ED physicians take action to promote firearm safety, curtail gun violence
Working on the front lines gives ED staff undeniable credibility when speaking to the public
ED nurses and physicians regularly witness the reality of gun violence, treating teenagers killed in gang violence, or children killed from playing with unlocked household guns. It's especially painful since these tragedies are preventable, says Stephen Hargarten, MD, MPH, chair of department of emergency medicine at Medical College of Wisconsin in Milwaukee. "Increasingly, physicians are realizing this is an important issue to address in the ED," he reports. "This is a public health problem that deserves our attention."
ED physicians should take a leadership role in addressing gun safety, Hargarten urges. "We have an opportunity, limited as it is, to address prevention strategies," he says. "Firearm safety should be part and parcel of the injury prevention information we give to patients."
Here are some ways to address firearms safety in the ED.
Educate yourself about gun safety. In one situation, which is now an urban legend in the emergency medical community, a physician accidentally discharged a firearm in the ED, wrongly assuming there was no bullet in the chamber. This illustrates the need for gun education on all levels.
ED physicians should become familiar with gun safety devices, says Victor LaCerva, MD, a former emergency physician and author of Pathways to Peace: 40 Steps to a Less Violent America. "A wide range of safety devices are currently available, ranging from a $7 trigger lock, to a three-number combination lock placed on the weapon, to lock boxes that respond to your palm print," he notes. "It is the responsibility of the ED physician to get educated about the safety devices that are out there and to offer information on those devices to patients."
Become a spokesperson. ED clinicians are the best candidates to go out into the community to address gun safety. "Physicians or nurses who actually have experience with gunshot wounds are very effective as spokespeople," says Denise Dowd, MD, MPH, assistant professor of pediatrics for the division of emergency medicine at Children's Mercy Hospital in Kansas City, MO.
Working on the front line gives you undeniable credibility, Dowd emphasizes. "It's very powerful to be able to tell a first-hand story," she says. "If someone in the audience asks, 'Why should I lock my weapon up?' You can say, 'I'll tell you why, because just the other day I saw a child who was killed by a handgun.'"
Consider developing a presentation on gun safety. "When ED physicians speak, their voices are really heard, since they are the ones who have to patch up these gun victims," says LaCerva. "Physicians willing to take that next step into an advocacy role will find an attentive audience."
Take advantage of "teachable moments." "If a patient comes to the ED with a firearm injury, that's an opportunity to address prevention, just as we would if a patient was involved in a motor vehicle crash without a seatbelt," says Hargarten. "Once we have addressed the life-saving issues and determined that this patient is not in acute danger, then we can begin to address some prevention strategies."
When tragedy strikes, it can be a "teachable moment," but some amount of time needs to pass. "You can't address prevention when somebody was shot 10 minutes or an hour ago," Dowd advises. "You've got to let a little bit of time pass between the traumatic event and hitting them with prevention messages.
If the patient is admitted to the hospital, it buys you time to address prevention. "You can go back to the patient the next day and talk in a quieter environment, instead of the hectic ED setting," says Dowd.
Be aware that injured patients may not be receptive. For the most part, severely ill or injured ED patients are resistant to prevention messages, says Dowd. "If you have a kid that's hurting, that's the only thing [he or she] cares about," she notes. "Often, patients aren't open to listening about prevention, and we can't force them to be, nor should we."
If the firearm injury was caused by an assault, it's often too chaotic to get prevention messages across. "When teenagers are shot in drive-bys, they often will tell a resident one story, me another story, and the police something else," says Dowd. "You're dealing with a lot of emotionally charged people, and if you can't even ascertain what happened, then it's difficult to talk about prevention."
It's important to be aware of resistance. "Despite the fact that prevention messages are important, we also need to consider the receptiveness of people that you will be delivering this message to," says Dowd. "For the most part, it's difficult to capture the attention of people who are hurt, because it's not their priority then."
Teach patients while they wait to be seen. Putting an informational video in the waiting room VCR is another way to get the message across, says Dowd. "Written pamphlets should be in the waiting room for people who are interested," she recommends. "People who are waiting to be seen for things which aren't urgent are probably more open to passive prevention messages."
Track incidents. "If we document the firearms injuries we see in the ED, it can help us with prevention in the long run," says Dowd. "If we understand the circumstances, we can do more about it," she says. "We should be asking patients such questions as, `Was the gun locked up? Whose gun was it? Was there a trigger lock? Was there a storage box?"
Firearm injuries should be tracked through the ED, Hargarten recommends. "Certainly we need better information about firearm injuries in our states and communities, and the ED is in a key position to characterize the nature of those injuries," he says.
No effective tracking systems are currently available, says Hargarten. "The state of Massachusetts has the best tracking system for nonfatal firearm injuries, and these data come from the EDs," he notes. "As you get more rural, the proportion of wounds from unintended events increases, as opposed to urban areas, where there are disproportionately more assaults, which is helpful to know when you're addressing prevention."
Collaborate with colleagues. Firearm injury prevention should be part of a hospital wide effort, Hargarten advises. "The ED physician should lead that endeavor, since we are involved in the initial phase of care of all injured patients, whether they are ultimately admitted or discharged," he says. Ideally, prevention leadership should be a collaborative effort along with a trauma surgeon on the inpatient side, he adds.
Work with law enforcement. ED physicians should work together with local police. "There are limits to ascertaining the circumstances of a shooting incident, especially with assaults, so the cooperation of law enforcement is crucial," Hargarten says.
Address even minor gun injuries. Some firearm deaths that appear accidental could actually be suicide, says LaCerva. "In some cases, kids are putting themselves in dangerous situations as a way of getting themselves killed," he reports. "There is no hard evidence, but some young people have a sense of hopelessness about their lives, and they won't walk away from a fight even though the other person has a weapon."
It's important to recognize these larger needs and offer help, says LaCerva. "Even if a firearm injury is insignificant medically, an injured child or adolescent needs a complete bio/psycho/social evaluation and should be admitted to the hospital," he recommends.
Tailor prevention strategy to your area. "If your ED is in an area with high levels of gun ownership, you should inquire about the presence of guns in the home, and ask about how those guns are secured, particularly when there are children or adolescents present," advises LaCerva.
Screen all patients. Asking about guns should be a routine aspect of the patient history, LaCerva recommends. "If you take an average ED and look at how many domestic violence cases which actually get reported, and then you simply put a stamp on the chart, that says, 'Is this patient a victim of domestic violence?' you will double the people you will identify by asking the direct question," he says. "The same thing is true concerning screening of potential firearm injury in the home. It's a very simple question, and should be asked of every patient."
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