CME: Firearm Violence & Youths

CME: Firearm Violence & Youths
Author Information (click to view)

Patrick M. Carter, MD

Assistant Professor of Emergency Medicine
U-M Injury Center
University of Michigan Health System

Patrick M. Carter, MD, has indicated to Physician’s Weekly that he has or has had no financial interests to report.

Figure 1 (click to view)
Target Audience (click to view)

This activity is designed to meet the needs of physicians.

Learning Objectives(click to view)

Upon completion of the educational activity, participants should be able to:


  • Review the findings of a study that assessed risk for firearm violence in high-risk youths after treatment for an assault.
  • Discuss the opportunity emergency physicians have to decrease the risk for future firearm violence among high-risk youths seeking care for a violent injury.

Method of Participation(click to view)

Statements of credit will be awarded based on the participant reviewing monograph, correctly answer 2 out of 3 questions on the post test, completing and submitting an activity evaluation.  A statement of credit will be available upon completion of an online evaluation/claimed credit form at  You must participate in the entire activity to receive credit.  If you have questions about this CME/CE activity, please contact AKH Inc. at

Credit Available(click to view)


CME Credit Provided by AKH Inc., Advancing Knowledge in Healthcare

This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of AKH Inc., Advancing Knowledge in Healthcare and Physician’s Weekly’s.  AKH Inc., Advancing Knowledge in Healthcare is accredited by the ACCME to provide continuing medical education for physicians.


AKH Inc., Advancing Knowledge in Healthcare designates this enduring activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Commercial Support(click to view)

There is no commercial support for this activity.

Disclosures(click to view)

It is the policy of AKH Inc. to ensure independence, balance, objectivity, scientific rigor, and integrity in all of its continuing education activities. The author must disclose to the participants any significant relationships with commercial interests whose products or devices may be mentioned in the activity or with the commercial supporter of this continuing education activity. Identified conflicts of interest are resolved by AKH prior to accreditation of the activity and may include any of or combination of the following: attestation to non-commercial content; notification of independent and certified CME/CE expectations; referral to National Author Initiative training; restriction of topic area or content; restriction to discussion of science only; amendment of content to eliminate discussion of device or technique; use of other author for discussion of recommendations; independent review against criteria ensuring evidence support recommendation; moderator review; and peer review.

Disclosure of Unlabeled Use & Investigational Product(click to view)

This educational activity may include discussion of uses of agents that are investigational and/or unapproved by the FDA. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer(click to view)

This course is designed solely to provide the healthcare professional with information to assist in his/her practice and professional development and is not to be considered a diagnostic tool to replace professional advice or treatment. The course serves as a general guide to the healthcare professional, and therefore, cannot be considered as giving legal, nursing, medical, or other professional advice in specific cases. AKH Inc. specifically disclaim responsibility for any adverse consequences resulting directly or indirectly from information in the course, for undetected error, or through participant’s misunderstanding of the content.

Faculty & Credentials(click to view)


Keith D’Oria – Editorial Director
Discloses no financial relationships with pharmaceutical or medical product manufacturers.
Patrick M. Carter, MD
Discloses no financial relationships with pharmaceutical or medical product manufacturers:

Dorothy Caputo, MA, BSN, RN- CE Director of Accreditation
Discloses no financial relationships with pharmaceutical or medical product manufacturers.

AKH planners and reviewers have no relevant financial relationships to disclose.


Patrick M. Carter, MD (click to view)

Patrick M. Carter, MD

Assistant Professor of Emergency Medicine
U-M Injury Center
University of Michigan Health System

Patrick M. Carter, MD, has indicated to Physician’s Weekly that he has or has had no financial interests to report.

A study has found that high-risk youths who present to EDs for assault have higher rates of subsequent involvement with firearm violence. Interventions are needed to help decrease rates of firearm violence involvement among high-risk youth.

Previous studies have shown that firearms are responsible for about 31% of the 900,000 annual non-fatal assault injuries suffered by adolescents and young adults who are treated annually in EDs. Overall, firearm-related injuries rank as the second leading cause of death among all youths in the United States and the leading cause of death among African-American youth. The cost of caring for acute firearm-related injury care is substantial, approaching nearly $630 million each year, with youths accounting for a significant portion of these costs.

Past research on firearm violence among youth populations has primarily been retrospective or has only examined adolescents requiring hospitalization. This can miss many ED patients who do not need to be hospitalized after an assault-related injury. The risk for firearm violence in high-risk youths after treatment for an assault has not been thoroughly studied. “This information is critical to informing the development and implementation of evidence-based firearm violence interventions that can be applied to adolescents and young adults who experience assault-related injuries,” says Patrick M. Carter, MD.


Firearm Violence Over Time

Dr. Carter and colleagues from the University of Michigan Injury Center conducted a 2-year prospective cohort study that analyzed data from nearly 600 people aged 14 to 24. Two cohorts were followed every 6 months for 2 years in the study, which was published in Pediatrics. The primary cohort included youths who were treated in an urban ED for an assault-related injury and had a history of recent drug use within the past 6 months. These data were then compared with a comparison cohort of drug-using youths who were not assaulted and sought ED care for a medical or non-violence related injury complaint. The research team conducted a number of assessments within the 2-year period, including measures assessing patients’ level of involvement with firearm violence.

“Overall, 59% of assault-injured youths in the study reported firearm violence within 2 years of their initial ED visit as either the aggressors in an event or the victim of firearm violence,” Dr. Carter says. “This included threats, near misses, and injuries due to firearms.” Nearly 97% of the study participants reported being victims of firearm violence and about one-third reported being aggressors. Assault-injured youths were at 40% higher risk for involvement with firearm violence than the comparison group of drug-using youths seeking medical care for reasons other than an assault.

The analysis also demonstrated that 77% of participants who endorsed firearm violence reported that their involvement was not limited to a single episode. Those who engaged in firearm violence reported an average of almost eight such incidents over the 2-year study period.


Identifying Risk Factors

Importantly, the study revealed that the majority of assault-injured youths with firearm violence reported having at least one or more firearm-related events within the first 6 months after their ED visit (Figure). Several baseline factors were identified as predictors of subsequent firearm violence involvement, including male gender and African-American race. Experiencing an assault injury, favoring retaliation for assaults, and possessing a firearm were also predictors of firearm violence.

About half of study participants with firearm violence also reported a mental health diagnosis at baseline, most commonly PTSD and/or depression. These findings emphasize the possible benefit of enhanced mental health services among people presenting to the ED with violent injuries. An association was also observed between firearm violence and substance use, with higher severity drug use (eg, dependence or abuse) predicting involvement with firearm violence. In addition, almost 25% of participants with firearm violence reported recently carrying a firearm while impaired. This raises concerns about the contribution of alcohol or drug intoxication to impulsive firearm use during altercations.


A “Teachable Moment”

“Our findings illustrate that emergency physicians have an opportunity to decrease the risk for future firearm violence among high-risk youths seeking care for a violent injury,” says Dr. Carter. “We need to be vigilant about identifying youths who are at high risk for subsequent firearm violence. Our data can be used as a roadmap for developing and enhancing evidence-based violence interventions to prevent severe firearm-related injuries or deaths among high-risk youths.”

Until recently, most healthcare providers have focused on treating patients’ physical wounds after experiencing firearm violence, but Dr. Carter says efforts should be made to capitalize on such teachable moments by tackling the issue at an initial presentation for a violent injury. “We should intervene and address the underlying risk for future firearm violence in the same way that we would when managing patients with asthma, diabetes, or other diseases,” he says.

While many high-quality violence prevention programs exist, efforts are needed to enhance these secondary violence prevention initiatives. There is also a need to develop best practices to treat substance use and mental health diseases and to prevent retaliatory violence and illegal firearm possession among high-risk youth, Dr. Carter says. “This can further help us capitalize on the teachable moment and decrease the morbidity and mortality associated with urban firearm violence.” Greater use of technology, such as cell phones and mobile devices, may further augment interventions to reduce firearm violence. These technologies may allow for consistent contact and continued interventions with adolescents and young adults after their ED visit.

Readings & Resources (click to view)

Carter PM, Walton MA, Roehler DR, et al. Firearm violence among high-risk emergency department youth after an assault injury. Pediatrics. 2015 Apr 5 [Epub ahead of print]. Available at:

Carter PM, Walton MA, Newton MF, et al. Firearm possession among adolescents presenting to an urban emergency department for assault. Pediatrics. 2013;132:213–221.

Cunningham R, Knox L, Fein J, et al. Before and after the trauma bay: the prevention of violent injury among youth. Ann Emerg Med. 2009;53:490–500.

Frattaroli S, Webster DW, Wintemute GJ. Implementing a public health approach to gun violence prevention: the importance of physician engagement. Ann Intern Med. 2013;158:697–698.


  1. So gun violence and mental health go hand in hand…what a shocker. But let us ban guns because then mental health will get cured once all guns are banned. Wait, let’s ban knives…no no wait, let’s ban bats…no no wait, let’s ban water….no no wait, let’s ban everything

    • Gavin Newsom, as in the Lieutenant Governor of California?


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