Categories
Choosing Wisely Psychiatry

Do we need labs to medically clear a patient for psych admission?

For most children requiring admission to an inpatient psychiatric facility laboratory studies are generally not required. Many of the children and adolescents being admitted already have an established mental or behavioral diagnosis, and a reassuring history and exam. The heterogeneity of clinical settings makes it challenging to establish processes that account for the needs of our patients while limiting the use of unnecessary resources broadly.

This podcast episode is designed to disseminate the important work of Choosing Wisely, an initiative of the the American Board of Internal Medicine Foundation, the goal of which is the spark conversations between clinicians and patients about what tests, treatments, and procedures are needed – and which ones are not.

The Choosing Wisely recommendation: Do not obtain screening laboratory tests in the medical clearance process of pediatric patients who require inpatient psychiatric admission unless clinically indicated

The Choosing Wisely Pediatric Emergency Medicine Recommendations

The Choosing Wisely Campaign Toolkit


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References

Thrasher TW, Rolli M, Redwood RS, et al. ‘Medical clearance’ of patients with acute mental health needs in the emergency department: a literature review and practice recommendations. WMJ. 2019;118(4):156-163

Donofrio JJ, Horeczko T, Kaji A, Santillanes G, Claudius I. Most routine laboratory testing of pediatric psychiatric patients in the emergency department is not medically necessary. Health Aff (Millwood). 2015;34(5):812-818

Chun TH. Medical clearance: time for this dinosaur to go extinct. Ann Emerg Med. 2014;63(6):676-677

Donofrio JJ, Santillanes G, McCammack BD, et al. Clinical utility of screening laboratory tests in pediatric psychiatric patients presenting to the emergency department for medical clearance. Ann Emerg Med. 2014;63(6):666-675.e663.

Santillanes G, Donofrio JJ, Lam CN, et al. Is medical clearance necessary for pediatric psychiatric patients? J Emerg Med. 2014;46(6):800-807

Santiago LI, Tunik MG, Foltin GL, Mojica MA. Children requiring psychiatric consultation in the pediatric emergency 

Berg JS, Payne AS, Wayra T, Morrison S, Patel SJ. Implementation of a Medical Clearance Algorithm for Psychiatric Emergency Patients. Hosp Pediatr (2023) 13 (1): 66–71

Categories
Choosing Wisely Radiology Respiratory

Do children with bronchiolitis, croup, asthma, or first-time wheezing need a Chest X-Ray?

For most children with children with bronchiolitis, croup, asthma, or first-time wheezing chest X-Rays are not necessary. These X-Rays are often obtained due to the possibility of missing pneumonia. But, these radiographs are hard to interpret, increase length of stay and the cost of care, and expose children to excess radiation.

This podcast episode is designed to disseminate the important work of Choosing Wisely, an initiative of the the American Board of Internal Medicine Foundation, the goal of which is the spark conversations between clinicians and patients about what tests, treatments, and procedures are needed – and which ones are not.

The Choosing Wisely recommendation: Do not obtain radiographs in children with bronchiolitis, croup, asthma, or first-time wheezing

The Choosing Wisely Pediatric Emergency Medicine Recommendations

The Choosing Wisely Campaign Toolkit


PEMBlog

@PEMTweets on… sigh “X” (Twitter)

My Instagram

My Mastodon account @bradsobo

References

Shah SN, Bachur RG, Simel DL, Neuman MI. Does this child have pneumonia? The rational clinical examination systematic review. JAMA. 2017;318(5):462-471. PMID: 28763554.

Schuh S, Lalani A, Allen U, et al. Evaluation of the utility of radiography in acute bronchiolitis. J Pediatr. 2007;150(4):429-433. PMID: 17382126.

Ramgopal S, Ambroggio L, Lorenz D, Shah SS, Ruddy RM, Florin TA. A Prediction Model for Pediatric Radiographic Pneumonia. Pediatrics. 2022 Jan 1;149(1):e2021051405. doi: 10.1542/peds.2021-051405. PMID: 34845493

Florin TA, Carron H, Huang G, Shah SS, Ruddy R, Ambroggio L. Pneumonia in Children Presenting to the Emergency Department with an Asthma Exacerbation. JAMA Pediatr. 2016;170(8):803-805. https://doi:10.1001/jamapediatrics.2016.0310

Categories
Nephrology Rheumatology

Henoch–Schönlein Purpura (HSP)

Henoch–Schönlein Purpura (HSP) is a common vasculitis seen in younger children. The classic skin finding is palpable purpura in gravity dependent areas of the body (buttocks and legs). Children can also have arthralgias, abdominal pain and intussusception, and even nephritis. Learn about the diagnosis and management of Henoch–Schönlein Purpura (HSP) in this brief podcast episode.

PEMBlog

@PEMTweets on… sigh “X” (Twitter)

My Instagram

My Mastodon account @bradsobo

References

Chen JY et al. Henoch-Schönlein purpura nephritis in children: incidence, pathogenesis and management. World J Pediatr. 2015 Feb;11(1):29-34.

Saulsbury, FT (1999) Henoch-Schönlein purpura in children. Report of 100 patients and review of the literature. Medicine (Baltimore) 78: pp. 395-409

Saulsbury FT. Henoch-Schonlein Purpura. Current Opinion in Rheummatology. Jan. 2001;13(1):35-40.

Little KJ, Danzl DF. Intussusception associated with Henoch-Schonlein Purpura. The Journal of Emergency Medicine: 1991;9(1):29-32.

Chamberlain RS, Greenberg LW. Scrotal involvement in Henoch-Schonlein Purpura: A case report and review of the literature. Pediatric Emergency Care;8(4):213-215.

Saulsbury FT. Henoch-Schonlein Purpura. Current Opinion in Rheummatology: Jan. 2001; Vole 13(1). Pp.35-40.

Categories
Toxicology

Stings and Envenomations

It is summertime, so the bees and bugs are out! In this episode, Dr. Ben Grebber, a pediatric resident at Boston Children’s Hospital/Tufts Children’s Hospital, discusses Bee Stings and Spider Bites. A very common pediatric summer complaint in emergency departments, urgent cares, and primary care offices, this episode covers common signs and symptoms, some pathophysiology, and recommended treatments.

PEMBlog

@PEMTweets on Twitter

My Mastodon account @bradsobo

References

Arif F, Williams M. Hymenoptera Stings. [Updated 2022 Jun 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK518972/

Bond, G. R. (1999). Snake, spider, and scorpion envenomation in North America. Pediatrics in review, 20(5), 147-151.

Pansare, M., Seth, D., Kamat, A., & Kamat, D. (2020). Summer buzz: All you need to know about insect sting allergies. Pediatrics in Review, 41(7), 348-356.

Shireen Banerji, PharmD, Alvin C. Bronstein, MD, 2016. “Envenomations”, American Academy of Pediatrics Textbook of Pediatric Care, Thomas K. McInerny, MD, FAAP, Henry M. Adam, MD, FAAP, Deborah E. Campbell, MD, FAAP, Thomas G. DeWitt, MD, FAAP, Jane Meschan Foy, MD, FAAP, Deepak M. Kamat, MD, PhD, FAAP, Rebecca Baum, MD, FAAP, Kelly J. Kelleher, MD, MPH, FAAP

Categories
Mental Health

Agitation Episode 5: The boarded ED patient

We are in the midst of a staggering mental health crisis. Thousands of children and adolescents spend days at time in Emergency Departments waiting for definitive mental health disposition. This podcast episode hosted by Brad Sobolewski (@PEMTweets) and co-authored by Dennis Ren (@DennisRenMD) is all about what we should consider when boarding children in the ED for mental health reasons. It is also the final episode in a 5 episode series focused on agitation in children and adolescents.

After listening to this episode you will be able to:

  • Identify some of the reasons why we are boarding so many children in the ED and which children are the highest priority
  • Describe the challenges these patients face as they await inpatient psychiatric care
  • Describe best practices and what we should be doing for them 
  • Discuss some of the stresses that these children place on the healthcare system, and possible alternative strategies.

This episode is a co-production of the Emergency Medical Services for Children Innovation and Improvement Center whose mission is to minimize morbidity and mortality of acutely ill and injured children across the emergency continuum.

EMDocs Collaboration

EMDocs.net – the excellent Emergency Medicine site will also be contributing a supplementary article for each episode that will be posted each Friday following the release of the podcast episode. These articles will take another look at the content included in this episode.

Special thanks to Manpreet Singh, MD (@MprizzleER) for helping to put this collaboration together. 

Other Episodes in the Agitation Series

Episode 1: Differentiating organic versus psychiatric causes of agitation and altered mental status | Supplementary EMDocs article

Episode 2: Non-pharmacologic management of agitated children | Supplementary EMDocs article

Episode 3: Pharmacologic management of agitated children | Supplementary EMDocs article

Episode 4: Safe prehospital transport of the agitated patient | Supplementary EMDocs.net article

EMSC IIC

To learn more about the Emergency Medical Services for Children Innovation and Improvement Center visit https://emscimprovement.center

Email km@emscimprovement.center

Follow on Twitter @EMSCImprovement

EMSC IIC: Pediatric Education and Advocacy Kit (PEAK): Agitation

PEAK Agitation resources

Brad’s stuff

PEMBlog

@PEMTweets on Twitter

My Mastodon account @bradsobo

My Educator Portfolio

References

Fiona B. McEnany, Olutosin Ojugbele, Julie R. Doherty, Jennifer L. McLaren, JoAnna K. Leyenaar; Pediatric Mental Health Boarding. Pediatrics October 2020; 146 (4): e20201174. 10.1542/peds.2020-1174

AAP-AACAP-CHA Declaration of a National Emergency in Child and Adolescent Mental Health

Jennifer A. Hoffmann, Polina Krass, Jonathan Rodean, Naomi S. Bardach, Rachel Cafferty, Tumaini R. Coker, Gretchen J. Cutler, Matthew Hall, Rustin B. Morse, Katherine A. Nash, Kavita Parikh, Bonnie T. Zima; Follow-up After Pediatric Mental Health Emergency Visits. Pediatrics March 2023; 151 (3): e2022057383. 10.1542/peds.2022-057383

Nordstrom K, Berlin JS, Nash SS, Shah SB, Schmelzer NA, Worley LLM. Boarding of Mentally Ill Patients in Emergency Departments: American Psychiatric Association Resource Document. West J Emerg Med. 2019 Jul 22;20(5):690-695. doi: 10.5811/westjem.2019.6.42422. PMID: 31539324; PMCID: PMC6754202.

Cushing AM, Liberman DB, Pham PK, et al. Mental Health Revisits at US Pediatric Emergency Departments. JAMA Pediatr. 2023;177(2):168–176. doi:10.1001/jamapediatrics.2022.4885

Nash  KA, Zima  BT, Rothenberg  C,  et al.  Prolonged emergency department length of stay for US pediatric mental health visits (2005-2015).   Pediatrics. 2021;147(5):e2020030692. doi:10.1542/peds.2020-030692

Lo CB, Bridge JA, Shi J, Ludwig L, Stanley RM. Children’s Mental Health Emergency Department Visits: 2007-2016. Pediatrics. 2020 Jun;145(6):e20191536. doi: 10.1542/peds.2019-1536. Epub 2020 May 11. PMID: 32393605.

Parent/Professional Advocacy League: Best Practices: Pediatric Emergency Department Psychiatric Boarding

Kraft CM, Morea P, Teresi B, et al. Characteristics, Clinical Care, and Disposition Barriers for Mental Health Patients Boarding in the Emergency Department. American Journal of Emergency Medicine. Nov. 2020. Doi.org/10.1016/j.ajem.2020.11.021

Disclaimer

The Emergency Medical Services for Children Innovation and Improvement Center is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award (U07MC37471) totaling $3M with 0 percent financed with nongovernmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.

Categories
Mental Health

Agitation Episode 4: Safe prehospital transport

There are protocols in place that assist highly trained Emergency Medical Service providers in assuring that agitated children are safely transported to their destination. This podcast episode hosted by Brad Sobolewski (@PEMTweets) and co-authored by Dennis Ren (@DennisRenMD) is all about what pre-hospital providers should do to get these agitated children safely to the ED. It is also episode 4 in a 5 episode series focused on agitation in children and adolescents.

After listening to this episode you will be able to:

  • Identify unique aspects of the pre-hospital environment that impact assessment and treatment of agitated children
  • Describe the role of EMS personnel and EMS director in the care of agitated children.
  • Describe the role of medical control in determining destination and goals of safe transport

This episode is a co-production of the Emergency Medical Services for Children Innovation and Improvement Center whose mission is to minimize morbidity and mortality of acutely ill and injured children across the emergency continuum.

EMDocs Collaboration

EMDocs.net – the excellent Emergency Medicine site will also be contributing a supplementary article for each episode that will be posted each Friday following the release of the podcast episode. These articles will take another look at the content included in this episode.

Special thanks to Manpreet Singh, MD (@MprizzleER) for helping to put this collaboration together. 

Other Episodes in the Agitation Series

Episode 1: Differentiating organic versus psychiatric causes of agitation and altered mental status | Supplementary EMDocs article

Episode 2: Non-pharmacologic management of agitated children | Supplementary EMDocs article

Episode 3: Pharmacologic management of agitated children | Supplementary EMDocs article

Episode 5: Management of the child with mental health problems who is boarded in the Emergency Department (Coming June 14, 2023)

EMSC IIC

To learn more about the Emergency Medical Services for Children Innovation and Improvement Center visit https://emscimprovement.center

Email km@emscimprovement.center

Follow on Twitter @EMSCImprovement

EMSC IIC: Pediatric Education and Advocacy Kit (PEAK): Agitation

PEAK Agitation resources

Brad’s stuff

PEMBlog

@PEMTweets on Twitter

My Mastodon account @bradsobo

My Educator Portfolio

References

Kupas D et al. NASEMSO: Clinical care and restraint of agitated or combative patients by emergency medical service practitioners. https://nasemso.org/wp-content/uploads/Clinical-Care-and-Restraint-of-Agitated-or-Combative-Patients-by-Emergency-Medical-Services-Practitioners.pdf

Patient restraint in emergency medical services [Position Statement]. Prehosp Emerg Care. 2017;21(3):395-396.

Disclaimer

The Emergency Medical Services for Children Innovation and Improvement Center is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award (U07MC37471) totaling $3M with 0 percent financed with nongovernmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.

Categories
Mental Health

Agitation Episode 3: Pharmacologic management

When we think of managing agitated patients we think of medicines – but that shouldn’t be our first option. However, medications can be adjuncts to non-pharmacologic means to help keep agitated children safe from harm. This podcast episode hosted by Brad Sobolewski (@PEMTweets) and co-authored by Dennis Ren (@DennisRenMD) is all about age-appropriate pharmacologic management strategies for agitated children. It is also episode 3 in a 5 episode series focused on agitation in children and adolescents.

After listening to this episode you will be able to:

  • Discuss the medications commonly used to treat acute agitation in children and adolescents
  • Discuss the different routes of administration to safely administer these medicines

This episode is a co-production of the Emergency Medical Services for Children Innovation and Improvement Center whose mission is to minimize morbidity and mortality of acutely ill and injured children across the emergency continuum.

EMDocs Collaboration

EMDocs.net – the excellent Emergency Medicine site will also be contributing a supplementary article for each episode that will be posted each Friday following the release of the podcast episode. These articles will take another look at the content included in this episode.

Special thanks to Manpreet Singh, MD (@MprizzleER) for helping to put this collaboration together. 

Other Episodes in the Agitation Series

Episode 1: Differentiating organic versus psychiatric causes of agitation and altered mental status | Supplementary EMDocs article

Episode 2: Non-pharmacologic management of agitated children | Supplementary EMDocs article

Episode 4: Safe pre-hospital transport of the agitated child | Supplementary EM Docs Article

Episode 5: Management of the child with mental health problems who is boarded in the Emergency Department (Coming June 14, 2023)

EMSC IIC

To learn more about the Emergency Medical Services for Children Innovation and Improvement Center visit https://emscimprovement.center

Email km@emscimprovement.center

Follow on Twitter @EMSCImprovement

EMSC IIC: Pediatric Education and Advocacy Kit (PEAK): Agitation

PEAK Agitation resources

Brad’s stuff

PEMBlog

@PEMTweets on Twitter

My Mastodon account @bradsobo

My Educator Portfolio

References

Gerson R, Malas N, Feuer V, Silver GH, Prasad R, Mroczkowski MM. Best Practices for Evaluation and Treatment of Agitated Children and Adolescents (BETA) in the Emergency Department: Consensus Statement of the American Association for Emergency Psychiatry. West J Emerg Med. 2019 Mar;20(2):409-418. doi: 10.5811/westjem.2019.1.41344. Epub 2019 Feb 19. Erratum in: West J Emerg Med. 2019 May;20(3):537. Erratum in: West J Emerg Med. 2019 Jul;20(4):688-689. PMID: 30881565; PMCID: PMC6404720.

Foster AA, Saidinejad M, Duffy S, Hoffmann JA, Goodman R, Monuteaux MC, Li J. Pediatric Agitation in the Emergency Department: A Survey of Pediatric Emergency Care Coordinators. Acad Pediatr. 2023 Mar 21:S1876-2859(23)00091-8. doi: 10.1016/j.acap.2023.03.005. Epub ahead of print. PMID: 36948291.

Wong AH, Ray JM, Eixenberger C, Crispino LJ, Parker JB, Rosenberg A, Robinson L, McVaney C, Iennaco JD, Bernstein SL, Yonkers KA, Pavlo AJ. Qualitative study of patient experiences and care observations during agitation events in the emergency department: implications for systems-based practice. BMJ Open. 2022 May 11;12(5):e059876. doi: 10.1136/bmjopen-2021-059876. PMID: 35545394; PMCID: PMC9096567.

New A, Tucci VT, Rios J. A Modern-Day Fight Club? The Stabilization and Management of Acutely Agitated Patients in the Emergency Department. Psychiatr Clin North Am. 2017 Sep;40(3):397-410. doi: 10.1016/j.psc.2017.05.002. PMID: 28800797.

Disclaimer

The Emergency Medical Services for Children Innovation and Improvement Center is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award (U07MC37471) totaling $3M with 0 percent financed with nongovernmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.

Categories
Mental Health

Agitation Episode 2: Non-pharmacologic management

Agitated children should always be treated with dignity and respect. This entails utilizing the least invasive non-pharmacologic means of assisting them, before moving to physical or chemical restraints. This podcast episode hosted by Brad Sobolewski (@PEMTweets) and co-authored by Dennis Ren (@DennisRenMD) is all about age-appropriate non pharmacologic management strategies for agitated children. It is also episode 2 in a 5 episode series focused on agitation in children and adolescents.

After listening to this episode you will be able to:

  • Discuss specific age-appropriate non pharmacologic management strategies for agitated children
  • Discuss how we can safely use holds and restraints, and how these are temporary measures

This episode is a co-production of the Emergency Medical Services for Children Innovation and Improvement Center whose mission is to minimize morbidity and mortality of acutely ill and injured children across the emergency continuum.

EMDocs Collaboration

EMDocs.net – the excellent Emergency Medicine site will also be contributing a supplementary article for each episode that will be posted each Friday following the release of the podcast episode. These articles will take another look at the content included in this episode.

Special thanks to Manpreet Singh, MD (@MprizzleER) for helping to put this collaboration together. 

Other Episodes in the Agitation Series

Episode 1: Differentiating organic versus psychiatric causes of agitation and altered mental status | Supplementary EMDocs article

Episode 3: Pharmacologic management of agitated children (Coming May 31, 2023)

Episode 4: Safe pre-hospital transport of the agitated child | Supplementary EM Docs Article

Episode 5: Management of the child with mental health problems who is boarded in the Emergency Department (Coming June 14, 2023)

EMSC IIC

To learn more about the Emergency Medical Services for Children Innovation and Improvement Center visit https://emscimprovement.center

Email km@emscimprovement.center

Follow on Twitter @EMSCImprovement

EMSC IIC: Pediatric Education and Advocacy Kit (PEAK): Agitation

PEAK Agitation resources

Brad’s stuff

PEMBlog

@PEMTweets on Twitter

My Mastodon account @bradsobo

My Educator Portfolio

References

Berzlanovich AM, Schöpfer J, Keil W. Deaths due to physical restraint. Dtsch Arztebl Int. 2012 Jan;109(3):27-32. PMC3272587.

Coburn VA, Mycyk MB. Physical and chemical restraints. Emerg Med Clin North Am. 2009 Nov;27(4):655-67, ix. doi: 10.1016/j.emc.2009.07.003. PMID: 19932399.

Downes MA, Healy P, Page CB, Bryant JL, Isbister GK. Structured team approach to the agitated patient in the emergency department. Emerg Med Australas. 2009 Jun;21(3):196-202. PMID: 19527279.

Knox DK, Holloman GH Jr. Use and avoidance of seclusion and restraint: consensus statement of the american association for emergency psychiatry project Beta seclusion and restraint workgroup. West J Emerg Med. 2012 Feb;13(1):35-40. PMC3298214.

Melamed E, Oron Y, Ben-Avraham R, Blumenfeld A, Lin G. The combative multitrauma patient: a protocol for prehospital management. Eur J Emerg Med. 2007 Oct;14(5):265-8. PMID: 17823561.

Disclaimer

The Emergency Medical Services for Children Innovation and Improvement Center is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award (U07MC37471) totaling $3M with 0 percent financed with nongovernmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.

Categories
Mental Health

Agitation Episode 1: Differentiating organic versus psychiatric

Most children who present to Pediatric Emergency Departments these days with mental health concerns – including agitation – have a known psychiatric problem or diagnosis. Furthermore, the connection between physical and functional symptoms is inextricably linked in many patients. Why then do we persist with the “is it medical/organic or psych” question? Ultimately, this episode hosted by Brad Sobolewski (@PEMTweets) and co-authored by Dennis Ren (@DennisRenMD) is less about “is it psych or not” and more about not missing something because you assumed the patient had a mental or behavioral problem. It is also episode 1 in a 5 episode series focused on agitation in children and adolescents.

After listening to this episode you will be able to:

  • Describe the findings on history and physical examination that differentiate organic vs psychiatric causes of agitation and altered mental status.
  • Develop a strategy to differentiate organic from psychiatric causes of altered mental status, including using ancillary studies

This episode is a co-production of the Emergency Medical Services for Children Innovation and Improvement Center whose mission is to minimize morbidity and mortality of acutely ill and injured children across the emergency continuum.

EMDocs Collaboration

EMDocs.net – the excellent Emergency Medicine site will also be contributing a supplementary article for each episode that will be posted each Friday following the release of the podcast episode. These articles will take another look at the content included in this episode.

Special thanks to Manpreet Singh, MD (@MprizzleER) for helping to put this collaboration together. 

Other Episodes in the Agitation Series

Episode 2: Non-pharmacologic management of agitated children (Coming May 24, 2023)

Episode 3: Pharmacologic management of agitated children (Coming May 31, 2023)

Episode 4: Safe pre-hospital transport of the agitated child (Coming June 7, 2023)

Episode 5: Management of the child with mental health problems who is boarded in the Emergency Department (Coming June 14, 2023)

EMSC IIC

To learn more about the Emergency Medical Services for Children Innovation and Improvement Center visit https://emscimprovement.center

Email km@emscimprovement.center

Follow on Twitter @EMSCImprovement

EMSC IIC: Pediatric Education and Advocacy Kit (PEAK): Agitation

PEAK Agitation resources

Brad’s stuff

PEMBlog

@PEMTweets on Twitter

My Mastodon account @bradsobo

My Educator Portfolio

References

Hua LL, COMMITTEE ON ADOLESCENCE. Collaborative Care in the Identification and Management of Psychosis in Adolescents and Young Adults. Pediatrics 2021; 147.

Sedel F, Baumann N, Turpin JC, et al. Psychiatric manifestations revealing inborn errors of metabolism in adolescents and adults. J Inherit Metab Dis 2007; 30:631.

Chun TH, Sargent J, Hodas GR. Psychiatric emergencies. In: Textbook of Pediatric Emergency Medicine, 5th, Fleisher GR, Ludwig S, Henretig FM (Eds), Lippincott Williams & Wilkins, Philadelphia 2006. P.1820.

Cunqueiro A, Durango A, Fein DM, et al. Diagnostic yield of head CT in pediatric emergency department patients with acute psychosis or hallucinations. Pediatr Radiol 2019; 49:240.

Gerson R, Malas N, Feuer V, Silver GH, Prasad R, Mroczkowski MM. Best Practices for Evaluation and Treatment of Agitated Children and Adolescents (BETA) in the Emergency Department: Consensus Statement of the American Association for Emergency Psychiatry. West J Emerg Med. 2019 Mar;20(2):409-418. doi: 10.5811/westjem.2019.1.41344. Epub 2019 Feb 19. Erratum in: West J Emerg Med. 2019 May;20(3):537. Erratum in: West J Emerg Med. 2019 Jul;20(4):688-689. PMID: 30881565; PMCID: PMC6404720.

Disclaimer

The Emergency Medical Services for Children Innovation and Improvement Center is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award (U07MC37471) totaling $3M with 0 percent financed with nongovernmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.

Categories
Advocacy and Injury Prevention

Gun Violence and Safety (2023)

Dr. Kit Carney and Dr. Kristen Humphrey discuss gun violence, its impact on our patients and their families, as well as practical tips on advocating for safe storage of firearms, and how we can support victims of violence.

PEMBlog

@PEMTweets on Twitter

My Mastodon account @bradsobo

Advocacy and education resources

Be SMART Campaign
Be SMART emphasizes the importance of responsible gun ownership and secure gun storage. Ultimately, secure gun storage prevents kids from accessing guns. When we protect our kids from the dangers of gun violence, the whole community stands to benefit.

Brady: Asking Saves Kids (ASK)
ASK (Asking Saves Kids) is a simple way to help keep kids safe and a fundamental part of our End Family Fire campaign. Parents and guardians ask all sorts of questions before they allow their children to visit other homes; they ask about pets in the house, discuss allergies and Internet access, and ask questions about supervision. As part of our End Family Fire campaign, ASK encourages parents and guardians to add one more question to this conversation: “Is there an unlocked gun in your house?” 

AAP Gun Safety Toolbox

Resources for gun violence survivors

Everytown

Sandy Hook Promise

Moms Demand Action

Giffords: Courage to Fight Gun Violence

Talking to children about gun violence

Cincinnati Children’s Blog: Tips for Talking to Kids About Violence in the News

National Association of School Psychologists: Talking to Children About Violence: Tips for Parents and Teachers

HealthyChildren.org: How to Talk With Kids About Tragedies & Other Traumatic News Events

Ohio specific resources

Ohio coalition against gun violence

Ohio coalition against gun violence resource list

References

Council on injury, violence, and poison prevention executive committee, M. Denise Dowd, Robert D. Sege, H. Garry Gardner, Kyran P. Quinlan, Michele Burns Ewald, Beth E. Ebel, Richard Lichenstein, Marlene D. Melzer-Lange, Joseph O’Neil, Wendy J. Pomerantz, Elizabeth C. Powell, Seth J. Scholer, Gary A. Smith; Firearm-Related Injuries Affecting the Pediatric Population. Pediatrics November 2012; 130 (5): e1416–e1423. 10.1542/peds.2012-2481

Haasz, M., Boggs, J. M., Beidas, R. S., & Betz, M. E. (2022). Firearms, physicians, families, and kids: Finding words that work. The Journal of Pediatrics247, 133–137. https://doi.org/10.1016/j.jpeds.2022.05.029 

Gifford. (2022, August 10). Child Access & Safe Storage. Giffords. Retrieved October 7, 2022, from https://giffords.org/lawcenter/gun-laws/policy-areas/child-consumer-safety/child-

Goldstick, J. E., Cunningham, R. M., & Carter, P. M. (2022). Current causes of death in children and adolescents in the United States. New England Journal of Medicine386(20), 1955–1956. https://doi.org/10.1056/nejmc2201761 

Gun violence prevention. Children’s Defense Fund. (2022, March 18). Retrieved October 7, 2022, from https://www.childrensdefense.org/policy/policy-priorities/gun-violence-prevention/access-prevention-and-safe-storage/

Episode Transcript

[Kit] Hello! I’m Dr. Carney and I am a pediatric resident at Cincinnati Children’s Hospital Medical Center. I’m here with my co-resident, Dr. Humphrey. Today, we are going to discuss firearm safety and ways to screen for it in both the ED and clinic settings. Thank you for hosting us, Brad!

The goals of this episode are to:

  1. Report updated statistics about pediatric firearm-related injuries and deaths in the US
  2. Discuss and review the updated American Academy of Pediatrics’ recommendations on firearm safety
  3. Discuss updated strategies for counseling your patients and families on firearm safety, and 
  4. Talk about how we can support patients and families who are victims of gun violence 

[ Kit ] To best understand how prevalent firearm-related injuries are, let’s discuss some statistics:

  • Firearms are now the leading cause of death among children 0-19 years old in the United States. While gun violence is a global issue, the United States houses a disproportionate amount of these gun violence instances. 
  • While the United States accounts for just 4% of the world’s population, it accounts for 35% of firearm suicides and 9% of firearm homicides.
  • Each year, 3200 children die from firearm-related injuries. This means that a child dies from a firearm every 2 hours and 45 minutes. Unfortunately, this number has continued to rise as gun sales have soared. 
  • From 2019 to 2020, the rate of firearm related deaths among children increased by 30%. When we look more closely at these numbers, we note that prominent racial disparities exist regarding firearm injury, as well. 
  • Black children and teens are 4 times more likely than their white peers to die by firearms.

[ Kristen ] These fire-arm related fatalities among children are due not only to homicide or accident, but also suicide. 

  • Firearms account for the greatest number of suicide deaths. Guns are by far the greatest risk for completed suicide, because they are so lethal. Guns have a 90% mortality rate when used for suicide. 
  • Unfortunately, of the weapons used in these suicides, as well as in school shootings and unintentional homicides, 70-90% of them came from unsecured weapons at the child’s home. 
  • Research demonstrates that fewer than half of all gun owners store their firearms safely, and that many children have access to these guns. 
  • Of the estimated 4.6 million children in the US who live with at least one unsecured firearm in their home, 75% of those know where guns are stored in their home and 22% have handled guns without their caregivers’ knowledge. 

[ Kit ] To help address these harrowing statistics, the American Academy of Pediatrics has released updated recommendations concerning safe firearm storage practices.      

  • The most effective measure caregivers can take to prevent fire-arm related injuries is to remove them from the home. 
  • For those families who do have guns in the home, these firearms should be unloaded and locked, with ammunition stored and locked separately.
  • Cable locks, trigger locks, and lockboxes are all safe ways to store firearms. 
  • A Cable lock is a looped wire that works similarly to a bike lock. This mechanism allows you to loop one end of the wire through the handgun to prevent the gun from being fired or loaded, and then connect that end of the wire to the lock at the end of the loop. You can purchase these for about $10 at local retailers.  
  • A trigger lock is a two-piece mechanism. The two pieces fit over the trigger guard so that the gun’s trigger cannot be released and allow the gun to fire. These trigger locks come with either a key and lock; a keypad, or a combination lock. One can purchase these for about $10 at local retailers. 
  • Finally, a Gun lock box is a combination-protected box that is similar to a safe but is small enough to house just a gun. You can purchase these for about $25-100. 
  • Studies demonstrate that utilizing one of these storage methods can reduce the suicide and unintentional gun deaths in children by up to 54%. 

[ Kristen ] Great question. 

  • In our current environment, it can feel overwhelming as a healthcare provider to discuss firearms. The encouraging news is that the majority of parents report that they would feel comfortable discussing firearm safety with their pediatrician. Nonjudgmental communication is key to this conversation. Healthcare providers need to be aware of and manage their biases concerning this topic, and that starts by ensuring that we ask all families about it.
  • Firearm safety can be discussed in any setting, but ideally it is a preventative, rather than a reactionary, conversation. 
  • It helps to first frame this conversation as one about safety, perhaps in the context of discussing car seats, water safety, or bike helmets because optimizing a patient’s safety is often a common goal of both caregivers and healthcare providers. 
  • For example, you might say “I like to talk about firearm safety with all of my patients because we know firearms can pose a safety risk to children. Research has shown that the safest way to store firearms is to store them locked, unloaded, and separately from ammunition.” 
  • While the AAP continues to emphasize that the most effective measure to prevent firearm-related injuries is their absence in the home.

New studies demonstrate that families respond best to a normative statement. This means that the clinician normalizes that many people have firearms in the home. An example of this normative statement would be “for any firearms in the home, or other homes your child may visit, are they stored locked and unloaded?” Asking about both their home and other homes they visit allows families to talk about this subject without having to disclose a gun in their own house. 

  • After asking this question, you can also ask if families would like to hear more information about safe storage practices, such as cable locks and lockboxes.
  • When discussing firearms, it is important to keep in mind the age of the patient.  
    • In younger children (ages 1-9), firearm injuries are typically related to unintentional injury, as children as young as 2-3 are capable of pulling a trigger. 
    • However, In adolescents, (ages 10-19), nearly 97% of firearm injuries are related to intentional homicide or suicide. In this patient population, especially if there are significant mental health concerns, discussion about removing firearms from the home temporarily and voluntarily may help promote the patient’s safety. 

[ Kit ] 

  • It is important that both the adolescent and the parent be engaged in these discussions, as adolescents are prone to more impulsivity and need to understand the dangers for themselves, as they are able to get access even without a caregiver’s knowledge.  
  • To help caregivers keep their adolescents and younger children safe, I often refer families to the ASK (or asking saves kids) campaign to provide them with the tools to ask their children about the presence of firearms in both new and familiar circumstances. These new circumstances can include a new babysitting job, a new roommate, or a new playmate. 
  • The Be SMART campaign is another excellent resource for both parents and healthcare providers for modeling firearm safety conversations. S stands for secure all guns  in the home and vehicles; M stands for model responsible behavior around guns; A stands for ask about presence of unsecured firearms in other locations; R stands for recognize the role of guns in suicide T stands for tell peers to be SMART. Check out the references section of this PEM currents episode for links to the ASK and Be SMART websites, as well as for other links for learning how to talk to children about gun violence. 

[ Kristen]

  • Because those impacted by gun violence often experience trauma and are at higher risk for suicide, we as healthcare providers need to ensure that families get early access to mental health support. National support groups for families and patients who have experienced gun violence include: Trauma Survivors Network, Survivors Empowered, and the Gun Violence Survivors Foundation. There are also local survivors groups through Cincinnati’s chapter of Mom’s Demand Action and Every Town.

[Kit] Let’s review what we talked about today:

  • [Kit] Gun sales and violence have increased since 2020, and firearms are now the leading cause of death for those aged 0-19 
  • [Kit] While younger children are more likely to become injured 2/2 unintentional use, adolescents are more likely to become injured due to intentional homicide or suicide attempts
  • [Kit] Many caregivers are open to discussing firearm safety with their healthcare provider in the context of other anticipatory guidance 
  • [Kristen] The American Academy of Pediatrics states that discussing with ALL families that firearms should be unloaded and locked, with locked ammunition stored separately, would significantly decrease the rate of firearm-related injury among children
  • [Kristen] Victims of firearm related injury and their families are at higher risk for mental health crises; providing them with support is essential to ensuring their ongoing well-being 

[Kristen] If you are interested in becoming involved at a legislative level, Moms Demand Action is a national organization that provides information for local, state, and national advocacy around gun safety.