Gun Safety 2023

 

Gun Safety

I don’t pretend that I am neutral when it comes to discussions about guns. I am a pediatric nurse who lives in San Francisco, California; it's easy to figure out my view on guns in general. But if you are a gun lover, please keep reading. I am really hoping that we can find something here that we can stand together on. It is inexplicable to me how so many issues these days have become partisan, but there MUST be some common ground. If you are a parent, regardless of how you feel about firearms, I am hoping that we can all agree that we want to keep our children safe. I actually consulted with my brother-in-law who tends to be on the opposite side of the aisle from me when it comes to many politically hot topics. I wanted to make sure that this post can speak to folks on both sides. Year ago I was approached by Krystal, a mom in my old practice, who was involved in a program called Be Smart For Kids. This group is tackling the gun safety issue. I was startled by the statistics. The Centers for Disease Control has stated that firearm-related deaths from homicide, suicide or unintentional injury remain one of the top three causes of death for American children. Every year, hundreds of children in this country gain access to a firearm and unintentionally shoot themselves or someone else. This happens every 34 hours! The vast majority of these shootings happened with a gun that the child found in their own home or car. These accidents are tragic. What is also sadly happening is that every day, at least one child takes their own life with a gun. Almost 500 American children die by gun suicide every year and the rate is climbing. More than 80% of the children who commit suicide use a gun that they found at home. Suicide attempts are often spur of the moment, feeling overwhelmed with despair, situations, but those who attempt suicide with a gun more often than not, don’t get a second chance. Most of the gun suicide attempts end in death. If you hate statistics, feel free to ignore them. One accidental death is too many. Be SMART's goal is to prevent children's access to firearms. o Secure guns in homes and vehicles. o Model responsible behavior. o Ask about unsecured guns in other homes. o Recognize the risks of teen suicide. o Tell your peers to be SMART. I am including some of the Be Smart strategies along with other information that I gathered while researching for this post. Secure the guns Research shows that nearly 4.6 million children live in homes with guns that are not properly stored. The American Academy of Pediatrics defines responsible gun storage as locked, unloaded and stored separate from the ammunition. Hiding a gun is not a good solution. Kids find things. They know how to poke around in closets and drawers. Guns simply must be locked up. If your gun is used for hunting, this should be a no brainer. If the gun is used for protection, I can understand the concern with anything that limits quick access. There is a solution! If Nurse Judy and the NRA are both in agreement with something, it must be good. There are biometric safe options. You can access the guns within several seconds with a fingerprint. They can be programmed to open with more than one person’s fingerprints for the adults in the family. Sentry Safe - Quick Access Pistol Safe has videos on their website showing access in as little as 2-3 seconds. Barska Mini Biometric Safe also claims 2.5 second access. The parents of the six year old who took a gun to school and shot his teacher recently, were stunned that their child was able to get ahold of their gun.  That gun was reported to be in a locked box on the top of a closet. Kids are smart. They know where the keys are. They can climb. They can figure out a combination. A fingerprint is a safer solution. Perfect would be a biometric box, but don’t let perfect get in the way of good. At the very least ammunition should be locked away in a different location. Model responsible behavior If you own a gun, of course teach your children all of the safety rules. Don't be lulled into a false sense of security because you think your child knows what to do if they come across a gun. The thing to remember is that kids will be kids. Study after study has found that even though kids have been taught never to touch a gun that they found, and that they should instead run to tell a grown up, most are unable to resist the temptation to handle it. Trusting your kids to do the right thing in this case is not the answer. The responsibility rests 100% on the grown ups. 20/20 has done some stories on this. 20/20 Gun Safety Clip As one wise person says in the above clip, “You can’t educate the curiosity out of the child.” It doesn’t help that so many of our kids are exposed to guns on television, movies and video games where people almost seem to be bulletproof. Ask about guns I have to confess that this never occurred to me before meeting with Krystal. I have taught a safety class for years. The topics are numerous - how to deal with a strange dog on the sidewalk, how to avoid burns, how to remove an edamame from a nostril, how to rescue your child if they are choking; discussion about guns wasn’t on the agenda. It will be from now on. When you allow your child to leave your protective orbit and entrust them into the care of someone else, it is quite reasonable to have a routine safety list. Is there a pool? Are any pets safe with kids? Is there a safe car and appropriate car seats for any driving? Are medications childproofed? Does anybody smoke? Are there any unsecured guns in the house? If so, can they be safely locked away, separate from ammunition while your child is visiting? Even a BB gun can cause an injury if not used properly. This is not only for a short play date. It is also an important checklist if your family is traveling and staying with relatives. You might be surprised at the answer to the gun question. Many people might even have guns that they inherited, or used to collect and don’t think much about it. Some households don’t have young children so this isn’t an issue until you point it out. If this conversation feels awkward, perhaps do it via email or text. Feel free to blame me. ”Nurse Judy asks all of her parents to go through this safety list”…. If someone is entrusting their child to your care for a visit, feel free to front load your own safety info. They will likely appreciate it. “Just so you know...in our house there is no smoking. We do have a cat, but she will likely make herself scarce and has always been gentle. There are no guns. Are there any food allergies that I should know about?” Recognize the risk of teen suicide It is essential for family members and friends of teens to be on the lookout for change in mood and behavior or increased aggression. Any talk about killing themselves or statements such as “you would be better off without me” need to be taken very seriously. Contact the Suicide Prevention center for more guidance. In children under 16 the presence of a gun in the house is a more significant risk factor than psychiatric illness. This is likely because suicidal behavior in children and adolescents of this age can be a spur of the moment choice. We don’t always know. Some of the kids who on the outside seem to have it all together are quite troubled. Knowing the impulsiveness of teens, let’s get the gun option off the table. When children and teens can’t get access to a gun in their moment of crisis, they are much less likely to die, even if they attempt suicide by another method. In the US, children are 11 times more likely than their peers in other nations to die by gun suicide, while they are no more likely to die by other suicide method. Tell your friends and family to be smart Many people, like me, hadn't really thought about this. I never recall asking anyone if they had a firearm before sending my children into someone's home. Sharing this info with your friends can help get this message out there. For readers in San Francisco, the Be SMART campaign has trained volunteers who can give presentations to parents' groups, PTAs/school groups, and any other interested community groups about simple strategies to help keep children safe from the risk of unsecured firearms. Please contact BeSMARTforKids@gmail.com if you would like to schedule a presentation or invite Be SMART to be part of your community safety fair or other events. A month before I first put out this post back in 2018, I was in Vietnam where there are NO guns. Even law enforcement doesn’t carry weapons with live ammunition. There are limited situations when a special swat team has access to them, but that’s it. I know that is never going to happen here. I dream of a day when sensible, common sense conversations can take place to figure out a way to slow down the relentless violence here in our nation. Some issues feel so big and impossible to tackle. The inability to have calm discussion about guns in this country is one of them. The Be SMART program shows that there is something measurable that YOU can do. It won’t get rid of gun violence, but it can tilt the odds for your child We need to start somewhere. Let’s keep all of our kids safe from OUR guns. Thanks Very much to my B-I-L Jeff for his thoughtful feedback.

Homage to Uncle Bert

 

For those of you who have been reading these posts for all of these years, I appreciate that you put up with the random assortment of topics. They bounce between health related issues, responses to relevant headlines, and updates of old posts. Some are more personal musings. This is one of those. An Homage to our Uncle Bert Uncle Bert was born in NY in 1929. He was an optometrist. I remember going to his office under the shadow of the old World Trade Center. He moved to Florida in the 80s. He was fiercely independent, never married, but ended up being the ultimate caregiver to many of his family members. He lived alone until he was 90, but moved into a wonderful assisted living facility right before Covid changed the world as we knew it. Our Uncle Bert had the travel bug. Not only did he go all over the world, but he had the lofty goal of visiting all 50 states in the US. He had made it to every state except North Dakota. Several years ago, I got a good laugh when he told me that he had used some frequent flyer miles to book a flight to Fargo. He left the airport, rented a car, drove around a little bit, returned to the airport and then got back on a plane and went home. Mission accomplished. When he traveled he would take hundreds of photos. This was before the age of digital cameras. He would develop them as slides, pick a handful of the best shots and simply discard the rest. I don’t think any of his North Dakota photos made the cut. There is a good lesson there. He didn’t weigh himself down with things that weren’t worthy or important. His favorites were some candid shots of kids and animals that were absolutely magical. To this day, if I catch sight of an endearing moment, I think “that would be an Uncle Bert shot!” Uncle Bert didn’t sweat the small stuff. This became apparent in one of my very first interactions with him.  He generously allowed 19 year old Sandy to borrow his old stick shift Toyota. We hadn’t driven very far when we realized that if there were any brakes left, they weren’t working very well. That was one scary ride. When we returned the car with a, “Hey Uncle Bert, thank you so much for lending us the car, BUT, uh….you need new brakes!” The response was, “yeah, probably true. I just down shift and go slow” He may have gone slowly in his car, but until his last year or so, I could barely keep up with him on foot. I remember waiting for him to exit security at the airport on his last visit to San Francisco. I waited and waited, I got a call from baggage claim where Sandy had gathered both Uncle Bert and his small suitcase. He had zoomed by so fast that I missed him. I guess I had been waiting for an ambling elderly fellow.  During that same visit, we surprised him with front row seats to a Giants game. It turns out that he had bought some bleacher tickets in advance. This almost 90 year old had a grand time scalping his ticket outside the stadium before joining us inside the park. Sadly, Uncle Bert died last week. He was the last relative of Sandy's from that generation. Due to the pandemic, we hadn’t been able to see him in person. We were all set for a visit this spring. Sigh, I am so sad that we didn’t make it in time. Here is something my sister-in-law (Sandy's sister) wrote about him: Bert was our mother's oldest brother and the last of the four siblings to survive. He was a few weeks short of 94, and we can truly say that he lived until he died. He walked on a treadmill daily; did the New York Times crossword puzzle daily - in ink; listened to Ella Fitzgerald, Nat King Cole, Dinah Washington, and his favorite, the Mills Brothers, on the computer; watched every sport on tv and could tell you who the superstars were. He loved playing tennis in his younger days and was looking forward to this week's Australian Open, when due to the time difference, he would get up in the middle of the night to watch it live. He also watched every episode of Big Bang Theory over and over again because, as he put it, "I never remembered what happened so each time was like it was the first time." He was unique. We loved him and will miss him. I am grateful I was part of his life for 45 year! We spoke on the phone regularly. His refrigerator was covered with photos of his great-great-nephew Elliot. Especially the ones where we captured an “Uncle Bert” moment. I am grateful that he lived well and passed relatively easily. Because it is in my nature for most of these posts to have a ‘takeaway’, here it is. If you are still fortunate enough to have older relatives, try to make it a habit to call them on a regular basis. A week passes, a month passes before you realize it has been a long gap in between your calls. Something as simple as a calendar reminder can help you make then happen on a more regular cadence. Enjoy your loved ones while you have them. If you have the opportunity, look at their photos and have them help you identify the people in them and tell you their stories. Once the final generation is gone, so many stories and family information is gone with them.

Tummy Bug Basics

 

By far most of the tummy bugs that people get resolve on their own. A tincture of time will usually take care of them. The typical symptoms are stomach aches, vomiting, loose stools and sometimes fever. Not everyone has every symptom. Vomiting without the loose stools could also indicate something else going on, like strep throat, a urinary tract infection, an ear infection or even appendicitis. When the diarrhea comes along, the good news is that it usually signals that we can narrow our attention to some type of gastro-intestinal issue. The bad news of course is that when the patient is losing fluids from both ends, dehydration now becomes more of a concern. I also don’t want to minimize how miserable it is when you are in the full throes of an acute GI episode and don’t know whether to sit on the toilet or kneel at it.

How do they spread?

Viruses like the Norovirus or Rotovirus are spread in a variety of ways including

• Having direct contact with an infected person
• Consuming contaminated food or water. If an infected person is involved in preparing the food, tag, you’re it
• Touching contaminated surfaces and then putting your unwashed hands in your mouth. For parents of kids who are vomiting, be careful when you are cleaning up after them. This can easily go from family member to family member

For young babies

If your baby is under two months old and you suspect that they have a tummy bug, we will want to monitor them closely. Young babies can get dehydrated much more easily than a larger child or adult.

Of course it is not always easy to know what's up with the little ones. Many babies spit up on a regular basis daily. Actual vomiting will usually have a larger volume and be more forceful. Baby poop can seem pretty liquid and diarrhea-like even when everything is perfectly normal.

It may be worth checking in with a doctor if the stool is copious, watery, and clear, there has been more than one episode of vomiting in a several hour period, and they are fussier than usual.

 If they are nursing well, and peeing fine, that is very reassuring, but if they are little and you are worried, go ahead and get them checked.

How to assess hydration

If your child is running around and has good energy, I am usually not too concerned. There is a big difference between subdued and lethargic. Some kids are well hydrated but still feel lousy and are quieter than usual. We can call them subdued. If you have a kid with big juicy tears and lots of drool, they are probably not terribly dehydrated. The body doesn’t waste the fluid.

On the other hand, a dehydrated child is lethargic. They do not want to play. The urine is more concentrated (darker and smellier) and way less frequent. Their mouths feel dry. Their breath might be stinky (of course if they have been vomiting that is probably a given.) Their skin may be dry. Normally if you pinch up a bit of skin on the wrist, it will immediately correct itself. If someone is dry, it may remain up in the pinch for a moment.

Kids can actually look greenish. Please note, so that you don’t freak out, right before someone is going to vomit, it is normal for them to look quite miserable. Some kids get very pale and shaky. Some folks actually look greenish. Once they throw up, most of the time they feel a bit better and the color normalizes.

Home treatment is usually adequate

Frequent but tiny amounts of fluids is a remarkably effective approach. If you are breastfeeding, smaller, more frequent feeding will often be much easier for the baby to keep down. It is okay and even expected for the patient to have less of an appetite for food for a few days. Unless the person is extremely slender, we are not too worried about a bit of weight loss. Most folks will gain it right back up when this passes. Don’t stress about the food intake. Pushing food will likely just aggravate the situation if they aren’t hungry. 

Your job is to make sure that they are getting adequate fluids.

Start by giving clear fluids (breast milk is great if you have it.) Because we lose lots of electrolytes when we vomit or have diarrhea, it is best to replace the fluids with something that replaces the electrolytes as well. Water is not your best choice. There are products on the market that are specially formulated for this purpose.

Pedialyte is the classic brand that has been around for many years. They have significantly improved the taste over the years. It used to taste like soap.

The exercise drinks like Gatorade are another option but have more sugar than the Pedialyte. Pedialyte is one of the products that is worth keeping on hand so that you are prepared if a tummy bug strikes. It also comes in popsicle form which is great for older kids, as well as a little tube of powder that you mix yourself. 

I actually suggest that it makes a great addition to any travel emergency kit. 

I don’t have any hard and fast rules about fluid amounts. Electrolytes are the better choice, but you have to do the best you can if they simply refuse those. Try some diluted juice, coconut water, ginger ale, or colas that have lost some of the fizz. Whatever they are agreeing to drink, wait a bit after they have thrown up before offering anything. There is nothing exact about the timing. I generally try to wait 30 minutes after they vomit before giving anything. Many folks tell you to wait longer than that. But, if they are begging you for sips, go ahead and offer something.

Think of a drip irrigation system. If all you can get in there is a dropper full, that’s okay! Get that fluid in, drop by drop, ice chip by ice chip. Do the best you can. Plus, if someone is busting your chops for a cracker, a nibble of a saltine may actually feel a bit soothing. If the worst comes to worst, and you move too fast, they will just throw up again and you will know that you need to wait a bit longer before offering the next sip or nibble.

Don’t let them guzzle. Stick with an ounce at a time. If you have a tiny tea set, or a fancy shot glass, those are fun ways to measure small amounts. You can have a star chart for the reluctant drinkers.

If your child has an elevated temperature as part of this illness, a tepid bath can help get the fever down. If the bath hasn’t done the trick, the fever is over 101, and your child is miserable, it is worth giving some fever reducing medicine. Ibuprofen tends to be a bit harder on the stomach so I would choose acetaminophen (Tylenol) when I have an illness that includes tummy symptoms. Another advantage to the Tylenol is that it comes in suppository form, so it is more easily tolerated by a vomiting kid. 

Dosage Chart

Generally, vomiting is the first thing to ease. If they remain nauseated, there is a magic pill called Zofran. This is an effective but strong medication. Most doctors would like to do a quick evaluation prior to prescribing this, to make sure they are not ignoring an underlying cause that needs treatment.

Time to get evaluated

If they are refusing fluids or can't keep down anything, you need to check in with your doctor’s office. If they are vomiting up bile (bright green, not just yellow) that is another signal that their tank is really empty and they need a little help turning things around. These are the kids that are significantly low energy.

If the child is truly lethargic (can’t be roused for more than a couple seconds) and you have been attempting small amounts of fluids and failing, then a trip to the emergency room is appropriate. Once there, your child may get some IV fluids which will often perk them right up.

For adults, just google mobile IV services to see if you live in an area where that is available. If you know you simply need fluids, this is a great way to avoid a trip to the emergency room. If you don’t know what is going on, it is worth seeing an MD

Recovery and advancing the diet

Once your child has started keeping down fluids, it is okay to advance the diet if they are interested in food. More often than not, we expect the stools to continue to be looser than normal for a bit longer. Trust your kids to some extent. I find that most of the time they crave the foods that their bodies can handle. If you have an outlier asking for a hotdog, follow your instincts and say no.

Bland starchy foods are your best bet. I suggest a modified BRAT diet. Bananas, rice, applesauce, crackers, toast, potato, pasta, boiled chicken and watermelon are all okay. I find that folks have a quicker time getting over this if they avoid dairy (some folks can stay on yogurt and tolerate that fine). There are plenty of dairy alternatives

In my experience, getting started with probiotics right away is the key to getting over this quickly. Fermented foods are also very beneficial but not in lieu of the probiotics. We need to get the gut healthy again so that it can tolerate a normal diet and the good bacteria in the probiotics is critical to this. There are plenty of good brands out there. Jarro is usually easily available at Whole Foods and has a baby formulation.

One of the most common calls to the doctor’s office after a tummy bug is when a patient seemed like they were improving and seemed to have had a bit of a relapse. This is usually caused by advancing the diet a little too quickly (especially dairy.) You may need them dairy free for a week before things return to normal. Yes, this includes cheese. See Dr. Ted’s tidbits below for an explanation about this.

What if it isn’t a virus?

It could be bacterial. If you or your child has a fever, chills, bloody diarrhea and vomiting, that could be bacterial food poisoning. The most common culprits are Salmonella, Shigella and Campylobacter. Sometimes the symptoms might not show up for a few days, making it hard to identify the source.

Even though many of those illnesses are self limiting, getting seen is a good idea. Your doctor may send a stool sample to the lab to check for a bacterial stool culture. There are usually special containers required for this. 

It could be Parasitic.

If you or your child are just back from travel or camping and have awful gassy, incredibly stinky stools, we should make sure that you don’t have giardia or some other parasite. If that is a possibility, we would send another type of stool sample to the lab that requires a different set of specialized containers. This is called an O&P (ova and parasites.) As opposed to many of the other tummy issues, these do not usually resolve without help of some medication. Even if you haven’t been around any obvious sources, if you have a pet with loose poops, that can be an important clue. Dogs can get it from drinking nasty water and then can spread it to their humans.

Dr. Ted’s Tidbit

The intestines can take a long time to recover after an infection. It’s important to understand that vomiting or diarrhea after recovering from a tummy bug are not necessarily signs that the infection is still active. Up to one third of patients will have weeks of irritable bowel symptoms after recovering from bacterial gastroenteritis. Many symptoms after recovery from a tummy bug can be explained by understanding the physiology of the intestines. The intestines represent your largest internal organ and demand a ton of cellular energy. Often-times, the entire internal lining can be significantly damaged after a tummy bug. In the weeks it takes to repair all that lining, patients can feel unbelievably drained because of the energy required to create new cells. They also may lack the enzyme lactase, which sits in the walls of the cells that line the intestines and can be lost after infection. That may cause new symptoms of lactose intolerance, diarrhea, bloating, or even vomiting or reflux after having dairy or other large meals. If you’re experiencing symptoms after recovering from gastroenteritis, stick with Nurse Judy’s advice and eat small, easy to digest foods.

Extra discussion points

• With anything poop related, often defense is your best offense. Wash your hands!!!

• While it is quite normal to lose a little bit of weight, getting a baseline and monitoring recovery is important.

• Any steady abdominal pain that is lasting more than several hours should be evaluated.

• The issues I have talked about in this post are acute. This means they are generally short lived.

Chronic intestinal issues should not be ignored. Many times general tummy pain is from constipation. Gas pains tend to be sharp and intermittent. Start keeping track. When and if you do see a doctor this data will be valuable:

• Where is the discomfort?
• How severe?
• Does it get better or worse with food?
• Did it go away on its own?
• If not, what did you try?
• How often are the poop? Are they hard or soft?