Prevention of firearm-related injuries and deaths among youth. A product-oriented approach

Epidemiology of 577 Pediatric Firearm Fatalities: A 2-year Review of the National Trauma Data Bank

The purpose of this study was to delineate the epidemiology of pediatric firearm injuries, including ethno-demographic patterns with impact on years of potential life lost (YPLL). A 2-year review of the National Trauma Data Bank (2007 to 2008) was conducted. Firearm fatalities in records of patients younger than 18 years were identified. Data were analyzed by demographic and injury characteristics and YPLL was calculated by ethnicity. A total of 577 deaths were identified in the pediatric group. Blacks accounted for 49.7 per cent of the fatalities; Hispanics, 19.2 per cent; whites, 17.7 per cent, and other ethnicity, 13.4 per cent. Median Injury Severity Score was 25 with a median Glasgow Coma Scale score of 3. Traumatic brain injury was present in 84.2 per cent of the records. Assault accounted for 72.8 per cent, self-inflicted injury 12.7 per cent, and unintentional injuries were 8.2 per cent. Most firearm fatalities occurred at home (33.6%). By emergency department (ED) disposition, 29.3 per cent died in the ED, 32.9 per cent were admitted to the intensive care unit, and 30.0 per cent taken to the operating room. Blacks had a total of 17,446 YPLL, Hispanics 6,776 YPLL, and whites 6,718 YPLL. Pediatric firearm fatalities still remain an important public health concern. Inclusive gun control policies focused on primary prevention of accidental injuries may be more effective in mitigating its impact.

Safer storage of firearms at home and risk of suicide: a study of protective factors in a nationally representative sample

OBJECTIVE

To estimate the protective effect of storing firearms locked or unloaded, or both, on the risk of suicide by firearms among people with relatively low intention to die.

DESIGN AND SETTING

Cross sectional survey. The 1993 National Mortality Followback Survey of 22 957 deaths in the United States, representing 2.2 million people, conducted by the National Center for Health Statistics.

PARTICIPANTS

Decedent's next of kin answered questions regarding various aspects of decedent's life to supplement information from death certificates.

MAIN RESULTS

Compared with decedents who stored their firearm unlocked or loaded, those who stored their firearms locked or unloaded, or both, were less likely to commit suicide by firearms (locked: OR = 0.39, 95% CI = 0.24 to 0.66; unloaded OR = 0.30, 95% CI = 0.18 to 0.49).

CONCLUSIONS

This study further supports the utility of devices and practices intended to reduce the likelihood of unauthorised or impulsive use of firearms.

Nonfatal and fatal firearm-related injuries among children aged 14 years and younger: United States, 1993-2000

OBJECTIVE

To provide national estimates of fatal and nonfatal firearm-related (FA) injuries among children < or =14 years old and to examine the circumstances under which these injuries occurred.

METHODS

For nonfatal FA injuries among children, we analyzed data on emergency department (ED) visits from the National Electronic Injury Surveillance System for 1993 through 2000. National estimates of injured children who were treated in hospital EDs were examined by selected characteristics, such as age, gender, race/ethnicity of the patient, primary body part affected, intent of the injury, the relationship of the shooter to the patient, where the injury occurred, and activity at the time of injury. For fatal FA injuries among children, we analyzed mortality data from the National Vital Statistics System for 1993 through 2000. Data from both sources were used to calculate case-fatality rates.

RESULTS

From 1993 through 2000, an estimated 22,661 (95% confidence interval [CI]: 16,668-28,654) or 4.9 per 100,000 (95% CI: 3.6-6.2) children < or = 14 years old with nonfatal FA injuries were treated in US hospital EDs. Assaults accounted for 41.5% of nonfatal FA injuries, and unintentional injuries accounted for 43.1%. Approximately 4 of 5 children who sustained a nonfatal, unintentional FA injury were reportedly shot by themselves or by a friend, a relative, or another person known to them. During this period, 5542, or 1.20 per 100,000 (95% CI: 1.17, 1.23), children < or =14 years old died from FA injuries; 1 of every 5 children who were wounded by a firearm gunshot died from that injury. Most FA deaths were violence related, with homicides and suicides constituting 54.7% and 21.9% of these deaths, respectively. For individuals < or =14 years old, the burden of morbidity and mortality associated with FA injuries falls disproportionately on boys, blacks, and children 10 to 14 years old. Both fatal and nonfatal injury rates declined >50% during the study period.

CONCLUSIONS

Although rates of nonfatal and fatal FA injuries declined during the period of study, FA injuries remain an important public health concern for children. Well-designed evaluation studies are needed to examine the effectiveness of potential interventions aimed at reducing FA injuries among children.

Outcomes in children and young adults who are hospitalized for firearms-related injuries

OBJECTIVES

To compare outcomes by intent of nonfatal firearms-related injuries in a hospitalized population, newborn to 19 years of age, and estimate the national incidence of ensuing disability.

METHODS

Descriptive statistics and comparative analysis using chi(2), odds ratio, and t test were applied to data from the National Pediatric Trauma Registry (NPTR) and the National Electronic Injury Surveillance System of the US Consumer Product Safety Commission. Demographics, preinjury medical history, scene of injury, primary body part injured, severity of injury, utilization of resources, short-term and long-term disability, medical cause of disability, and disposition at discharge were studied.

RESULTS

NPTR unintentional (n = 268) and assault-related firearms-related injuries (n = 506) were compared. In both groups, the majority of patients were male (80%). Compared with the unintentionally injured, the assaulted children were older and more frequently black (59.3% vs 32.5%). Approximately 17% in both groups had a preinjury history of medical/psychosocial problems. Unintentional injuries occurred mainly in private dwellings (75.7%), and assaults occurred in public places/street (53.8%). In both groups, injuries to multiple body regions were prevalent, and a substantial proportion sustained injuries of serious to critical level. Most children were transported by ambulance, but a significant proportion in the unintentional group were transported by helicopter. The rate of admission to the intensive care unit was approximately 40% for both groups. The unintentionally injured had a higher rate of surgical intervention (66.8% vs 50.8%) and stayed in the hospital longer than the assaulted ones (median: 5 days vs 3 days). Almost half of the children in both groups were discharged with disability, and approximately 87% returned to their home. Applying the NPTR disability rate to National Electronic Injury Surveillance System estimates of hospitalization suggests that approximately 3200 children nationwide develop disability from firearms-related injuries annually.

CONCLUSIONS

Nonfatal firearms-related injuries in a pediatric population are associated with a high use of medical resources and lasting disability. Public policies should be developed and implemented to reduce the occurrence of these catastrophic events.

Unintentional and undetermined firearm related deaths: a preventable death analysis for three safety devices

OBJECTIVE

To determine the proportion of unintentional and undetermined firearm related deaths preventable by three safety devices: personalization devices, loaded chamber indicators (LCIs), and magazine safeties. A personalized gun will operate only for an authorized user, a LCI indicates when the gun contains ammunition, and a magazine safety prevents the gun from firing when the ammunition magazine is removed.

DESIGN

Information about all unintentional and undetermined firearm deaths from 1991-98 was obtained from the Office of the Chief Medical Examiner for Maryland, and from the Wisconsin Firearm Injury Reporting System for Milwaukee. Data regarding the victim, shooter, weapon, and circumstances were abstracted. Coding rules to classify each death as preventable, possibly preventable, or not preventable by each of the three safety devices were also applied.

RESULTS

There were a total of 117 firearm related deaths in our sample, 95 (81%) involving handguns. Forty three deaths (37%) were classified as preventable by a personalized gun, 23 (20%) by a LCI, and five (4%) by a magazine safety. Overall, 52 deaths (44%) were preventable by at least one safety device. Deaths involving children 0-17 (relative risk (RR) 3.3, 95% confidence interval (CI) 2.1 to 5.1) and handguns (RR 8.1, 95% CI 1.2 to 53.5) were more likely to be preventable. Projecting the findings to the entire United States, an estimated 442 deaths might have been prevented in 2000 had all guns been equipped with these safety devices.

CONCLUSION

Incorporating safety devices into firearms is an important injury intervention, with the potential to save hundreds of lives each year.

The history of adolescent medicine

The field of adolescent medicine is unique as a subspecialty in that the practice of providing care to teenagers has always been viewed historically as a responsibility of generalists. Scientific advances in subspecialty fields such as endocrinology, gynecology, gastroenterology, infectious disease, and sports medicine were incorporated with considerable success into the general practices of not only pediatricians but also internists and family practitioners. However, societal changes in the past century began to shape the way health professionals thought about adolescents and their families and significantly influenced the practice of providing health care to adolescents. The most notable change, however, was the shift from the traditional role of providing anticipatory guidance to parents toward a reduction of risk-taking behaviors aimed directly at the adolescent. The subspecialty of adolescent medicine thus emerged as an amalgam of researchers, clinicians, and educators, who, through a variety of settings, hoped to advance science, moderate public and social policy, improve health care, and stimulate health promotion to this special population of patients.

Lethality of firearms relative to other suicide methods: a population based study

OBJECTIVES

(1) To quantify lethality of firearms relative to other suicide methods, (2) to quantify the extent to which suicide mortality may be reduced by limiting access to firearms.

METHODS

Data on suicides and hospitalised para-suicides that occurred in the state of Illinois from 1990 to 1997 were combined. Total number of episodes for each suicide method was estimated as the sum of the number of suicides and the number of para-suicides for that method. Gender and suicide method were used as proxies for intention to die, and estimated lethality of suicide methods within method-gender groups (for example, male firearm users). Logistic regression was used to quantify the lethality of firearms relative to other suicide methods. Excess mortality associated with the use of firearms was estimated by conservatively assuming that in the absence of firearms the next most lethal suicide method would be used.

RESULTS

From January 1990 to December 1997, among individuals 10 years or older in the state of Illinois, there were 37,352 hospital admissions for para-suicide and 10,287 completed suicides. Firearms are the most lethal suicide method. Episodes involving firearms are 2.6 times (95% CI 2.1 to 3.1) more lethal than those involving suffocation-the second most lethal suicide method. Preventing access to firearms can reduce the proportion of fatal firearms related suicides by 32% among minors, and 6.5% among adults.

CONCLUSIONS

Limiting access to firearms is a potentially effective means of reducing suicide mortality.

Effect of current federal regulations on handgun safety features

STUDY OBJECTIVE

In the late 1960s, the Bureau of Alcohol, Tobacco, and Firearms implemented the "factoring criteria," a set of minimum size and safety standards required for any handgun imported into the United States. These standards, however, were not applied to guns manufactured domestically. We determine whether extending the factoring criteria to all handguns sold in the United States, as has been proposed in Congress, would increase the likelihood that safety devices would be included in new handgun designs.

METHODS

Imported and domestic handgun models produced in 1996 were examined to determine the prevalence of 4 passively acting safety devices on pistols and 1 passive safety device on revolvers. Domestic models were also scored against the factoring criteria.

RESULTS

Compared with domestic pistol models, imported pistols were more likely to include a firing pin block (odds ratio [OR] 2.43; 95% confidence interval [CI] 1.54 to 3.85) and a loaded chamber indicator (OR 1.59; 95% CI 0.98 to 2.56). Domestic pistol models that already met the factoring criteria were more likely to include a loaded chamber indicator (OR 12.05; 95% CI 2.74 to 53.02), a grip safety (OR 24.12; 95% CI 7.8 to 74.33), and a firing pin block (OR 4.92; 95% CI 2.35 to 10.29) than domestic models that did not meet the criteria.

CONCLUSION

Although pistol models that meet the factoring criteria are more likely to contain safety devices than those that do not, the net effect is modest. Thus, the factoring criteria alone are insufficient to ensure consistent incorporation of safety features into new handgun designs.

Law enforcement officers' opinions about gun locks: anchors on life jackets?

OBJECTIVES

One way law enforcement officers support firearm safety is by promoting the use of gun locks. This investigation examined law enforcement officers' willingness to use gun locks on their own guns, as well as their opinions regarding gun locks in general.

SETTING

Law enforcement officers from an urban agency in the southern region of the United States.

METHODS

Free keyed cable gun locks were distributed to all law enforcement officers in one agency who wanted one, and then an anonymous questionnaire survey was conducted about their subsequent use of, and attitudes toward, these devices.

RESULTS

About half of the 207 officers collected gun locks (n=103). Nearly three quarters (73%) completed and returned the questionnaire. Two thirds reported that they were not using the gun lock they collected (65%), and over half disagreed that gun lock use should be required (56%). Very few cited any actual or potential technical problems with the device. An important reason given for non-use of gun locks related to being able to access the weapon quickly in case of an emergency.

CONCLUSIONS

The findings highlight the need for further investigation into law enforcement officers' attitudes toward gun locks, the degree to which their attitudes affect their firearm safety counseling, and the need to develop a gun safety device that can be disengaged quickly.

Firearm storage practices of officers in a law enforcement agency in the South

BACKGROUND

Law enforcement officers play an important role in promoting firearm safety. This study examined their firearm-related attitudes and practices.

METHODS

We conducted an anonymous, self-administered survey of law enforcement officers in an agency in the South concerning firearm ownership, storage practices, and opinions.

RESULTS

The 207 respondents (response rate=71%) were primarily white (60%) and male (89%). The proportions of respondents with (55%) and without (45%) children were similar. Eighty percent of the officers had firearms in addition to the one they were issued for work. Most stored firearms unlocked (59%) and loaded (68%); almost half (44%) reported storing firearms both unlocked and loaded. Eighty-five percent indicated that they felt an added need to protect themselves and family because of their job. Those who reported having firearms for self-protection were less likely than those who had firearms for recreation to store firearms securely. As compared to those without children, law enforcement officers with children were more likely to store firearms safely, and were especially likely to store firearms locked up (chi(2)=12.72, p<0.0001). Respondents favored background checks, mandatory safety training, and enforcement of storage laws. Three quarters approved of government safety regulations for handguns.

CONCLUSIONS

Despite the law enforcement officers' prominent role in firearm safety promotion and support for initiatives that limit unauthorized access, our study found that many do not practice safe storage. Apparently, many officers keep their firearms stored unlocked and loaded for the purpose of protecting themselves and their families. Addressing concerns about personal safety is a necessary step in promoting safe storage to law enforcement officers.

Firearm storage patterns in US homes with children

OBJECTIVES

This study determined the prevalence and storage patterns of firearms in US homes with children.

METHODS

We analyzed data from the 1994 National Health Interview Survey and Year 2000 objectives supplement. A multistage sample design was used to represent the civilian noninstitutionalized US population.

RESULTS

Respondents from 35% of the homes with children younger than 18 years (representing more than 22 million children in more than 11 million homes) reported having at least 1 firearm. Among homes with children and firearms, 43% had at least 1 unlocked firearm (i.e., not in a locked place and not locked with a trigger lock or other locking mechanism). Overall, 9% kept firearms unlocked and loaded, and 4% kept them unlocked, unloaded, and stored with ammunition; thus, a total of 13% of the homes with children and firearms--1.4 million homes with 2.6 million children--stored firearms in a manner most accessible to children. In contrast, 39% of these families kept firearms locked, unloaded, and separate from ammunition.

CONCLUSIONS

Many children live in homes with firearms that are stored in an accessible manner. Efforts to prevent children's access to firearms are needed.

Handgun safety features: a review for physicians

OBJECTIVE

Handguns are a ubiquitous consumer product in the United States, which annually cause significant morbidity and mortality. Handgun safety devices are often proposed as potential solutions to this problem. Their effectiveness at reducing handgun injuries and deaths is intensely debated. However, to effectively analyze the potential utility of handgun safety devices, physicians need to be aware of the safety devices available in the consumer market and how they operate.

METHODS

A wide variety of safety devices are available in the consumer market, which vary in terms of their ease of operation, cost, and the types of injuries they may prevent. We reviewed several types of handgun safety devices, including loaded chamber indicators, manual thumb safeties, grip safeties, magazine disconnectors, drop safeties, built-in locks, trigger locks, lockboxes, and personalized handguns. Each device is described within the context of reducing unintended discharge and unauthorized use.

RESULTS

This review is not exhaustive. There are other types of safety devices that limit access to handguns. Many of these devices, such as barrel locks and chamber locks, work in a similar manner as trigger locks and have the same limitations. The user of any type of safety device should think about the types of injuries the device is designed to prevent and be aware of its limitations.

CONCLUSION

Physicians have the potential to reduce the risk of firearm injuries with their patients and communities. Providing accurate information on firearm safety devices and their limitations is important, just as it is for other aspects of health care advice. Armed with accurate information, physicians can hopefully be effective in firearm injury prevention.