Gun Violence

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Growing up in a South Asian family in the Bay Area, CA, I can’t say I know the first thing about guns. So today I’m going to touch on some of the basics of guns and the demographics of gun violence in the United States. This email is meant to be purely educational, so I apologize if any of this information ends up being upsetting to anyone. Also, this is a massive topic, so I’ve just chosen just a few points to touch on. 

Epidemiology:

  • In 2020, 45,222 people died from gun violence according to the CDC. There was a 34% increase from the year before.

  • There are over 70,000 ED visits for nonfatal gun violence each year.

  • 80% of US homicides involved a firearm in 2020

  • Suicides account for 55% of firearm deaths, while homicides account for most of the remainder. 

    • Most suicide attempts with firearms are fatal, while most most assaults are nonfatal. 

  • Mass shootings are defined as events where 4+ victims are killed

    • They account for <1% of gun deaths in the USA

Demographics:

  • Firearm homicide disproportionately affects African American men, accounting for nearly 60% of firearm deaths despite making up only 13% of the population

  • Males account for 86% of firearm deaths and 87% of nonfatal firearm injuries

  • Majority of victims are between 15-34 years of age

  • Firearm suicide rates are the highest among adults 75+ years old

More quick facts:

  • The United States has some of the highest rates of gun ownership of the developed world

    • Highest rates of gun ownership in Montana (66% of residents), Wyoming, and Alaska

  • El Savador & Venezuela have the highest gun fatality rates 

  • The US spends $230 billion / year on gun-related violence. This equates to each murder costing approximately $500,000.

  • There are 400 million guns in the US across 82 million Americans. 

3 major types of guns:

  • Handguns / pistols: short barrel with thick walls to withstand high pressures 

    • Accounts for 45% of all homicides

    • 80% of firearm injuries are due to handguns

    • Used to fire at stationary target typically

  • Rifles: long barrel with thick walls to withstand high pressures

    • The rifle puts a spiral spin on the bullet, thus increasing the accuracy and distance

    • These bullets are bigger and have higher velocities

    • Usually they’re used for firing at stationary targets 

    • Accounts for 2% of homicides

    • Assault rifles are subtypes that became popular during World War II, the most famous name being AK-47

      • They are typically selective fire

      • More dangerous because they can fire more bullets and have larger magazines

      • Banned in 7 states, including New York

  • Shotguns: long barrel and thin walled to reduce pressure

    • Typically used to shoot at moving targets in the air

Key terms:

  • Caliber: describes the diameter of the bullet, typically in inches or millimeters

    • Clinical correlation: fatal shootings are usually higher diameter relative to nonfatal shootings

  • Automatic: 

    • Often referred to as machine guns

    • Squeezing the trigger fires cartridges repeatedly until released

    • These are a little harder to purchase – you have to pay $200 to pass a federal background check that shows no history of domestic violence or felony convictions

    • Banned in some states like California, Iowa, and Kansas

    • Clinical correlation: 

  • Semi-automatic:

    • Firearm that fires one bullet / trigger squeeze and then automatically reloads the chamber

    • AR-15 falls under this category – it typically holds 30 bullets before the operator needs to reload the gun. The reason these are tricky weapons is because they can be macgyvered into becoming an automatic weapon by using a “bump stock.” This was the case for the Las Vegas shooting and many other mass shootings.

  • Selective fire: this is a feature of assault rifles. They have the ability to toggle between automatic and semi-automatic modes

  • Safety:

    • Built in mechanism to prevent accidental discharge

  • Muzzle velocity: The average speed of a handgun bullet travels at 300m/s when it leaves the barrel, this is referred to as the “muzzle velocity.” Assault weapons are > 700m/s. As a throwback, just remember: KE=½ mv^2.

  • Magazine: the container that holds the ammunition

Recommendations for physicians:

It's advised that physicians talk to their patients about safe storage options. While this is typically a conversation that should occur with a PCP, it may be relevant at times in the ED setting:

  • Have these conversations in a non-judgmental way. Identify high risk patients.

  • Stored guns should be: 

    • Unloaded

    • Locked

    • Separate from ammunition

    • Locked in a way that's inaccessible to others/children

  • The parents should always assume that other people in the house know where it is.

  • There's a few recommended storage options:

    • Lock boxes: combination locks, keys, fingerprinted

    • Gun safes: can store many sizes of guns. Tend to be more expensive.

    • Cable locks: temporarily prevents it from being loaded or fired

    • Trigger lock: blocks the trigger from being fired. You can still load the gun. Sometimes can still accidentally allow for firing, so it's not super safe.

    • Trigger locks: prevents you from pulling the trigger. It’s important these guns are not loaded because otherwise using the trigger lock can lead to misfiring.

  • If you have a high risk patient, you can also recommend temporarily transferring ownership. Most gun retailers or shooting ranges will store them for a small fee. Some states also allow you to transfer the gun to another individual as long as they're 18+ years old and not prohibited from ownership. The temporary holder may not use the firearm during this time. 

I hope this was educational for you. I know there was some explicit detail here, but I think it’s important for physicians to understand the mechanisms and the terminology in order to participate in policy-making and advocacy at all levels since we see the effects of gun violence in our line of work. Feel free to chime in with additional information or clinical pearls.

References:

POTD: Test taking tips

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Today I’m going to be covering some test-taking strategies.

Focus on your weaknesses:

Don’t waste too much of your time reinforcing your strengths. Study your weakest topics that you don’t have daily exposure to in residency. If you have very limited time to study, consider filtering your Rosh Review question bank by your weaker topics, like Environmental, Heme/Onc, etc. 

Spaced repetition:

In order to retain information long term, you will likely need spaced repetition of the material. Don’t finish all of the environmental questions 3 months before the test. Try to revisit the material by doing some of those questions again, or by reviewing some of your notes.
Try to incorporate mental repetition into your daily routine. For example, quiz yourself on some topics that you learned earlier that day while you’re on the train or while you’re walking. 

Quick blocks:

Try to study in small blocks more frequently. 

Actively learn:

Don’t just passively nod your head and highlight each wrong answer you get in Rosh Review. Try to mentally quiz yourself after reading the explanations. Consider keeping a document with high yield notes.

Answering the questions:

All questions are created equal, and unanswered questions are marked as incorrect. Give yourself time to finish the test! Don’t spend too long on one question – it’s more important to finish the entire test.

Know your learning style:

Supplement your learning and tailor your study plan to your learning style. There are excellent free videos (https://www.intrainingprep.com/) and EMRAP Crunch Time audio reviews for the boards. 

Never pick an answer that uses “absolute terms:”

Avoid answer choices that include: always / never. 

If in doubt, pick the “long correct” answer: 

The detailed beautifully explained answer choice is often correct. They might include double options, more information, and caveats. 

1-2 days before the test:

Review a high yield document with a bunch of buzzwords and highly tested concepts. I’ve attached one of my favorite ones to this document. This will help refresh concepts you’ve reviewed a few weeks ago. I highly, highly recommend using this!!! I think like 20+ questions last year came up from this document. 

They’re not trying to trick you:

If the question stem obviously sounds like a PE, it’s probably a PE. Don’t overthink it. Just make sure you read the question carefully, and then move on.

I hope this helps! I know most of this is pretty obvious, but trust yourself and go with your gut. 


References:

https://knowledgeplus.nejm.org/blog/10-mistakes-studying-for-the-boards/ 
https://www.roshreview.com/blog/how-to-increase-your-emergency-medicine-board-exam-score-by-10-points/


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POTD: Can I Go Home With My PE?

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Congrats, Maimo Fam! You ordered the correct CT and you subsequently found that Pulmonary Embolus (PE). ...Now what?

This POTD was requested for further discussion on risk stratifying patients that can potentially be discharged with a pulmonary embolus. Let's talk about the PESI Score!

Pulmonary Embolism Severity Index (PESI)

The PESI is designed to risk stratify patients who have been diagnosed with a PE in order to determine the severity of their disease. This can help physicians make decisions on the management of those patients who could potentially be treated as out-patient, as well as raise concern for those who are determined to be high-risk and could benefit from higher levels of care.

In the setting of a patient diagnosed with PE, the PESI can be utilized to determine mortality and long term morbidity. For those determined to be very low risk (score ≤ 65), all studies showed a 30-day mortality <2%. In the validation, low risk (Class I and II) had a 90-day mortality of 1.1%. The non-inferiority trial demonstrated Class I and II could have been treated as outpatients assuming no other issues.

Sounds great, but what's the catch? Although the PESI tool has been externally validated, there are a few pitfalls to be aware of.

In the setting of a patient with renal failure or severe comorbidities, clinical judgement should be used over the PESI, as these patients were excluded in the validation study.

The PESI score determines risk of mortality and severity of complications.

The score does not require laboratory variables.

It is meant to aid in decision making, not replace it. Clinical judgement should always take precedence.

The PESI score determines clinical severity and can influence treatment setting for management of PE. Class I and II patients may possibly be safely treated as outpatients in the right clinical setting.

Class I - Scores ≤ 65 indicate very low risk.

Class II - Scores of 66-85 indicate low risk.

Class III - Scores of 86-105 indicate intermediate risk.

Class IV - Scores of 106-125 indicate high risk.

Class V - Scores >125 indicate very high risk.

Again, studies show PE patients with PESI class I or II seem safe to manage as outpatients. But as always, cOrReLaTe ClInIcAlLy.

Some final thoughts:

Social situation should also be taken into account before considering outpatient management (including the appropriate administration of anticoagulants).

Given low mortality of low risk PE, outpatient management would save significant funds over hospitalization (cited as $4,500 per avoided admission).

The non-inferiority trial showed successful and safe outpatient management of Class I and II patients.

As with other tools and scores we use in the ED, use your gut and your clinical judgement. These tools are to help you in your decision, but you're the only one that can put all the pieces of your patient's clinical puzzle together. I have faith in all of you to do what's best for your patient.

References:

Aujesky D, Obrosky DS, Stone RA, et al. Derivation and validation of a prognostic model for pulmonary embolism. Am J Respir Crit Care Med. 2005;172:1041-1046.

https://www.mdcalc.com/pulmonary-embolism-severity-index-pesi

https://wikem.org/wiki/Pulmonary_embolism

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