Night Shift – Red Flags and Black Boxes

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By the time you are reading this the mass shootings of the weekend of Aug. 3-4 may be old news, replaced by some further atrocity, followed by more political posturing, pontification and finger pointing. However, one thing is clear, despite the fact that mass shootings, incidents involving four or more deaths, is a small percentage of the total deaths by homicide in this country, they have succeeded in focusing the public’s attention on the problem.

And reasonable people across the political spectrum have a variety of insights and proposals that could positively impact our approach to mitigating the damage. But most importantly, many of these ideas will have implications on emergency physicians.


One of these “insights” that seems to finally be gaining bi-partisan support is that idea that crazy, sick or otherwise demonstrably violent people should have restraints on their access to firearms. Even the National Rifle Association is warming to the idea that so-called “red flag” laws, when implemented with appropriate legal due process to protect the rights of otherwise law-abiding citizens, makes sense in today’s environment.

Any bipartisan consensus is likely to steer clear of empowering the neighborhood busybody from removing the firearms from an otherwise non-threatening law abiding gun owner.  Rather, red flag laws will likely look to law enforcement, mental health professionals and physicians to raise a warning flag that could result in removal or immobilization of firearms in the possession of potentially violent people.

The details of any such laws will be debated hotly by both sides to protect the rights of lawful gun owners on the one hand and the safety of people at risk from mentally unstable and/or violent people on the other. But the general outlines are already somewhat in place in the current powers that emergency physicians possess concerning patients who’s mental health presents a risk to themselves or others. But it’s likely that those currents powers and responsibilities might be expanded somewhat.


As we all know, currently a patient who is acting bizarre — even having psychotic hallucinations — may be beyond the legal scope of involuntary hospitalization if the emergency physician or psychiatrist cannot document a patient’s specific admissions of intent to harm themselves or others. But look for these current restrictions to be hotly debated and possibly relaxed to allow a patient’s access to firearms to be restricted even when they themselves cannot be involuntarily committed to a psychiatric hospital. The legislature and ultimately the courts will have to draw a fine distinction between a person’s right to bear arms and the right to personal liberty, but I suspect they will find the legal reasoning to do so.

This may be one of those cases of “tough cases making bad law” that I’ve written about before. But even a superficial examination of many of the histories of the mass killers reveals that there were multiple warnings raised by friends, family, school mates, neighbors, teachers, social workers and even law enforcement that were ignored because they failed to rise to the level of involuntary psychiatric treatment. But new “red flag” laws may lower that bar because they only restrict one’s access to firearms. And that in itself might be the leverage needed to get a more thorough psychiatric evaluation of a potential killer.

There is another touch point for emergency physicians in this debate. We may be provided the opportunity and possibly even a responsibility to intervene with respect to third parties. Every triage note queries the patient as to whether they feel safe in their home environment. Red flag laws may place upon us the responsibility to delve deeper into the responses to these questions. In the past if the victim of domestic trauma has only minor physical injuries; our duty to that patient was largely fulfilled if we gave them a sheet of shelters. But new laws may look more closely at the role of emergency physicians as the last barricade of safety for our patients from their “potential” assailants and mandate that we investigate and/or report the “potential” perpetrators of violence, especially if they are suspected to have access to guns.

Leaving that side of the violence prevention equation, there is another aspect of this problem that may fall into the laps of emergency physicians. And that is the role of neuropsychiatric side effects of some of the medications we prescribe or see prescribed for our patients.


In 2007, the FDA updated the existing black box warning on Selective Serotonin Reuptake Inhibitor (SSRI) antidepressants of the potential of suicidal thinking to warn “Families and caregivers of patients should be advised to look for the emergence of such symptoms on a day-to-day basis, since changes may be abrupt.”  But how is a non-medical person to monitor the psychiatric stability of a potentially aggressive patient?  The authors of review of literature published in the British Medical Journal looked at 70 clinical trials and found that SSRIs increased the rate of aggression in children twofold. This is particularly important in view of the fact that many of the school shootings were perpetrated by patients on SSRIs.

In a systematic review of placebo-controlled trials in adult healthy volunteers, it was shown that antidepressants doubled the occurrence of events that the FDS has defined as possible precursors to suicide or violence. The number needed to treat to harm one healthy adult was only 16. But some have argued that these studies only looked at “precursor events” and not actual suicides or homicides. But this is like looking at smoking, hypertension and diabetes as only precursor events to cardiac disease and death.

And SSRIs are not the only medications that are currently being prescribed that have warnings for the emergency of suicidal or violent behavior. Medications to stop smoking, prevent incontinence and much more have warnings that include the potential for the emergence of suicidal thoughts. Further, if we try to limit the potential dangers of these drugs to suicidal thoughts, we fail to recognize that many of the mass killers seemed to have signaled that their actions were really intended to be “death by the police.”

So how does that impact us as emergency physicians?  First, while antidepressants have been shown to have beneficial effects in some patients over a short course, we should think long and hard about prescribing these meds without a thorough risk benefit analysis and an even more thorough discussion of the same with the patient. Just as important, we have to take our drug reconciliation responsibilities more seriously. We may be the last line of defense for the over prescription of these potentially harmful medications. Even when the meds are prescribed by another physician, it behooves us to discuss the potential harm with patients, family and caregivers.

It may seem like a disparate grab bag of responsibilities that are being laid at the feet of emergency physicians. Make no mistake. It is my firm belief that in the end, it is the people who commit violent acts who bear the responsibility for such. But the emergency department, and specifically we emergency physicians, are at the crossroads of so many pivotal issues in society. And as such we have become important players, who, acting with knowledge, judgment, courage and compassion can have a positive impact on this terrible scourge of violence.


FOUNDER/EXECUTIVE EDITOR Dr. Plaster has been an emergency physician for more than 30 years, working exclusively night shifts for the past 20 years in emergency departments across the country. During that period, he joined the U.S. Navy and served two tours in Iraq. Dr. Plaster is the founder and executive editor of Emergency Physicians Monthly and the founder of Plaster Publishing.

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