July 21, 2023 • 38 mins
Gun violence takes a massive toll on the US healthcare system and medical professionals. To discuss how, hosts Kelly and JJ were joined by Dr. Christine Petrin and Dr. Babak Sarani, who shed light on this pressing issue. Together, we delve into the emotional and physical ramifications, illustrating the stark reality through a heartbreaking story of a patient who suffered gunshot wounds on multiple occasions.
We also underline the cruciality of discussing safe gun storage and usage, proving that advocating for gun control isn't the only answer. Shifting the narrative, Dr. Petrin and Dr. Sarani open up about their journey to create a firearm curriculum for medical professionals, and how important it is for health care providers and patients to be able to speak about firearms and firearm safety.
Further reading:
Gun Violence Prevention strives to create a safer and healthier community by reducing the incidence of gun violence and its impact on individuals, families, and society as a whole. (Doctors for America)
Stop filling our Trauma Centers with your thoughts and prayers. (#ThisIsOurLane)
#ThisIsOurLane — Firearm Safety as Health Care’s Highway (the New England Journal of Medicine)
This Is Our Lane: Mobilizing the Medical Community (Brady)
Doctors and hospitals can help prevent gun deaths. (Association of American Medical Colleges)
How Doctors Suffer from America's Gun Violence Problem (Time)
For more information on Brady, follow us on social media @Bradybuzz or visit our website at bradyunited.org.
Full transcripts and bibliographies of this episode are available at bradyunited.org/podcast.
National Suicide Prevention Lifeline: 1-800-273-8255.
In a crisis? Text HOME to 741741 to connect with a Crisis Counselor 24/7.
Music provided by: David “Drumcrazie” Curby
Special thanks to Hogan Lovells for their long-standing legal support
℗&©2019 Red, Blue, and Brady
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:08):
This is the legal disclaimer, where I tell you
that the views, thoughts andopinions shared on this podcast
belong solely to our guests andhosts, and not necessarily Brady
or Brady's affiliates.
Please note this podcastcontains discussions of violence
that some people may finddisturbing.
It's okay, we find itdisturbing.
Hey everybody, welcome back toanother episode of Red, Blue and
(00:45):
Brady.
I'm one of your hosts, JJ, andI'm your other host, Kelly.
And today, kelly and I have thehonor of sitting down with two
doctors.
You've got Dr Christine Petronand Dr Babak Sarani, both of
whom are sitting down with us totalk about all the different
ways that folks working inhealthcare can be joining in for
the fight against gun violence.
Speaker 2 (01:05):
Yeah, and this is a great episode if you're a
medical professional, it's alsoa great episode if you're not a
medical professional, becausehearing from doctors who are on
the immediate response tosomeone who has suffered from a
gunshot wound and also along thejourney of healing, really
shows us the toll of gunviolence, not just in the
(01:25):
immediate moments but in theyears to come, both on the
people who are shot and also onthe medical professionals who
care for them.
Speaker 3 (01:36):
So I'm Christine Petron.
I'm a third-year resident atGeorgetown.
I'm doing a combined residencyin internal medicine and
pediatrics, so I see both adultsand kids and I got interested
in gun violence preventionreally by seeing the difference
in how these two professions arehandling it.
On the pediatrics side, I feellike we do a pretty good job of
screening other guns in the home.
(01:56):
We put that in the bucket ofall of our other safety
questions Are you wearing yourhelmet?
Are you wearing your sunscreen?
It's a normal part of ourinterview process and on the
internal medicine side it'sreally just not a part of the
adult visit.
At least as part of my trainingso far, and seeing that
discrepancy and trying tograpple with the news I'm seeing
when I come home at night andwhat can I do to help fix
(02:18):
everything that's going on inthe world and address gun
violence in a clinical settingthat's one reason I got more
involved in this advocacyPhenomenal.
Speaker 2 (02:26):
And Dr Therani.
What about you?
Speaker 4 (02:28):
So my name is Bob Ack Therani.
I am the chief of traumasurgery at George Washington
University Hospital.
I'm a professor in theDepartment of Surgery and also
in the Department of EmergencyMedicine, and a couple other
hats that I wear with pride isI'm the past chair of the Brady
United Against Gun ViolenceRegional Leadership Council for
Washington DC, which iswonderful, and I am the current
(02:50):
chair of the American College ofSurgeons Committee on Trauma
for Washington DC.
That's the committee that kindof oversees trauma care for the
nation, and I representWashington DC on the committee.
So kind of honored to havethose hats to wear.
I've been doing trauma surgerysince about 2005.
And really throughout my career, even during my training, I've
(03:10):
just seen tremendous number ofgunshot wounds, and the irony is
I feel substantially morecomfortable taking care of a
gunshot wound than, say, ahemorrhoid, because I just see
more of them.
Speaker 1 (03:20):
And we're going to have to unpack all of that.
But we were so thankful thatboth of you were able to come on
and speak with us today andthat you're doing work in this
area, particularly the advocacyfocused work, because, as we're
going to talk about, this is ahuge burden that's being placed
on the healthcare system and onour healthcare workers right
Because of gun violence, and Iwonder, can we unpack even that
(03:41):
a little bit?
Because certainly I wouldassume that a hernia might be a
little bit less mentally oremotionally taxing, right when
you go home at night, as opposedto say, you know a pediatric
gunshot wound, or am I wrong?
Are people haunted by thehernias of past, of yesteryear?
Speaker 4 (03:57):
Yeah, I mean, look, what you're saying is exactly
right.
The hernias, even if they'reemergency cases, will come to
the hospital.
By and large we can fix them.
By and large they go home andthankfully all as well.
The experience for the patientis relatively short-lived, maybe
stressful, but they all getover it.
And cost to care for them maybea little bit high initially
because you have to go to theoperating room and stuff like
(04:17):
that, but again it's ashort-lived kind of thing.
On Saturday I think of this pastweek you're not going to phone
call from the in-house traumasurgeon.
We have a 20-some-odd-year-oldgentleman gunshot wound to the
abdomen.
He has a spinal cordtransaction.
He'll be paralyzed for the restof his life, and so the surgeon
was you know, appropriately so,I think concerned the
(04:38):
individual.
The surgeon was taking multipleother traumas and now is handed
this person who's in extremis.
You know the person goes to theoperating room but comes in
unable to walk, will be unableto walk and the cost of that
outside of his own mentalwell-being, which is a big, big,
big, big big deal that nobodytalks about for the rest of his
life, just the physical costalone of the wheelchair and then
(05:00):
the source that he's apt to geton his bottom because he can no
longer feel anything.
You know, his life expectancyhas been shortened by decades
and it's that simple, you know,I kind of tell people when you
look at Christopher Reeve, whowas the actor who played
Superman so he was a multi,multi, multi-millionaire.
He fell off a horse, broke hisneck and was paralyzed.
(05:21):
He ultimately died.
Most people don't know whatSuperman died of.
Superman died of a soreness,bottom and pneumonia.
So if you're amulti-hundred-millionaire and
you can't afford to have someonetake that meticulous care of
you, what do you expect peoplewho are shot in the inner city
of America to do?
Right?
And so this young gentleman,his destiny is sealed.
(05:43):
There's nothing we can do forthat.
And so, whether you look at itin the short term, which is the
on-call surgeon, taking allthese incoming injured and
having to sort through them all,and now you hand the individual
, this particular very, veryseverely injured person, or you
look at it in the long term, theprimary care physician, who has
to deal with all theramifications for the rest of
the patient's life, it's just, Idon't know.
(06:04):
I'll tell you, man, it's tragic, pathetic, sad.
Speaker 3 (06:09):
I don't know what the adjunct is I think to, in
addition to the, the mentalhealth burden for the patient
who's experience gun violence,the number of my patients who
have a loved one who's been avictim of gun violence, and just
the I mean the completelydifferent trajectory their life
takes after that moment.
I've had patients in the I?
C?
U coming in in complete liverfailure because they started
drinking or using drugs in thesetting of losing a child, both
(06:30):
a young child or even a grownchild, and their lives are never
the same.
Speaker 2 (06:34):
it this isn't just one person who gets shot, it's
an entire community of peoplewho are unable to recover after
an event like that I thinksomething that's coming out from
both of you shared is so oftenwe just look at death, but it's
whether you survive and, as yousaid, this person is now going
to be susceptible to Source thatcould kill him or family
(06:55):
members.
Gun violence has such a bigtoll and, dr serrani, last year
you had a story game attentionin washington post and it was
about a patient of yours whohave been shot For separate
times and the last time resultedin him dying.
I'm just wondering if you telllisteners a little bit about
that story and do you often seesort of repeat patients who come
(07:17):
in and they've been shot andthen they're shot again?
Speaker 4 (07:20):
Yeah, so he's, you know he's.
He was in washington post, itwas also in all the local news,
so you have to search to hard tofind him.
He's a.
He was, I think, a wonderfulkid.
He arrived to us the first timehe was shot.
I want to say was, roughlyspeaking, sixteen years old when
he first was shot I may be offby here and his initial wounding
he was shot in the chest andthe bullet across his lung, his
(07:41):
left lung, his heart, hisdiaphragm, his liver, his
stomach and I think, isintestine.
And on arrival he cardiacarrest three separate times,
three separate times.
His heart fully stop and weopen his chest.
We identified the hole in theheart.
We were able to show that shot.
We were giving him bloodtransfusion and because he's
such a young kid, he was able tocome back as I started beating
(08:04):
again and then he was reallyunstable and so we're wondering
like, why is he so unstable?
So we open up the abdomen tofind that was bleeding
aggressively from his liver.
So we started fixing the liver.
Then we looked around.
We saw there's a hole in thestomachs.
We fixed the stomach and Ithink I'm pretty sure there was
a hole in the intestine we fixedas well.
By some miracle of god honesty,he survived.
And he survived to become to betotally normal.
(08:24):
No, like strokes, known braininjury, nothing, despite his
heart stopping three times.
And I remember I would speak tohim.
His father was always here.
I would speak to him and hisfather and I said to him you
know his name was quarry.
I would say, look, quarry you.
Whatever led to this event.
You can't get shot again.
And the reason is, you know,I've operated on your chest and
(08:44):
I've operated on your belly andnobody can get into your body
again as fast as I did not.
I can't do it either, by theway, it's not that I'm magical,
it's just that the scars you seeon the outside, you know have
scars on the inside and thesurgeon won't be able to operate
as quickly as I did.
So you gotta be careful, man.
You get shot again like that,you're gonna die.
And the conversations he and Ihad, both in the hospital as
(09:06):
well as in my office, when youwould come for his post
operative visits, what coriwould do is cry.
I mean, he would cry a river.
I'm talking tears coming out ofthese young kids eyes.
I would hit the ground and is apicture of the two of us on the
internet when he came to ourtrauma survivors day and I
introduced him and I offered himto come up and say a few words
(09:26):
and he was so distraught heactually could speak.
He was.
He was so distraught withcrying, couldn't speak as I
didn't know what to do and Ididn't want to be embarrassed in
front of everybody.
So I just want to hug them.
I mean I like what else yougonna do to sixteen year old kid
who's completely lost controlof his emotions?
As a picture of us hugging andI kind of felt for the, for the
poor guy did.
And you know, as time went by, Ithink I think you can talk
(09:48):
about from the primary carephysician's perspective.
He and I caught a lost touchbecause I'm a surgeon and we
were done.
You know I was still in oursystem, still recovering and
stuff.
I wanna spoke to our injuryprevention people.
All the trauma centers in thecountry have a dedicated injury
prevention program.
You have to have one In orderto be a trauma center.
I and I'm with all do you knowI'm a little biased, I get it,
(10:09):
but I think ours is fantasticand so I want to them and I said
to them you know, look, youguys, I, you guys do great work
every day.
I just appreciate everythingyou do so much.
What can you do me a huge favor, please?
Cori is a sixteen year old whowas severely injured and his
family home situation is notideal.
I can tell you that he's atextreme risk for injury.
Can we just bring him into thefold a little bit more than we
(10:30):
do others and just put somespecial attention on this kid?
And they did.
They went.
They went and spoke to my greatlengths.
They found out that he had somefamily in philadelphia.
They found out that he was kindof hanging out with not not the
right crowd, perhaps here in dc, and they tried to facilitate a
move from dc to philly.
But cori said no, and I can.
I can see that from hisperspective.
(10:51):
I'm not blaming him.
He's a teenager, he's in highschool.
And I telling him why don't youget up and leave and go to some
other you know city with no?
After, after you've been shotand everything else to yeah so
he said no, and I kinda, youknow, fell apart.
And so then last next I heardof him was in coven, and I
remember this very well cuz hecame to my office out of the
blue I'm with both wearing masksand I can't see.
(11:14):
You know what, what brings youhere?
And his hand was completelymangled and I was like what
happened to you?
And he goes.
I got shot again and he hadsutures in his hand that had
been removed his bones andhealed correctly.
His fingers were crooked.
I was a cori, what, what?
What happened, man?
So I called our hands surgeonhere and I said, you know, his
name is a doctor, sam, up todairy.
And I said, look, sam, I needyou just to me a solid favor.
(11:37):
You know, this kid doesn't haveinsurance, he doesn't have good
follow up just to see him inyour office and he just needs
help.
And sam was like, yeah,absolutely, I, no problem, and I
know that sam's office try toget a hold of cori.
But the phone would just ringand ring and nobody ever picked
up.
So he never followed up.
And then I heard that that wasthe second or third time he been
shot.
And then I heard he got shotone more time and the fourth
time I heard someone called meand said hey, he never came back
(12:00):
to do again for shooting.
See must gone either tohospital center or to howard I
don't know where, what they callme and said hey, your patient
from you know how many years agocori was just killed and I just
that just killed me because Iwas so predictable and it was so
like you know, when you knowsomething bad is going to happen
, you think you have theopportunity to prevent that bad
(12:20):
thing from happening, like yousee it coming.
But time and time again wetried and it just failed.
Now that's the bad news.
There's no superlative todescribe what that is.
That is insufficient.
The good news, if there'sanything to be had, is,
strangely enough, in theDistrict of Columbia we're a
little bit of an outlier and theDistrict we don't see recurrent
(12:40):
gunshot wounds.
Commonly, the vast majority ofpeople that we see who were shot
are shot de novo, and there'san article that actually we just
finished writing as aconsortium Us, the doctors at
hospital center, doctors over atChildren's National as well as
Howard University Hospital, soall the trauma centers got
together and we shared our data,which is not easy, by the way.
(13:02):
When you want to share data likethat, the lawyers tend to get
involved very quickly.
They become very difficult andhospitals in general don't
really like to share data right,everyone's always afraid of
getting sued.
But we somehow convinced thelawyers to let us share data,
and by share data I mean likename and date of birth.
So we were able to then trackand I'll just use my own name.
We were able to track, you know, bob Axarani, november 13, 1971
(13:25):
, was injured and went to thishospital, and then we tracked by
name and date of birth everyother admission that Bob Axarani
had over the next 10 years.
And so if the Corey Rigginsepisode occurred, where he came
to me first and then went to,let's say, medstar or Howard.
Second, we knew that we startedoff in Children's Hospital
because a lot of kids get shotand we wanted to track them from
(13:48):
when the kids are shot to andthey transition from children to
adults.
So we knew that too, and wewere expecting a very, very high
recurrent injury rate.
We were expecting a recurrentinjury rate somewhere in the
order of 20 to 40 percent.
We actually found six, sixpercent.
Speaker 1 (14:01):
Can I, can you offer a second?
Why were you expecting the rateto be so high?
Speaker 4 (14:05):
Because, historically , when you look at like
Philadelphia and you look atChicago, those are the numbers
that they found that if you'vebeen shot once, one in five of
you will be shot again.
That's about 20 percent.
And so what led to this projectin the first place is I got my
first job in Philadelphia and sowhen I came to DC I would tell
people, when you get a gunshotvictim, make sure you ask them
(14:25):
if they've been shot before.
And the reason you have to askthem that is they may have
bullets inside them.
And when we get X-rays we needto know what bullets are old and
what bullets are new.
We don't know what to do, butover the course of the last 10
years that have been DC, I kindof kept saying have you been
shot before?
And they'd be like no, and Iwould get X-rays and there was
no bullets and I was like thisis really strange.
This is so not likePhiladelphia.
And so we decided to study itand come to find out.
(14:48):
Dc is different.
Now, why it's different?
I don't know.
Some people would say maybe theinjury prevention arm in DC is
better funded, and it is.
I'm not saying it's funded tothe point where I would want it
to be funded, but it's betterfunded than perhaps other
centers.
I think it's because DC is sosmall and it's just easier to do
stuff when you're a small youknow a little boat, than when
you're an aircraft carrier likePhiladelphia.
(15:09):
I don't know why DC isdifferent, but what I can tell
you is the recurrent injury ratein DC is small.
Having said that, the number ofgunshots is, as you know,
increasing significantly, and soI think we've stumbled upon
something.
This is something we're kind ofnoodling on a little bit
ourselves, like all my authorsand I of.
I think we've identified a wayto identify the next people who
(15:30):
are going to get shot beforethey're actually shot.
I think I can't prove this.
I think if you know someonewho's been shot, odds are
someone in their geospatialnetwork, whether it's their
friends or just theirneighborhood or their colleagues
in school.
They're the vulnerable cohort,because what you find is the
(15:52):
gunshots are occurring kind ofin that same area, even if it's
not Bob Ack getting shot again,it's Bob Ack's friend, bob Ack's
classmates, bob Ack's family,whatever.
So maybe what we should do isincrease, widen the penumbra for
injury prevention.
Right now, injury prevention isif I get shot, I get resources,
(16:12):
but if I don't get shot, I don'tget resources.
And I wonder if we should sayBob Ack got shot, all of his
people are going to getresources to try to prevent the
next shooting.
That's what I'm noodling on.
But that's like I said, that'sa theory I'm not interested in.
You want to talk about it froma primary care, like when I'm
done with a patient and then youget to see the person in your
clinic for the rest of his orher life and your career.
(16:34):
How do you guys deal with it?
Speaker 3 (16:36):
It's very similar to what you were describing before
A lot of sacral wounds, a lot ofwound care and making sure that
they're there.
Luckily, at Georgetown we haveaccess to that, but I'm sure
there's plenty of places in thecountry that don't have wound
care centers available.
A lot of risk for infection.
Like I said, I think the mentalhealth, the mental health
pieces is critical.
I think that one other thingthat we don't talk a lot about
(16:57):
is we're talking a lot aboutsort of when people think about
shootings.
I think about school shootingsand gang violence and community
violence, like you're talkingabout, but over half of gun
violence is suicide.
In 2020, I think it wassomething like 54% of firearm
deaths were from suicide, andthat number only climbed during
the pandemic.
A teen kills themselves in thiscountry every seven hours, and
I think this is something thatwe see across medical specialty
(17:20):
right.
So whether you're in clinic,you're in the emergency
department, you're gettingadmitted to the hospital for
suicidal ideation or attempts,even OBGYNs dealing with
prepartum or postpartumdepression everyone needs to
make sure that when we're doingour depression screening and our
counseling, that we'rescreening to see if the access
of guns in the home, becausethose numbers are really just
staggering.
Speaker 1 (17:40):
When we're doing and we'll get into the nitty gritty
of some of the screenings lateron, which I think is really
important.
But for folks who maybe haven'tbeen to the doctor, haven't
been in a while, when we'redoing those pre screenings, are
there questions for other thingsthat may cause harm to an
individual that comes up?
Is it you know?
Would you like a quite kind ofthe firearm part of the
screening, for the same as whenthey're asking you know if you
(18:01):
do any substances, if you smoke,you know how much do you drink?
That sort of thing.
Speaker 3 (18:06):
Absolutely, and this is why it's so important to wrap
it into this bucket of justyour regular safety questions.
These are just mynon-judgmental, routine run of
the mill questions about safetyAre you wearing your helmet?
Are you wearing your sunscreen?
Do you have a smoke detector athome?
For my older patients I askabout you know, are you having
safe sex?
Are you?
I do my intimate partnerviolence screening for people as
(18:29):
well.
It's all just sort of routinequestions and this needs to be
something that we routinely askour patients and kind of just
put it into that bucket ofthings that we are ready to ask.
Speaker 2 (18:39):
And it just to kind of make sure I understand you
were saying that right now onthe whole tends to be in the
pediatric space the gun violencescreeners are part of it but
not in the adult space, andthat's something that you're
trying to to to advocate for inthe adult space as well.
Speaker 3 (18:58):
Yes, exactly, and I think, too I, as wonderful as it
is, and on the pediatric sidewe ask the question I think
there's still a lot of lack oftraining and knowledge and
confidence and actuallycounseling on.
You know, when a patient says,well, yes, we do have a gun at
home, I know when I firststarted I would sort of say,
okay, great, and you'reeverything safe there, right,
(19:18):
great, and move on.
I had no idea what language touse or how to ask them questions
, how to make sure that, like,they were practicing safe
storage, and so I think there'sthere's room for improvement on
both ends.
And you know the other piecethat I think is really important
when I started residency onlythree years ago, the lead and
cause of death in children wascar accidents, as we all know.
Now that's not the case.
(19:39):
It's gun deaths.
It's wild that I have come toresidency to learn how to study
and treat and improve the healthof children and adults.
Here I am.
It's not the respiratoryillnesses, it's not the
pediatric cancers or any of theother things, that I'm sitting
here spending four years in mylife learning to treat it's
bullets, and it's something thatcan't not be part of my
(20:01):
practice anymore.
Speaker 2 (20:03):
If I know.
Some people listening to thismight be thinking well, I don't
want you all to have my guns,they're sacred to me, or maybe I
shouldn't have one, but I haveone anyway.
I'm wondering if I'm a patientand I come in and you're asking
me the screeners, and you say,do you have a gun at home?
And I say yes, what does thatconversation look like?
(20:24):
And is it confidential?
I assume it is, but just whatactually would happen next?
Speaker 3 (20:32):
I can try to answer this first, dr Sarani, and then
pass it over to you, but we knowthat patients want to have
these conversations.
There's data on this.
We know that the majority ofpatients, including those who
own firearms, believe it'swithin the role of a physician
to counsel on firearm safety.
As long as it's doneappropriately and you're right
these conversations can go verywell.
They can go very badly.
(20:52):
That's something that Dr Saraniand I have worked on to think
about how we can teach traineesand other providers how to
counsel in a way that'snon-judgmental and
non-stigmatizing.
I've had patient interactionsstart to go poorly.
I've had patients say why areyou bringing up something
political?
I don't want to talk about this, but 100 percent of the time
when I bring it back to theissue of safety, we get back on
(21:15):
track.
The patient engages in theconversation.
I have never lost a patientfrom having this conversation.
They always come back.
Speaker 4 (21:22):
Yeah, I think it comes down to no one's saying
get ready a gun, just for therecord.
You can have whatever gun typeyou like, whether it's a handgun
, shotgun or I'll even dare sayan assault weapon.
You can buy that legally.
And that it is what it is, myfriend.
The point is to store it safely, store it responsibly and make
(21:42):
sure that those who should nothave access to it don't have
access to it.
That's the message.
Once you say that, I've got acouple of friends who are very
much so gun owners.
We talk about guns and we haveyet to get into a tussle Because
I quickly tell them look youguys, I'm not talking about
getting rid of guns.
That's not going to happen.
So let's just talk about safegun storage and safe use of guns
(22:05):
.
I think most patients are goingto be okay with that If they
have a trusted relationship witha physician.
I'm not sure I wouldnecessarily open up on the first
encounter with that, but onceyou establish a relationship
then it's weird.
In America we can talk about,to Christine's point, your
sexual practice and your smokingand everything else, but
somehow this is the topic that'sgoing to be personally
(22:27):
insulting.
You're kind of as a physician,you kind of have to set it up
and know how to approach that,like you would any other private
topic.
Speaker 1 (22:34):
I wonder if you could share with some folks how you
developed the resources thathave been put together.
So maybe help if there'sphysicians or other health care
workers listening to this,because I know a lot of times
maybe folks don't see thatthey're primary care physician,
they're seeing a nursepractitioner or they're seeing
somebody at maybe like a medclinic really quickly.
So do you see a difference, onein that breakdown, because
(22:58):
depending on who people aretalking to and then what are
some of the resources to maybetrain folks on how to have these
conversations.
Speaker 4 (23:05):
So I'll start because I kind of began the process,
but really Christine is the onewho's taken it, so she gets 99%
of the credit.
But one of the things that Inoticed was, to your point,
there was no curriculum in anyof the medical schools in DC.
Dc has a lot of medical schools.
Nobody was teaching how to evenspeak about guns like the
(23:26):
verbiage, and that was my ownshortcoming as well.
Here I am Chief of Trauma,doing all this stuff for decade
plus, and every time the topicof guns comes up, even I start
kind of hemming and hawing andstuttering, and it was very
awkward and so I thought, okay,well, if I'm not going to be
able to do it, then surelyothers aren't either.
Now I think to Christine'spoint, there's a yearning desire
for this, and so what I simplydid is called a bunch of my
(23:49):
colleagues across the othertrauma centers and the medical
schools in the district and Iwas like look, we should
probably put together some sortof a curriculum, and I bet you
the surgeons will say, yes,that's kind of easy, because I'm
a surgeon, I kind of knoweverybody face to face.
But I bet you, like in myhospital, I know the internal
medicine doctors, and I bet youthe surgeons at Washington
Hospital Center know theirinternal medicine doctors, and I
(24:10):
bet you the surgeons atChildren know their
pediatricians.
So I bet you we can kind of puttogether a critical mass of
people who are interested.
That's exactly what happenedJust a couple of phone calls,
literally, and the ball startedrolling.
And then the question was allright, well, at least people
interested.
Now what do we do?
And so for that I leaned onBrady United, because I was the
chair of the leadership council,and so I turned to the Brady
(24:32):
folks and I was like look, youguys know how to, how to message
this, but what you don't knowis how to message us to
physicians.
I know what, I know what I wantto say, I just don't know how
to say it.
Can we all come together?
And so we crafted a number ofscenarios that we then
videotaped.
(24:53):
The budget for this, by the way, is zero.
This is Bobak, one of hisinjury prevention coordinators
His name is Alistair and Brady,with a video camera.
Speaker 1 (25:02):
I will say Bobak Alistair Brady productions,
though sounds very legit.
It sounds like a very goodstudio, if I could make a
million bucks and have aninfinity pool.
Speaker 4 (25:10):
guys, I'm in, I'm not holding my breath.
And so we made these videos.
But then we hit a little bit ofa hurdle, and this is where
Christine comes in.
Is OK, we got all these videosand now we want to insert them
into the medical curricula.
But guess what?
The medical curricula is reallyfull of medicine.
So what are you not going toteach in order to teach this?
That was difficult, and that'skind of where we are.
(25:31):
So, christine, you want to takeit from there.
Sure.
Speaker 3 (25:33):
So we developed, with the videos, developed a full
lecture, so there's about a45-minute or so presentation
that's supposed to beinteractive and lead for
discussion.
We reflect on the videostogether and there's even some
role playing where you pretendto be a patient and a provider,
kind of having this type ofdiscussion.
But you're right, and in factthe first time I tried to even
(25:54):
work this into what we call amorning report or sort of like a
very basic lecture for ourinternal medicine residents, I
got a little pushback, it was alittle hard to kind of get it in
and then, once I did it, it wasso well received that I've now
been asked to give it as grandrounds for the entire internal
medicine department atGeorgetown as well as at
Virginia Hospital Center, whichI'm actually doing tomorrow.
So very well received once it'sactually done.
(26:16):
But you're right, it's a littleoutside of the realm of maybe
sort of your normal medicalcurriculum.
And the thing I start with whenI introduce this lecture is that
my goal is not to turn everyoneinto a gun safety expert, like.
The laundry list of things thatevery physician needs to
counsel on is just way too long.
It grows longer by the day.
I don't want to add to that orburden the clinicians
(26:40):
inappropriately.
So my goals really are let'sintroduce some quick tips, some
quick tricks on how to have somehelpful key phrases to bring up
this issue with your patients,just to get the conversation
going.
Give you some basic languagearound safe storage, because,
frankly, before I started doingthis, I had no idea what the
difference was between a triggerlock and a cable lock and I
would never have been able tocounsel patients on those.
(27:02):
So it's sort of let's just giveyou a couple of quick
definitions and then, mostimportantly, let's point you to
the experts.
Let's show you who to go to,who are your trusted resources,
who can you count on when youdon't really know what you're
supposed to say?
But you've got a patient infront of you who you think could
benefit from having thisdiscussion, and the website that
I typically point everyone tois nfamilyfireorg.
Great list of brochures onthere that we can print out and
(27:24):
give our patients right there inthe exam room, as well as some
of the videos that Dr Serani hadfilmed, as well as others
discussion guides on how to dothis, state by state legislation
, so that you feel unsure ofwhat exactly the rules are in
your state, you can go and check, and that's sort of the
catch-all resource that I giveto everyone of.
Hey, listen, I don't need youto be an expert in this.
(27:46):
This is who the expert is.
If you have a question, go tothem and they can help.
Speaker 1 (27:50):
I wonder if we could talk about kind of where this
work goes next.
So you have the resourcesavailable, obviously, it seems
like especially Dr Petrin isthere going to be a Worldwide
Speaking Tour on training folkshow to do this?
But where do you see this going?
And then what sort of nextsteps?
Too, would you like to see DC,but then also other cities
(28:12):
across the US, roll out to maybehelp, kind of as we've
articulated deal with a problemthat just seems to be increasing
, unfortunately.
Speaker 3 (28:19):
I'd actually say I would hope for the opposite of a
speaking tour.
I would hope that thiscurriculum can really just go to
different residency programs,hospitals, clinics it doesn't
necessarily need to be trainingprograms and have them be able
to give it themselves, likehopefully there is some advocate
, some person who's alsocommitted to this work, whether
it's in South Dakota or in Maineor in New Mexico, and it's not
(28:41):
just me trying to run around DCand give this lecture over and
over again.
I'm hoping that people kind oftake it on and present it to
their own institutions and thenright now, as we've mentioned,
really a primary care focus onit.
So far, definitely a lot ofengagement from internal
medicine, from pediatrics, fromsurgery, but I would love to see
this be used by psychiatry, byOBGYN, by emergency medicine.
(29:05):
I feel like this should be apart of every clinician's
curriculum, no matter wherethey're practicing or what
setting they're practicing in,and that would be my hope.
Speaker 4 (29:16):
Yeah, I really agree with that.
We've made a key point thatthis is not proprietary.
We're not going to put itbehind some firewall.
I know that the trauma groupover at Harvard in Boston are
also doing something extremelysimilar.
They're a little bit ahead ofus and so theirs is a bit more
sophisticated, with simulatedpatient encounters and
videotapes that they then playback and debrief dedicated time
(29:39):
for the residents.
So I think as our program grows, hopefully we can kind of do
something along the same linesas what they're doing.
But I think importantly, I'mreally hoping that via Brady and
as well as via the own academicmedical school societies, that
our curriculum will kind of justexpand to other medical schools
(29:59):
that haven't even started this.
Speaker 2 (30:01):
And I just had a follow up from my own
understanding, to be honest.
So I heard you say right now,the way you've been rolling this
out is in sort of the morningreport or morning what was that
yeah morning report grand roundskind of these big academic
terms for essentially a lecture.
Okay.
So if you are like a nurse,practitioner or something in
(30:21):
that setting in the future, whenhopefully this is sort of
rolled out to everyone, like howwould that be disseminated to
those other fields?
Would it just be in like theclassroom level, like in the
academic part of their studies,or something else?
Speaker 3 (30:35):
I think it would start similar to how this has
started.
Is that you find one advocate,one person either?
In an NP program and a PAprogram, who it takes this on as
something they're reallypassionate about and they
introduce it into theircurriculum and it hopefully just
grows from there.
Speaker 1 (30:48):
Because I'm picturing folks who are not.
Maybe if you're in a rural areawhere you might be a doctor at
a very small practice or a nurseat a very small practice, not
connected maybe with a bighospital nearby, these things
are still available to youonline.
So it's all there present, soyou can start your own little
wave of it going in your areaand, I'm guessing, kind of
(31:08):
tailor it as well to the folksthat you're seeing and the gun,
the firearms and the firearminjuries that you're seeing.
Speaker 4 (31:15):
That's exactly right Because remember what Christine
mentioned early on in thepodcast, which is currently
still the majority slightmajority, but majority of gun
related deaths are suicides andwhat you just said is the kind
of the cohort that it's at riskfor suicide.
It's the rural.
The classics person at risk forsuicide by gunshot is going to
(31:35):
be rural America, typicallyolder male, caucasian.
That's kind of the basicdemographic, not to say that
they're the only people, butthat's the majority of them.
And so if someone is a ruralpractitioner then they really
need to gear their conversationmore toward safe gun storage,
access, depression, things thatlead to suicide by handgun, as
(31:58):
opposed to urban, where themajority of the gun related
deaths are homicide, and that'sa whole different conversation
to be had.
So the idea is to create thisvarious tools that the
physicians can use and thenadjust them to their own patient
population.
In DC last I checked with themedical examiner's office of all
gunshot related deaths, about93 to 95 percent are homicide,
(32:22):
about five to seven percent aresuicide, and that's because we
are an urban center.
That would not be true if Iwent to some very rural area,
say in West Virginia orsomething like that.
Speaker 1 (32:32):
One of the things that I think is so interesting,
just about kind of what we knowabout firearms in general, is
that we are talking a lot aboutlike death data, and but we also
know that there's so much goinginto.
You know we've many, many morepeople are shot in the US than
are killed by firearm every year, and so we have that on top of
it too, that like the, thatinjury data of how many people
(32:53):
in the US are shot every day orwho are living with long term
gun injuries.
Or I think, dr Petron, as youpointed out, are, you know,
dealing with the ripple effectsof long term gun injuries.
Maybe they have a sibling who'sbeen shot and who is now having
to deal with a lifelongdisability because of it.
Speaker 3 (33:07):
So that's going to change the whole family dynamic
and finances and whole dominostarts and part of our part of
our survey data on thecurriculum we do.
We do a pre survey and one ofthe questions we ask is have you
ever treated a patient who'sbeen a victim of gun violence
and 100 percent of respondentssay yes.
I've never seen 100 percent ofa room full of doctors say agree
(33:27):
to anything other than thisquestion.
So it's.
It's something that everysingle person, whether they're
right at the beginning of theircareer or they are a seasoned,
attending, and they've beendoing this for decades.
It comes across everyone'sdoorstep eventually.
Speaker 2 (33:39):
And one of the things I would love if if you haven't
already been able to address ityou talked about.
For one example, the majorityof gun deaths are suicides.
I'm wondering is there anythingelse that people tend to
misunderstand about firearms orfirearm injuries in the US that
you've seen from your experiencepracticing?
Speaker 4 (33:59):
Well, I mean, look, the, the, the headline you don't
have to look too far to find is, you know, especially with mass
shootings, the assailant iscrazy and if we just kind of had
some better mental health,clearly none of this would
happen.
That is 100 percent factuallyincorrect.
The, the, the assailants, arenot crazy in the sense of, you
(34:19):
know, diagnosed psychiatricdisorders.
They do not have bipolardisease, they are not
schizophrenic, they are notmanic, any of the common
diagnoses that one kind ofthinks about when you talk about
mental health.
These people just don't have it, and that's one.
Secondly, the people who dohave, who do carry mental health
diagnoses, are actually far,far more at risk of being
(34:41):
victims of gun violence thanperpetrators of gun violence.
And these people, unfortunately, have been really mislabeled
that it is almost their fault.
That is not true, that is justnot true.
And I can say this with such asuch oomph because, guess what,
many of the people who are theassailants are my patients,
because in new turn they will beshot.
(35:01):
And I can tell you they're notschizophrenic, they're not
bipolar, they're not you knowanything.
I think this comes down to avariety of, depending on what
instance we're talking aboutmass shootings, urban related
attempted murder or ruralsuicide.
There are different reasons whythese things happen, but to put
(35:22):
them under one umbrella ofmental health is wrong.
And it really gets to access.
It really gets to knowing whomight have had, might have been
appropriate to have access, butnow is no longer appropriate,
and you know red flag laws orpolos, things like that.
That is a far, far moreeffective approach than just to
say, well Jesus, if we just hadmore psychiatrists, clearly this
(35:44):
wouldn't happen.
That is not true.
Speaker 2 (35:46):
Yeah, and that misperception that mental
illness is related to somethinglike dangerousness, when in
reality it makes people morelikely to be victims of gun
violence, is something that weconfront on this podcast all the
time, and there's a lot ofnuances to it and a lot to dig
into, to tease out thoserelationships, and so if people
(36:09):
want to learn more about that,where can they find you?
So yeah.
Speaker 3 (36:11):
So, like I said, med Peds at Georgetown and that's
where a lot of this is beingruled out right now.
I always point other providersto endfamilyfireorg for
different resources.
As far as our curriculum andour videos, we are working on
getting those put up into apublicly accessible sort of
repository with other resourcesso that people can download
those and start using them.
Speaker 4 (36:32):
Not quite ready just yet, so endfamilyfireorg is the
main plug that I'm yeah, I thinkI would echo that until we get
all of our videos up to someform of a public domain we're
talking about what type of setupthat will be.
I was I'm leaning on Brady tokind of help me with something
that is accessible to allnationwide and worldwide, but
we're not quite there yet.
But stay tuned.
(36:52):
I would certainly hope thatwe'll be there in the next six
months or so.
Speaker 1 (36:55):
Well, we will definitely keep an eye out for
that, because it looks like it'sgoing to be amazing.
So thank you all so much.
Hey want to share with thepodcast.
Listeners can now get in touchwith us here at Red, blue and
Brady via phone or text message.
Simply call or text us at480-744-3452 with your thoughts.
(37:15):
Questions concerns ideas, catpictures, whatever.
Speaker 2 (37:19):
Thanks for listening.
As always, brady's lifesavingwork in Congress, the courts and
communities across the countryis made possible thanks to you.
For more information on Bradyor how to get involved in the
fight against gun violence,please like and subscribe to the
podcast.
Get in touch with us atBradyUnitedorg or on social at
Brady Buzz.
Be brave and remember.
(37:40):
Take action, not size.
This is the legal disclaimer, where I tell you
that the views, thoughts andopinions shared on this podcast
belong solely to our guests andhosts, and not necessarily Brady
or Brady's affiliates.
Please note this podcastcontains discussions of violence
that some people may finddisturbing.
It's okay, we find itdisturbing.
Hey everybody, welcome back toanother episode of Red, Blue and
(00:45):
Brady.
I'm one of your hosts, JJ, andI'm your other host, Kelly.
And today, kelly and I have thehonor of sitting down with two
doctors.
You've got Dr Christine Petronand Dr Babak Sarani, both of
whom are sitting down with us totalk about all the different
ways that folks working inhealthcare can be joining in for
the fight against gun violence.
Speaker 2 (01:05):
Yeah, and this is a great episode if you're a
medical professional, it's alsoa great episode if you're not a
medical professional, becausehearing from doctors who are on
the immediate response tosomeone who has suffered from a
gunshot wound and also along thejourney of healing, really
shows us the toll of gunviolence, not just in the
(01:25):
immediate moments but in theyears to come, both on the
people who are shot and also onthe medical professionals who
care for them.
Speaker 3 (01:36):
So I'm Christine Petron.
I'm a third-year resident atGeorgetown.
I'm doing a combined residencyin internal medicine and
pediatrics, so I see both adultsand kids and I got interested
in gun violence preventionreally by seeing the difference
in how these two professions arehandling it.
On the pediatrics side, I feellike we do a pretty good job of
screening other guns in the home.
(01:56):
We put that in the bucket ofall of our other safety
questions Are you wearing yourhelmet?
Are you wearing your sunscreen?
It's a normal part of ourinterview process and on the
internal medicine side it'sreally just not a part of the
adult visit.
At least as part of my trainingso far, and seeing that
discrepancy and trying tograpple with the news I'm seeing
when I come home at night andwhat can I do to help fix
(02:18):
everything that's going on inthe world and address gun
violence in a clinical settingthat's one reason I got more
involved in this advocacyPhenomenal.
Speaker 2 (02:26):
And Dr Therani.
What about you?
Speaker 4 (02:28):
So my name is Bob Ack Therani.
I am the chief of traumasurgery at George Washington
University Hospital.
I'm a professor in theDepartment of Surgery and also
in the Department of EmergencyMedicine, and a couple other
hats that I wear with pride isI'm the past chair of the Brady
United Against Gun ViolenceRegional Leadership Council for
Washington DC, which iswonderful, and I am the current
(02:50):
chair of the American College ofSurgeons Committee on Trauma
for Washington DC.
That's the committee that kindof oversees trauma care for the
nation, and I representWashington DC on the committee.
So kind of honored to havethose hats to wear.
I've been doing trauma surgerysince about 2005.
And really throughout my career, even during my training, I've
(03:10):
just seen tremendous number ofgunshot wounds, and the irony is
I feel substantially morecomfortable taking care of a
gunshot wound than, say, ahemorrhoid, because I just see
more of them.
Speaker 1 (03:20):
And we're going to have to unpack all of that.
But we were so thankful thatboth of you were able to come on
and speak with us today andthat you're doing work in this
area, particularly the advocacyfocused work, because, as we're
going to talk about, this is ahuge burden that's being placed
on the healthcare system and onour healthcare workers right
Because of gun violence, and Iwonder, can we unpack even that
(03:41):
a little bit?
Because certainly I wouldassume that a hernia might be a
little bit less mentally oremotionally taxing, right when
you go home at night, as opposedto say, you know a pediatric
gunshot wound, or am I wrong?
Are people haunted by thehernias of past, of yesteryear?
Speaker 4 (03:57):
Yeah, I mean, look, what you're saying is exactly
right.
The hernias, even if they'reemergency cases, will come to
the hospital.
By and large we can fix them.
By and large they go home andthankfully all as well.
The experience for the patientis relatively short-lived, maybe
stressful, but they all getover it.
And cost to care for them maybea little bit high initially
because you have to go to theoperating room and stuff like
(04:17):
that, but again it's ashort-lived kind of thing.
On Saturday I think of this pastweek you're not going to phone
call from the in-house traumasurgeon.
We have a 20-some-odd-year-oldgentleman gunshot wound to the
abdomen.
He has a spinal cordtransaction.
He'll be paralyzed for the restof his life, and so the surgeon
was you know, appropriately so,I think concerned the
(04:38):
individual.
The surgeon was taking multipleother traumas and now is handed
this person who's in extremis.
You know the person goes to theoperating room but comes in
unable to walk, will be unableto walk and the cost of that
outside of his own mentalwell-being, which is a big, big,
big, big big deal that nobodytalks about for the rest of his
life, just the physical costalone of the wheelchair and then
(05:00):
the source that he's apt to geton his bottom because he can no
longer feel anything.
You know, his life expectancyhas been shortened by decades
and it's that simple, you know,I kind of tell people when you
look at Christopher Reeve, whowas the actor who played
Superman so he was a multi,multi, multi-millionaire.
He fell off a horse, broke hisneck and was paralyzed.
(05:21):
He ultimately died.
Most people don't know whatSuperman died of.
Superman died of a soreness,bottom and pneumonia.
So if you're amulti-hundred-millionaire and
you can't afford to have someonetake that meticulous care of
you, what do you expect peoplewho are shot in the inner city
of America to do?
Right?
And so this young gentleman,his destiny is sealed.
(05:43):
There's nothing we can do forthat.
And so, whether you look at itin the short term, which is the
on-call surgeon, taking allthese incoming injured and
having to sort through them all,and now you hand the individual
, this particular very, veryseverely injured person, or you
look at it in the long term, theprimary care physician, who has
to deal with all theramifications for the rest of
the patient's life, it's just, Idon't know.
(06:04):
I'll tell you, man, it's tragic, pathetic, sad.
Speaker 3 (06:09):
I don't know what the adjunct is I think to, in
addition to the, the mentalhealth burden for the patient
who's experience gun violence,the number of my patients who
have a loved one who's been avictim of gun violence, and just
the I mean the completelydifferent trajectory their life
takes after that moment.
I've had patients in the I?
C?
U coming in in complete liverfailure because they started
drinking or using drugs in thesetting of losing a child, both
(06:30):
a young child or even a grownchild, and their lives are never
the same.
Speaker 2 (06:34):
it this isn't just one person who gets shot, it's
an entire community of peoplewho are unable to recover after
an event like that I thinksomething that's coming out from
both of you shared is so oftenwe just look at death, but it's
whether you survive and, as yousaid, this person is now going
to be susceptible to Source thatcould kill him or family
(06:55):
members.
Gun violence has such a bigtoll and, dr serrani, last year
you had a story game attentionin washington post and it was
about a patient of yours whohave been shot For separate
times and the last time resultedin him dying.
I'm just wondering if you telllisteners a little bit about
that story and do you often seesort of repeat patients who come
(07:17):
in and they've been shot andthen they're shot again?
Speaker 4 (07:20):
Yeah, so he's, you know he's.
He was in washington post, itwas also in all the local news,
so you have to search to hard tofind him.
He's a.
He was, I think, a wonderfulkid.
He arrived to us the first timehe was shot.
I want to say was, roughlyspeaking, sixteen years old when
he first was shot I may be offby here and his initial wounding
he was shot in the chest andthe bullet across his lung, his
(07:41):
left lung, his heart, hisdiaphragm, his liver, his
stomach and I think, isintestine.
And on arrival he cardiacarrest three separate times,
three separate times.
His heart fully stop and weopen his chest.
We identified the hole in theheart.
We were able to show that shot.
We were giving him bloodtransfusion and because he's
such a young kid, he was able tocome back as I started beating
(08:04):
again and then he was reallyunstable and so we're wondering
like, why is he so unstable?
So we open up the abdomen tofind that was bleeding
aggressively from his liver.
So we started fixing the liver.
Then we looked around.
We saw there's a hole in thestomachs.
We fixed the stomach and Ithink I'm pretty sure there was
a hole in the intestine we fixedas well.
By some miracle of god honesty,he survived.
And he survived to become to betotally normal.
(08:24):
No, like strokes, known braininjury, nothing, despite his
heart stopping three times.
And I remember I would speak tohim.
His father was always here.
I would speak to him and hisfather and I said to him you
know his name was quarry.
I would say, look, quarry you.
Whatever led to this event.
You can't get shot again.
And the reason is, you know,I've operated on your chest and
(08:44):
I've operated on your belly andnobody can get into your body
again as fast as I did not.
I can't do it either, by theway, it's not that I'm magical,
it's just that the scars you seeon the outside, you know have
scars on the inside and thesurgeon won't be able to operate
as quickly as I did.
So you gotta be careful, man.
You get shot again like that,you're gonna die.
And the conversations he and Ihad, both in the hospital as
(09:06):
well as in my office, when youwould come for his post
operative visits, what coriwould do is cry.
I mean, he would cry a river.
I'm talking tears coming out ofthese young kids eyes.
I would hit the ground and is apicture of the two of us on the
internet when he came to ourtrauma survivors day and I
introduced him and I offered himto come up and say a few words
(09:26):
and he was so distraught heactually could speak.
He was.
He was so distraught withcrying, couldn't speak as I
didn't know what to do and Ididn't want to be embarrassed in
front of everybody.
So I just want to hug them.
I mean I like what else yougonna do to sixteen year old kid
who's completely lost controlof his emotions?
As a picture of us hugging andI kind of felt for the, for the
poor guy did.
And you know, as time went by, Ithink I think you can talk
(09:48):
about from the primary carephysician's perspective.
He and I caught a lost touchbecause I'm a surgeon and we
were done.
You know I was still in oursystem, still recovering and
stuff.
I wanna spoke to our injuryprevention people.
All the trauma centers in thecountry have a dedicated injury
prevention program.
You have to have one In orderto be a trauma center.
I and I'm with all do you knowI'm a little biased, I get it,
(10:09):
but I think ours is fantasticand so I want to them and I said
to them you know, look, youguys, I, you guys do great work
every day.
I just appreciate everythingyou do so much.
What can you do me a huge favor, please?
Cori is a sixteen year old whowas severely injured and his
family home situation is notideal.
I can tell you that he's atextreme risk for injury.
Can we just bring him into thefold a little bit more than we
(10:30):
do others and just put somespecial attention on this kid?
And they did.
They went.
They went and spoke to my greatlengths.
They found out that he had somefamily in philadelphia.
They found out that he was kindof hanging out with not not the
right crowd, perhaps here in dc, and they tried to facilitate a
move from dc to philly.
But cori said no, and I can.
I can see that from hisperspective.
(10:51):
I'm not blaming him.
He's a teenager, he's in highschool.
And I telling him why don't youget up and leave and go to some
other you know city with no?
After, after you've been shotand everything else to yeah so
he said no, and I kinda, youknow, fell apart.
And so then last next I heardof him was in coven, and I
remember this very well cuz hecame to my office out of the
blue I'm with both wearing masksand I can't see.
(11:14):
You know what, what brings youhere?
And his hand was completelymangled and I was like what
happened to you?
And he goes.
I got shot again and he hadsutures in his hand that had
been removed his bones andhealed correctly.
His fingers were crooked.
I was a cori, what, what?
What happened, man?
So I called our hands surgeonhere and I said, you know, his
name is a doctor, sam, up todairy.
And I said, look, sam, I needyou just to me a solid favor.
(11:37):
You know, this kid doesn't haveinsurance, he doesn't have good
follow up just to see him inyour office and he just needs
help.
And sam was like, yeah,absolutely, I, no problem, and I
know that sam's office try toget a hold of cori.
But the phone would just ringand ring and nobody ever picked
up.
So he never followed up.
And then I heard that that wasthe second or third time he been
shot.
And then I heard he got shotone more time and the fourth
time I heard someone called meand said hey, he never came back
(12:00):
to do again for shooting.
See must gone either tohospital center or to howard I
don't know where, what they callme and said hey, your patient
from you know how many years agocori was just killed and I just
that just killed me because Iwas so predictable and it was so
like you know, when you knowsomething bad is going to happen
, you think you have theopportunity to prevent that bad
(12:20):
thing from happening, like yousee it coming.
But time and time again wetried and it just failed.
Now that's the bad news.
There's no superlative todescribe what that is.
That is insufficient.
The good news, if there'sanything to be had, is,
strangely enough, in theDistrict of Columbia we're a
little bit of an outlier and theDistrict we don't see recurrent
(12:40):
gunshot wounds.
Commonly, the vast majority ofpeople that we see who were shot
are shot de novo, and there'san article that actually we just
finished writing as aconsortium Us, the doctors at
hospital center, doctors over atChildren's National as well as
Howard University Hospital, soall the trauma centers got
together and we shared our data,which is not easy, by the way.
(13:02):
When you want to share data likethat, the lawyers tend to get
involved very quickly.
They become very difficult andhospitals in general don't
really like to share data right,everyone's always afraid of
getting sued.
But we somehow convinced thelawyers to let us share data,
and by share data I mean likename and date of birth.
So we were able to then trackand I'll just use my own name.
We were able to track, you know, bob Axarani, november 13, 1971
(13:25):
, was injured and went to thishospital, and then we tracked by
name and date of birth everyother admission that Bob Axarani
had over the next 10 years.
And so if the Corey Rigginsepisode occurred, where he came
to me first and then went to,let's say, medstar or Howard.
Second, we knew that we startedoff in Children's Hospital
because a lot of kids get shotand we wanted to track them from
(13:48):
when the kids are shot to andthey transition from children to
adults.
So we knew that too, and wewere expecting a very, very high
recurrent injury rate.
We were expecting a recurrentinjury rate somewhere in the
order of 20 to 40 percent.
We actually found six, sixpercent.
Speaker 1 (14:01):
Can I, can you offer a second?
Why were you expecting the rateto be so high?
Speaker 4 (14:05):
Because, historically , when you look at like
Philadelphia and you look atChicago, those are the numbers
that they found that if you'vebeen shot once, one in five of
you will be shot again.
That's about 20 percent.
And so what led to this projectin the first place is I got my
first job in Philadelphia and sowhen I came to DC I would tell
people, when you get a gunshotvictim, make sure you ask them
(14:25):
if they've been shot before.
And the reason you have to askthem that is they may have
bullets inside them.
And when we get X-rays we needto know what bullets are old and
what bullets are new.
We don't know what to do, butover the course of the last 10
years that have been DC, I kindof kept saying have you been
shot before?
And they'd be like no, and Iwould get X-rays and there was
no bullets and I was like thisis really strange.
This is so not likePhiladelphia.
And so we decided to study itand come to find out.
(14:48):
Dc is different.
Now, why it's different?
I don't know.
Some people would say maybe theinjury prevention arm in DC is
better funded, and it is.
I'm not saying it's funded tothe point where I would want it
to be funded, but it's betterfunded than perhaps other
centers.
I think it's because DC is sosmall and it's just easier to do
stuff when you're a small youknow a little boat, than when
you're an aircraft carrier likePhiladelphia.
(15:09):
I don't know why DC isdifferent, but what I can tell
you is the recurrent injury ratein DC is small.
Having said that, the number ofgunshots is, as you know,
increasing significantly, and soI think we've stumbled upon
something.
This is something we're kind ofnoodling on a little bit
ourselves, like all my authorsand I of.
I think we've identified a wayto identify the next people who
(15:30):
are going to get shot beforethey're actually shot.
I think I can't prove this.
I think if you know someonewho's been shot, odds are
someone in their geospatialnetwork, whether it's their
friends or just theirneighborhood or their colleagues
in school.
They're the vulnerable cohort,because what you find is the
(15:52):
gunshots are occurring kind ofin that same area, even if it's
not Bob Ack getting shot again,it's Bob Ack's friend, bob Ack's
classmates, bob Ack's family,whatever.
So maybe what we should do isincrease, widen the penumbra for
injury prevention.
Right now, injury prevention isif I get shot, I get resources,
(16:12):
but if I don't get shot, I don'tget resources.
And I wonder if we should sayBob Ack got shot, all of his
people are going to getresources to try to prevent the
next shooting.
That's what I'm noodling on.
But that's like I said, that'sa theory I'm not interested in.
You want to talk about it froma primary care, like when I'm
done with a patient and then youget to see the person in your
clinic for the rest of his orher life and your career.
(16:34):
How do you guys deal with it?
Speaker 3 (16:36):
It's very similar to what you were describing before
A lot of sacral wounds, a lot ofwound care and making sure that
they're there.
Luckily, at Georgetown we haveaccess to that, but I'm sure
there's plenty of places in thecountry that don't have wound
care centers available.
A lot of risk for infection.
Like I said, I think the mentalhealth, the mental health
pieces is critical.
I think that one other thingthat we don't talk a lot about
(16:57):
is we're talking a lot aboutsort of when people think about
shootings.
I think about school shootingsand gang violence and community
violence, like you're talkingabout, but over half of gun
violence is suicide.
In 2020, I think it wassomething like 54% of firearm
deaths were from suicide, andthat number only climbed during
the pandemic.
A teen kills themselves in thiscountry every seven hours, and
I think this is something thatwe see across medical specialty
(17:20):
right.
So whether you're in clinic,you're in the emergency
department, you're gettingadmitted to the hospital for
suicidal ideation or attempts,even OBGYNs dealing with
prepartum or postpartumdepression everyone needs to
make sure that when we're doingour depression screening and our
counseling, that we'rescreening to see if the access
of guns in the home, becausethose numbers are really just
staggering.
Speaker 1 (17:40):
When we're doing and we'll get into the nitty gritty
of some of the screenings lateron, which I think is really
important.
But for folks who maybe haven'tbeen to the doctor, haven't
been in a while, when we'redoing those pre screenings, are
there questions for other thingsthat may cause harm to an
individual that comes up?
Is it you know?
Would you like a quite kind ofthe firearm part of the
screening, for the same as whenthey're asking you know if you
(18:01):
do any substances, if you smoke,you know how much do you drink?
That sort of thing.
Speaker 3 (18:06):
Absolutely, and this is why it's so important to wrap
it into this bucket of justyour regular safety questions.
These are just mynon-judgmental, routine run of
the mill questions about safetyAre you wearing your helmet?
Are you wearing your sunscreen?
Do you have a smoke detector athome?
For my older patients I askabout you know, are you having
safe sex?
Are you?
I do my intimate partnerviolence screening for people as
(18:29):
well.
It's all just sort of routinequestions and this needs to be
something that we routinely askour patients and kind of just
put it into that bucket ofthings that we are ready to ask.
Speaker 2 (18:39):
And it just to kind of make sure I understand you
were saying that right now onthe whole tends to be in the
pediatric space the gun violencescreeners are part of it but
not in the adult space, andthat's something that you're
trying to to to advocate for inthe adult space as well.
Speaker 3 (18:58):
Yes, exactly, and I think, too I, as wonderful as it
is, and on the pediatric sidewe ask the question I think
there's still a lot of lack oftraining and knowledge and
confidence and actuallycounseling on.
You know, when a patient says,well, yes, we do have a gun at
home, I know when I firststarted I would sort of say,
okay, great, and you'reeverything safe there, right,
(19:18):
great, and move on.
I had no idea what language touse or how to ask them questions
, how to make sure that, like,they were practicing safe
storage, and so I think there'sthere's room for improvement on
both ends.
And you know the other piecethat I think is really important
when I started residency onlythree years ago, the lead and
cause of death in children wascar accidents, as we all know.
Now that's not the case.
(19:39):
It's gun deaths.
It's wild that I have come toresidency to learn how to study
and treat and improve the healthof children and adults.
Here I am.
It's not the respiratoryillnesses, it's not the
pediatric cancers or any of theother things, that I'm sitting
here spending four years in mylife learning to treat it's
bullets, and it's something thatcan't not be part of my
(20:01):
practice anymore.
Speaker 2 (20:03):
If I know.
Some people listening to thismight be thinking well, I don't
want you all to have my guns,they're sacred to me, or maybe I
shouldn't have one, but I haveone anyway.
I'm wondering if I'm a patientand I come in and you're asking
me the screeners, and you say,do you have a gun at home?
And I say yes, what does thatconversation look like?
(20:24):
And is it confidential?
I assume it is, but just whatactually would happen next?
Speaker 3 (20:32):
I can try to answer this first, dr Sarani, and then
pass it over to you, but we knowthat patients want to have
these conversations.
There's data on this.
We know that the majority ofpatients, including those who
own firearms, believe it'swithin the role of a physician
to counsel on firearm safety.
As long as it's doneappropriately and you're right
these conversations can go verywell.
They can go very badly.
(20:52):
That's something that Dr Saraniand I have worked on to think
about how we can teach traineesand other providers how to
counsel in a way that'snon-judgmental and
non-stigmatizing.
I've had patient interactionsstart to go poorly.
I've had patients say why areyou bringing up something
political?
I don't want to talk about this, but 100 percent of the time
when I bring it back to theissue of safety, we get back on
(21:15):
track.
The patient engages in theconversation.
I have never lost a patientfrom having this conversation.
They always come back.
Speaker 4 (21:22):
Yeah, I think it comes down to no one's saying
get ready a gun, just for therecord.
You can have whatever gun typeyou like, whether it's a handgun
, shotgun or I'll even dare sayan assault weapon.
You can buy that legally.
And that it is what it is, myfriend.
The point is to store it safely, store it responsibly and make
(21:42):
sure that those who should nothave access to it don't have
access to it.
That's the message.
Once you say that, I've got acouple of friends who are very
much so gun owners.
We talk about guns and we haveyet to get into a tussle Because
I quickly tell them look youguys, I'm not talking about
getting rid of guns.
That's not going to happen.
So let's just talk about safegun storage and safe use of guns
(22:05):
.
I think most patients are goingto be okay with that If they
have a trusted relationship witha physician.
I'm not sure I wouldnecessarily open up on the first
encounter with that, but onceyou establish a relationship
then it's weird.
In America we can talk about,to Christine's point, your
sexual practice and your smokingand everything else, but
somehow this is the topic that'sgoing to be personally
(22:27):
insulting.
You're kind of as a physician,you kind of have to set it up
and know how to approach that,like you would any other private
topic.
Speaker 1 (22:34):
I wonder if you could share with some folks how you
developed the resources thathave been put together.
So maybe help if there'sphysicians or other health care
workers listening to this,because I know a lot of times
maybe folks don't see thatthey're primary care physician,
they're seeing a nursepractitioner or they're seeing
somebody at maybe like a medclinic really quickly.
So do you see a difference, onein that breakdown, because
(22:58):
depending on who people aretalking to and then what are
some of the resources to maybetrain folks on how to have these
conversations.
Speaker 4 (23:05):
So I'll start because I kind of began the process,
but really Christine is the onewho's taken it, so she gets 99%
of the credit.
But one of the things that Inoticed was, to your point,
there was no curriculum in anyof the medical schools in DC.
Dc has a lot of medical schools.
Nobody was teaching how to evenspeak about guns like the
(23:26):
verbiage, and that was my ownshortcoming as well.
Here I am Chief of Trauma,doing all this stuff for decade
plus, and every time the topicof guns comes up, even I start
kind of hemming and hawing andstuttering, and it was very
awkward and so I thought, okay,well, if I'm not going to be
able to do it, then surelyothers aren't either.
Now I think to Christine'spoint, there's a yearning desire
for this, and so what I simplydid is called a bunch of my
(23:49):
colleagues across the othertrauma centers and the medical
schools in the district and Iwas like look, we should
probably put together some sortof a curriculum, and I bet you
the surgeons will say, yes,that's kind of easy, because I'm
a surgeon, I kind of knoweverybody face to face.
But I bet you, like in myhospital, I know the internal
medicine doctors, and I bet youthe surgeons at Washington
Hospital Center know theirinternal medicine doctors, and I
(24:10):
bet you the surgeons atChildren know their
pediatricians.
So I bet you we can kind of puttogether a critical mass of
people who are interested.
That's exactly what happenedJust a couple of phone calls,
literally, and the ball startedrolling.
And then the question was allright, well, at least people
interested.
Now what do we do?
And so for that I leaned onBrady United, because I was the
chair of the leadership council,and so I turned to the Brady
(24:32):
folks and I was like look, youguys know how to, how to message
this, but what you don't knowis how to message us to
physicians.
I know what, I know what I wantto say, I just don't know how
to say it.
Can we all come together?
And so we crafted a number ofscenarios that we then
videotaped.
(24:53):
The budget for this, by the way, is zero.
This is Bobak, one of hisinjury prevention coordinators
His name is Alistair and Brady,with a video camera.
Speaker 1 (25:02):
I will say Bobak Alistair Brady productions,
though sounds very legit.
It sounds like a very goodstudio, if I could make a
million bucks and have aninfinity pool.
Speaker 4 (25:10):
guys, I'm in, I'm not holding my breath.
And so we made these videos.
But then we hit a little bit ofa hurdle, and this is where
Christine comes in.
Is OK, we got all these videosand now we want to insert them
into the medical curricula.
But guess what?
The medical curricula is reallyfull of medicine.
So what are you not going toteach in order to teach this?
That was difficult, and that'skind of where we are.
(25:31):
So, christine, you want to takeit from there.
Sure.
Speaker 3 (25:33):
So we developed, with the videos, developed a full
lecture, so there's about a45-minute or so presentation
that's supposed to beinteractive and lead for
discussion.
We reflect on the videostogether and there's even some
role playing where you pretendto be a patient and a provider,
kind of having this type ofdiscussion.
But you're right, and in factthe first time I tried to even
(25:54):
work this into what we call amorning report or sort of like a
very basic lecture for ourinternal medicine residents, I
got a little pushback, it was alittle hard to kind of get it in
and then, once I did it, it wasso well received that I've now
been asked to give it as grandrounds for the entire internal
medicine department atGeorgetown as well as at
Virginia Hospital Center, whichI'm actually doing tomorrow.
So very well received once it'sactually done.
(26:16):
But you're right, it's a littleoutside of the realm of maybe
sort of your normal medicalcurriculum.
And the thing I start with whenI introduce this lecture is that
my goal is not to turn everyoneinto a gun safety expert, like.
The laundry list of things thatevery physician needs to
counsel on is just way too long.
It grows longer by the day.
I don't want to add to that orburden the clinicians
(26:40):
inappropriately.
So my goals really are let'sintroduce some quick tips, some
quick tricks on how to have somehelpful key phrases to bring up
this issue with your patients,just to get the conversation
going.
Give you some basic languagearound safe storage, because,
frankly, before I started doingthis, I had no idea what the
difference was between a triggerlock and a cable lock and I
would never have been able tocounsel patients on those.
(27:02):
So it's sort of let's just giveyou a couple of quick
definitions and then, mostimportantly, let's point you to
the experts.
Let's show you who to go to,who are your trusted resources,
who can you count on when youdon't really know what you're
supposed to say?
But you've got a patient infront of you who you think could
benefit from having thisdiscussion, and the website that
I typically point everyone tois nfamilyfireorg.
Great list of brochures onthere that we can print out and
(27:24):
give our patients right there inthe exam room, as well as some
of the videos that Dr Serani hadfilmed, as well as others
discussion guides on how to dothis, state by state legislation
, so that you feel unsure ofwhat exactly the rules are in
your state, you can go and check, and that's sort of the
catch-all resource that I giveto everyone of.
Hey, listen, I don't need youto be an expert in this.
(27:46):
This is who the expert is.
If you have a question, go tothem and they can help.
Speaker 1 (27:50):
I wonder if we could talk about kind of where this
work goes next.
So you have the resourcesavailable, obviously, it seems
like especially Dr Petrin isthere going to be a Worldwide
Speaking Tour on training folkshow to do this?
But where do you see this going?
And then what sort of nextsteps?
Too, would you like to see DC,but then also other cities
(28:12):
across the US, roll out to maybehelp, kind of as we've
articulated deal with a problemthat just seems to be increasing
, unfortunately.
Speaker 3 (28:19):
I'd actually say I would hope for the opposite of a
speaking tour.
I would hope that thiscurriculum can really just go to
different residency programs,hospitals, clinics it doesn't
necessarily need to be trainingprograms and have them be able
to give it themselves, likehopefully there is some advocate
, some person who's alsocommitted to this work, whether
it's in South Dakota or in Maineor in New Mexico, and it's not
(28:41):
just me trying to run around DCand give this lecture over and
over again.
I'm hoping that people kind oftake it on and present it to
their own institutions and thenright now, as we've mentioned,
really a primary care focus onit.
So far, definitely a lot ofengagement from internal
medicine, from pediatrics, fromsurgery, but I would love to see
this be used by psychiatry, byOBGYN, by emergency medicine.
(29:05):
I feel like this should be apart of every clinician's
curriculum, no matter wherethey're practicing or what
setting they're practicing in,and that would be my hope.
Speaker 4 (29:16):
Yeah, I really agree with that.
We've made a key point thatthis is not proprietary.
We're not going to put itbehind some firewall.
I know that the trauma groupover at Harvard in Boston are
also doing something extremelysimilar.
They're a little bit ahead ofus and so theirs is a bit more
sophisticated, with simulatedpatient encounters and
videotapes that they then playback and debrief dedicated time
(29:39):
for the residents.
So I think as our program grows, hopefully we can kind of do
something along the same linesas what they're doing.
But I think importantly, I'mreally hoping that via Brady and
as well as via the own academicmedical school societies, that
our curriculum will kind of justexpand to other medical schools
(29:59):
that haven't even started this.
Speaker 2 (30:01):
And I just had a follow up from my own
understanding, to be honest.
So I heard you say right now,the way you've been rolling this
out is in sort of the morningreport or morning what was that
yeah morning report grand roundskind of these big academic
terms for essentially a lecture.
Okay.
So if you are like a nurse,practitioner or something in
(30:21):
that setting in the future, whenhopefully this is sort of
rolled out to everyone, like howwould that be disseminated to
those other fields?
Would it just be in like theclassroom level, like in the
academic part of their studies,or something else?
Speaker 3 (30:35):
I think it would start similar to how this has
started.
Is that you find one advocate,one person either?
In an NP program and a PAprogram, who it takes this on as
something they're reallypassionate about and they
introduce it into theircurriculum and it hopefully just
grows from there.
Speaker 1 (30:48):
Because I'm picturing folks who are not.
Maybe if you're in a rural areawhere you might be a doctor at
a very small practice or a nurseat a very small practice, not
connected maybe with a bighospital nearby, these things
are still available to youonline.
So it's all there present, soyou can start your own little
wave of it going in your areaand, I'm guessing, kind of
(31:08):
tailor it as well to the folksthat you're seeing and the gun,
the firearms and the firearminjuries that you're seeing.
Speaker 4 (31:15):
That's exactly right Because remember what Christine
mentioned early on in thepodcast, which is currently
still the majority slightmajority, but majority of gun
related deaths are suicides andwhat you just said is the kind
of the cohort that it's at riskfor suicide.
It's the rural.
The classics person at risk forsuicide by gunshot is going to
(31:35):
be rural America, typicallyolder male, caucasian.
That's kind of the basicdemographic, not to say that
they're the only people, butthat's the majority of them.
And so if someone is a ruralpractitioner then they really
need to gear their conversationmore toward safe gun storage,
access, depression, things thatlead to suicide by handgun, as
(31:58):
opposed to urban, where themajority of the gun related
deaths are homicide, and that'sa whole different conversation
to be had.
So the idea is to create thisvarious tools that the
physicians can use and thenadjust them to their own patient
population.
In DC last I checked with themedical examiner's office of all
gunshot related deaths, about93 to 95 percent are homicide,
(32:22):
about five to seven percent aresuicide, and that's because we
are an urban center.
That would not be true if Iwent to some very rural area,
say in West Virginia orsomething like that.
Speaker 1 (32:32):
One of the things that I think is so interesting,
just about kind of what we knowabout firearms in general, is
that we are talking a lot aboutlike death data, and but we also
know that there's so much goinginto.
You know we've many, many morepeople are shot in the US than
are killed by firearm every year, and so we have that on top of
it too, that like the, thatinjury data of how many people
(32:53):
in the US are shot every day orwho are living with long term
gun injuries.
Or I think, dr Petron, as youpointed out, are, you know,
dealing with the ripple effectsof long term gun injuries.
Maybe they have a sibling who'sbeen shot and who is now having
to deal with a lifelongdisability because of it.
Speaker 3 (33:07):
So that's going to change the whole family dynamic
and finances and whole dominostarts and part of our part of
our survey data on thecurriculum we do.
We do a pre survey and one ofthe questions we ask is have you
ever treated a patient who'sbeen a victim of gun violence
and 100 percent of respondentssay yes.
I've never seen 100 percent ofa room full of doctors say agree
(33:27):
to anything other than thisquestion.
So it's.
It's something that everysingle person, whether they're
right at the beginning of theircareer or they are a seasoned,
attending, and they've beendoing this for decades.
It comes across everyone'sdoorstep eventually.
Speaker 2 (33:39):
And one of the things I would love if if you haven't
already been able to address ityou talked about.
For one example, the majorityof gun deaths are suicides.
I'm wondering is there anythingelse that people tend to
misunderstand about firearms orfirearm injuries in the US that
you've seen from your experiencepracticing?
Speaker 4 (33:59):
Well, I mean, look, the, the, the headline you don't
have to look too far to find is, you know, especially with mass
shootings, the assailant iscrazy and if we just kind of had
some better mental health,clearly none of this would
happen.
That is 100 percent factuallyincorrect.
The, the, the assailants, arenot crazy in the sense of, you
(34:19):
know, diagnosed psychiatricdisorders.
They do not have bipolardisease, they are not
schizophrenic, they are notmanic, any of the common
diagnoses that one kind ofthinks about when you talk about
mental health.
These people just don't have it, and that's one.
Secondly, the people who dohave, who do carry mental health
diagnoses, are actually far,far more at risk of being
(34:41):
victims of gun violence thanperpetrators of gun violence.
And these people, unfortunately, have been really mislabeled
that it is almost their fault.
That is not true, that is justnot true.
And I can say this with such asuch oomph because, guess what,
many of the people who are theassailants are my patients,
because in new turn they will beshot.
(35:01):
And I can tell you they're notschizophrenic, they're not
bipolar, they're not you knowanything.
I think this comes down to avariety of, depending on what
instance we're talking aboutmass shootings, urban related
attempted murder or ruralsuicide.
There are different reasons whythese things happen, but to put
(35:22):
them under one umbrella ofmental health is wrong.
And it really gets to access.
It really gets to knowing whomight have had, might have been
appropriate to have access, butnow is no longer appropriate,
and you know red flag laws orpolos, things like that.
That is a far, far moreeffective approach than just to
say, well Jesus, if we just hadmore psychiatrists, clearly this
(35:44):
wouldn't happen.
That is not true.
Speaker 2 (35:46):
Yeah, and that misperception that mental
illness is related to somethinglike dangerousness, when in
reality it makes people morelikely to be victims of gun
violence, is something that weconfront on this podcast all the
time, and there's a lot ofnuances to it and a lot to dig
into, to tease out thoserelationships, and so if people
(36:09):
want to learn more about that,where can they find you?
So yeah.
Speaker 3 (36:11):
So, like I said, med Peds at Georgetown and that's
where a lot of this is beingruled out right now.
I always point other providersto endfamilyfireorg for
different resources.
As far as our curriculum andour videos, we are working on
getting those put up into apublicly accessible sort of
repository with other resourcesso that people can download
those and start using them.
Speaker 4 (36:32):
Not quite ready just yet, so endfamilyfireorg is the
main plug that I'm yeah, I thinkI would echo that until we get
all of our videos up to someform of a public domain we're
talking about what type of setupthat will be.
I was I'm leaning on Brady tokind of help me with something
that is accessible to allnationwide and worldwide, but
we're not quite there yet.
But stay tuned.
(36:52):
I would certainly hope thatwe'll be there in the next six
months or so.
Speaker 1 (36:55):
Well, we will definitely keep an eye out for
that, because it looks like it'sgoing to be amazing.
So thank you all so much.
Hey want to share with thepodcast.
Listeners can now get in touchwith us here at Red, blue and
Brady via phone or text message.
Simply call or text us at480-744-3452 with your thoughts.
(37:15):
Questions concerns ideas, catpictures, whatever.
Speaker 2 (37:19):
Thanks for listening.
As always, brady's lifesavingwork in Congress, the courts and
communities across the countryis made possible thanks to you.
For more information on Bradyor how to get involved in the
fight against gun violence,please like and subscribe to the
podcast.
Get in touch with us atBradyUnitedorg or on social at
Brady Buzz.
Be brave and remember.
(37:40):
Take action, not size.
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