Proceedings from the Medical Summit on Firearm Injury Prevention: A Public Health Approach to Reduce Death and Disability in the US

Shots fired: evaluation of vascular injury, compartment syndrome, and transfusion rates among civilian ballistic orthopaedic fracture patients presenting to two Level I trauma centres

PURPOSE

This study investigates baseline patient demographics and predictors of vascular injury, blood transfusion, and compartment syndrome in patients with orthopaedic fractures secondary to GSWs at two high-volume Level I trauma centres.

METHODS

A retrospective chart review of all GSW-related trauma patients at two Level I trauma centres between July 2019 and September 2021 was conducted. Chi-squared and two-tailed independent t tests were used for data analysis, and logistic regression with odds ratios (OR) determined predictors of primary outcomes.

RESULTS

Among 478 GSW patients, 94 (19.7%) sustained 130 orthopaedic fractures, most commonly at the lower extremity (77.7%). Orthopaedic fracture patients showed significantly higher rates of vascular injury (29.8 vs. 4.7%, p < 0.001), transfusion (27.7 vs. 12.8%, p = 0.006), and compartment syndrome (3.2 vs. 0.3%, p = 0.011) compared to non-orthopaedic injury patients. Univariable analysis identified ankle (OR = 47.50, p < 0.001) and hip/femur fractures (OR = 5.31, p < 0.001) as predictors of vascular injury. Multivariable logistic regression revealed lower extremity vascular injury (OR = 54.69, p = 0.006) and anatomic fracture sites of the humerus (OR = 15.17, p = 0.008), clavicle/scapula (OR = 11.30, p = 0.009), and acetabulum/pelvis (OR = 7.17, p = 0.025) as predictors of blood transfusion. Univariable analysis showed lower extremity vascular injury (OR = 30.14, p = 0.007) as a predictor of compartment syndrome.

CONCLUSION

These findings underscore the importance of diagnosing and managing vascular injuries and compartment syndrome in GSW-related orthopaedic fractures, emphasizing the necessity for targeted transfusion strategies in such cases.

Promoting Firearm Injury Prevention and Advocacy as Pediatric Surgeons: A Call to Action From the APSA/AAP Advocacy Committee

Firearm injuries have become the leading cause of death among American children. Here we review the scope of the problem, and the pivotal role pediatric surgeons have in preventing pediatric firearm injury. Specific methods for screening and counseling are reviewed, as well as how to overcome barriers. Community and hospital resources as well as organizational efforts are discussed. Finally, a path for surgeon advocacy is outlined as is a call to action for the pediatric surgeon, as we are uniquely poised to identify pediatric patients and deliver timely interventions to reduce the impact of firearm violence. LEVEL OF EVIDENCE: Level IV.

Firearm injuries treated at trauma centers in the United States

BACKGROUND

While firearm injuries and deaths continue to be a major public health problem, the number of nonfatal firearm injuries and the characteristics of patients are not well-known. The American College of Surgeons Committee on Trauma leveraged an existing data system to collect additional data on fatal and nonfatal firearm injuries presenting to trauma centers. This report provides an overview of this initiative and highlights the challenges associated with capturing actionable data on firearm-injured patients.

METHODS

A total of 128 trauma centers that are part of the American College of Surgeons Trauma Quality Improvement Program collected data on individuals of any age arriving alive between March 1, 2021, and February 28, 2022, with a firearm injury. In addition to the standard data collected for Trauma Quality Improvement Program, abstractors also extracted additional data specific to this study. We linked data from the Distressed Community Index to patient records using zip code of residence.

RESULTS

A total of 17,395 patients were included, with mean (SD) age of 30.2 (13.5) years, 82.5% were male, and the majority were Black and non-Hispanic. The mean proportion of variables with missing data varied among trauma centers, with a mean of 20.7% missing data. Injuries occurred most commonly in homes (31.2%) or on the street (26.6%); 70.4% of injuries were due to assaults. Nearly one third of patients were discharged from the emergency department, 25.9% were admitted directly to the operating room, and 10.9% were admitted to the intensive care unit; 5.9% died in the emergency department, and 10.3% died overall during their course of care. Nearly two thirds of patients lived in the two highest distressed categories of communities; only 7.5% lived in the least distressed quintile.

CONCLUSION

Using trauma center data can be a valuable tool to improve our knowledge of firearm injuries if clinical practices and documentation of patient risks and circumstances are standardized.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Toward Tailored and Targeted Communication for the Promotion of Firearm Safety: A Qualitative Study With Firearm Retailers

Firearm injury is a major yet understudied public health issue in the U.S. This qualitative study explored firearm retailers' perspectives to inform messaging and communication approaches to promote firearm safety among the gun owning population. Semi-structured interviews were conducted with 17 retailers at a single gun shop in Texas. Thematic analysis identified key themes related to (1) audience segmentation, (2) appropriate use of language, and (3) trusted messengers and modalities for the communication of firearm safety information. This formative work provides practical insights to optimize public health messaging in this arena and ultimately reduce firearm injuries. Overall, this study provides valuable insights to guide the development and implementation of evidence-based, social marketing efforts aiming to promote firearm safety across various gun-owning audiences.

Documentation of Trauma-Informed Care Elements for Young People Hospitalized After Assault Trauma

INTRODUCTION

Violent traumatic injury, including firearm violence, can adversely impact individual and community health. Trauma-informed care (TIC) can promote resilience and prevent future violence in patients who have experienced trauma. However, few protocols exist to facilitate implementation of TIC for patients who survive traumatic injury. The purpose of the study is to characterize documentation of TIC practices and identify opportunities for intervention in a single academic quaternary care center.

METHODS

This study is a retrospective chart review analyzing the documentation of trauma-informed elements in the electronic medical record of a random sample of youth patients (ages 12-23) admitted for assault trauma to the pediatric (n = 50) and adult trauma (n = 200) services between 2016 and mid-2021. Descriptive statistics were used to summarize patient demographics, hospitalization characteristics, and documentation of trauma-informed elements. Chi-square analyses were performed to compare pediatric and adult trauma services.

RESULTS

Among pediatric and adult assault trauma patients, 36.0% and 80.5% were hospitalized for firearm injury, respectively. More patients admitted to the pediatric trauma service (96%) had at least one trauma-informed element documented than patients admitted to the adult service (82.5%). Social workers were the most likely clinicians to document a trauma-informed element. Pain assessment and social support were most frequently documented. Safety assessments for suicidal ideation, retaliatory violence, and access to a firearm were rarely documented.

CONCLUSIONS

Results highlight opportunities to develop trauma-informed interventions for youth admitted for assault trauma. Standardized TIC documentation could be used to assess risk of violent reinjury and mitigate sequelae of trauma.

Can Baseline Patient Clinical and Demographic Characteristics Predict Response to Early Posttraumatic Stress Disorder Interventions After Physical Injury?

OBJECTIVE

A growing evidence base supports stepped care interventions for the early treatment of posttraumatic stress disorder (PTSD) after physical injury. Few investigations have examined the characteristics of patients who do and do not respond to these interventions.

METHOD

This investigation was a secondary analysis that used previously collected data from three randomized clinical trials of stepped care interventions (patient N = 498). The study hypothesized that a subgroup of patients would manifest persistent PTSD symptoms regardless of randomization to intervention or control conditions, and that characteristics present at the time of baseline injury hospitalization could distinguish patients who would develop persistent symptoms from potential treatment responders. Regression analyses identified baseline patient clinical and demographic characteristics that were associated with persistent PTSD symptoms over the 6-months post-injury. Additional analyses identified treatment attributes of intervention patients who were and were not likely to demonstrate persistent symptoms.

RESULTS

A substantial subgroup of patients (n = 222, 44.6%) demonstrated persistent PTSD symptoms over time. Greater numbers of pre-injury trauma, pre-injury PTSD symptoms, elevated early post-injury PTSD symptoms, unemployment, and non-White race identified patients with persistent symptoms. Patients with ≥3 of these baseline risk characteristics demonstrated diminished treatment responses when compared to patients with <3 characteristics. Intervention patients with ≥3 risk characteristics were less likely to engage in treatment and required greater amounts of interventionist time.

CONCLUSIONS

Injured trauma survivors have readily identifiable characteristics at the time of hospitalization that can distinguish responders to PTSD stepped care interventions versus patients who may be treatment refractory.

Surgeon views on firearm safety counseling in clinical practice: A cross-sectional survey

BACKGROUND

Firearms are commonplace in the United States, and one proposed strategy to decrease risk of firearm injury is to have physicians counsel their patients about safe firearm ownership. Current rates of firearm safety counseling by surgeons who care for injured people are unknown.

METHODS

This study used an anonymous cross-sectional survey derived from previously published survey instruments and was piloted (n = 13) at the annual meeting of the American Association for the Surgery of Trauma (2022). The finalized survey was distributed using a quick response code during two sessions at the 2022 American College of Surgeons Clinical Congress. Eligible participants included the surgeons and surgical trainees who attended these sessions.

RESULTS

One hundred fourteen individuals completed the survey (20% response rate), and a majority were male (n = 71 [62.3%]), attending surgeons (n = 108 [94.7%]), and specialized in acute care surgery (n = 72 [63.2%]). Few participants (n = 43 [37.7%]) reported counseling patients on firearm safety as part of their routine clinical practice; however, the majority (n = 102 [89.5%]) believed that surgeons should provide firearm safety counseling. Counseling rates did not vary significantly by age, sex, surgical specialty, or region of practice, but attitudes toward counseling did differ by firearm safety counseling practices ( p = 0.03) and region of practice (0.04). Noted barriers to counseling included lack of time (n = 47 [41.2%]), perceived lack of training (n = 43 [37.7%]), and lack of firearm knowledge/experience (n = 36 [31.6%]).

CONCLUSION

Most surgeon respondents did not provide firearm safety counseling to their patients despite the fact the majority believed they should. This suggests that counseling interventions that do not solely rely on surgeons for implementation could increase the number of patients who receive firearm safety guidance during clinical encounters.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Firearm-Related Violence in the Pediatric Population

Children, particularly adolescents, are dying from firearm-related injuries. Screening for firearms, early recognition of firearm-related concerns, appropriate referrals, and follow-up are crucial to the safety of our patients and their families. Clinicians are strongly encouraged to address firearm-related violence during clinical encounters. Risk reduction, advocacy, and policy implementation are key in mitigating the long-term negative sequelae of firearm violence in youth. The epidemiology of firearm-related death, mass shootings, school firearm violence, adolescent health, prevention, injury patterns, postinjury care, policy, and resources are all discussed in this article. [Pediatr Ann. 2024;53(1):e28-e33.].

Pediatric Surgery Firearm Injury Collaborative Symposium

Injury from a firearm is now the leading cause of death of children and youth under age 19 in the United States (U.S.) [1] and the incidence of these deaths continues to increase each year [2]. For every death from firearm violence, there are several young people who have been injured by a bullet but not killed. As pediatric surgeons, we are on the front lines of treating these young patients. We have the unforgettable memories of delivering the horrible news to parents in "quiet rooms." [3]. As these injuries fall within our scope of practice, it is incumbent on us as professionals to work to prevent these injuries, apply best practices and work for the best pathways to recovery for our patients who do survive. There is a diverse community of pediatric surgeons tackling this public health problem in a variety of ways [4]. In a pre-meeting symposium at the APSA 2023 Annual meeting, we brought together a community of pediatric surgeons working on this critical area. The following summarizes the presentations of the symposium, with topics including Risk Factors, Injury Prevention, Treatment, Public Initiatives, and National Collaborative Efforts. TYPE OF STUDY: Review Article, Proceedings of a Symposium. LEVEL OF EVIDENCE: 1 through 4 all presented.

Addressing health equity in pediatric surgical care in the United States- Progress and challenges

There are notable inequities in health outcomes for children based on their social determinants of health (SDOH), including where they are born and live, their primary language, their race and ethnicity, socioeconomic status, and more. These health inequities are not restricted to resource limited settings; here we highlight three broad topics that are relevant to pediatric surgeons in the United States (US): access to care and disparities, and examples of inequities in firearm-related injuries and appendicitis. Most of our patients will at some point require operative interventions, yet there can be significant challenges in accessing this care and navigating our health systems, particularly around complex perioperative care. There are significant opportunities to improve equitable care by helping patients navigate our health systems and connecting them with additional resources, including screening for primary care services. Firearm-related injuries are now the leading cause of death in children in the US, with significant associated morbidity for non-fatal injuries. There are notable inequities in the risk of injury and types of injuries experienced by children based on their SDOH. Appendicitis is one of the most common pathologies managed by pediatric surgeons, with similar inequities in the rates of perforated appendicitis based on a child's SDOH. For both issues, addressing the inequities our patients experience requires moving upstream and working towards prevention. Key opportunities include better research and data to understand the drivers for observed inequities, multidisciplinary collaboration, community engagement, and public health advocacy among others. As a profession, we have a responsibility to work to address the health inequities our patients experience.

State Reporting Requirements for Involuntary Holds, Court-Ordered Guardianship, and the US National Firearm Background Check System

Importance

Firearm violence is a leading cause of death in the US. There is broad public agreement that individuals at high risk of perpetrating violence should not be allowed to purchase or possess firearms. The National Instant Criminal Background Check System (NICS) is a national system intended to stop firearm purchases or possession by prohibited persons, but there is heterogeneity in how states interact with and report data to NICS.

Objective

To examine variability in state requirements for NICS reporting for mental health prohibitions.

Design and Setting

This cross-sectional study in the US reviewed current statutes for all 50 states and the District of Columbia (enacted through the 2021 legislative session) regarding reporting mental health prohibitions to NICS or state systems. Data were analyzed from October 2022 to April 2023.

Main Outcomes and Measures

For each state, the following were recorded: reliance on Federal Bureau of Investigation vs state point of contact for NICS checks; regulation requiring or allowing reporting to NICS for 3 hypothetical cases; and details on reporting responsibility and time frame. The number of NICS listings for adjudicated mental health reasons was obtained, and state rates per 1000 population were calculated. To compare states, we developed 3 hypothetical cases of individuals with risk of firearm violence, whether possibly temporary (involuntary commitment for decompensated psychosis, or involuntary short-term psychiatric hold for suicidal ideation) or chronic and progressive (court-appointed guardianship for dementia).

Results

A total of 39 states required and 5 allowed reporting to NICS for court-ordered, involuntary psychiatric hospitalization. Thirteen states required and 5 allowed reporting to NICS when a court determines an individual is mentally incompetent to manage their affairs (with or without guardianship). Two states required NICS reporting for short-term emergency psychiatric holds. Five states and the District of Columbia had no legislation explicitly requiring or allowing NICS reporting in the 3 scenarios.

Conclusions and Relevance

In this cross-sectional study of state laws, there was substantial heterogeneity in NICS reporting requirements and lack of clarity around processes. This raises questions about the ability of NICS to be used to block firearm purchases or possession by individuals with court-identified high risk of perpetrating violence toward themselves or others.

Funding the war in America: A look in the mirror

BACKGROUND

Health care political action committees (HPACs) historically contribute more to candidates opposing firearm restrictions (FRs), clashing with their affiliated medical societies. These societies have increasingly emphasized the prevention of firearm violence and it is not known if recent contributions by their HPACs have aligned with their stated goals. We hypothesized that such HPACs still contribute similar amounts toward legislators up for reelection opposing FR.

METHODS

We identified HPACs of medical societies endorsing one or both calls-to-action against firearm violence published in the Annals of Internal Medicine (2015, 2019). House of Representatives (HOR) votes on H.R.8, a background checks bill, were characterized from GovTrack. We compiled HPAC contributions between the H.R.8 vote and election to HOR members up for re-election from the National Institute on Money in Politics. Our primary outcome was total campaign contributions by H.R.8 stance. Secondary outcomes included percentage of politicians funded and total contributions.

RESULTS

Nineteen societies endorsed one or both call-to-action articles. Three hundred eighty-five of 430 HOR members ran for reelection in 2020. Those endorsing H.R.8 (n = 226, 59%) received $2.8 M for $4,750 (interquartile range [IQR], $1000-$15,500) per candidate. Those opposing (n = 159, 41%) received $1.5 M for $2,500 (IQR, $0-$11,000) per candidate ( p = 0.0057). Health care political action committees donated toward a median of 20% (IQR, 7-28) of candidates endorsing H.R.8 and 9% (IQR, 4-22) of candidates opposing H.R.8 ( p = 0.0014). Those endorsing H.R.8 received 1,585 total contributions for a median of 3 (IQR, 1-10) contributions per candidate, while those opposing received 834 total contributions for a median of 2 (IQR, 0-7) contributions per candidate ( p = 0.0029).

CONCLUSION

Politicians voting against background checks received substantial contributions toward reelection from the HPACs of societies advocating for firearm restrictions. However, this is the first study to suggest that HPAC's contributions have become more congruent with their respective societies. Further alignment of medical society goals and their HPAC political contributions could have a profound impact on firearm violence.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Follow-up household assessment for child unintentional injuries two years after the intervention: A community-based study from Karachi, Pakistan

BACKGROUND

Unintentional childhood injuries are a growing public health concern, and the home is the most common location for non-fatal injuries in children less than 5 years of age. This study describes the long-term effects of two injury prevention educational interventions for caregivers-an educational pamphlet and an in-home tutorial guide-by comparing the change in the prevalence of home injury hazards before and after the interventions.

METHODS

This was a pre- (June and July 2010) and post-study with short-term follow-up (November-December 2010) and long-term follow-up (November 2012- January 2013). Neighborhood one included households that received only educational pamphlets after completing a baseline assessment; neighborhood two included households that received an in-home tutorial guide after completing the baseline assessment and receiving the educational pamphlet. The main outcome of this study was the reduction in home injury hazards for children under 5 years of age.

RESULTS

A total of 312 households participated in the long-term phase to compare the effect of the interventions. Between the short-term to long-term follow-up, injury hazards significantly reduced in neighborhood two compared to neighborhood one. These included fall hazards (walker use) (IRR 0.24 [95% CI 0.08-0.71]), drowning hazards (open bucket of water in the courtyard and uncovered water pool) (IRR 0.45 [95% CI 0.85-0.98] and IRR 0.46 [95% CI 0.76-0.94]), burn hazards (iron, water heater within reach of child) (IRR 0.56 [95% CI 0.33-0.78] and IRR 0.58 [95% CI 0.32-0.91]), poisoning hazards (shampoo/soap and medicine within reach of child) (IRR 0.53 [95% CI 0.44-0.77] and IRR 0.7 [95% CI 0.44-0.98]) and breakable objects within reach of child (IRR 0.62 [95% CI: 0.39-0.99]).

CONCLUSION

An injury prevention tutorial to caretakers of children supplemented with pamphlets could significantly decrease the incidence of falls, drowning, burns, poisoning, and cut injury hazards for children under 5 years of age in their homes in a low-resource setting. This intervention has the potential to be integrated in existing public health programs, such as Lady Health Visitors (LHVs), to disseminate injury prevention information in routine home health visits.

Firearm Injuries during Pregnancy in the USA

Trauma during pregnancy is the leading cause of non-pregnancy-related maternal deaths, with some due to injuries from firearms. It was the purpose of this study to characterize the patterns and presentations of firearm-associated injuries in pregnant women using a national emergency department visit database. Data from the Inter-University Consortium for Political and Social Research Firearm Injury Surveillance Study 1993-2020 were utilized. The data include age, sex, race, type of firearm, perpetrator of injury, intent of injury (unintentional, assault, suicide, or law enforcement), anatomic location of the injury, incident locale, disposition from the emergency department (ED), and whether the patient was shot or not with the firearm. Of the 3.36 million ED visits over this time span for firearm injuries, 4410 were pregnant women. The mean age of the pregnant cohort was 23.6 years, with more Hispanic and fewer White women in the pregnant group compared to the non-pregnant cohort. Pregnant women were more likely to experience an injury involving the lower trunk and had a higher percentage of fatalities and hospital admissions compared to the non-pregnant cohort. Fetal demise occurred in at least 70% of cases. Nearly one half of the assaults (44%) occurred on Saturdays and Sundays. As the cause of these injuries is complex, prevention will require input from multiple sources, including health care providers, social agencies, government agencies, elected officials, and law enforcement.

Firearm locking device preferences among firearm owners in the USA: a systematic review

BACKGROUND

Preventing firearm-involved injuries is a critical public health priority. Firearm locking devices can prevent firearm injuries, such as suicide and unintentional shootings, as well as theft. Various firearm locking devices exist; however, little is known about firearm owners' preferred locking devices for secure firearm storage. In this systematic review, we examined existing literature on preferred locking devices for secure storage of personal firearms among United States (US) firearm owners with the purpose of understanding practical implications and needs for future research.

METHODS

We searched 8 major databases, as well as the grey literature, for English-language sources published on or before January 24, 2023, that empirically examined firearm locking device preferences. Following PRISMA guidelines, coders independently screened and reviewed 797 sources using pre-determined criteria. Overall, 38 records met inclusion criteria and were included in this review.

RESULTS

The majority of studies measure and report on participant use of various types of locking devices, but few go on to measure preference between device options and the attributes and features that may contribute to an individual's preference. Included studies suggest that a preference for larger devices, such as lockboxes and gun safes, may exist among US firearm owners.

CONCLUSIONS

Review of included studies suggests that current prevention efforts may not be aligned with firearm owners' preferences. Additionally, findings from this systematic review emphasize the need for additional methodological rigorous research to understand firearm locking device preferences. Expanded knowledge in this area will result in actionable data and foundational best practices for programming that encourages behavior change concerning secure storage of personal firearms to prevent injury and death.

Firearm Injuries to the Wrist and Hand in Children and Adults: An Epidemiologic Study

BACKGROUND

Gunshot wounds (GSWs) to the wrist and hand are a major health and economic burden in the United States. There are few studies examining the circumstances and epidemiological factors surrounding these injuries. This study assesses the epidemiological factors, as well as the shooting circumstances, injury details, and surgical management of wrist and hand GSWs in children and adults.

METHODS

Medical records and radiographs were reviewed for all patients with ballistic injury to the wrist or hand treated at an urban academic level 1 trauma center from 2016 to 2019. Fisher exact and Pearson χ2 tests were used to assess differences between groups.

RESULTS

Two hundred forty-nine victims (29 children, 220 adults) with complete documentation were identified. Among 180 victims with known shooting circumstances, 132 (70%) were shot by another person and 110 (65%) were injured by intentional gunfire. Eighty-seven victims (35%) suffered a concurrent GSW to another body region. Metacarpal fracture was the most commonly diagnosed bony injury (37%), followed by proximal phalanx fracture (25%). One hundred twenty-nine victims (52%) underwent surgery following their injuries. Nerve discontinuity was diagnosed in 27 victims (11%), while 20 victims (8%) had vascular disruption. There was no significant difference between children and adult victims' type of fracture, concurrent injuries, rates of surgery, or in the most common fracture fixation method.

CONCLUSIONS

Most wrist and hand GSW victims were injured due to intentional, non-self-inflicted gunfire. Most patients present with hand fractures, and fortunately, nerve and vascular disruptions are uncommon.

Fractures in Children Due to Firearm Activity

The purpose of this study was to investigate fracture patterns due to pediatric firearm injuries. The data used was from the US Firearm Injury Surveillance Study 1993–2019. Over these 27 years, there were 19,033 children with fractures due to firearm activity with an average age of 12.2 years; 85.2% were boys and the firearm was a powder type in 64.7%. The finger was the most common fracture location, while the tibia/fibula was the most common location for those admitted to the hospital. Children ≤ 5 years of age sustained more skull/face fractures; most spine fractures occurred in the 11–15-year age group. The injury was self-inflicted in 65.2% of the non-powder and 30.6% of the powder group. The injury intent was an assault in 50.0% of the powder and 3.7% of the non-powder firearm group. Powder firearms accounted for the majority of the fractures in the ≤5 and 11–15 year-olds, non-powder firearms accounted for the majority of the fractures in the 6–10 year-olds. Injuries occurring at home decreased with increasing age; there was an increase in hospital admissions over time. In conclusion, our findings support the need for safe storage of firearms in the home away from children. This data will be helpful to assess any changes in prevalence or demographics with future firearm legislation or other prevention programs. The increasing acuity of firearm-associated injuries seen in this study is detrimental to the child, impacts familial wellbeing, and results in significant financial costs to society.

Factors associated with new mental health diagnoses and resource utilization among pediatric patients following trauma admission

PURPOSE

Injured children are at risk for a variety of physical and emotional sequelae that may impair their ability to return to prior function. The effect of traumatic injury on mental health in children is not well characterized or understood. We sought to determine factors associated with new mental health diagnoses and/or mental health resource utilization following admission to a Level 1 pediatric trauma center for traumatic injury.

METHODS

A retrospective chart review of patients admitted for accidental trauma between 2016 and 2019 was performed. Demographic data, injury characteristics, new mental health diagnoses and/or mental health resource utilization following hospitalization were extracted. Patients with prior mental health diagnosis, psychotropic prescription(s), or resource utilization were excluded from this cohort. A multivariable logistic regression model was used to examine predictors of new mental health diagnoses and/or resource utilization.

RESULTS

The prevalence of new mental health diagnoses or resources utilization was 9.5% (363/3828). The most common diagnoses were anxiety disorders and nonbipolar depression. The most common psychotropic medication prescribed was antidepressants. Patients with new mental illness were older (odds ratio [OR] 1.1 [95% CI: 1.06, 1.12]), more likely to sustain burn injuries (OR 6.3 [4.2, 9.5]), have non-sports related injuries (OR 3.5 [2.1, 6.0]), and be pedestrian struck (OR 2.7 [1.5, 4.8]). They additionally were more likely to sustain head, neck, and spine injuries (OR 3.8 [2.9, 5.1], 2.4 [1.1, 5.5], and 2.1 [1.3, 3.3], respectively).

CONCLUSIONS

There are a variety of demographic and injury specific factors associated with new mental health diagnoses and/or resource utilization in children following admission for trauma. Knowledge of these risk factors may ensure patients are allocated adequate resources to promote timely access to appropriate mental health services after hospitalization.

TYPE OF STUDY

Retrospective comparative study LEVEL OF EVIDENCE: III.

Extreme Risk Protection Orders in Washington State: Understanding the Role of Health Professionals

Objective

Extreme Risk Protection Orders (ERPO) allow a petitioner to file a civil order to temporarily restrict access to firearms among individuals ("respondents") deemed to be at extreme risk of harming themselves, others, or both. Although unable to file ERPOs for their clients in most states, health professionals may play a pivotal role in the ERPO process by recommending an eligible petitioner initiate the process. We describe the process of filing an ERPO when a healthcare, mental health, or social service professional contacted an ERPO petitioner.

Method

Court documents of ERPOs involving health professionals in Washington State between December 8th, 2016 and May 10th, 2019 were qualitatively analyzed (n=24). We constructed pen portraits from the documents and analyzed them using an inductive qualitative thematic approach.

Results

Themes included factors influencing the process by which each professional evaluated respondent behaviors, factors considered during assessment, factors influencing interpretation of respondent behaviors and subsequent provider response during a crisis. These influenced the outcome of the crisis event that led to ERPO filing.

Conclusions

Each professional group differed in their approach to risk assessment of respondent behaviors. Strategies to better coordinate and align approaches may improve the ERPO process.

Legal Firearm Sales at State Level and Rates of Violent Crime, Property Crime, and Homicides

INTRODUCTION

The effects of firearm sales and legislation on crime and violence are intensely debated, with multiple studies yielding differing results. We hypothesized that increased lawful firearm sales would not be associated with the rates of crime and homicide when studied using a robust statistical method.

METHODS

National and state rates of crime and homicide during 1999-2015 were obtained from the United States Department of Justice and the Centers for Disease Control and Prevention. National Instant Criminal Background Check System background checks were used as a surrogate for lawful firearm sales. A general multiple linear regression model using log event rates was used to assess the effect of firearm sales on crime and homicide rates. Additional modeling was then performed on a state basis using an autoregressive correlation structure with generalized estimating equation estimates for standard errors to adjust for the interdependence of variables year to year within a particular state.

RESULTS

Nationally, all crime rates except the Centers for Disease Control and Prevention-designated firearm homicides decreased as firearm sales increased over the study period. Using a naive national model, increases in firearm sales were associated with significant decreases in multiple crime categories. However, a more robust analysis using generalized estimating equation estimates on state-level data demonstrated increases in firearms sales were not associated with changes in any crime variables examined.

CONCLUSIONS

Robust analysis does not identify an association between increased lawful firearm sales and rates of crime or homicide. Based on this, it is unclear if efforts to limit lawful firearm sales would have any effect on rates of crime, homicide, or injuries from violence committed with firearms.

A mixed methods protocol to implement universal firearm injury risk screening and intervention among youth and adults in emergency departments across a large US health system

BACKGROUND

Firearm injury is a leading cause of preventable death in the USA. Healthcare providers are uniquely poised to focus on firearm safety and injury prevention from an apolitical harm reduction lens; however, few providers and healthcare settings incorporate firearm injury prevention strategies into usual care. We outline the first protocol to determine how to implement universal Firearm Injury and Mortality Prevention (FIMP) strategies that identify and address firearm access and violence risk in healthcare settings as part of routine care using the Consolidated Framework for Implementation Research (CFIR) to inform implementation and evaluation.

METHODS

The components of our FIMP strategy, including universal screening, intervention for patients at risk, and resources, will be developed from existing evidence-based strategies for firearm access and violence risk (intervention characteristics). The implementation process will include components of Screening, Brief Intervention, and Referral to Treatment (SBIRT) for substance use, adapted to FIMP (implementation process). To engage stakeholders, harmonize language, and garner support, an Executive Advisory Board (EAB) will be formed, consisting of the site- and system-level stakeholders (inner setting) and community stakeholders, including influential figures such as local religious and spiritual leaders, individuals with lived experience, and community-based organizations (outer setting). Pre-implementation surveys will identify the characteristics of individuals and guide the development of education prior to implementation. Patient-level screening data will be analyzed to identify the risk factors, implementation will be evaluated using mixed methods, and a limited-efficacy study will evaluate whether strategies were successful in driving behavior change.

DISCUSSION

This study protocol has breakthrough and methodological innovations, by addressing FIMP as part of usual care to directly mitigate firearm injury risk among youth, adults, and household members (e.g., children) and by using rigorous methods to inform healthcare industry implementation of FIMP strategies. The expected outcomes of this study protocol will provide a solid basis for larger-scale dissemination and evaluation of implementation, effectiveness, and usability across broader pediatric and adult healthcare settings. This project will advance the implementation science and have a positive impact on the health of our patients and communities by preventing firearm injury and mortality and shifting the paradigm to view FIMP through a public health lens.

Patient and Clinician Perspectives of a Standardized Question About Firearm Access to Support Suicide Prevention: A Qualitative Study

Importance

US residents report broad access to firearms, which are the most common means of suicide death in the US. Standardized firearm access questions during routine health care encounters are uncommon despite potential benefits for suicide prevention.

Objective

To explore patient and clinician experiences with a standard question about firearm access on a self-administered mental health questionnaire routinely used prior to primary care and mental health specialty encounters.

Design, Setting, and Participants

Qualitative semistructured interviews were conducted from November 18, 2019, to October 8, 2020, at Kaiser Permanente Washington, a large integrated care delivery system and insurance provider. Electronic health record data identified adult patients with a documented mental health diagnosis who had received a standard question about firearm access ("Do you have access to guns? yes/no") within the prior 2 weeks. A stratified sampling distribution selected 30% who answered "yes," 30% who answered "no," and 40% who left the question blank. Two groups of clinicians responsible for safety planning with patients at risk of suicide were also sampled: (1) licensed clinical social workers (LICSWs) in primary and urgent care settings and (2) consulting nurses (RNs).

Main Outcomes and Measures

Participants completed semistructured telephone interviews, which were recorded and transcribed. Directive (deductive) and conventional (inductive) content analyses were used to apply knowledge from prior research and describe new information. Thematic analysis was used to organize key content, and triangulation was used to describe the intersections between patient and clinician perspectives.

Results

Thirty-six patients were interviewed (of 76 sampled; mean [SD] age, 47.3 [17.9] years; 19 [53%] were male; 27 [75%] were White; 3 [8%] were Black; and 1 [3%] was Latinx or Hispanic. Sixteen participants had reported firearm access and 15 had reported thoughts of self-harm on the questionnaire used for sampling. Thirty clinicians were interviewed (of 51 sampled) (mean [SD] age, 44.3 [12.1] years; 24 [80%] were female; 18 [60%] were White; 5 [17%] were Asian or Pacific Islander; and 4 [13%] were Latinx or Hispanic) including 25 LICSWs and 5 RNs. Key organizing themes included perceived value of standardized questions about firearm access, challenges of asking and answering, and considerations for practice improvement. Clinician interview themes largely converged and/or complemented patient interviews.

Conclusions and Relevance

In this qualitative study using semistructured interviews with patients and clinicians, a standardized question about firearm access was found to encourage dialogue about firearm access. Respondents underscored the importance of nonjudgmental acknowledgment of patients' reasons for firearm access as key to patient-centered practice improvement.

Firearm Violence in Wilmington, DE:: An Update on 2020

Firearm violence within Delaware has been concentrated in the City of Wilmington and rates disproportionately affect populations, with the highest disparity and inequity in mortality among young Black men. This commentary provides an update to a prior review from 2018 with an analysis of the factors contributing to a surge in 2020 and the years beyond.

Firearm-Related Injuries and Deaths in Children and Youth: Injury Prevention and Harm Reduction

Firearms are the leading cause of death in children and youth 0 to 24 years of age in the United States. They are also an important cause of injury with long-term physical and mental health consequences. A multipronged approach with layers of protection focused on harm reduction, which has been successful in decreasing motor vehicle-related injuries, is essential to decrease firearm injuries and deaths in children and youth. Interventions should be focused on the individual, household, community, and policy level. Strategies for harm reduction for pediatric firearm injuries include providing anticipatory guidance regarding the increased risk of firearm injuries and deaths with firearms in the home as well as the principles of safer firearm storage. In addition, lethal means counseling for patients and families with individuals at risk for self-harm and suicide is important. Community-level interventions include hospital and community-based violence intervention programs. The implementation of safety regulations for firearms as well as enacting legislation are also essential for firearm injury prevention. Increased funding for data infrastructure and research is also crucial to better understand risks and protective factors for firearm violence, which can then inform effective prevention interventions. To reverse this trend of increasing firearm violence, it is imperative for the wider community of clinicians, public health advocates, community stakeholders, researchers, funders, and policy makers to collaboratively address the growing public health crisis of firearm injuries in US youth.

A Qualitative study on diverse perspectives and identities of firearm owners

OBJECTIVE

Research surrounding firearm ownership is often contextualised within the perspectives of older white men. We expand this description using the perceptions of a diverse group of firearm-owning stakeholders.

METHODS

We conducted semistructured interviews from October 2020 to May 2021 with Colorado/Washington State stakeholders representing (1) firearm ranges/retailers; (2) law enforcement agencies or (3) relevant state/national firearm organisations. Data were analysed using standard qualitative techniques and included 25 participants, representing varied sociocultural groups including racial and ethnic minorities, political minorities and sexual minorities.

RESULTS

Participants for this analysis were of different self-identified sociocultural groups including racial and ethnic minorities (African American, Hispanic and Asian), political minorities (liberal) and sexual minorities, defined as Lesbian, Gay, Bisexual, and Transgender (LGBT). Perspectives on firearm ownership included an idea of gun culture as a component of (1) personal identity, (2) an expression of full citizenship and (3) necessary for self-protection. A strong subtheme was the intersection of minority group and firearm owner identities, creating a need for divergent social communities because of ideas on traditional gun culture. These communities are a safe place for individuals belonging to minority groups to escape negative external and internal group associations with firearms.

CONCLUSION

Perspectives on firearms and firearm ownership in the secondary analysis were heterogeneous and related to personal experiences, external and internal group pressures that influence individual behaviour. Understanding the breadth of perspectives on firearm ownership is imperative to engaging individuals for risk reduction. This study adds to the literature by expanding an understanding of the motivation for firearm ownership among diverse communities.

Childhood injury prevention: Where we've been and where we need to be

Injury remains the leading cause of death for children and adolescents in the US, and firearm injury has overtaken motor-vehicle crashes as the leading mechanism in the US since the topic of injury prevention was last reviewed in this journal. The success of injury prevention efforts relies on multidisciplinary collaboration, and pediatric surgeons play a central role as clinicians who provide and coordinate the care for injured children, as trauma program leaders, and as advocates for children's health and safety. This review will provide a concise history of injury prevention in the US and highlights three areas where pediatric surgeons have an opportunity to impart impactful change in their communities that could lead to lower injury rates.

Taking Aim at the Injury Prevention Curriculum: Educating Residents on Talking to Patients About Firearm Injury

The medical community recognizes that firearm injury is a public health problem. Yet we lack both the tools for and the implementation of evidence-based firearm injury screening and counseling techniques. One reason for these deficits is the lack of clinical training related to engaging patients in firearm injury risk reduction. In this issue, Rickert et al describe a pre-post evaluation of a 2-part firearm injury prevention training curriculum for first-year medical residents at a single academic medical center. Their manuscript serves an important, but still preliminary, step forward for the field of postgraduate medical education on firearm injury and its prevention. Important elements of this project and paper consist of the inclusion of multiple medical disciplines and the use of standardized patients to evaluate participants' learning. This project also points to the need for further growth. We must commit to consistently and conscientiously framing injuries from guns not as "gun violence" but rather as "firearm injuries" to ensure that they are considered squarely in both the public health space and the clinical space. An ideal curriculum would also highlight the importance of trauma-informed care, cultural competency, and antiracist medical practice while countering implicit biases (e.g., toward gun owners, victims of firearm violence, perpetrators of violence). It should address barriers, as well as facilitators, to change. And most importantly, future educational work must evaluate the effect of these trainings on actual clinical practice-and, even better, the efficacy of education in changing behavior and patient-level outcomes.

The Role of Academic Medical Centers in the Prevention of Violence and Firearm-Related Morbidity and Mortality

This Viewpoint argues that academic medical centers should address firearm violence through clinical care, education of health care professionals, research, and public policy discussions.

Lead toxicity due to retained intracranial bullet fragments: illustrative case

BACKGROUND

Lead toxicity (plumbism) secondary to retained lead bullet fragments is a rare complication in patients with gunshot wounds. To the authors' knowledge, there has been no definitive case reported of lead toxicity due to retained intracranial bullet fragments.

OBSERVATIONS

The authors reported the case of a 23-year-old man who presented after being found down. Computed tomography scanning of the head revealed bullet fragments within the calvaria adjacent to the left transverse sinus. During follow-up, he developed symptoms of plumbism with paresthesias in his bilateral hands and thighs, abdominal cramping, labile mood, and intermittent psychosis. Plumbism was confirmed with sequentially elevated blood lead levels (BLLs). The patient opted for surgical removal of the bullet fragments, which led to reduction in BLLs and resolution of his symptoms.

LESSONS

Although rare, lead toxicity from retained intracranial bullet fragments should be considered in patients who have suffered a gunshot wound to the head and have symptoms of lead toxicity with elevated BLLs. For safe and accessible intracranial bullet fragments in patients with plumbism, surgical intervention may be indicated.

Implementation of an Outpatient Violence Intervention Program to Increase Service Uptake

Challenges in participant recruitment and retention limit the effectiveness of hospital-based violence intervention programs (HVIPs). This study aimed to determine if an outpatient violence intervention program (VIP) could be integrated into a trauma clinic and increase uptake of violence prevention services. Patients previously hospitalized for intent-to-harm being seen for outpatient follow-up were eligible. VIP counselors met with participants during their clinic visit, administered the survey, and offered violence prevention services (April to June 2019). Patients were followed for 6 months to assess involvement. The primary outcome of interest was long-term participation in the VIP, defined as uptake of services at 6 months, in comparison to inpatient recruitment. Out of 76 patients, 34 (44.7%) did not appear for their appointment. The remainder (n = 42) were offered participation in the study, of which 32 (76.2%) completed the survey. From the group offered VIP services, 57.1% expressed interest, and 5 (20.8%) ultimately took part yielding an overall participation rate of 11.9% at 6 months. The inpatient recruitment rate in 2019 was 2.4%. An outpatient VIP program can be integrated into a clinic setting but suffers from the same challenges faced by inpatient programs resulting in low rates of long-term participation in services. Although a high proportion of participants reported interest, actual engagement at 6 months was low. Reasons behind low participation in VIP services must be investigated.

The association between gun shows and firearm injuries: An analysis of 259 gun shows across 23 US cities

Guns shows are estimated to account for 4-9% of firearm sales in the US. Increased regulation of firearm sales at gun shows has been proposed as one approach to reducing firearm injury rates. This study evaluated the association between gun shows and local firearm injury rates. Data regarding the date and location of gun shows from 2017 to 2019 were abstracted from the Big Show Journal. Firearm injury rates were estimated using discharges from trauma centers serving counties within a 25-mile radius of each gun show. Clinical data were derived from the National Trauma Databank (NTDB). We used Poisson regression modeling to adjust for potential confounders including seasonality. We evaluated injury rates before and after 259 gun shows in 23 US locations using firearm injury data from 36 trauma centers. There were 1513 hospitalizations for firearm injuries pre-gun show and 1526 post-gun show. The adjusted mean 2-week rate of all-cause firearm injury per 1,000,000 person-years was 1.79 (1.16-2.76) before and 1.82 (1.18-2.83) after a gun show, with an incident rate ratio of 1.02 (0.94, 1.08). The adjusted mean 2-week rate did not vary significantly by intent after a gun show, (p = 0.24). Within two weeks after a gun show, rates of hospitalization for all-cause firearm injury do not increase significantly within the surrounding communities. The relatively small increase in available firearms after a show and the short time horizon evaluated may account for the absence of an association between gun show firearm sales and local firearm injury rates.

Selection and Use of Firearm and Medication Locking Devices in a Lethal Means Counseling Intervention

Background: While some suicide prevention initiatives distribute locking devices for firearms and medication, little evidence exists to guide the selection of devices. Aims: This study aimed to describe safety standards for locking devices and compare parental acceptance rates for different types of devices. Method: As part of the larger SAFETY Study, behavioral health clinicians provided free locking devices to parents whose child was evaluated in the emergency department (ED) for a suicide-related or behavioral health-related problem. For logistical reasons, we changed the specific devices offered midstudy. Data on device use came from follow-up interviews with 226 parents. Results: Few effective standards exist for locking devices for home use; we could easily break into some. At follow-up, twice as many gun-owning parents were using ED-provided handgun lockboxes as cable locks (28% vs. 14%, p = .02). Overall, 55% of parents reported using an ED-provided medication lockbox, with more using the drawer-sized lockbox than the larger, steel toolbox (60% vs. 42%, p < .01). Limitations: Storage outcomes are from parents' self-report and from one state only. Conclusion: Parents appeared to prefer some devices over others. Our findings suggest the need for (a) effective safety standards, (b) affordable devices meeting these standards, and (c) further research on consumer preferences to ensure use.

Adolescent Suicide—Understanding Unique Risks and Opportunities for Trauma Centers to Recognize, Intervene, and Prevent a Leading Cause of Death

Purpose of Review

This provides up-to-date epidemiology of adolescent suicide and risk factors for suicide and highlights the overlap of risks for suicide and injury. It reviews signs and symptoms, and the up-to-date evidence on screening for depression, post-traumatic stress disorder (PTSD), suicide, substance abuse, and lethal means, and offers strategies of implementation in trauma centers.

Recent Findings

The incidence of adolescent suicide has continued to rise in the USA to 6.5 per 100,000, with notable racial disparities. The risk factors are complex, but many pre-existing risk factors and sequela after injury such as exposures to violence, suicidal behaviors, substance abuse, depression and post-traumatic stress disorder, and specific injuries including traumatic brain injury and spinal cord injury have further emerged as risks. Studies show rates of suicidality as high as 30% in the acute care setting. There are short screening instruments that can be used to universally screen for depression and suicidality in adolescent trauma patients. Step-up models of care for PTSD are promising to increase screening and services after injury. Lethal means counseling, secure firearm storage practices, and firearm safety policies can reduce the risk of suicide.

Summary

Suicide is the second leading cause of death in US adolescents, and trauma patients have significant risk factors for mental illness and suicidality before and after injury. Trauma centers should strongly consider screening adolescents, establish strategies for mental health support and referrals, and provide lethal means counseling to help prevent suicide.

Pediatric Firearm Injury Mortality Epidemiology

Firearm injury is a leading and preventable cause of death for youth in the United States. The Centers for Disease Control and Prevention web-based injury statistics query and reporting system was queried to examine changes in firearm injury mortality among youth aged 0 to 19 from 2001 to 2019. This includes assessment of overall mortality rates, mortality rates based on intent and race/ethnicity, and the proportion of deaths due to homicide, suicide, and unintentional shootings among different age groups. Regression analysis was used to identify significant differences in mortality rate over time between Black and White youth. Deaths due to firearm injury were compared with deaths due to motor vehicle traffic collisions. In 2019, firearm injuries surpassed motor vehicle collisions to become the leading cause of death for youth aged 0 to 19 years in the United States. Homicide is the most common intent across all age groups, but suicide represents a large proportion of firearm deaths in 10- to 19-year-old youth. In 2019, Black youth had a firearm mortality rate 4.3 times higher than that of White youth and a firearm homicide rate over 14 times higher than that of White youth. For each additional year after 2013, the mortality rate for Black youth increased by 0.55 deaths per 100 000 compared with White youth (time by race interaction effect P < .0001). These data indicate the growing burden of firearm injuries on child mortality and widening racial inequities with Black youth disproportionately affected by firearm violence. This public health crisis demands physician advocacy to reduce these preventable deaths among youth.

Nationwide Survey of Trauma Center Screening and Intervention Practices for Posttraumatic Stress Disorder, Firearm Violence, Mental Health, and Substance Use Disorders

BACKGROUND

Posttraumatic stress disorder (PTSD) symptoms, firearm violence events, alcohol and drug use problems, and major depression and suicidal ideation are endemic among patients admitted to US trauma centers. Despite increasing policy importance, the current availability of screening and intervention services for this constellation of conditions in US trauma centers is unknown.

STUDY DESIGN

Trauma program staff at all Level I and Level II trauma centers in the US. (N = 627) were contacted to complete a survey describing screening and intervention procedures for alcohol and drug use problems, PTSD symptoms, depression and suicidality, and firearm violence. Additional questions asked trauma centers about the delivery of peer interventions and information technology capacity for screening and intervention procedures.

RESULTS

Fifty-one percent of trauma centers (n = 322) responded to the survey. More than 95% of responding sites endorsed routinely screening and/or intervening for alcohol use problems. Routine services addressing PTSD were less common, with 28% of centers reporting routine screening. More than 50% of sites that screened for PTSD used previously established trauma center alcohol use services. Programmatic screening and intervention for firearm injury sequelae was occurring at 30% of sites.

CONCLUSION

Alcohol screening and intervention is occurring frequently at US trauma centers and appears to be responsive to American College of Surgeons Committee on Trauma verification requirements. Routine screening and intervention services for PTSD and firearm injury were occurring less frequently. Regular national surveys may be a key element of tracking progress in national mental health and substance use screening, intervention, and referral policy.

UNIVERSAL SCREENING FOR FIREARM INJURY RISK COULD REDUCE HEALTHCARE'S HESISTANCY IN TALKING TO PATIENTS ABOUT FIREARM SAFETY

Despite vast long-standing healthcare industry support for a public health approach to firearm injury and mortality prevention - still -- the minority of physicians, surgeons, nurses, and social workers ask patients questions about firearm access or gun violence risk, let alone counsel about firearm safety.1,2 For most of us, screening and counselling related to firearm injury prevention, though demonstrated to be beneficial,3 continues to fall outside the umbrella of 'usual care' and is often reserved for patients deemed 'high risk' such as those presenting with suicidality, assault-related injuries or perceived risk.1,2,3 But for us to practice what we preach, a complete re-think using a novel, unconventional and non-discriminatory universal firearm injury risk screening approach across trauma, emergency, and primary care settings - for all patients regardless of reason for visit -- may be the transformative change needed to shift the paradigm. By asking each and every patient questions about firearm injury risk as part of routine surgical or medical care, we may finally be able to break down barriers and get comfortable talking to patients about firearm safety. After all, for any public health issue, it all starts with surveillance and screening. If we can't get comfortable asking the necessary questions in the first place, holistic progress from the healthcare lane on our nation's public health crisis of firearm injury and violence will continue to prove elusive.

Consensus-Driven Priorities for Firearm Injury Education Among Medical Professionals

PURPOSE

Firearm injury is a leading cause of morbidity and mortality in the United States. However, many medical professionals currently receive minimal or no education on firearm injury or its prevention. The authors sought to convene a diverse group of national experts in firearm injury epidemiology, injury prevention, and medical education to develop consensus on priorities to inform the creation of learning objectives and curricula for firearm injury education for medical professionals.

METHOD

In 2019, the authors convened an advisory group that was geographically, demographically, and professionally diverse, composed of 33 clinicians, researchers, and educators from across the United States. They used the nominal group technique to achieve consensus on priorities for health professions education on firearm injury. The process involved an initial idea-generating phase, followed by a round-robin sharing of ideas and further idea generation, facilitated discussion and clarification, and the ranking of ideas to generate a prioritized list.

RESULTS

This report provides the first national consensus guidelines on firearm injury education for medical professionals. These priorities include a set of crosscutting, basic, and advanced learning objectives applicable to all contexts of firearm injury and all medical disciplines, specialties, and levels of training. They focus on 7 contextual categories that had previously been identified in the literature: 1 category of general priorities applicable to all contexts and 6 categories of specific contexts, including intimate partner violence, mass violence, officer-involved shootings, peer (nonpartner) violence, suicide, and unintentional injury.

CONCLUSIONS

Robust, data- and consensus-driven priorities for health professions education on firearm injury create a pathway to clinician competence and self-efficacy. With an improved foundation for curriculum development and educational program-building, clinicians will be better informed to engage in a host of firearm injury prevention initiatives both at the bedside and in their communities.

A Preclinical Medical School Curriculum on Firearm Violence to Develop Patient Counseling and Foundational Health Policy Skills

BACKGROUND

Firearm violence is a unique public health crisis in the USA (US). A majority of U.S. physicians believe they should discuss firearm safety with patients. However, little education on firearm injury prevention and counseling exists in medical school. We sought to address this gap by creating a curriculum on firearm violence as a part of a required preclinical medical school course focused on health policy issues.

METHODS

The Kerns 6-step model for curriculum development was used to define the problem and assess learner needs. The two-hour small group session was co-authored by a student and faculty member to address the course theme of health policy as applied to firearm violence. The Issue-Attention Cycle, history of firearm policy, and US politics were incorporated from published literature, with a patient counseling role-play added in 2019.

RESULTS

The 'Current Case in Health Policy - Firearm Violence' small group was implemented in 2018 and 2019 for all first-year medical students. Of the 2018 student evaluations, 57% selected this small group as the most valuable in the course. In a follow-up survey in 2020, 78% of the respondents agreed that they felt more confident counseling patients on firearm safety following the role-play.

CONCLUSION

Students broadly endorsed the incorporation of firearm policy and counseling skills into medical education. This curriculum can be adapted for learners at all stages of training, especially given the limited exposure to this topic in medical education.

A Prospective US National Trauma Center Study of Firearm Injury Survivors Weapon Carriage and Posttraumatic Stress Disorder Symptoms

OBJECTIVE

To describe the demographic, injury-related, and mental health characteristics of firearm injury patients and trace firearm weapon carriage and PTSD symptoms over the year after injury.

SUMMARY AND BACKGROUND DATA

Based on the increasing incidence of firearm injury and need for novel injury prevention strategies, hospital-based violence intervention programs are being implemented in US trauma centers. There is limited data on the long-term outcomes and risk behaviors of firearm injury survivors to guide this work.

METHODS

We conducted a secondary analysis of a pragmatic 25-trauma center randomized trial (N = 635). Baseline characteristics of firearm-injured patients (N = 128) were compared with other trauma patients. Mixed model regression was used to identify risk factors for postinjury firearm weapon carriage and PTSD symptoms.

RESULTS

Firearm injury patients were younger and more likely to be black, male and of lower socioeconomic status, and more likely to carry a firearm in the year before injury. Relative to preinjury, there was a significant drop in firearm weapon carriage at 3- and 6-months postinjury, followed by a return to preinjury levels at 12-months. Firearm injury was significantly and independently associated with an increased risk of postinjury firearm weapon carriage [relative risk = 2.08, 95% confidence interval (1.34, 3.22), P < 0.01] and higher PTSD symptom levels [Beta = 3.82, 95% confidence interval (1.29, 6.35), P < 0.01].

CONCLUSIONS

Firearm injury survivors are at risk for firearm carriage and high PTSD symptom levels postinjury. The significant decrease in the high-risk behavior of firearm weapon carriage at 3-6 months postinjury suggests that there is an important postinjury "teachable moment" that should be targeted with preventive interventions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02655354.