Recommendations from the American College of Surgeons Committee on Trauma’s Firearm Strategy Team (FAST) Workgroup: Chicago Consensus I

Abstract

This brief report of recommendations is from the American College of Surgeons Firearm Strategy Team (FAST) Workgroup. The FAST Workgroup was created by the American College of Surgeons Committee on Trauma (ACS COT) to serve in an advisory capacity toward the development of an effective and durable strategy for reducing firearm injury, death, and disability. The ACS COT has pursued a broadly inclusive strategy taking in all points of view to effectively develop a consensus approach.1-3 This strategy has incorporated input from views across the spectrum, including multiple survey(s) of surgeons, town hall meetings of COT members, ACS COT Injury Prevention Committee Meetings, interactions with the ACS Board of Regents and Board of Governors, and multiple small group/individual meetings with surgeons across the country. This approach has led to a dialogue between those who might differ with respect to their views on the benefits of firearm ownership and personal liberty, but who agree on the critical importance of reducing injuries and deaths related to firearms. Through this dialogue, we came to realize that the community of firearm owners are often approached as a part of the problem, but less commonly approached as a part of the solution.4 The ACS COT and others have called for a public health approach to the epidemic of firearm-associated injury, and more specifically firearm violence.1,5-8 A key step integral to a public health approach is community engagement.9-15 Community engagement strategies for public health interventions are a core step in implementation and are recommended by major international public health organizations.9-11 The degree of community engagement can make a critical difference in efficacy or lack of efficacy of a public health program. As a specific example, if a local trauma center’s injury prevention and outreach team were moving forward with a bicycle safety initiative, an important early step would be to reach out to bicycle owners to engage them as a part of the solution and to use their expertise in the activity with the goal of making the prevention initiative as effective as possible. For the initial work of our FAST Workgroup, the community of interest is the community of firearm owners in the US. Just as with surgery, engagement is a blend of science and art.9 A good example of this type of effort in the firearm injury prevention arena is Barber and colleagues’4 work on suicide prevention through engagement of the firearm owner community. Barber and colleagues describe the importance of working with “trusted messengers” as a necessary step in community engagement. As described here, the individual bicycle rider is simply more receptive to a safety message from a bicycle enthusiast or representative from the bicycle community, and generally much more receptive if the message comes from those who are supportive of bicycling. This is also true in medicine; surgeons are much more receptive to messages from their surgical colleagues. Likewise, critically injured trauma patients are more receptive to advice and counseling from trauma survivors who have been in a similar position, which is the basis of the using a trauma survivors’ network.16 To create the FAST Workgroup, the ACS COT leadership sought out surgical leaders who are firearm owners, specifically looking for a geographically representative sample of trauma surgeons passionate about firearm ownership with expertise as hunters, sport shooters, self-defense, law enforcement, and/or previous military service. The FAST Workgroup is composed of respected surgeons who meet the criteria of being on the frontline for the care of firearm injuries, involved in meetings with the COT Injury Prevention Committee, have a track record of working well as a part of a team, are avid firearm owners, and practice in areas distributed across the US. This article describes the FAST Workgroup’s approach and methods, and summarizes consensus recommendations for strategies and tactics to increase firearm safety, reduce the probability of mass shootings, reduce firearm-associated violence, address mental health factors, and encourage federally funded firearm injury research, while preserving the right to own and use a firearm. METHODS AND APPROACH For the past 5 years, the ACS COT has worked to develop a consensus strategy around how best to reduce the firearm injury death and disability. This strategy was built around 3 guiding principles: Advocate and promote a public health approach to firearm injury prevention; Implement evidence-based violence prevention programs through the network of ACS COT-verified trauma centers Provide, foster, and promote a forum for civil dialogue within our own professional organization with the goal of moving toward a consensus on programs or interventions aimed at reducing firearm injuries and deaths. These principles have allowed a maximally inclusive process whereby input has been obtained from all points of view. This inclusive approach has led to the creation of a common narrative that creates a bridge between groups of people who do not agree about the general benefit of firearms, but agree on the need to reduce violence, injuries, and deaths.17 We have demonstrated that surgeons with strong opinions about the benefit or lack of benefit of firearms can and will work together to reduce firearm death and disability. The next steps of this process are multifaceted, but the goal is to develop a durable, effective, and common-ground set of policies that reduce firearm injury and death. The COT leadership believes that a durable and effective strategy requires the engagement and partnership with firearm owners. Members of the FAST Workgroup had all been engaged in previous discussions with the COT Injury Prevention and Control Committee and had all either expressed an interest in the topic or had contributed their opinion(s) about the work of the ACS COT’s firearm injury prevention initiative. Three of the authors (RMS, DLK, EMB) worked to identify surgeons who had identified themselves as avid firearm owners. These surgeons were then invited to attend as a member of the focus group. Multiple conference calls were held along with 3 in-person meetings. The group consciously worked to focus the discussion on efforts that could reduce injury and death and preserve the ownership rights of responsible Americans. The group recognizes that firearm injury is a complex and multifaceted problem and that the underlying cause of the injuries might be different and can require different solutions based on the context of the injury. For the purpose of this initial set of meetings, the FAST Workgroup centered its efforts on how best to make firearm ownership safer, decrease the risk of intentional mass shootings, and start to address the culture of violence in the US. A consensus process was used for making the recommendations. To be included as a recommendation in this article, all members of the group needed to agree with the recommendation. There were some differing degrees of agreement, but if every participating member did not agree enough that they could accept and support a given recommendation, then the concept or idea was not put forward as a recommendation from the Workgroup. The recommendations are given in the form of stating a principle that the group believed is important, followed by specific recommendations related to the principle. We believe this provides a description of the rationale and also allows for flexibility in implementation. RECOMMENDATIONS FROM THE FIREARM STRATEGY TEAM WORKGROUP Obtaining ownership Principle: We believe those who are a danger to themselves or others should not be allowed to purchase or receive a firearm as a gift or as a transfer from another person. Recommendation: We support a robust and accurate background check in accordance with federal law 18 U.S.C. § 922[g][1-9] for all purchases and all transfers of firearms. Rationale and background for recommendation: The FAST Workgroup believes the bipartisan Fix NICS Act of 2017 was a necessary step in the right direction; however, not conducting background checks on all transfers and sales of firearms creates a real opportunity for those who are a danger to themselves or others to illegally obtain firearms. The law requires federally licensed dealers (those with a Federal Firearms License) to conduct background checks on all gun sales and transfers through the FBI’s National Instant Criminal Background Check System (NICS). No such requirement is codified in law for private sales or transfers of firearms. We recommend a NICS background check for all transfers of firearms with the recognition that this recommendation creates some potential challenges to legitimate private purchasers and sellers of firearms, and would also create an increased load on the computerized system on which the NICS functions. After extensive discussion, we believe these challenges can be effectively and efficiently managed by partnerships between private sellers (who do not have a Federal Firearms License) and retailers (who have a Federal Firearms License) who routinely conduct background checks through the NICS. The federal government must insure that the computerized system can handle the increased number of background checks required before implementation of this recommendation. Effective state implementation is critical if the Fix NICS Act of 2017 is to achieve its purpose. We recommend expeditious full and complete implementation of the Fix NICS Act of 2017 by all states, combined with continuing ongoing efforts to improve the NICS. This comprehensive approach requires more complete, timely, and standardized state reporting of information to the NICS, particularly regarding criminal convictions, drug abuse, and mental health data. In discussion, our FAST Workgroup supports the addition of intimate partner domestic violence offenses and the misdemeanor offense of stalking be added to the disqualifying criteria for purchasing a firearm. Although the group did not reach consensus, there were extensive discussions and a significant amount of support for the concept of a permit to purchase approach (which is implemented in some states) especially for high-capacity, magazine-fed, semi-automatic rifles, and for those younger than 25 years who wish to purchase a firearm. Firearm registration Principle: A firearm should be transferred with registration in accordance to federal law 18 U.S.C. § 922[g][1-9] just as other properties are, such as vehicles or a home. This would include the private sale and the transfer of property that is bequeathed from an estate or among family members. Recommendation: We support firearm registration and the development and implementation of an electronic database for all registered firearms. Rationale: We believe firearm registration and the ability to track a registered firearm is important to aid law-enforcement professionals in preventing the illegal sale of firearms to those who cannot pass a background check due to criminal activity or serious mental illness. We recommend a reliable database to track these registrations. Licensure Principle: Certain classes of weapons with significant offensive capability are currently appropriately restricted and regulated under the National Firearms Act classification as class III weapons (eg fully automatic machine guns, explosive devices, and short-barreled shotguns). Recommendation: We recommend a formal reassessment of the firearms designated within each of the National Firearms Act classifications. For instance, high-capacity, magazine-fed, semi-automatic rifles should be evaluated, and consideration given to reclassification as an National Firearms Act class III firearm or a new class designation. Rationale: The FAST Workgroup extensively discussed licensure for all firearms, which is distinct from the ability to purchase a firearm. The group did not reach a consensus on the recommendation for licensure of all firearms; however, the group does support state licensure in the form of concealed carry permits18 and, therefore, believes that licensure could be applied, and might be warranted, for high-capacity, magazine-fed, semi-automatic rifles. In this setting, increased screening and additional evidence of safety training could be opted for by individual states. This could also provide a more efficient and focused setting for an electronic database, in contrast to a database for all firearm purchases. Education and training Principle: Responsible firearm ownership and use comes with significant responsibility and understanding of safe handling, care, and use. Recommendation: We endorse formal gun safety training for all new gun owners and endorse hunter safety and safe gun handling education. Any training program must include the 4 vital safety rules: assume the gun is always loaded; finger off the trigger until ready to fire; never point at anything you do not intend to kill or destroy; and always check all chambers before cleaning. Recommendation: We recommend direct adult supervision in the use of firearms for children younger than 12 years and indirect supervision for children between the age of 12 and 18 years, where not already state-regulated. Rationale: As surgeons who routinely provide care to patients that is important and generally beneficial, but also entails risk, we believe education is a cornerstone of safety. There are numerous resources available for high-quality firearm safety education and we believe this should be universal, foundational training for all new firearm owners. Ownership responsibilities Principle: Owners who do not provide reasonable, safe firearm storage should be held responsible for adverse events related to discharge of their firearm(s). Recommendation: We endorse requiring firearm owners to provide safe and controlled firearm storage. Owners who do not provide reasonable, safe firearm storage should be held responsible for adverse events related to discharge of their firearm(s). This includes the responsibility for the use of a stolen firearm, unless there has been timely reporting of a stolen weapon made to law enforcement. Rationale: Safe, controlled storage reduces the risk of unintentional harm to others. Mandatory reporting and risk mitigation Principle: For individuals who are deemed an imminent threat to themselves or others, firearm ownership should be temporarily or permanently restricted based on due process. Recommendation: Programs to remove firearms from those individuals should be standard as is done in Extreme Risk Protection Order policies, Red Flag laws, and federal law 18 U.S.C. § 922[g][1-9]. Specific due process measures should be required for removal and return of firearms. Mandatory reporting to (and by) law enforcement and medical personnel for those who are threatening to themselves or others should become standard practice. Recommendation: We recommend treating mass shootings as terrorism and support and encourage domestic law-enforcement efforts and strategies (within the limits of Fourth Amendment protections) to predict, detect, and deter future mass firearm violence. Rationale: We believe that risk mitigation by law-enforcement professionals is important to public safety, and is necessary to prevent individuals from harm at an individual and and Principle: Firearm ownership should be made through the use of such as that used in safety. Recommendation: We encourage the development of firearm that would reduce the risk of prevent unintentional and prevent use by other than the registered owner of the firearm. Principle: to health the practice of and is to improve care and develop effective interventions for all health care Recommendation: We recommend that for firearm injury and firearm injury prevention must be federally funded at a with the of the Recommendation: This must be in a The should broadly address firearm safety, including safe storage and safe violence and serious mental and firearm and of patients injured from firearms. The should of violence. These should be focused on programs and strategies to prevent of violence a firearm, as well as all other of and on violence. This should the of to of violence in The should be to this is related to violence, and should be to the of this in Effective of safe storage and safe as to firearms could prevent their use by those other than the safe storage in the or could prevent unintentional injury and death. Effective firearm safety counseling and of to firearms by of based on and for mass shootings, intimate partner violence, unintentional injury, and other of firearm violence. of firearm based on specific type of firearm and of deaths and injuries Rationale: research, and are to improve safety, and We believe this approach is to firearm owners and those who do not own firearms. in safety have in with in We believe a similar approach to firearms could the safety with intentional violence requires a robust that is at a with the of the and are critical if we are to have effective of violence Principle: We all own the culture of violence. The principle of with responsibility to the in which mass are to the We have that the and in which information is to the public and by the to mass Recommendation: The professionals in law enforcement, and the should steps to of the and an approach to the of these Rationale: Although we would based on research, we believe we should encourage best toward or for individuals from moving from to This point of view is well by the to a similar to mass in the age of that also our own This the or not reporting important events of not the with the they of and and a focus on reporting of such as the type of of and the the might have and others recommend that law enforcement professionals not of the and of the and those who those should not This is not a for but a for and and mental health Principle: combined with of violence, especially to violence in the Recommendation: We encourage recognition of mental health and by and and these are to mental health of or become and family members should be to and report to local and law enforcement. Rationale: Although evidence of to common would efforts be focused on and This combined with a of to and This responsibility on all of Firearm injuries are a major public health problem in the US. As a group of surgeons, we care for the patients who and from firearm In the solutions to be however, we believe implementation of this Workgroup’s recommendations would in injuries and deaths while preserving We and that American surgeons have held views on this and we of those on who might with the recommendations that the FAST Workgroup has we also that the has a major public health problem with firearm injuries and believe our recommendations endorse the to the of firearm violence at the programs through the ACS such as the the ACS COT Trauma and the Trauma Programs to be effective in the care of patients and will have a on as these programs to The FAST Workgroup was created based on work by the ACS COT Injury Prevention Committee to focus on effective and durable strategies for the prevention of firearm The ACS COT has pursued a maximally inclusive process to develop effective and strategies for firearm injury prevention as they to and unintentional We have engaged with major including the National to to and for The approach we have is with other injury prevention strategies used by the ACS We have worked and to develop an inclusive narrative that can be by of the about firearms in the This and are to engage groups and have them that they can be part of the The FAST Workgroup includes surgeons of years for trauma of these surgeons all of the criteria described in the surgical leaders who are firearm owners that are passionate about firearm ownership with expertise as hunters, sport shooters, self-defense, law enforcement, and/or previous military service. the leadership of the ACS COT and the ACS have and to care patients with serious firearm The group is geographically states, and includes surgeons that injured children and injured surgeons in the FAST Workgroup have past or military and others have formal training in public are members of the National and 4 are members. are to preserving and preventing firearm injury using an evidence-based Although the group was not on where they is that the group is supportive of Amendment We are not but we do not believe that of the FAST Workgroup’s recommendations on the rights by the These recommendations from surgeons who are representative of the of American surgeons who own of the recommendations is that they from a small sample of surgeons, and are to To the in potential every an of their firearm years of for injury National and and past or military of Firearm Firearm and Firearm of Firearm Strategy Team Workgroup FAST Workgroup is not to for all firearm owners, and is not for all however, as a group of firearm owners and surgeons who were by the the members of the FAST Workgroup did to and a of to the public health of firearm injury and death. The members of the believe that the recommendations are and preserve Amendment rights for responsible firearm owners. The FAST Workgroup that some firearm owners will the on with but our view from our that a requires that its The members of the also that some will these recommendations based on the that the FAST Workgroup might be or by firearm or by the about the Just as this is not for all firearm owners, the FAST Workgroup is not for all As surgeons, we to make these recommendations with the best of our patients and their who from the of firearm injury and death. The FAST Workgroup as currently composed will need additional input and from different comes to of patients based on age and of injury and This requires an ongoing process and will require of and recommendations The members of the FAST Workgroup believe these recommendations will increase public safety and improve our understanding of firearm injury in the US. We that there is not a or solution for an as complex as firearm injury in These recommendations would make firearm ownership for those who own a firearm, as well as those who do The general approach is centered on enforcement of and and with the goal of firearms out of the of those who are a danger to themselves or others. This responsible approach is by across the Through the ACS COT’s firearm injury prevention ACS COT members have demonstrated the ability to work together and to public health recommendations and We this approach can serve as a for other and other The members of the FAST Workgroup there will be people who we did not and also people who we but we believe the the purpose We of American can be each implementation of the measures we for in this report would preserve and make our safer, and and of and of of