AUTHORS

Megan L. Ranney, MD, MPH, Assistant Professor, Department of Emergency Medicine, Alpert Medical School, Brown University, Providence, RI.

Marian E. Betz, MD, MPH, Associate Professor, Department of Emergency Medicine, University of Colorado School of Medicine, Denver.

PEER REVIEWER

Steven M. Winograd, MD, FACEP, Core Faculty and Assistant Clinical Professor of Emergency Medicine, NYiTCOM, St. Barnabas Hospital, Bronx, NY, Albert Einstein Affiliate Residency in Emergency Medicine.

Statement of Financial Disclosure

To reveal any potential bias in this publication, and in accordance with Accreditation Council for Continuing Medical Education guidelines, we disclose that Dr. Farel (CME question reviewer) owns stock in Johnson & Johnson. Dr. Stapczynski (editor) owns stock in Pfizer, Johnson & Johnson, Walgreens Boots Alliance Inc., GlaxoSmithKline, Bristol Myers Squibb, and AxoGen. Dr. Ranney (author) is a medical advisor with equity options for Study Cue LLC. Dr. Schneider (editor), Ms. Fessler (nurse planner), Dr. Betz (author), Dr. Winograd (peer reviewer), Ms. Mark (executive editor), Ms. Coplin (executive editor), and Mr. Landenberger (editorial and continuing education director) report no financial relationships with companies related to the field of study covered by this CME activity.


Risk of Unintentional Harm to Self or Others. The risk of unintentional self-harm or other-harm from unsecured firearms is elevated in individuals with impaired judgment and cognitive skills. These include those with brain injuries and dementias148 and children and adolescents, as their cognitive skills are still developing.149 Discussing the risk of unintentional harm from firearms in this group may be the most difficult firearm topic in the ED setting, but patient educational materials are available. (See Table 3.)

The American Academy of Pediatrics (AAP) recommends that pediatricians counsel all parents about prevention of firearm injuries;150 this type of “anticipatory guidance,” similar to that used for car seats and smoking, may be appropriate in EDs as well, although patients may be most receptive to it when directly relevant to the reason for visit. Indeed, some studies suggest that providing counseling on multiple injury prevention topics at once may dilute the effectiveness of all topics.151

Counseling to family members of those with impaired cognition or judgment who are at risk of unintentional self-harm (e.g., children, adolescents, and those with brain disorders) typically will focus on in-home secure storage. Given the different time scale of risk days to weeks for suicide risk vs. years for unintentional injury out-of-home storage with friends, family, firearm stores, or law enforcement is less likely to be a feasible solution. The AAP recommends that providers educate parents that permanently removing guns from the home is the best option to reduce unintentional firearm “accidents” in children. Although some groups have advocated for firearm safety training for children, studies show that these programs (including NRA’s Eddie Eagle program) are often ineffective in real life.152-154 The safest storage option inside the home is to keep a gun locked up, unloaded, and separate from ammunition.97

Other Considerations

EPs may have medico-legal concerns related to ED-based discussions of firearm safety.

The first concern is over proposed or enacted “gag laws” aimed at preventing healthcare providers from asking or documenting about patients’ firearm access. No true gag law is currently in effect,6 as even Florida’s well-known and controversial law allows for questioning by a provider who “in good faith believes that this information is relevant to the patient’s medical care or safety, or the safety of others” and stipulates that the only information excluded from medical records is that which is “not relevant to the patient’s medical care or safety, or the safety of others.”122 Thus, providers should feel confident that they may question patients about firearms and document these discussions when relevant (as in the scenarios discussed above). Not asking about firearms in relevant situations in fact may raise liability concerns for the provider. As an example, national guidelines now suggest that ED providers conduct lethal means assessments with all suicidal patients,136 and it is conceivable that failure to do so could be grounds for legal action.31

The second concern is that statutes about how best to minimize risk of harm differ greatly between locales. Therefore, each EP should become familiar with local statutes about when and how to handle firearm access by patients at high risk of hurting themselves or others. For instance, in Iowa, anyone served a domestic violence protection order must surrender firearms and ammunition, either to a “qualified person” (as determined by the court) or to a sheriff.155 In many other states, this is limited to a “may” surrender. In Rhode Island, even those convicted of domestic violence misdemeanors may own firearms.156 The strongest level of protection exists in California, where concerned family members or law enforcement officers (but not healthcare providers) may obtain a “Gun Violence Restraining Order” (GVRO).157 A GVRO is designed to be similar to a domestic violence restraining order or a psychiatric hold: A concerned party may ask a judge to deem someone at risk of hurting themselves or others, and then may temporarily remove firearms and ammunition from that person’s possession; the firearms and ammunition are returned after expiration of the GVRO. The efficacy of GVROs has yet to be proven, and these provisions are not currently an option in most U.S. states.

A third concern is how screening and counseling for firearm safety will affect the doctor-patient relationship. Some providers are concerned that encouraging doctors to screen and counsel may dissuade patients who own firearms from seeking medical care, disclosing suicidal ideation, or disclosing psychosis; indeed, a decrease in disclosure of partner violence has been observed in states with mandatory reporting of domestic violence to the police.158 In most states, only court-adjudicated (e.g., involuntary) hospitalizations for mental illness are reported to the national firearm background check system. Of note, time-limited emergency mental health holds (e.g., 72-hour hold, psychiatric hold, M1, 5150, etc., with name variations among states) do not result in the patient being entered into the national background check system or being prohibited from possessing or purchasing firearms. In a few states, such as New York, mental health professionals are required to make a report to a state database if they conclude, using reasonable professional judgment, that the individual is likely to engage in conduct that would result in serious harm to self or others.159 The effect of these laws on either rates of harm to self and others, or on rates of care-seeking, are unknown.160

In response to these three concerns, it is important to reiterate that screening and counseling a patient on firearm safety is optional, and should be performed when a patient fits into one of the three general high-risk categories outlined above. Also, EPs always should be informed and have knowledge of local statutes and resources.

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