Welcome to the Annual Assembly for the American Academy of Physical Medicine and Rehabilitation. We are so pleased that you chose to join us for our session, which is called Advocating for Rehabilitation Care of Firearm-Related Injuries. These are our panelists. We have no disclosures. We have a dynamic group of people that are going to speak to you, both physiatrist clinicians as well as a patient advocate and a survivor of a firearm injury. We very much look forward to your active participation and any feedback you can give us virtually via Twitter or via our email would be greatly appreciated. So I want to give you a little bit of a background on the agenda, what we're going to talk about today. The first thing we're going to talk about is why do firearm injuries happen? Some of the epidemiology behind this condition, the patient experience, specifically our patient's injury and the impact of physiatry care on their outcomes and long-term access to care. Experience of providing acute and chronic care for victims of firearm injuries. This will be given from the spinal cord injury perspective, as well as musculoskeletal injuries. We will then finish up with the policy discussion. Multiple speakers on our panel are members of the Health Policy and Legislation Committee for the American Academy of PM&R. So we're going to talk about what stances on firearms has AAPM&R taken in the past and what role do physicians play in speaking on this issue moving forward. So a little bit of information about why firearm injuries occur. The issue of gun violence in the USA is very complex. It takes a dramatic and long-term consequence on patients across the US. Here's some CDC data from 2018 about non-fatal firearm injuries. Males account for 88% of these injuries. 70% of medically treated firearm injuries are from firearm-related assaults. 20% are unintentional. There are a lot of guns in the market. So for every 100 people, there are approximately 120 and a half guns within the United States. There is a little bit of division and politicization of gun laws, the red versus the blue, and that ends up having a significant amount of feedback, negative feedback, when it comes to trying to establish laws that protect Americans in this country. There are societal disparities in minority populations as well that definitely contribute to firearm-related injuries. So what is the physiatric view of addressing this issue? So we have a unique role as physiatrists in reducing firearm injury through intervention by identifying risk, asking the right questions, and educating about the potential short and long-term effects of firearm injuries. This is a public health issue. It is not a political issue. PMNR can place emphasis on how gun injury affects the trajectory of quality of life in our patients. I'm going to turn the slide deck over to Dr. Stuart Glassman, who will be speaking more about this topic. Thank you, Dr. Ofejiga. So why do firearm injuries happen? We've gone through that. But now we look at the medical cost of firearm injury hospitalizations. The focus of this talk is really on survivors, not the deaths related to firearm violence. Not a lot of research, unfortunately, because a lot of funds that would have gone for research were prohibited for the Centers for Disease Control to utilize funding for about 20 years. If you're interested, look at the Dickey Amendment. That'll explain sort of why there was a lack of research for so long. But the National Gun Violence Research Center did look back in 2017 at data from 2003 to 2013, 30,617 hospital admissions for firearm injuries, an annual rate of 10 admissions for every 100,000 U.S. population. More than 80% of those hospitalizations were for individuals age 15 to 44. Males were nine times higher than females to have suffered a firearm injury. And there was a 10 times higher rate for African Americans than white population of firearm injury victims. The average annual admission cost was over $622 million, and the highest per admission costs were injuries from assault weapons, about $32,000 per admission, as well as for legal interventions, $33,462 per admission. And a quarter of firearm injury hospitalizations were among the uninsured, yielding average costs of about $155 million that the hospitals bore the brunt of that cost. So what are the consequences of firearm violence survival? The CDC is looking at violence prevention. It's known that surviving a firearm-related injury may lead to long-term consequences, including for brain injury, survivor's memory, thinking problems, emotions, and physical disability issues, spinal cord injury, paraplegia, quadriplegia, chronic mental health problems from conditions including post-traumatic stress disorder. The effects of firearm violence extends beyond the victims directly and their families. Mass shooting incidents often involve schools, houses of worship, workplaces, shopping areas, and community events, and this impacts those communities directly as well. Firearm homicides and assaults can affect the sense of safety and security of entire communities and impact everyday decisions. So the economic impact of firearm violence is substantial. The violence for firearms costs the United States tens of billions of dollars every year in both direct medical costs and lost productivity costs. Now I'm going to turn it over to Mr. Terrell Williams, talk about his experience as a firearm violence survivor. Hey, thank you, Dr. Glassman, I appreciate that. And so we're going to just hop right into it. March 29th, 2017 is the day my life changed forever. And so it started off as a normal day, went to work, got off, and I was heading to my brother's house. And as I was on my way to my brother's house, I stopped at a store right up the street from his house. I ran inside quickly. I was in the store for less than a minute. And as I went into the store, I made one mistake that I'm pretty sure we've all made at least one time in our life. I left my car running. And so as I'm exiting the store and walking back to my car, I see a guy in my car attempting to steal my car. Natural reaction kicks in. And I reach for my gun, cock it back, and I point it at the guy. And you know, everybody in the neighborhood carried a gun. Reasons vary, but for me, it was just simple self-protection. You know, if something was to go bad, I knew that I would be okay. And so I pull out my gun, cock it back, point it at the guy in my car. All of a sudden, I just feel something pierce my right side. And so what I never noticed was the multiple guys across the street who was looking out for the thief who was trying to steal my car. And so one of the guys shot, his bullet hit me in my chest, hit my lung, and hit my spine as I hit my spine as it exited my body. Instantly I fell to the ground. And now when I fall to the ground, I'm hearing gunshots all around me. And so I pick up my gun, and I shoot at the only target I see, and that's the guy who's driving away in my car. And you know, luckily I didn't hit anybody or anything else besides my car, and so extremely thankful for that. And so empty my clip, I don't hear any more gunshots, and so I start trying to get up, but I can't. And so I'm trying to get up, but I can't, and I'm thinking to myself, like, man, did I get shot in my legs? Like, what's going on? And so I reached down, grabbed my thighs, and they just felt like bags of water. Instantly I knew something was wrong, and I just started panicking. But you know, still in the moment, I'm trying to get up. And out of nowhere, the gunfire returned. And so what happened was, the guy who was attempting to steal my car, he ended up wrecking about 10, 15 yards away from me, and I never saw him wreck. And so when he wrecked, he didn't want the car anymore. What he did want to do was he wanted to kill me. And so he got out the car, he started walking around, he started walking down on me, shooting his gun several times. And I could literally see bullets bouncing left, right, left, right, all around me. And I knew it was a matter of time before one of those bullets to each shot was going to hit me. And I wish I was wrong, but I wasn't. And so the last shot to each shot hit me in my neck, hit me in the right side of my neck, and got stuck in the left side of my chin. And so instantly, I just stopped moving, because I knew if I moved again, there was a chance that more bullets would come my way, and I didn't want that. And so I sat, well, I laid on the ground, 20, 30 seconds, and I realized there was one thing left that I needed to do, because I just knew I was about to die. And so the one thing I needed to do was pray. And so that's what I did, said the same words over and over, God, please take care of me. God, please take care of me. God, please take care of me. And he did, because as you can see, I'm here talking to you all today, giving this presentation. So extremely, extremely blessed. And since that day, I've had a lot of positive experiences and got involved with a lot of positive things. So for example, I got back in school, and currently I go to the University of Louisville, where I'm studying to be in the accounting program. I work for the Youth Violence Prevention Research Center, which is a CDC-funded organization, and we attempt to prevent violence using a social justice approach. I'm also on the board of Whitney Strong, and so Whitney Strong is a nonprofit focused on preventing gun violence through responsible gun ownership. And I also do some work with Frazier Rehab and UofL Hospital as far as peer mentoring, just whatever they need me to do, I'm always willing to help and trying to help them out. And then lastly, real. So that's new, kind of more of a hobby than a business, but it's just me going around and pretty much inspirational speaking, telling my story and just hopefully inspiring some people to live good lives. And so that's a little bit about me. But now I want to talk about my experience as an inpatient. And so there are a couple of positives, a couple of negatives. But one of the positives was Dr. Castillo, my guy, he definitely made me feel like family. And so what do I mean by that? Of course, he's a doctor, he has job responsibilities, he's entitled, so he has to do these job responsibilities. But for me and my experience with him as a doctor, he made it feel more of like more than just a business relationship or more than just a doctor-patient relationship. He made me really truly feel like family. He's kind of like that uncle you see at the Christmas party once a year and you see him, it's like, hey, what's up, uncle? And so that's kind of what it made me feel like, because he talks to me about different stuff besides just medical stuff. He asked me, how are you doing in school? Are you still in school? Still going to be my accountant? And just things like that that make our relationship more personal rather than just a doctor and a patient. And then lastly, him and his team as well helped me find purpose in life. You have these traumatic injuries, and I know our viewers can't tell, but due to my injuries, I am wheelchair-bound. The one that hit my chest, it caused me to be paralyzed from the waist down. And so this all happened when I was 21 years old, living my whole life, physically able to do everything, and all of a sudden, in a matter of seconds, life changes that fast. And unfortunately, Dr. Castillo, he sees this type of injury more than a normal human should, and it's not new to him. And so for him to use his experience to help me find purpose in life that it's not over was an extreme positive, and I'm extremely thankful for it still to this day. And then lastly, as far as positives, outstanding medical treatment. I can literally, if there's anything that's wrong with me, I can go up to the hospital, call the office or whatever the case may be, and they were willing to help me with my issues and, you know, if I'm having problems, what is it? We're going to get on top of it. We're going to fix it. And so that outstanding medical treatment is key because I'm a guy who's never been to the doctor before my injury, and so now all the medical issues that come with this type of injury, you need outstanding medical treatment, and he provides that for me, and so thankful for it. As far as negatives, okay, I remember inpatient and, you know, being there in the mornings, early mornings, I can't remember how early, but it was early, and I would have numerous doctors come in at once, and I'm not sure if some of the doctors may have been residents or whatever the case may have been, but it kind of felt like at times anyway that I was more of like an experiment rather than a patient, and so having these doctors come and pretty much practice on me, it was like, yeah, this is real life for me, so, like, you know, I need somebody who knows what they're doing and not just learning, and so that was one of the negatives a little bit, but, I mean, I definitely understand the process, but I do think it can be maybe handled a little bit differently, and then lastly on the negatives, couldn't quite relate. What do I mean by that? So, of course I'm black, and Dr. Castillo isn't, and, you know, it was just difficult kind of trying to relate to somebody as far as, like, who would know me and know my lifestyle before my injury, you know, someone who comes from my neighborhood who sees the same things that I see. It was just different, and I didn't have anybody who could really understand that I didn't feel, and so that could have been a little different as well. And then lastly on my list, I just want to talk a little bit about the reasons for gun violence, and I'm not going to be able to touch on all of them, but one that I do want to talk about specifically is the systematic issues, and so one systematic issue that we see that relates to gun violence is redlining, and so what is redlining? Back in the 1930s, the Homeowners Loan Corporation, they started grading over 200 major cities real estate with A being the highest, B, C, and then lastly D, and if you look at these maps that we have on our PowerPoint on the presentation, the red represents D as far as redline grades. The yellow represents C, and so these are the lower grades, and the Homeowners Loan Corporation kind of made these maps to tell people what areas to invest in and what areas not to invest in, okay, and how does that relate to gun violence? So recently there was a study done by UofL, some UofL doctors, and they used a study, and on the map, they used the same map that we see here as far as redline, and the study was done between 2012 and 2018, and that study, there's a black dot on the map for every gun violence victim's home address, not where they got shot, but their home address, and this map, I will try to get it sent in so if we need to add it to the presentation that our viewers can have it, but you will see that there are heavy focuses of black dots in the lower grade areas compared to the higher graded areas, and so I'm not saying that, you know, redlining is the single-handed cause of gun violence issues, but what I am saying is that there is enough of a correlation between the two maps that warrant extra attention, you know. And so if we're going to look at gun violence, we've got to look at the roots. We can't just look at the outside branches and the leaves on the branch. We got to take the root causes if we really want to stop the problem. And so thank you all. I'll pass it to you, Dr. Castillo. Thank you, Terrell. We admire your courage for doing this and your ability to, how you have accomplished everything after such a, you know, difficult times that you have here. But my topic here is related to spike rangers. Obviously, I'm a spike ranger physician, rehabilitative physician. And the spike ranger, obviously, Terrell said it well, is a traumatic event that can basically result in a temporary or permanent deficit, either sensory or motor. And even though there are many racial and ethnic groups that are at risk of this problem, 60 percent of the spike rangers happens in Caucasians just because of the population. So because of that fact, there are very little research concerning about racial differences in acute ACIs and chronic ACI, especially in determining if there are disparities in alcohol, which we know we have. And because of the violence and gunshot wounds, they are important cause of morbidity, mortality in our population, especially among young people, as Terrell just described. Firearms contribute about 13 to 17 percent of all spike rangers. And you can see in that chart, it's the third most common cause of spike ranger. And in general, individuals with spike ranger due to gunshot wounds are either younger, less educated, usually male, single, African-American, unemployed, and have paraplegia with complete lesion. That's statistically. And some of the things that we have found and it's described for comparing with patients with spike ranger gunshot wounds and non-gunshot wounds is pain. And we don't know why they refer more pain after the injury. But some researchers talk about the mechanism of injury may play an essential role in the type and frequency, intensity, and duration of the pain, including also quality of life. Some research talk about exposure of situations involving gunfire, likely associated with the complex demographic characteristics that place individuals in increased risk of poor self-reported quality of life. So racial disparities are seen following NCI and including rate of complications, length of stay, disposition, acute rehab centers. I can tell you many stories about how difficult sometimes because of language barrier, either education level, poor health literacy, communication barrier, managed care, geography, and then constant containment that we have hinders the process of rehabilitation to bring these patients faster to our hospital. So even if in some research, even after controlling for insurance status, racial disparities still remain a fundamental problem in health care system. So the medical management of spinal cord injuries has to be integral. Part of the long-term follow-up, like Mr. Williams told you, coordinated comprehensive services and long-term continued care. And because of the rising cost of spinal cord injury care and the associated personal, vocational, and family impact, this further enhances this issue of spinal cord injury due to violence. And even though we have treatments for spinal cord injury, the overall success of this injury depends upon some non-medical factors, such as social support, access to resources, education, and many other factors that are influenced by the patient's sometimes racial and cultural backgrounds. So, for instance, like Mr. Williams told you, we have a health care navigator. Our nurse Heather helps the patients from the acute care to the inpatient and then outpatient. And she's the web to help us to keep the patient in the system because we know that they need support. And we know there are many barriers for them to access care. So further studies, just to keep it simple, needs to examine the initial impact, the comorbidities, and more in-depth demographics factors on long-term complications in this type of patient. For instance, sometimes we ask, are pressure injuries more frequent in SCI-related injuries due to firearms because of the characteristics of population support and things like that? Bowel and bladder, we don't have enough research on that. So the research priority should be given to studies that are aimed to reduce the incidence of SCI complications from these related firearm injuries and for identified risk factors and treatment strategies for these type of patients. This is a very costly disease. We do know they have a less quality of life in some instances as well as life expectancy. So the need for increasing efforts on prevention tactics to target the appropriate group of this population is extremely, extremely important. So I'm going to pass to Dr. Chan. Thank you. OK. Thank you, Dr. Castillo. So I'll be discussing firearm-related musculoskeletal injuries. These are the topics I'll be reviewing. So we'll give a little background history. In 1996, the Dick Amendment was passed. It was sort of a rider amendment attached to a bill that wasn't related to sort of firearms research, but essentially prohibited the CDC from being funded for any research related to prevention or limitation of firearms. This happened because around the same time, it was being increasingly recognized that firearm-related injuries were a public health issue. And this was spurred on in sort of the media with a study by Kellerman et al. in one of the leading journals in the New England Journal of Medicine. Essentially, it showed that having a firearm did not protect the owner, essentially, and increased the risk for homicide within the home, usually due to a family member or acquaintance. So the NRA took a hold of this and essentially ran with it. And the Dickey Amendment was passed in 1996. There were some funds available, but essentially this scared researchers from doing any sort of related research to firearm-related injuries because they were afraid that they weren't going to get funded. In 2011, this was sort of expanded, unfortunately, to the National Institutes for Health. And in 2018, it was clarified that research could be done. But again, essentially no funds were allocated by Congress. In 2015, in terms of actual data, by the CDC, there was an estimated 85,000 non-fatal firearm injuries in a year. But again, this is somewhat unreliable given the wide conference from 36,000 to 133,000. And this was based on the National Electronic Injury Surveillance System, NEISS. But they removed the data after 2016 and 17, given that there's criticism in terms of how unreliable the data was. So this is a graphic looking at in terms of the funding and how dismal the situation was for the last two decades. Pretty much 1% of the total budget for NIH was allocated to firearm-related research. And then this sort of underscores, again, firearm injuries are also one of the top leading causes of mortality besides morbidity, which is what we're discussing and focusing on in this presentation. But again, it's pretty much a drop in the bucket. In terms of more specific data sets, sort of nonprofit organizations such as the Everytown for Gun Safety Support sort of looked at the National Emergency Data Department sample. It's not the best, per se. It looks at 31 million discharge records from ER, U.S. emergency departments, about 20%, encompassing about 950 hospitals in 36 states and the District of Columbia, but doesn't include the VA hospitals, military hospitals, or Indian Health Services. So in terms of, you know, for what we have based on this database, for every two, for every mortality, there are two sort of victims who sustain a more chronic injury. And looking at by region, you know, there are myths, you know, in terms of, you know, for example, maybe the Northeast may be more prone to firearm violence, but based on the existing data, the South, followed by the Midwest, have the highest number of gun-related firearm injuries per year. This is just a graphic re-demonstrating sort of the chart from prior. In terms of age, this is what Dr. Castillo and Mr. Williams sort of highlighted, as well as Dr. Glassman. Unfortunately, firearm violence as well as sort of musculoskeletal injuries do impact young people below the age of 30, unfortunately, as well as those in adolescence. And in terms of income, socioeconomic status, the great majority, I would say over 50 percent, affects those with an income of the bottom quartile in terms of income scale. In terms of literature, again, this is highlighted because of the lack of funding. Most of it is focused on trauma, and it's been done by our colleagues in orthopedics, you know, general surgery, and some in ER medicine. And, again, it kind of highlights, again, the disparities that occur in terms of demographics. Again, it was alluded by Mr. Williams and Dr. Castillo. You know, it's primarily affects males, those of African-American descent. I mean, they're older when you compare it to children, but, again, kind of highlights, again, younger than the age of 30. In terms of sort of medical-related knowledge, majority of injuries are in the long bones of the lower extremity, followed by the upper extremity. And then traumatic perinatal nerve injuries seem to be more common than vascular injuries. And, again, that is a condition that physiatrists generally see in conjunction, of course, with their colleagues in neurology. This study was done recently by sort of orthopedic pediatric specialists. And it shows that there is a very sparsity of data in terms of the last two decades. So this slide, again, highlights, in terms of economic cost, we know that firearm-related injuries has a significant morbidity, but also has a cost to society as well as to medical systems. So if you're discharged from the ER, if you sustain a firearm-related injury and not fatality, again, it's still significant. And when you combine this with loss of productivity, work, and time, not just to the victim, but to their caregivers and family members, again, this is a significant impact on the economy as well. In terms of how this is related to our outpatient colleagues in musculoskeletal physiatry, personally, I am a sports and intramuscular spinal physiatrist. I would generally see these patients more on the chronic side after the injury when they're taken care of by my acute care colleagues. I would say the majority, as Mr. Williams sort of alluded to, is sort of barrier in terms of coverage for certain durable medical equipment, especially since these injuries can be lifelong, whether it's a traumatic spinal cord injury, traumatic brain injury, or even a peripheral nerve injury from such violence. For example, authorization for physical therapy. Again, these patients generally would require more than 20, 30 visits that are approved by insurances. And again, physiatrists are sort of best positioned to act as leaders in the multidisciplinary team to treat these patients holistically, not just only to improve their function, but to reduce their pain, disability impairment, and potentially help their psychosocial sort of burden after experiencing some injury. So in terms of limitation recommendations, again, we know that the data is sparse, but there is a light at the end of the tunnel. Last year in December, President Trump signed two spending packages. And finally, there's been funding allocated to the CDC and NIH for firearm-related research. But again, it's very little. It was less than $300 million, if I recall correctly. But again, at least it's a start, and it would allow us in terms of grants and researchers to act without fear from industry and politics to treat this as a public health issue. Again, in terms of greater guidance in terms of policy, education, we need more data. We're grateful to stories from Mr. Williams in terms of personal experience. But to help convince our policymakers, we do need hard data in order to show what is available and then what sort of interventions are actually, in this case, prevention. And our size rehabilitation sort of treatments would benefit such patients. And then I'm going to pass this to Dr. Glassman. All right. Thank you, Dr. Chang, for that great overview of the muscle-skeletal injuries and firearm consequences. I'm Dr. Stuart Glassman, and I am not only one of the members of the Health Policy and Legislation Committee, but also one of the two national delegates for the American Medical Association. And I'm going to talk about policy issues that we've talked about at the AMA level and also for the Academy as well. And it's important to remember that policy is not politics. Policy is how we try to use the best information to create the best opportunities for better public health. So the AMA House of Delegates has been looking at gun safety issues for decades. But a number of events happened starting in 2016 that really pushed forward policy discussion on a major national level. These included the Pulse nightclub shooting in Orlando, Florida in June 2016, which actually occurred right during one of the national annual meetings for the American Medical Association. The Las Vegas shootings in October 2017 at the Country Music Festival. The shootings in Parkland, Florida on Valentine's Day, February 2018. And shootings in El Paso, Texas and Dayton, Ohio in August 2019. This really led to the members of the AMA House of Delegates to really look at gun issues and public policy decision making in a much bigger way. So in 2018, the House of Delegates really came out with a number of different recommendations for what are called resolutions, which essentially is House of Delegates policy. Some of these included establishing laws allowing family members, intimate partners, household members, and law enforcement personnel to petition a court for the removal of a firearm when there is a high or imminent risk for violence. Prohibiting persons who are under domestic violence restraining orders or convicted of misdemeanor domestic violence crimes or stalking from possessing or purchasing firearms. These are known as red flag laws. Expanding domestic violence restraining orders to include dating partners, not just people you are married to, engaged to, life partners with. Requiring states to have protocols or processes in place for requiring the removal of firearms by prohibited persons. Also requiring domestic violence restraining orders and gun violence restraining orders to be entered into the national instant criminal background check system. Efforts to ensure the public is aware of these laws to allow for the removal of firearms from high-risk individuals. So this was the major focus in 2018 because it did take a couple of years to get some of these policies through the House of Delegates. But the discussions continued because the gun violence continued. So in 2019 some of the other policies that came about and the resolutions included opposing private ownership of assault type weapons and high-capacity ammunition magazines. This really came out of what occurred in Las Vegas in 2017. Requiring licensing or permitting of firearms owners and purchasers including the completion of a required safety course and registration of all firearms. We also talked about the enactment of child access prevention laws. You want to have guns locked up, make sure there are safety locks on them so the children can't get to them and have accidental firearm injuries. We reaffirmed current AMA policy for gun regulation stating that it supports stricter enforcement of current federal and state gun legislation. We advocated for physician led committees in states to get further recommendations concerning driving issues with persons with brain injuries and or gun use by individuals who are brain injured or cognitively impaired. And we also discussed supporting federal legislation, House Representatives 8, the Bipartisan Background Checks Act of 2019. So on the federal level there have been a number of different legislative bills submitted to Congress over the last two to three years. H.R. 674 which is the Gun Violence Research, sorry the Gun Violence Prevention Research Act of 2019 introduced by representatives in New York and Senator Markey from Massachusetts. This directs Congress to appropriate committed funding for the CDC to study gun violence epidemic for the next five fiscal years. Due to the Dickey Amendment going back to 1996 the CDC really couldn't use any appropriated funds for gun research for almost 20 plus years. The National Gun Violence Research Act H.R. 435 was introduced in January of 2019 by Representative Johnson of Texas. It removes limitations on the use of firearms tracing data by the Bureau of Alcohol, Tobacco, Firearms and Explosives. It permits funds made available to the Department of Health and Human Services to be used for gun violence research and establishes a national gun violence research program to promote gun violence research, authorizes various competitive grants to support research into the nature, causes, consequences and prevention of gun violence. And the Gun Violence Prevention and Community Safety Act of 2020 introduced by Representative Johnson of Georgia raised the minimum purchase age of firearms from 18 to 21, removes civil liberty limitations of gun manufacturers and promotes research on firearm safety and gun violence prevention. Understand that none of these proposed legislative bills removes the Second Amendment. So again we're talking about public health policy not politics. So where's the APM&R been on these issues of firearm public health regulations, legislations and policy? Going back to 2015 the American College of Physicians had a call to action concerning public health approaches to firearms and we supported that call to action. You may also recall that the ACP wrote a paper in the Annals of Internal Medicine in 2018 concerning reducing firearm injuries for public health issues and the National Rifle Association told doctors to stay in our lane. So the ACP has been pushing the issue of public health research and advocacy for a very long time and the Academy has supported that. There were call to actions in 2018 also looking at again gun violence research, looking at shareholder stakeholder issues for violence prevention and ensuring that we have adequate data to understand what's happening with research issues in the United States for gun violence. Also looking at what the House of Delegate resolutions have done as mentioned previously supporting public statements for gun violence representing a public health crisis and again supporting that physicians be part of the state committees. So I think it's important to realize that our Academy has been involved in looking at this public health issue and supporting other organizations in trying to ensure public safety and safe use registration and knowledge about firearms and prevention of firearm injuries. And I appreciate being able to speak today and I'll turn it back over to Dr. Ofejiga. All right on to our panel discussion. Question number one, do physiatrists have an ethical responsibility to talk to patients who own firearms about owning them? So I'm going to lead off with this one and say yes. So I live in the great state of Texas where you can carry concealed weapons, you can carry weapons into a grocery store, people have gun racks on the backs of their trucks, a lot of people are armed here. Therefore when a person sustains a stroke or traumatic brain injury, something where they have some type of cognitive impairment, I specifically talk to the patients, their caregivers, and their families about firearms. It's extremely important because there's an increased risk of accidental injuries in this population as well as if the guns aren't appropriately locked away and cared for pre-injury, no one's going to know that post-injury. So I specifically request that the caregivers and other family members find the guns, lock up the guns, and have discussions about whether it's a good idea to keep guns in the house for people who have cognitive disorders after any kind of injury, not just a fire related injury, but any kind of central nervous system injury. Dr. Glassman, you had a little bit of commentary on this as well? So yes, so this question also brings to mind the case in Florida of the Firearm Owners Privacy Act. So if you remember back in around 2009-2010, there was a case in Florida where a pediatrician asked one of their patients if they owned any firearms in the house because they had little kids that they were taking care of, and the the parent was very offended that the physician would ask about gun ownership. Eventually a law got passed in the state of Florida that said that doctors could not ask patients about gun ownership, and if they did, they could lose their license, be fined, and go to jail. It was known as the Docs versus Glocks case that took about six or seven years until 2017 to finally be ruled in favor of the physicians, saying it's a First Amendment privilege and right to be able to ask about firearm ownership of your patients. So the courts decided that yes, we as physicians not only have a freedom of speech reason for it, but also ethically for protecting the kids who may not know what their parents have, we need to talk about it. Okay, so I think you asked me about how patients and physicians can use their experiences to work together to change policy. It's important to be able to understand that the storytelling is important for legislators, for representatives, for getting public information out there. So as a physician, if you have a patient that you can work with together, you try to, you know, meet with your legislative and elected officials. Talk about the impact of what this firearm violence has led to. Potentially reach out to some of the newspapers, reach out to some of the national public radio broadcasters in your state, and be able to talk about, again, the public health issue and policy issues, and not bringing sort of a political focus on it by any means, but just a patient safety focus. I think physicians are able to be very helpful to patients like Mr. Williams, who have an important story to tell, and the public probably wants to hear about that story, for sure. Thank you. Thank you, I appreciate it. Great question. Um, and kind of just to touch on what Dr. Glassman just mentioned, um, we don't necessarily want the doctors to speak to government officials for us. We want to speak ourselves. At least in my case, I know that's the, that's what it is, because, you know, Dr. Castillo, he's an expert in gun violence, I feel like, and he can go to these government officials and he can tell them plenty of stats, uh, quantitatively, but where's that qualitative side? You know, you got to make sure you're touching on that qualitative side and telling these government officials why these injuries are happening instead of just what's happening, because you can make a story, looking at numbers, you can make your own story. People do it all the time, but when you bring patients in and talk to these government officials themselves, we can go a little bit deeper into their story, into their story, you know, kind of like this presentation, you know, of course, Dr. Castillo could have just got on here and he could have talked about me, but it wouldn't have been, it's not the same as me getting on here and telling my story. And so, yes, that's what I find. What about difficulties coordinating care between multiple providers? So Dr. Castillo and Mr. Williams, looking forward to your touching on this topic. So I'm going to, thank you, I'm going to let Terrell talk the first part because he obviously experienced, we both together experienced the challenges of insurance denying things and because of the challenges we have to control costs and also the time that we keep the patients here, I want Terrell to tell me what you experienced as far as getting your DME coverage and all that at the time of the injury when you were here at Frayser. I appreciate that. Thank you for letting me go first. So challenges that I faced with coverage of care and DME, I've definitely had some challenges that I face and still to this day face as far as getting my durable medical equipment. One that I think about specifically is like catheters. And like, you know, with this injury, like the worst part of it for me was, you know, using the DME, you know, the catheters or the bowel programs and things like that, like that's the worst part in my mind. When the insurance, they don't want to work with you and don't want to give you the equipment that makes it easier, makes your quality of life better. Like so, for example, a closed system catheter makes life so much easier, ten times easier. But with insurance and certain policies, they say, for example, you can't get this certain type of thing, this certain type of system unless you've had proof of using that or something like that. And so it's like you're telling me that I have to I have to have problems in order to live a better life. And so it's just it doesn't make sense. And it is quite it bothers me, to be honest. But like, you know, with the help of, you know, Dr. Castillo and your team, like I said, provide that outstanding medical equipment. So I need samples in the meantime. Like that definitely is a help, but not everybody has access to that. You know what I'm saying? And so it definitely can be troublesome. And as far as coordinating, you get and as far as like coordinating with multiple providers, it's different, too, because it's like you got to talk to every doctor for something that get done. For one thing to get done, you got to talk to all three doctors. And it's like, I shouldn't have to do all this. It takes too much time and it's just it puts that quality of life lower than what it should be, I think. So to add to that, one of the things in particular spinal cord injury and we try to educate is that we pretend that after such an injuries, we ask the patient go home with this much paperwork and call your doctors, get the DMEs, get insurance. So we notice in my career, I've been doing this 10 years, is that when we have a person like a navigator that we have here, it makes things easier for the patients and less cost. And this is something that we've been many hospitals been trying to implement because of the cost. Some hospitals don't want to put navigators in this role, but it's actually a smart move for patients with disabilities because we start the process from acute care through all the continuum of care, rehab and outpatient. And like Mr. Williams said, the our web, he keeps we keep in our web to make sure he gets what he needs. It's a challenge. It's exhausting, but it's safe. It saves time and money. And also, obviously, the patient's satisfaction is higher. Thank you both. And our final question, should physiatrists be involved in the continuum of care for firearm injury patients? Starting when the patient is admitted into the ED. So I'm going to ask for Dr. Chang and Dr. Glassman to please chime in on this topic. Sure, that's definitely a very important question. You know, even though we're not like surgeons, we are best prepared in terms of taking care of patients from anywhere from the acute setting to consequently with. We're having a few audio difficulties, Dr. Chang. I'll turn it over to Dr. Glassman quickly. Sure. So I think that obviously these firearm victims are going to come through the emergency room trauma service. So making sure that you're aligned with the trauma service, understanding that being involved early with these cases for the survivors, you'll be able to address things much sooner than some of the other providers. They're worried about the literal stability and survival of that patient in the short term. But we may also be able to bring in some ideas about where do they go after the acute care hospital stay? What are they going to need as far as long term follow up? So it really is sort of a natural fit for our specialty to be involved for treating these patients from the acute care emergency room all the way through to outpatient and beyond. Thanks so much. That is the end of our session. Thank you so much for attending. We greatly appreciate your feedback. Please email the Health Policy Legislation Committee if you have any questions, comments through FIS form or directly and enjoy the AAPMNR 2020. Thanks so much.

Advocating for Rehabilitation Care of Firearm-Related Injuries

firearm injuries

patient experiences

policy discussions

physiatrists

coordinated care

durable medical equipment

emergency room admission

public health impact