Uptick in Gun Deaths 'At the Scene' Point to Increased Injury Lethality

Rates of firearm deaths "at the scene" have significantly increased over the past two decades, suggesting that firearm injuries have become more deadly, according to a study of U.S. data from 1999 to 2021.

Over this time period, the proportion of deaths at the scene increased from 51.8% to 56.6%, reported Lauren L. Agoubi, MD, MA, of the University of Washington School of Medicine and the Harborview Injury Prevention and Research Center in Seattle, and co-authors.

Each year, there was a significant proportional increase in deaths at the scene (mean annual percent change [APC] 0.25, 95% CI 0.17-0.32, P<0.001), they noted in a research letter published in JAMA Surgery.

Deaths in the emergency department also increased over the two decades, from 25.9% in 1999 to 29.9% in 2021 (mean APC 0.13, 95% CI 0.07-0.18, P<0.001), though deaths on arrival decreased from 7.8% to 1.9% (mean APC -0.25, 95% CI -0.27 to -0.22, P<0.001) and inpatient deaths decreased from 13.8% to 11.3% (mean APC -0.09, 95% CI -0.13 to -0.06, P<0.001).

The decline in the proportion of deaths in the inpatient setting suggests "that the heightened lethality of firearm injury was associated with an increase in deaths among people who never reached a medical facility," Agoubi and colleagues wrote.

A steady stream of mass shootings in recent years has galvanized healthcare professionals and associations to advocate for stronger gun control policies, including restrictions on the sale of semi-automatic rifles, which cause more serious injuries than pistols.

"Studies suggest that both the risk and lethality of firearm injuries have increased, partly due to larger magazine capacity and growing use of high-caliber weapons," Agoubi and team noted, adding that though the "locations of firearm deaths remain poorly characterized," this information could help to inform where to focus treatment and prevention efforts.

"We wanted to be able to analyze the concept of lethality from a scientific perspective and see if the data supported what has been suggested," co-author Joseph Sakran, MD, MPH, MPA, of Johns Hopkins University School of Medicine in Baltimore, told MedPage Today.

Christopher Colwell, MD, chief of emergency medicine at Zuckerberg San Francisco General Hospital and Trauma Center, said the study's findings lined up with his experience -- both in responding to mass casualty scenes at the Columbine High School and Aurora, Colorado movie theater shootings, and also over the years working in the hospital.

"On a nearly daily basis in our Level I trauma centers, both in Denver and now here in San Francisco, those high-caliber weapons that are designed to get off many, many bullets, cause more damage," he said, "and are not only more lethal, but cause more injuries, a higher number of injuries and to a higher number of victims, and a higher number of injuries within each individual victim."

"These weapons are now more available, so the injuries are getting more frequent and worse," he added.

The research group is currently working on a study in collaboration with the chief medical examiner in Maryland, looking at violent homicides there, Sakran said. "The type of granular details we have captured will help us better understand patterns of injury, and what we call the intensity of violence that we are seeing in Baltimore and many other cities across America."

Of the injuries he sees, Colwell said, "more than half are coming from assault weapon types ... but I recognize that that's not perfect data. That's the kind of data we should be tracking."

He added that it would also be critical to gather data on the role that higher-caliber weapons play in the hands of civilians. "The essence of the Second Amendment is that we should be able to bear arms in order to defend ourselves," Colwell said. "How many of the assault weapon injuries that we see in the emergency department, or that result in deaths at the scene, are the result of defensive efforts? I can tell you that my experience is almost zero."

For this study, Agoubi and team used the CDC's Wide-Ranging Online Data for Epidemiologic Research (WONDER) database to collect data on firearm deaths from assaults, unintentional injuries, and unknown intent from 1999 to 2021. They excluded self-inflicted firearm deaths, leaving a total of 306,772 deaths.

The primary outcome of location of death was defined using CDC categories: inpatient medical facilities; outpatient medical facilities (including the emergency department); death on arrival at a medical facility; nursing home or long-term care facility; decedent home; medical facility with unknown status; other place; and unknown. Deaths at decedent home and "at other place" were classified as "deaths at the scene."

The authors noted that a limitation to their study was the assumption that deaths in the "other place" category indicated deaths at the scene before arriving at a medical facility. In addition, definitions characterizing the differences between "death on arrival" and "death at outpatient facility" were unavailable.

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