What about non-fatal firearm injuries?

(Intentional) non-fatal firearm injuries (NFIs) outnumber fatal firearm injuries (FFI) by about 2:1

One potential explanation for the reduction in firearm fatalities that started in the late-1990s and persisted through the early 20-teens is that trauma care surgeons got drastically better at treating gunshot wounds. If this were a primary cause of the sharp reduction in intentional fatal firearm injuries, then we’d observe: 1) an inverse relationship between non-fatal firearm injuries and fatal firearm injuries, with reductions in firearm homicides being accompanied by increases in firearm injuries coupled with, 2) stable and consistent amount of total firearm violence (FFIs + NFIs).

While it’s an elegant hypothesis in a sea of unsatisfying causal explanations for the plunging firearm homicide rates observed during the late 1990s and early 2000s, the evidence doesn’t bear out a relationship between improved trauma care and reductions of firearm homicides.

For instance, in “The epidemiology of trauma-related mortality in the United States from 2002 to 2010,” researchers examine survival rates for gunshot wounds, falls, and motor vehicle accidents treated in trauma centers over time. They found that across the study period, mortality rates decreased for falls and car accidents, suggesting improvements in trauma care were saving more lives. At the same time, national rates of firearm-related mortality were stable and actually increased (slightly) each successive year, but this was driven by increases in self-inflicted firearm injury mortality (i.e. suicides), not homicides. Importantly, the authors conclude this doesn’t mean trauma surgeons got worse at treating gunshot wounds over time. Rather, “a change in the nature of firearm injuries presenting to trauma centers,” explains the increase in mortality. (That the change was more people attempting suicide with a gun and succeeding.)

This comports with the official national statistics on firearm assaults and homicides around this period. The firearm homicide rate plummeted between 1993 and 2011. If improved trauma care contributed to this outcome, we’d observe commensurate decreases in mortality among the 78% of firearm injuries treated in trauma care centers, coupled with an inverse relationship between assaults and homicides. Instead, firearm assaults and homicides fell in tandem during this period: Firearm-related homicides declined 39%, while nonfatal firearm crimes declined 69%.

My research on the pandemic-era spike in gun violence also shows that NFIs and FFIs move in tandem. Between 2019 and 2020, I found that both fatal and non-fatal firearm injuries increased 29% across the over 1300 cities included in my analysis. I also show that NFIs outnumber FFIs by 2:1 and that cities with over 100,000 residents have a larger proportion of NFIs (2.4 to 1) compared to the smaller cities (1.8 to 1). This suggests gunshot victims are more likely to survive if they live in a larger city, likely due to being in closer proximity to a trauma care center than victims who live in the smallest cities.

In summary, just as there’s limited evidence to suggest that drastically improved trauma care for gunshot wounds caused the firearm homicide rate to plunge 40% in recent decades, there’s also little evidence to suggest we should attribute the recent surge in homicides to trauma care surgeons becoming much, much worse at treating gunshots overnight. Instead, we should acknowledge that trauma surgeons are likely becoming vastly better at treating bullet wounds through repeat experience. There’s just an upper limit on how many lives they can save due to the nature of firearm injuries they’re treating and not all victims have equal access, i.e., proximity to a trauma care facility. This will persist as gun violence continues to spread to smaller and smaller communities.

I’ll share a visualization of my data on FFIs and NFIs in another post soon, please stay tuned!

In the meantime, thank/hug an ER doctor, trauma nurse, and any other medical professional you see who is

treating all these gunshot victims, many of whom are children.

Suggested listening: PHILLY UNDER FIRE EPISODE 2: THE OTHER EPIDEMIC

Suggested reading: ‘We’re seeing this every day’: UAB adds surgeons to handle surge of gunshot wounds