Critical Medicine

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.

Monika Goyal

Keeping children safe from firearm-related harm

Monika Goyal

A research paper by Monika K. Goyal, M.D., M.S.C.E., and colleagues reports on the epidemiology of firearm-related violence, summarizes public health and legislative efforts and discusses the role of pediatricians in reducing firearm-related harm.

A review led by Children’s National Health System researchers presents new insights about pediatric firearm-related injuries. The findings, published May 23, 2017 in Hospital Pediatrics, show that up to 64 percent of U.S. households have firearms, and almost 40 percent of parents erroneously believe that their children are unaware of where weapons are stored. Additionally, about 22 percent of parents wrongly think that their children have never handled household firearms.

According to the Centers for Disease Control and Prevention, firearm-related injuries are leading causes of injury deaths for youths. Younger children are more likely to be victims of unintentional firearm injuries, the majority of which occur in the home. Older adolescents are more likely to suffer from intentional injuries. Homicide by firearm is the second-leading cause of death for 15- to 19-year-olds, and suicide by firearm ranks as the third-most common cause of death for children aged 10 to 19. Estimates suggest that the cost of medical treatment for firearm-related injuries suffered by youths younger than 21 exceeds $330 million.

“While this preventable public health crisis occurs in the home, pediatricians who see children in clinic or at hospitals can play a pivotal role in helping to reduce gun violence,” says Kavita Parikh, M.D., M.S.H.S., associate professor of pediatrics in the Division of Hospitalist Medicine at Children’s National and study lead author. “In the course of providing care, pediatricians can ask patients and their families about children’s access to firearms, can encourage safe storage of firearms in the home and can support research into firearm-related injury prevention.”

The review article provides an overview of the prevalence of pediatric firearm-related injuries around the nation and a summary of legislative efforts and health care-related advocacy efforts to reduce firearm injuries around the nation. It includes research by four Children’s National co-authors who comprise the institution’s newly formed firearm-injury prevention research work group. Alyssa Silver, M.D., Children’s Hospital at Montefiore, is another co-author.

The study team found that about 20,000 children are transported to Emergency Departments each year for firearm-related injuries. Youths aged 12 to 19 make up 90 percent of this total. On average, 20 U.S. children and youths are hospitalized daily for firearm-related injuries. About 50 percent of the children who are hospitalized for firearm-related injuries are discharged with a disability.

The researchers identified regional variations in the percentage of households with firearms, as well as differences in firearm ownership by race and ethnicity. Across a number of surveys, 6 percent to nearly 50 percent of families reported storing firearms safely by using such methods as trigger locks and locked storage containers. There is a mismatch in what parents report — with many saying their child would never touch a firearm – compared with children who tell researchers they handle “hidden” firearms, including by pulling the trigger. One survey of 5,000 fifth-graders and their caregivers living in three metropolitan areas found 18 percent had household firearms. Of this group, African American and Latino households had lower odds of firearm ownership than families of white, non-Latino children. Among these survey respondents, families of white non-Latino children were less likely than families of African American children to use safer strategies for firearm storage.

“While public health interventions have had varying degrees of success in improving firearm safety, the most effective programs have offered families free gun safety devices,” says Monika Goyal M.D., M.S.C.E., assistant professor of pediatrics and emergency medicine at Children’s National and senior study author. “The stark differences in how parents perceive their children would act and the children’s own recollections to researchers underscore the importance of the combination of counseling parents to talk to their children about firearms and instituting safe storage practices for household guns.”

Sabah F. Iqbal, M.D., assistant professor of pediatrics and emergency medicine at Children’s National and study co-author, adds: “Most families are willing to discuss firearm safety with health care providers. It is encouraging that when families receive safety counseling from health care professionals, they store firearms more safely within the home. Pediatricians need to ask children and their families about the presence of firearms in the home. These essential conversations can occur in any medical setting and need to begin before a child begins to walk and explore their own home.”

Screening for access to firearms within the health care setting where youths receive routine care may represent a beneficial strategy, the authors write. A recent survey conducted among 300 adolescents seen in an Emergency Department found that 16 percent reported having a gun in the home and 28 percent said they could access a loaded gun within three hours. About 50 percent of adolescents screened for firearm access said a friend or relative owned a gun.

The study authors also discuss the benefit of “rigorous, well-conducted” research of firearm-related injuries to guide the work of public health agencies, policymakers and pediatricians, as well as supporting state-level laws shown to be effective in preventing firearm injuries, such as universal background checks and firearm identification.

“Rigorous investigations, with the use of validated scoring systems, large comprehensive databases and accurate detailed reporting and surveillance of firearm access and related injury are urgently needed,” Shilpa J. Patel, M.D., M.P.H., assistant professor of pediatrics and emergency medicine at Children’s National, and co-authors conclude. “A collective, data-driven approach to public health is crucial to halt the epidemic of pediatric firearm-related injury.”

Related reading: Pediatric firearm-related injuries in the United States.

Sabah IqbShilpa Patel, Monika Goyal

Stronger firearm laws reduce ED visits

Sabah Iqbl, Shilpa Patel, Monika Goyal

Children’s National researchers Sabah F. Iqbal, M.D., Shilpa J. Patel, M.D., and Monika K. Goyal, M.D., M.S.C.E., found that regions of the United States with the strictest gun laws also have fewer emergency department visits for pediatric firearm-related injuries.

A new study by researchers from Children’s National Health System find that regions of the United States with the strictest gun laws also have the fewest emergency department visits for pediatric firearm-related injuries. The work is among the few studies to evaluate the association between local laws and firearm-related injury to children and youth. The results, presented at the 2017 annual meeting of the Pediatric Academic Societies, could inform policies at the state and regional levels.

“Our results suggest an association between regional gun laws and firearm-related injuries in children,” says Monika K. Goyal, M.D., M.S.C.E., director of research within Children’s Division of Emergency Medicine and senior author of the poster. “Regions with stricter gun laws had lower incidence rates of firearm-related emergency department visits by children.”

Firearm-related injuries are a leading cause of death and disability among children and adolescents in the United States. It is well established that states with more restrictive gun laws have fewer firearm-related fatalities. However, it has been unclear how these laws affect the rates of firearm-related injuries among children.

To investigate this question, Children’s National researchers gathered data from the Nationwide Emergency Department Sample (NEDS), a set of hospital-based emergency department databases created by the federal Agency for Healthcare Research and Quality to aggregate data about emergency department visits across the country. The researchers matched NEDS data from 2009 to 2013 in patients 21 and younger with state-level Brady Gun Law Scores, a measure of the strength of firearm laws, in four geographic regions: The Midwest, Northeast, South and West.

The researchers found that during this five-year study period, there were 111,839 emergency department visits for pediatric firearm-related injuries nationwide, an average of 22,368 per year. The mean age of patients was 18 years, and the vast majority was male. Just over one-third were publicly insured. About 30 percent of these recorded injuries resulted in hospital admission, and about 6 percent resulted in death.

Overall, firearm-related visits to emergency departments remained consistent over time at a rate of 65 per every 100,000 visits until 2013, when they decreased slightly to 51 per 100,000 visits. However, these rates varied significantly by geographic region. The Northeast had the lowest rate at 40 per 100,000 visits. This was followed by the Midwest, West and South at 62, 68 and 71 per 100,000 visits, respectively.

These numbers roughly matched the Brady Gun Law Scores for each region. The Northeast had the highest Brady score at 45, followed by 8, 9 and 9 for the South, West and Midwest.

These findings, the study authors say, suggest that stricter gun laws might lead to fewer fatalities as well as fewer gun-related injuries among children. Future studies about the role of regional gun culture and its impact on firearm legislation at the regional level, they say, is an important next step in advocating for changes to firearm legislation and reducing pediatric firearm-related injuries.

“Future research work should seek to elucidate the association of specific gun laws with the incidence rates of pediatric firearm-related injuries,” says Shilpa Patel, M.D., M.P.H., an assistant professor of pediatrics and emergency medicine at Children’s National and co-author of the poster. “This work also could evaluate how regional differences — such as social gun culture, gun ownership and other factors — contribute to the significant regional variation in firearm legislation.”

The American Academy of Pediatrics, an organization of 66,000 pediatricians, has repeatedly advocated for stricter gun laws, violence prevention programs, research for gun violence prevention and public health surveillance, physician counseling to patients on the health hazards of firearms and mental health access to address exposure to violence.

test tubes

2016: A banner year for innovation

test tubes

In 2016, clinicians and research scientists working at Children’s National Health System published more than 1,100 articles in high-impact journals about a wide array of topics. A Children’s Research Institute review group selected the top articles for the calendar year considering, among other factors, work published in top-tier journals with impact factors of 9.5 and higher.

“Conducting world-class research and publishing the results in prestigious journals represents the pinnacle of many research scientists’ careers. I am pleased to see Children’s National staff continue this essential tradition,” says Mark L. Batshaw, M.D., Physician-in-Chief and Chief Academic Officer at Children’s National. “While it was difficult for us to winnow the field of worthy contenders to this select group, these papers not only inform the field broadly, they epitomize the multidisciplinary nature of our research,” Dr. Batshaw adds.

The published papers explain research that includes discoveries made at the genetic and cellular levels, clinical insights and a robotic innovation that promises to revolutionize surgery:

  • Outcomes from supervised autonomous procedures are superior to surgery performed by expert surgeons
  • The Zika virus can cause substantial fetal brain abnormalities in utero, without microcephaly or intracranial calcifications
  • Mortality among injured adolescents was lower among patients treated at pediatric trauma centers, compared with adolescents treated at other trauma center types
  • Hydroxycarbamide can substitute for chronic transfusions to maintain transcranial Doppler flow velocities for high-risk children with sickle cell anemia
  • There is convincing evidence of the efficacy of in vivo genome editing in an authentic animal model of a lethal human metabolic disease
  • Sirt1 is an essential regulator of oligodendrocyte progenitor cell proliferation and oligodendrocyte regeneration after neonatal brain injury

Read the complete list.

Dr. Batshaw’s announcement comes on the eve of Research and Education Week 2017 at Children’s National, a weeklong event that begins April 24. This year’s theme, “Collaboration Leads to Innovation,” underscores the cross-cutting nature of Children’s research that aims to transform pediatric care.

Cardiac Intensive Care Unit

Michael Bell to head Division of Critical Care

Cardiac Intensive Care Unit

Michael J. Bell, M.D., will join Children’s National as Chief of the Division of Critical Care Medicine, in April 2017.

Dr. Bell is a nationally known expert in the field of pediatric neurocritical care, and established the pediatric neurocritical care program at the Children’s Hospital of UPMC in Pittsburgh.

He is a founding member of the Pediatric Neurocritical Care Research Group, an international consortia of 40 institutions dedicated to advancing clinical research for children with critical neurological illnesses. Prior to joining the University of Pittsburgh, Dr. Bell served on the faculty at Children’s National and simultaneously conducted research on the impact of inflammation on the developing brain at the National Institute of Neurological Disorders and Stroke (NINDS), within the laboratory of the Chief of the NINDS Stroke Branch.

Dr. Bell also leads the largest study to date evaluating the impact of interventions on the outcomes of infants and children with severe traumatic brain injury (TBI) and analyzing findings to improve clinical practice across the world. The Approaches and Decisions for Acute Pediatric Traumatic Brain Injury (ADAPT) Trial, funded by NINDS, has enrolled 1,000 children through 50 clinical sites across eight countries and compiled an unmatched database, which will be used to develop new guidelines for clinical care and research on TBIs. Dr. Bell is currently working on expanding the scope and continuing the trial for at least the next 5 years.

In his time at Children’s National, he played a critical role in building one of the first clinical pediatric neuro-critical care consult services in the country, which established common protocols between Children’s Divisions of Critical Care Medicine, Neurology, and Neurosurgery aimed at improving clinical care of children with brain injuries. Dr. Bell’s current research interests include: barriers to implementation of traumatic brain injury guidelines, the effect of hypothermia on various brain injuries and applications for neurological markers in a clinical setting.

The Children’s National Division of Critical Care Medicine is a national leader in the care of critically ill and injured infants and children, with clinical outcomes and safety measures among the best in the country across the pediatric, cardiac, and neuro critical care units.

Dr. Kurt Newman and HHS Secretary Price

Kurt Newman: prioritize children in health care

Dr. Kurt Newman and HHS Secretary Price

Children’s National President and CEO Dr. Kurt Newman welcomed Secretary of Health and Human Services Tom Price to the hospital for his first official visit as a member of the Cabinet.

On February 14, Children’s National President and CEO Dr. Kurt Newman met with Secretary of Health and Human Services Tom Price at Children’s National. As part of his first official visit as a member of the Cabinet Dr. Price, who is an orthopaedic surgeon by training, toured our clinics and engaged in open dialogue with patients and families, clinicians, and members of the Children’s National leadership team.

The visit highlighted the excellence of Children’s National care providers and the essential role pediatric hospitals play in helping kids grow up stronger. It was also an opportunity to ensure that children’s health needs are top of mind for a leader who will be central to shaping policies that affect millions of America’s kids.

In their conversations, Dr. Newman emphasized the need for continued investment and dedicated health care infrastructure to support specialized care and research for children – an approach he outlined in detail this week in an op-ed in the Washington Post.

Dr. Newman intends to continue engaging directly with policy leaders and speaking up for children during this pivotal period for the nation’s health care system.

Learn more about advocacy efforts at Children’s National.

Patient-centered family conferences can boost satisfaction with care

Malone Brand Shoot January 2015 CICU Cardio Patient Baby Boy African American Dailen Miles Staff
The medical team typically speaks for nearly three-quarters of the time allotted to family conferences in the pediatric intensive care unit (PICU). Clinicians can transform those one-sided conversations into patient-centered interactions by ensuring that they show empathy, ask questions, and speak from the heart as well as from their clinical experience, according to a cross-sectional study published June 17 by Pediatric Critical Care Medicine.

A research team led by Tessie W. October, MD, MPH, a critical care specialist at Children’s National Health System, sought to clarify the association between the patient-centered nature of physicians’ communication patterns and the degree to which parents were satisfied with decision-making during family conferences in the PICU. In order to dissect the dynamics of those conversations, the team recorded 39 family conferences, which averaged 45 minutes in length. The medical team spoke 73 percent of the time. Physicians contributed 89 percent of the dialogue and spent 79 percent of their time speaking about medically focused topics. Parents’ contribution amounted to 27 percent of the conversation, according to the study, “Parent Satisfaction With Communication is Associated With Physician’s Patient-Centered Communication Patterns During Family Conferences.”

“These conferences cover some of the toughest decisions that families of critically ill children will ever make: Whether to start life support, place a tracheostomy, repeat bone marrow transplantation, or to withdraw life-sustaining interventions,” Dr. October says. “Rather than essential decisions about the child’s care being made in partnership with families, the conferences are akin to monologues with the medical team deciding the pace and content of the conversation.”

A few subtle changes can shift more of the balance of the conversation to the parents and, when clinicians use these skills, parents are more satisfied with the decision-making, she says. Simple changes include maintaining eye contact, smiling when appropriate, and acknowledging the parents’ emotions by saying “I can’t imagine how difficult this must be for you” or “I wish I had better news” ­–  rather than simply informing the parents of the child’s prognosis. When these social niceties are skipped, parents can perceive their medical team to be uncaring, she says. Slowing the pace of the conversation is helpful, as are including open-ended questions and moments of silence, which both tease out opportunities for parents and family members to offer their thoughts.

“There is an art to it,” October says. “From the outset, clinicians can ask about the family’s understanding of their child’s medical condition and follow up with questions about their family’s goals, such as ‘What does a meaningful life look like? Has anyone ever spoken with you about that?’ ”

The parents who were involved in the study completed satisfaction surveys within 24 hours of the family conference. “The median parent satisfaction score was significantly higher (82.5) when the patient-centeredness score was greater than or equal to 0.75, compared to a median satisfaction score of 70.0 when the patient-centeredness score was less than 0.75,” October and co-authors write.

“We do not know the optimal balance of discussing psychosocial elements compared to medical talk, but our results reveal that the amount of psychosocial elements does impact[the degree of parent satisfaction with communication. It is clear that parents want their fears and concerns to be understood and addressed, and they want to feel cared for and about. Making our interactions with parents more patient-centered can likely improve the communication experience for parents and also improve the grieving process should their child not survive their illness,” the authors continue.

In the next phase of research, the team will explore how parents’ perceptions change when additional members of the medical team speak during family conferences. In the current study, case managers and bedside nurses each spoke 2 percent of the time while social workers spoke 7 percent of the time.

Related Resources: Patient centered family conferences can boost satisfaction with pediatric ICU care