Community-level firearm injury surveillance: local data for local action.

In the United States, firearms are used to commit homicide more frequently than all other methods combined. According to the US Department of Justice, firearms are used to commit more than 1 million crimes each year. Despite the magnitude of this problem, little is known about the epidemiology of firearm crimes and assaults. Many states require medical personnel to report all nonfatal shootings to law enforcement, but the rate of compliance with this requirement is unknown. To enhance cooperation between community emergency departments and law enforcement agencies, we created a unified firearm injury notification system for the City of Atlanta, Georgia, and 5 surrounding counties: Fulton, DeKalb, Cobb, Gwinnett, and Clayton. Our findings are reported here.

Seeing is believing: what do boys do when they find a real gun?

OBJECTIVES: To determine how boys behave when they find a handgun in a presumably safe environment and to compare parental expectations of their child's interest in real guns with this observed behavior. METHODS: A convenience sample of 8- to 12-year-old boys was recruited from families that completed a survey on firearm ownership, storage practices, and parental perceptions. Parents were asked to rate their child's interest in real guns on a scale from 1 to 5: 1-2 = low interest, 3 = moderate interest, and 4-5 = high interest. Parents of an eligible child were asked to bring to the exercise 1 of their son's playmates and/or a sibling in the same age range. After informed parental consent was obtained, each pair or trio of boys was placed in a room with a 1-way mirror and observed for up to 15 minutes. Two water pistols and an actual.380 caliber handgun were concealed in separate drawers. The handgun contained a radio transmitter that activated a light whenever the trigger was depressed with sufficient force to discharge the firearm. After the exercise, each boy was asked whether he thought that the pistol was real or a toy. Before leaving, each child was counseled about safe behavior around guns. RESULTS: Twenty-nine groups of boys (n = 64) took part in the study. The mean age of participants was 9.8 years. Twenty-one of the groups (72%) discovered the handgun (n = 48 boys); 16 groups (76%) handled it (n = 30 boys). One or more members in 10 of the groups (48%) pulled the trigger (n = 16 boys). Approximately half of the 48 boys who found the gun thought that it was a toy or were unsure whether it was real. Parental estimates of their child's interest in guns did not predict actual behavior on finding the handgun. Boys who were believed to have a low interest in real guns were as likely to handle the handgun or pull the trigger as boys who were perceived to have a moderate or high interest in guns. More than 90% of the boys who handled the gun or pulled the trigger reported that they had previously received some sort of gun safety instruction. CONCLUSION: Many 8- to 12-year-old boys will handle a handgun if they find one. Guns that are kept in homes should be stored in a manner that renders them inaccessible to children.guns, weapons, firearms, children, childhood behavior, injury prevention.

Do reminder signs promote use of safety belts?

STUDY OBJECTIVE: To determine whether reminder signs placed at the exits to parking decks increase the rate of safety belt use. METHODS: The subjects in this study were drivers of automobiles with permits to park in campus decks at a major university. Volunteer observers were positioned near the exits of 5 parking decks around the campus. Rates of safety belt use were noted before and at 2 intervals after reminder signs were installed. RESULTS: A total of 6, 780 observations were collected. The baseline rate of safety belt use was 83%. Female drivers were significantly more likely to wear a safety belt than male drivers (85.3% versus 79.6%, P <.001). Safety belt use did not increase after the signs were installed (83.3% before versus 83.5% after, P =.86). CONCLUSION: Placing reminder signs at the exits to parking decks did not boost the rate of safety belt use at our institution. Other strategies are needed to achieve the National Highway Traffic Safety Administration's goal of increasing the overall rate of safety belt usage to 90% by the year 2005.

Public opinion about guns in the home.

OBJECTIVES: (1) Determine the frequency of gun ownership, acquisition, and transfer; (2) assess gun storage practices; and (3) compare the views of firearm owning and non-owning adults regarding the protective value of keeping a gun in the home. SETTING AND METHODS: Over three different time periods (1995, 1996, and 1999) stratified, random digit telephone surveys were conducted in a five county area of metropolitan Atlanta, Georgia. Five hundred adults (aged 21+ years) responded to each survey. RESULTS: The proportion of Atlanta area households reporting firearm ownership was generally stable over this interval (38%, 40%, and 35% respectively). The percentage of gun owning households containing a handgun (approximately 75%) was stable as well. In 1995, more than half of gun owning households kept one or more guns unlocked; since that time, the trend has been gradually downward. In 1995, 44% of gun owning respondents kept one or more guns loaded, compared with 38% in 1996 and 40% in 1999. A majority of respondents to all three surveys (55%) agreed with the statement "A home with a gun is less secure than a home without a gun, because a gun can be involved in an accidental shooting, suicide or family homicide". Among five home security measures, respondents rated a burglar alarm most effective, and keeping a gun in the home least effective. CONCLUSIONS: In Atlanta, many households keep a firearm for protection, but they are ambivalent about the associated risks. These findings suggest that education about gun safety should include a discussion of the risks of unsafe storage, and non-lethal alternatives for home security.

Effect of a ban on carrying firearms on homicide rates in 2 Colombian cities.

CONTEXT: Homicide is a leading cause of death in Colombia, with much of the fatal interpersonal violence concentrated in the country's largest cities. Firearms are involved in as much as 80% of homicides in Colombia. OBJECTIVE: To evaluate the effect of an intermittent police-enforced ban on carrying firearms on the incidence of homicide in urban Colombia. DESIGN: Interrupted time-series study with multiple replications. SETTING: Cali, Colombia, during 1993 and 1994 and Bogotá, Colombia, from 1995 through August 1997. PARTICIPANTS: The populations of Cali and Bogotá. INTERVENTION: Carrying of firearms was banned on weekends after paydays, on holidays, and on election days. Enforcement included establishment of police checkpoints and searching of individuals during traffic stops and other routine law enforcement activity. MAIN OUTCOME MEASURE: Homicide rates during intervention days were compared with rates during similar days without the intervention; estimates were based on comparisons within the same month, day of week, and time of day. RESULTS: There were 4078 homicides in Cali during 1993 and 1994 (114.6 per 100,000 person-years). In Bogotá, 9106 homicides occurred from 1995 through August 1997 (61 per 100,000 person-years). The incidence of homicide was lower during periods when the firearm-carrying ban was in effect compared with other periods (multivariate-adjusted rate ratio, 0.86 [95% confidence interval [CI], 0.76-0.97] for Cali, and 0.87 [95% CI, 0.77-0.98] for Bogotá). CONCLUSION: An intermittent citywide ban on the carrying of firearms in 2 Colombian cities was associated with a reduction in homicide rates for both cities.

Firearms in the home: parental perceptions.

BACKGROUND: Each year, thousands of children are injured or killed from unintentional gunshot wounds. Discovering a gun while playing in the home places children at risk of being injured by the firearm. OBJECTIVES: To determine parental firearm storage practices and parental perceptions of the behavior of their children around guns. METHODS: Cross-sectional survey of parents of children from 4 to 12 years of age. A sample of 424 parents, bringing their children to one of five pediatric ambulatory care centers, were asked to complete a 20-point self-administered questionnaire at the time of their visit. RESULTS: A total of 400 parents (94%) completed the questionnaire; 113 parents (28%) reported keeping a firearm (most often a handgun) in the home. Firearm owners were predominantly male, 30 years of age or older, white, and married. Of the gun owners, 52% stored their firearms loaded or unlocked, and 13% kept one or more guns loaded and unlocked. Three fourths of gun-owning parents believed that their 4- to 12-year-old child could tell the difference between a toy gun and a real gun, and 23% believed that their child could be trusted with a loaded gun. Although the majority of gun-owning parents (53%) endorsed safe storage as the best firearm injury prevention strategy, 61% of parents who do not own firearms endorse not owning guns as the best way to prevent pediatric firearm injuries. CONCLUSION: A majority of gun-owning parents store their firearms loaded or unlocked, substantially underestimating the risk of injury to their children. Many firearm-owning parents trust their child with a loaded gun and believe that their young child can tell the difference between a toy gun and a real gun.

Simple CPR: A randomized, controlled trial of video self-instructional cardiopulmonary resuscitation training in an African American church congregation.

STUDY OBJECTIVE: Despite the proven efficacy of cardiopulmonary resuscitation (CPR), only a small fraction of the population knows how to perform it. As a result, rates of bystander CPR and rates of survival from cardiac arrest are low. Bystander CPR is particularly uncommon in the African American community. Successful development of a simplified approach to CPR training could boost rates of bystander CPR and save lives. We conducted the following randomized, controlled study to determine whether video self-instruction (VSI) in CPR results in comparable or better performance than traditional CPR training. METHODS: This randomized, controlled trial was conducted among congregational volunteers in an African American church in Atlanta, GA. Subjects were randomly assigned to receive either 34 minutes of VSI or the 4-hour American Heart Association "Heartsaver" CPR course. Two months after training, blinded observers used explicit criteria to assess CPR performance in a simulated cardiac arrest setting. A recording manikin was used to measure ventilation and chest compression characteristics. Participants also completed a written test of CPR-related knowledge and attitudes. RESULTS: VSI trainees displayed a comparable level of performance to that achieved by traditional trainees. Observers scored 40% of VSI trainees competent or better in performing CPR, compared with only 16% of traditional trainees (absolute difference 24%, 95% confidence interval 8% to 40%). Data from the recording manikin confirmed these observations. VSI trainees and traditional trainees achieved comparable scores on tests of CPR-related knowledge and attitudes. CONCLUSION: Thirty-four minutes of VSI can produce CPR of comparable quality to that achieved by traditional training methods. VSI provides a simple, quick, consistent, and inexpensive alternative to traditional CPR instruction, and may be used to extend CPR training to historically underserved populations.

Support for new policies to regulate firearms. Results of two national surveys.

BACKGROUND: New policy options are emerging in the debate regarding the regulation of firearms in the United States. These options include the treatment of firearms as consumer products, the design of which can be regulated for safety; denial of gun ownership to those convicted of misdemeanors; and strategies to curtail the illegal sale of guns. The public's opinion of these innovative gun-policy options has not been thoroughly assessed. METHODS: We conducted two telephone surveys of 1200 adults each in the United States in 1996 and 1997-1998. Cognitive interviews and pretests were used in the development of the survey instruments. Potential participants were then contacted by random-digit dialing of telephone numbers. RESULTS: A majority of the respondents favored safety standards for new handguns. These standards included childproofing (favored by 88 percent of respondents), personalization (devices that permit firing only by an authorized person; 71 percent), magazine safeties (devices that prevent firing after the magazine or clip is removed; 82 percent), and loaded-chamber indicators (devices that show whether the handgun is loaded; 73 percent). There was strong support for policies prohibiting persons convicted of specific misdemeanors from purchasing a firearm. Support for such prohibitions was strongest for crimes involving violence or the illegal use of a firearm (83 to 95 percent) or substance abuse (71 to 92 percent). There was also widespread support for policies designed to reduce the illegal sale of guns, such as mandatory tamper-resistant serial numbers (90 percent), a limit of one handgun purchase per customer per month (81 percent), and mandatory registration of handguns (82 percent). Even among the subgroup of respondents who were gun owners, a majority were in favor of stricter gun regulations with regard to 20 of the 22 proposals covered in the poll. CONCLUSIONS: Strong public support, even among gun owners, for innovative strategies to regulate firearms suggests that these proposals warrant serious consideration by policy makers.

Injuries and deaths due to firearms in the home.

OBJECTIVE: Determine the relative frequency with which guns in the home are used to injure or kill in self-defense, compared with the number of times these weapons are involved in an unintentional injury, suicide attempt, or criminal assault or homicide. METHODS: We reviewed the police, medical examiner, emergency medical service, emergency department, and hospital records of all fatal and nonfatal shootings in three U.S. cities: Memphis, Tennessee; Seattle, Washington; and Galveston, Texas. RESULTS: During the study interval (12 months in Memphis, 18 months in Seattle, and Galveston) 626 shootings occurred in or around a residence. This total included 54 unintentional shootings, 118 attempted or completed suicides, and 438 assaults/homicides. Thirteen shootings were legally justifiable or an act of self-defense, including three that involved law enforcement officers acting in the line of duty. For every time a gun in the home was used in a self-defense or legally justifiable shooting, there were four unintentional shootings, seven criminal assaults or homicides, and 11 attempted or completed suicides. CONCLUSIONS: Guns kept in homes are more likely to be involved in a fatal or nonfatal accidental shooting, criminal assault, or suicide attempt than to be used to injure or kill in self-defense.

Preventing youth violence: what works?

Between 1985 and 1992, serious youth violence in the United States surged to unprecedented levels. The growing use of firearms to settle disputes has contributed to this phenomenon. Youth are most often victimized by one of their peers. In response to this problem, a wide variety of programs have been implemented in an attempt to prevent youth violence or reduce its severity. Few have been adequately evaluated. In general, interventions applied between the prenatal period and age 6 appear to be more effective than interventions initiated in later childhood or adolescence. Community-based programs that target certain high-risk behaviors may be beneficial as well. A sustained commitment to evaluation research is needed to identify the most effective approaches to youth violence prevention.

Injury-control education in six U.S. medical schools.

PURPOSE: To assess knowledge, attitudes, and formal instruction related to injury control among fourth-year medical students. Injury is the leading cause of death among Americans aged 1 to 44 years. METHOD: The authors conducted a cross-sectional survey of fourth-year students at six U.S. medical schools, four of which maintain federally funded injury prevention research centers. Main outcome measures included injury-related knowledge scores, three attitude measures, and self-reported exposures to injury prevention education. RESULTS: Six hundred and thirty-five fourth-year medical students (73% of those eligible) participated. The responding students were, on average, unable to correctly answer half of the questions testing injury-related knowledge. They rated medical problems more important and more preventable than injury problems, and they felt more comfortable asking their patients about risk factors for medical problems. These findings may be explained, in part, by the students' reported minimal exposure to injury control education in medical school. The students encountered the topic more frequently on rotations in pediatrics (84%), family medicine (73%), and preventive medicine (66%) than on rotations in emergency medicine (47%), internal medicine (41%), or obstetrics and gynecology (34%). Injury control was encountered least often on rotations in psychiatry (23%) and surgery (14%). CONCLUSIONS: These findings suggest that injury control is given limited coverage in the curricula of U.S. medical schools. As a result, students have little understanding of the principles and benefits of injury control.

Collaboration in emergency medicine research: a consensus statement.

The role of collaboration in medical research and how it applies to emergency medicine (EM) research are discussed. The guidance of the Division of Health Sciences Policy of the Institute of Medicine is reviewed. Application of the principles of collaborative efforts and recognition of each individual's contribution are overviewed. Emergency physicians can and should be invaluable contributors to collaborative research. Collaborative research relationships, whether established at individual institutions or through national clinical trials, must be developed deliberately. The specialty of EM must make the necessary commitment of time and resources to ensure that these occur.

Randomized, controlled trial of video self-instruction versus traditional CPR training.

STUDY OBJECTIVE: We conducted a prospective, randomized, controlled trial to test the hypothesis that a 34-minute video self-instruction (VSI) training program for adult CPR would yield comparable or better CPR performance than the current community standard, the American Heart Association Heartsaver course. METHODS: Incoming freshman medical students were randomly assigned to VSI or the Heartsaver CPR course. Two to 6 months after training, we tested subjects to determine their ability to perform CPR in a simulated cardiac arrest setting. Blinded observers used explicit criteria to assess our primary outcome, CPR performance skill. In addition, we assessed secondary outcomes including sequential performance of individual skills, ventilation and chest compression characteristics, and written tests of CPR-related knowledge and attitudes. RESULTS: VSI trainees displayed superior overall performance compared with traditional trainees. Twenty of 47 traditional trainees (43%) were judged not competent in their performance of CPR, compared with only 8 of 42 VSI trainees (19%; absolute difference, 24%; 95% confidence interval, 5% to 42%). CONCLUSION: In a group of incoming freshman medical students, we found that a half-hour of VSI resulted in superior overall CPR performance compared with that in traditional trainees. If validated by further research, VSI may provide a simple, quick, and inexpensive alternative to traditional CPR instruction for health care workers and, perhaps, the general population.