What’s the role of physicians in the aftermath of mass shootings?

Domestic terrorism has become a nationwide epidemic—and it’s contagious. As of this writing, there have been 271 mass shootings in 2019, leaving 290 people dead and 1,121 injured, according to the non-profit organization Gun Violence Archive. In early August, the mass shootings in Dayton, OH, and El Paso, TX, resulted in the deaths of 31 people in less than one day’s time.

Researchers have found that mass shootings are contagious, in the sense that one mass shooting inspires more mass shootings within the following days. Notably, in the weeks following the tragic co-occurrences in Dayton and El Paso, more than two dozen people were arrested for making mass shooting threats.

In the fight against epidemics and contagion, the work of physicians saves lives. So, you may be wondering how physicians can help with mass shootings. But before we get to what you can do, let’s look at some existing research on the topic.

Misattributed factors

It’s tempting to think that mental illness—which involves alterations in mood, thinking, and behavior— would be a major contributor to mass violence. Researchers have largely focused on schizophrenia and related disorders, and have shown that there is only a two- to four-fold increase in the risk of violence among those with schizophrenia. Notably, the studies were highly heterogeneous, which confounded results. Also, schizophrenia is not the only type of mental disorder associated with an increased risk of violence. Others include depression, bipolar disorder, anxiety disorders, and personality disorders.

The best estimate for population-attributable risk for violence due to mental disorders is between 3% and 5%. In other countries, with lower rates of violence, these percentages are higher, but nowhere do they exceed 10%. In other words, if the proportion of violence due to mental disorders were somehow eliminated, between 90% and 97% of violent behavior would remain.

Attributing mass violence and domestic terrorism to mental illness serves to further stigmatize this already marginalized population.

In an opinion piece published in JAMA Psychiatry, Paul S. Appelbaum, MD, a psychiatrist at Columbia University School of Medicine, New York, NY, wrote: “Violence is a complex, multicausal phenomenon, and its prevention requires attention to the means used to perpetrate violence; in the United States of the 21st century, that means guns. Pointing the finger at people with mental illness as the cause of the problem of violence in this country is misleading, counterproductive, and just plain mean.”

In addition, many people assume that the violent nature of many video games may promote gun violence. However, in a study published in PLOS ONE, researchers uncovered no link between video games or other types of screen time and gun ownership among teenagers.

Data were mined from the CDC’s Youth Risk Behavior Surveillance System to uncover factors correlated with carrying firearms. The authors found that substance use, engagement in physical fighting, and exposure to sexual violence were much more important predictors of carrying a firearm than video game use.

Gun laws

In a cross-sectional study assessing US gun owners between 1998 and 2015, researchers examined whether restrictiveness/permissiveness of state gun laws or gun ownership were significantly tied to mass shootings. Mass shootings were defined as the killing of four or more people by firearm.

Results indicated that a 10-unit increase in state gun law permissiveness was correlated with an 11.5% (95% CI: 4.2% to 19.3%; P = 0.002) higher rate of mass shootings. Additionally, a 10% increase in state gun ownership was linked to a 35.1% (95% CI: 12.7% to 62.7%; P = 0.001) higher rate of mass shootings.

The authors put these results in perspective: “On the absolute scale, this means that a state like California, which has approximately two mass shootings per year, will have an extra mass shooting for every 10 unit increase in permissiveness over five years. It will also have three to five more mass shootings per five years for every 10 unit increase in gun ownership. These results were also consistent across multiple analyses and when stratified as to whether or not mass shootings were committed by someone in a close relationship with the victims.”

What healthcare systems are doing

Throughout the United States, officials at hospitals are staging real-life simulations to prepare to treat victims of a mass shooting. Not that emergency training is something new—for decades, healthcare institutions have conducted drills simulating mass casualty events, such as hurricanes or earthquakes. Instead, this training has expanded to incorporate the reality of the random threat of mass shootings.

One daunting aspect of the mass shooting training in which physicians participate is the need to shift mindsets from doing everything you can to save the individual patient to focusing on patients who have the best chance of surviving. 

Here is some guidance provided during mass shooting preparedness training:

First, physicians, nurses, and first responders need to be mobilized and called into the hospital. Every available staff member who can assist should be called to the emergency department.

Second, following a mass shooting, victims don’t necessarily enter the emergency department by ambulance, thus giving staff time to prepare. Instead, they tend to stream in on their own, often with the help of the public. Room must be made available for victims, which may require repurposing of non-traditional spaces, such as in hallways, the pediatric emergency department, and the post-anesthesia care unit.

Third, efficient triage is key. This priority often means setting up triage tents outside the emergency room entrance. Furthermore, instead of prioritizing the chief complaint when triaging, staff should employ the START method, which stands for “simple triage and rapid treatment.” With this approach, more immediate concerns rise to the surface, such as the ability to walk and breathe, as well as mental status.

Fourth, all bleeding must be stopped. In the aftermath of a mass shooting, physicians and nurses, and even non-medical personnel must staunch the flow of blood—all hands on deck. Often, all that is needed to stop bleeding is gauze and pressure, but tourniquets may become necessary depending on the degree of the bleed.

As a physician, you can participate in these mass shooting emergency drills and make sure that emergency room staff have your direct contact information in case of an emergency.

Consequences

Survivors of mass shootings appear to be at higher risk of suicide. Survivors often struggle with grief, and dates like anniversaries can prolong complicated grief and trauma.

Even those who are not directly affected by the tragedy of a mass shooting can suffer from fear and anxiety due to the concrete portrayal of mass shootings in the media.

Most people who survive mass shootings are resilient, but some—especially those who lost loved ones, felt in particular danger, or lack social support—are at higher risk of PTSD, depression, anxiety, and substance abuse. In fact, the National Center for PTSD estimates that 28% of people who have witnessed a mass shooting develop PTSD, and about one-third develop acute stress disorder.

Stages of shock

In the acute phase after a mass shooting event, survivors often experience denial, shock, and disbelief. Survivors should be directed to mental health professionals who can help normalize survivor feelings of fear, anxiety, and helplessness, as well as providing brief psychotherapy.

During the acute phase, it’s important to help victims feel connected to the community and recognize that ongoing support is available. Researchers have shown that memorial events, either organized by student or community groups, can serve as useful tools in recovery. As a show of support from the healthcare community, you can consider attending such events.

During the intermediate phase, victims may exhibit fear, anger, anxiety, attention deficit, depression, and disturbed sleep. During this phase, in addition to seeking help from a mental health professional, survivors can also find support in the community through schools, faith-based organizations, recreation centers, and other local organizations.

During the long-term phase, which occurs several months after the event, victims can continue to experience periods of adjustment and relapse, but most survivors, particularly children, no longer need dedicated mental health support. Some survivors even report having grown from the experience, as well as feeling increased self-worth, purpose, and gratitude.

On the other hand, some people suffer from untreated behavioral health effects, such as flashbacks, debilitating anxiety, or self-medication. These stressors exacerbate mental health or substance use disorders and require specialized care.

Physicians can help those who were victims of mass shootings by checking in on them periodically, inquiring about their mental health, and directing them to community resources and support. Finally, physicians can provide trauma-informed care and counsel the victims on the long-term health effects of trauma even years after the mass shooting occurred.