Firearm Violence as a Public Health Crisis with Dr. Kristin Mueller

Mark Mullen: [00:00:00] Welcome back to Psychiatry Boot Camp. Today we are joined by Dr. Kristin Mueller, and Dr. Mueller is gonna talk to us about firearm violence as a public health problem. Dr. Mueller, like all of our guests-- Well, I should say we're recording live today. Yes. So we're recording live for the first time on Psychiatry Boot Camp.

Dr. Mueller is a visiting professor for my place of employment, St. Louis University. And we're so excited to have her. And, though neither one of us speak for any of our employers or anyone that we're affiliated with, only for ourselves, we are honored to host her here at SLU. So we're in the SLU library today in the official recording studio.

Now, Dr. Mueller, I will ask you to introduce yourself to our audience. 

Kristin Mueller: Sure. Great. Thank you so much for having me, and it's very exciting to be recording live. SLU's campus is beautiful. Had an amazing walk in this morning. But I am really excited to be here. My name is Kristin Mueller. I'm an associate professor of emergency medicine at Wash U in St.

[00:01:00] Louis. So I'm an ER doctor in most of my life, but then I'm also a physician researcher and work closely with the Life Outside of Violence program here in St. Louis, which I'm sure we'll get into, but that is a region-wide hospital-based violence intervention program that thinks about how we can support recovery and prevent re-injuries after patients have come to our hospitals with a violent injury, like a gunshot wound, or assault.

So I got really into like the operations side of that, and then became a researcher later, which was exciting. 

Mark Mullen: Well, hopefully we'll cover all of it. We'll cover kind of that clinical stuff, talk about the operational side of running a team like that, and then also some of the data analysis, epidemiology. I wanna start really clinically here.

Kristin Mueller: Sure. 

Mark Mullen: We ask all of our patients in the emergency department about firearms. Do you have access to firearms? I actually think that our residents do a really good job of that, but I have to admit that sometimes it's hard to know what to do next, right? Mm-hmm. So the patient might say, "I sure do have a firearm," and then, "What about it?"

You know? How do you approach that conversation? What do you think every hospital-based [00:02:00] clinician should know about asking about access to firearms? 

Kristin Mueller: Yeah. That's a great question, and I'm really excited to hear that it's happening regularly at SLU, which is wonderful. Because I always wanna highlight, especially for our trainees, that every physician, healthcare provider in this country can ask about access to firearms and their patients and how they're stored in the context of trying to support health and support safety for our patients.

So just, like, having that framing, we can and we should be asking, which is wonderful. So I see patients in the emergency department, so usually when I'm asking about firearms, it is in the context of a mental health crisis. But our conversations around firearm access and talking about secure storage don't have to be just in that specific crisis environment.

This is really a conversation that can happen anywhere in our hospital or clinic spaces with a lens on thinking about prevention. So as we, think about how to have these conversations, if I'm seeing somebody who's coming in with a mental health crisis, for example, it's a little bit different than if I'm just having a general safety conversation.[00:03:00] 

But I think the most important thing, just like with any conversation we'd wanna have with our patients in our H&P, like, having a really calm demeanor, open body language, non-judgmental approach is very helpful. I have found that patients who are coming to us for help in their mental health crisis are very open and willing to talk about their firearm access, eh, much in the same way that we'll also ask people about their access to pills and how pills are stored as we think about harm reduction and preventing risk in times of crisis.

Mark Mullen: So in your experience, the vast majority of the time the patients are actually open to having this conversation. You're not sort of having to pull teeth. 

Kristin Mueller: I really am not, and I think part of the way that I frame it is I don't talk usually just about the firearms. That's like one piece of the puzzle for somebody's risk of injury or suicide, again, in the context where I'm doing it.

But usually I'm talking to patients- 

Mark Mullen: Right ... 

Kristin Mueller: and I'm asking like, "Why are you in the ER today?" And then I'll usually roll through, like, "Are you a smoker? Do you drink alcohol? do you use any recreational drugs?" And if patients are suicidal, I ask like, [00:04:00] "What medicines do you take? Who helps you take your medicines?

How are they stored?" Same thing with firearms. "Do you have access to any weapons like a gun?" And if so, how do you store it? And that's usually how I open the box. 

Mark Mullen: Let's open the box. So if you don't mind, could we do a- Yeah ... mock firearm counseling session? Love to. I will be the patient. so let's just say in this scenario, because this is a psychiatry podcast, most of our clinicians- Mm-hmm

are seeing patients for, psychiatric-related problems. Sure. So, let's say I'm in the emergency department. Maybe I was brought in by... Let's say my, my wife called the police- Okay ... and said she was really worried about me, so I was brought into the emergency department. You're doing an assessment, on me.

Kristin Mueller: Mm-hmm. 

Mark Mullen: let's just go from there, and you can ask me about firearms, and we'll see where it takes us. 

Kristin Mueller: Okay. Sounds great. Okay, so walking into the room. Start the scene. hi, my name's Dr. Mueller. What's your name? 

Mark Mullen: My name's Mark. 

Kristin Mueller: Okay, great. Nice to meet you. I heard a little bit about your story, but can you tell me why you're in the hospital today?

Mark Mullen: I've been having some really dark thoughts lately, and they won't seem to go away. 

Kristin Mueller: Oh, I'm sorry [00:05:00] to hear that. Can you tell me a little bit more about that? 

Mark Mullen: I've just been under a lot of stress at work. I've been under a lot of financial stress. my relationship is under stress, and I'm just not sure how much longer I can do it.

Kristin Mueller: Okay. Well, I really appreciate you telling me that, and there's a lot that we can do to help. So I'm just gonna kind of ask you a couple different questions to get a sense of where we are, and then we'll talk about next steps. Does that seem reasonable? Sounds 

Mark Mullen: great. 

Kristin Mueller: Okay, great. just a couple questions.

Like, how have you been sleeping at night? 

Mark Mullen: not very well. 

Kristin Mueller: Yeah. How many hours do you say you get? 

Mark Mullen: I would say about four hours. 

Kristin Mueller: Okay. What's keeping you up? 

Mark Mullen: you know, I'm scrolling my bank account. I'm just trying to figure out how to make ends meet, and I'm just thinking about, I don't... You know, I don't know.

I don't know what the next day's gonna look like, and I'm... I feel like maybe if I don't go to sleep, I won't have to wake up. 

Kristin Mueller: Okay. Well, again, I appreciate you sharing that with me, and I'm sorry you've been feeling that way. Have you-- And I like to ask directly, have you been having any thoughts of wanting to hurt yourself?

Mark Mullen: they kinda creep in here and there, but I do okay at keeping them away, I think. 

Kristin Mueller: Okay. Do you have a plan for how you would try and hurt yourself? 

Mark Mullen: I got a lot [00:06:00] of plans. Yeah, I've definitely got a few plans. 

Kristin Mueller: Okay. Would you mind sharing some? 

Mark Mullen: I feel like there's a lot of ways to do it. overdosing on pills, or something quicker than that, or maybe jumping in front of traffic.

I feel like my thoughts just kinda go and go 

Kristin Mueller: Understood. well, again, we're gonna kinda make some plans so we can help you f- not get quite to that stage. But as we think about helping to keep you safe, do you have, You mentioned pills. Do you have any medications at home, prescription medications 

Mark Mullen: or anything like that?

we have some opioids. We have oxycodone- Mm-hmm ... for my arthritis. And, other than that, just, like, Tylenol, Advil, and stuff like that. 

Kristin Mueller: Okay. How are those stored? 

Mark Mullen: just in the medicine cabinet above the sink. 

Kristin Mueller: Okay. is anybody else-- You mentioned a wife. Does anybody else live at home with you? 

Mark Mullen: I have an 11-year-old grandson that lives with us, and that's about it.

Kristin Mueller: Okay. All right. And then, do you have access to any weapons, like a gun? 

Mark Mullen: well, I am a hunter, so I will [00:07:00] say that's something that's pretty important to me, so yes 

Kristin Mueller: Of course. And I appreciate you being honest with me. Everything that we're gonna talk about today is just thinking about how we can keep you and your family safe while you're feeling the way that you are and thinking ahead towards next steps.

in terms of any time that someone like you is, you know, having the dark thoughts, the creeping in, potentially thinking about suicide, we like to talk about safe or secure storage. Have you ever heard those terms before? Of course. Okay. Great. What we like to talk about in... Is your wife here with you?

Would you like to have her in the room with you? 

Mark Mullen: I, you know, I'd prefer to be private. 

Kristin Mueller: Okay. Yeah, that's just fine. We absolutely respect your wishes. but what can help is if you either on your own or if you're willing to lean into your family or friend or social networks are-- can start storing your pills and guns safely, that can make a big difference while you're feeling down.

This doesn't mean forever. It means just right now when we're helping to get you connected with mental health care while we're working through these, feelings that are new, if that makes sense. So from [00:08:00] the pills, what we recommend is trying to keep them locked up or having somebody else hold them and just give them to you when you need them.

So for example, your wife could be in charge of the pills, and that just, if there's ever a moment where you ever get tempted to take something extra, she'll just have them, and you can talk through that moment so you wouldn't have to just, like, be holding all of your feelings in on your own and having to take responsibility for all of that.

So that's one option. and then we also, when we think about guns or firearms, we have a lot of hunters. We got a lot of folks with guns here. I appreciate you sharing me. That's totally fine and appropriate to have them at home. but any time that we, are having folks who are, you know, feeling more depressed, feeling more down, we always like to think about how can we store the guns the safest.

So if you ever get to a point of crisis, there-- you have to go through some extra hoops to get to them, and it's a little bit harder to, you know, take action without talking to somebody like your family or a therapist. So usually we recommend storing your guns locked and unloaded with the bullets in a different physical [00:09:00] space.

Do you know how your guns are stored right now? 

Mark Mullen: my gun is behind the bookshelf right by the front door, just in case I need to use it. 

Kristin Mueller: Yeah. I hear you on that. So that's one option. And we-- I know it can be hard when you think about, like- What could happen? usually in time, like just-- there, there's been pretty good data showing that in times of, folks having mental health crises, having the gun out of the home is actually the safest or having it secured even more so than, like, needing to have it ready just in case something might happen with a home invasion scenario or something like that, which, thankfully in St.

Louis, it's very uncommon. so what we would recommend is either you could talk to your wife, about helping you to store your gun securely in the home with, again, putting the gun and the bullets in separate places. We can help you get a gun lock. We can help you get a gun safe. Or even better, if you've got family members, or friends who you-- like maybe hunting buddies, somebody who could just hold your gun for you while you're getting treatment, and then when you're feeling better, you can have it come back and be stored in your home.

[00:10:00] so that's kind of some of the things that we think about early on. Or if you're part of a hunting range-- or excuse me, a gun range or a gun club, sometimes they'll store your guns for you too. but again, just having it out of the home while we're helping to get you into a better place emotionally can make a big difference on keeping yourself safe and keeping your family safe Do you have any questions for me?

Mark Mullen: I don't. And let's exit our- Sure. mock interviewing. That was amazing. I can't believe how effectively regulated you helped me to be in that moment. let's kinda unpack a little bit. Let's see if you can give me the secret sauce behind what you did. So first I'll say I'm amazed at how you were able to make me feel comfortable throughout that conversation.

Great. And I feel like I tried to give you a couple of difficult things to deal with. Mm-hmm. And, we talk a lot about verbal de-escalation, and I felt like immediately de-escalated as you were talking about it. So when you're going through that conversation, what's going through your mind in terms of your process, the goals- Mm-hmm

principles, et cetera? 

Kristin Mueller: Yeah. So I mean, number one, it's America, so the expectation that people are gonna have pills and guns in the home [00:11:00] is just coming into that knowing that, so it's not like a surprise when you tell me that I'm like, "Oh, no, I can't believe you shared that controversial information with me."

So again, just having like a really calm and open demeanor. We think about our body language again. It can be a little bit hard in clinical spaces. You've given me like a nice chair. We've got like a nice seated environment. 

Mark Mullen: Yeah. 

Kristin Mueller: it's harder when I'm like hunched in a corner and it's dark. But like again, having your arms uncrossed and making good eye contact, but also not too much eye contact.

There's a balance- Mm-hmm ... for some of our trainees especially. Sure. And then just trying to be open and accepting of the information that patients are giving us. So we want to acknowledge how patients are feeling. what I've really learned from this work is people want to know that they're being heard and cared about, and just giving that reinforcement that I hear what you're saying, that I appreciate you telling me this, that it's totally acceptable and appropriate that we're having this conversation at all.

That kind of framing, I feel, is very helpful just no matter what you're talking about when you're having- Sure ... an encounter, but especially mental [00:12:00] health crisis 'cause there can be so much stigma, especially, well, I mean, for so many different populations. There can be a lot of stigma around seeking mental health care, so that's one side of it.

And then in terms of secure storage, I try to just ask a lot of open-ended questions about what people do already. Again, try not to be judgmental about the storage practices. I also accept that even if I recommend secure storage, patients might not do it. 

Mark Mullen: Right. 

Kristin Mueller: And that's okay. 

Mark Mullen: And you can sleep with that.

Kristin Mueller: And I can sleep with that. But maybe it's just emergency medicine in general, but I've accepted that there's only so much that we can do every time in terms of like sharing the best information, the best practices, and trying to give our patients all the tools that they need to succeed. But the reason I brought up, if we could have your wife in the room, which obviously not in this scenario probably.

But if you can get family engaged or friends, that can help build up a support network at home and have extra accountability for secure storage, too. Because here in St. Louis, our options for where to store guns are, again, in the home, locked, unloaded, bullets in a different physical location, with friends or [00:13:00] family, sometimes at the gun range if you have a preexisting relationship, or you can surrender them to police but we're not a state with EROs or extreme risk protection orders, which you may or may not be familiar with, that exist in some other parts of the country.

Could you 

Mark Mullen: go into that? We have an international audience. Mostly- Sure ... in the States, but- 

Kristin Mueller: Oh, no. I shouldn't have opened up the box- ... 'cause I'm not an expert in this area. Sure. But please, I encourage you to go to the Gun Violence Policy Groups for the official information. But ... And part of that is I've just never lived in 

Mark Mullen: a state that's had that.

Kristin Mueller: Right. Totally. But my understanding is if somebody's in a mental health crisis, suicidal crisis, certain domestic violence situations, too, law enforcement can actually fill out forms, that get certified by a judge to have weapons, like guns- Gotcha ... removed from the home- 

Mark Mullen: Gotcha ... 

Kristin Mueller: in an emergency crisis situation.

And sometimes they return, sometimes they're not, depending on the exact situation. 

Mark Mullen: Whereas here in Missouri and other very, let's call them very pro-Second Amendment states, it's always okay to bring this up. It's always okay to have a conversation about. It's always okay as a clinician to counsel on pa- our patients on what can [00:14:00] keep them healthy and safe.

But in terms of legal mechanisms and levers that we can pull to force people to give these weapons up- 

Kristin Mueller: Mm-hmm ... 

Mark Mullen: it sounds like in Missouri, actually, there's not much you can do. 

Kristin Mueller: There's not much, no. And I mean, in the emergency department, if I'm worried somebody's really in crisis, they have access to weapons or other access to lethal means, like somebody who really wants to jump in front of a car, for example.

Sure. we're not gonna get all the cars off the road. 

Mark Mullen: Right. 

Kristin Mueller: But in patients who are in true crisis, we consult with our psychiatry colleagues, and patients can be, evaluated and admitted to the hospital 

Mark Mullen: for a few days. While we sort of sort everything else out, right? Exactly. And they have a conversation with their family members about what needs to be done.

Okay, so you mentioned kind of the interface between emergency medicine and psychiatry. Mm-hmm. And this next question is ... I shouldn't call it a fun question- Mm-hmm ... 'cause it's a really depressing topic, but one thing that we talk a lot about- Mm-hmm ... on Psychiatry Boot Camp is failures of the psychiatric system and places where the psychiatric system breaks down.

And in my experience, usually we see that- In the emergency department more than anywhere else. [00:15:00] And I'd love to just ask you, as a practicing emergency medicine- physician for 15-ish years- 

Kristin Mueller: Mm-hmm ... 

Mark Mullen: where do you personally think the biggest breakdown in psychiatric care is in our community? 

Kristin Mueller: Yeah, I appreciate that question, and I'm gonna give the caveat that everything I'm about to say is not specific to psychiatry, but thinking about emergency medicine and the emergency department as a safety net catchment for everybody who's been left behind by healthcare- Right, yes

or had challenging access- challenges accessing it. So I think about maybe our gaps in mental healthcare in two places. The first is access, so just physical reach or ability of there to be enough psychiatrists, especially pediatric psychiatrists for our children and teens, who have room on their schedules to accept new patients, who are within a reasonable distance of wherever patients live, who have hours that are available when patients are available.

So again, a lot of our medical practices are traditionally structured 9:00 to 5:00, and that's the time when a lot [00:16:00] of people are at work or at school, and it can be really hard to... Not everybody can take time off to make those hours. So even if they were ready to accept and... Sorry, not just accept, but like be in- Totally

psychiatric care- 

Mark Mullen: Yeah ... 

Kristin Mueller: they might not physically be able to due to time, transportation, job competing priorities. So access, I think, is the biggest barrier. and as part of that also the ability to afford healthcare in general, and outpatient healthcare specifically. So if you've got insurance, that's great, and I actually don't...

You would actually know better than I do off the top of your head if most insurances will cover psychiatry as preventative care or if it's a consulting, seen as subspecialty care and if there'd be an extra copay or not. 'Cause that's a real consideration for a lot of our patients, is a copay required at all, and is it expensive?

Mark Mullen: For sure. I think it depends on where you're getting care, and there are probably some organizations that do a better job with that than others. 

Kristin Mueller: Yeah. And I guess I'll give the caveat, I'm not trying to put it on the private physicians at all- Yeah ... [00:17:00] because there are many organizations across St. Louis in particular that do try and address healthcare and mental healthcare for folks who are uninsured.

I know that, both of our academic institutions, SLU and WashU, will have, care that they provide, and then the St. Louis Mental Health Board and a lot of the FQHCs will work to help, federally qualified health centers- 

Mark Mullen: Beautiful ... 

Kristin Mueller: will work to provide additional support, too. So that's kinda one pillar is the, like just the access and the reach of available psychiatrists.

I feel like the other part is acceptability to receiving care, which again, I know we're gonna talk about hospital violence intervention programs in a little bit, but it's something I've been thinking a lot about in terms of how do we get more folks into our programs and actually receiving services that can help them recover after injury.

And I think there's crossover with getting into mental health or psychiatry care as well, not just for vi- victims of violence, but for everybody with unmet mental health needs. Because there can be a lot of stigma around [00:18:00] acceptability of care. So that can be intrinsic, like do I recognize that I have a problem?

That do I recognize that I'm depressed at all, or having PTSD, or having any sort of psychological symptoms? And do I recognize that I need help? And that I want help. And those are three different things, and that can be a lot to overcome for some of our patients. So again, thinking about how we can be constantly and continuously de-stigmatizing mental health care, I think this is something everybody should be a part of.

I don't know. I just... I think that we've got work to do, but also, like, a lot of positive progress in the space, too. 

Mark Mullen: Yeah, I think even once patients are ready to sort of make that step and engage with services, whether or not the particular services available are acceptable to that patient- Mm-hmm ... is sort of another thing to navigate entirely.

Just kind of wrapping up this segment- Mm-hmm ... was there anything else you wanted to get to in terms of principles for counseling access to lethal means? I feel like I might have ended that conversation [00:19:00] prematurely. I know one thing I'm thinking about is kind of pushing through, I'll call it resistance- Mm-hmm

in psychiatry speak of, "Well, what about this?" or, "I have this consideration." Any just kind of down and dirty clinical pearls that you can give us about how to effectively navigate those conversations beyond what you've already said? 

Kristin Mueller: Yeah. I mean, again, I just want to reinforce everybody can and should be having these conversations.

But behavior change is hard. It's one of the hardest things that we try and enact in medicine, whether it's take your blood pressure medicine every day, go to the doctor, stop smoking. And secure storage of firearms and pills and other lethal means is in the same bucket. So for folks to really make a change, they have to be ready to make a change.

They have to have a support system. They have to have means to make the change. So as we think about patients who may or may not be resistant, for example, there are a lot of patients in St. Louis who carry a gun with them for protection- 

Mark Mullen: Right ... 

Kristin Mueller: because they perceive their neighborhoods as, or communities as dangerous- 

Mark Mullen: Right

Kristin Mueller: or their home environment as dangerous, and they just are like, "I need my gun on me to feel safe." 

Mark Mullen: Mm-hmm. 

Kristin Mueller: And I think just [00:20:00] acknowledging that is important. Like, "I hear you. That's-- how you're feeling is valid. I would like to give you some tips on how we can... and some tools on how we can store your firearm more securely, at least while you're at home, even if you're not ready to do it while you're out in the community.

Again, I can give you a free gun lock today. We distribute them from the emergency department at Barnes Children's. SSM has a big initiative around this, too. Most of the libraries give out gun locks free in St. Louis. The fire departments do it. There's a lot of places where you can get a free gun lock in St.

Louis." 

Mark Mullen: Yeah, and you might be mu-much more willing to- Yeah ... interact with firefighters or policemen, depending on- 

Kristin Mueller: Exactly ... 

Mark Mullen: what you are kinda into than you would with the mental health care system. 

Kristin Mueller: Yeah. So just like people when they need to quit-- when we want them to quit smoking as physicians, we're like, "Ooh, we gotta tell you 13 times-" Yeah.

before you're ready." Okay. And actually, when I do, smoking cessation counseling in the ED too, like, I'm like, "Oh, do you smoke? Do you drink? Do you use drugs?" And somebody's like, "Oh, yeah, I smoke cigarettes, half a pack a day." And I'm like, "Great. Thank you for telling me that. you may or may not be ready to quit today, but I just wanna let you know quitting smoking is the best thing you can do for your health.[00:21:00] 

Most people need to hear this message 13 times, so I'm putting my time in right here." Yeah. "And if you want, I can give you some extra resources on how we can do that." And some patients take me up on it, and some don't. And I see, especially in the preventative medicine space on counseling on secure storage Put your heads in.

Like, have you that extra touch- Right ... with your patients- Right ... where you're talking to them about secure storage, where we're normalizing these conversations. Definitely pediatrics is doing this really well in the pediatric just preventative healthcare space. Yeah. Just like car seats. Talk about using your car seats, talk about locking up your pills, talk about locking up your guns.

And I think those conversations and just kind of the matter-of-factness of it can be very easily applied to other spaces like psychiatric encounters or mental health crises. 

Mark Mullen: I think it's matter-of-factness, but one thing that I noticed is that you didn't beat me over the head with data either. I feel like for any physician, one of our favorite defense mechanisms is intellectualization, and when we learn in medical school that having a fire alarm- Mm-hmm

in the house is much more likely to harm [00:22:00] you in terms of harm to your family- Mm-hmm ... harm to yourself, just, just- Sure ... cold statistics, you know, than it is to actually be useful to protect you. I think for a lot of clinicians, it's like, "Well, duh," you know? Mm-hmm. But if you lead with "Well, don't you...

What are you arguing with statistics," right? Like, "This is just a fact." Sure. "Having a firearm in your home is gonna make you less safe," I would imagine that no patient would respond well to that. So I noticed that when I kind of pushed back against that- Mm-hmm ... you gave me... You told me very clearly, right, this is more likely to be unsafe for you-" Mm-hmm

than to promote your safety," but you did it in a way that acknowledged my concerns and sort of said, "I'm just here to provide some information and help you the best that I can." 

Kristin Mueller: Mm-hmm. Yeah, I, mean, I think that's a great point, and some of it's, like, you gotta read who you're talking to- For sure ... a little bit- 

Mark Mullen: For sure

Kristin Mueller: on what kind of information they're seeking. But a lot of our patients, you're correct, they don't wanna be hit over the head with facts. They want to feel like they have agency in their decision-making. Right. And I see it as our role as healthcare providers to really just give [00:23:00] our patients as much information as we can concisely and at their learning level or receptiveness level, 'cause again, thinking that people come with all different backgrounds into our care, can make a big difference in will they follow up on our recommendations.

Mark Mullen: Let's take a quick break, and when we come back- Okay ... we'll talk about hospital-based violence prevention programs. 

Kristin Mueller: Great. It is a mouthful. 

Mark Mullen: It is a mouthful.

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All right, welcome back to Psychiatry Boot Camp. Joined today by Dr. Kristin Mueller. she's an emergency medicine physician, and I thought about making this whole episode Psychiatry for the Emergency Medicine Physician. But I'm all up-to-date on The Pitt, so I feel like I know everything there is to know about emergency medicine.

I'm sure you'd agree that pretty much covers it. 

Kristin Mueller: So this is weird. It's terrible. I admit I haven't watched The Pitt yet. It's on my list. ER Die Hard- 

Mark Mullen: Yeah. 

Kristin Mueller: okay ... from back in the 

Mark Mullen: day. Huh. 

Kristin Mueller: Yeah. I'm a little bit worried that it's gonna be like, "Ooh, did I go to work for 10 hours?" But I have re-embraced Scrubs and approve of everybody who's been watching The Pitt lately.

Mark Mullen: Just stay there. You're in the right head space. Yeah. It is very much like going to work. I think that's probably why people like it, is it's a little bit more realistic. Yeah. So we usually see firearm violence in the news as events, right? Mm-hmm. There's a story if you scroll any of the St. Louis news organizations- Mm-hmm

there's all these discreet stories about firearm violence as different events. Why do you think it's important that we start to talk about this as a public health problem? 

Kristin Mueller: Yeah. Great question. So for a number of [00:27:00] reasons. The biggest one is that when we think about firearm violence, firearm injury as a public health issue, we can think about it as just like any other disease that we treat.

So something that can be tracked, treated, and ultimately prevented, just like any other disease like COVID, like strokes, like heart attacks. We can use all of the methods that we already have and know how to use to be tracking this forward. it's also really exciting to think about firearm violence and firearm injuries, and I kinda separate them out because we think about gun violence sometimes as, like, the most politicized form of the terms that we use.

But gun violence or firearm violence is only part of the story when we think about all the spectrum of how folks get hurt or injured or die from firearms in this country. Because as we've been talking about, suicide is certainly a real consideration. There's a lot of accidental shootings, especially among our young kids.

And of course, community violence or interpersonal violence can be part of this picture, too. But when we think about it as firearm injuries and firearm injuries as a public health issue, it really helps us encompass the full [00:28:00] breadth of how folks are getting injured. But one other point I would like to make on that is it is very helpful and real, I think, to think about firearm injury as a public health issue because it takes away some of the individual accountability...

Maybe not accountability isn't the right word- Mm-hmm ... but the individual- Mm-hmm ... blame- implicit or explicit, that goes into somebody being injured Because when we think about the news stories about victims of gun violence or perpetrators of gun violence, there's a certain amount of implicit bias that can come with it that, like, this person did something that put them- Right

in that position of risk. When really there are a whole multitude of structural and systemic inequities and barriers and structural racism that really can s- contribute to the risk for having, for sustaining a firearm injury or being a perpetrator of firearm injury too. And I think that when we are able to apply our public health lens, it lets us kind of appreciate the whole [00:29:00] community violence intervention ecosystem.

So it's not just one person's individual choices, but it's the community where they live, it's their home environment, it's kind of the whole network of people around them and their society that really impact choices, impact action, impact injuries. So again, trying to think about it not just as like, "Here's one individual who I'm gonna modify," but how can we more comprehensively address this as a collective issue?

Mark Mullen: Yeah, I think there's a very radical reframing from these people are doing certain things- Mm-hmm ... and we need to fix this problem or, some people act violently and so those people need to be dealt with, right? 

Kristin Mueller: Mm-hmm. 

Mark Mullen: Versus this is something that's affecting all of us, and how can we systematically address this and, decrease the prevalence and keep everyone safer and healthier.

So when you are attacking this as a public health problem, how do you go about collecting the data? Like, what types of data are you collecting and how are you obtaining it? 

Kristin Mueller: Yeah. So kind of putting my physician hat to the side a little bit. Perfect. When [00:30:00] we think about this as a research problem or a public health issue to be addressed, any questions that we ask, any interventions that we do are only as good as the data that we have to support our outcomes.

So for firearm injuries, there's no comprehensive database in this country that looks at non-fatal firearm injuries. The CDC collects fatal firearm injury, but if you only look at fatal injuries, you're missing most of the story. So think about, for example, if you were looking at mental health as a spectrum, let's say depression, but instead of looking only at the people who are depressed, you only count the people who committed suicide.

Mark Mullen: Mm-hmm. 

Kristin Mueller: I mean, that's such a small percentage of people, and I do not ever minimize the impact of one suicide death, so I wanna be really clear on that. 

Mark Mullen: No. Yeah. 

Kristin Mueller: But it's a really small percentage- Right ... compared to everybody who's walking around with- With 

Mark Mullen: mental illness, wow ... 

Kristin Mueller: depression. And as we've started to build out our new data sources, we've worked across the hospitals kind of as a starting place.

So I work at, with WashU, I work at Barnes-Jewish Hospital and St. Louis Children's Hospital, which are two adult and pediatric level one trauma hospitals. [00:31:00] And then we have been partnered with St. Louis University's, nearby adult and pediatric level one trauma hospitals, St. Louis University Hospital and Cardinal Glennon Children's Hospital, which is a mouthful.

But what I'm trying to say is we've gotten all of our level one trauma hospitals in the cities together to share our data so we can actually have a better understanding of our regional firearm injury epidemiology and be positioned to evaluate our programs. And this has been really impactful because one of our recent studies, we found that in the last decade, so from 2010 to 2019, and this is where I'm, I am gonna get in the numbers, so warning.

Please. We'll do this at the bedside. But between 2010 and 2019, just our four hospitals in, St. Louis, we took care of over 10,000 unique individuals with firearm injuries. And of those, that included 1,340 children in that decade who came in shot. But one important part of the story is that when our patients survive their injuries to come to the hospital from a firearm, 93% of the time they go home.

So [00:32:00] 93% of our firearm-injured patients across our level one trauma hospitals are surviving their injuries, they're recovering, and they're going back home to where they lived, maybe where they were injured, maybe their, like, existing community context. And these are folks who have to recover, deal with the sequelae of their injuries, and again, be in their social networks afterwards So it's been really eye-opening with having this data and just painting a picture of how in our St.

Louis hospitals at least, most firearm injuries now are non-fatal. Again, I am not promoting more firearm injuries. 

Mark Mullen: Right. 

Kristin Mueller: But how do we kinda transform that knowledge into intervention and prevention and action? 

Mark Mullen: Some of the numbers when I was prepping for this episode were really pretty impressive. I don't know if you remember off of your head, but I remember reading one figure about firearm injuries and recurrent firearm injuries among, like, 15 to 17-year-olds.

Do you remember that one off the top of your head? 

Kristin Mueller: Yeah. 

Mark Mullen: Like, I remember my jaw... I read it, my jaw literally hit the floor. 

Kristin Mueller: Yes. I, [00:33:00] I don't have that exact number in me. So I know among our whole cohort, so this was all ages- 

Mark Mullen: Okay ... 

Kristin Mueller: our risk of a second firearm injury in one year was 7%. So that's 7% of people who came to our hospital shot were shot a second time within one year.

Mark Mullen: Within one year. 

Kristin Mueller: Within one year, and that number goes up to 17% of people within eight years, which is an insanely high recurrence rate- Yeah ... when we think about disease pathology- Right ... just period. I can tell you that I think it was maybe 8% for the one-year risk of re-injury for the teens, and poss- 23 or 25%, I think, oh, by eight years- 

Mark Mullen: Yeah, that sounds-

Kristin Mueller: if I'm remembering correctly. but we know that our teens age 15 to 17, and then again, our young adults going up to about age 24, that, like, 15 to 24-year-old range is really the folks who are at highest risk for a second injury when they're the age of the first injury. 

Mark Mullen: Okay, so when you're collecting this data, is this something where the federal government has just said, "You're kind of on your own.

We don't see this as a public health problem-" Mm-hmm. "... and so you're having to obtain solely private funding and no governmental funding"? 

Kristin Mueller: [00:34:00] Yeah, great question. So it's a mix. We definitely got our program and our data sources up and off the ground with the support of the Missouri Foundation for Health, which is a local statewide organization that supports different public health and other healthcare initiatives.

And they gave us over a million dollars in seed funding to help develop our violence intervention program, and we were able to develop this data repository that's given us this really deep understanding- Gotcha ... of our regional epidemiology out of that same pool, with additional institutional support from our hospitals, from our universities, and then from kind of a hodgepodge of different foundation grants and increase...

And kind of over the years, some federal grants as well. 

Mark Mullen: And your program is Life Outside of Violence. Yes. Is that right? And you're wearing the swag right here. I 

Kristin Mueller: am, yes. Thank 

Mark Mullen: you. Tell us about the work that Life Outside of Violence does. 

Kristin Mueller: Yes. So I will be... Very often I'm so proud of the work that our team is doing.

So as an ER doctor, again, my number one priority is, like, how do we support our patients? Sure. How do we help patients stay safe? How do we help them recover? How do [00:35:00] we keep them... Like, give our patients all the resources they need to thrive after injury? So our program developed as a way to really support the recovery and intervene after a violent injury.

So the Life Outside of Violence program, has been a partnership between Barnes Children's, Cardinal Glennon, and SLU over the last many years. we're entering a new phase where we're, like, navigating what the next- Sure ... stage will look like. Sure. but we have been enrolling patients aged 8 to 30, so kids through young adulthood who come to one of our hospitals with a violent injury, and that can be a gunshot wound, a stabbing injury, or a blunt assault like a fistfight, especially in the kids with the idea that kids who are in, or even, and even young adults who might be involved in fistfights may have escalating dangerous injury mechanisms over time.

And if we can intervene when it's just a fistfight, maybe we prevent a firearm injury down the road So with our programs, it's been really exciting because we employ clinically licensed social workers who are LCSWs, for those of you who are [00:36:00] in the social work crowd. But these are folks who are really experienced working with traumatized populations, have very specific extra training around care of these folks.

And our social work clinical case managers, what they do is they meet with patients and their families who are in the program for up to a year after injury, and they provide all sorts of wraparound care services. So that can be on the case management side of doing things like, "Do you have a safe place to live?

Do you have food? Do you have wound care supplies?" or a hospital-based program, so helping to coordinate medical care, transportation so you can actually get to your appointments and get back, again, with the medicine and wound care supplies. And then from a psychiatric lens or a mental health lens, our case managers are also all trained in trauma counseling.

Mark Mullen: Wow. 

Kristin Mueller: So they can actually do real-time counseling with our patients or their families wherever the patients are. So rather than having somebody who survived a bullet wound or, you know, some other traumatic injury have to come into the office, which may or may not be a possibility for them, maybe they've got a lot of PTSD or, you know, trust issues and they're [00:37:00] like, "I can't even leave the house," our case managers are able to go meet our patients in their homes, in their schools, in their community, and kind of weave in the therapeutic counseling component in the course of all the other work they're doing.

So, like, sometimes they might sit down and have a session like this at the kitchen table or in-- We do have program offices up on the Delmar DivINe as well, which is our community-based office space. but sometimes it might be just, like, walking down the street or, like, you know, shooting hoops or something and just weaving it into real life to help kind of think about how we can reinvent healthcare to be more acceptable, available, and, like, really meet patients where they're at physically and emotionally.

Mark Mullen: it strikes me that one of the major symptoms of PTSD is avoidance. Mm-hmm. And so after you've had a traumatic event, sometimes even though you know maybe the data says that sitting down with someone and doing talk therapy- Mm-hmm ... is an evidence-based intervention, nothing sounds worse than- carving out an hour a week to talk specifically about- Mm-hmm ... the worst thing that's [00:38:00] ever happened in your life. So what you're saying is you're putting these people with these specific professional skills- Mm-hmm. Yep ... right? In this case, licensed clinical social workers. Yep. And you're putting them in scenarios where these conversations can happen, if they happen, right?

Kristin Mueller: Yep. 

Mark Mullen: They're there to provide very concrete services, right? Definitely. Helping people with things like housing- Food insecurity, navigating the healthcare system. I'll just speak for myself. I'm an attending physician, and navigating the healthcare system can feel impossible. And I mean that really s- really genuinely.

Yeah. It's really hard to navigate the healthcare system, so you can only imagine if you're not well-resourced, you don't know how the system works, and you're trying to navigate this stuff. So you have someone that can really provide these sort of basic, if we think of Maslow's hierarchy of needs- Mm-hmm

needs, but then also is able to kind of flex into those conversations during some of those maybe golden moments when the person does feel more open to discussing some of these things. 

Kristin Mueller: Yeah. I think that's a great way to frame it. And one thing that we've been learning through this work, too, I've done a lot of, again, thinking about the research work on How [00:39:00] we improve the acceptability and availability of our program services.

initially, we thought there was just one golden moment, like at the bedside, "I've been shot. I'm ready to change my life-" Wow ... "I've survived this life-threatening injury." And for some patients, that's still real, and their families. But some folks are like, dishearteningly, a shocking number of teens and young adults in St.

Louis always thought they would get shot, so this isn't even like a life-changing moment. "I'm shot. My friends have been shot. My family's been shot. This is something I always-" It's just part of life ... thought was gonna happen." Breaks my heart, does not have to be this way. 

Mark Mullen: Right 

Kristin Mueller: But because of that kind of mindset, or like, "I just need to go home.

I need to get on with my life," or, "There's too much going on in the hospital," like not everybody is ready to hear about the program or accept services in the hospital. So we've been doing a lot to improve our marketing materials, website, handouts, contact information going into discharge summaries and things like that to, again, make it easier to navigate healthcare.

So later, maybe it's days, weeks, or months later when patients are like, "Ooh, I am not doing well. I need some help," or mom or dad- 

Mark Mullen: Right ... 

Kristin Mueller: or like, you know, family [00:40:00] network who might have access to your healthcare information is like, "Ooh, you're really not doing well either. Let's call those folks who tried to talk to you about this program," and then we can get patients in later too.

So we've really extended our window to, again, try and meet patients where they are in terms of what kind of care they need and when and how they're ready to receive services. 

Mark Mullen: It's good for me to know. I'll be honest, I didn't know about the program until, you were our AOA visiting professor- Yeah.

But- ... at SLU, and so I feel like we see this population all the time, and it-- w- to me it's a population that we can identify specifically- Mm-hmm ... that they have this need, and we can create this service, and we can match the service to the population. But I think one of the most important things is it's totally voluntary.

Yeah So if somebody says, "I don't want any of this. I don't need any of this," right? We can do our absolute best to create a relationship- Mm-hmm ... and give them this ongoing opportunity. Yeah. Right? You don't have to enroll right here and now. You can enroll whenever you do feel ready. But, it's not really punitive, and it's not- it's not-- there's no forensic aspect to it. And when I [00:41:00] think about that sad reality that a lot of people just live with the fact that, "Gun violence happens in my community. It's happened to people that I love, and it might very well happen to me," it's just so cultural, right? Yeah. And it's based on so many firmly held cultural beliefs, and how you deal with the gun violence is also culturally informed, whether that be retribution for gun violence because that's a culturally held value that needs to occur, or whether that be not engaging with professional services for a lot of reasons, I, that I think we probably shouldn't even go into right now.

Some really, good reasons from the past- ... and some reasons that probably have more to do with stigma that we need to, decrease over time. So I like that it's a very, Usually where we think gun violence, we think of the forensic system and the legal system, and this is sort of an alternative pathway for these people to engage with.

Kristin Mueller: Mm-hmm. Yeah, that's a great way to phrase it. And we like to... Again, we are partnered with law enforcement in certain ways, but, like, we would never disclose healthcare information or program information to law [00:42:00] enforcement. But we're trying, in some ways to be part of the community violence intervention ecosystem, or CVI ecosystem.

So for those of us who are, like, deep in the weeds- 

Mark Mullen: Yeah ... 

Kristin Mueller: and this work- Go for it ... is really a framework to acknowledge that none of us are doing this work in isolation. So our hospital violence intervention programs are designed to serve victims of violence who come to our hospitals, so that's just one piece- Right

of the traumatized community violence population in St. Louis, for example, or other urban centers. So we also think about how we can be partnered with street outreach or other folks on the ground out in communities who are doing violence intervention work with law enforcement to, like, help collaborate on de-escalation and trauma-informed practices in law enforcement.

we have... I mean, our program, Life Outside of Violence, is part of the St. Louis Violence Prevention Commission, or STLVPC, which is, like, a whole regional network around violence prevention that's run through the mental health board. it's got support from the St. Louis City Office of Violence Prevention.

There's folks from government and the county there, too. So really [00:43:00] thinking about, like, how we can all come together and do our part. But as healthcare providers, HVIPs, or hospital violence intervention programs, like, this is, our jam- 

Mark Mullen: Right. 

Kristin Mueller: Got it ... in terms of where we can be. 

Mark Mullen: And it's certainly my jam as a consult psychiatrist- Yeah

who only exists in the hospital, and obviously- Mm-hmm ... our, our audience is mostly healthcare professionals. 

Kristin Mueller: Sure. 

Mark Mullen: So that's a little bit about the program. You kind of opt in. You have this social worker assigned to you. You have this slew of community resources available to you. Do you have any data yet on how this is actually affecting violence in the community?

Kristin Mueller: Yeah. So we're getting there, and that's a really important and timely question because my dream for our hospital violence intervention programs, for all violence intervention programs everywhere, is that they will prevent all violent re-injury, get to, like, scale to the point where we can have, even do primary prevention where communities are getting safer, people aren't getting injured in the first place.

But I want to talk about evaluation in the context of Life Outside of Violence. And, like, in my opinion, every single violence intervention program in this country, no matter where you [00:44:00] are all still scaled primarily for individual impact. So if you wanna dig into the scientific frameworks, we use the social ecological model of violence prevention, which really thinks about, different levels that impact intervention.

So individual level impact, these are people in the program, they're getting the services, they're being intervened on. Some spillover effect into the relationship level, which will be their families, their peer networks, that sort of thing. When we help an individual, we help their families and the people around them, too.

But we don't have enough staff, we don't have enough, you know, awareness of the program or reach, as we like to think about it in the DNI dissemination implementation framework, to be able to get every single person who's eligible for these programs in yet. So until we're starting to have that bigger scaling, we're not gonna see the community level benefit.

That makes sense. 

Mark Mullen: That makes sense. 

Kristin Mueller: So there's a lot of our patients who are in the program, they're doing great. They're, you know, they're healing, their mental health is improving, they're getting jobs, they're going to college. But if they're still living in their same context- Right ... they could still be walking home from the corner store and get shot.

Mark Mullen: Yeah. 

Kristin Mueller: And that's just a reality. [00:45:00] And this is where taking the risk of injury or re-injury off the individual- Right ... is really important when- Yeah ... we consider why that happens in the first place, 'cause this person could be doing everything right- Yeah ... if we're... Which, again, it's never that, black or white, but, and still get re-injured.

So thinking about our program evaluation needs to take into account the context in which our programs are operating. So we, and I'm gonna say this, we did a big study looking at our pilot data on violent re-injury reduction. We looked at patients who were in the program during the first several years of their program compared to patients who were eligible but hadn't enrolled.

And we were able to follow both groups forward in time and look at return to the hospital within one year for re-injury. And what we found is that both groups were coming back with re-injuries. Again, gunshot wounds, stabbing, blunt assault, all through, not, all three, not just firearm injuries. But they were coming back between, like, 7% and 8%, no statistical difference in terms of re-injury risk, which is about on par for our regional [00:46:00] firearm re-injury risks already.

so there's like one arm that could say like, "Oh, your program didn't do anything." Right. But we have to think about how these programs are designed to not just prevent re-injury, which is again, the overarching goal, but really in, intervene at the individual level. So I'm not shocked that we haven't fixed community violence yet.

Mark Mullen: Right. 

Kristin Mueller: That like, we haven't fixed poverty. We haven't fixed structural racism. We haven't changed all the other things, and we need to, like, really openly acknowledge that these are all contributing factors- Sure ... in our program outcomes. So that has led us to actually change up some of the ways that we think about program evaluation, both in our Life Outside of Violence or LOVE program here, but also nationally, because we have been working through the HAVI, which is the Health Alliance for Violence Intervention, which is the national network for violence intervention programs.

It's a big mouthful, but these, we're not doing this work in isolation. There's a bunch of different hospital violence intervention programs and hospital-linked programs coming up all over the country. [00:47:00] We're working with researchers and program leaders to think about collectively, like, what are the right outcomes?

and I think we're having a much bigger shift towards patient-centered outcomes. So these would be things like patients set a goal, are they achieving the goal? Right. So we look at goal setting and goal completion as one of our key metrics of success for our program. So that can be things like setting a goal, like getting to the next grade in school, going to detention less, getting a job, getting my GED.

For others, it can be having secure housing, having, like, getting a driver's license or the things you need to, like, be able to get a job and exist in society. for others, it can be addressing underlying mental health concerns, which is, We have a lot of our teens and kids especially, like, identify anger management as something that they wanna work on.

So that's, again, something that the community- People 

Mark Mullen: identify these goals themselves. 

Kristin Mueller: They identify- 

Mark Mullen: Choosing- Yep ... very relevant things for themselves. 

Kristin Mueller: Exactly. With some coaching from their- Sure ... social work case managers, which is a little bit of a misnomer for the healthcare community. We call them case managers 'cause that is the term our patients prefer, again, [00:48:00] using language that's acceptable to our population, but they're all clinically licensed social workers.

Gotcha. But there is some stigma in the background of, like, not all of our patients wanna interact with a social worker 'cause they're like, "Ooh, what happened- Oh, gosh ... that I've got a social worker?" Yeah. Or, "A social worker's gonna come take my kids." 

Mark Mullen: Right. Yeah. 

Kristin Mueller: And that's not what this program is. 

Mark Mullen: Right.

They're just here to help me manage things. 

Kristin Mueller: Exactly. 

Mark Mullen: Yeah. Okay. So when you look at those individual goals, what are you seeing? 

Kristin Mueller: Yeah. So, during our pilot data, we are seeing... And these are some studies that are just going out for publication now, so fresh out. Not even off the press yet. 

Mark Mullen: Sweet. 

Kristin Mueller: Yeah.

But during our pilot period of the first couple years of the program, which launched in 2018, we found that about 85% of our patients had at least o- one documented set goal that they had chosen for themselves. May have had more actually set, but as I like to tell our med students and our resident trainees too, it only happened if you document it.

So you may have had a, like, huge clinical care discussion with somebody at the bedside- So true ... if you didn't write it down. 

Mark Mullen: So true. 

Kristin Mueller: I mean, did the care happen? Of course, it did. Yeah. But you just can't account for it in the same way. 

Mark Mullen: Right. 

Kristin Mueller: and we've had over 60% of patients achieve their [00:49:00] goals. 

Mark Mullen: Wow. 

Kristin Mueller: And it's a wide spectrum 'cause some goals are just inherently more achievable than others.

Like, I want to heal from my wounds. Great. We are, like, really well-positioned to help you do that. I want to buy a house in this economy, and while recovering from injury and maybe a tough socioeconomic background, like, that's a bigger goal that takes time. But we want our patients to still be setting their goals and to help them get on their path, if you will.

So we're looking at goal setting, goal achievement. we're also- Starting to get into, developing some protocols to look more specifically at healthcare utilization with the hope that patients in our program are more accessing care more appropriately. So it's not that we don't want patients in the program to be accessing healthcare, but we'd like them to come in when it's early.

So for me as an ER doctor, like, if somebody's been shot and they're having trouble, I wanna see them on, like, day one of the interaction. 

Mark Mullen: Right, 

Kristin Mueller: right. Or when they're just starting to feel a little bit depressed and not when they're in a full-blown psychiatric crisis or coming in with osteomyelitis that needs, you know, three or six weeks of IV [00:50:00] antibiotics and a prolonged hospitalization.

So thinking about how we can, like, really support our patients getting to their clinic appointments, having their medicines, having good nutrition after being injured, which again, we think about... I know you're not surgical-based specialties, but, like, having access to good nutrition and protein can make a big difference in healing- Mm-hmm, mm-hmm

after injury or after any kind of surgery. So we think about that as well. Like, do our patients have food to eat? As basic as that. 

Mark Mullen: And I imagine when you talk to your case managers- Mm-hmm ... what are they telling you about what they're seeing in the people that they're working with? 

Kristin Mueller: Yeah, it's a big mix.

So there's some people who just need, especially the young adults, we're finding that usually two or three months of care and services is enough to kinda get them back on their feet and get them where they need to be with the, of course, exceptions for longer care for folks who need it. So that'll again be like, "I need help healing from my wounds, going to my doctor's appointment, and I wanna get back to work."

Mark Mullen: Mm-hmm. 

Kristin Mueller: That's a kinda like the trajectory- Thank you, goodbye ... for a lot of our young adults. And, you know, giving them the resources to stay [00:51:00] connected with healthcare longer. Whereas for some of the kids, what we'll see is they'll recover from their injury, but they are still... They got a lot going on. So they really benter, benefit from both, like, the counseling and the mentorship piece that this program offers 'cause it's not just mental health counseling, although that can be a big part of it, but also modeling, like, what does it look like to have a professional adult in your life- 

Mark Mullen: Yeah, totally

Kristin Mueller: who, like, can coach you on how to do well in school, how to apply for college, how to apply for jobs. we can help get kids into job training programs, and young adults too, like the Job Corps in St. Louis. So being able to, like, model that sort of life again. And 

Mark Mullen: again, since you're on a podcast now and this is not- Yeah

peer-reviewed data, your case managers would tell you that when they are engaging with these children at, let's say, 14- Yeah ... after firearm violence, after any violent- 

Kristin Mueller: Mm-hmm ... 

Mark Mullen: traumatic event- Mm-hmm ... are they seeing success stories, so to speak? 

Kristin Mueller: Oh my gosh, yes. So many. I should have brought all my qualitative quotes 'cause I've also, like, really gotten into the qualitative [00:52:00] side of things as we think about evaluation too, like asking patients and families- Okay

and staff and partners, like, how is the program going? 

Mark Mullen: Right, like- How are we doing? ... we just take you at face value. we're not studying this to get confidence intervals and- Yeah ... we're studying 10,000 patients. We're just talking to you about how is this going for you. What do they tell you?

Kristin Mueller: Yeah. so again, maybe some sampling bias in who's- Sure ... responding to our studies. Fair 

Mark Mullen: enough. 

Kristin Mueller: but on the whole, it's going really well. So parents of kids are like, "I'm able to communicate with my child in a way we could never communicate before," because our, your case, our, well, case managers are teaching them how to express themselves better, how to articulate what they're feeling.

again, for the kids who are working on their anger management, so it's not just, like, shouting or throwing a tantrum, which is a very, normal response to trauma, wanna be clear about that in children. Sure. But, like, how do they process their feelings? How do they communicate what they want and need to their family members?

So, like, that's a much more productive, successful, like, emotional relationship in the family. So that's some of it. Kids doing better in school. We had, like, one kid who just needed... [00:53:00] I think more than one, but like one story that stuck with me, a kid who just wanted football equipment. So he-- like, when he was healed, he wanted to get back on the football team, but he couldn't afford his football equipment.

So like, "Yeah, we can help you do that." 

Mark Mullen: Wow. "

Kristin Mueller: We wanna have you, like, have that protective team environment-" Yep ... around you, like, promote that positive activity." So it can be stuff like that. and then for some of the-- honestly, the kids and the adults, one of the, like, most heartwarming and heartbreaking piece of it is that, like, somebody cares about me, and how important that has been to our participants and to our community is that there are people in this program whose whole job it is to just care about me.

Yeah. 

Mark Mullen: And they're reliable adults. 

Kristin Mueller: And reliable. Yeah. Yeah, and consistent and accountable. They do the things they say they're gonna do. They're here for me. We've had some of our case managers go to graduations for kids from high school or different things, and they're like, "I was the person who was there for my kid."

And the kid was like, "That was the only person..." Or like young adult. I'm using the term kid usel- loosely. Sure. But, like, my case manager came and was there [00:54:00] for me, and I'd never had somebody in my life like that before. So it's really kind of amazing to think about how we can leverage our inpatient hospital infrastructure- 

Mark Mullen: Mm-hmm

Kristin Mueller: to be able to provide that level of wraparound care and long-term-- like, being an important person in somebody's life. 

Mark Mullen: Yeah. Yeah. It's really a pretty radical reimagining of what the hospital is for, and when I was prepping, I noticed that Life Outside of Violence, the acronym is LOV. 

Kristin Mueller: Mm-hmm. 

Mark Mullen: And I was wondering, I know academics are really into their creative acronyms, and I wondered if there was something to that.

But I feel like based on just this last part of our conversation, I'm guessing that the answer is that was a deliberate choice. 

Kristin Mueller: So it was a deliberate choice. I can't take credit for it. I am the worst at acronym generation. I think this one actually goes to trauma surgeon Doug Scherr- 

Mark Mullen: Okay ... 

Kristin Mueller: at Barnes, came up with this acronym, vetted by the team.

but it really does encompass our mission because we want to help support our patients having a life outside of violence where violent injury is not their defining feature, but we also want them to feel the love. We want to... [00:55:00] Like, we do. We-- I care about my patients. Our program cares about our patients.

Mark Mullen: Yeah. 

Kristin Mueller: It's really how can we take it to the next step. Again, as you mentioned, like, how can we be reimagining healthcare to bring this level of real human connectedness and care in front of our patients and their families in a way that supports health? 

Mark Mullen: Beautiful. Dr. Mueller, thank you for all of your work on behalf of our community.

Mm-hmm. Thank you for joining me, for visiting SLU as our AOA Visiting Professor. Do you have any final thoughts for our Psychiatry Boot Camp audience? Oh my gosh. 

Kristin Mueller: Well, again, Hospital Violence Intervention Program's part of the CVI ecosystem Find out if you're-- where you're living, if you've got one in your community, in your local hospital, your local university.

Find out who else is doing violence prevention or different community groups. And I'm just gonna give a quick shout-out to the Brick Bullet Related Injury Clinic and Crime Victim Center, who are big partners in our work and help support our patients kinda throughout their journey, and to every other partner who I didn't mention by name, so we got a 

Mark Mullen: lot- It's a lot.

It's-- I appreciate you not mentioning them by name- Yeah. ... 'cause there's quite the laundry [00:56:00] list. 

Kristin Mueller: Yes. But I also want to just highlight, going back to the first part of our discussion, is that maybe not everybody who's listening to this podcast is gonna be in a position to help or support an HVIP. but to the psychiatrist in particular, reaching out to see if you do have violence intervention programs- Yeah

in your community, could you become a referral source for those programs? Because we do the counseling where patients are in their recovery period, but we would really love to have more of our patients in long-term psychiatric care if that's what they need for their mental health needs. So, like, how can we-- even if you got a six-month wait list, how on, like, week one do we get them referred to your clinic so we've got a long-term transition plan?

Mark Mullen: I can promise you there are zero psychiatrists listening that don't appreciate the value of a caseworker. 

Kristin Mueller: Mm-hmm. 

Mark Mullen: Do you know off the top of your head, if people are listening in other states, where can they find their local hospital-based violence prevention program? 

Kristin Mueller: Yes. So I would go to the havi.org, H-A-V-I.O-R-G, and that's kinda the best place to just see the map of all the different hospital violence intervention programs that exist.

[00:57:00] And m- you should have resources to get connected through there. 

Mark Mullen: Okay. 

Kristin Mueller: Okay. 

Mark Mullen: Sounds good. We'll link that in the episode notes, and we'll move into our outro. Thank you, Dr. Muelner. Thank 

Kristin Mueller: you so much.

Mark Mullen: Thank you so much for listening. I'm your host, Mark Mullen. If you're enjoying the show, we'd love to hear from you. We're on Instagram and TikTok @psychbootcamp, and you can connect with our fun human content podcast family at Human Content Pods. You can contact me directly at psychiatrybootcamp.com. If you are enjoying the show, we would really appreciate a review on Apple Podcasts or rating on Spotify.

We have CME coming out soon, so that will be another great way to support the show. And as promised, we are gonna read some of our latest reviews on air. This one I actually did cry a little bit over, so I appreciate the incredible gift for whoever wrote this. The title says, "Addresses the why, not just the how.

An extremely important podcast for anyone going into psychiatry and a useful reminder for those within the field. Dr. Mullen does a spectacular job tackling the difficult to answer questions about what the role of a [00:58:00] psychiatrist should be and evaluates what the goals of different services should be.

While as an intern, I was initially disappointed that this podcast did not have the high yield facts I had been hoping to find, I now on a re-listen am realizing this podcast influenced my day-to-day goals and values more than any other resource did." Full episodes are available on YouTube at Psychiatry Boot Camp.

Thanks again for listening. I'm your host, Mark Mullen. Our executive producers are me, Mark Mullen, Aron Korney, Rob Goldman, and Shahnti Brooke. Episode outline was produced by Matthew Braddock, who is also the season producer with Amina Janjua. Our editor and engineer is Jason Portizo. Music by Omer Ben-Zvi.

To learn about our program disclaimer and ethics policy, submission verification and licensing terms, and our HIPAA release policy, go to psychiatrybootcamp.com or reach out to us directly with any questions or concerns. Psychiatry Boot Camp is a Human Content production.[00:59:00] 

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