SomeGuy wrote:you don't really need to be a firearms expert to advise someone that toddlers probably shouldn't be running around with a loaded weapon.
Given that I brought a direct quote from AAP materials into this thread earlier showing what they are actually pushing, you know that is disingenuous to say.
The purpose of the "firearm safety" advice is not common sense, it is geared towards diminishing ownership, and relies on the respect that the medical and nursing professions have earned to push this agenda.
No. The purpose as far as the AAP is concerned. How many doctors do you think follow, rigidly, the guidelines of the AAP? How about the AMA? It isn't a universal viewpoint, which is why we should lean more on providers to adopt a common sense approach, not an all or nothing approach.
The issue I see is that if we start dictating to providers what they can and cannot ask in the interview, we will drive the sensible practitioners further away from a common sense approach, and move into the area we don't want -- straight recommendation on banning.
The further you get into that pocket book, you will undoubtedly realize that many of the guidances are not in practice, not used, and simply not appropriate in the office.
At the same time, I don't see these political groups, of which many of these societies are, especially the AMA, as backing off their stance, which is why I can support legislation to stop asking. But that doesn't mean it is the right approach. It is not for us to dictate to the provider what is medically relevant. And if the provider feels that it is medically relevant, we do a disservice to our patients by not asking.
I could care less what the AMA, ACP, AAP and the list goes on says is important in the office. That is their opinion and approach, not mine. But to lump all practitioners in the same category as these politically motivated groups is simply unfair. Very few practice strict adherence to these guidelines. By limiting their history taking, we are doing harm to them and possibly their patients. I'm not disagreeing with you about what the AAP is stating, I'm disagreeing with you on how we should approach the issue. And if we take the approach that all providers are operating along the guidelines of the AAP, I think we are making the wrong assumption, at least in this State, and it has the potential to push others who may be more receptive to altering the approach away.
SomeGuy wrote:
Being in the top 10 does not mean it ought to be "a leading cause". My point has been, and remains that to classify something "a leading cause" ought to mean it involves a significant number of deaths. The overly broad label dilutes the importance of actual issues that kill significantly more. Firearms as a cause of accidental death do not belong in the leading causes group, it diminishes the real causes, such as MVA, suffocation etc. By your standards, anti-gunners could always expand the leading causes list to keep firearms in it so as to always keep them demonized.
Returning to the anti-gun materials the AAP pushes, it spends more time concerned with firearms than causes that are much greater. It is openly misleading.
I understand what you are saying, that if we extract MVA from the injury list, and set it at #1, and extract suffocation, and set it at its individual level, we put firearms deep into the list. But firearms accidents still rank near things we still screen for. So saying that it is minor and we shouldn't screen, but believing that something further down the list that is also minor should be screened for, is doing exactly the same thing as our opponents, just on the other side of the spectrum. We should screen for all of them, especially when it doesn't take long and it might be beneficial. But this only comes from the common sense approach, which is the true goal, prevention. Like I said much earlier, several groups have lost sight of the original goal.
If you want to go round about as you are, we can. It isn't McDonald's that caused your elevated cholesterol, it was the break down in the transport mechanism. McDonald's was just the tool. It wasn't smoking that caused your lung cancer, it was the malfunction of the repair system in your DNA that causes the mutation. Smoking was just the tool. It wasn't the sugar that caused your diabetes, it was a breakdown in the effectiveness of the insulin you produced. The sugar was just the tool!
Does the above sound ridiculous, as a medical practitioner, to you? Good, it should.
Quite ridiculous, but for a different reason. You have no concious ability to control what your pancreas does regarding insulin production and blood sugar, same for cholesterol (though the McDonalds is a bad habit that will likely exacerbate the problem). Picking up a gun and committing suicide is a very concious decision, one that requires a person to think it is a good idea and act on it. Cigarettes are likewise a poor example you use. While it to requires concious thought, there are no benefits of cigarette smoking. To even consider them comparable in a conversation on firearms diminishes the value of firearms to our society both in daily protection from criminals, recreational uses, and defense of liberty.
Since you mentioned self-destructive activity (smoking) in your argument, let us consider firearm suicides a moment. A person is considering suicide, is screening for firearms the best way to treat this, or would it not be better to actually talk to the person about what they are thinking, and planning. IF they bring up firearms then so be it, but what medical purpose is advanced from inquiring about firearms if the patient is not thinking of using one to commit suicide? As a practitioner you treat the patient, you can look earlier in this thread for my example conversation in that vein. Are there firearm suicides? Yes. Should practitioners be aware of them, and prepared to inqure about them? Yes. Should practitioners bring it up first? Absolutely not.
Suicide prevention is not the same as firearm prevention. A comparison of Japans suicide rate, and the methods used against the USAs shows this quite well.
You do have conscious control over portion sizes, exercise, what you eat, what you don't eat and everything that leads to a great number of maladies. You don't believe lack of exercise (often conscious), poor diet (often conscious) and not having self control over how much carbs you ingest doesn't play a major role in development of Type II DM? You don't believe that life choices and life style play a huge role in not only progression, onset and outcome of several rather common disease states? A person who chooses to use lots of salt on their meals, because they think it tastes good and thus thinks it a good idea, consciously decided to do something bad for themselves. They exhibited every single stage that the person committing suicide did, except maybe mental anguish. Instead they got pleasure and malignant hypertension, not death.
Now, there are a lot of issues with cholesterol that are not conscious, but are instead genetic. There are lots of issues with BP that are not conscious decisions. There are lots of disease states that cannot be prevented. Which is why so much emphasis is placed on those that can be prevented. I thought you handled your suicide example beautifully. You were direct in your question, when asking if they were going to hurt themselves, instead of beating around the bush. You didn't put a thought into their head and you handled it the exact way the crisis center would. And you are absolutely correct, suicide prevention is not firearms prevention. Just as nutritional counselling is not hypertension prevention. But there is still nutritional counselling. In suicide intervention, you are not looking to limit unintentional acts. In firearms counselling, you are trying to raise awareness of the unintentional action. Again, in the common sense approach. Therefore, it does have a role. It does not a role in eliminating death by suicide, death by homicide, or death by unintentional action, it merely serves as a tool in the overall picture.
Screening, preventing, and intervening in ownership of firearms, as if it were an infection that might kill you whether you wish to die or not? Let us consider the comparison you make:
"The point is we can lessen the deaths where firearms are involved by better understanding the reasoning people own firearms, better pursuit of educating our patients to the danger of firearms, preventing ownership by encouraging laws to be passed restricting firearms, and intervening in their use by unregistered persons." How can you seriously consider firearms, an inert mechanical object that is less complex than a cell phone with a living pathogen that kills people? By the comparison you make firearms are as bad as sepsis; thankfully sepsis is not really comparable to firearm ownership (but it would be nice if the love of firearms and ownership/activity in protecting our rights was as easily transmitted as the common cold).
I believe you missed the point. In your example, you suggested that it would be as ridiculous to continuously run antibiotics at all times as it would be to advocate removal of firearms as a cure. I am saying that the comparison is erroneous. If we didn't have to worry about opportunistic infection from the decreased normal flora, if we didn't have to worry about emerging resistance, and if we could kill the pathogen without harming the patient, and doing so in a cost effective way... we would run IV Ab 24/7. In other words, we would attempt to completely rid the planet of the pathogen. This is the only way that this example could equate to removal of firearms completely. However, we cannot, will not and do not, and thus your comparison is not valid. That is my point. Instead, we tend toward prevention. Again, my point. We do this by limiting the spread of the bug by hand washing, we do this by finding new approaches to kill the bug by using new drugs or combining other therapy. If we were to use the IV drip vs the handgun counselling as the def acto model, the only way to compare the two treatments is in prevention. My point. Thus, how we work to prevent septicaemia and how we work to prevent firearm related accidents work similarly, we observe, we counsel and we intervene. That was the point.
Continuing your poor comparison of firearms to sepsis, consider, a patient enters the office, complains of a fever, is lethargic and has not urinated in 2 days. This patient clearly requires aid. A person with a firearm on his hip, or a rifle in his truck however, does not need any questioning of his firearms simply because he entered a clinic.
Consider the patient who comes into your office with complaints of generalized joint pain, has a malar like rash on his face and hearing loss that lateralizes, though no obstruction is noted. Can you think of a scenario where knowing that this patient owns firearms will help exclude a very costly test (~$850) from your differential?
I can. It is a bit contrived, but follow for fun. Bob, 23, comes into the clinic with CC polyarthritis. During history, pt reports family history of rheumatoid arthritis on maternal side. Patient states joint pain is 1 month duration, and denies any other abnormalities. A red rash is noted sub-orbitally extending across the nose. Pt is advised that condition is not chronic, but due to family history and lupus like face rash, coupled with hearing loss, it is suggested that the patient have ANA and RF testing. Due to cost effective nature of doing these two tests in a panel, we order the panel. $850 billed.
ANA negative. RF negative. Insurance cost $850 test+$40 office visit, patient co-pay $350.
Now, if I said, "Do you own guns?" and he replied "Yea, I duck hunt, just got back this weekend." I would have asked, "Did you wear ear protection" "No, was in a blind and needed to communicate with friends." Hearing loss acute, removed from symptoms. "Did you wear any sunscreen?" "No, just these sunglasses." "So that rash is sunburn from water reflection around the sunglasses?" "I have a sunburn? Yea, probably." Malar rash removed, Lupus removed from DDx. No ANA test, no RF test. No un-necessary billing.
Was a complete history on this patient better than missing something? Absolutely.
But, for sake of discussion... the #8 cause (firearms) is minor. Thus, along the same lines, the #7 cause (septicaemia) is also minor... so we should stop screening for firearms... and stop screening for bacterial infection? No. I don't think so. Medically, do you?
The firearm is not a CAUSE. I cannot blame my keyboard when I mistype a word in a paper. Sepsis however IS a cause. There is
no legitimate medical/nursing/healthcare reason to screen for firearm ownership as if it damages health like high blood pressure will. No amount of strawman arguments will change that.
I find it highly unlikely that a 2 yr old who has an accidental discharge that kills him or herself is to be blamed. I rather think that, yes, in this case, the firearm is to be blamed. Or the parents. Which is generally who is counselled, as 2 yr olds tend to have a very poor memory... As to the rest, see above. History, as you know, is the most important aspect of forming a DDx. The more history, the better the DDx.
