Recurrent Firearm Injury

Those who survive gunshot wounds are at higher risk for future firearm injuries

Clinicians can help reduce future firearm-related harm in patients who have already sustained a firearm injury.

For patients who are hospitalized with a nonfatal firearm injury, clinicians have an opportunity to educate them and link them to resources that will decrease their risk of reinjury with a gun. This includes patients whose injuries are from self-harm, interpersonal violence, and unintentional injury.

 

For every firearm death in the US, at least two people are shot and survive.1

Who’s at Risk

The risk of reinjury with a firearm is high for patients who sustain nonfatal firearm assault injuries. In California, 4.1% of patients admitted to the hospital or emergency department for nonfatal firearm assault injury were reinjured with a firearm, usually within two years. Among patients with multiple nonfatal firearm assaults, 2% subsequently died from firearm homicide.2 Studies combining trauma registry and law enforcement data have estimated even higher rates of reinjury: about 6% within two years and 16% within 10 years.3

Subsequent firearm assault injuries tend to be more severe than initial injuries and have increasingly worse prognoses.4 With each successive nonfatal firearm assault injury, the risk of death by firearm increases.2,4 Recurrent firearm assault injuries disproportionately impact men and Black people.2-4

Although the vast majority of people who attempt suicide with a gun will die,5 survivors of suicide are at continued risk of future attempts.

Consequences of Firearm Injury

When clinicians initially evaluate patients after a firearm injury, their focus is on the immediate treatment of physical harm and patient survival. However, patients may also experience social and emotional problems associated with trauma that require attention and treatment. In a national survey of violent crime victims, nearly three-fourths of people victimized with a firearm reported experiencing moderate to severe distress, problems with family or friend relationships, or problems at work or school as a result of the incident.6

Many survivors of firearm violence begin to carry firearms after the incident because they feel unsafe, increasing the likelihood that they will use a gun in a future altercation.7 A study of adolescents in Chicago indicates that exposure to firearm violence, including being shot or shot at or seeing someone shot or shot at, doubles the probability that an adolescent will perpetrate serious violence over the next two years.8

Clinicians in all specialties should be aware of the wide-ranging impacts of firearm violence on patients, as well as on their friends and families, and can provide referrals to mental health or social services when appropriate.

What You Can Do

Caring for patients after they have sustained a firearm injury should include interventions to reduce the risk of future injury.

Clinicians who care for patients with any type of firearm injury should inquire about the psychosocial factors that may have contributed to the shooting, such as unsecured firearms in the home, domestic violence or other interpersonal disputes, high rates of violent crime where the person lives, and high rates of firearm use among associates. Referrals and other services offered should be tailored to the patient’s individual circumstances and needs.

Clinicians working with patients who present after firearm suicide attempts should discuss the heightened risk of suicide when firearms are in the home. Counseling patients and other firearm owners in the patient’s home on the importance of removing access to guns through safe storage within or outside of the home when risk is increased may be an effective strategy. Following a suicide attempt, the clinician may refer a patient to mental health services; if the risk is still imminent, they should consider whether a 5150 hold is appropriate.

Clinicians should also counsel patients who present after unintentional injuries, including the caregivers of injured children, on the importance of safe storage. Such counseling is generally accepted by families: in a study of over 1,200 parents, 75% thought their child’s physician should advise about safe gun storage.9

Patients presenting with assault-related firearm injuries can be connected with support services and violence prevention groups. For example, clinicians can connect survivors of intimate partner violence to local resources and coalitions, which are searchable on the National Domestic Violence Hotline’s website. Hospital-based violence intervention programs (HVIPs) are another way to connect violently injured patients with resources, such as community services, mentors, employment support, and long-term care, in order to break the cycle of violence.

 

Dr. Sarah Stokes from the University of California, Davis contributed to this content.

Click to view references

  1. Schwab, C. W., Richmond, T., & Dunfey, M. (2002). Firearm Injury in America. LDI Issue Brief.
  2. Pear, V. A., Mccort, C. D., Kravitz-Wirtz, N., et al. (2020). Risk factors for assaultive reinjury and death following a nonfatal firearm assault injury: A population-based retrospective cohort study. Preventive Medicine.
  3. Marshall, W. A., Egger, M. E., Pike, A., et al. (2020). Recidivism Rates Following Firearm Injury as Determined by a Collaborative Hospital and Law Enforcement Database. The Journal of Trauma and Acute Care Surgery.
  4. Nygaard, R. M., Marek, A. P., Daly, S. R., et al.(2018). Violent trauma recidivism: Does all violence escalate?. European Journal of Trauma and Emergency Surgery.
  5. Miller, M., Azrael, D., & Hemenway, D. (2004). The Epidemiology of Case Fatality Rates for Suicide in the Northeast. Annals of Emergency Medicine.
  6. Langton, L. & Truman, J. (2014). Socio-emotional Impact of Violent Crime U.S. Department of Justice Statistics, Office of Justice Programs, Bureau of Justice Statistics.
  7. O'Neill, K. M., Vega, C., Saint-Hilaire, S., et al. (2020). Survivors of Gun Violence and the Experience of Recovery. The Journal of Trauma and Acute Care Surgery.
  8. Bingenheimer, J. B., Brennan, R. T., & Earls, F. J. (2005). Firearm Violence Exposure and Serious Violent Behavior. Science.
  9. Garbutt, J. M., Bobenhouse, N., Dodd, S., et al. (2016). What Are Parents Willing to Discuss with Their Pediatrician About Firearm Safety? A Parental Survey. The Journal of Pediatrics.

Learn more about potential interventions

Storing guns outside the home when someone is at risk can be lifesaving.

If guns are kept in the home, storing them safely can prevent firearm injury.

Mental health holds can help people at risk of suicide or violence get into psychiatric care.

HVIPs weave social care into medical care to prevent recurrent firearm injury.

For more information, see these peer-reviewed articles.

O’Neill, K. M., Vega, C., Saint-Hilaire, S., et al. (2020). Survivors of Gun Violence and the Experience of Recovery. The Journal of Trauma and Acute Care Surgery.

Pear, V. A., Mccort, C. D., Kravitz-Wirtz, N., et al. (2020). Risk factors for assaultive reinjury and death following a nonfatal firearm assault injury: A population-based retrospective cohort study. Preventive Medicine.

Violano, P., Bonne, S., Duncan, T., et al. (2018). Prevention of firearm injuries with gun safety devices and safe storage: An Eastern Association for the Surgery of Trauma Systematic Review. The Journal of Trauma and Acute Care Surgery.

Carter, P. M., Walton, M. A., Zimmerman, M. A., et al. (2016). Efficacy of a Universal Brief Intervention for Violence Among Urban Emergency Department Youth. Academic Emergency Medicine.

Garbutt, J. M., Bobenhouse, N., Dodd, S., et al. (2016). What Are Parents Willing to Discuss with Their Pediatrician About Firearm Safety? A Parental Survey. The Journal of Pediatrics.

Additional Resources on Preventing Recurrent Firearm-Related Injury

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