Unregulated gun access and its drain on medical resources

On September 17, 2013, I joined the growing  ranks of physicians who  have gotten  a message they hoped  never  to  receive: “There has been a mass shooting in the area.  Prepare to receive casualties.”

That morning, a  gunman was indiscriminately mowing down people at the US Navy Yard.  Within an hour my hospital had geared up to provide both medical and supportive care, answer calls from those seeking to know the identity of victims, and coordinate other services with the rest of the hospitals in the city. In the end, we provided care to only one bereaved family and treated a few minor injuries. Still, the experience drove home the point that  medical services are essential to the sense of justice and safety of an entire community. Knowing that  physicians and hospitals are there for emergencies contributes immeasurably to the well-being of a community as a whole.

Although on September 17, I was proud that no survivor who came to my hospital would  have been turned away, on September 18, it was back to business as usual. In the ordinary course of events, medical care in the US is distributed too much based upon what people can afford rather than upon what they or the community actually need. In an emergency, people are treated without regard to their resources, but as soon as the dust settles, only those who have been accepted into the tent of the insured have their needs recognized. Others are left literally out in the cold, or driven into bankruptcy and abject poverty, merely from the misfortune of being ill or injured. The process of healing social rifts, from the effects of atrocity to the more subtle corrosion of poverty and chronic disease, requires the availability of medical care to all.

The days following the shooting drove home other lessons. As more information about the gunman emerged, we learned that he had a history not just of mental illness, and violence, but of prior gun violence. He had  apparently recently rented an assault weapon and may have tried to buy a handgun. In the end, he passed a federal background check and lawfully purchased a shotgun.  Perhaps because he did not have an assault rifle, the death toll was much less than it might have been. But my religious tradition teaches us that whoever saves single life,  it is as if he had saved a whole world. The twelve victims and the gunman himself  were  each a world lost, lost in a sea of inadequate gun regulations, NRA obstructionism, and a society that puts the right to have a weapon before almost any other right of citizenship.

As a physician, and particularly as a psychiatrist, I am also acutely aware that the tragedy of mass shootings is overshadowed by the daily tragedies of  gun murders, accidental and suicidal gunshot wounds and deaths. As a political activist I am continually amazed that the issue of controlling health care costs has been ruthlessly divorced from the issue of controlling the violence, especially gun violence, that drives patients to our hospitals, operating rooms, rehabilitation facilities and morgues at rates unheard of in any other civilized society.

Whatever meaning we choose to derive from this terrible event, it is my belief that all physicians have an obligation to use our medical standing  to highlight the tragedy posed by unregulated gun access, and by implication, the drain on medical resources that these completely unnecessary injuries represent.

Julia Frank is a psychiatrist who blogs at Progress Notes.

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  • Mengles

    Another Doctors for America (previously known as Doctors for Obama) shill pushing an agenda rather than based on facts. I’m shocked.

    “it is my belief that all physicians have an obligation to use our medical standing to highlight the tragedy posed by unregulated gun access” — So in other words misuse your standing to push an agenda?

    • John S.

      I don’t know why this doctor even brought Obamacare into this, why she saw this tragedy as an opportunity to do a little cheerleading on the side for Obamacare.

      This guy HAD free government healthcare through the VA. He used that free government healthcare to seek psychiatric help. And what good did it do him; indeed, what good did it do any of us?

      And yet, somehow, the fact that single-payer government healthcare, and the mental health profession, failed him utterly here isn’t to be mentioned… instead the answer to this tragedy is BAN GUNS!

      “Never let a crisis go to waste”, hey?

      • azmd

        Actually, what we know is that he went to a VA complaining of insomnia, but denied other psychiatric symptoms. It’s misleading to say that he had free government healthcare through the VA, if the healthcare available to him was an ER doc, probably one that was too overloaded to carry out the kind of extended interview that could have elicited the fact that the patient was actually psychotic.
        We get what we pay for. If we don’t want to pay for a system where doctors have more than five minutes to see a patient asking for sleep medication, we won’t get the kind of system where the doctors are able to ferret out evidence of a more serious mental illness every time.

  • Ron Smith

    That’s quite a leap from the recount of the events to your ‘clear’ cause of uncontrolled gun access. Obviously you have a personal agenda and nothing really of significance to add to the discussion. It is slovenly in my opinion to use a tragic event that was the failure of psychiatric care rather than guns to purport an erroneous cause and effect.

    Face it. Stuff happens and its because bad people do bad things with things that in and of themselves are not bad, but used in bad ways.

    Ron Smith, MD

  • PoliticallyIncorrectMD

    DC has the strictest gun laws in the country. US Navy Yard is essentially gun free. Yet, the tragedy occurred. In fact, the perpetrator was likely suffering from PSYCHIATRIC DISORDER which was not recognized and treated. Should we stop playing political games and focus on the real issue here. Ironically, the author is the Psychiatrist. Shame on you, Dr. Frank!

  • PoliticallyIncorrectMD

    DC has the strictest gun laws in the country. US Navy Yard is essentially gun free. Yet, the tragedy happened.

  • guest

    I am a psychiatrist as well. There is not much to work with in this so called mental health system we have(or what’s left of it.) Depending on what state you live in, it is extremely difficult to hospitalize anyone. At best he could have received antipsychotics and an outpt followup visit. Not exactly sure that would be sufficient containment for someone as psychotic as this.

    The airport or motels that witnessed his psychotic aggressive behavior could have had police intervention to 5150 but no doubt that would never fly. The laws really air on the side of personal freedom over protection or care for the mentally ill. Even if he was sent to an ER if he calmed down he would likely be released.I don’t think it’s just the psychiatrist’s failure. The laws are set up to have the mentally ill have the right to suffer alone with their illness in the streets. Or in this case he would not have met criteria for a 5150 until he took out his gun and starting shooting. Unfortunately it’s a little late at that point.

  • guest

    I notice the comments are very negative towards this article. it really depends on your experience. i did my internship at a large county hospital in a bad neighborhood as most are. Back then we called it the knife and gun club when these kinds of admissions came in to the ER. It was ugly. I suppose if you see enough of this one is not an advocate of giving guns freely to this population. Depends what you have seen. if you have witnessed people get inadequate care because of insurance or inability to get insurance perhaps you might think differently. or not. It is disturbing to witness.

    • guest

      what’s with the down votes? I am not a political activist. I am just reporting what it was like to work around violence in an ER setting and don’t think it’s wise for this population to have guns. If you disagree speak up?

  • azmd

    Actually, one thing that we do know would save lives would be expanded civil commitment standards, i.e. making it easier to involuntarily hospitalize someone for psychiatric evaluation. A recent study has shown that there is a state-by state correlation between more restrictive commitment standards (harder to commit someone) and higher homicide rates.

    In my state, which has one of the most liberal civil commitment statutes in the country, the patient in question likely would have been brought in by the police to the county psych ER where he would have received a thorough evaluation which would have included contacting friends and family for collateral information as well as ascertaining gun ownership. He would have been offered antipsychotic medication and if he had refused, would possibly have been petitioned for continued inpatient evaluation.

    Our state is able to provide these services because we have a standard for civil commitment which includes “persistently and acutely disabled,” meaning that the patient’s mental illness appears to put him or her at risk for dangerous behavior of some sort. It is a much broader standard than exists in most states, where the patient must be imminently suicidal or homicidal in order to be committed for treatment.

  • guest

    comrade! LOL! Seriously it is a huge relief to chat with someone that sees the nightmare that most folks are unaware of. In what state do you practice?
    For the life of me have no clue why there are down votes. Not sure if they don’t believe it’s happening or they blame psychiatrists which is laughable if that is the case. But it is just a fact.
    When I worked for the county in an entire year I NOT ONCE ever successfully hospitalized any pt I put on a 5150 from outpt. After a year of this where the pt would go to the ER and immediately got discharged, I asked a colleague who worked in the ER. He said that in that ER, unless you threaten to harm others and have a clear plan and means, no one is admitted for SI or Grave disability.
    So like you said IMMINENT is the word. You basically have to have a gun to your head or others. If you are threatening others i guess that means jail and the psychiatrist can see you there.

  • guest

    I said it earlier i think in my post. ‘The knife and gun club” as we affectionately referred to the wounded gang members coming into the ER at the county hospital I did my internship in. That is the “population” i was referring t.

    • Ambulance_Driver

      It is ugly to see that culture indeed.

      Unfortunately, they’re going to get guns no matter how many laws we pass, and if no guns are available, they’ll find other ways to kill each other.

      • guest

        If you drive ambulances I am sure you have seen it all. Really am not making a political statement about gun control. I don’t know what the answer is and don’t pretend to. Just an observation.

  • guest

    I would say there is inadequacy of psychiatric services for most people in this country even those with insurance. Any VA is going to be hard hit with budget cuts. The colleagues i have in psychiatry at the VA have told me that they are spending a lot of energy dealing with PCP issues that have been overlooked because they are so short staffed. They did not feel they could adequately do their job with the lack of resources at the VA.

    • Mengles

      I can’t believe you were given a thumbs down for telling the truth about the VA.

      • guest

        Thanks. In this case I would guess it was more complicated than just VA budget cuts, but it is true what i said.

  • guest

    Hi there back. You had a tough job there. Seriously. I haven’t done ER work for years now. I am in California and I have pretty much decided it is pretty bad here for mental health. It is interesting to compare.

    I had a very psychotic guy who was also abusing drugs. Do not remember details well but felt he was a danger to self as well as GD. Sometimes the feeling you get as to their level of dangerousness as you know interviewing these folks is the most important indicator. In any case he was out every single time. He was noncompliant with meds of course so there was really nothing I could do but watch this horror. I was really afraid he would die.

    Anyone that was GD as you mentioned i would never bother to send to the ER. Clearly they would be sent right back to me. I would call the ER to notify my concerns each time but I was clueless as to why they were let go until I spoke to my colleague that had done your previous job in the ER. I would just find out the next visit they were discharged within an hour.

    It’s interesting pbat. We learned the GD SI HI for 5150. But what I missed as a resident is it really has nothing to do with the laws. It’s all about funding. If there is no money than anyone with GD is let go. And in my county anyone i felt was at risk for SI was let go.

    It would be interesting to compare Psychiatrist’s experiences in all the states. I bet it is very different even though the law is the same in all 50 states. How it is implemented due to poor funding is another story. Great chatting with you. How is Ohio?

  • Vincent C

    What’s the cost from unregulated drug use? Unregulated alcohol use?

  • Tiredoc

    Before 9/11 the largest mass murder is this country was committed with diesel fuel, fertilizer and a rental truck. China’s schizophrenics take after elementary school children with hammers. The preferred method of suicide in Asia is ingestion of pesticide. The murder rate in pre-industrial societies was 50 times that of today, with the most common method being blunt force trauma. It is the height of irrationality to think that banning guns serves any useful purpose whatsoever. The Navy Yard shooter used a pump-action shotgun that he could have legally purchased in Soviet era Russia.

    Guns are the penultimate defensive weapon. A 6 year old with a 22 can defend themselves successfully against an NFL linebacker. As long as humans come in a wide variety of sizes and capacity for violence guns will be made and used.

    In Papua New Guinea, basically no guns are imported for the civilian population. The gangsters there make quite functional guns in third world conditions with no formal training. Steel is cheap. Black powder is easy to make. Rimfire cartridges are not complicated. The basic technology predates the heliocentric model of the solar system. You’d have more luck banning the sofa.

    • guest

      And loving it as Get Smart would say. That is so true and seems to be missed by the media and average person.

  • guest

    yes that is the problem. if you implement gun control the more organized types of paranoid mentally ill can read the internet on how to make a bomb. Like the joker i colorado was it. A bright neuroscience grad student. Some of these folks are determined and crafty. it would actually probably help if the media did not glorify these mass murderer types as it just inspires copy cats.

  • guest

    But i wonder how he got and continued to maintain security clearance even during all those psychotic episodes in his motel and at the airport is a mystery.

    As you know, a psychiatric diagnosis as well as really any medical diagnosis is sorted out over time. Sometimes it is history that comes more from observation from others than from an initial psychiatric exam that solidifies the diagnosis.

    The way the laws are now none of this information could be pieced together. Even though I am sure that a lot of people were afraid of this guy including his coworkers. His right to be crazy overshadowed I am sure many peoples fears of him.

    There are not good laws protecting someone that feels threatened by a mentally ill paranoid person. Whether that be a spouse or coworker or passenger flying an airplane. If the person makes a direct threat to harm they can be taken to prison. But most paranoid aggressive psychotic folks don’t verbally tell you verbally that they are going to harm you. After all, they are paranoid. This has been a problem for a very long time and is still NOT getting addressed. Even with all this madness going on.

  • guest

    Comrade you took the words out of my mouth! For a split second I thought i wrote that post. It is just a fact. I wish i could say that we were exaggerating but it’s just not so.
    For those non psychiatrists. little known fact. They are now closing residency programs as well where both the mentally ill are treated as well as psychiatrists are trained. Why is this bad? Well for example the last fatality around here was Cedar Sinai. So now no training program NOR place to send any psych patients. I think in all of LA there are 2 hospitals that take psychiatric admissions. Don’t quote me but there is a severe shortage. Has anyone noticed over the past many years that there are more mentally ill homeless on the streets? Unlikely they will harm you but these people are really suffering.

  • guest

    good point. the other issue NOT getting discussed are laws that protect the mentally ill person from getting help. It is very hard to actually commit someone for necessary treatment. The odds are they will get discharged before they are ready. in part the law is there for budgetary reasons.

  • NormRx

    Unregulated gun access and its drain on medical resources

    Guns are the most regulated item in America. There are over 2,000 federal, state, and local laws regulating guns. Guns are more highly regulated than drugs. Prescription drugs kill over 30,000 people a year. Maybe it is time to regulate doctors. Oh I forgot, Obamacare will take care of that.

  • Joe Williams

    Figured I would add my support here as well.
    I don’t know how comfortable anyone would be if you had us (psychiatrists) putting people on a list of people who shouldn’t have guns from an outpatient environment, though we probably should have the capability if you really wanted a system that could prevent gun access. Heck hospitals already have a tough enough time wanting to report any and everyone who gets admitted to the psych ward (I base this comment on conversations had with multiple people at my hospital).
    These days it is always about getting rid of guns and not nearly enough about addressing or even understanding the mental health treatment challenges.
    And to the author, Virginia tech still outranks the massacre done in my town in terms of people killed. Virginia Tech was done with pistols.
    (yes I’m a gun guy)
    These are tragedies of the wrong people having gun access, not the specific guns they had access to.

  • Matthew House

    Something everyone seems to forget when they say ‘we need another law’.

    The government had two separate chances -that we know of- to make this guy a felon, and bar him from legally owning a firearm.

    they pled him out both times.

    You can’t say ‘we need another law’, if the people enforcing the laws REFUSE TO USE THE ONES WE ALREADY HAVE.

    • EE Smith

      The government had yet another chance to have stopped him: They could have vetted his application for a security clearance more thoroughly. If he hadn’t lied on his application, or if they had caught his lies on his application, he never would have been given a security clearance, he never wouldn’t have gotten that job, and he never would have been allowed into the Navy Yard.

      “Defense officials have acknowledged that a lot of red flags were missed in Alexis’ background, allowing him to maintain a secret-level security clearance and have access to a secure Navy facility despite a string of behavioral problems and brushes with the law.”

      I am very worried about the apparently lousy job our government is doing vetting people for security clearances. And if they’re doing that bad of a job doing background checks on people applying for military security clearances, I’m pretty sure they wouldn’t be doing any better vetting civilians for firearms licenses.

  • guest

    Saying “access to jobs” and “fathers restored to the head of the household” is redundant.

    The overwhelming reason that fathers lose their position as “head of the household” is that they lose their ability to support the family financially.

    It just follows logically that very, very few mothers/wives who are supporting their husbands financially are going to acquiesce to the husband continuing to make the major decisions for the family.
    That would not be rational.

  • ED52

    Dealing with mental health issues is too politically incorrect for the liberals. It involves making value judgments, recognizing and defining an objective “normal”, and disapproval of individual actions. It also involves placing restrictions on behavior and forcing medications upon individuals.
    For some set of illogical reasons it seems it is preferable to place
    restrictions on society as a whole rather than on individuals.

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