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Read the provided article attach
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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
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