Policy Playbook: Firearm Injury Prevention from the Bedside

Authors: Melanie Yates, MD (PGY-3 Resident Physician, University of Cincinnati Medical Center); Summer Chavez, DO, MPH, MPM (University of Houston) // Reviewed by: Alex Koyfman, MD (@EMHighAK); Brit Long, MD (@long_brit)

Case:

In February 2022, a 25-year-old female presented to the emergency department (ED) with intentional overdose and suicidal ideation. She had attempted to overdose on ibuprofen, and the doses taken were relatively unharmful. She had presented several months ago to the same emergency department for suicidal ideation, but at that time her potential plan had included a gun. At that previous visit, the provider had discussed safe firearm storage in the setting of the patient’s acute mental health crisis. Ultimately, the gun was temporarily transferred to a family members’ home for safe keeping while the patient was getting treatment for her suicidal ideation.

If the first visit health care provider had not appropriately addressed firearm safety with the patient and her family, how different could the second visit have looked?

What’s the issue?

Firearm injuries are a major cause of morbidity and mortality in the United States (US), and account for a significant amount of health care costs annually according to the U.S. Congress Joint Economic Commission¹. With the rising number of gun-related deaths in the United States, there has been significant debate over the past ten years on whether increased firearm policy at the state and federal level will reduce gun violence. This Policy Playbook summary aims to highlight firearm transfer laws that emergency physicians should know in their area of practice, along with some of the major legislation surrounding gun violence and research, including the newly signed Bipartisan Safe Communities Act.

• Temporary Transfer of Firearms
  • Studies have repeatedly shown that when a common lethal method for suicide is restricted, this reduces suicide rates overall in that specific area. Firearms account for a large portion of suicide deaths in the US². Therefore, restricting firearm access, particularly during mental health crises, is likely to reduce suicides by firearm and all-around suicide rates². Broadly, temporary transfer laws allow for firearms to be voluntarily given to family members, friends, or other community organizations while a patient is experiencing thoughts of harm to themselves or others.
  • Federal law only requires universal background checks (UBC) for purchases of guns from licensed gun dealers, and limits specific groups from purchasing firearms such as felons and those convicted of specific domestic violence offenses. However, laws governing intrastate transfers of firearms are state based³.
  • Some states do require UBCs with any and all transfers or private sales. While this may decrease the likelihood of high-risk groups obtaining firearms, this might also make temporary transfer more difficult. In these states with required UBCs, there are often 72-hour temporary transfer exceptions, along with exceptions to immediate family members, in order to assist when there is a concern an owner is a harm to self or others³.
  • In addition to immediate family members, firearms can also be transferred to gun sellers and stores, shooting ranges with safe storage availability, and law enforcement⁴. Creating Firearm Storage Maps can be beneficial for clinicians and patients if transfer to family or friends is not feasible or safe.
• Legislation surrounding gun violence
  • Dickey Amendment: In 1996, a provision was added to appropriations legislation that deterred researchers from using federal funds or grants to “advocate or promote gun control”⁵. This was known as the “Dickey Amendment” and has significantly limited federal gun violence research and its funding over the last two decades. While this amendment is still present in every spending bill, there has been softening of the language since 2018 to allow for CDC grant-funded research on the causes and effects of gun violence⁶.
  • “Red Flag” Laws: While temporary transfer laws allow for the voluntary removal of firearms for patient safety, red flag laws also known as Extreme Risk laws, allow for the involuntary removal of firearms from personal possession by court order. In certain states, these laws make it so law enforcement, loved ones, and medical professionals can petition courts to temporarily remove firearms from an individual’s possession who is at risk for harm to themselves or others. Opponents argue these laws violate due process of the individual gun owner, whereas proponents say evidence shows the laws increase safety when enforced appropriately.
  • Bipartisan Safe Communities Act: On June 25th, 2022, President Biden signed into law the Bipartisan Safe Communities Act. While this legislation covers significant ground in multiple disciplines, a good portion of it includes improving the background check process, creating enhanced background checks for purchasers aged 18-21, and increasing protections for victims of domestic violence. One of the biggest wins for emergency physicians is the significant increase in funding for mental health programs and community-based violence intervention programs. While not a cure-all for the public health problem of gun violence, ACEP released a statementsupporting this legislation for a step in the right direction.

Why does this matter?

In 2020 alone, more than 45,000 people died by firearms in the US, with most of these deaths attributed to suicide. The number of annual firearm deaths in the US surpassed the number of motor vehicle deaths in 2017, and that trend has continued according to the CDC⁷. Firearms also have a high lethality rate. Gun use makes up roughly 1% of all suicide attempts, yet accounts for about 50% of completed suicides and has an 85% rate of death when used⁸. Including patients with suicidal ideation, those with dementia, experiencing intimate partner violence, and patients with potential for recurrent injury are the most at-risk populations for firearm injury⁹, and should be considered in screening for safety in the emergency department.

In 2018, there were an estimated 390 million privately owned firearms in the US¹⁰, with this number growing significantly with an increase in firearm sales from 2020-2021¹¹. There were an estimated 13.8 million new first-time buyers during this time period¹¹. Approximately 44% of households have at least 1 firearm, meaning a significant proportion of patients seen in the emergency department across the US every day¹¹.

Counseling from the bedside on firearm safety and injury prevention is possible, and assessments on lethal means is recommended in all suicidal patients. Yet in one recent study, only 50% of patients presenting to the ED with suicidal ideation received a lethal means assessment¹². Patients are willing and feel it is appropriate to discuss firearms and safety with physicians in the ED, but firearm owners are less likely to follow advice about safe firearm storage and temporary firearm removal because they do not perceive physicians as knowledgeable about the topic¹³. Patients are more likely to discuss firearms and listen to physician counseling when there is a focus on well-being and safety, physicians are knowledgeable about the topic and culture, and it is individualized and not prescriptive¹³.

What can I do about it?

• Become knowledgeable – If you are unfamiliar with types of guns and safe storage mechanisms, there are great resources online to educate yourself. This will allow for better counseling of at-risk patients. There are many useful resources already created to increase firearm knowledge and risk factors for injury, including Stanford’s “Clinicians and Firearms” curriculum and The BulletPoints Project.
• Implementing Counseling – Lethal means assessments and counseling on firearm safety needs to be standard of care across emergency medicine. Teaching on basic firearm information, along with training on how to counsel patients from the bedside, could be implemented across medical schools and residencies across the country. Studies have shown that including firearm training is effective and feasible¹⁴, and examples such as the Breaking through Barriers from the Consortium for Risk-Based Firearm Policy are easily accessible.

This post is a collaboration between emDocs and the EMRA Health Policy Committee.

Resources

1. U.S. Congress Joint Economic Committee. A State-by-State Examination of the Economic Costs of Gun Violence. https://www.jec.senate.gov/public/_cache/files/b2ee3158-aff4-4563-8c3b-0183ba4a8135/economic-costs-of-gun-violence.pdf. Published September 18, 2019. Accessed September 19, 2019.9.
2. Mann JJ, Apter A, Bertolote J, et al. Suicide prevention strategies. JAMA. 2005;294(16):2064. doi:10.1001/jama.294.16.2064
3. McCourt AD, Vernick JS, Betz ME, Brandspigel S, Runyan CW. Temporary transfer of firearms from the home to prevent suicide. JAMA Internal Medicine. 2017;177(1):96. doi:10.1001/jamainternmed.2016.5704
4. Kelly T, Brandspigel S, Polzer E, Betz ME. Firearm Storage Maps: A pragmatic approach to reduce firearm suicide during times of risk. Annals of Internal Medicine. 2020;172(5):351. doi:10.7326/m19-2944
5. Omnibus Consolidated Appropriations Act, Pub. L. No. 104-208 (1996).
6. Rostron A. The dickey amendment on federal funding for research on gun violence: A legal dissection. American Journal of Public Health. 2018;108(7):865-867. doi:10.2105/ajph.2018.304450
7. WISQARS Data Visualization. Centers for Disease Control and Prevention. https://wisqars.cdc.gov/data/explore-data/home. Accessed March 30, 2022.
8. Fowler KA, Dahlberg LL, Haileyesus T, Annest JL. Firearm injuries in the United States. Preventive Medicine. 2015;79:5-14. doi:10.1016/j.ypmed.2015.06.002
9. Physicians and firearms. Physicians and Firearms – Stanford Med Education. https://mededucation.stanford.edu/courses/physicians-and-firearms2020/. Published 2020. Accessed July 26, 2022.
10. Karp A. Estimating global civilian-held firearms numbers. Small Arms Survey. https://smallarmssurvey.org/resource/estimating-global-civilian-held-firearms-numbers. Published June 2018. Accessed March 30, 2022.
11. NSSF retailer surveys indicate 5.4 million first-time gun buyers in 2021. NSSF. https://www.nssf.org/articles/nssf-retailer-surveys-indicate-5-4-million-first-time-gun-buyers-in-2021/. Published January 31, 2022. Accessed April 11, 2022.
12. Betz ME, Miller M, Barber C, et al. Lethal means access and assessment among suicidal emergency department patients. Depression and Anxiety. 2016;33(6):502-511. doi:10.1002/da.22486
13. Wintemute GJ, Betz ME, Ranney ML. Yes, you can: Physicians, patients, and firearms. Annals of Internal Medicine. 2016;165(3):205-213. doi:10.7326/m15-2905
14. Rickert CG, Felopulos G, Shoults B, et al. Development and implementation of a novel case-based Gun Violence Prevention Training Program for first-year residents. Academic Medicine. 2022;97(10):1479-1483. doi:10.1097/acm.0000000000004656