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little girl reaching for gun

Empowering pediatricians to reduce preventable firearm injuries and deaths

little girl reaching for gun

Lenore Jarvis, M.D., MEd, FAAP, will participate in a symposium of surgeons, neurosurgeons and emergency medicine doctors during the American Academy of Pediatrics National Conference and Exhibition – the first time these groups have come together to help reduce the number of kids hurt or killed by firearms.

Lenore Jarvis, M.D., MEd, FAAP, remembers feeling fatigue and frustration when, despite her team’s herculean efforts, a 5-year-old died from accidental gunshot wounds. The preschooler had been feeling playful: He surprised a family member who mistook him for an intruder and fired, fatally wounding the child.

As an Emergency Medicine and Trauma Services specialist at Children’s National Hospital, Dr. Jarvis has cared for kids with a range of firearm-related injuries from accidental shootings, intentional acts of violence or suicide attempts. Even when children survive such traumatic injuries, their lives are indelibly altered.

“We’re trained to save lives, but we also want to prevent childhood injuries, if possible. As I considered this young child’s life ending so prematurely and so tragically, I thought I should do more. I could do more,” recalls Dr. Jarvis, the division’s director of advocacy and health policy.

To that end, in addition to advocacy at the regional and national level, on Oct. 26, 2019, Dr. Jarvis will participate in a four-hour symposium of surgeons, neurosurgeons and emergency medicine doctors during the American Academy of Pediatrics (AAP) National Conference and Exhibition – the first time these groups have come together to explore ways they can help to reduce the number of kids hurt or killed by firearms.

Dr. Jarvis will set the stage for the day’s collective call to action when she counsels pediatricians about how they can advocate within the clinic by simple actions such as:

  • Asking families if there are firearms in the home
  • Making time for such conversations during routine care, including well-child visits
  • Paying special attention to warning signs of suicide and depression
  • Having frank conversations with parents about curious toddlers

“The safest home is a home without a firearm. If that’s not possible, the firearm should be stored in a locked cabinet with the ammunition stored separately,” she says. “Toddlers are especially curious and they actively explore their environment. An unsecured firearm can be a tragic accident waiting to happen with curious young children in the home. And if teenagers happen upon the weapon, it could be used in a homicide or suicide.”

In addition to empowering clinicians to have these conversations routinely, symposium speakers will emphasize empowering parents to ask other families: “Is there an unlocked gun in your house?”

“It’s no different than a parent of a child with a life-threatening sensitivity to peanuts asking if there are peanuts in any home that child may visit,” she adds. “As one of the leading causes of death among children and youth, unsecured firearms are even more dangerous than peanuts. And families should feel comfortable making informed decisions about whether their children will be safe as they play and socialize with friends.”

***
AAP National Conference and Exhibition presentation
Saturday, Oct. 26, 2:15 p.m. to 6:15 p.m. (ET)
“AAP NCE Section on Emergency Medicine/Section on Surgery/Section on Neurosurgery gun advocacy joint program”

Gavel in front of a pistol

Saving children’s lives with stricter gun laws

Gavel in front of a pistol

A new study led by clinician-researchers at Children’s National finds states with stricter gun laws had lower firearm-related deaths among children and adolescents.

A new study led by clinician-researchers at Children’s National in Washington, D.C., shows an apparent benefit to stricter laws regulating firearm access: They can save children’s lives.

The study published online July 15, 2019, in Pediatrics shows that states with stricter gun laws had lower firearm-related deaths among children and adolescents. In addition, state laws that had been in place for more than five years requiring universal background checks for firearm purchases were associated with a 35% lower firearm-related death rate among children.

The authors say the findings underscore the need for robust research to understand the interplay between legislation type and pediatric deaths due to firearm injuries.

The cross-sectional study examined 2011 to 2015 firearm fatality data from the Web-based Injury Statistics Query and Reporting System (WISQARS), de-identified data collected by the Centers for Disease Control and Prevention about fatal injuries in the U.S. The team used the Brady Campaign to Prevent Gun Violence’s gun law scorecards which measure the strength or weakness of state laws, with higher scores designating states with consistently strong firearm laws.

Some 21,241 children aged 21 years and younger died from firearm-related injuries over the five-year study period, or about 4,250 deaths per year.

“Firearm injuries represent the second-leading cause of death for U.S. children. That’s about 10 funerals a day for kids whose untimely deaths could have been prevented,” says Monika K. Goyal, M.D., MSCE, director of research in the Division of Emergency Medicine and Trauma Services at Children’s National and the study’s lead author. “For every 10-point increase in the strictness of firearm legislation, there was a 4% drop in firearm-related mortality rates among children and youth.”

States that had laws in effect for five years or longer requiring universal background checks for firearm purchase had 35% lower rates of death due to firearms in children.

“Our findings demonstrate a powerful association between the strength of firearm legislation and pediatric firearm-related mortality, Dr. Goyal adds. “This association remains strong even after we adjust for rates of firearm ownership and other population variables, such as education level, race/ethnicity and household income.”

Just as a combination of evidence-based public health approaches – including legislation mandating seatbelt use – reduced mortality from motor vehicle crashes (6.1 deaths per 100,000 children in 2015 compared with 9.8 deaths per 100,000 in 2007), the authors contend that a similar strategy could help to inform decision-making to reduce childhood injuries and deaths due to firearms.

In addition to Dr. Goyal, additional study authors include Gia M. Badolato, MPH, coauthor, Shilpa J. Patel, M.D., MPH, coauthor and emergency medicine specialist, Kavita Parikh, M.D., MSHS, coauthor and hospitalist, and Robert McCarter Jr., ScD, coauthor and research section head, design and biostatistics, all of Children’s National; and Sabah F. Iqbal, M.D., PM Pediatrics, coauthor.

Katie Donnelly

Firearm injuries disproportionately affect African American kids in DC Wards 7 and 8

Katie Donnelly

“Because the majority of patients in our analyses were injured through accidental shootings, this particular risk factor can help to inform policy makers about possible interventions to prevent future firearm injury, disability and death,” says Katie Donnelly, M.D.

Firearm injuries disproportionately impact African American young men living in Washington’s Wards 7 and 8 compared with other city wards, with nearly one-quarter of injuries suffered in the injured child’s home or at a friend’s home, according to a hot spot analysis presented during the Pediatric Academic Societies 2019 Annual Meeting.

“We analyzed the addresses where youths were injured by firearms over a nearly 12-year period and found that about 60 percent of these shootings occurred in Ward 7 or Ward 8, lower socioeconomic neighborhoods when compared with Washington’s six other Wards,” says Monika K. Goyal, M.D., MSCE, assistant chief of Children’s Division of Emergency Medicine and Trauma Services and the study’s senior author. “This granular detail will help to target resources and interventions to more effectively reduce firearm-related injury and death.”

In the retrospective, cross-sectional study, the Children’s research team looked at all children aged 18 and younger who were treated at Children’s National for firearm-related injuries from Jan. 1, 2006, to May 31, 2017. During that time, 122 children injured by firearms in Washington were treated at Children’s National, the only Level 1 pediatric trauma center in the nation’s Capitol:

  • Nearly 64 percent of these firearm-related injuries were accidental
  • The patients’ mean age was 12.9 years old
  • More than 94 percent of patients were African American and
  • Nearly 74 percent were male.

Of all injuries suffered by children, injuries due to firearms carry the highest mortality rates, the study authors write. About 3 percent of patients in Children’s study died from their firearm-related injuries. Among surviving youth:

  • Patients had a mean Injury Severity Score of 5.8. (The score for a “major trauma” is greater than 15.)
  • 54 percent required hospitalization, with a mean hospitalization of three days
  • Nearly 28 percent required surgery, with 14.8 percent transferred directly from the emergency department to the operating room and
  • Nearly 16 percent were admitted to the intensive care unit.

“Regrettably, firearm injuries remain a major public health hazard for our nation’s children and young adults,” adds Katie Donnelly, M.D., emergency medicine specialist and the study’s lead author. “Because the majority of patients in our analyses were injured through accidental shootings, this particular risk factor can help to inform policy makers about possible interventions to prevent future firearm injury, disability and death.”

Pediatric Academic Societies 2019 Annual Meeting poster presentatio

  • “Pediatric firearm-related injuries and outcomes in the District of Columbia.”
    • Monday, April 29, 2019, 5:45 p.m. to 7:30 p.m. (EST)

Katie Donnelly, M.D., emergency medicine specialist and lead author; Shilpa J. Patel, M.D., MPH, emergency medicine specialist and co-author; Gia M. Badolato, co-author; James Jackson, co-author; and Monika K. Goyal, M.D., MSCE, assistant chief of Children’s Division of Emergency Medicine and Trauma Services and senior author.

Other Children’s research related to firearms presented during PAS 2019 includes:

April 27, 8 a.m.: “Protect kids, not guns: What pediatric providers can do to improve firearm safety.” Gabriella Azzarone, Asad Bandealy, M.D.; Priti Bhansali, M.D.; Eric Fleegler; Monika K. Goyal, M.D., MSCE;  Alex Hogan; Sabah Iqbal; Kavita Parikh, M.D.; Shilpa J. Patel, M.D., MPH; Noe Romo; and Alyssa Silver.

April 29, 5:45 p.m.: “Emergency department visits for pediatric firearm-related injury: By intent of injury.” Shilpa J. Patel, M.D., MPH; Gia M. Badolato; Kavita Parikh, M.D.; Sabah Iqbal; and Monika K. Goyal, M.D., MSCE.

April 29, 5:45 p.m.: “Assessing the intentionality of pediatric firearm injuries using ICD codes.” Katie Donnelly, M.D.; Gia M. Badolato; James Chamberlain, M.D.; and Monika K. Goyal, M.D., MSCE.

April 30, 9:45 a.m.: “Defining a research agenda for the field of pediatric firearm injury prevention.” Libby Alpern; Patrick Carter; Rebecca Cunningham, Monika K. Goyal, M.D., MSCE; Fred Rivara; and Eric Sigel.

Lenore Jarvis at #thisisourlane meeting

#thisisourlane: Pediatricians call for safer firearm storage, enhanced research funding

Lenore Jarvis at #thisisourlane meeting

The 2-year-old scampered unexpectedly into a room, startling a family member. Thinking the toddler was an intruder, the family member fired, hitting the child in the chest.

In the emergency department at Children’s National Health System, Lenore Jarvis, M.D. MEd, FAAP, emergency medicine specialist, and colleagues tried to save the boy’s life, inserting tubes, transfusing blood and attempting to restart his dying heart via CPR. The Children’s team was unsuccessful and emerged covered in the blood of a boy whose death was heartbreaking and preventable.

Firearm violence is a leading cause of childhood traumatic death and injury,” Dr. Jarvis told attendees of a recent congressional news conference intended to prod the incoming Congress to take more concrete action to prevent firearm violence. She provided snapshots of some of the countless lives of local youths cut short by firearms, including an 8-year-old girl killed on a playground in a drive-by shooting, a 13-year-old young man murdered during a fight, a 15-year-old young woman who committed suicide and an entire family who died from firearm injuries.

“I wish it were not so. But these stories are endless. In our emergency department, the effects of gun violence are frequent, life-altering and personal,” Dr. Jarvis said.

The #ThisISOurLane press conference, convened by U.S. Rep. Robin Kelly, (D-Illinois), included haunting stories by clinicians from across the nation about the devastating impact of firearm injuries on children and youth. According to a retrospective, cross-sectional study led by Children’s researchers, younger children are more likely to be shot by accident, and odds are higher that older youths are victims of an assault involving a firearm.

“Gun violence is a public health crisis and should be addressed as such. We need to reduce the numbers of suicides, homicides and accidental gun deaths in children,” added Dr. Jarvis, who also is president-elect of the District of Columbia Chapter of the American Academy of Pediatrics.

During the news conference, U.S. Rep. Frank Pallone Jr., (D-New Jersey), vowed that the House Energy and Commerce Committee he chairs this session will move forward languishing bills, including funding the Centers for Disease Control Prevention to conduct firearms violence research.

Stricter state firearms laws can save children’s lives

In a new study presented at the Pediatric Academic Societies (PAS) 2018 annual meeting, Children’s researchers find that states with stricter firearm laws have lower rates of firearm-related deaths in children. The same cross-sectional analyses also found that states with laws that mandate universal background checks prior to firearm and ammunition purchases were associated with lower rates of firearm-related mortality in children, compared with states that lack these laws.

“Injuries due to firearms are the nation’s third-leading cause of pediatric death,” says Monika Goyal, M.D., M.S.C.E., director of research in the Division of Emergency Medicine and Trauma Services at Children’s National Health System and lead author of the research paper. “Firearm legislation at the state level varies significantly. Our findings underscore the need for further investigation of which types of state-level firearm legislation most strongly correlate with reduction in pediatric injuries and deaths.”

The research team analyzed data from the 2015 Web-based injury statistics query and reporting system maintained by the Centers for Disease Control and Prevention to measure the association between Brady Gun Law Scores – a scorecard that evaluates how strict firearms legislation and policies are in all 50 states – and state-based rates of firearm-related death among children aged 21 years and younger.

In 2015, 4,528 children died from firearm-related injuries. Eighty-seven percent were male; 44 percent were non-Latino black; their mean age was 18.

State-specific firearm-related mortality rates among children were as low as 0 per 100,000 to as high as 18 per 100,000. Median mortality rates were lower among the 12 states requiring universal background checks for firearm purchase at 3.8 per 100,000 children compared with 5.7 per 100,000 children in states that did not require background checks. Similarly, the five states with this requirement had a lower median mortality rate, 2.3 per 100,000 children, when compared with states that did not require background checks for ammunition purchase, 5.6 per 100,000 children.

“Newtown. Orlando. Las Vegas. Parkland. Those are among the mass shootings that have occurred across the nation in recent years. While these tragedies often are covered heavily by the news media, they represent a subset of overall pediatric injuries and deaths due to firearms. Pediatric firearm-related injuries are a critical public health issue across the U.S.,” Dr. Goyal adds.

“Pediatricians have helped to educate parents about other public health concerns, such as the danger posed by second-hand exposure to tobacco smoke or non-use of seat belts and car seats. In addition to presenting our most recent study results, members of our research group also hosted a workshop at PAS aimed at inspiring pediatric clinicians to similarly tackle this latest public health challenge and to advocate for firearm safety,” she says.

In addition to Dr. Goyal, study co-authors include Gia Badolato; Shilpa Patel, M.D.; Sabah Iqbal; Katie Donnelly, M.D.; and Kavita Parikh, M.D., M.S.H.S.

Monika Goyal

Monika Goyal M.D., M.S.C.E., consultant on $5M NIH grant to reduce pediatric firearm injuries

Monika Goyal

Monika Goyal M.D., M.S.C.E., director of research in Children’s Division of Emergency Medicine and Trauma Services, has been named a consultant on a new $5 million National Institutes of Health research grant that represents the agency’s largest funding commitment in more than two decades to reduce pediatric firearm injuries.

“I am honored that Children’s National Health System is among the 12 universities and health systems around the nation selected to work collaboratively to identify solutions to lower pediatric deaths and injuries due to firearms,” Dr. Goyal says. “This grant will expand the nation’s research capacity on this important subject area and will power the next wave of research to inform policy at the state and national level.”

Dr. Goyal is a member of Children’s firearms research work group which has published or presented at academic meetings on topics that include efforts to reduce pediatric firearm-related injuries and the pivotal role pediatricians can play in reducing the burden of firearm-related injuries among children.

Faculty from Ann & Robert H. Lurie Children’s Hospital of Chicago/Northwestern University, Arizona State University, Brown University, Children’s National Health System, Columbia University, Harvard University, Medical College of Wisconsin, Michigan State University, University of Colorado, University of Michigan, University of Pennsylvania and University of Washington make up the Firearm-Safety Among Children & Teens Consortium (FACTS). The initiative is co-led by Rebecca Cunningham, M.D., and Marc Zimmerman, Ph.D., of the University of Michigan.

In addition to tapping the expertise of scientists and researchers who specialize in criminal justice, emergency medicine, pediatrics, psychology, public health and trauma surgery, FACTS will include a stakeholder group that includes teachers, parent groups, gun owners, firearm safety trainers and law enforcement partners.

The five-year grant will produce a number of deliverables, including:

  • A research agenda for the field of pediatric firearm injury
  • Generating preliminary data through five small pilot projects that focus on topics such as the epidemiology of pediatric firearm injuries and prevention of firearm injuries
  • A data archive on childhood firearm injury
  • Training for the next generation of researchers, including postdoctoral trainees and graduate students

Financial support for this research was provided by the National Institute of Child Health & Human Development under award number R24HD087149.

Pediatric ED visits and regional firearm laws

A Children’s research team led by Monika Goyal, M.D., M.S.C.E., found that the Northeast region had the most restrictive firearm laws and the lowest overall burden of firearm-related pediatric emergency department visits.

Pediatric emergency department (ED) visits for gun-related injuries were lower in regions with stronger firearm legislation, according to a five-year study led by Children’s National Health System.

Presenting the findings during the 2017 American Academy of Pediatrics (AAP) national conference, the Children’s research team found that the Northeast region had the most restrictive gun laws and the lowest overall burden of firearm-related pediatric ED visits. Firearm-related pediatric ED visits were significantly higher in the West, South and Midwest, according to the study.

“Firearm-related injuries are a leading cause of injury and death among children and represent a significant public health concern,” says Monika Goyal, M.D., M.S.C.E., director of research in the Division of Emergency Medicine at Children’s National and senior study author. “This study provides compelling data that an evidence-based approach to public policy may help to reduce firearm-related injuries among children.”

The research team extracted data from the Nationwide Emergency Department Sample, the nation’s largest such database, and included ED visits from 2009 to 2013 by patients younger than 21. The team excluded emergency visits due to air, pellet, BB or paintball guns because they are not governed by firearm legislation. They used state-level Brady gun law scores to calculate median regional scores as measures of firearm legislation strictness.

During the five years covered by the study, there were 111,839 ED visits for pediatric firearm-related injuries, or 22,368 per year. The mean age of patients with firearm-related injuries was 18 years old. The majority were male. Across all age groups, 62.8 percent of firearm-related ED visits were because of accidental injuries, a statistic that rose to 81.4 percent for children aged 6 to 10. Six percent of patients died from their injuries, and 29.8 percent of injuries were serious enough to prompt hospital admission.

When compared with the low rates of firearm-related ED visits in the Northeast, the odds of children visiting EDs for firearm-related injuries were significantly higher in other U.S. regions, including the West (2.5), the South (1.9) and the Midwest (1.8).

“Regions with higher Brady scores – and, by extension stricter gun laws – had lower rates of ED visits by children and youth,” Dr. Goyal adds. “To our knowledge, this is the first study to characterize the relationship between children’s firearm-related injuries and the rigor of regional firearm legislation.”

The authors note that unlike adults, most children rushed to the Emergency Department overwhelmingly suffered from accidental firearm injuries. This fact underscores the importance of robust research that focuses specifically on children.

“Despite the importance of this topic, there has been a paucity of published research about firearm-related injuries and how they may be prevented. Most existing data have focused on adults; these findings cannot necessarily be extrapolated to children,” Dr. Goyal says.

Lenore Jarvis

Firearm-related injuries are leading causes of child and adolescent deaths and are preventable

Lenore Jarvis

Lenore Jarvis, M.D., M.Ed., F.A.A.P. addressed Congressional staff on behalf of the American Academy of Pediatrics in an effort to reduce gun injuries and deaths in the home by encouraging parents to ask about safe firearm storage.

“I see firsthand in my emergency department practice children getting shot: Unintentional, accidental injuries and shootings, homicides, suicides. And it’s terrible. If I never had to treat another child … for a gun-related injury, I would be so happy,” Lenore Jarvis, M.D., M.Ed., F.A.A.P., Pediatric Emergency Medicine Attending at Children’s National Health System, told Congressional staff. “I will never forget … a 5-year-old shot and killed by a family member who mistook him for a home intruder.”

Dr. Jarvis’ comments on behalf of the American Academy of Pediatrics came during briefings for Congressional staff working in the U.S. Senate and U.S. House of Representatives just days after a gunman targeted Republicans practicing for a Congressional baseball game wounding five, including House Majority Whip Steve Scalise.

The June 16, 2017 Congressional briefings were intended to draw attention to National ASK Day, an annual effort to reduce gun injuries and deaths in the home by encouraging parents to ask about safe firearm storage.

“It’s pretty simple,” Dr. Jarvis told attendees. “I think that there is a mutual recognition about what a public health problem this is: Firearms … are leading causes of deaths in children and adolescents through homicide and suicide by firearms. And they are preventable.”

Her comments echoed a recent firearms review paper published May 23, 2017, by a Children’s National research team that found firearms are present in 18 percent to 64 percent of U.S. homes, and 20,000 U.S. children are transported to Emergency Departments each year for firearm-related injuries. According to the study authors, pediatricians can play a pivotal role in helping to reduce gun violence by encouraging safe storage of firearms in the home and supporting research into firearm-related injury prevention.

In addition to Dr. Jarvis, speakers during the Congressional briefings included a Johns Hopkins Hospital surgeon who decided to pursue a medical career after surviving a gunshot wound to the throat while he was a teenager, a Missouri state representative who co-founded the Children’s Firearm Safety Alliance and a Brady Campaign strategist.