Thank you for being here today. So we are presenting on a topic outrunning the bullet, the physician's role in firearm injury prevention. Let me move this away. We are being live streamed as well. We will ask that we leave questions to the end. The microphones over here will be activated. And those of you live streaming, we will have the opportunity to answer your questions too that you text us. So without further ado, let's get started. So it is very important for me to mention, at no point during this session will we dispute the right to bear arms. That is not our intention. We just want to apply publicly known facts to facilitate a broader discussion. We as physicians cannot ignore the epidemic of firearm injuries plaguing our society. We know firearm injuries, not just bullet holes, right? There's so much more. There's so much more of an impact. It extends far beyond physical injuries, at least lasting trauma on individuals, families, community members, so on and so forth. The devastating consequences of gun violence are becoming more common as well. So it's definitely a public health issue that we need to start addressing. By fostering collaboration between several entities, right, advocates for mental health, for advocates for gun ownership, right, we need to all come together and work together to promote a way to save lives. So without further ado, let me go ahead and introduce you to my colleagues here. So I have Dr. Keshav Deshpande. He is a trauma surgeon at Grant Medical Center, which is the busiest trauma center in Ohio. It's also one of the top 10 busiest trauma centers in the country. Dr. Deshpande is involved in several different public health efforts, including violence prevention. He's on several surgical committees nationwide to help prevent injuries in general, including firearms. My esteemed colleague here, Jesse Cannella, is actually a triple board resident at Indiana. So pediatrics, child and adolescent psychiatry, and adult psychiatry. He's also an ambassador for the APA Foundation. And finally, I have Dr. Andrew Carell over here. He is a rising intern, actually, at Wright State University. He is the first medical student to actually be able, permitted to be able to join a committee for the Ohio Psychiatric Physicians Association. And with that, he is part of our public health committee. He's also author of different publications, which is wonderful at his stage in training. But one of the most relevant to this topic is psychotherapy roles in evaluating the invisible wounds of moral injury. And then finally, I'm Dr. Neetha Bhatt. I am a staff psychiatrist at Twin Valley. It's the state psychiatric hospital in Columbus, Ohio. I'm also faculty, I'm an associate professor at Wright State University. I am soon to be the president of the Ohio Psychiatric Physicians Association. And I'm also chair of our public mental health committee over in Ohio, so let's get started. So first of all, we have nothing to disclose. We have no financial interests. The views and opinions we express today are our own. They do not reflect those of our past nor current employers. So they do not represent the beliefs of the Ohio Mental Health and Addiction Services, Wright State University, Ohio Health, Indiana University. Okay, let's talk real quick about the objectives, the overall objectives of this talk. So what do we wanna do here? What's our goal today? We wanna learn ways physicians and other healthcare providers can really help in times of mass shootings. So we're gonna hear the trauma surgery perspective as well. You know, during mass shootings, during disaster management. It's really interesting how some of this really applies to what we just went through as a society for COVID-19 and different things as well. We're gonna talk about emergency preparedness and hospital and community-based violence intervention programs. We'll learn ways physicians can really stand together, band together to fight stigma. We as psychiatrists do this often. This is one of our talents, I should say. But working with folks from other specialties, pediatrics, trauma surgery, all the different specialties to really fight stigma. We wanna help promote responsible gun ownership and better serve our patients and our communities. And finally, we will look at factors that are strong predictors for firearm-related self-injury, violence, and mass shootings, and address common firearm violence and mass shooting-related misconceptions, things such as violent video games and mental illness. As far as my section topics, I'm gonna talk a little bit about mass shootings, you know, to define the problem, factors linked to mass violence, federal funding for research, and then how many of you here are aware of the Dickey Amendment? Okay, so we'll talk a little bit about that. And I would love to have some of your comments and input as well at the end. And then finally, current and future research. Sorry, this computer's sticking here. All right, so mass shooting. Let's talk a little bit about it. What is a mass shooting? How can we define a problem that does not have a universal definition? So take the FBI, for example. They have no definition of mass shooting. They do talk about mass murders, right, which, according to their 2008 definition was a mass murder kills four or more people in a single incident. Again, this is mass murder, not mass shooting. They actually don't even have a definition and specific for mass shooting. So this includes people, you know, stab victims or, you know, various other forms of mass murder. In 2013, though, they revised their criterion a bit to be three or more deaths. Again, this is not gun-specific. Looking at other entities, for example, the Congressional Research Service Report, they define it completely differently, right? They say four or more deaths, and that's not including the shooter themselves, right? And the gunmen, you know, they do not pursue criminal profit. There's certain definitions. Again, it's not universal. How are we supposed to do research if we can't even, you know, agree on a definition or come up with a definition? So let's talk a little bit about federal funding for research. So we all, we know, you know, the U.S. makes up less than 5% of the world's population. However, we own over 40% of the world's civilian-owned guns. That's quite a significant number. So federally funded public programs, you know, public health programs are crucial. They're extremely important, right, for us to address public health concerns. So what am I talking about? You know, do any of you remember any examples? Do you remember back to sleep for SIDS, to prevent SIDS? You know, we know click it or ticket, right, for when we're talking about automobiles, right, and motor vehicle accidents. You know, it was only 20 years ago that these smoking laws, these were really enacted to, you know, of course, nationwide within each state, though, to prevent exposure to secondhand smoke. Think of how many lives have been saved due to some of those public health initiatives. Again, these are just a few examples, right? And so just like we're saying, it's harm reduction, right? We were talking to a gentleman earlier. I'm, you know, we didn't have to take, we didn't have to remove every single motor vehicle, right, from our society or country. No, we learned ways to, you know, prevent injury, right? So same thing with gun violence. So let's talk a little bit more about that, right? Unfortunately, some folks, some entities, it feels very black and white. Either we prevent gun violence, right, or we protect gun rights. That's not at all, we're approaching that, that's not the best way to approach this, right? We need to work together, to partner together. Folks, again, folks in society are looking at this very black and white, but luckily things are starting to change. Before we can help promote gun violence, we need some things, though, right? It's really important, but we need data, we need research, and unfortunately, that's not necessarily something we have at this current state. It's something that is improving. You know, before we can save lives, we need to know what's the problem. We need to know who gets killed, where are they getting killed, when are they getting killed, what role does substance uses or drugs or mental illness play, right? Other things we need to look at is what works, right? We need to collect data on how to prevent gun violence, but while also protecting gun rights. And how do you take that research and translate it to public policy? And then how does public policy relate to your community? And then how does that relate to your patient interaction? Again, data is incredibly important. So here's an example, again, a public health initiative where we have saved a ton of lives, right? So, you know, looking at motor vehicle accidents. So advocates for motor vehicle safety had persuaded Congress to enact new legislative standards despite a lot, a large amount of opposition from the automobile industry. And because of that, we were able to really collect data. And what did that mean? We were able to create safer highways, safer infrastructures, putting guardrails up, right? Barriers, other campaigns we talked about, click it or tick it, airbags, right? Various things within our automobiles, how can we make them safer? And also criminalizing unsafe driving, right? Again, we didn't ask to take every motor vehicle off the road, that's not what we did, right? We worked with the automobile industry to make everything safer, to make our community safer. What's really interesting, this is a wonderful statistic, is the reduction in fatality rate from motor vehicle accidents decreased 81%, right? From 1956 to 2017. That's incredible to me. So let's talk a little bit about motor vehicles. How many folks in this room find themselves in a motor vehicle, like on a weekly basis, a daily basis, most of us, right? So this is a very interesting slide to me. So starting in 2017, for the first time in history, the number of firearm-related deaths surpassed that of motor vehicle accidents. I'm not gonna ask you to raise your hand if you wanna go on that, we won't go there. But the average American spends eight hours per week in a car, right? And there's far fewer guns. Many of us have much, much, much less interaction with guns, so it's just something to keep in mind. In 2021, for example, there were 48,830 lives lost to gun violence, and comparing that to motor vehicles, 45,404. Again, think of how many more people own motor vehicles or find themselves in a motor vehicle. Again, we're gonna talk a little bit about the importance of federal funding to prevent death and how well it worked here for motor vehicles. Okay, so again, a few of you have heard of the Dickey Amendment, which is wonderful. Generally, most psychiatrists, most physicians have not heard of it, so I'm very, very happy that we're discussing it today, but that some of you are aware of it. So let's talk a little bit, what is the Dickey Amendment? So in 1996, there effectively became a government freeze for the CDC to research gun violence, right? And gun safety, so what do I mean here? What am I talking about? So, you know, the CDC had made some efforts, right? They had allocated at one point $2.6 million in funding to gun research, and they actually changed some of their task forces around to study this. And so what happened? The NRA and various other entities had issues with this, and so at this point, what happened was the NRA accused the CDC of being biased towards guns and began lobbying to eliminate the Injury Prevention Center at the CDC. And although the center did survive, the NRA persuaded folks in Congress to take action. So what happened? In 1996, Jay Dickey, it's named after a congressman in Arkansas, right, the Dickey Amendment. This amendment was signed, and what it did was it banned, the amendment did not, while it did not ban gun violence research, it did prohibit the CDC from using federal funds for research that advocated and promoted gun control. So what was happening is folks, researchers, very well-intentioned, became nervous. They were basically put in a corner. You know, if you study this gun violence, you know, this issue, we're gonna defund your funding for cancer researches, right, colorectal cancers, breast cancers, so on and so forth. So these researchers were really put in a corner. So again, Congress also slashed the CDC's funding by $2.6 million. That's the exact amount that the CDC spent on firearm violence research the previous year. So that was not just by accident, you know, that was a very clear picture, unfortunately, for those researchers. So the NIMH, or sorry, NIH actually ended up following suit as well. So in 2011, following a publication that they put out on firearm injury prevention, gun possession and assaults, the Congress then, in 2011, applied that Dickey Amendment to the NIH. So this has really caused a huge barrier, right, for us gathering data and really addressing the problem. So according to a JAMA internal medicine article, in 2017, the number of publications between 1998 and, so data from 1998 to 2012 showed during this 2017 publication that the number of publications about gun violence decreased by 64%. It was basically, the research was reduced to 10 to 20 full-time research projects. And so what was happening is grant funding was being scrapped together by different entities. So hospitals, right, universities, states, different foundations, they were the ones that were doing their best to try to scrap together data. Following the Sandy Hook and Aurora tragedies, activism was very, very reignited, right, within our communities. Physicians, citizens in our society, they all found their voice again. They advocated for research and a public health approach, much like the motor vehicle accidents, right, to tackling this issue. President Obama at the time urged Congress to allocate funding for the CDC to work on gun violence prevention, but Congress denied the request. President Obama directed the CDC not to regard the Dickey Amendment as a complete bar to funding research on gun violence. Nevertheless, the CDC, they did not adjust their practices. They didn't want to be defunded, right, for other projects. They were scared. So in 2012, following the Aurora, Colorado theater shooting, Congressman Dickey, Jay Dickey himself, along with the CDC researchers, argued that the CDC should be able to research gun violence. So Congressman Dickey took a, he had a change of heart. He has since then said that he has regretted his role in stopping the CDC from researching gun violence. And he simply said, I didn't want to let any of those dollars go to gun control advocacy. So in 2018, following the Parkland shooting, that really, again, led to more activism by young people around the country. And they used their voice and they demanded that lawmakers enact substantive gun control legislation. So in 2018, Congress then clarified language in the amendment to state that federal government does have the authority to conduct research into the causes of gun violence. But the clarification did not come with any money, no funding, right? And so it also didn't change the culture at the CDC. Again, they were still worried, they were scared. So it has been, of course, this Dickey Amendment has been quite the obstacle, right? So in 2018, out of a total budget of more than $8.2 billion, the CDC, they devoted only $199,000 to firearm-related research. Can you imagine if we did that little research for diabetes, strokes, hypertension, I mean, cancer, since 1996? So in 2018, congressional negotiators actually reached a deal on an omnibus continuing resolution. While the Dickey Amendment itself still remained, the language accompanying the omnibus spending bill clarified that the CDC can conduct research, but cannot use government-appropriated funds to specifically advocate against gun control. Again, it included no funding for firearm injury prevention or safety. However, it was a start, right? We have clarifying language. And the bill was signed into law by President Trump in March of 2018. So what's happened since? Again, the bipartisan, at this point, Congress came together. And so in December of 2019, they came to an agreement that we need research, right? Both sides of the aisle. And they actually approved $25 million for the 2020 fiscal year for gun violence research. This is huge. And again, this money is actually to be split between the CDC and the NIH. So for the first time in 24 years, federal funding was approved for firearm-related prevention research. It clarified that the Dickey Amendment did not actually, that it allows us to use federal grant money to fund firearm-related research, again, but not to lobby against gun control. So we are hoping, you know, we're still collecting data, but we're hoping that this research will allow us to answer basic, the most basic of questions about gun ownership and to evaluate effectiveness of firearm policies and prevention efforts. So actually, in 2020, it's really great. Some of this money was allocated to nine different states in the District of Columbia. So they were working in partner. So the CDC gave these states and D.C. money, right, to conduct their own research, to really figure out what's the best public health approach here. Again, these are, I have a couple of examples that we'll go over, but what have we learned so far? So far, we've learned that nearly two-thirds of gun-related deaths in this country are suicides. So again, they're able to apply that data and look at strategies. As we know, firearms are the most lethal method, right, of harm, of self-harm, with 90% of suicide attempts resulting in death, right? 90% of firearm-related suicide deaths. So it's up to us as physicians to become vocal about the importance of this work. We need to have bipartisan effort to really help come up with prevention strategies, right? We're gonna take this, just as how effective as we were for the automobile industry, we can do that for firearms. Very, very important statistic that I wanted to mention is nearly half of those who die from suicide had an encounter with a healthcare professional in an inpatient, outpatient, or emergency room visit within four weeks of their death. So what does that mean for us as psychiatrists? So we are trained, we are programmed to discuss firearms, to discuss suicidality, and those sorts of things, but it's really working with our partners from pediatrics, from trauma surgery, from all the different specialties, working with them and having them feel more comfortable about having these conversations that are so ingrained within us. Another statistic that is very alarming is up to 80% of folks have seen a provider, a medical provider, within a year of completing suicide. So that's alarming. Assessments by clinicians of patients' access to lethal means, such as firearms, have been linked to a reduction in suicide rates from the data we have collected so far. So at this point, more than 45 medical professional societies, including the American College of Surgeons, pediatrics, APA, AMA, we have all adapted and come up with a guidance to recommend that physicians counsel their patients on firearm safety when it's clinically relevant. But again, nonetheless, some of our colleagues and other specialties are still needing encouragement and still needing the confidence, right, to be able to have these conversations. So I just wanted to bring up a couple of, you know, different studies and different programs. So Washington State, for example, they're part of that group of states that got CDC funding. So they actually had their own FASTER program, which was modeled after a successful program in their state with the opioid epidemic surveillance. So again, we're not reinventing the wheel in that sense, and we're talking about harm reduction. So a large amount, a large number of state and county level health departments were paid by the CDC to engage in, you know, research and surveillance. So they worked with health officials at the local level to share data, which then in turn helped with prevention. So, and what they found was it was similarly as successful to Saving Lives as their initiatives of the opioid epidemic. In Washington, D.C., what did they do with their money, right, within their community? So they started actually a really great public health dashboard to collect data. And what they found with their data is over a one-year period, or within a year-to-year period, the, so it showed an alarming 18% increase in firearm-related visits to the emergency rooms. They found that 11 p.m. is actually the peak time of day for a hospital visit related to firearm injury. And 40% of people in D.C. show up to hospitals with non-fatal injuries only to go on to be killed later, right, by a firearm. 40%, that's an astounding number to me. So being able to identify what works successfully in our communities, our individual communities, to prevent further violence is very important. We're starting to finally collect that data, so. The CDC does have some fast facts to really help providers, help physicians, but how do we prevent firearm violence and suicide? So what we need to do is address the needs of people at the greatest risk, right, and we're gonna talk about some risk factors and things real soon. Gatekeeper programs, what does this mean? It's embedding people within the community, right, that are able to serve as gatekeepers, you know, to identify people that are at risk. So whether it's in a school or some sort of community setting, a church, so on and so forth, people that can recognize folks that are hurting or at risk, and really help direct them to the proper resources. Other things, hospital-based violence and suicide intervention programs. Just something as simple as improving physical conditions within our communities. So there's been studies, the data is showing that just cleaning and maintaining a vacant parking lot, right, can actually help prevent and save lives. It's a gathering space for folks where they can feel safe, right, where they can come and have a sense of community. Sounds so simple, right? Probably easier said than done, right? But such a simple intervention that we can do. Also, of course, strengthening economic and household security. And then talking about secure storage of firearms, which we'll get to in a little bit. Here are some of my references. If anybody wants a copy of our slides, we are more than happy to email them out. Please see us afterwards. But I will hand it over to my colleague, Dr. Keshav Deshpande, our trauma surgeon on the team. Thank you, everybody. And I'm honored to have the privilege of your time to share a little bit about my specialty and what we kind of see on a day-to-day basis, and kind of share with you what is being done at the level of the American College of Surgeons to kind of help promote the idea of decreasing violence due to firearms. While I don't have any financial disclosures, I just do want to point out that some of the interventions that I'll talk about that are happening at my local hospital were funded by the Ohio Health Foundation, as well as the Victims of Crime Act grant. And so I just want to say thank you to having these abilities to be able to do this work. Let's wait for that screen to pop back on. There we go. Okay, so my personal motivation to come here and speak to you all and to kind of do this work really revolved around last summer when I started kind of preparing for this talk. And I just did a very, very fast Google search. And there were no shortages of headlines talking about children or families being affected by firearm violence. And this is all within just two months of last summer where all of this happened in central Ohio. So where we're gonna go with this talk is I'll share a little bit about the history of ATLS, what we're seeing in trauma centers, how we are preparing for disaster management, and then we'll kind of switch roles a little bit and go into the American College of what are some of our current strategies for prevention and talk about kind of where this is going politically by taking the politics actually out of the discussion and talk about some of our consensus statements, which includes the APA. So the history of ATLS. ATLS stands for the Advanced Trauma Life Support. And it serves as the framework for anybody coming into the emergency department to receive their initial evaluation. It starts with a primary survey assessing their airway, their breathing, their circulation, and their neurologic disability. But the origins of ATLS is actually rather new. It hasn't been around for very long. And it started with an orthopedic surgeon who was flying his family across the Midwest when their plane came into some difficulty and it crashed in Nebraska. And he was able to see the emergency care that was delivered to his family, not necessarily the specifics of the talent of the physicians or the healthcare team that provided it, but the actual resources that they had to be able to deliver that healthcare. And so based on that, he dedicated the rest of his career to developing ATLS as a certain framework of how to do an initial resuscitation. And we've been able to take that initial framework and move it into how do we do that on a much bigger scale where there's either a mass casualty event or there's completely austere or conflict-ridden environments with limited resources and be able to deliver the same level of care. Because in a mass casualty, this is my hospital in Columbus, Ohio, and I like to think it's a pretty sophisticated trauma center, but even the most sophisticated places can become very austere environments after a disaster. And so when we talk about the tenets of how to move into disaster management, it is not business as usual. You really have to switch that to adapt and how to overcome. And so while there's no definition of mass casualty shootings, a mass casualty event from the perspective of an emergency department really comes down to are the casualties exceeding the resources that we have the ability to deliver complete individual care. And so for some hospitals, that might be six patients. For some hospitals, that might be 25 patients. Places that are receiving a lot, how do we organize and shift that evolution of the event to certain areas where they can deliver their care is how we kind of change the paradigm of delivering trauma care. And so the idea of initial trauma care or ATLS is really the greatest good for your patient, but that really changes in a mass casualty or in disaster management because it's really the greatest good for the number of people who are gonna survive. And that depends on the causality of the incident, the resources available, and how that situation is evolving. Because one of the key pitfalls that happens during a disaster management is that the key resources you have available end up getting depleted with just a few people that may not have even survived their injuries. And now people that potentially could, we don't have those resources anymore. So there are a couple of phases of disaster management that are fairly standardized. And we can kind of predict how things are gonna kind of go along. And in order to prepare for it, there's a lot of planning and training that has to happen initially. So whether it be something like a marathon or a sporting event or even just like a bus rolling over on the highway. How, at a level of your hospital, can you figure out what your vulnerabilities are and be able to mitigate those? And then how is the actual response to an incident gonna happen? And then after the fallout of the disaster, how do we get back to recovery and restoration? So the ABCs of the actual incident itself, we talk about search and rescue, triage, definitive care, and evacuation. And I'll talk a little bit more about that. But before I get there, I wanna kind of talk about the incident command system, which really is the foundation of how to do disaster management. And this slide, while it was kind of new and novel when I first started giving this kind of talk, a lot of you have probably seen this because this is exactly what was used during COVID-19 across many hospital systems, state systems of how to deal with an incident. And what I really wanted to point out on this slide is where medical care actually falls. You can see when we talk about disaster management, we think about people getting hurt and we think about saving lives, but medical care is just one small part under the operations of mass casualty. And so it's really important to know that being a physician on the ground, dealing with that is just one small part of a much grander effort and help that's necessary for this. So in mass casualty, there's three levels that I wanna talk about as far as how to be prepared. So first, it starts with the community and that starts with medical and public health organizations. Keeping in mind very special needs populations such as children, elderly, disabled, the poor or the homeless. When it comes to hospital preparedness, understanding where those vulnerabilities all are of each hospital, how many chest tubes do you have in stock? How many central lines do you have available? How much blood does every hospital have? And then understanding what the difference between your hospital's capability is versus the capacity, right? And I think we're probably all feeling this now where we have a huge nursing shortage or a workforce shortage. And while our capacity may be one thing, our actual capability of delivering that care is a very different story. And then how we're gonna mobilize our personnel. Just the other week, we had a marathon in Columbus, Ohio that was going through downtown. And all of the streets that the physicians and other hospital personnel would need to get to the hospital are all closed off. So coming up with a plan to mitigate that in the situation of a mass casualty was important. And lastly, there's your personal preparedness, right? Not just for yourself, but for your family. So if there's a mass casualty, as a trauma surgeon, I hear about it. My first instinct is to wanna go in and be there and help operate and help stabilize people. But if I know that I'm on call the next day, I know my partners are gonna want me to stay home, get my rest, and then be able to show up the next day with a full set of energy because everyone else is gonna be depleted of that. The other part of it is how do you take care of your family? If you're in the middle of a mass casualty and you're at work the entire day, who's gonna pick your kids up from the bus stop? Who's gonna be able to get home to other people who have needs, who are depending on you to be there? This is probably the toughest part about our job in a disaster management. This is how we decide who is going to receive what kind of care. We use this acronym SALT triage to really figure this part out and then decide who's gonna go to what hospital or what level of care. So you're gonna sort through the patients and we use this algorithm here. The first idea is are they just breathing? If the answer is no, that's a very easy answer. They're gonna get a gray tag or a black tag so that everyone can identify that this patient is no longer gonna, either they're not survived or they're not going to survive despite anyone's best effort. But if they are breathing, we have to understand these next set of questions. Are they obeying commands? That gives us an idea of their neurologic status. Same thing with purposeful movements. And then identifying hemorrhage. So do they have peripheral pulses? Are they in any kind of respiratory distress? Or are they exsanguinating visibly? How can we stop that? If the answer is yes to a lot of those things, chances are they're likely gonna survive and they can get either a green tag or a yellow tag which means that it's a minor injury or it's an injury that's not immediately life-threatening. But if the answer is no to any of those questions, then we have to really step back and think. So those first couple questions about neurologic status, that's really gonna give us an idea of traumatic brain injury. And brain injury almost always has roughly 50% mortality to it. So are they going to likely benefit from any of the resources? Are there life-saving interventions like the ones in the right upper corner there, or sorry, left upper corner there, that we can do to help the patient? So controlling their hemorrhage, opening their airways, decompressing their chest, or if it's some kind of chemical or a gas, are there antidotes that can be given? And if the answer is they are likely to survive, they get a red tag. And those are the patients that are gonna get priority for resources that you have at the hospital. Once a trauma center has been notified of a mass casualty event, there is a whole lot of breakdown every time. And so there's predictable disruptions that are gonna happen, and you just have to be mindful of them as they unfold. The first thing that happens is that big communication barrier. People on Instagram, people on these different apps that we can see these things happening before. EMS even lets us know they're happening. And so the spiral of stories evolves through the emergency department, through the whole hospital, and it's just confusing because you have no idea what actually is happening. You don't know how the evolution of the incident is going on. Is it over? Is it continuing on? What's going on? And that first wave of patients to arrive to your hospital are usually the walking wounded. And so they're minimally injured, but they're scared, they don't know what's going on, so they're showing up to get treatment. And it's really incumbent on the hospital to be able to identify who these people are and have a different triage area for them, or just to tell them they don't need medical care at the moment and reassure them of that. Next, what happens is, let me wait for my screen to pop back up there, is you have convergers on the hospital. And so this is well-intentioned people or people that just really wanna know what's going on, and they're coming down. And they're just occupying space that is a hot commodity at the moment. And some of those convergers can even be medical volunteers, so physicians, other hospital providers that are coming. And at that moment, their services are just, you don't need them at the moment until you've figured out what's going on and when you need those people to show up. Then the difficult stuff happens. The demands for supplies and equipment starts to surge. Beds, rooms become filled, and record-keeping systems become overloaded, and we can't identify who patients are, who their relatives are, and so forth. And then the most difficult part comes, which is the compassionate care. How do we deliver that in a respectful and dignified way to people that are gonna expire? And lastly, and certainly something that's important to keep in mind, is how the caregiver's needs are being managed. It's not normal for people to have to see massively injured patients. It's not normal for us to be able to see a horrible, whether it be related to gun violence or just natural disasters. It's not normal for us to see that. So how can we make sure we take care of each other during that? So from the American College of Surgeons and many other committees, it wasn't until after Sandy Hook that there was a national call to action, saying, hey, this is preventable. Hemorrhage is preventable. And so the American College, Department of Defense, many other organizations came together, and we really wanted to create a program and a campaign that could help people that aren't necessarily trained, not medical professionals, not paramedics, but just lay the public on how to be able to control hemorrhage. Because we know that that's the number one preventable cause of death in people that are injured. And so with the initiative from the White House, this program was started, and it was really simple. It's about three things. How to apply pressure appropriately to a bleeding wound. How to put a dressing into a wound. How to pack a wound. And if it's in an extremity that's exsanguinating, how to apply a tourniquet properly. And it's about an hour course. Every single one of these courses is free to offer. In Central Ohio, we've done it through almost every one of the public high schools, through our state house, and many other local venues, which everyone says is quite a great learning experience for them. And then, sorry. One other area on this is, you know, we talk about having AEDs in every public space, and there's a big push to also have these bleeding kits right alongside them. And the chances of requiring a bleeding kit is actually much higher than the need for an AED in those situations. So, that's something there, if you can take back to your cities and your hospitals. Safe storage is not new in your world, and I know that because I feel like that's a common conversation that everybody has with their patients. This was not something that was pretty common in the emergency departments. It's still not something very common in the surgical world. In the last two years now, we've really pushed this idea of safe storage and how it can impact a family or a person with all of this. Just with children, so many are living in homes with access to unsupervised guns, and 75% of kids know exactly where those guns are in their home. And many of these children know exactly how to access them and play with them, even though their parents think that they might not be. And a somber statistic that almost 51% of all suicides are by firearms, and 60% of all gun deaths are by suicide. 75% of our school shootings are facilitated by kids having access to unsecured guns at their home. Self-storage, this image kind of shows a gun lock. Gun safe storages or lockboxes are a very popular new thing that are being done on so many different levels, being named certain things. It doesn't always have to be called a gun lockbox. It can be a medical lockbox for medications as well. And in Ohio, with the help of the NRA and Buckeye Firearm Association, which is kind of the most influential Second Amendment rights organization in Ohio, have come together with the Ohio State Medical Association and a few other state organizations to really promote safe storage. So I feel like this is something that both sides are really coming together with. And so as we talk about why this is such a political hot fire, because it's not about the guns, it's about the violence that's happening from guns. And I think both sides of the group can really understand that we just don't want to see people getting hurt. And that's really the goal, is how to keep people from getting hurt. Because sometimes when we talk about gun control, what gets interpreted is that it's freedom control. And that's really not where we're going. And the other group that's thinking of gun control thinks of violence control and really, and forgive my real cheesy graphic here, but it really means the same. We really need to learn how to find that common place. And that's the idea that the American College of Surgeons took, and they did this alongside the APA and several other organizations. And they said that if we just approach this like a public health problem, maybe we can take some of the politics out of it. And we can look at data, and we can create an environment where we're coming together for creating that form of civil, collegial, and professional dialogue with the main aim of reducing death and suffering. So this was kind of the tenets that took place of creating that approach, where it said that we just want to start with the basic idea that violent injuries or intentional injuries is a poorly addressed form of public health. And while there's two very polar opposite sides on this, we need to be able to work together to identify common ground, and that we should agree that making firearm ownership as safe as reasonably possible is really the goal. There's no disputing whether ownership or violence or whether it's the right to bear arms. None of that is really here. It's just about how can we make things as reasonably safe. So together with the APA, the American College of Surgeons put together this consensus. And so these were kind of the ideas put forth that we can hopefully all agree to, that anyone who is in a danger to themselves or others probably should not have access to a firearm. And while owning a firearm is OK, I had the idea of safe storage, education, training, and that commitment to keep firearms out of family members that are at high risk should be controlled. Access to mental health and mental health hygiene should be looked at as a strong point and encouraged. And then we must identify, understand, and address the proximate causes of violence using data. So I want to share a little bit of the data that we see from a trauma center's perspective. While this information is from 2014, this is still the same data that we're seeing now. Across the country, most trauma centers are seeing 4% of their injuries related to firearms. So it's a rather small percentage of what we actually see. But when we see the mortality rates, they're all the same across all these injuries. And so the idea here is that firearms, while small in proportion, really are creating a devastating injury profile, leading to death. Back in 2014, firearms in children were second to motor vehicles as far as the leading cause of death. The New England Journal just published this in the last few years. And firearms are now ahead of motor vehicle crashes. Homicides, while they have been increasing over the last few years, are not nearly as increasing as suicides. And I'm sure that's something that's being seen quite frequently in your world. Children are not immune to firearms, right? That's kind of the whole point of my being here is to see that protection. But suicide is on the rise in children. Homicides and unintentional injuries is on the rise for children as well. Fatalities by location. This is where all the data is really necessary, right? We can see it on a national level. But where are those pockets in our communities where having these campaigns and driving these campaigns for safer storage and safer use of firearms is necessary? We can't ignore the cost. And in 2010, this was the cost compared to all kinds of other things. And you're just talking about the entire Department of Defense and then the cost of firearm injuries to our system. You can't ignore that. A local effort that's being done in central Ohio is, and I'm very proud of this because the data that we're getting back from this, and this is being funded from not only a federal level but a state level and a local city level, it's a program called VOICE. And it stands for Violence Outreach, Intervention, and Community Engagement. And the idea here is that it's going to be a collective of all different sorts of people coming together to have a program along anti-violence and the recidivism caused by gun violence. So we launched this pilot in 2001 with the help of the city of Columbus, Parks and Recreation, and Grant Medical Center. And with the mayor's support, we were able to pull resources together to create an intervention specialist. So the idea here is that in the moment of gun violence happening, you have a crisis interventionalist that can reach out not only to the patient but to the scene and act along with the people that are involved in that shooting. So whether it's family members, cousins, all the people who's mind is a little bit inflated at that moment because of everything that's going on, those people can be spoken to and hopefully de-escalate the situation from that end. And part of this program that made it so successful was the incentives. So as you move through the program, you receive an incentive, a financial incentive for being part of it. And you can see the phases of the care is the crisis intervention, which is taking that right to the moment it's happening. After the patient gets stabilized, that's kind of the medical care part. But then everything that happens after the medical care. So it's the action of creating that plan for the patient and then eventually getting to a point where they can have some self-sufficiency. And so as you move through here, it's a little bit small on my slide. But really, the kind of benefits these victims are getting is they're getting direct access to legal help, educational help, vocation, housing, and then their access to their medical team. And one of the success stories I always like to share with here is every year we kind of put it together where we have our survivors come back and speak to how they've been living their life since their injuries. And my patient didn't show up. I was kind of like, what happened? He just bailed on me. And after the show was over for that day, I got a text message from him. And he said, hey, I'm really sorry I didn't show up. I was actually at an interview for becoming a barber. And I got the job. So I'm really sorry I didn't make it. So we're seeing a lot of positives from these kind of programs, being able to get people into different vocations and so forth. One of the other benefits that we get from this kind of programming is identifying with a heat map of where this stuff is happening so that we can channel a lot of our resources to those areas and create this culture of infiltration to that area to reduce violence. So from our initial pilot, the biggest success was trying to identify recidivism, where zero participants were re-victimized. So that, for us, was a big success. 43% of them obtained employment. 53% were linked with counseling. And this may or may not resonate with people in the room here, but 100% of people showed up for their trauma follow-up, which was almost abysmal for us prior to this program. And unfortunately, 13% were rearrested during the pilot. So along with the program, because it gained so much popularity, it actually created such a great environment for other community resources to kind of help pool in. And they all kind of wanted to chip in and say, how can we offer help in this area? So it really brought the community together. And these are some of the testimonials of some of our victims and where they're getting to and how thankful they were for the program. So in summary, we know that the impulsivity of firearms, the power behind a firearm, is just something that maybe the community doesn't quite understand every time. We know so many children have access to these things. So how can we create an environment where we normalize the conversations around guns and gun safety is really the direction that the American College of Surgeons wants to go. And so with your help, this is something I feel like psychiatrists are very comfortable with, whereas a lot of other specialties in medicine are not quite there yet. As we instituted our gun lockbox program for our hospital, part of our questionnaire that our nurses do for every patient, almost every consistently, is asking, do you have suicidal thoughts? Do you feel safe in your home? Do you feel safe? These are things that we've done great in the emergency department about asking our patients. But when we pose the question, can you ask about, do they own firearms? Are they kept in a safe space? That was met with a lot of resistance because they didn't want to lose the trust of their patients. And they felt that asking that question was going to do that. So how can we translate what you've done very successfully in the world of psychiatry to the rest of the medical specialties is very, very important. And I look forward to continuing that collaboration with APA on how to do that. These are my references for everything in the talk. And I am going to turn the podium over to Dr. Cannella. Thank you. So I'll be talking a little bit about the pediatrics and child psychiatry perspective, along with some myths having to do with firearm violence. So a couple of common misconceptions. We always think of mass shooters or perpetrators in a pretty consistent pattern. We typically have an image in our mind of who we think these people are. Often think of them as bullied, outcasts, alone, not much social support. Often think about mental illness, psychosis, severe mental illness. And we typically think that it's impossible to predict these events, that mass shootings or mass casualty events cannot be predicted in any way. Another common thought is that violent video games increase the risk of mass shootings. And I'll take a few minutes to discuss each of these points. So first, as far as the pattern of perpetrators or mass shooters, in reality, there is significant diversity among these perpetrators and their motives. Sorry. Let's see. There we go. When we think about the patterns with them, it's often in retrospect and in a hindsight 20-20 situation, similar to thinking about mental illness and psychotic prodrome. It seems obvious sometimes in retrospect, but is not necessarily the case proactively. So in a study by the National Council for Behavioral Health, they look at these risk factors, look at these demographics, and do find that most frequently they occur in males who are often hopeless or harboring grievances related to multiple different factors, including work, school, finances, or relationships, and often have feelings of victimization or lack of sympathy with others similar to their mistreatment, often see an indifference to life, and often die by suicide following the event. Despite the fear and scrutiny these events have, they're actually statistically rare. So between 2000 and 2016, despite many mass casualty events and mass shootings, less than 0.2% of homicides in the US were actually mass shootings rather than individual homicides. And so guns, while we see them often in the setting or think of them often in the setting of mass casualty events, very frequently occur in individual homicides and in suicides. So when we think about this, another study is a retrospective 50-year review looking at 64 school shooters who had multi-victim attacks between 1966 and 2015, again looking at demographics and these people's identities. So in that time span, we initially see about 30% who died by suicide following the events. And as suicides have increased in prevalence, now up to about 60% ending in suicide. Ages were actually fairly well distributed. About 50% of events were in children and adolescents, and 50% of events in adults, which is typically much more children and adolescents than we think about. Sorry. Racial and ethnic disparities, about 50% of the individuals were Caucasian, with a fairly even split beyond that as far as African-Americans, Asian-Americans, and Native, sorry, Latinos, with smaller populations of Native American and Middle Eastern individuals. The breakdown of age, again, is quite dramatic when you look at it more closely. Almost 50% of shooters in mass shootings in school shootings, I should say, were under the age of 19, between 10 and 19, with about 25% being in their 20s and the other 25% above that age. And again, we think of this typical picture of bullied loners. There's actually very little evidence that bullying is the primary cause of shootings or mass shootings. Often, it's associated with the situation, but not shown to have a causal effect. Intended victims are often ambiguous. We often think about bullied outcasts shooting their bullies, but in reality, it tends to be ambiguous just to anyone at the school, anyone in the public setting, including teachers, younger children, et cetera. And the massive potential for collateral damage, again, makes it very difficult for targets to be picked out. In a school setting, the likelihood of finding your specific bully, your specific antagonist, so to speak, is unlikely. And the collateral is just across all demographics. So kind of in another setting of somebody with history of bullying and uncertainty of motive, this was a shooting when I started medical school in Dayton, Ohio, actually just a couple of weeks after I started school in a public setting. Many of my friends and colleagues were there, and it was a mass shooting, unfortunately. So we have the perpetrator, who meets this picture of history of bullying without really any other apparent motive, attacking ambiguous individuals in a public setting, and massive collateral damage. A common misconception, though, is that mass shooters are necessarily mentally ill, and it's a very imprecise argument. In psychiatry, we know that mental illness and mental health is a broad domain. When we say mass shooters are mentally ill, do we mean psychotic, insanity, depression, anxiety? What information actually supports that? And again, when we think about these categories of mental illness, are we picturing psychopaths, psychosis, trauma? In reality, mental illness does predict violence as a retrospect, but does not necessarily predict who will commit violence, just classifications as far as shootings. And that falls more into the category of whether the mass shooting has personal ties, social ties, familial ties, not that the person is necessarily mentally ill. And part of this misconception is that these shootings are impossible to predict. So again, we can't predict precise things, necessarily, but that doesn't mean there aren't actionable predictions. We think about limited threats and prediction abilities and the difficulty of impinging on civil liberties in the Second Amendment, but a limited number of threats and violence actually lead to material violence. And again, that comes back to the actual protection and safety around violence and around firearms, rather than necessarily no one should have firearms. And we think about this threat assessment comprehensively. So thinking about the intensive intervention kind of on a specific level with counseling, community-based treatment, alternative schools, supervision for people that might have severe mental illness or history of violence. And we think of children with mild behavioral problems, maybe ADHD, and thinking about social skills groups, shorter counseling, tutoring, special services. But then again, for all students, it's important to have this positive support system, school security system, character development, conflict resolution. So in another study by the School of Psychology Quarterly with the APA, the American Psychological Association, we looked at student threat assessment as a standard school safety practice statewide, and did in fact show that these efforts help. Serious threats were more likely to lead to actual violence when following the stratification, although very limited by the fact that you can't really have a control group in this sort of study. Another thing we think about is contagion theory in mass killings and school shootings. In this study, they looked at mass killings, again, of three or more people by firearms from 98 to 2013 through the Brady campaign to prevent gun violence, and used a mathematical contagion model to show relationships here with the mass killings occurring between 2006 and 2013 from USA Today, and then FBI examinations of homicide reports. This on the studies showed that mass killings involving firearms with four or more people based on the USA Today report occur every 12.5 days in the US, less than every two weeks. And school shootings specifically occur an average of 31 every 31.6 days. So approximately every month there's a school shooting in the US. The FBI results showed very similar findings with events every 13 days and an average of at least 0.22 new incidents. Sorry, I'm confused by my statistic here. But yeah, about every 13 days shown by the FBI. So similar to the USA Today report. Part of this question comes down to the media side of things. Does media coverage and sensationalism drive the contagion theory? The idea that seeing violence inflicts violence or incites violence? We actually don't know. The data and the studies are equivocal. Is it even possible to show a causal effect? That's a difficult question, but we know that there's certainly broad sensationalism through media on these subjects. The Dayton shooting, which I referred to earlier, occurred just 13 hours after the El Paso shooting. So again, we see this temporal relationship between events. Another thought comes down to video games and violent video games. So we often think about in the 90s and the 80s, while there might be video games, they're less violent, less frequent, maybe arcade games. Early violence in video games was Goldeneye and 007 and Mortal Kombat. With games becoming more violent over time, including Call of Duty and Grand Theft Auto. And frequently thought to play a role. We frequently look back at these perpetrators and see that they play video games, they play violent video games, and frequently blame this glorification, a quote from President Trump showed that it's too easy to see youth surrounded by the glorification of violence. And Kevin McCarthy showing that these video games dehumanize individuals and make a game of shooting. In actual studies, however, the causation and correlation is less clear. So while some video games do have educational content, a large quantity of video games have killing of people or animals, use of drugs and alcohol, sexual exploitation, criminal behavior, sexual, racial, and gender stereotypes, foul language, obscene gestures. And children can often become very involved in video games. They have difficulty controlling their time. They have difficulty separating reality from imagination or reality from fiction. And we see that children who play video games do have less time socializing with people in person, often have poor social skills, lower grades, less reading, poor health, poor sleep, and potentially aggressive thoughts and behaviors. However, in an AAP, and in another AAP Academy of Pediatrics report, they find that the typical child actually witnesses 8,000 murders and 100,000 acts of violence, including rape and assault, before middle school. In the 90s, these reports were limited to television and mostly arcade games, whereas today the media and platforms include iPhones, computers, other touchscreen devices. But this policy statement really emphasizes that aggression is different from violence. So while some of these studies show increased aggression or aggressive behavior, they do not show increased violence or physical actions based on that aggression. And they define aggression as a behavior intended to harm someone, whereas violence is the actual extreme physical harm or acted on behavior. For example, a dog might growl, but that's not the same as a dog biting someone. So summarizing these studies, the AAP emphasizes that of over 400 studies, including violent media of all types, there was a significant association between media violence and aggressive behavior without any evident causal association and without actual violent behavior in the individual rather than portrayed in media. In another study by the American Psychological Association, they looked at aggression, empathy, and social behavior in a meta-analysis, looking between Japanese and Western countries and generating kind of theory-based predictions on if you can predict violence. We do see that violence is associated with decreased empathy and aggressive behavior, pro-social behavior, but the increase in aggression for violent video game players does not equate to a causal effect that's shown in any of the research here. There is this specific study which shows increased violent video game players without a, so increased violence in violent video game players, but without a clear causal effect, and importantly, in just an experimental paradigm with self-reports, not through actual population studies. So the American Academy of Pediatrics really targets this from a few settings on how to limit these behaviors and risks. They talk about limiting media exposure to children, giving children media diets, and kind of talking about this in well-child exams, asking how much they're watching TV, how much they're playing video games, and trying to regulate that. Talk about increasing supervision and co-play with parents. So if children are playing aggressive video games that parents are worried about, the parents can play them with them and actually participate and help explain the fictionality and the difference between fiction and reality. Cartoon violence can seem very real and have detrimental effects, and so these children should also kind of be explained to that the trauma still might be there, even if the violence isn't real. And again, avoid glamorization of weapons and normalization of violence. So frequent media reports make us less sensitive and less empathetic to these events, and the same for children, but limiting children's exposure to these events can help limit their desensitization. So as far as video games and mass shootings, violent crimes perpetrated by youth have actually decreased since 1996, whereas video game exposure, number of video games and violence in video games has certainly increased. And while there is a significant correlation between violent video games and actual violence, which is not universal, again, it does not equate to causation and no clear direct link. And these are my- Okay, I found this on the web- Sorry. Well, there is a significant correlation between violent video games and actual violence, which is not universal. Again, it is not a clear causation and no clear direct link. Check it out. I do not know how to turn that off. Okay. All right, and now to Dr. Crow. Thank you. Great. So I'll be talking about risk factors mainly. So here we go. So this is an FBI report that was published between 2000 and 2013 that looked at different mass shootings. So there was a variety of different ages as a takeaway from this slide. They also, the majority of these people ended up having purchased legally or already possessed a weapon rather than having borrowed or stole a weapon, which I thought was interesting. Interestingly, a lot of time was spent planning in general. So I think that's a takeaway from this as well. Less than 12% were done within a day of planning. 86% plus of people involved with these mass shootings did not have a prior criminal conviction. And 38% or so were unemployed, which is higher than the national average, which I thought was interesting as well. There was an average of about 4.7 concerning behaviors per shooter, primarily around mental health and interpersonal interactions. So a takeaway from a psychiatrist perspective would be to look more for interpersonal degradations, work performance and school performance problems before anger and physical aggression problems, because that's actually more commonly showing up in this population if you're concerned about that. 25% of these shooters, about 16 in the study, had a previous diagnosis of a mental illness, which is really close to the national average. The most common one was a mood disorder, 12 of the sample. Only three had a psychotic disorder. And this led them to conclude that formally diagnosed mental illness is not a very specific predictor of violence of any type, let alone targeted violence, which I thought was interesting. This is a Harvard Perspectives review of mass shootings in the literature associated with them. A diagnosis of a mental illness alone is a negligible factor. They had a similar conclusion to the FBI reports. And as psychiatrists, we have an opportunity to be voices in our community, to maybe shift a discussion away from sensationalized symptoms of mental illness towards maybe a more evidence-based approach of risk factors. But what are the risk factors? So these are, I'll just talk about a few of these and highlight them from the literature. But a history of violence is the biggest risk factor for violence in general. Animal torture is also another one, 18, 25, and male are risk factors. Substance use and antisocial traits are really important risk factors for violence. And access to lethal weapons I'll highlight as well, which will play into a case we'll talk about later. All right. So 70% of mass shootings involve family members. Many individuals are driven by ideology, not necessarily by personal gain or anything. They seem to be injustice collectors oftentimes, adapting a warrior mindset. And group affiliates are actually less likely to have active psychosis at the time, to be drug users or be otherwise engaged in criminal activity. More common traits, a history of being bullied, like we mentioned. They often anticipate their own death. They may adopt a pseudo-commando identity and crave media coverage. And they frequently communicate their intentions beforehand, which we'll talk about in a case coming up. So this was a study of violence in general for patients discharged from a psychiatric institution. And they looked at just the people who had committed a violent act at some time. And they asked them about symptoms surrounding that. And 80% plus who repeatedly had violent acts did not have psychotic symptoms before committing those violent acts. And oftentimes they had a relationship between the person who was the victim of the violence. All right, and then this is with people who were being treated for schizophrenia. And they found that basically a history of previous violence in the past six months was the biggest risk factor. And that drug use, sexual abuse, and medication non-adherence were also risk factors for violence in general. So these are things to kind of be looking for when you're talking with patients and wondering, are they at risk for hurting someone else? Interestingly, they found that negative symptoms of schizophrenia in the literature tended to be negatively correlated with violence. And then positive symptoms were positively correlated with violence. This is a highly cited study from Andrews and Bonta about risk factors for criminogenic activity in general. And antisocial personality, cognition, and companions are the first three of the big four. And then family stressors. But substance abuse is coming in there at the moderate four risk factors. And lack of employment, like I talked about earlier, is a huge risk factor. And lack of recreation or things to do in your free time. Can we predict violence effectively? There are different scoring systems out there for a lot of different things in medicine. The VRAG-R is one in particular for violence in psychiatry. Antisociality gives you the most points on this particular form. And then there are different points for other things. And this tries to be as evidence-based as possible. But does this work? So this paper ended up looking at a bunch of different predictors, including the VRAG, and found that the positive predictive values weren't amazing, but they were the best at having a high negative predictive value. So if someone's at low risk already, it effectively kind of screens them out. And so if you look at this graph, from the bottom left to the top right in kind of a diagonal line, that would be complete chance. We're not there, we're kind of up towards the upper left, which is showing we're getting some signal in a lot of different predictive violence studies. All right, and then here's another study looking at how well we can predict violence in people. They looked at whether a clinician was better than just looking at previous history. And there were a lot of different studies they included in this meta-analysis. They concluded that there's a lot of heterogeneity in the data, but that the area under the curve was 0.73, whereas complete chance would be about 0.5. So there is some signal we're getting from these questionnaires about predicting violence. And interestingly enough, clinical judgments weren't quite as good in this study as behavior-based predictions, but clinical judgments was better than chance. So you can, they concluded that you can kind of say that you have an ability to detect risk, but you're not an expert based off the data in predicting violence in patients. So I want to kind of move towards a case study of an Oxford High School shooting that occurred recently in Michigan. And, but before going to that, I kind of want to talk about what should you do if the media calls you about a violent incident as a psychiatrist, what are some good tips? Clarifying what's on the record and what's off the record is wise, approving of any quotes that you give or that they're going to use is a good idea. Representing your work well is important. And adhering to the Goldwater rule, which if you're not familiar, Barry Goldwater was running for president in the 60s and a survey was sent out to a lot of different psychiatrists and it asked, is he psychologically fit to serve as president? A lot of psychiatrists ended up responding and this kind of unsavory headline came through of 1,100 psychiatrists saying he's not fit to serve as president. They didn't personally see him. So the Goldwater rule is just advising to not make public comments on the mental state of individuals not personally examined. So keep that in mind if you're trying to represent psychiatry well in these interviews and keeping all statements consistent with widely accepted opinions is a good idea. But going back to the Oxford High School shooting, and I'll keep these principles in mind as we go through this, but the shooter received life in prison, but interestingly enough, his parents also were sentenced in their parts to not secure the gun primarily. Not about poor parenting, the prosecutor said, or the judge, but not stopping an oncoming runaway train. So how can we as psychiatrists stop oncoming trains and be able to see them before they derail? I'll kind of go through some news articles and I want you to kind of personally think about whether or not you would be concerned if you heard these things and what you might do. Hindsight's 20-20 and a lot of things are not predictable. I don't think, in this case, the patient was particularly following anybody outpatient for any mental health condition. But animal torture was involved in this case. There's a notebook with Nazi symbols in it, like I talked about earlier, with ideologies commonly being involved. There's photos of guns in notebooks. He intimated his intentions beforehand to a friend with a text message. He'd ask about going shooting. The only friend moved. The dog died. The son was sadder than usual, the parents were kind of noticing. He was fascinated with guns, researching ammunition a lot, watching violent videos of shootings the morning of the shooting. And in particular, writing, the thoughts won't stop and then a drawing of a gun in school, which he later redacted on the right to say, I love my life so much. And the veracity of this, in hindsight, may not have been 100%. So what are the implications for us as psychiatrists? Increased scrutiny and responsibility may be placed on us to be able to recognize risk factors in the future for those who might be violent to others. We might be called upon to give parents guidance on what to do if they're seeing these behaviors in their kids. There's also gonna be a dilemma of balancing a clinical judgment with maybe trying to protect yourself legally and what's best to do there. And there also might be a reluctance to share particular mental health symptoms if they know there's legal repercussions that could be involved if they share it with a psychiatrist. And we wanna be as preventative as possible and prevent these situations from even happening. And this is a article here, an advertisement about how Thorazine can stop violent outbursts. And there's kind of the assumption here that violence is a psychotic or a break from reality symptom. And, but is it though? I think a lot of news articles focus particularly on shocking psychosis-related symptoms and not as much on antisocial behavior, whereas antisocial behavior is more associated with violence in general. Only .02 to 1% of gun-related homicides are committed by individuals with serious mental illness. And less than 3% of all gun violence involves individuals with serious mental illness. This is an American Psychiatric Association publication on access to firearms. And they concluded that people with mental disorders are far more likely to be the victims themselves than the perpetrators of acts of violence. So what kind of gun access bills have been enacted or whatever? So many gun control policies disproportionately target populations with serious mental illness. The Brady Handgun Violence Protection Act is one of those, passed in 1993. And the major thing that this started was point-of-purchase background checks. And this is the mainstay of federal and state efforts to prevent gun violence. And they particularly classified those who have been committed to a mental institution or were considered a mental defective. What is a mental defective? Guardianship, incompetency to stand trial, and NGRI. So that's the Brady Act. So that's involved with point-of-purchase background checks for ammunition, for gun purchases. There was also a federal assault weapons ban between 1994 and 2004, I wanna mention. This wasn't a complete ban. There were quite a number of stipulations on what is and what's not allowed. But people have looked at, did this actually result in any kind of reduction in violence or anything? Did JAGER 2018 found inconclusive evidence on the reduction of incidents? CERANI 2018 reported limited impact on overall gun death rates. This is kind of a trend. In general, FLEAGER 2013 suggested some positive effects of specific policies, but RAND 2018 had mixed conclusions as well. What there is more evidence for are red flag laws where particular individuals can be flagged as potentially dangerous and have their rights to a firearm removed. So that's been since 1999. 19 states have enacted similar laws. I'll talk about this earlier, but this is non-criminalizing in particular. And one study suggested one life saved for every 10 to 20 removals, especially from suicide. And there does seem to be a lot of support for this legislatively, including Donald Trump. So this is a study about Connecticut's version of red flag laws. And their temporary preemptive gun removal was originally enacted in response to a well-publicized homicide event, but ended up being more for individuals, when they looked at the studies of who's actually having their guns removed, for people who are suicidal. Those are the numbers per year of the number of people having their guns removed. Suicide concern was the most common type of risk. They estimated with some back of the hand math that 10 to 20 gun seizures were carried out for every averted suicide. I think just in conclusion, people who perpetrate violence are not simply crazy. In fact, most are in touch with reality from studies that we've kind of conglomerated here. There are a variety of violence risk factors, especially anti-sociality and substance use. Prediction is difficult as risk factors are neither necessary or sufficient for mass violence. Targeted and temporary gun removal policies have had more favorable results on gun deaths than global gun access bills so far from the research. All right. Those are our references. Now we would like to open it up for some questions or comments. Thank you all for coming. We are actually right out of time. If you have any questions or comments, please come up to the podium, and we'd be happy to talk with you. My name is Bell Mandica. I'm board certified in preventive medicine. I'm very impressed with this panel, trauma surgeons, psychiatry. We're missing a couple people. My question goes in the line of lack of comments on ... Please excuse my pronunciation, but lack of comments on no notoriety campaigns that are common in Europe that we don't mention names of the mass shooters. How do you pronounce that? No notoriety? I cannot pronounce that. You mentioned non-glorification twice, once quoting Trump and second time American Pediatrics Society, non-glamorizing weapons. We didn't talk about non-glamorizing faces. We saw four faces today. Is there any ... I agree, without research, and all those statistics are mainly retrospective analysis of their demographics. We don't really have research on preventative measures in this environment that we cannot talk about politics, so we are kind of just talking about hypotheses for preventative research, but is there any appetite from you as experts in this that we kind of stop, and maybe we need journalists here. That was my point, right? Trauma surgeons, psychiatrists, preventative medicine, but how about journalists? How about us delivering that message in this light of kind of soft initiatives? We don't have research on that, but Europe is pretty successful in not publishing their pieces. I think your point is really well taken. I think journalists have a really important role in the platform they have to get the message out there, and they do a very good job of investigating and identifying points of intervention. Yeah, absolutely. I think having journalists part of the panel would be a really great idea. Yeah, I mean, that's obviously important. Look at how we've sort of been able to ... There's a direct correlation, right, with media sensationalizing people. Even when we talk about contagion theory for suicide, that sort of thing, we've worked with them. I feel as if there's definitely been a shift over the last decade with how they've sensationalized that particular suicide. I think we're moving towards that for mass shootings. Definitely in Europe, they're much better about it, but definitely recognizing the victims rather than glorifying this perpetrator is something that the media is getting better about. However, the coverage is still there. We know mass shootings are increasing. We know the number of casualties is increasing. We know, again, the coverage, the media coverage is increasing. Absolutely, I think having them part of the conversation is extremely important, just like we need to have NRA, and we need to have the Bucca Gun Association and these folks having a seat at the table. That's a really great point. I just want to comment that you guys are talking about a particular subset of mass shootings, and this is going to sound a bit like a criticism in a sense, because the fact is that most mass shootings in the United States happen to black and brown people in urban settings over and over and over again. In Baltimore, for example, in 2022, there were 13 in the first 10 months of the year, but none of them make the news. There are many things that we as physicians can do involved in those situations. One. Two, in terms of voice, is that a hospital-based? It's city and hospital. Because there's a relative history of these hospital-based trauma programs, and the data shows that they just kind of don't work, randomized controlled trials and such. It may be worthwhile taking a look at the work of Daniel Webster and Joe Richardson in Baltimore, because they pay attention and focus to some of this kind of stuff. Even ceasefire in Dr. Slutkin's town, the data's mixed. It really kind of didn't work so well. Yeah, I think the ceasefire, it's a common thing that's been done in a lot of big cities, and the idea is awesome. It's a great idea, but you're right, it doesn't actually change anything. I think what has been really helpful is cities or different organizations, and now even on a federal level, the willingness to just try something and just seeing if it's going to be able to work. I think that's what Voice did for us in Columbus, was just to say, hey, this was our hospital's foundation that just gave $50,000 to these incentives, just to say, hey, will this work? Because even one recidivism event costs way more than $50,000. Preventing one of those, we've already recouped the money invested into it. Identifying different things, maybe Voice wouldn't have worked, but okay, well, that part didn't work. Let's try something different. The willingness to keep trying different ways of doing it, I think, is very important. I would like to make a few comments. One that was related to kids playing video games. I know that you made an assertion that there are fewer kids using guns, but more kids playing video games. What we know is that it is not the owning a firearm, it's carrying a firearm that is a risk factor for the youth. If you look at the number of kids who are carrying guns at school or outside of schools, it goes slightly, slightly year by year is going down. I think this is an important intervention, and I'm not sure how to factor in video games into the equation. On the broader spectrum, access to weapons, everything from Red Flag Laws pointed out to other things, makes a significant importance. There are states that now started putting out maps where people could safely store their guns. I think the most recent one I've seen from Colorado is pretty cool. You put your zip code and you can see the places where you can go and temporarily put your gun in storage and not to worry about having easy access to it. I mentioned to you guys before that started that in Nevada, our Suicide Prevention Office now gives out free safes for medication storage, but I saw those safes. They're about the size of what you get in the hotel room. You can easily put several handguns in it if you need to. If people are concerned about transferring firearms, it may be an issue to get them back because it may be illegal for them to get the gun back, or it may be illegal for that person to possess a gun even temporarily, but they can disassemble the gun, take a non-serialized part of it, and give it to somebody to hold it. Without it, the gun is inoperable, and it is a safe option to consider for those people who may otherwise be reluctant to surrender their weapons. There are quite a bit. A number of years ago when I was on the School Safety Task Force during my first tour of duty for the state of Nevada, when I proposed an idea of having public service announcement for parents to know how dangerous it is to have insecure guns, I was looked at as somebody out of this world. But nowadays, in Nevada, not only the gun stores put posters informing people about the laws requiring safe storage, but they also are mandated to provide gun locks with any gun that they sell on there. So we are making progress, and it's nice to see that it catches off all over the U.S. Thank you. Thank you for sharing, and thank you for being a leader in this space and sharing what's being done there. Really great. Hi, everyone. My name is Donovan Dennis. I'm a second-year medical—rising third-year medical student at Michigan State University, and I wanted to thank you all for speaking about this increasingly relevant issue. It's something that—I also want to emphasize a point that you've all talked about, but in case it's lost for, like, folks here in the audience, that, like, since 2020, firearms have been the number one killer of children and adolescents. And that's something that's relevant to me because it was just last year on my campus that a man entered our campus and took the lives of four students, which, by the way, happened a month—like, I'm sorry, a block away from my apartment. So I was in lockdown, like, studying. So like many things in medicine, this is a multifactorial issue, right? It involves advocacy. It involves policy. It involves starting with the community and involving community members in the solution. That way, we have a better effect of, like, changing the sort of culture. But I think there's also this aspect of education. And so for, like, youth, I think especially for, like, us as providers and future providers, like, it's easy to feel disillusioned when we have this big burden, like this firearm burden, this culture. But one thing that was able to help me channel my sort of disillusionment was advocacy and education. And hopefully I'm not the only one in the room that's heard of a group called SAFE, which is Scrubs Addressing the Firearm Epidemic. A physician started and is a group of healthcare providers that are committed towards ending this preventable public health epidemic. And so when in my involvement following the shooting, I got involved with, like, the education of my curriculum. And so of the seven medical schools in Michigan, only one, which is my school, has a chapter for SAFE. And when we looked at our curriculum for four years, the word firearm or gun was only mentioned three times in the curriculum. So I think that's sad because as we do more trainings like Stop the Bleed, we have a better way of improving, like, we have physicians who are uncomfortable talking about firearms. As we do those trainings, we can change that. We can better recognize the myths, right? And then also talk about the risks that are related. We can do all of that with education. So that leads to my question for you all. If you recall, in your residency training and in particular your medical school training, what was the education or the inclusion of firearm violence like when you were in my shoes as med students, if there was any? For me, it was zero. It wasn't a question. That was top of mind for anybody at that time. So it brings to your point, like, that relevant things that are affecting our culture, our community today, they are infused in your education now, which is awesome because that wasn't the case ten years ago when I was there. I would say a little bit better for me. I think pediatrics is really kind of the one specialty that both in my residency and in medical school that emphasizes kind of part of your well child check to really emphasize are there firearms at home? Do you know where they are? Are they locked up? Is ammunition locked up separately are kind of the big things we emphasize. And I'd say that's been the main focus in my education. I would say I think our medical school did a really good job of making sure we ask about firearm access at home on our clinical rotations in particular, not necessarily like preclinical studies. That's my experience. So that was a particular emphasis on our rotation. Thank you. And thank you for starting so early. That's amazing. Yeah. Thanks very much for your patience with our lingering questions. My name is Matthew Gambino. I'm a psychiatrist at the VA in Chicago and I'm absolutely not representing the VA with my question. I want to end I guess on a little bit of a contrarian question. I really appreciate the need to work across the aisle and I really appreciate the need to be pragmatic. The idea of working with gun advocacy groups, with the NRA, with gun shops. But when we conceptualize this as a public health problem, we didn't make any meaningful success with tobacco until we took on the tobacco industry. And to say that this is a sort of both sides issue neglects the fact that there are a lot of people invested in creating an emotional attachment to the right to bear arms. The problem is the guns. And I wonder if by being pragmatic, we lose sight of the importance of advocating along those lines. Yeah, I agree with you on so many levels on that. But when we take different things and we look at kind of the history of stuff, and Dr. Bott mentioned all the things about seatbelts and Ralph Nader and when he was doing all that stuff in the 60s, and car manufacturers were absolutely against all of this stuff. But what happened was the people spoke up and the people said, no, we are demanding that our government study this stuff and enact safer cars, safer automobiles, because there's no future without automobiles that you could see. And so just taking that lesson from history, now guns don't necessarily have to be a part of our society. But they're so ingrained in our Americanness that to be able to say that taking away guns is just, I don't see that happening. So how can we even just start nibbling at it, I guess is where we need to start. Because maybe that day will come where people will start saying, we demand guns be off the streets. That's not coming anytime soon. Ingrainedness, though, is a historical product. And it's the result of the other side's efforts. You brought up a great point. Gosh, I remember when I was in medical school, so this must have been around like 2011, I was driving around like the different boroughs in New York and on rotations, and I remember there were like these big billboards from the NRA that said, AMA, stay in your lane. I don't know if any of you remember that, but that was a huge campaign on their own. The NRA, I will say, they have a couple of different campaigns of their own, talking about safe storage, or they have a cartoon with an eagle that says, what do you do? It's this little eagle in a playground with little children saying, what do you do if you find a gun? How do you get help? I think what we're trying to do is foster a collaboration. I don't think that whole campaign of AMA, stay in your lane, it is our business. It is about saving lives. It is about improving our communities, and not just quality, quantity, all that stuff, right? Everything we all agree with. And I think we're trying to take the most neutral way we can, so we've got to seat at the table. That's how I see it. We need a seat at the table. The other thing, too, though, folks, if you're in a rural part of this country, or in urban areas, depending, one of the things that really needs to happen, if you're going to do anything with gun violence, and guns particularly, particularly guns, is you've got to get beyond the public comments about guns, or the statements that people make, and actually listen to people who own guns and have them, and why they have them, and what they feel about those guns. Because you have a 0% chance if you look down upon them, if you judge them, if you think of them as idiots, or fools, or yahoos, or in part a flyover country, good luck. And the other thing, too, is that there's also a huge population of African Americans who are very much in favor of their guns. Fannie Lou Hamer said that, she's a civil rights person, a Winchester in every corner. She meant a Winchester rifle in every corner of your home. And so there's a whole concept around gun ownership that a lot of people don't have any appreciation for, and there's not a chance that you're going to be able to do anything about it if you don't understand where people are coming from. I love that comment. I will say, you know, like I said, I work at the State Psychiatric Hospital, and my partner, my unit partner, is actually, I won't say his name, we have open discussions all the time, but, you know, he is very pro-gun and a member of the NRA, and, you know, that's guns are something that have never interested me. I've never, nothing has ever, I've never had a motivation to own one or even touch one, frankly. But to have these conversations with him, with our medical students, and our residents is so valuable. The way we're both able to come together and say, this is a problem. You know, how can we discuss this? How can we have this conversation? I will tell you, years ago, I wouldn't have been comfortable having this conversation with folks that own guns. So I think even starting at that level is just so incredible. We can both agree that people are dying unnecessarily because of it. And there's also folks that will say, great, it's so wonderful that you, you know, you want to help save lives and have this discussion on guns, but you should know what you're dealing with, what you're talking about. You know, even talking to Dr. Deshpande, part of his research was going to, he had never touched a gun in his life. Going to a range, right? Do you want to talk about that? To get to know, what is a firearm? What does it mean to hold one? What is it that these folks are experiencing? Being able to have open conversations with our colleagues, with people in the community, you know, all these different entities, you know, we need to know about it. We need to understand. I'm scared of guns, frankly, but I need, I as a person should be able to respect them and understand them. So that's actually an exercise I never thought I would do, but that I will do. It's important for me to understand and respect the gun. Do you think that understanding each other will help us eventually change the policy? I think so. I think one of the, to your point, when I walked into that gun range, the very first thing I learned was, one, how proud they were of their firearms, but they recognized and respected the magnitude of the repercussions of what they could do with that gun. And so there was this ultimate amount of respect for that gun that laid in front of them. And so the cardinal rules they laid out, do not point your muzzle, do not, you know, do all these things. Those seem to never leave, like, you know, that's a big message from the NRA too, right? Like, we just don't give them the credit for sharing that necessarily. And so, you know, when working with them to provide that kind of messaging, I think we'll go a long way working together. And to go back to that, I think we, we've always sort of tried to, I would say as a community, as a medical profession, we've tried to foster this conversation, but we're very clearly left out, not by accident, right? Again, looking at the NRA's recommendations, they're very similar to ours. They're actually almost spot on. Same thing with, like, the CDC's recommendations. And when they tell you who they've worked with to come up with these recommendations, it very clearly leaves out physicians. You know, it brings in community leaders, you know, school leaders. It brings in basically everybody but physicians. And I think our goal is to take the opportunity to have these conversations because we absolutely need a seat at that table, just like we did with the automotive industry and motor vehicle accidents. It's a real challenge. It's a real challenge. Great discussion. Thank you. Thank you, everyone.

firearm injury prevention

public health

responsible gun use

healthcare collaboration

trauma surgeon

psychiatry

Dickey Amendment

gun violence research

emergency preparedness

safe firearm storage

risk factors

red flag laws

second amendment

public health education