just at the same that it’s been looked at in other cultures around the world, Australia, New Zealand, compared to South Africa compared to Brazil. And I think more and more, these cultural comparisons and contrasts and exploring strategies that help make personal protection be made, while the community protection is achieved as well.
These are areas that deserve more and more research as the, the toll continues to occur across not only the United States, but across many other different countries, so there are cultural differences. We do have a Second Amendment that is not placed in other constitutions around the world, but that serves as an opportunity for comparison and contrast with other countries who have individuals wanting to own a gun for again sporting and personal protection. So, these comparisons and contrasts are going to be really important to advance our understanding.
Would you think there is anything that anyone listening to this, be they from a medical background, be they a member of the public or someone involved in healthcare policy, social policy, is there anything that they could take away from this that they might not have known before or anything that might steel their resolve to hope for better?
Well, if we take on the environment that I’m most familiar with – healthcare systems – I’ve just outlined a couple of very important strategies for health systems to incorporate to integrate into the fabric of their activities, and this can be done across healthcare systems across the world.
So the initial care of the patient, as I mentioned, should be comprehensive in scope and nature. The biopsychosocial platform for caring for patients and maximizing their outcomes should be incorporated across all trauma centers. And including that would be trauma-informed care training for the providers. And we talked about that, initially, that these providers know they’re trained in a better way to better care for these patients and maximize outcomes. And they’re screening for depression that can occur in a general internist’s office.
We can talk about other screening opportunities for domestic violence risk, interpersonal violence risks. We can talk about the fact that pediatricians and other primary care health care providers can be effectively and culturally sensitively asking questions about the safety of a home, whether it be a pool with a, uh, with not a fence around it, it could be around certain chemicals, poisonings that are not properly secured, as well as a firearm that’s not properly secured when there’s a despondent teenager.
So healthcare systems can do a lot for the care of their patients. Screening for primary prevention and the care of the patient once they become injured. And then they can adopt other opportunities to inform the community by adopting the Cardiff model with the community and their emergency department experience to help inform place-based interventions that I just mentioned as part of the Cardiff model.
So the healthcare systems can do a lot, and can do more and perhaps can generate policy recommendations, small ‘P’ policy recommendations that inform the care of their patients and help the community devise ways to prevent it.
I think there’s other opportunities for depending on where a listener may be coming from, Will, that could perhaps talk about other policies related to the nature and scope of this product being sold.
Smart handguns: are they available for those who wish to buy them, and if not, why not? And I think this is an area that deserves thoughtful exploration about having a car equipped with an airbag, with seatbelts. Why not have guns that are designed in a way that’s only for the authorized user?
Well, I think there is an increasing element that is occurring in the United States and I think it’s going to be happening more and more in other countries, particularly those that I’ve referenced where healthcare systems are increasingly being activated and it’s increasingly being identified as a global health pandemic.
We’ve been suffering from COVID. We’ve been suffering from other infectious diseases that we need to take care of. Malaria, tuberculosis, HIV.
But I think it’s important for us to recognize that this pandemic of bullets, of this product moving illicitly across borders has to be addressed and has to be addressed intentionally with good research and evidence based policies.
We have formed a network of organizations to prevent gun violence in the Americas, and we’ve been working closely with a consortium of universities for global health and its executive director Keith Martin, and we feel this is a very important initiative to address gun violence, not only in the, in, as part of global health, but also gun violence, particularly in the Americas, as I mentioned, and I think that’s an important development that’s occurred over the last couple of years now, where we’ve been calling attention to the challenges of US manufactured guns finding their way with illicit trafficking, diversion to gangs and other individuals in Mexico, in Guatemala, in Central America. These, I think, are areas that deserve important research and improving our understanding to strengthen US agencies to address this flow of this product that’s unfortunately occurring and penetrating across our borders.