Americans are victimized by episodes of mass gun violence and active shooter events with increasing regularity. The news coverage after each event commonly portrays a perpetrator whose behavior, although negative, was not sufficiently explicit that others could have predicted his violent conduct. Regrettably, this attitude ignores the relevance of numerous validated risk factors for identifying and stratifying individual risk of violence and dismisses opportunities for prevention. (Mother Jones, Oct. 15, 2014, http://bit.ly/2Hn5qBI; Federal Bureau of Investigation. Sept. 16, 2013, http://bit.ly/2Pb9awm; U.S. Department of Homeland Security. April 2019, http://bit.ly/2ZoPNzZ.)

It is certainly impossible to predict future violence from specific individuals, and the majority of individuals with negative behaviors and access to firearms never complete acts of interpersonal violence. We emergency physicians, however, recognize that the confluence of negative risk factors and firearm access often leads to poor outcomes, and we treat the consequences of this unfavorable association every day in emergency departments.

Firearms augment the risk of injury and death from self-directed or interpersonal violence, and may also have a causal role in inciting violent conduct. (JAMA Pediatr. 2013;167[12]:1094.) Emergency physicians commonly care for individuals who demonstrate risk factors for violence, such as previous violent conduct, intoxication, agitation, and impaired impulse control, among many others. If we discover that these same patients also have access to firearms, it may cause us to change our perception of risk and influence our treatment plan and disposition.

An intoxicated patient delivered to the ED by law enforcement for a welfare check following a bar fight, for example, generally presents a threat only to himself. When the same patient stumbles onto the gurney and drops a handgun from his coat pocket, he poses a threat to everyone, including himself. The same may be true for an agitated patient who expresses menacing sentiments against individuals or groups but does not specify a plan or a target. Would firearm access by this individual constitute a public safety threat, and what can clinicians do to mitigate the risk of harm?

Numerous cases in the public domain demonstrate that such individuals cause concern for safety among laypersons and law enforcement, and these individuals are then transported to EDs for mental health evaluations. (Bennington Banner. Jan. 3, 2013, http://bit.ly/2ZokgSL; Jan. 30, 2013, http://bit.ly/2L1sCXc; and Nov. 5, 2014, http://bit.ly/2NtTrWM; and VTDigger. Dec. 18, 2018; http://bit.ly/2NolJ5b.)

The incidence of these cases is unknown, and certainly many more may not be reported due to confidentiality concerns. Emergency physicians in these situations are explicitly challenged with the responsibility of determining how such behaviors with a firearm contribute to clinical status and whether firearm access paired with negative behaviors indicate an unstable mental or physical condition in need of treatment.

We emergency physicians require clarity about our role and accountability in these circumstances. We have legal, ethical, and professional obligations to protect individual and public safety when we are concerned that a patient under our care may pose a threat to himself or others. HIPAA permits disclosure of protected health information without consent when providers believe that such disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. (Health & Human Services Regulations, 164.512 [j][i][A]. 5 Jan 2001; http://bit.ly/2TZ0gkD.) In situations where patients do not explicitly endorse an intention to harm themselves or others, clinical concerns about serious and potential bodily harm may fall below the reporting thresholds permitted by HIPAA, which precipitates a dilemma between safety and compliance.

No professional guidelines exist for evaluating firearm access among acute care patients despite the fact that access possibly contributes to the clinical estimation of risk. There are also no guidelines to advise us how to diminish the risk of firearm violence when present. The treating physician must weigh the dynamics of risk v. protective factors that can influence individuals toward or away from violence even though that is not a common component of emergency medicine training.

Understanding risk factors for firearm injury and interpreting them in clinical practice will require a systematic, multidisciplinary effort based in science. As long as the Centers for Disease Control and Prevention and the National Institutes of Health persist in not funding firearm injury prevention research, the American Foundation for Firearm Injury Reduction in Medicine (AFFIRM) will try to fill the void.

AFFIRM was founded in October 2017 to reduce the incidence and health consequences of firearm victimization, injury, and death through research, evidence-based practice, and community partnerships. AFFIRM is the hub of a growing network of more than 20 of the nation's leading physician, nurse, and public health organizations, including the American College of Emergency Physicians, the American Academy of Emergency Medicine, and the Emergency Nurses Association.

We as health care providers must address the epidemic of firearm violence in the same manner that we address other public health concerns. By investing in science and putting the house of medicine to work, we can create evidence-based strategies to understand which behaviors and cognitions about firearms are unsafe and how a patient's access to firearms should inform our work to identify, stratify, and treat patients at risk of self-directed and interpersonal firearm violence. It is up to us to create the change we all need to see.

Dr. Barsottiis the founding chief executive officer of the American Foundation for Firearm Injury Reduction in Medicine (AFFIRM) and an emergency physician at Berkshire Medical Center in Pittsfield, MA. He is also the immediate past chair of the trauma and injury prevention section of the American College of Emergency Physicians, and a member of the Massachusetts Medical Society committees on preparedness and violence intervention and prevention. Follow AFFIRM on Twitter @ResearchAffirm. Find more information about AFFIRM athttps://affirmresearch.org.

AFFIRM and the Coalition on Psychiatric Emergencies are holding a pre-course on gun violence and threat assessments in the ED at the ACEP Scientific Assembly this month. Care Under Fire will be held Sat., Oct. 26, 1-5 pm, at the Colorado Convention Center. Registration is $99 at http://bit.ly/CareUnderFire.

Emergency Medicine News41(10):14, October 2019.

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