Articles, Blog

Firearm Injury Prevention and Health Care Providers

My name is Garen
Wintemute, I’m an ER doc, and I became involved in firearm
violence prevention in order to intervene upstream in the
flow of events that brings people through the doors of
the emergency department. The fact of the matter is, most
people who die from firearm violence never make
it to the hospital; they die where they’re shot. So we need to prevent
people from getting shot in the first place. For years I’ve heard from
providers who wanted to get involved in firearm violence
prevention but didn’t know where to start. After that awful shooting in Las Vegas in October 2017, I wrote a journal
article asking clinicians to make public commitments
to discuss firearms with their patients. I solicited feedback
on what providers needed to make their
efforts a success. We learned that providers need
more training and knowledge—on how to identify risk factors and
how to ask about firearms—and they need materials to give to patients. A team of clinicians
and researchers is meeting these needs. Our new What You
Can Do initiative provides background
information, specific how-to recommendations, and fact
sheets for both patients and providers. We’ve designed the initiative
to help providers assess patient risk, counsel on safe firearm
practices when indicated, and take further action
when there is imminent risk of danger. This point-of-care
intervention is something that providers can do now, in
their everyday interactions with patients. Public mass shootings are
driving the national narrative. Whoever we might be, the
victims are just like us; the shootings happen in
places just like our places. But the overwhelming majority
of firearm deaths in the United States—98% or so—are everyday
events that often don’t make the headlines. Two facts dominate any depiction
of fatal firearm violence in the United States: the
remarkably high rate of firearm homicide among young
men—particularly young black men—and the high rate of firearm
suicide among older white men. To prevent the greatest number
of firearm deaths and injuries, our attention should be
on the prevention of these and the other types of, if you will,
“everyday” firearm mortality. And here’s a point of
the utmost importance: our efforts should be driven by
the knowledge that it doesn’t have to be this way. Our success in preventing deaths
and injuries from motor vehicle crashes proves that health care
professionals can take action that will make a difference. Here in the US, firearm laws
vary widely from state to state and can change from
one year to the next. But one key policy is consistent
right across the states, It’s that we CAN ask
patients about firearms. Here are the tasks at hand: identify risk
for firearm injury and death, discuss firearms with
patients who are at risk, and act when someone is
in imminent danger. We’re not recommending here
a universal approach. We should have
conversations about firearms and firearm safety when we
feel it’s directly relevant to the health of our
patients or others. To start asking patients
about firearm access, we need to be comfortable
identifying risk factors. Generally, there are three
types of risk for firearm injury or death: Belonging to a demographic
group that’s at increased risk, having individual risk factors,
and having thoughts or active intent to commit harm. Demographic groups
at risk include Children and adolescents, for
unintentional firearm injury and adolescent suicide Middle-aged and older
men, for suicide And adolescent and
young men, for homicide. Those with individual-level
risk factors for firearm violence or
unintentional firearm injury are patients: with a history of
violent behavior or of violent victimization with an abusive partner with a history of
alcohol or drug misuse with serious and poorly
controlled mental illness, or with impaired
cognition or judgment. Risk for patients with these
individual-level risk factors can easily be increased by a
factor of 5. Finally, patients with suicidal
or homicidal ideation or intent may well present an acute danger
to themselves or others. When we’ve identified a
patient at increased risk, we should remember to frame
firearms in a health and safety context—as a matter
of patient wellbeing. We should be ready to explain
why we’re asking about firearms and why the patient is at
risk. Our message, as
providers, should be to reduce access for those
who are at increased risk. Given risk, we should ask. You might start by saying
“in situations like these, I’m concerned about safety, so
I ask questions about safety hazards. For example, are there any
firearms in your home?” Given an affirmative answer—that
an at-risk person has access to a firearm—we should counsel. We might want to know: Who
can access the firearms, how the firearms are stored, and who the firearms belong to. We should plan a
tailored conversation. Our counseling, just as with
counseling on other risks and health behaviors, should: Be respectful and nonjudgmental, Relate clearly to patient’s
health and wellbeing, Be conversational
and educational, Acknowledge local
firearm customs, and Include appropriate follow up. If not all firearms in
the home are stored safely and the situation
is not urgent, we should discuss safe firearm
storage options and plan to follow up at the next visit. Let’s take a quick look at what
“safe firearm storage” actually means. First, store firearms
unloaded, locked up using a storage device, and
separate from ammunition. Assume that children know
the location of firearms and ammunition in the home. Keep the keys or
combinations to firearm locking devices
inaccessible to children and other people at risk. The right firearm locking
device for a firearm owner will vary based on what type
of firearms he or she has and the reasons for
owning those firearms. If someone is at high risk
for harm in the near future and firearms are
not stored safely, referrals to social services
or mental health services, substance abuse referrals,
and lethal means counseling might be appropriate. Depending on the circumstances,
we may need to contact local law enforcement or the patient’s
family so that firearms can be recovered and kept safe. Our team has put materials
at our website for you to use for you to send home with patients. More information on firearm
violence—epidemiology, risk factors, asking
and counseling, patient receptivity, and
interventions—is there as well. And if you can’t
find your answer, please get in touch with us
at the email address you see on the screen and
we’ll be happy to help. As providers, we can
play a critical role in reducing firearm injury and
death, right where we work, with the patients we
are seeing every day. Thanks very much, and good luck!

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