Surgery Session_Beyond the Bullet Points

Beyond the Bullet Points

Firearm Safety Counseling for Military Pediatric Providers

Daniel Ferman, MD

February 2026

Beyond the Bullet Points

Firearm Safety Counseling for Military Pediatric Providers

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Daniel Ferman, MD

January 2026

Firearm injury is the leading cause of death for children and adolescents in the United States.

12

children every day

01. Scale of the Issue

Leading Cause of Death for U.S. Children

Motor vehicle

Percentage of all causes

Firearm

Cancer

Suffocation

Poisoning

01. Scale of the issue

30 million children

4.6 million live in a home with at least one firearm unlocked and loaded

of u.s. households

02. access

Bedroom: 30%

Access locations in pediatric fatalities

Closet: 20%

Furniture: 10%

• Most firearms used in adolescent suicides are obtained from the home.
• Most unintentional firearm-related deaths occured while playing with the firearm.

Stored loaded and unlocked

3/4

Bag, purse, clothing: 9%

Vehicle: 12%

Kitchen: 9%

These are not acts of aggression. They are acts of curiosity.

03. Military

Providers and the military family

Health professionals rarely counsel on firearm safety

• Military families have higher risk / exposure

• Increased training = Increased safety

04. Solution

Polls show that a majority of the public and gun owners are receptive to discussing firearms in healthcare settings

Firearm injuries are preventable

Modifiable risk

• Safe firearm storage
• Health professional counseling

04. Solution

SORTING ACTIVITY

Evidence-based recommendations / resources

Less-effective or not recommended practices

https://forms.gle/PPnUwybbsUy2JPBS9

Modifiable risk

• Safe firearm storage
• Health professional counseling

05. Storage

UNLOAD

lock

separate

Store ammunition in a separate, locked location away from firearms.

Ensure all firearms are completely unloaded before storage.

Secure all firearms with an effective locking device.

05. Storage

Out of home Storage options

• Family, Friend, Neighbor (free)
• Gun Dealers ($)
• Shooting Range ($$)
• Commercial Storage Facility ($$$)
• Pawn Shop ($$$)
• Police / Sheriff (free)
• Base Armory (free)

05. Storage

in home Storage options

CABLE LOCK$0 - $50

TRIGGER LOCK$10 - $75

ELECTRONIC LOCK BOX$50 - $350

GUN CASE $10 - $150

LOCK BOX / LOCKER$25 - $350

CONSOLE STORAGE $250 - $300

CARGO AREA STORAGE $500 - $1,500

WIRELESS GUN SAFE MONITOR $150 - $200

ELECTRONIC HOLSTER $200 - $300

FULL-SIZE GUN SAFE$200 - $2,500

06. Counseling

Assess existing knowledge, current practices, risk factors, and readiness to engage.

Assess

Share information, make tailored recommendations.

Advise

Check understanding, reflect change talk, ask importance ruler questions.

Ask

Provide resources, continue to revisit, escalate when necessary.

Act

06. Counseling

Stages of Change (Transtheoretical Model)

How are they stored?

What knowledge do they have?

Who is in the home?

Do children have access to firearms at home?

What about elsewhere?

Adolescent -> Ask about ideation

Do parents own firearms?

Pre-contemplation

Maintenance

Assess

• Risk factors
• Current practices and knowledge
• Access to firearms

• Ideation or threats

• Willingness to collaborate

Contemplation

Action

Preparation

The goal is incremental change.

06. Counseling

Assess risk

• Presence of firearm within any home
• Unsafe storage
• Adverse childhood experiences
• Mental illness
• Previous firearm injury
• Recent stressors
• Weak state-level firearm legislation

Post-Injury

Emergency Visit

Surgical Clinic

Primary Care

The goal is incremental change.

06. Counseling

Advise: approach matters

Be informed

Be respectful

Firearms: use, terminology, ownershipSafety options and resources

Acknowledge role of firearms and ownershipAsk permission when possible Use autonomy-supporting language

The exception is immediate or imminent danger

Focus on harm reduction

Be individualized

Neutral, non-stigmatizing languageRedirect

Find solution that worksLong-term relationship mindset

06. Counseling

Advise: misconceptions

Child play with replica/toy firearms increase riskYoung children do not have the physical strength to pull a trigger Child-focused firearm education (e.g., trigger discipline) reliably reduces risk Hiding a firearm out of sight is as effective as securing it safely Quick access to a firearm prevents violence Local / state laws can prohibit providers from discussing firearms

06. Counseling

Case

You are caring for an 11-year-old who was admitted to the pediatric surgery service after a nonfatal unintentional firearm injury. The child is stable and expected to recover. The parent is active-duty military and shares that the firearm was kept at home for protection and was thought to be hidden safely. Firearm safety has not yet been discussed since admission.

think

pair

share

Individual Reflection:Consider an opening statement to introduce firearm safety in this visit

Partner Collaboration:Turn to neighbor(s) and discuss. Refine statement that is respectful, preserves autonomy, reduces defensiveness, focuses on harm reduction, and acknowledges known risk factors and identity without assumptions

06. Counseling

share

Strong characteristics

• Compassionate acknowledgement of injury without assigning blame
• Normalizes conversation, framed as standard of care
• Collaborative over corrective tone
• Respect for autonomy while addressing elevated risk
• Focuses on safety, not ownership, politics, or policy

Examples

• “Part of our job after an injury like this is to talk about how we can help prevent anything similar from happening again.”
• “Many families in our community keep firearms for protection, and accidents can happen even with good assumptions. Can we talk about what storage looks like at home? / Can you tell me how they’re stored where your child lives and spends time? / What’s your approach to storage?”
• “As your child heals, we want to make sure the home environment is as safe as possible. What would feel realistic for your family in terms of secure storage?”

06. Counseling

Ask

• Check understanding
• Invite reactions
• Reflect change talk
• Use importance rulers

Change talk

sustain talk

My child doesn't know where my gun is kept.

I'd like to store my gun securely but still want to be able to defend myself.

They can't pull the trigger anyways.

I wish things were different.

I feel safe with a loaded gun at home.

I could store my guns differently, but I'm not so sure I want to.

Open to change

maintain the status quo

We've explained that guns aren't toys.

My partner is frustrated with me about carrying.

Everyone I know stores them this way.

I really don't want my kid to find my shotgun; he's been going through a rough time.

06. Counseling

Ask

• Check understanding
• Invite reactions
• Reflect change talk
• Use importance rulers

Why not lower? What would help move it higher?

06. Counseling

Act

Provide handouts / resourcesRevisit at future visits Escalate when risk is high

Education: safe storage counseling, safety devices, resources.

Low risk

Consider temporary transfer to trusted person, additional safety devices, or out-of-home storage.

Mod risk

Mental health hold, civil protective order, urgent temporary transfer.

High risk

07. Key Takeaways

• Firearm injury is the leading cause of death for U.S. children - 12 die every day, mostly from accessible guns taken from the home.
• Parents frequently underestimate children’s access, but most are open to safer storage.
• Military families have unique stressors and risk factors.
• Safe storage and counseling are effective strategies to reduce firearm injuries.

Knowledge / practicesRisk factorsMotivational interviewing

Assess

Be informed & respectfulFocuse on harm reduction Individualized solutions

Advise

Check understandingReflect change talk Importance ruler

Ask

Provide resourcesContinue to revisit Escalate when necessary

Act

Beyond the Bullet Points

Firearm Safety Counseling for Military Pediatric Providers

Please scan the QR code to complete a brief post-survey.

• Your feedback is crucial for improvement
• Takes approximately 5 minutes
• Confidential and anonymous

https://forms.gle/unTxcxB27nMphhNRA

Contact: Daniel.Ferman@usuhs.edu

08. Resources

Military

• Military One Source
• Free armory firearm storage
• Family readiness center
• Installation safety office

Families

• Be SMART Campaign
• Brady United
• A.S.K. (Asking Saves Kids) Campaign
• BulletPoints Project
• Project Child Safe
• End Family Fire
• Everytown for Gun Safety
• Lethal means restriction
• Hospital- and Community-based prevention programs
• Community training / safety classes
• Free safety device provision
• Unwanted firearm disposal

Providers

• National Organizations, e.g. AAP, ACS, CDC
• Safer: Storing Firearms Prevents Harm Video Series
• CALM for Pediatric Providers: Counseling on Access to Lethal Means to Prevent Youth Suicide Course
• Promoting Firearm Injury Prevention & Patient Safety in the Emergency Department
• Referrals for social services, substance abuse, mental health

Bibliographic references

Evidence-based firearm safety recommendations / resources

Less-effective or not recommended practices

Routine firearm safety counseling during specialty encounters with the healthcare system

Relying on supervision in household with unlocked firearms

Ammunition stored separately from firearms

Trigger discipline education for children

Firearms stored unloaded

Routine firearm safety counseling as part of well-child care

Storing firearm in locked glovebox

Ammunition stored locked

Firearms stored locked

Storing firearm hidden out of sight of child (e.g. under mattress or high shelf in closet)

Storing firearm loaded but magazine removed

Relying on children being too young to know

Lethal means restriction

Use of locked gun safe or lockbox

Video game parental controls

Biometric or keyed lock

Temporary off-site storage

Use of cable lock or trigger lock

Relying on children being too young to pull trigger

Using fear-based or graphic injury examples

Threatening punishment for handling firearms

Teen hunting license course

Community provision of free safety devices

Family readiness center or installation safety office

Referrals for social services, substance abuse, mental health

Community-based youth violence prevention programs

Hospital-based violence prevention programs / anticipatory guidance and community outreach

Military exchange firearm lock rebate program

DoD installation armory storage

Accidental injuries are rare and unavoidable

Military One Source (educational counseling, crisis support, etc)

DoD installation adult firearm training / safety programs

Temporary transfer of firearm to person outside home

TRICARE-covered firearm lock benefit

Unwanted firearm disposal

03.knowledge gap

04.ownership

02.location & mechanism

01.scale of the issue

TABLE OF CONTENTS

07.solutions

05.protection

08.safe storage

06.military

11.Resources

12.bibliography

10.key takeaways

09.counseling