Trends in firearm production and firearm deaths in U.S. youth.

INTRODUCTION: Firearms are now the leading cause of death for U.S. children and teens ages 0-19. The U.S. Department of Justice Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF) reported data in 2022 on firearm production, for specific firearm types and calibers. We hypothesized there would be a correlation between firearm production and firearm deaths and nonfatal injuries in youth. METHODS: All firearm deaths and nonfatal injury rates for youth ages 0-19 were extracted from the Centers for Disease Control and Prevention from 2001 to 2020. Firearm production from 2001 to 2020 was extracted from the 2022 ATF Firearms in Commerce Report for overall firearm production, production by weapon type and pistol caliber. Relationships between firearm death and injury and firearm production were evaluated using correlational analyses. RESULTS: Firearm death and nonfatal injury rates for youth increased from 2001 to 2020 by 48.2% and 69.2%, respectively, and firearm production increased 265% overall and 1298% for 9 mm pistols. There was no correlation between total firearm manufacturing and total firearm deaths or nonfatal injury rates from 2001 to 2020 (all r < 0.28). Pistol caliber (25 and 9 mm) was associated with total firearm deaths and nonfatal injuries (all r > 0.55). CONCLUSION: While total firearm manufacturing was not related to firearm deaths and injuries, except suicides, there were strong relationships between 9 mm pistol production and firearm deaths and injuries in youth. Firearm injuries are preventable; we must invest in stronger information systems that track details of firearms linked with deaths and injuries.

Saving Lives with Tourniquets: A Review of Penetrating Injury Medical Examiner Cases.

Background: After numerous recent mass casualty events, civilian hemorrhage control has taken a militaristic approach with aggressive and early use of tourniquets. While military literature has demonstrated the utility of tourniquets in preventing battlefield deaths from extremity injuries, there is limited understanding of their role in civilian penetrating trauma deaths. The purpose of this study is to review medical examiner (ME) autopsy records in a defined population to determine the incidence of preventable deaths from extremity wounds amenable to tourniquet placement. Methods: This is a retrospective review of ME cases from one urban county with a descriptive analysis of the demographics, mechanisms of injuries, and causes of death of homicide cases from 2003 to 2017. Mechanism of injury and wound patterns were reviewed to determine the overall occurrence of extremity injuries and amenability of tourniquet placement. Results: A total of 1,804 homicide cases were reviewed with 1,521 (84.3%) resulting from penetrating trauma. Isolated extremity injuries were present in 22 (1.45%) of the penetrating cases, all of which were amenable to tourniquet placement. There were 409 (26.9%) concurrent extremity and central penetrating injuries. The vast majority of extremity wounds were amenable to tourniquet placement (92.1%). Extrapolating nationally to 16,187 annual penetrating injury related homicides in 2016, an estimated 235 (1.45%) isolated extremity injury related deaths could be prevented and an additional estimated 4,354 (26.9%) concurrent extremity and central injury related deaths could potentially receive enhanced care with early tourniquet placement. Conclusion: Among urban ME cases, both isolated extremity cases and concurrent extremity-central injuries exist that may be amenable to life-saving tourniquet use. Extrapolating our findings nationwide suggests that many lives could be saved with early tourniquet use. Considering these findings, tourniquet availability and early placement may have a prominent role in reducing injury deaths from penetrating trauma.

The Wisconsin Firearm-Related Injury Surveillance System.

CONTEXT: Firearm-related injuries rank second only to motor vehicle-related injuries as a cause of injury death in Wisconsin. OBJECTIVE: To evaluate the attributes of the Wisconsin Firearm-Related Injury Surveillance System. DESIGN: A structured surveillance system evaluation using predetermined criteria. SETTING: A passive surveillance system linking administrative data from existing state-funded inpatient hospitalization and mortality databases. PARTICIPANTS: State health department. MAIN OUTCOME MEASURES: Attributes assessed included simplicity, flexibility, acceptability, sensitivity, predictive value positive, representativeness, timeliness, resources, and data quality. RESULTS: The use of two existing state databases simplifies data acquisition and linkage. However, hospital discharge and vital records databases are not sufficiently flexible to collect perpetrator and circumstance information. Acceptability is high because of state-mandated reporting to both databases. For firearm-related injuries requiring hospitalization, the system's predictive value positive is 97% when E codes are compared with data from chart reviews. The system is considered timely because annual data from the hospital discharge and vital records systems can be obtained, linked, analyzed, and reported by September of the subsequent year. The system is sustainable largely because existing software is used for annual evaluations, which requires less than 2 weeks of staff time. CONCLUSIONS: With minimal resources and time, the Wisconsin Firearm-Related Injury Surveillance System uses existing state government databases to describe and report the burden of firearm-related injuries. Additional information on circumstances, perpetrators, and weapons involved are available but additional resources are needed to integrate this information with existing data.

"I didn't know the gun was loaded": an examination of two safety devices that can reduce the risk of unintentional firearm injuries.

Some handguns contain built-in safety devices intended to prevent injuries caused by erroneously believing that a handgun is loaded. A loaded chamber indicator indicates the presence of ammunition in the gun; a magazine safety prevents the gun from being fired when the ammunition magazine is removed, even if one round remains in the firing chamber. In our patent search these devices date back to the turn of the century. But on 1998 pistol models, only 11% contained a loaded chamber indicator and 14% had a magazine safety. In our random-digit-dial telephone survey of U.S. adults, 34.8% of poll respondents (incorrectly) thought that a firearm with its ammunition magazine removed could not be shot, or said that they did not know. Some of the 1100 unintentional gun deaths in the U.S. each year might be prevented if the prevalence of these and other safety devices is increased through legislation, litigation, or voluntary manufacturer action.

Preventive care in the emergency department: a systematic literature review on emergency department-based interventions that address smoke detectors in the home.

OBJECTIVES: To assess the effectiveness of an emergency department (ED)-based strategy to identify and counsel selected patients about the importance of an operational smoke detector in the home and to offer a graded recommendation regarding such a strategy. METHODS: A systematic review was facilitated through the use of a structured template, a companion explanatory piece, and a grading and methodological scoring system based on published criteria for critical appraisal. Two Medline combined searches were performed using the following terms: emergency medical services and counseling, protective devices and smoke detectors, accidents, home, burns, fires, and residential fires. A free-text search of indexed and nonindexed citations in Emergency Medical Abstracts from 1977 to 1999 and a search of the Cochrane Library were also performed. In addition, reviewers performed independent Medline searches and suggested four additional studies. Studies selected for inclusion in this systematic review were required to meet the following criteria: 1) report ED-based research and 2) address the topic of fire and burn prevention with some pertinent discussion of ED-based interventions. The initial inclusion criteria had restricted studies to those that reported the results of counseling strategies for smoke detectors. The authors later decided to consider, as indirectly relevant, studies that did not investigate counseling strategies. Data from the selected studies were extracted using the template form, and the validity and applicability of the results to emergency practice were assessed. Recommendations were derived following criteria developed by a systematic review of preventive interventions in the ED. RESULTS: Six articles were closely reviewed. Four of the six studies met the inclusion criteria. One other study that did not meet the inclusion criteria was also considered. No study focused specifically on the counseling of ED patients about smoke detectors. CONCLUSIONS: Following the criteria of the graded recommendations used for the parent project. a recommendation cannot be made either for or against an ED-based strategy to counsel patients on the importance of smoke detectors. No studies located in our review directly assessed the effectiveness of such a strategy. Based on the retrospective case series study of the potential opportunity for a home fire safety intervention during an emergency medical services visit and the Safe Block Project study, it may be worthwhile to consider further research on the effectiveness of systems-level/structural interventions, with a targeted focus on strategies that attempt to overcome barriers associated with active interventions.

Evaluation of error in medicine: application of a public health model.

A case of a chest tube placed on the wrong side during a trauma resuscitation in the emergency department is presented as an example of medical injury. Two traditional models, the legal model and the managerial model, are described and their application to medical injury discussed. A new public health model is then applied to the case example as a more effective way to address medical injury. The public health model addresses the injury event rather than the error itself using Haddon's matrix as a framework. Pre-event, event, and post-event phases are examined to find the weakest link, where intervention has the highest likelihood of successfully preventing future injuries.

Strengthening emergency medicine in Poland: a training and partnership model.

OBJECTIVE: To report a qualitative evaluation of the Partnerships in Health Care/EMS Project between Poland and the United States. The goal of the partnership was to strengthen the emergency medical services (EMS) system in three Polish cities, Krakow, Bialystok, and Lodz. METHODS: The Polish participants were interviewed in Poland approximately eight months after a U.S.-based training program. They were asked to evaluate the effectiveness of the partnership project and discuss their experiences incorporating U.S. emergency medicine (EM) knowledge and technology in the Polish EMS system. RESULTS: The Polish physicians identified three major factors that had the greatest impact on the implementation of U.S. EM knowledge in Poland. These factors were the substantive differences between Polish and U.S. EM knowledge and technology, staffing differences in Polish and U.S. ambulances, and the differing role the EMS system plays in the delivery of primary care in the two countries. CONCLUSIONS: The Polish physicians succeeded in training EM providers in the three cities, thus strengthening clinical skills of EMS providers. They also were able to adapt the principles of U.S. EM that they had learned to fit the specific circumstances that characterize Polish emergency care. As in the United States, the health care system in Poland is inseparable from the social, political, and economic realities of the nation.

Alcohol use among injured patients aged 12 to 18 years.

OBJECTIVE: To examine the scope of alcohol use among a population of injured adolescents. METHODS: A convenience sample of injured patients aged 12-18 years seen at a pediatric ED was tested for the presence of alcohol. Injured patients seen within 6 hours of their injuries were asked to submit urine samples for testing using reagent strips. Data were collected from the patient, out-of-hospital emergency care personnel, and parents regarding the circumstances of the injury. RESULTS: Of the 243 injured patients who were tested during an 8-month period, 231 were included in the final analysis. Ninety patients (39%) were alcohol-positive. The mean age of the alcohol-positive group was 16.0 +/- 1.64 years, compared with 15.3 +/- 1.8 years for the alcohol-negative group (p < 0.003). There was no significant difference between the 2 groups based on race, gender, or injury characteristics. A positive urine alcohol test was found for 18 (33%) of motor vehicle crash victims, 9 (38%) of the motor vehicle drivers, 10 (37%) of the patients who attempted suicide, and 49 (44%) of the assault victims. CONCLUSIONS: A substantial percentage of injured adolescent patients were alcohol-positive. The authors recommend the use of alcohol screening when treating injured adolescents.

Hypoglycemia manifested by sinus bradycardia: a report of three cases.

Three cases are reported of hypoglycemia manifested by profound sinus bradycardia and fatigue, which responded to i.v. dextrose with prompt normalization of the cardiac rhythm. The cases involved 3 different patients and disease processes: a young female who had anorexia nervosa and profound malnutrition; an elderly, nondiabetic male who subsequently experienced a transient ischemic attack: and a patient who had diabetes mellitus managed with chronic, subcutaneous insulin administration. It is vitally important that the emergency physician recognize unusual clinical manifestations of hypoglycemia and fully evaluate such scenarios when hypoglycemia may occur. Untreated, hypoglycemia may result in significant chronic morbidity, and rarely, in death. Bradyarrhythmias--particularly sinus bradycardia--should be added to the list of potential clinical manifestations of hypoglycemia.

A public health approach to emergency medicine: preparing for the twenty-first century.

This paper focuses on the implications of an inadequate public health/preventive health care system for emergency medicine (EM), the role that EM providers can play in remedying critical health problems, and the benefits gained from a public health approach to EM. A broad definition of public health is adopted, suggesting shared goals of public health and EM. Critical problems posed for EM include alcohol, tobacco, and other drug abuse; injury; violence; sexually transmitted diseases and human immunodeficiency virus (HIV) infection occupational and environmental exposures; and the unmet health needs of minorities and women. A blueprint for future merging of public health issues with EM is presented that includes the application of public health principles to 1) clinical practice; 2) public education, community involvement, and public policy advocacy; 3) development of medical school and residency public health/prevention curricula and teaching methods; and 4) research opportunities and surveillance. Finally, recommendations are proposed that require restructuring the present health care system to provide resources, incentives, and organizational changes that promote an integration of public health and preventive services in the practice of EM.

Prevention of firearm-related injuries and deaths among youth. A product-oriented approach.

Firearm-related injuries are the second leading cause of death in youth. A product-oriented approach, focusing on the gun, may be an efficient and effective strategy to reduce firearm-related injuries and death. Such an approach includes decreasing the number of guns in the environment and modifying the gun to reduce it potential for harm. As with efforts to reduce childhood injuries from motor vehicle crashes and poisonings, pediatric health professionals can assume a leadership role in preventing firearm-related injuries and death in youth.

The uncounted dead--American civilians dying overseas.

The Federal Government, U.S. physicians, their patients who travel, insurance companies, the travel industry, and multinational corporations should know the health hazards facing Americans overseas. However, the deaths overseas of almost 5,000 Americans every year have never been analyzed. A previously unreported, unexamined data source is analyzed by cause, sex, age, length of stay, and country of death of Americans dying overseas. The major findings are 1. Most Americans who die overseas die in the developed countries of Western Europe, where most Americans live or visit. The patterns of deaths in these countries are similar to death patterns in the United States. 2. Surprisingly, the deaths of Americans in less developed countries are not from infectious and tropical disease, as many health professionals would expect, but are from chronic diseases, injuries, suicides, and homicides. The importance of these findings for the Federal Government, travelers' clinics, insurance companies, multinational corporations, and Americans living and traveling overseas is discussed.

Injury control. A crucial aspect of emergency medicine.

We have briefly described the theoretic and strategic concepts of injury control and suggested ways for emergency medicine to be more broadly involved. It is not enough for emergency physicians to be active solely in the acute management of injured patients. Emergency physicians need to "look upstream" and balance their focus on the acute management of injuries with a focus on the prevention of injuries.

Ligamentous injuries of the wrist.

Wrist injuries occur commonly. Significant wrist injuries such as perilunate dislocation and scapholunate dissociation may occur without carpal bone fracture. The emergency physician can recognize these ligamentous wrist injuries by noting abnormalities of the shapes, joint spaces, and alignments of the carpal bones. Early diagnosis allows for prompt referral and optimal outcome.

Wisconsin needs to support death investigation: here's why.

Medical examiners and coroners (ME/CO) can provide essential data for injury reporting and prevention, but often lack the resources, support and training to supply this important information. With increased interest in injury data, questions surrounding data collection and reporting are being raised. This article describes the experience of the Wisconsin Firearm Injury Reporting System, discusses results of a survey completed by Wisconsin ME/CO and offers recommendations for improved injury reporting and support for death investigation.

Public health strategies to reduce and prevent alcohol-related illness, injury and death in Wisconsin and Milwaukee County.

This paper illustrates the application of a Public Health Model toward understanding the nature and extent of alcohol-related problems and, in turn, provides examples of strategies targeted at reducing or preventing alcohol-related illness, injury and death in Wisconsin and Milwaukee County. More specifically, data are provided detailing the widespread use and misuse of alcohol as well as the medical, behavioral and social problems associated with its use. Alcohol use and misuse is the third leading cause of preventable death behind only tobacco use and diet/activity patterns, and therefore, warrants the implementation of prevention strategies from a public health perspective. In sum, the public health model specifies three interrelated factors--the host, the agent or vehicle, and the environment--that focus strategies to reduce and/or prevent illness, injury and death. The paper concludes with specific examples of alcohol-related public health strategies targeting the host (e.g., youth and families, minority groups), the agent/vehicle (e.g., alcohol content, labeling of containers, large containers), and the environment (e.g., motor vehicle operation BAC limits, zero tolerance laws, alcohol advertising).

The availability of extrinsic handgun locking devices in a defined metro area.

Extrinsic safety devices, such as trigger locks, have been central in the recent state discussions on how to reduce firearm injuries. The actual prevalence of handgun locking devices in the consumer market, however, is unknown. This study catalogued the extrinsic safety devices available from handgun dealers and discount retail chains in Milwaukee, WI. We found that all locations studied (n = 13) stock at least 1 type of extrinsic safety device. A total of 21 unique models of safety devices were stocked by the 13 locations, with trigger locks being the most common (n = 9). Other types of devices included lock-boxes (n = 5), cable locks (n = 4), hammer locks (n = 1), barrel locks (n = 1), and a rubber slide strap (n = 1). Handgun owners in the Milwaukee metro area have a selection of extrinsic handgun safety devices available from handgun dealers and discount retailers. However, there does not appear to be a consistent availability on type of device.

Public health: a successful paradigm applied to firearm injuries.

Firearm injuries are a major contributor to injury mortality and morbidity in the United States and account for substantial loss of productive years of life. A public health approach to injury reduction, and particularly firearm injury prevention, has promise because it emphasizes prevention rather than reaction, it utilizes a scientific approach to policies and programs, it brings an integrative, multi-disciplinary approach to the effort, and it emphasizes the role of communities in solving health problems. The new Firearm Injury Center at the Medical College of Wisconsin exemplifies the public health approach to this vexing problem.