Tasks Read the provided article attach – Summarize the article (or part of the article) in one sentence. – Write this sentence in two ways, with the proper citation: – In parenthetical citatio

E D I T O R I A L S

Three Shots, Two Dead, Five Errors, One Gun: A Recipe for Prevention?

See related article, p. 333.

[Hargarten SW. Three shots, two dead, five errors, one gun: a recipe for prevention? Ann Emerg Med. March 2001;37:340- 341.]

“A gun is a tool, no better, no worse than any other tool, an axe, a shovel, or anything. A gun is as good or bad as the man using it.” (Shane talking with Marion Starrett from the movie Shane, 19531)

In 1953, the movie Shane was produced starring Alan Ladd as the classic maverick hero. The year before, High Noon, starring Gary Cooper and Grace Kelly, was made to real time: it started at 10:30 AM and ended at high noon! Many of us know what happened next—the movie and television screens of the United States exploded with tales of the West, bravery, and peacemakers! In 1949, Mr. William Ruger started a company to manufacture fire- arms and, in 1952, in what many consider a brilliant mar- keting maneuver, his company began to manufacture an exact replica of the Colt Peacemaker, the single-action revolver that “won the West.”2 Mr. Ruger’s company sold 1.5 million of these firearms over the next 20 years, all like the Peacemaker, right down to the design flaw, a design flaw that was known to Mr. Ruger and known to Colt’s Manufacturing Co. (the original manufacturer of the Peacemaker) since the late 1800s. When the hammer of these single-action handguns rests against the firing pin and the chamber opposite the firing pin has a live car- tridge, the gun will discharge if the hammer is struck, such as when the gun is dropped.3 This is basic handgun design. And a recipe for death and injuries.

In this issue of Annals, Lee and Nolte4 report on 2 deaths and 1 injury that resulted from 2 separate unintentional discharges of the same Ruger Blackhawk revolver. Opera- tor error and design defects both had critical roles in this story of firearm mortality. The behaviors involved included pointing the gun at another person while adjusting the hammer, dropping the gun (this occurred on 2 separate occasions, once resulting in a broken window, the other resulting in death), not being informed that Ruger was offering to convert the revolver with a safety device de- signed to prevent discharge of a dropped gun, not keep- ing the chamber that was opposite the firing pin empty, and not learning from one’s mistakes. The gun involved in the cases was a Sturm Ruger Blackhawk, single-action

3 4 0 A N N A L S O F E M E R G E N C Y M E D I C I N E 3 7 : 3 M A R C H 2 0 0 1

revolver, with one design flaw (no transfer bar, no drop safety). The authors provided information on the defec- tive firearm and described a series of contributing behav- iors, then encouraged physicians, armed with knowledge about this specific gun, to counsel patients and their fami- lies on firearm safety issues.

Approaches to injury prevention include education, technology, and legislation. Knowledge of the character- istics of the agent/vehicle, the host and environment is essential to develop effective strategies for injury control.5

Although physician education of parents, families, and gun owners is a laudable goal, it should be appreciated that the effects of this approach have limits. In a random- ized controlled trial, Grossman et al6 found that a single firearm safety–counseling session during well-child care, combined with economic incentives to purchase safe storage devices, did not lead to changes in household gun ownership and did not lead to statistically significant over- all changes in storage patterns. In a study of the impact of gun training on the way in which gun owners store their guns,7 it was determined that firearm training, as it is cur- rently provided, does not substantially reduce the inap- propriate storage of firearms. By providing accurate infor- mation on firearm safety devices and their limitations, just as they counsel patients on other aspects of preven- tive health care, physicians hopefully can be effective in firearm injury prevention.8 However, the impact of physician counsel about the full range of firearm safety issues has not been fully evaluated.

In addition, placing an emphasis on anticipatory guid- ance requires modifications of graduate and continuing education for emergency physicians. Future prevention education initiatives, currently being examined for emer- gency medicine applicability, will possibly include fire- arm injury prevention counseling in the emergency department.9

Let us think for a moment about each of the behaviors in this case study. Try to imagine educating the estimated 1.5 million individuals who purchased these flawed revolvers to always do the right thing: be careful, safe, and smart when using this handgun. Think of the implica- tions for physician training. Think of the requisite evalua- tion efforts. It will be a huge undertaking. There are tens of thousands of physicians to educate and hundreds of thousands of gun users and families to reach. The deadly evidence, as reported by Lee and Nolte,4 points to the limits of human behavior change as the sole strategy for reducing these unintended firearm deaths.

The authors4 did a credible job of arming themselves with accurate information about the safety issues related

E D I T O R I A L S

tools—tools for sports and recreation. They need to be made safer. I think Alan Ladd and Gary Cooper would support this recipe for prevention.

I thank Marge Stearns, MA, MPH, for her assistance in the preparation of this manuscript.

1. Adatto K. Picture Perfect: The Art and Artifice of Public Image Making. New York, NY: BasicBooks; 1993:129.

2. Wilson RL. The Peacemakers: Arms and Adventure in the American West. New York, NY: Random House; 1992:392.

3. Karlson TA, Hargarten SW. Reducing Firearm Injury and Death: A Public Health Sourcebook on Guns. New Brunswick, NJ: Rutgers University Press; 1997:172.

4. Lee C, Nolte KB. Two separate unintentional fatalities with the same revolver. Ann Emerg Med. 2001;37:333-336.

5. Withers RL, Mercy JA, Hargarten SW. Public health: a successful paradigm applied to firearm injuries. Wisc Med J. 2000;99:48-49.

6. Grossman DC, Cummings P, Koepsell TD, et al. Firearm safety counseling in primary care pediatrics: a randomized, controlled trial. Pediatrics. 2000;106:22-26.

7. Hemenway D, Solnick SJ, Azrael DR. Firearm training and storage. JAMA. 1995;273:46-50.

8. Milne JS, Hargarten SW. Handgun safety features: a review for physicians. J Trauma. 1999;47:145-150.

9. Irvin CB, Wyer PC, Gerson LW, et al. Preventive care in the emergency department, part II: clinical preventive services—an emergency medicine evidence-based review. Acad Emerg Med. 2000;7:1042-1054.

10. Larson E. Wild west legacy: Ruger gun often fires if dropped, but firm sees no need to recall. Wall Street Journal. June 24, 1993:A1.

11. Freed LH, Vernick JS, Hargarten SW. Prevention of firearm-related injuries and deaths among youth: a product-oriented approach. Pediatr Clin North Am. 1998;47:427-438.

12. Barber C, Hemenway D, Hargarten S, et al. A “call to arms” for a national reporting sys- tem on firearm injuries. Am J Public Health. 2000;90:1191-1193.

13. Centers for Disease Control and Prevention. Non-fatal and fatal firearm-related injuries—United States, 1993-97. MMWR Morb Mortal Wkly Rep. 1999;48:1029-1034.

14. Mercy JA, Ikeda R, Powell KE. Firearm-related injury surveillance: an overview of progress and the challenges ahead. Am J Prev Med. 1998;15(3S):6-16.

15. Koo D, Birkhead GS. Prospects and challenges in implementing firearm-related injury surveillance in the United States. Am J Prev Med. 1998;15(3S):120-124.

16. Wilmsen S. Smith and Wesson, city settle lawsuit. Boston Globe. Available at: http://www.boston.com/dailyglobe2/347/metro/Smith_Wesson_city_settle_lawsuit+.shtml. Accessed December 12, 2000.

The Education of Researchers—Big Brother, Watching

[Biros MH. The education of researchers—big brother, watching. Ann Emerg Med. March 2001;37:341-344.]

How we spend our days is how we spend our lives. —Annie Dillard

As a clinician, a researcher, a research director, and an editor, it seems like every time I turn around there is another demand on my time. I naively thought this would get better as I became more efficient in time management, more expe- rienced in a focused research area, and more comfortable

to the Ruger Blackhawk and are to be commended, but they might consider taking an additional approach to pre- vent these deaths by focusing on the gun itself. It is esti- mated that this particular firearm has been linked to at least 40 deaths and more than 600 injuries.10 What is extraordinary about this case report is not that there are 2 deaths and 1 nonfatal injury but that there was 1 gun, 1 manufacturer, 1 design flaw, and 1 additional strategy: safer guns. Just as we have made major gains in reducing motor vehicle crash injuries and deaths by adding air bags, seatbelt, and center-mounted brake lights to cars, we can make similar strides in reducing firearm injuries by standardizing safer gun design by adding drop safeties, magazine safeties, and loaded-chamber indicators to all handguns.11

The other remarkable aspect about this case study is that the authors4 happened to be in the right place at the right time twice and were positioned to collect the infor- mation on 2 completely separate but related events and make the connections. Unlike most other products, national data on firearms linked with deaths and injury are not available. We simply cannot determine the precise magnitude of the problem, with this handgun or with others with similar or different design flaws. Since the 1970s, the Fatal Accident Reporting System (FARS) has collected national data on all aspects of motor vehicle fatalities and has been able to provide accurate, complete, timely information and analysis that has been used to improve motor vehicle safety. The recent Firestone tire/ Ford crash deaths illustrated the ability of the FARS to identify defective products.

Our nation needs a similar surveillance system to cap- ture data on the firearms linked with deaths and injuries.12

In the United States in 1997, 32,436 deaths resulted from firearm-related injuries and an estimated 64,207 persons sustained nonfatal firearm-related injuries and were treated in hospital EDs.13 Firearm injuries rank as the sec- ond leading cause of injury death after motor vehicle crashes. Yet despite the magnitude of this problem, ongo- ing, systematic collection of data on firearm-related injuries to help guide research, prevention, and policy development has been lacking.14 The nation needs to commit to moving away from simply conducting studies of firearm injuries and place prevention of firearm-related injuries in the mainstream of public health efforts.15

Firearms and their design have been largely unchanged since the early 1900s. Recent developments suggest that manufacturers are interested in addressing safer gun design.16 Organized medicine, and in particular emer- gency medicine, should support these efforts. Guns are

M A R C H 2 0 0 1 3 7 : 3 A N N A L S O F E M E R G E N C Y M E D I C I N E 3 4 1