Impact of the COVID-19 pandemic on gunshot injuries at a level-1 trauma centre: a retrospective study on a 5-year period

Abstract

Background:

Gunshot injuries are a major cause of morbidity and mortality, and evidence shows that violent crimes increased during the COVID-19 pandemic. The aim of this study was to investigate the impact of the pandemic on the prevalence of gunshot injuries and to analyze the demographic characteristics of patients with gunshot injury at a level-1 trauma centre.

Methods:

We conducted a retrospective analysis from April 2018 to February 2023. We collected demographic information, injury type, weapon involved, and mechanism of injury. We examined the annual incidence of gunshot injuries to assess the potential influence of COVID-19-related public health measures on rates of violent injury.

Results:

We identified 158 patients with gunshot injury. The mean age of patients was 35 (range 18 to 78) years, and 9% were women. Seventy percent were homicide attempts, 8% were suicide attempts, and 20% were unspecified. Weapons used included low-velocity handguns (78%) and hunting rifles (7%), and the remainder were unspecified. There were no injuries from military or other high-velocity firearms. Emergency department patients with hemodynamic shock (18%) were 7.5 times more likely to die before discharge than stable patients (29% v. 4%). Gunshot injuries significantly increased by 52% during the COVID-19 period compared with the baseline period (p = 0.03). After the COVID-19 period, injuries significantly decreased (p = 0.048), returning to levels statistically indistinguishable from the baseline period (p = 0.7). Seasonal variation analysis confirmed significant peaks during the summer and early autumn months.

Conclusion:

This study highlights the impact of the COVID-19 pandemic on gun violence, with a significant increase in the number of firearm injury victims during this period. Our findings show a return to prepandemic baseline levels in 2022.

Gunshot injuries are becoming a major cause of morbidity and mortality, particularly among young male homicide victims.¹ The first year of the pandemic saw the highest number of police-reported hate crimes since Statistics Canada began tracking these data in 2009.² Similarly, in the United States, 2020 was one of the deadliest years on record, with gun violence increasing by 30% from 2019. In 2021, firearms were involved in 2.6% of violent crimes perpetrated in Canada, a 25% increase from 2012.² Although gunshot injuries are less frequent in Canada than in the US,³ they remain an important cause of emergency department admissions in our centre. American studies report a recent increase in firearm violence and trauma centre admissions.⁴ This new phenomenon has also been associated with the COVID-19 pandemic by multiple authors.^5,6

Anecdotally, surgeons in our centre reported treating an increasing number of gunshot traumas in the last few years, but data are lacking that present a Canadian perspective on this issue. The objectives of this study were to analyze the impact of the COVID-19 pandemic on the number of firearm-related admissions to our Canadian level-1 trauma centre, present epidemiologic data on our local population, and correlate these data to the public health measures during the COVID-19 pandemic.

Methods

We conducted a retrospective chart review to analyze data from all patients with gunshot injuries admitted to our level-1 trauma centre from April 2018 to February 2023. This study design facilitated a comprehensive evaluation of patient demographic information, injury patterns, and outcomes. We included all patients with a new gunshot injury admitted during the specified period, excluding individuals who were injured outside of Canada and were seeking follow-up care at our centre.

Two physicians (G.Y.L and P.M.) independently conducted a comprehensive review of electronic medical records (Oacis, Telus), extracting relevant information from medical notes, laboratory results, radiology reports, and surgical records. We collected demographic data, including patient age and gender, along with the type of weapon used and the circumstances surrounding the injury, including the location and setting. We assessed the injury pattern, including details of entry and exit wounds, and whether any organs were involved. We recorded hemodynamic status on arrival, such as blood pressure and heart rate. We documented surgical interventions, including the type and number of procedures performed. Additionally, we noted death and any complications during the hospital stay, such as infections or postoperative complications.

We analyzed the collected data using R software (R Core team, 2021) with descriptive statistics summarizing the characteristics of the patient population, injury patterns, surgical procedures, and complications observed. We employed the arithmetic mean to determine central tendencies of the different demographic groups. We calculated frequency distributions and proportions to examine categorical variables, such as the type of weapon, survival rate, and any complications. We compared monthly counts of firearm-related trauma cases across 3 defined periods: baseline (April 2018–February 2020), COVID-19 (March 2020–January 2022), and post-COVID-19 (February–December 2022). We performed the analysis using negative binomial regression, adjusting for seasonality. We conducted pairwise comparisons between periods without adjustments for multiple testing to clearly identify direct differences.

Ethics approval

The ethics committee of the Hôpital du Sacré-Coeur-de-Montréal (CER: 2023-2476) provided ethics approval, and the study was performed in accordance with the ethical standards outlined in the 1964 Declaration of Helsinki.

Results

From April 2018 to February 2023, 158 patients were admitted to our trauma centre with firearm-associated injuries. The mean age of patients was 35.4 (standard deviation 14.1; range 18 to 78) years, with 48% under the age of 30. Men accounted for 91% of patients, with 14 women in the cohort.

Homicide attempts were the cause of injury in 70% of patients, suicide attempts in 8%, and hunting accidents in 3%. The cause of the injury could not be identified in 20% of patients. The weapon used was a low-velocity handgun in 78% of cases, a hunting rifle in 7%, and unknown in 14%. No military rifles or automatic weapons were associated with the injuries in our patient cohort (Table 1). A total of 142 patients (90%) sustained their injury in a public setting, and 10% were in a private property. Owing to the number of patients in our study, we were not able to draw conclusions regarding differences in the injury setting for the years covered.

Table 1.

Type of injury and firearm used among 158 patients admitted to a trauma centre with firearm-associated injuries

Variable	No. (%) of patients
Type of injury
Homicide attempt	110 (70)
Suicide attempt	13 (8)
Hunting accident	4 (3)
Unspecified	31 (20)
Firearm used
Handgun	124 (78)
Hunting weapon	11 (7)
Military rifle	0 (0)
Unspecified	23 (14)

Among patients admitted alive to our centre, the total survival rate to discharge was 92%, and 8% died. Of the patients, 82% were hemodynamically stable at admission, and 18% were in shock. We defined shock as mean arterial blood pressure inferior to 65 mm Hg or hypotension with tachycardia (heart rate > 90 beats/min) and signs of systemic hypoperfusion (e.g., altered mental status, cold extremities, decreased urine output). Eighty-six percent of patients arriving in hemodynamic shock received blood transfusions, with almost half of them (43%) treated with a massive transfusion protocol. A high death rate was observed in patients presenting with hemodynamic instability. Patients in shock on admission were approximately 7.5 times more likely to die from their injury than patients who were stable on admission (Table 2). The main cause of early death in our cohort of gunshot injuries was hemorrhagic shock.

Table 2.

Hemodynamic status on arrival and patient survival among 158 patients admitted to a trauma centre with firearm-associated injuries

Variable	No. (%) of patients
	Stable on arrival n = 130	Shock on arrival n = 28
Death	5 (4)	8 (29)
First 24 h	1 (1)	7 (25)
1 wk	2 (2)	1 (4)
> 1 wk	2 (2)	0 (0)
Transfusion	11 (8)	24 (86)
Massive transfusion	0 (0)	12 (43)

Various patterns of injury were observed, with the lower extremity being the most common area affected (55%), followed by the upper extremity (22%), and a combination of both (11%). In 12% of cases, the penetrating wound was on the trunk or in the head region. Among the 13 patients who died, 8 (62%) had an entry wound in the head region, 4 (31%) in the abdominal region, and 1 (8%) in the pelvis. All patients who suffered an isolated or combined injury to the lower or upper extremity survived until discharge.

There was a significant increase in gunshot injuries (52%) during the COVID-19 period compared with the baseline period (p = 0.03). Following the COVID-19 period, injuries significantly decreased (p = 0.048), returning to levels statistically indistinguishable from the baseline period (p = 0.7). Seasonal variation analysis confirmed significant peaks during the summer and early autumn months (Table 3 and Figure 1).

Table 3.

Negative binomial regression analysis by study period, showing the impact of the COVID-19 pandemic on monthly gunshot injuries^*

Comparison	Coefficient (SE)	Percent change	p value	Mean injuries per month
COVID-19 v. baseline	0.420 (0.197)	+52%	0.03	Baseline: 2.08; COVID-19: 3.17
Post-COVID-19 v. COVID-19	−0.516 (0.260)	−40%	0.048	COVID-19: 3.17; post-COVID-19: 1.91
Post-COVID-19 v. baseline	−0.096 (0.272)	−9%	0.7	Baseline: 2.08; post-COVID-19: 1.91

SE = standard error.

^*The analysis was adjusted for seasonal variations by month.

Coefficient estimates indicate log-scale differences in monthly counts between the defined periods.

Fig. 1.

Number of monthly firearm-related trauma admissions (shaded area = period of COVID-19-related public health measures).

Discussion

This retrospective study analyzed data from 158 patients who were admitted to our level-1 trauma centre from April 2018 to February 2023 for firearm-related injuries. Most patients were young men, with a mean age of 35.4 years; 48% were under the age of 30. Homicide attempts were the leading cause of injury, followed by suicide attempts and hunting-related incidents. The survival rate for patients admitted alive was 92%, and 8% of patients died, predominantly patients who presented in shock. Following the removal of public health measures, there was a notable decline in the number of firearm injuries. However, a monthly analysis revealed some variability, with periods of increased activity during the summer months while other periods appeared to stabilize at lower levels.

Much of the literature on firearm injuries originates from the US. The demographic data presented in this study, however, is markedly different, offering valuable insights that contribute to a better understanding of the unique characteristics of our patient population. Our survival rate was high compared with those of US studies, in which the range is typically 70% to 80%.⁷ This difference may be explained by the high proportion of low-velocity weapons involved in most of our cases; no patients with injuries from military rifles or automatic weapons were admitted to our centre. Furthermore, our patient cohort differs from those presented in the available literature, with a very low proportion of self-inflicted injuries (8%), which typically have the highest fatality rate.⁸ The leading cause of fatal firearm injuries is suicide (72.3%), followed by homicide (23.3%), according to a recent study published in 2023.⁹ Gomez and colleagues conducted a population-based cross-sectional study in Ontario from 2002 to 2016.¹⁰ The authors identified 6483 firearm injuries, of which 42.3% were fatal, most of these consisting of suicide attempts (79%). Indeed, suicide attempts involving firearms are often lethal, with most victims not surviving long enough to reach the hospital.

Our data analysis indicates a clear increase in the incidence of firearm-related injuries during the COVID-19 pandemic at our centre. The mean number of penetrating firearm injuries rose from 2.08 per month before the pandemic to 3.17 during the COVID-19 public health measures, and the associated restrictions, before returning to the prepandemic levels (1.91/mo) after public health measures were lifted. Our findings show that most firearm injuries in our cohort were the result of homicide attempts.

When the pandemic was officially declared a public health emergency by the World Health Organization, firearm sales skyrocketed in the US, along with increases in mental illness, substance abuse, and alcohol use disorder, creating a context in which hospitals across the US admitted many vulnerable patients.¹¹ Despite strict firearm regulations in Canada, where carrying a handgun is illegal, the incidence of firearm-related injuries admitted to our trauma centre increased by 52% during the COVID-19 period. These findings are consistent with trends reported in studies conducted in the US, which also documented a rise in penetrating firearm injuries during the pandemic.¹² Krzyzaniak and colleagues also found that firearm assaults increased dramatically during the COVID-19 pandemic.¹³ However, this increase was maintained through 2022. Krzyzaniak and colleagues reported significantly more assaults by firearm 2 years after the onset of public health measures, with rates that nearly doubled from 15% to 27% (p < 0.01).¹³

In our study, the monthly gun-related injury rate returned to the normal prepandemic baseline; therefore, we hypothesize that local COVID-19 public health measures did not have a long-lasting influence on trends in interpersonal gun violence nor on the general level of safety, compared with some areas where the rate of assault by firearm remained high throughout 2022.¹³ A longer period should be covered to test this hypothesis and determine if this trend was long-lasting. Our findings are consistent with local police reports indicating a decline in events related to gun violence during 2022.¹⁴ A statistical analysis based on official data revealed an overall decrease of 11% in incidents involving firearms when comparing 2020 and 2022. This trend continued in 2023, with a 25.4% decrease compared with the previous year.¹⁴

We observed a significant increase in gunshot injuries during the COVID-19 period, followed by a return to baseline levels. This trend was characterized by peaks of 9 to 10 injuries per month during the pandemic, as opposed to the more random pattern in the number of monthly injuries before the pandemic, with fewer extreme spikes. After Jan. 17, 2022, when public health measures were lifted, there was a noticeable decrease in gunshot injuries, with numbers returning to levels similar to those seen before the pandemic. However, some variability remained, with periods of lower activity followed by modest increases, but without reaching the peak levels seen during the COVID-19 period. The temporal correlation between the rise in gun-related trauma admissions and the public health measures in place during this time frame support the hypothesis that this increase was associated with the restrictions. This surge in gunshot injuries may be attributed to a combination of socioeconomic and psychological factors exacerbated by the pandemic, including increased financial strain, social isolation, and disruptions to community services.¹⁵ According to several studies, these issues can contribute to impulsive and violent behaviours,¹⁶ including the use of firearms to resolve conflicts.¹⁷ Our study highlights the need for violence prevention and community support during times of crisis.

Limitations

Limitations of the present study include its design as a single-centre retrospective analysis with a relatively small sample compared with those of larger studies from the US. Additionally, many patients with gunshot injuries do not survive long enough to reach the hospital, meaning that these patients could not be included in our analysis. Our findings are specific to our centre and cannot be generalized to other populations. Considering the size of our cohort, correlating the significant monthly fluctuations, marked by sudden peaks and abrupt drops, with specific events that exacerbated gun-related injuries during the pandemic was not possible.

Nevertheless, this study provides a valuable perspective on an international issue by presenting data from a single trauma centre.

Conclusion

This study highlights the impact of the COVID-19 pandemic on gun violence, showing a significant increase in the number of firearm injury victims admitted to our trauma centre during that period. Fortunately, contrary to concerns that gun violence would continue to worsen, our findings show a return to prepandemic baseline levels in 2022. Future research should explore the specific factors contributing to this increase in assault by firearm in times of crisis and the surgical outcomes of these patients.