We applaud Cook et al.1 for their work improving analysis of gunshot injuries in the National Electronic Injury Surveillance System data set. Their adjustment decreased the denominator during the study period, resulting in an increased case-fatality rate over time. Our experience at busy urban trauma centers showed a similar increase in the case-fatality rates for gunshot injuries.2 Other busy trauma centers have reported similar trends.3,4 We believe that this public health crisis is attributable to increasingly severe injuries and strongly disagree that the mortality increase is the result of alack of improvement in trauma care.
The previously cited reports describe increases in gunshot injuries per patient, gunshot injuries to critical regions (head, spine, chest), and gunshot injuries to multiple regions. Injury Severity Scores were also higher over similar intervals correlating with lower probability of survival. The location where death was declared in a data set is important. In many emergency medical services protocols, patients in extremis are brought to the emergency department, deferring declaration of death until after arrival. Patients surviving to admission also appear physiologically more severely ill with increased intensive care use. Despite this worsening severity, patients surviving evaluation in the emergency department had no significant increase in mortality.2
Major strides in trauma care have occurred over the last two decades, and nationwide organizational changes have expanded the delivery of these improvements.5 Examples such as damage control surgery, resuscitation and transfusion protocols, improved emergency medical services, and regionalization of trauma care have been proven to reduce risk of mortality after injury.6
The study by Cook et al.1 highlighted several points of caution when investigating gunshot injury mortality. Existing data sets may be insufficient, as suggested by the National Academies of Medicine.7 The discrepancies between the studies from busy trauma centers cited earlier and that by Cook et al. may reflect the limitations of probabilistic sampling over a heterogeneous population, particularly when physiological analysis of the disease requires granular data that are not available. Most important, the authors neglected major, important confounders by not discussing injury severity; Injury Severity Scores, number of gunshot injuries, gunshot injuries to the head or chest that injure the brain or heart (more lethal than gunshot injuries in the same area that miss these organs), presenting vital signs, and other indicators are known to correlate with mortality.
We appreciate the difficulty of improving analyses from a sample such as the National Electronic Injury Surveillance System that lacks known confounders. A thoughtful multidisciplinary approach in collaboration with practicing trauma surgeons to study gunshot injuries will better characterize this national epidemic and lead to development of rational interventions that could save lives.
REFERENCES
- 1.Cook PJ, Rivera-Aguirre AE, Cerdá M, Wintemute G. Constant lethality of gunshot injuries from firearm assault: United States, 2003-2012. Am J Public Health. 2017;107(8):1324–1328. doi: 10.2105/AJPH.2017.303837. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2. Efron DT, Haider A, Chang D, Haut ER, Brooke B, Cornwell EE 3rd. Alarming surge in nonsurvivable urban trauma and the case for violence prevention [Erratum appears in Arch Surg. 2006;141(10):1042. Haut, Elliot R corrected to Haut, Elliott R]. Arch Surg. 2006;141(8):800–803, discussion 803–805. [DOI] [PubMed]
- 3.Sauaia A, Gonzalez E, Moore HB, Bol K, Moore EE. Fatality and severity of firearm injuries in a Denver trauma center, 2000-2013. JAMA. 2016;315(22):2465–2467. doi: 10.1001/jama.2016.5978. [DOI] [PubMed] [Google Scholar]
- 4.Livingston DH, Lavery RF, Lopreiato MC, Lavery DF, Passannante MR. Unrelenting violence: an analysis of 6,322 gunshot wound patients at a Level I trauma center. J Trauma Acute Care Surg. 2014;76(1):2–9, discussion 9–11. doi: 10.1097/TA.0b013e3182ab19e7. [DOI] [PubMed] [Google Scholar]
- 5.National Academies of Sciences, Engineering, and Medicine. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: National Academies Press; 2016. [PubMed] [Google Scholar]
- 6.Cannon JW, Khan MA, Raja AS et al. Damage control resuscitation in patients with severe traumatic hemorrhage: a practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2017;82(3):605–617. doi: 10.1097/TA.0000000000001333. [DOI] [PubMed] [Google Scholar]
- 7.Haut ER MN, Kotwal RS. Military trauma care’s learning health system: the importance of data driven decision making. Paper commissioned by: National Academies of Medicine used to support the report titled “A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury.” Washington, DC: National Academies Press; 2016. Available at: http://www.nationalacademies.org/hmd/∼/media/Files/Report%20Files/2016/Trauma-Care/Importance-of-Data-Driven-Decision-Making-CP.pdf. Accessed September 18, 2017.