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WASHINGTON -- Working to understand and address the root causes of gun violence while also making firearm ownership as safe as possible will go a long way toward solving the problem of gun violence, Ronald Stewart, MD, said here Thursday at a briefing sponsored by the American College of Surgeons.

"Firearm ownership is a constitutionally protected liberty -- it is. We also, though, have an epidemic of violence and firearm-related injury, death, and disability in the United States," said Stewart, chair of the department of surgery at the University of Texas Health Science Center in San Antonio. "2020 was the year that firearm-related injury became the number one cause of death in U.S. children and adolescents ... [And] the deaths are just the tip of the iceberg."

Stewart and his colleagues treated four of the victims from the May 24 shooting at Robb Elementary School in Uvalde, Texas. "All of our current patients are improving, which really brings us joy in this dark time," he said. "But all of them have a long road to deal with recovery from both the physical and emotional impact of their injuries. And unfortunately, this moment of crisis will have a lifetime of impact on these innocent souls."

Eileen Bulger, MD, medical director of ACS Trauma Programs and chief of the trauma, burns, and critical care division at the University of Washington, reviewed a for reducing firearm injury, death, and disability. The list was developed in 2018 by the ACS Firearms Strategy Task Force (FAST). Recommendations included:

Barring firearm sale or transfer to dangerous persons. "Those who are a danger to themselves or others should not be allowed to purchase or receive a firearm as a gift or transfer from another person," Bulger said. The ACS "supports a robust and accurate background check for all purchases and all transfers of firearms," she noted. Firearms should be transferred with registration, in accordance with federal law, she added. "This will include the private sale and transfer of property that is bequeathed from an estate among family members." FAST also recommends developing an electronic database for all registered firearms. In addition, "mandatory reporting to and by law enforcement and medical personnel for those that are threatening themselves or others should be standard practice," she said.

Regulating heavy-duty firearms. Certain classes of weapons with significant offensive capability already are "appropriately restricted and regulated under the National Firearms Act as Class 3 weapons," Bulger said. "These include things like fully automatic machine guns, explosive devices, and short-barreled shotguns. We recommend a formal reassessment of the firearms designated within each of these National Firearm Act classifications. For instance, high-capacity, magazine-fed semi-automatic rifles such as the AR 15 should be considered for reclassification."

Increasing firearm safety training. "Firearm ownership and use comes with significant responsibility, which requires the understanding and safe handling and care of firearms," she said. "We endorse formal firearm safety training for all new gun owners, and hunter safety and safe gun handling education, and recommend appropriate adult supervision for all of those under the age of 18."

Holding gun owners responsible for harm. "Owners who do not provide reasonably safe firearm storage should be held responsible for adverse events related to the discharge of their firearms," said Bulger. "This includes the use of a stolen firearm, unless it has been timely reported to law enforcement."

Making firearms safer through technology. "There's an opportunity to make firearm ownership safer through the use of innovative technology, such as we have done with automobile safety," she said. "We encourage the development of firearm technology that would significantly reduce the risk of self harm, prevent unintentional discharge, and prevent unintended use by someone other than the registered firearm owner."

Increasing gun violence research. "We recommend that research for firearm injury and firearm injury prevention be federally funded at a level commensurate with the burden of disease, without restriction," said Bulger. "Such research [should] be conducted in a nonpartisan manner. The research agenda should broadly address firearm safety, including safe storage and safe use, the root causes of violence, violence intervention strategies, and improving the treatment of patients injured from firearms."

Improving coverage of gun violence. "The same principle of freedom with responsibility applies to the way mass killings are communicated to the public," she said. "We have concerns that the manner and tone in which information is released to the public may lead to copycat mass killers ... Public professionals, law enforcement, and the press should continue to take steps to eliminate the notoriety of the shooter and be mindful of the impact their coverage has."

Increasing recognition of mental health issues. "We encourage recognition of mental health warning signs and [of] social isolation by teachers, counselors, peers and parents and, when these warning signs are identified, immediate referral to appropriate medical health professionals," said Bulger. When a person is showing signs of violent ideation, thoughts or action, "peers, teachers and family members should be encouraged to 'See something, say something' and report to appropriate local and national law enforcement."

Firearm violence has a profound impact on surgeons, noted Patrick Bailey, MD, JD, medical director for advocacy at ACS and a clinical professor of surgery at the Uniformed Services University for the Health Sciences in Bethesda, Maryland. "I, like my other colleagues that are here today, have too often witnessed the impact of firearm violence."

As a gun owner himself, Bailey added, "I do not believe that the steps recommended by the ACS FAST workgroup pose an undue burden on the rights of individual gun owners. As a pediatric surgeon, it is my sincerest hope that Congress will come together in a bipartisan fashion to examine the recommendations made by the ACS and enact substantive legislation directed at mitigating firearm violence in this country."

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