Reference: Kemal et al. Emergency department utilization by youth before and after firearm injury. AEM July 2025

Date: July 28, 2025

Guest Skeptic: Dr. Kirsty Challen is a Consultant in Emergency Medicine in the UK and an evidence-based medicine advocate. She's a seasoned knowledge translator with her wonderful PaperinaPic infographics.  Case: Your non-US emergency department (ED) has recently been shaken by the attendance of a teenager with a gunshot injury. Subsequent investigation has found he attended a different hospital in the region six weeks ago with a stab wound. The team wonders if that attendance was an opportunity to intervene.Background: Firearm injuries are now the leading cause of death in youth in the United States, surpassing motor vehicle collisions.[1] While the immediate clinical management of gunshot wounds is well covered in emergency medicine training, there is less clarity around what happens before and after that ED visit. Could we identify these high-risk youth earlier? Do patterns of ED use provide clues for intervention?The ED often serves as the primary healthcare contact point for youth exposed to community violence. Some youth injured by firearms may have prior ED visits for mental health crises or minor injuries, presenting opportunities for preventative strategies. But are we missing these cues?Additionally, once youth survive a firearm injury, they face elevated risk for repeat injury, psychological trauma, and even death. Understanding post-injury healthcare utilization may reveal missed chances for intervention, particularly in general EDs that may lack pediatric-specific resources.

Clinical Question: Do youth with firearm injuries have increased emergency department utilization before and after their injury compared to their peers?

Reference: Kemal et al. Emergency department utilization by youth before and after firearm injury. AEM July 2025

Population: Youth aged 10 to 19 years who had an index ED visit for a firearm injury in 2019 across eight US states, identified from the Healthcare Cost and Utilization Project database.

Exclusion: Youth who lacked the data to assess 90 days before or after the index injury, and those without longitudinal ED visit linkage, injuries from non-power firearms, and recurrent visits with firearm injury.

Exposure: Having sustained a firearm injury as indexed by an ED visit.Comparison: ED utilization by the same patients in the 90 days before and after the firearm injury.Outcomes:

Primary Outcome: Number and types of ED visits 90 days before and after the index firearm injury.Secondary Outcomes: Types of ED visits and recurrence of trauma.

Type of Study: Retrospective cohort study using linked administrative claims data.

Dr. Samaa KemalThis is an SGEMHOP, and we are pleased to have the lead author on the episode. Dr. Samaa Kemal is an early-career pediatric emergency medicine clinician-investigator at Ann & Robert H. Lurie Children's Hospital of Chicago. Her work is primarily focused on the intersection of violence and health equity in children. Her research priorities are focused on developing and implementing novel and effective solutions to prevent violent injuries and subsequent adverse outcomes in children. 

Authors’ Conclusions: “Youth have high rates of ED utilization before and after firearm injury. Half of firearm-injured youth receive their emergency care exclusively in general EDs. Implementing firearm injury prevention and intervention efforts in all ED settings is critical.”

Quality Checklist for Observational Study:

Did the study address a clearly focused issue? YesDid the authors use an appropriate method to answer their question? YesWas the cohort recruited in an acceptable way? YesWas the exposure accurately measured to minimize bias? YesWas the outcome accurately measured to minimize bias? Yes