Violence: Recognition, Management, and PreventionPerceived Roles of Emergency Department Physicians Regarding Anticipatory Guidance on Firearm Safety
Introduction
In the United States, firearm violence is a major public health problem. In 2007, 31,224 people were killed by firearms, 69,863 individuals were non-fatally wounded by firearms, and 48,676 were treated in hospitals for their gunshot wounds 1, 2. In the same year, 782,750 years of potential life lost (YPLL) were attributed to firearm fatalities, which was 6.6% of the year's total YPLL (3). In 2000, the medical costs associated with interpersonal firearm violence were $17.4 billion, and from self-inflicted firearm violence were $16.4 billion (4). These statistics indicate that firearm violence accounted for almost half (48%) of the total medical costs associated with violence-related injuries (4). Considering the burden of intentional injuries in 2007, “assaults” and “other unspecified mechanisms” (i.e., assaults by firearms, explosives, and other mechanisms) were the cause of 1,477,000 and 587,000 Emergency Department (ED) visits, respectively (5). Some of these visits were recurrent intentional injuries that have been characterized as a chronic disease of urban trauma centers.
The extensive presence of firearms, especially handguns, is a significant contributory factor to the firearm violence in the United States. Approximately 42 million (38%) households and 57 million (26%) adults own at least one type of firearm, with almost half (48%) of those owning four or more firearms (6). Firearm violence is most prevalent in states with the highest levels of gun ownership (7). Firearms in households are linked to increased rates of both suicides and homicides. Those individuals who keep firearms in their home, when compared to individuals who do not have firearms at home, are 1.9 times more likely to die from homicides and 3.4 times more likely to die from suicides 8, 9. A disproportionate share of the firearm trauma occurs to African American urban males (10). The danger of unsecured or unlocked firearms in the household is also a danger to children, with at least 40% of households with both firearms and children having at least one firearm not locked or properly secured (11). The danger of firearm violence to American youth is a realistic one; one youth is killed with a firearm every 3 h (12). Additionally, for every child who dies from firearm injury, another four are wounded by firearms (13).
Emergency Physicians frequently deal with a variety of serious injuries, including firearm trauma to persons in need of immediate, often life-saving treatment. Violence to patients before they arrive at the ED and violence in the ED are occupational hazards encountered by physicians working in EDs. Approximately 75% of surveyed Emergency Physicians working in the state of Michigan reported having been verbally threatened, and 28% reported having been physically assaulted in the past year. Furthermore, 42% of the Emergency Physicians reported carrying a weapon for safety concerns, with knives (20%) and guns (18%) reported as the most carried weapons (14). Such role modeling seems to be antithetical to reducing firearm violence.
Experts in firearm trauma have concluded that one of the best ways to reduce firearm trauma is through “means restriction.” Means restriction is removing easy access to the most common and most lethal means of fatal homicides and suicides, namely firearms 15, 16. At least two studies have shown that when adults were advised by ED health professionals to restrict access to firearms, they were more likely to do so than adults not advised to restrict access 17, 18, 19.
Because Emergency Physicians regularly encounter firearm violence victims at a time when information on this issue is highly salient to the victims or their families, it would be important to know if Emergency Physicians avail themselves of this opportunity. Thus, the purpose of this study was to seek answers to the following questions. Do Emergency Physicians perceive firearm violence to be a major problem in the United States? What proportion of Emergency Physicians counsel patients on firearm safety, and what are the characteristics of physicians who counsel patients on firearm safety? Do Emergency Physicians routinely chart information on patient ownership and access to firearms? With what types of patients are they most likely to discuss firearm issues? What do they perceive as barriers to discussing firearm violence with patients or their families? How confident are Emergency Physicians in being able to use the 5 As (Asking, Advising, Assessing, Assisting, and Arranging follow-up contacts) in counseling patients or their families regarding firearms? What types of advocacy activities would Emergency Physicians be willing to engage in to reduce firearm violence?
Section snippets
Subjects
A membership list of approximately 18,000 Emergency Physicians was obtained from the American College of Emergency Physicians. This list was narrowed down to potential participants (n = 14,000) who were Emergency Physicians that lived in the United States, were currently working, and were not students or fellows. An a priori power analysis for external validity of the results was conducted (20). Based on an eligible population of 14,000 Emergency Physicians and an 80/20 split with regard to the
Background and Demographic Characteristics
Out of the 500 questionnaires that were mailed, 11 questionnaires could not be used (incorrect address, student member received the questionnaire, wrong specialty, etc.). A total of 278 out of 489 physicians responded (56.8%). The Emergency Physicians were primarily male (80.2%), white (83.1%), ages 40–49 years (40.3%), and worked in a suburban ED (46.8%) (Table 1). In addition, the majority (59.0%) did not own a firearm. However, if the physician owned a firearm, one-third (33.6%) kept the
Discussion
Over 100,000 Americans are shot each year; most will end up in the ED 1, 2. ED visits represent an important opportunity for anticipatory guidance regarding subsequent firearm mortality. When young male adults show up as victims of violent assault or when violence between significant others brings these individuals or others (i.e., mentally ill) into the ED, these individuals are important examples of the need for anticipatory guidance on firearm safety (26). Means restriction anticipatory
Conclusions
Emergency Physicians can play a critical role in screening patients for accessible firearms (i.e., handguns) and providing focused interventions on means restriction. Our results support the notion that Emergency Physicians need further formal training on firearms violence as it impacts both homicides and suicides. Additional research is needed assessing the outcomes of training Emergency Physicians on means restriction anticipatory guidance. It may be that a more efficient use of Emergency
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