Screening for adolescent firearms-carrying: one more way to save a life.

Firearms are second to motor vehicles as a leading cause of mortality among US children between the ages of 15 and 19.1,2 In fact, firearms are the second leading cause of injury death for Americans of all ages, killing 28,663 persons in the year 2000.3 More than half of these (16,586) were suicides, and in 2000, suicides surpassed homicides as the greatest contributor to firearmrelated mortality in the 10to 14-year-old age group.3 More Americans kill themselves with guns than by all other methods of self-destruction combined.2,4 From 1990 to 1998, homicides and suicides together resulted in more years of potential life lost for Americans aged younger than 65 years than heart disease.5 Firearm mortality is not distributed equally across all ethnic and racial strata.6 Among males aged 15 to 19 years, the firearm death rate was 22.7 deaths per 100,000 in 2000, but among young black males, it was almost 3 times higher: 62.2 deaths per 100,000.5 Overall, the ageadjusted case fatality rate for victims of firearm-injury is 31.7% (95% confidence interval [CI] 27.7% to 35.6%).7 For other major causes of injury, including motor vehicle crashes, burns, falls, and poisoning, case fatality rates are less than 2%.8 Firearms cause nonfatal injuries as well.9,10 In the year 2000, approximately 48,570 patients with nonfatal gunshot wounds were treated in US emergency departments (EDs).11 Of these, nearly one quarter (11,875) were children aged 10 to 19 years.12 As firsthand witnesses to the consequences of firearm violence, emergency physicians are ideally positioned to assist in the surveillance, identification, education, and secondary prevention of firearm-related injuries. Fortuitously, through the seminal work of Hayes and Sege13 in this issue of Annals, we may soon acquire a new weapon with which to wage peace in our EDs: the FiGHTS score (Fi=fighting, G=gender, H=hurt while fighting, T=threatened, S=smoker), a screening tool for adolescent firearms-carrying. The FiGHTS score is a Youth Behavior Risk Survey– derived screening tool that uses known risk factors for firearms-carrying (ie, fighting in the past year, male sex, hurt while fighting in the past year, threatened with a weapon at school in the past 30 days, smoker).14 One point is assigned for each positive response, and a score of 2 or more is considered positive for firearmscarrying. The authors are careful to point out that other variables may predetermine the utility of such a screen in different parts of the country. For example, a male smoker screened in Los Angeles would have a lower predicted probability of gun carrying than if the same smoker were screened in rural South Carolina. This may seem counterintuitive,15 but the gestalt and parsimony of the brief FiGHTS score is methodologically sound. Given the limitations of the Youth Behavior Risk Survey, the authors were unable to include the entire array of known risk factors for youth gun carrying. Gun carrying is a multifactorial behavior,16 and a brief, user-friendly tool such as the FiGHTS score cannot incorporate every possible candidate risk factor. The Youth Behavior Risk Survey does include a few items on suicidality, television viewing, and other potential risk factors that might have been added to the brief FiGHTS score. For example, in light of the strong univariate association between intravenous drug use and gun carrying, the authors could have changed their lowercase “i” in the FiGHTS acronym to a capital “I” for intravenous drug abuse. Largely missing from the Youth Behavior Risk Survey and, therefore, from the derived FiGHTS scores, are other important risk factors for firearms-carrying and subsequent injury. These include I N J U R Y P R E V E N T I O N / E D I T O R I A L