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markedly improved delivery of care following injury, regardless of where geographically the patient is injured.
As an extension, civilian bystanders in the field can initiate life-saving adjunctive measures such as tourniquet application and direct pressure to hemorrhage. However, these interventions are not intuitive and require some level of training in order to be successful. In conjunction with many trauma centers, the American College of Surgeons offers“ Stop the Bleed” training targeted for general public education. Nationwide, efforts are underway to equip public facilities with hemorrhage control kits( tourniquets, bandages, etc.) in a fashion similar to cardiac defibrillators. Much like CPR initiatives, we encourage the integration of this information in to common public knowledge and physicians can encourage at-risk populations to engage in this training.
Finally, there is significant opportunity for impact in the post-injury setting. We are well aware that we care for these patients for a very short period of time, whereas many of you care for them for a lifetime and will have a much greater impact on their future well-being.
2. PUBLIC EDUCATION AND PRIMARY INJURY PRE- VENTION
Primary injury prevention encompasses strategies devised to prevent injury from ever occurring. These strategies will typically fall under the purview of providers with regular contact in the outpatient setting, and thereby prevent patients from ever seeing a trauma center.
Implicit in injury prevention is clear characterization of the problem with accurate and detailed data. It’ s worth noting here that the quality of data surrounding firearm injury is, at current, abysmal. Statistics provided in popular media are generally pieced together from various porous databases. The lack of research funding over the years as a result of various legislative initiatives is likely in part a byproduct of the political narratives so closely intertwined with this issue. This hearkens back to the discussion regarding firearm injury not traditionally being perceived as a public health issue. Dramatic reductions in mortality from motor vehicle accidents were only realized following significant investment by stakeholders in characterizing the problem with quality data. Ongoing advocacy from physicians both as individuals and within various societies / organizations is of key importance in addressing this data gap.
Primary care providers, pediatricians and other frontline providers are essential in encouraging gun owners to seek training in both the operation and storage of firearms. Accidental injuries often result from insufficient expertise / training or unintended access to a firearm by an untrained individual. In our experience, the majority of accidental injuries occur either during cleaning of the firearm or in transportation. Ricochet injuries are often discussed but are exceedingly uncommon(< 3 percent of all accidental injuries). It is estimated that a quarter of firearms are stored loaded and that nearly half are kept unsecured within the home. Given that 50 percent of Kentuckians own firearms, all physicians with patient contact can proactively discuss these issues, with this short conversation having the potential to save a life.
3. COMMUNITY AND HOSPITAL VIOLENCE PREVEN- TION PROGRAMS
Hospital-based violence and injury prevention programs are increasing in frequency in trauma centers throughout the United States, including at ULH. Education, outreach and intervention are key principles. These programs attempt to take advantage of“ teachable moments” following injury where patients may be more apt to incorporate new behaviors into everyday life. Specially trained personnel engage patients in structured discussions in an attempt to reduce recidivism. Newer collaborative models such as the Cure Violence Initiative approach violent injury in much the same way that infectious epidemics are managed. Here, interruption of transmission, prevention of future spread, and the alteration of group norms are key principles. These models incorporate“ violence interrupters” into the framework of the community, facilitate resources and social services to individuals at risk, and actively participate in outreach efforts. This model has achieved significant global success in urban areas, and is evolving here in Louisville. Substantial and sustainable investments of time, finances and resources from communities are barriers.
Violent injury, and firearm injury in particular, are increasing in incidence in our community and represent a significant public health issue. Misconceptions persist regarding the management and nature of these injuries. The scope and magnitude of the problem can often trigger feelings of helplessness amongst health care providers, and we know that feeling all too well. However, together we as providers in our community can both improve the care of patients following violent injury and, optimally, work together with other stakeholders to prevent these injuries from occurring in the future.
Dr. Harbrecht is a professor of surgery at the University of Louisville and the practicing Trauma Medical Director of the UofL Dept. of Surgery.
Dr. Miller is an assistant professor of surgery at the University of Louisville and a practicing surgeon at the UofL Dept. of Surgery.
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