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Stopping the Bleeding Is Not Enough

Masiakos, Peter T. MD, FACS; Warshaw, Andrew L. MD, FACS

doi: 10.1097/SLA.0000000000001969

Department of Surgery MGH, Harvard Medical School.

Reprints: Peter T. Masiakos, MD, Massachusetts General Hospital, Boston 02114, MA. E-mail:

The authors report no conflicts of interest.

If not us, then who? If not now, then when?

—John E. Lewis

In the days that followed the recent mass shooting that occurred at the Pulse nightclub in Orlando, medical societies produced statements consoling the victims and the families of the dead while condemning the actions of the perpetrator who added yet another statistic to the gun violence epidemic in our country. Our professional society, the American College of Surgeons (ACS), similarly released Leadership Comments Following Orlando, a statement that was intended to share the ACS's thoughtful approach to reducing deaths from firearm injuries and mass casualty events with our membership (

Caring for the critically injured, as our colleagues did in the early morning of June 12 is an essential element of a surgeon's core skill set. Much of what we know about treating these types of gun-shot wounds, increasingly seen in cities and towns across the nation, has been learned from battlefield surgeons who cared for similar wounds in Korea, Viet Nam, and the Middle East. We are trained to care for the worst traumatic injuries under some of the worst circumstances to save lives, and we are doing this well. Many of our fellow surgeons within the ACS, however, believe that we are not only in the business of preventing death after injury; we also share a special obligation to prevent injury. We fear that the current debate about gun control has not adequately represented the concerns of the broader medical community about the public's health.

When it comes to injury prevention, physicians and surgeons have moved mountains. Although initially unpopular, Surgeon General Luther Terry's report on the dangers of tobacco to smokers, unborn children, and bystanders was, in fact, a brave and politically charged challenge to the very influential tobacco industry.1 His action was followed by Surgeon General C. Everett Koop's campaign to commemorate Terry by sending a clear, evidence-based message to the American public that smoking can be lethal.2 These actions by doctors affected a significant change in the public's perception of smoking risks and led to legislation that not only validated their work, but also ultimately reduced the incidence of lung cancer deaths in both active and passive smokers. Using data obtained through years of government-funded research, doctors have educated the public and endorsed many other public health initiatives, including mandatory vaccination programs for children that have eradicated common infectious diseases in the country and automobile modifications that have resulted in a significant reduction in preventable deaths and injuries from motor vehicle crashes.

In 2014, the incidence of gun-related fatalities in American teens surpassed deaths resulting from motor vehicle crashes.3 In addition, the rate of suicide by firearm continues to climb, particularly in our aging population.4 Doctors, among others, can no longer in good conscience remain apolitical about firearm violence. We can no longer afford to stand on the sidelines or continue fruitless debate. We must neither accept the inaction of our government to pass comprehensive firearm injury prevention legislation nor allow the restriction of our ability to do research on firearm injuries, while nearly 3 times as many American citizens are killed each year in this epidemic than they are by AIDS and the cost to care for these victims has exceeded the budget of the U.S. Department of Education (

As leaders in surgical care, we must be able to provide forward thinking recommendations for improving injury prevention strategies to stop the growing public health problem that has touched our lives from elementary schools, high schools and colleges, to houses of worship, and the places we seek for safe social interaction—a Christmas party, movie theaters, and most recently a nightclub. And in this aspect, we have not done enough.

In addition to the importance of training bystanders to stop bleeding with manual pressure and tourniquets and buttressing our trauma systems detailed in the report of the Hartford Consensus (, we should emphatically call for the repeal of the Dickey Amendment, a provision initially inserted as a rider into the 1996 federal government omnibus spending bill that restricts federal funding for data collection and evidence-based research that would allow us to understand the epidemiology of gun violence and to create sound policy based on scientifically supported data. In addition to this call for freedom of information, the following 4 points, laid out in the 2013 ACS Statement on Firearm Injuries (, should be considered:

  • banning civilian access to assault weapons, large ammunition clips, and munitions designed for military and law enforcement agencies;
  • enhancing mandatory background checks for the purchase of firearms;
  • ensuring that health care professionals can help to prevent firearm injuries through health screening, patient counseling, and referral to mental health services for those with behavioral medical conditions; and
  • promoting programs directed at improving safe gun storage and the teaching of nonviolent conflict resolution.

As a society, we often address health care problems after they occur. It is clearly preferable to prevent deaths and injuries rather than to treat them. Prevention will not only lessen the tolls on victims, families and friends of the victims, health care providers, and health care systems, but will also provide cost savings that could be applied to other pressing health care needs. As surgeons, we are charged with more than caring for the sick and injured. We must act now to advocate for firearm-related injury prevention. We must stand front and center to address the gun-violence epidemic that is indiscriminant of race, age, creed, gender, and sexual identity.”

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1. Smoking and health Terry. LL Prog Clin Cancer 1965; 10:538–542.
2. Koop CE, Luoto J. “The health consequences of smoking: cancer,” overview of a report of the Surgeon General. Public Health Rep 1982; 97:318–324.
3. Fowler KA, Dahlberg LL, Haileyesus T, et al Firearm injuries in the United States. Prev Med 2015; 79:5–14.
4. Kels CG. Firearm access and risk of suicide. JAMA 2016; 315:2124.
5. Lee J, Quraishi SA, Bhatnagar S, et al The economic cost of firearm-related injuries in the United States from 2006 to 2010. Surgery 2014; 155:894–898.
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