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Colorado has consistently had one of the highest rates of suicide in the United States, and El Paso County has the highest number of suicide and firearm-related suicide deaths within the state. Community-based solutions like those of the Suicide Prevention Collaborative of El Paso County may be more effective in preventing suicide as they are specific to local issues, sensitive to local culture, and informed by local data, community members, and stakeholders.

Reducing firearm access during times of risk is a key component of suicide prevention, including the person at risk voluntarily, temporarily storing firearms outside the home. However, this approach relies on the participation of storage providers (ranges/retailers and law enforcement agencies (LEAs)). Our objective was to describe stakeholders' views and experiences surrounding voluntary, temporary out-of-home firearm storage for suicide prevention.We conducted individual interviews with (1) firearm ranges/retailers; (2) LEAs (in Colorado or Washington State); and (3) state/national organizations involved in policy development or enactment; public health; or firearm rights. Transcripts were analyzed using a team-based mixed inductive-deductive approach.Across 100 interviews (October-May 2021), potential storage providers were supportive of voluntary storage programs, often reporting a desire to help their customers and community. However, potential storage suppliers cited civil liability, regulatory, and legal concerns associated with storing and/or returning firearms (to people who had previously expressed suicide risk). Stakeholders offered suggested strategies meant to address liability and increase storage accessibility.Understanding stakeholder views supports the development of acceptable, feasible programs for out-of-home firearm storage during times of suicide risk. Clarification of existing regulations or creation of new policies is necessary to address potential providers' concerns.

BACKGROUND There is substantial investment in layperson and first responder training involving tourniquet use for hemorrhage control. Little is known however about prehospital tourniquet application, field conversion, or outcomes in the civilian setting. We describe the experience of a metropolitan region with prehospital tourniquet application. METHODS We conducted a retrospective cohort study characterizing prehospital tourniquet use treated by emergency medical services (EMS) in King County, Washington, from January 2018 to June 2019. Emergency medical services and hospital records were abstracted for demographics, injury mechanism, tourniquet details, clinical care, and outcomes. We evaluated the incidence of tourniquet application, who applied the device (EMS, law enforcement, or layperson), and subsequent course. RESULTS A total of 168 patients received tourniquet application, an incidence of 5.1 per 100,000 person-years and 3.48 per 1,000 EMS responses for trauma. Tourniquets were applied for penetrating trauma (64%), blunt trauma (30%), and bleeding ateriovenous fistulas (7%). A subset was critically ill: 13% had systolic blood pressures of

We investigated the risk of coronavirus disease (COVID-19)­ patients transmitting severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) to emergency medical service (EMS) providers, stratified by aerosol-generating procedures (AGP), in King County, Washington, USA, during February 16–July 31, 2020. We conducted a retrospective cohort investigation using a statewide COVID-19 registry and identified 1,115 encounters, 182 with ≥1 AGP. Overall, COVID-19 incidence among EMS personnel was 0.57 infections/10,000 person-days. Incidence per 10,000 person-days did not differ whether or not infection was attributed to a COVID-19 patient encounter (0.28 vs. 0.59; p>0.05). The 1 case attributed to a COVID-19 patient encounter occurred within an at-risk period and involved an AGP. We observed a very low risk for COVID-19 infection attributable to patient encounters among EMS first responders, supporting clinical strategies that maintain established practices for treating patients in emergency conditions.

ObjectiveResearch surrounding firearm ownership is often contextualised within the perspectives of older white men. We expand this description using the perceptions of a diverse group of firearm-owning stakeholders.MethodsWe conducted semistructured interviews from October 2020 to May 2021 with Colorado/Washington State stakeholders representing (1) firearm ranges/retailers; (2) law enforcement agencies or (3) relevant state/national firearm organisations. Data were analysed using standard qualitative techniques and included 25 participants, representing varied sociocultural groups including racial and ethnic minorities, political minorities and sexual minorities.ResultsParticipants for this analysis were of different self-identified sociocultural groups including racial and ethnic minorities (African American, Hispanic and Asian), political minorities (liberal) and sexual minorities, defined as Lesbian, Gay, Bisexual, and Transgender (LGBT). Perspectives on firearm ownership included an idea of gun culture as a component of (1) personal identity, (2) an expression of full citizenship and (3) necessary for self-protection. A strong subtheme was the intersection of minority group and firearm owner identities, creating a need for divergent social communities because of ideas on traditional gun culture. These communities are a safe place for individuals belonging to minority groups to escape negative external and internal group associations with firearms.ConclusionPerspectives on firearms and firearm ownership in the secondary analysis were heterogeneous and related to personal experiences, external and internal group pressures that influence individual behaviour. Understanding the breadth of perspectives on firearm ownership is imperative to engaging individuals for risk reduction. This study adds to the literature by expanding an understanding of the motivation for firearm ownership among diverse communities.

Out-of-home storage of personal firearms is one recommended option for individuals at risk of suicide, and statewide online maps of storage locations have been created in multiple states, including Colorado and Washington. We sought to examine both the extent to which firearm retailers and ranges offer temporary, voluntary firearm storage and the perceived barriers to providing this service. We invited all firearm retailers and ranges in Colorado and Washington to complete an online or mailed survey; eligible sites had to have a physical location where they could provide storage. Between June-July 2021, 137 retailers/ranges completed the survey (response rate = 25.1%). Nearly half (44.5%) of responding firearm retailers/ranges in Colorado and Washington State indicated they had ever provided firearm storage. Among those who had ever offered storage, 80.3% currently offered storage while 19.7% no longer did. The majority (68.6%) of participants had not heard of the Colorado/Washington gun storage maps and 82.5% did not believe they were currently listed on the maps. Respondents indicated liability waivers would most influence their decision about whether to start or continue providing temporary, voluntary storage of firearms. Understanding current practices, barriers, and concerns about providing out-of-home storage by retailers and ranges may support development of more feasible approaches for out-of-home firearm storage during times of suicide risk.

Background Extreme Risk Protection Orders (ERPOs) are a relatively new type of law that are being considered or implemented in many states in the United States. Colorado’s law went into effect on January 1, 2020, after significant controversy and concern over potential misuse of the law to confiscate weapons; many (n = 37 of 64) counties declared themselves “2nd Amendment (2A) sanctuaries” and said they would not enforce the law. Here, reviewed the patterns of use of the law during its first year. Methods We obtained all court records for ERPO petitions filed between January 1 and December 31, 2020. Data elements were abstracted by trained staff using a standardized guide. We calculated the proportion of petitions that were approved or denied/dismissed, identified cases of obvious misuse, and examined patterns by 2A county status. Finding and results In 2020, 109 ERPO petitions were filed in Colorado; of these, 61 were granted for a temporary ERPO and 49 for a full (year-long) ERPO. Most petitions filed by law enforcement officers were granted (85%), compared to only 15% of petitions filed by family or household members. Of the 37 2A sanctuary counties, 24% had at least one petition filed, versus 48% of non-2A sanctuary counties. Across the 2A counties, there were 1.52 ERPOs filed per 100,000 population, compared to 2.05 ERPOs filed per 100,000 in non-2A counties. There were 4 cases of obvious law misuse; none of those petitions resulted in an ERPO or firearm confiscation. Conclusion State-level studies suggest ERPOs may prevent firearm injuries. Robust implementation, however, is critical for maximal effect. Understanding ERPO experiences and challenges can inform policy creation and enaction in other states, including identifying how best to address concerns and facilitate evaluation.

BackgroundRigorous assessment of occupational COVID-19 risk and personal protective equipment (PPE) use are not well-described. We evaluated 9-1-1 emergency medical services (EMS) encounters for patients with COVID-19 to assess occupational exposure, programmatic strategies to reduce exposure, and PPE use.MethodsWe conducted a retrospective cohort investigation of lab-confirmed COVID-19 patients in King County, WA who received 9-1-1 EMS responses from February 14, 2020 to March 26, 2020. We reviewed dispatch, EMS, and public health surveillance records to evaluate the temporal relationship between exposure and programmatic changes to EMS operations designed to identify high-risk patients, protect the workforce, and conserve PPE.ResultsThere were 274 EMS encounters for 220 unique COVID-19 patients involving 700 unique EMS providers with 988 EMS person-encounters. Use of “full” PPE including mask, eye protection, gown and gloves (MEGG) was 67%. There were 151 person-exposures among 129 individuals, who required 981 quarantine days. Of the 700 EMS providers, 3 (0.4%) tested positive within 14 days of encounter. Programmatic changes were associated with a temporal reduction in exposures. When stratified at the study encounters midpoint, 94% (142/151) of exposures occurred during the first 137 EMS encounters compared to 6% (9/151) during the second 137 EMS encounters (pConclusionLess than 0.5% of EMS providers experienced COVID-19 illness within 14 days of occupational encounter. Programmatic strategies were associated with a reduction in exposures, while achieving a measured use of PPE.

Key Points Question What is the clinical presentation to emergency medical services among persons with coronavirus disease 2019 (COVID-19)? Findings This cohort study of 124 patients with COVID-19 revealed that most patients with COVID-19 presenting to emergency medical services were older and had multiple chronic health conditions. Initial concern, symptoms, and examination findings were heterogeneous and not consistently characterized as febrile respiratory illness. Meaning The findings of this study suggest that the conventional description of febrile respiratory illness may not adequately identify COVID-19 in the prehospital emergency setting., This cohort study describes patient characteristics and prehospital presentation of patients with coronavirus disease 2019 (COVID-19) cared for by emergency medical services (EMS) in King County, Washington., Importance The ability to identify patients with coronavirus disease 2019 (COVID-19) in the prehospital emergency setting could inform strategies for infection control and use of personal protective equipment. However, little is known about the presentation of patients with COVID-19 requiring emergency care, particularly those who used 911 emergency medical services (EMS). Objective To describe patient characteristics and prehospital presentation of patients with COVID-19 cared for by EMS. Design, Setting, and Participants This retrospective cohort study included 124 patients who required 911 EMS care for COVID-19 in King County, Washington, a large metropolitan region covering 2300 square miles with 2.2 million residents in urban, suburban, and rural areas, between February 1, 2020, and March 18, 2020. Exposures COVID-19 was diagnosed by reverse transcription–polymerase chain reaction detection of severe acute respiratory syndrome coronavirus 2 from nasopharyngeal swabs. Test results were available a median (interquartile range) of 5 (3-9) days after the EMS encounter. Main Outcomes and Measures Prevalence of clinical characteristics, symptoms, examination signs, and EMS impression and care. Results Of the 775 confirmed COVID-19 cases in King County, EMS responded to 124 (16.0%), with a total of 147 unique 911 encounters. The mean (SD) age was 75.7 (13.2) years, 66 patients (53.2%) were women, 47 patients (37.9%) had 3 or more chronic health conditions, and 57 patients (46.0%) resided in a long-term care facility. Based on EMS evaluation, 43 of 147 encounters (29.3%) had no symptoms of fever, cough, or shortness of breath. Based on individual examination findings, fever, tachypnea, or hypoxia were only present in a limited portion of cases, as follows: 43 of 84 encounters (51.2%), 42 of 131 (32.1%), and 60 of 112 (53.6%), respectively. Advanced care was typically not required, although in 24 encounters (16.3%), patients received care associated with aerosol-generating procedures. As of June 1, 2020, mortality among the study cohort was 52.4% (65 patients). Conclusions and Relevance The findings of this cohort study suggest that screening based on conventional COVID-19 symptoms or corresponding examination findings of febrile respiratory illness may not possess the necessary sensitivity for early diagnostic suspicion, at least in the prehospital emergency setting. The findings have potential implications for early identification of COVID-19 and effective strategies to mitigate infectious risk during emergency care.