Gun Violence and the ER: America's Trauma Surgeons on the Front Line of a Public Health Crisis

Every day in the United States, approximately 120 people are killed by firearms and another 230 are wounded. The survivors — those who reach an emergency department alive — are treated by emergency physicians and trauma surgeons who have become, by default, the medical specialists most intimately acquainted with the consequences of gun violence. Many of them have been trying to speak publicly about what they see for years. For much of the past three decades, the political and funding environment made that difficult.

The Dickey Amendment: 26 Years of Suppressed Research

In 1996, Congress passed the Dickey Amendment, a provision in the federal budget that prohibited the Centers for Disease Control and Prevention from using federal funds to "advocate or promote gun control." The amendment was passed at the urging of the National Rifle Association following a 1993 study published in the New England Journal of Medicine that found having a gun in the home was associated with a nearly threefold increase in the risk of homicide.

The practical effect of the Dickey Amendment was to end federal funding for gun violence research at the CDC for more than two decades. The CDC, interpreting the amendment broadly, essentially stopped funding any research that touched on firearms as a public health issue. The National Institutes of Health, which was not subject to the same restriction, funded minimal gun violence research during this period. The result was a 26-year gap in the federal research infrastructure for one of the leading causes of death in the United States.

Jay Dickey, the Arkansas congressman who sponsored the amendment, later expressed regret about its consequences. In a 2012 op-ed co-authored with Mark Rosenberg, the former CDC official who had overseen the gun violence research program before the amendment passed, Dickey wrote: "We were on opposite sides of the gun debate, but we are in strong agreement that scientific research should be conducted into preventing firearm injuries and that ways to prevent firearm deaths can be found without encroaching on the rights of legitimate gun owners."

Congress partially reversed course in 2019, when the Consolidated Appropriations Act included $25 million in funding for gun violence research at the CDC and NIH — the first federal funding for this research in more than two decades. The funding has continued and expanded since then, but the research gap created by 26 years of suppression cannot be quickly filled.

The Numbers: Gun Violence as a Public Health Crisis

The scale of gun violence in the United States is without parallel among high-income countries. The U.S. firearm homicide rate is approximately 25 times higher than the average of other high-income countries. The firearm suicide rate is approximately 8 times higher. The total firearm death rate — combining homicide, suicide, and unintentional deaths — is approximately 11 times higher than the average of peer nations.

In 2020, for the first time in recorded history, firearm injuries surpassed motor vehicle accidents as the leading cause of death for Americans between the ages of 1 and 19. The milestone was driven by a surge in firearm homicides that began in 2020 — a surge that has been attributed to a combination of factors including the COVID-19 pandemic's disruption of social services, increased firearm purchases, and reduced police activity in some cities.

In 2022, approximately 48,830 Americans died from firearm injuries — 26,993 from suicide, 19,592 from homicide, 1,035 from unintentional injuries, and 210 from other causes. An additional estimated 74,000 were treated in emergency departments for non-fatal firearm injuries. The total economic cost of gun violence in the United States has been estimated at $557 billion annually, including medical costs, lost productivity, criminal justice costs, and the intangible costs of pain and suffering.

What Emergency Physicians See

Emergency physicians and trauma surgeons who work in high-volume trauma centers describe gun violence as a defining feature of their professional lives — not an occasional dramatic event, but a constant, grinding presence that shapes the culture and practice of their departments.

"We see it every shift," said one trauma surgeon at a Level I trauma center in a major American city, speaking on background. "Not just the acute injuries — though those are devastating enough. We see the families in the waiting room. We see the kids who come in with their brother or their father. We see the same patients coming back, because the conditions that put them at risk haven't changed. It's not a series of isolated incidents. It's a system."

The clinical management of firearm injuries has advanced significantly over the past two decades, driven in part by lessons learned from military medicine in Iraq and Afghanistan. Damage control resuscitation — the use of blood products rather than crystalloid fluids in hemorrhagic shock — has improved survival rates for penetrating trauma. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has provided a less invasive alternative to emergency thoracotomy for some patients in extremis. Tranexamic acid, an antifibrinolytic agent, has been shown to reduce mortality when administered early in hemorrhagic shock.

But the advances in trauma care have limits. High-velocity rifle rounds — the type fired by AR-15-style weapons — cause tissue destruction that is qualitatively different from handgun wounds. The kinetic energy transferred to tissue is dramatically higher, creating wound cavities that destroy organs and blood vessels in ways that are often not survivable regardless of the speed of surgical intervention. Trauma surgeons who treated victims of mass shootings involving AR-15-style weapons have described the injuries as unlike anything they encountered in their training.

The Research That Did Get Done

Despite the funding gap created by the Dickey Amendment, researchers at academic medical centers and public health schools continued to study gun violence using state-level data, hospital records, and private funding. The body of evidence that accumulated over those 26 years is substantial and consistent.

Studies have consistently found that access to firearms is associated with higher rates of firearm suicide. A 2020 study in Annals of Internal Medicine found that states with higher rates of household gun ownership had significantly higher rates of firearm suicide, even after controlling for mental health prevalence, poverty, and other confounders. The association between firearm access and suicide is particularly strong for adolescents: a 2019 study found that adolescents in states with the highest rates of household gun ownership were 3.6 times more likely to die by firearm suicide than those in states with the lowest rates.

Research on the effectiveness of specific gun violence prevention policies has been more limited, but the available evidence suggests that several interventions are associated with reduced firearm mortality. Universal background check laws, permit-to-purchase requirements, and extreme risk protection order (ERPO) laws — which allow courts to temporarily remove firearms from individuals who pose a danger to themselves or others — have all been associated with reduced firearm suicide rates in studies using quasi-experimental designs.

Emergency Medicine's Advocacy Role

The American College of Emergency Physicians, the American College of Surgeons, and other medical organizations have increasingly positioned themselves as advocates for gun violence prevention as a public health issue. In 2018, following the Parkland school shooting, a group of trauma surgeons and emergency physicians launched the "This Is Our Lane" campaign in response to an NRA tweet suggesting that physicians should "stay in their lane" on gun policy. The campaign generated more than 30,000 responses from physicians sharing their experiences treating gun violence victims and became a defining moment in medicine's engagement with the gun violence debate.

ACEP's current policy position calls for universal background checks, extreme risk protection order laws in all states, safe storage requirements, and expanded funding for gun violence research. The organization has also called for the repeal of the Dickey Amendment's successor provisions, which continue to limit the scope of federally funded gun violence research.

The Numbers: Gun Violence in America