Kiesha Fraser Doh, MD
It is a hot summer evening, and you are called overhead for a trauma stat or Level 1, or whatever the terminology is in your institution for penetrating torso gunshot wounds, and you think not again? This is my second one tonight! When the flight team arrives, they relay the history of one child unloading their dad’s gun and shooting the patient, their sibling. You reflect on the previous trauma alert earlier this evening where parents found a teenager with a gunshot wound to his head. These scenarios are increasingly common and entirely preventable.
What if there was something you the emergency medicine (EM) physician could do to combat this increasingly common scenario?
As many pediatric emergency medicine physicians are acutely aware pediatric emergency department (ED) visits decreased over the last year by 39%, but there was a 42% increase in firearm-related visits.1 In my institution, we saw a 50% increase in firearm-related injuries from 2019 to 2020. Furthermore, as of 2019, firearm injury is the 2nd cause of death in children 0-18 years and the number one cause of death in children 0-24 years.2 Underscoring these trends, this past month was gun violence awareness month, but in this month alone, a total of 541 children and adolescents 0-17 years were killed or injured by a gun.3 Reviewing the statistics on suicide are also increasingly grim. From 2007-2018, suicide rates among children ages 10-24 years increased by 56%.4 Suicide by firearm accounted for 657 of the 1,732, 0-17 year old pediatric firearm deaths in 2019 or 38%.5
As EM physicians, you may feel helpless and believe there is no way to impact this public health crisis. Many of us may think that we are not “preventionist” physicians; we are “reactionist” physicians. Something happens to a patient. They become injured or ill, and we step in to stabilize them and manage the acute process, whether it be a traumatic injury or devastating illness that brings a patient to the ED; prevention is seldom at the forefront of our management.
But I am an optimist that believes that we can reverse this trend of increasing firearm-related injuries. Let me describe a few situations we EM physicians have all encountered to potentially impact the rise in firearm-related injuries.
The first patient scenario is depressed, recently, or currently suicidal, homicidal patient, or aggressive patient. In separate conversations with the caregivers, provide counseling to them by saying, “What many parents do when there is someone in their family in crisis is that they store their guns away from the home with a relative, at a gun range, or self-storage facility. If you have guns at home, is that something you could consider?” Ensure that both parents are involved in this conversation as males are frequently the primary gun owner.6 Studies have shown that only 18% of ED physicians document a lethal means screening in patients who present with suicidal ideation.7 A lethal means screening entails asking about the presence of firearms or other lethal means in the home. Since fatalities occur in 90% of suicide attempts with a firearm compared to 2% of suicide overdose attempts, this could be a potentially life-saving conversation.8 Furthermore, 69% of persons treated for self-harm in a hospital setting have visited the ED in the past 30 days before their intentional self-harm and suicide visit.9
After screening the caregivers’ home, then in a separate conversation, ask the child if they access to instruments to hurt themselves, such as firearms, razors, and medications? Approximately 80% of firearm-related suicides occur in the home of the child or in a relative’s home, with the firearm belonging to either the child or parent in 90% of cases.10 Then inform the caregivers if the child states they have access as many parents may not be aware.11 Give parents ideas for ways to remove firearms. Utilize this link for tips on how to provide tips on counseling: https://www.hsph.harvard.edu/means-matter/recommendations/clinicians/
The second scenario I propose to intervene in is the impulsive, curious toddler who has ingested grandmother’s medication. This is an excellent time for general guidance on childproofing the home. Stating if your child can get into medicines, imagine what else they can get into in the home. Children as young as two years old have been able to pull the trigger on a gun,12 so recommending that families keep all guns locked up, unloaded, and separate from ammunition will decrease injury and death. One in 3 children in the US live in homes with guns.13 In addition, three-fourths of those children know where those guns are, and 20% of them state that they have handled the gun without their parent’s knowledge.14
So, the next time you have a level one trauma page involving a firearm injury, you can counteract the effects of that injury with a positive prevention intervention in your subsequent encounter with the suicidal adolescent or curious toddler. Your impact can make a difference one patient at a time. EM physicians can become “preventionist” physicians, not just “reactionist” physicians, with numerous opportunities to provide lethal means screening and childproofing guidance.
- Gastineau KAB, Williams DJ, Hall M, et al. Prepublication Release Pediatric Firearm-Related Hospital Encounters During the SARS-CoV-2 Pandemic. Pediatrics. Published online 2021. doi:10.1542/peds.2021-050223
- National Center for Injury Prevention and Control C for DC and P. Web-based injury statistics query and reporting system. Accessed March 8, 2019. https://webappa.cdc.gov/sasweb/ncipc/leadcause.html
- Gun Violence Archive. Accessed July 5, 2021. https://www.gunviolencearchive.org/
- Curtin SC. National Vital Statistics Reports Volume 69, Number 11 September 11, 2020 State Suicide Rates Among Adolescents and Young Adults Aged 10–24: United States, 2000–2018. Vol 69.; 2020. Accessed July 5, 2021. https://www.cdc.gov/nchs/products/index.htm.
- Centers for Disease Control and Prevention & NC for IP and C. Injury prevention and control: Data & statistics (WISQARS), key injury and violence data. Accessed January 11, 2021. https://www.cdc.gov/injury/wisqars/index.html
- The demographics and politics of gun-owning households | Pew Research Center. Accessed January 20, 2021. https://www.pewresearch.org/fact-tank/2014/07/15/the-demographics-and-politics-of-gun-owning-households/
- Betz ME, Kautzman M, Segal DL, et al. Frequency of lethal means assessment among emergency department patients with a positive suicide risk screen. Psychiatry Res. 2018;260:30-35. doi:10.1016/j.psychres.2017.11.038
- Conner A, Azrael D, Miller M. Suicide case-fatality rates in the United States, 2007 to 2014 a nationwide population-based study. Ann Intern Med. 2019;171(12):885-895. doi:10.7326/M19-1324
- Kammer J, Rahman M, Finnerty M, et al. Most Individuals Are Seen in Outpatient Medical Settings Prior to Intentional Self-Harm and Suicide Attempts Treated in a Hospital Setting. J Behav Heal Serv Res. 2021;48(2):306-319. doi:10.1007/s11414-020-09717-1
- Schnitzer PG, Dykstra HK, Trigylidas TE, Lichenstein R. Firearm suicide among youth in the United States, 2004–2015. J Behav Med. 2019;42(4):584-590. doi:10.1007/s10865-019-00037-0
- Parikh K, Silver A, Patel SJ, Iqbal SF, Goyal M. Pediatric Firearm-Related Injuries in the United States. Hosp Pediatr. 2017;7(6):303-312. doi:10.1542/hpeds.2016-0146
- #NotAnAccident Index | Everytown Research & Policy | Everytown Research & Policy. Accessed July 5, 2021. https://everytownresearch.org/maps/notanaccident/
- Crifasi CK, Doucette ML, McGinty EE, Webster DW, Barry CL. Storage practices of US gun owners in 2016. Am J Public Health. 2018;108(4):532-537. doi:10.2105/AJPH.2017.304262
- Baxley F, Miller M. Parental misperceptions about children and firearms. Arch Pediatr Adolesc Med. 2006;160(5):542-547. doi:10.1001/archpedi.160.5.542