“Hiding a gun under a mattress, in the closet, or on a high shelf is not safe storage,” Gonzalez explains. “Guns must be stored unloaded and locked away outside the reach of a child or teen.”

Gonzalez adds that safe storage can greatly contribute to reducing unauthorized use of firearms and gun violence among our youth.   

Cook Children’s Medical Center-Fort Worth treated 40 gun-related injuries in fiscal year 2025 (October–September). During the fiscal year 2024, Cook Children treated 62 gun-related injuries.

June 6 marks National Gun Violence Awareness Day and the beginning of Wear Orange Weekend, a time dedicated to raising awareness about gun violence prevention and honoring victims.

“Summer especially is a great time to practice the 3 T’s of gun safety: Talk, Teach, and Take Action,” Gonzalez said.

Gonzalez and Dan Guzman, M.D., a pediatric emergency medicine physician and Medical Director of the Aim For Safety® program, work together to educate the community, primarily focusing on preventing unintentional gun injuries by encouraging safe gun storage. Dr. Guzman has seen and treated an unfortunate number of children injured or killed due to firearms. As a gun owner and parent, he understands the importance of safely securing firearms.

“I don't want to watch another child die as a result of a firearm,” Dr. Guzman said.

He emphasizes that the initiative is not about advocating for or against gun ownership; the focus is on providing people with the tools and resources to be safe around guns.

The Aim For Safety® program has provided education and resources to thousands across the Dallas-Fort Worth Metroplex.

“We highlight how safe storage greatly reduces the risk of unintentional injuries, as well as how it contributes to keeping children safe during mental health crises and reducing the risk of use for gun violence,” Gonzalez said.

Between October 2024 and April 2025 alone, the program provided 252 gun safes and 206 gun cable locks to the community. This is in addition to almost 1,000 gun cable locks provided to families in the emergency department over the last year.

“That’s a total of 458 families which now have tools to keep their families safe,” Gonzalez said.

Gonzalez explains that safety extends beyond firearms such as handguns and also includes air-powered guns such as BB, pellet, and paintball guns.

“Guns should never be used without a guardian’s permission and should only be used while an adult is supervising,” Gonzalez said.

Open Dialogue: Talking to Other Parents about Gun Safety

• Keep the conversation focused on safety, not on whether someone should or should not own a gun.
• Simply ask if there are firearms in the home and if so, are they properly stored (unloaded and locked with a cable lock or in a gun safe).
  • If not, visit the Cook Children’s Aim For Safety website for tips on how to keep guns safely stored or for resources that we can offer to assist in safely storing the gun.

Aim for Safety in the Community

Aim for Safety will be out in the community throughout the summer:

• Defenderpalooza on July 12
• Fort Worth’s Premier Gun Show on August 23-24
• Scheels Great Outdoor Expo September 6-7
• If anyone is interested in a presentation, please reach out to  eric.gonzalez@cookchildrens.org

Lives Impacted by Gun-Related Injuries and Prevention Efforts at Cook Children's

• In FY 2025, Cook Children’s Medical Center-Fort Worth has treated 40 gun-related injuries
• In FY 2024, Cook Children’s Medical Center-Fort Worth treated 62 gun-related injuries
• Most non-fatal injuries were caused by air-powered guns (BB guns, airsoft guns, paintball guns, etc.), while most severe or fatal injuries were caused by handguns.
• Between October 2024 and April 2025 alone, we provided 252 gun safes and 206 gun cable locks to the community through various events.

Sophia Price, with Cook Children's Trauma and Injury Prevention says Cook Children's Medical Center in Fort Worth reported its first snakebites of the season in late April and early May, including its first copperhead bite in May. In 2024, the Cook Children's Health Care System treated 30 snakebites, with the first reported in March.

Jay Pearson, P.A., a physician assistant with Cook Children’s Trauma Services, offers crucial advice for parents on keeping children safe from snakebites. Price recommends avoiding walking in tall grass and wearing protective boots. She also warns that at night, snakes may rest on warm surfaces like driveways or sidewalks. Price emphasizes that individuals should never attempt to touch or handle a snake, even if it appears dead.

North Texas is home to three species of pit vipers:

• Copperheads
• Cottonmouths (also known as water moccasins)
• Rattlesnakes

A snakebite can cause localized pain and swelling that may spread as venom progresses. Other symptoms can include nausea, vomiting, and an increased heart rate. In severe cases, patients may experience difficulty breathing, low blood pressure, or bleeding disorders.

If a snake bites a child, seek immediate medical attention at the closest emergency department.

What to do if bitten by a snake:

• Do not try to capture, photograph, or kill the snake.
• Do not apply ice, tourniquets, or attempt to suck out venom.
• Immobilize the affected limb and keep it at heart level if possible.

How snakebites are treated at Cook Children's:

Once at the hospital, patients with moderate to severe envenomation may receive antivenom, which is readily available at Cook Children’s Medical Center.

Patients are closely monitored for symptom progression and may require hospital admission for observation and supportive care. 

“I dropped off Avyee and asked my dad if I could go one more ride,” Wyatt recalls.

Jimmy agreed. Wyatt drove to a new subdivision, where many of the homes were still being built or were vacant. The road was unpaved. Wyatt hit loose gravel while making a sharp turn, causing his golf cart to tip over. The cart landed on his foot, causing severe injuries.

“I was yelling for help,” said Wyatt.

The accident happened in front of a home where a family had just moved in that day. The mother there picked up Wyatt and rushed him to his home. As the unfamiliar car pulled up with Wyatt, Avyee rushed inside to tell April.

“I got outside and just saw this stranger holding Wyatt like a baby, and Jimmy wrapping his feet in a swim towel,” April said.

Jimmy sprang into action, grabbing his car keys and rushing him to the local emergency room, where Wyatt was stabilized and transferred to Cook Children’s Medical Center-Fort Worth.

The 11-year-old’s innocent evening stroll ended with scattered road rash along his side, three broken bones, and two ripped tendons.

April shares that it was not until the next day, when they met with the plastic surgeon, that they realized the severity and trauma their family had endured.

“I realized this is our new reality right now,” April said. “We’d have full days of surgeries, with doctors and nurses constantly in and out.”

During the first few days, the Hatchers were overwhelmed with friends and family pouring in to tend to their two youngest children at home. Their youngest was just 8 months old and breastfeeding. It was then that she realized the trauma affected her whole family.

She recalls one moment in the hospital where she was caring for Wyatt and his baby brother, Bodynn. April explained to Wyatt that while the trauma happened to him, it affected everyone.

She told him, "You must be patient versus expectant. We are all learning new things."

“It was a hard lesson for him, and just a beautiful opportunity to remind him that he was the one in the hospital bed, but it was changing all of our lives,” April said.

In the two years since the accident, Wyatt has undergone 11 surgeries and one tendon release. Wyatt's last tendon release surgery with a podiatrist will be when he is 18.

He says it was the words of an anesthesiologist that helped him face those surgeries head-on.

“He said, ‘When you face a challenge, you have to meet it, greet it, and then defeat it,’” Wyatt recalls.

Camp RISE

The family came to know their Cook Children’s child life specialist well. She suggested they attend Cook Children’s Trauma Support Group. Through the group, they learned about Camp RISE, a camp focused on families who have experienced a traumatic event. The camp helps families build coping skills, process trauma, and meet other families, all while taking part in fun activities like zip lining.

“It was an escape from the city life,” April said. “Being out where the stars are so numerous and it's just an oasis, and it’s just such an excitement.”

As the Hatchers arrived for their first day of camp, they were greeted with cheers and welcomed to their private cabin. Avyee, Bodynn, Wyatt, Jimmy, and April were excited for the experience.

Wyatt admits his favorite part of camp was archery, but during his second year, he felt compelled to encourage other children through their trauma. He credits Matthew 17:20-21 for finding that courage.

“If you have faith, faith the size of a mustard seed, you could tell a mountain to move and jump,” Wyatt recites.

To Wyatt, it was about giving hope to someone else.

“This is never going to be normal, but it will become a new normal, and it's going to be okay eventually,” said Wyatt.

After two years at Camp RISE, the Hatcher family graduated in 2024. April said it was a bittersweet moment. The family received a book signed by all the Trauma Support Group staff.

“The ripples were extensive, in what they had us do,” April said. “It’s just a scaffold to bring such healing.”

Just two weeks after the accident, wound vac and all, Wyatt used the anesthesiologist’s wise words to conquer any fears or hesitation he had about getting back in the golf cart. His dad placed him in the seat and gently drove him around the front yard, eventually taking him on the road.

Two years later, at 13, he shows his scar without hesitation. He openly shares and explains the accident with maturity.  

 For Wyatt’s 13^th birthday, he wanted to see starfish and swim with the dolphins. It was being with the dolphins that captivated him. He now has aspirations of becoming a Marineland dolphin trainer.

During that birthday adventure, April says Wyatt found his voice. On his own, while his parents watched, the 13-year-old had to explain to employees and the dolphin trainer why he wears a scuba sock on his injured foot. A scuba sock was something dolphins had never seen before. The trainer told Wyatt he would teach the dolphin what the sock was.

"It was the coolest moment for our kid," April said. "He just walked away with so much more confidence."

If you’re a parent, you’ve said it to your child a thousand times. 

“Don’t run with that in your mouth!”

It could be a stick, a toy, a utensil or any other random object a child finds palatable.

While your little one may scoff at the command, it’s a fair warning. An ill-timed bump or fall could cause that object to crack a tooth or injure your child’s tongue, mouth or throat.

Data from Cook Children’s Medical Center suggests that palate injuries from an object in the mouth are on the rise. In 2021, there were two reported palate injuries, followed by eight in 2022. Already this year, there have been 14.

Six of the injuries since 2021 occurred while a child was using a straw, with some being a hard plastic or metal straw. Four of the injuries were the result of an accident while using a toothbrush. The others are from various objects, including a stick, curtain rod, spoon and plastic bat.

The activities leading to the injuries differ. They include everything from walking into a door while drinking from a straw, sneezing while using a straw, roughhousing with a sibling while brushing teeth and getting hit in the head with a ball while brushing teeth. These may sound random and far from the norm, but if you spend any time with children, you know the possibility of any one of these exists.

The key to preventing these types of injuries is to stay vigilant. Give kids a flexible, rubber straw rather than a hard plastic or metal one. Remind them not to play, roughhouse or throw or catch a ball while brushing their teeth or while holding anything in their mouths. And keep telling them not to run with objects in their mouths, even if it’s for the 1,000th time.

Jay Pearson, P.A., a physician assistant with Cook Children’s Trauma Services , says these injuries happen more than you would think.

“These soft palate injuries are considered penetrating injuries to the back of the throat and are at risk for significant complications,” Pearson said. “The risk is high enough that we activate the trauma team to do a thorough workup to make sure a significant injury is ruled out. We have seen an increase in these activations recently.”   

The most common injury from these incidents is a laceration of the palate that results in a hole in the mouth. These can be painful and interfere with a child’s eating and drinking, according to Michelle Marcincuk, M.D., Ear, Nose and Throat specialist at Cook Children’s. 

“They could potentially lead to an infection deep in the neck or even extending down into the chest around the heart area which can be very severe, and very dangerous. Sometimes they need surgery,” Dr. Marcincuk said. “But the most feared complication is for the object to go deeper and injure the big blood vessels in the neck. This can cause a stroke, a blood clot, an aneurysm, a catastrophic hemorrhage or even death.”

If your child sustains an injury from carrying something in their mouth, Pearson says they need to be evaluated by a medical professional. 

“The majority of the time these palate injuries are minor, but due to the potential risk of serious injury, an abundance of caution is taken,” Pearson said.

Kaitlin Bates and her three young sons heard a loud pop while walking on a nature trail one day last summer. 

At first, Kaitlin thought their stroller ran over something, maybe a snake. Then her 18-month-old son Jace started screaming. Kaitlin was shocked to see blood flowing from a hole in Jace’s knee. The toddler, seated in the stroller, had been shot.   

The Bates family’s trip to a nature center in Wichita Falls on Aug. 11, 2022, turned tragic because someone fired a gun. Was the shooter aiming at the boys and their mom? Or was Jace randomly hit by a stray bullet? No one knows.

Whether or not the shooter intended to cause harm, the consequences were serious. The bullet tore through cartilage, ligaments and tendons, and also chipped off a bone fragment from his tibia. Jace required surgery – followed by months of physical therapy to regain the use of his left leg.

“Jace is so resilient,” Kaitlin said. “It slowed him down for awhile and he had a lot of pain for awhile while, but I think Jace has the beauty of ignorance because he’s so young. He never knew what happened. He didn’t know it was a gunshot.”

Jace was one of 42 children and teens treated at Cook Children’s Medical Center for gunshot wounds in 2022. Most of those patients were ages 11 or older, although some were babies or preschoolers. Five died from their injuries.

Hospital data show that handguns accounted for almost half of the gunshot wounds treated at Cook Children’s last year. Traumatic injuries also resulted from shotguns, BB guns and airsoft guns, which use compressed gas to launch pellets.

In an effort to reduce injuries and fatalities from firearms, the Cook Children’s Aim for Safety® program promotes awareness and responsibility to help protect kids from accidental shootings. The program emphasizes three basic steps:

1.     Safe Storage – Keep firearms unloaded and in locked locations out of reach of children. Use trigger locks and gun safes. Secure ammunition separately.

2.     Safe Children – Teach your child don’t touch if they see a gun or someone aiming a toy gun at others. Teach them to run and tell an adult.

3.     Safe Play – When non-powder guns are in use, remember to never aim BB guns or pellet guns at another person. Wear safety glasses when using a paintball gun, gel bead gun, water bead gun or soft foam gun. Before a playdate at a friend’s house, find out if guns are kept in the home and how those guns are secured.

Daniel Guzman, M.D. understands the Texas hunting culture; he’s a firearm owner himself and respects the Second Amendment. But as a physician at the Cook Children’s Emergency Department, he also knows the danger. Dr. Guzman started Aim for Safety® in 2017 after the upsetting experience of treating a 4-year-old shot on accident by a sibling. The child died from the injuries.  

“No one is here to talk about keeping a gun from anybody, but there are definitely things that we can do to help minimize the injuries,” Dr. Guzman said. “The number one thing that comes with gun ownership is safe storage and responsibility.”   

In Jace’s case, maybe the shooter hit the boy on purpose. His parents think the more likely scenario was carelessness … the shooter pulled the trigger without knowing what or who could be in the bullet’s path. Aim for Safety® wants to keep such tragedies from happening.

Jace can once again walk, ride a tricycle and romp around with his big brothers. Kaitlin and Justin Bates are thankful for their son’s recovery but don’t know if the injury will impact his growth or cause complications when he’s older. Here’s a closer look at events and the care Jace received at Cook Children’s.  

Bullet out of the Blue

The bullet came in at a downward angle, entering through the inner leg and protruding like a knot on the outside of his knee. Kaitlin unbuckled Jace and ran with him in her arms the short distance back to the nature center. She yelled for help.

“There was blood everywhere. Jace’s leg was just pouring blood,” Kaitlin remembers. “I was just looking at him and trying to assess what had happened. I saw a perfectly round hole in his leg.”

Two of Kaitlin’s former schoolmates happened to be there. They comforted the older Bates brothers, who were scared and crying. Someone called 911. Another guest offered a first aid kit, and Kaitlin sat Jace on the counter in the restroom. The two women made a tourniquet and applied pressure with paper towels. But the bleeding didn’t stop.

“Jace was kind of starting to pass out,” his mom said. “He had lost a lot of blood and he had quit crying. He was very still at this point.”   

The ambulance rushed Jace and Kaitlin to a local hospital, where doctors put his leg in a soft cast and lined up transport by helicopter to Fort Worth. Kaitlin knew it was a bad injury, and she wanted to go to pediatric specialists at Cook Children’s. The Emergency Department was ready and waiting to give Jace a scan and pain medication to get through the night.

In surgery early the next morning, two incisions were made to remove the bullet and to flush the wound of residue that could cause infection. Jace was put in a cast from his groin to the toes on his left foot. He went home the next day.

The cast prevented Jace from putting any weight on his leg. Normally a rowdy fireball of energy, the boy couldn’t stand up when the cast came off a month later.

“He couldn’t bend or straighten his leg. It was frozen in that position,” Kaitlin said. “It has been grueling. He's had a lot of pain. and even still, if I pick him up in a weird position or if I'm rocking him and I hold his leg funky, he still will reach down and grab his leg and start crying.”

Physical therapy sessions twice a week in Wichita Falls provided stretching and climbing practice to help Jace improve his strength and range of motion.

Cook Children’s will continue to monitor Jace, who limps when he’s tired. Doctors don’t know how the growth plates in his knee might respond to the injury. Arthritis could potentially be another long-term complication. 

Jace’s parents aren’t anti-gun. In fact, they practice safeguards at home because Justin owns a firearm.

“Being a responsible gun owner myself I never would’ve imagined that someone’s negligence would affect my family in this way,” Justin said. “It is paramount that firearm education is taught in our communities with the understanding that a firearm is a tool that should be operated, maintained and stored responsibly.”

His parents suspect the bullet that hit Jace came from a handgun fired blindly from a neighborhood or city park outside the grounds of the nature center. As of January 2023, the shooting remained unsolved.

“Maybe someone was just shooting up into the air and didn't realize that what comes up has to come down,” Kaitlin said. “I really don't know. There's a lot of yuck in this world, and so maybe someone did it intentionally. But overall, my husband and I really are on the page of somebody shot a gun not knowing what was behind him, which is just as stupid as doing it intentionally.”

Jace getting shot was one of the scariest things his parents have ever faced. They don’t want other families to go through what they experienced. But they rely on faith and see blessings throughout the ordeal. Kaitlin points out that if she had pushed the stroller one step further on the trail, Jace could have been shot in the head or heart instead of the knee. He could have been killed.

“We are constantly praying that the Lord would use this to bring about a mighty testimony in all of our lives, especially Jace’s,” she said. “We pray that Jace would come one day to know how much God loves him and protected him and that Jace would spread that love to all those he encounters in his life. No matter the circumstances, God is still good.”

Access and Risk

As medical director of Aim for Safety®, Dr. Guzman works to spread the three-point message of Safe Storage, Safe Children, and Safe Play through presentations at schools and community events. He and the program have reached thousands of families, provided hundreds of locks and safes for safe storage, and distributed more than 3,000 education and awareness resources.

In 2022, he made presentations to eight elementary schools and six community events in the Fort Worth area. The program also includes online classes offered through the Cook Children’s Center for Children’s Health.

“I wanted to get out there and talk to families and remind them of the importance of storing firearms safely – unloaded and locked in a safe,” Dr. Guzman said. “I’m not here to make a political statement. I’m here to educate families and keep our children safe!”

His goal is to help people understand the risk of gun ownership – similar to the risk of drowning that homeowners can proactively reduce by installing fences and locked gates around a backyard swimming pool.

Frequent conversations with your child are vital. Teach them never to touch a gun they might come across in a purse, nightstand drawer, vehicle or other location. But families also need to put barriers in place to limit access. Dr. Guzman estimates that Aim for Safety® has given away 175 gun safes and more than 1,000 gun locks in the past two years. 

The national Gun Violence Archive website lists 314 fatal shootings of U.S. children ages 0-11 in 2022. Unintentional shootings can be prevented, Dr. Guzman pointed out. He never wants to hear another grieving mother in the emergency room say she didn’t think it would happen. 

“I know my kids like to explore. They’re curious about things. They’re going to play hide and seek and play with things they may across,” he said. “Again, it’s not about browbeating anybody. It’s just about keeping our kids safe.”

Cook Children’s Aim for Safety® presents a non-political educational approach to keeping everyone safe when guns are in a home, The program emphasizes responsibility through three steps: Safe Storage. Safe Children. Safe Play. It doesn’t debate whether guns are right or wrong. It's about protecting our children.

For more information or to register for an online firearms safety course, go to Gun Safety (centerforchildrenshealth.org)

From Aug. 22 to Aug. 28, Cook Children’s treated five patients who were struck by vehicles in separate incidents.

As the new school year gets underway for many districts across North Texas, it’s crucial that drivers look out for children, especially in school zones.

Injuries treated:

• 3 patients (pedestrians) struck by vehicles
• 1 patient (pedestrian) struck by an ATV
• 1 patient (bicyclist) struck by a vehicle

Drivers should eliminate distractions and pay attention to their speed, especially in school zones. Always look out for pedestrians and don’t text and drive.

Dan Guzman, M.D., pediatric emergency medicine physician with Cook Children’s Medical Center, says that it’s important that parents also teach their children safety precautions for walking near a road, including paying attention, using sidewalks and crosswalks, and always looking both ways before crossing a street.

“It’s really important to teach your kids and make sure they understand that we need to pay attention because this is your life, there’s only one you and there’s no way to get this back if something bad were to happen,” Dr. Guzman said.

Dr. Guzman says the emergency department sees more children this time of year as kids walk or ride bikes to school and are, unfortunately, struck by vehicles.

“We want our children to be safe and no one wants to hurt a child,” Dr. Guzman said. “We all need to slow down close to school zones and neighborhoods. Make sure we take care of our kids.”

Elementary school children are very active and impulsive. Although they’re learning and growing, school-age children 10 and younger still need guidance and supervision when playing and walking near traffic, according to the National Highway Traffic Safety Administration.

Pedestrian tips:

1. Children less than 10 years old should not be crossing the street without an adult.  All kids are different, but developmentally until they are about 10 years old they don’t have the cognitive ability to judge the speed of an oncoming car.
2. Don’t be distracted while walking.  Stay off your phone and if you HAVE to use headphones, only use one. You have to be aware of your surroundings!
3. Look left, right and back left again before crossing the street. 
4. Only cross at the light, corner or crosswalk. Never cross the street between parked cars.
5. Walk on the sidewalk. If there isn’t a sidewalk walk FACING traffic.
6. Be alert for cars pulling into parking lots and driveways as well as cars backing up.
7. When there is a car approaching or even stopping, make eye contact with the driver and wait for them to motion for you to cross the street. Often times you may think the driver is looking at you but they may be in a “daze” and not truly see you.
8. More than 80% of pedestrians die when hit by a car going 40 mph or faster, and less than 20% die when hit at 20 mph or less. As a driver, SLOW DOWN.

School Zone tips:

1. Slow down and follow all speed limits.
2. Pay attention and look out for pedestrians.
3. Cell phone use is prohibited.
4. Obey crossing guards.
5. Stop for school buses.

Tips for Drivers:

1.  Always stop for pedestrians.
2.  Yield to pedestrians in crosswalks and stop well back from the crosswalk to give other vehicles an opportunity to see the crossing pedestrians so they can stop too.
3. Yield to pedestrians in crosswalks and stop well back from the crosswalk to give other vehicles an opportunity to see the crossing pedestrians so they can stop too.
4. Never pass vehicles stopped at a crosswalk. There may be people crossing where you can’t see.

Media partners: If you are interested in telling this story, please contact Public Relations Manager Kim Brown at Kim.Brown3@cookchildrens.org or at 682-885-1080, 817-266-3728

In Cook Children’s Emergency Department, treating gunshot victims requires all hands on deck. The moments are precious as staff work against the clock to save young lives. The goal? To rescue every child who comes through the sliding doors. The reality? Children with gunshot wounds are among those most likely to die from their injuries.

For emergency room physicians like Dan Guzman, M.D., caring for shooting victims is particularly bothersome because gunshot wounds are preventable. He fears he will see many shooting victims in the coming months as summer is typically a busy time for this type of injury.

“Kids are out of school, and parents are working,” he said. “Children will find a gun that’s not locked or hidden, and a matter of seconds can change a family’s life.”

As of May, 35 children have already been treated at Cook Children’s with gunshot wounds in 2021. Two died. Compare that to 2019 when 41 children were treated for gunshot wounds, including five deaths, and 2020, which totaled 47 patients and four deaths.

“We are five months into 2021 and are on track to exceed prior years,” Dr. Guzman said. “We haven’t reached the halfway point and we’ve already lost two patients.”

While most of the situations stemmed from unintentional gunshots, Dr. Guzman says all of the incidents could have been avoided.

“The vast majority of the kids that we see suffer from head and neck injuries. It's almost impossible to save a life because the damage has been done to the brain.” Dr. Guzman said.

Celeste Calhoun and Jill Plunkett are emergency room nurses with a combined 20+ years of experience. They both agree that seeing gunshot victims coming through the emergency department has happened more often than they’d care to see.

“Gunshots are preventable for children,” Calhoun said. “Children don't go out with an intent to harm each other. They usually obtain the gun because it was left open or out, and by playing with it. Not knowing that it's loaded or what it can do when they aim it at someone and squeeze the trigger.”

Plunkett says her husband was raised around police officers and guns, she and her husband made it a point to teach their two children about gun safety and education at a young age.

“We have guns in our home, they were never loaded and my children didn’t even know the code to the safe until they were adults. They knew the guns were in our home, and if they ever wanted to see them or had questions, my husband would take them out and educate them, but they were never accessible,” Plunkett explained.

Dr. Guzman agrees that education is key. He says he understands why parents may feel they need guns for the safety of their family, however, there is a safe way to have a weapon in the home - locked up.

“Let's put our guns away. For the safety of our children, let's make sure that we're making the right choices,” Dr. Guzman said. “If you can buy a safe, 100%, get a safe and put that gun away. This is not about who can have a gun or who shouldn't have a gun. The bottom line is our children’s safety.”

Dr. Guzman worries that recent state legislation coupled with a spike in gun sales nationwide could lead to more unintentional child shootings.

“Last year (2020) was a bad year, we saw more injuries than we’d seen in the last five years,” Dr. Guzman explained.

The plea is simple. If there are guns in your home, educate your children and make sure they are in a safe and secure place.

“We want to help people avoid having to be in our emergency department, to be safe at home, and live a long life without ever having to see us,” Dr. Guzman said.

Calhoun, who is also a mother, shares another piece of advice that is often forgotten by parents.

“Make sure you know where your child's going to visit and play,” Calhoun said. “If they're going to another home with another child, have that awkward conversation with the parents to find out if they have guns in their home and what safety precautions they take to protect their children.”

Lastly, Dr.Guzman says when educating families, it is important to note that handguns are not the only kind of gun that can injure a child.

“We hear about handguns and firearm accidents in the news,” Dr. Guzman said. “We can’t forget children are injured by BB guns and pellet guns too. I’ve seen children die from BB guns and pellet guns, so we have to be cognizant at all times.”

“Just because it says crash tested doesn’t mean it’s been reviewed or approved by any regulatory agency,” said Sharon Evans, RN, trauma injury prevention coordinator at Cook Children’s.

Previously, non-regulated car seats were seen most in areas like California and New York. But according to Evans, these products are now showing up in North Texas.

Here’s what you need to know:

• To be approved by the National Highway Traffic Safety Administration (NHTSA), car seats must meet all the criteria to be able to state they meet or exceed FMVSS 213.
• Unregulated products may be found at well-known stores and online, so it is important for parents to check if the product is approved by the car seat manufacturer to be used with your specific car seat.

“The problem occurs when a parent buys a car seat that meets FMVSS 213, but adds accessories, which are not regulated. These products can alter the way the car seat works in a crash, or the accessory can become a flying missile, like a snap-on mirror,” explains Sharon Evans, trauma injury prevention coordinator at Cook Children’s. “I think parents feel that if it’s being sold by a big name retailer, it has to be safe, but often it isn’t.”

Evans big concern is that many car seat accessories claim to be “crash tested,” even though they are not regulated and do not meet the criteria by NHTSA.

The car seat manufacturers realize this is a problem and many now make non-regulated products such as seat protectors, water-resistant pads or covers for their specific car seats. If parents are going to add something to the car seat, it is important to verify the car seat manufacturer states the accessory is safe to use with the specific brand and model of the car seat.

“Accessories and non-regulated products are designed, made and sold by car seat manufacturers and anyone else who wants to,” Evans explained. “Even though the product may say ‘crash tested’ or meets NHTSA standards or FMVSS 213, however, there are no standards for these products. The product may be crash tested but we don’t know how and we don’t know if the product was tested in specific car seats and/or what car seats.”

What to look for:

• Make sure car seats are labeled with FMVSS 213. This means the product is approved by the NHTSA.
• Non-regulated products often have a similar label of FMVSV 213. These products are not federally registered, and cannot claim to effectively restrain the child or claim to prevent injury.
• Regulated products and accessories will state: Meets or exceeds all federal standards for car seat safety (FMVSS 213 Federal Motor Safety Standard for USA).

“Parents need to be really careful with car seat accessories, because you run the risk of your child being injured due to something like a footrest or head strap,” Evans said. “Unfortunately, some companies are intentionally using confusing labels to sell their products, so it’s really important that parents know what to look out for.”

The National Highway Traffic Safety Administration provides child passenger safety that can be found here. 

Unfortunately, it can also be a time of tragedy when kids are rushed to Cook Children’s for help.

Cheerleading has changed in the past 30 years from yells and claps to routines with high level gymnastic tumbling runs and stunts. It has also become a year-round sport with summer camps and cheerleading competitions. This has increased the number of injuries, especially in females. Most common injuries are fractures, strains, sprains, and concussions. Due to this change in the demands of cheerleading, it is important for coaches and cheerleaders to understand proper techniques during stunts and tumbling, strengthening, leg and arm alignment, core activation and different risks related to floor surface and practice time.

Cheerleading has not historically been recognized as a sport, at many levels. This means cheer may not be under the control of an athletic department.  Cheerleading does not have to follow certain rules and regulations that other sports monitor and improve for  safety. Therefore, increasing safety awareness is key for protecting cheerleaders.

Loading, body mechanics and alignment

The way in which a cheerleader lands when tumbling is also very important in preventing injuries. Soft landings are the way to go. A soft landing is best with knees slightly bent and weight more on the toes rather than heels. Do not allow the knees to go in or forward over the toes; instead, keep toes and knees pointing forward with upright chest and tightened core. Tumbling and stunting on a softer surface is always preferred rather than a hard or wet surface.

Injuries have been related to improper loading due to decreased strength, body awareness and lack of proper alignment with body mechanics.  Loading refers to the pressure or weight a cheerleader has through their arms, legs, and spine while holding a stunt and landing a tumbling pass.

Cheerleaders need  to be aware of their body mechanics. Body mechanics is proper body movements to prevent or correct posture problems, reduce stress on the body, and enhance physical capabilities.   Strengthening cheerleaders’ cores, legs and arms will improve body mechanics and decrease injuries.

Here are some proper basing and spotting techniques from the bottom up, to address proper alignment for good loading and body mechanics: 

• Keep feet shoulder width apart with toes forward or slightly out; heels on the ground.
• Knees should never go forward past the toes or inward.
• Hips should stay over feet with equal weight.
• Trunk stays upright- do not bend or arch the back/spine when spotting a stunt.  
• Arms directly above shoulders; not behind your head when spotting a stunt.

Cheerleaders can be strong too

As cheerleading has become more about stunts and tumbling, it requires strength, balance and stability.  Coaches should be focused on strength-building conditioning, which includes core stability and proper lifting techniques. It is also beneficial for coaches to attend safety certification classes, such as those offered by the American Association of Cheerleading Coaches and Administrators (AACCA). Prior to any cheerleading event, a proper warm up with aerobic activity and dynamic stretching is necessary to prevent injuries. Stretching after cheerleading is just as important to decrease injuries. The longer the practice, the higher the risk for injury is. Most injuries happen between 61 and 90 minutes of practice.

Increasing awareness of concussions 

Cheerleaders are at high risk for sustaining concussions, which is a head injury/trauma to the head when hit.  Cheerleaders sustain concussions with a fall from high heights, being hit in the head when basing, or landing on their head during tumbling.  It is important to stop cheerleading if there is a possibility of a concussion. Signs to watch for include: headaches, dizziness, visual blurriness/double vision, memory issues, decreased coordination and balance problems. If these symptoms are present, the cheerleader should seek medical attention immediately.

Most concussions heal in about a month, however if cheerleaders continue to have the symptoms, they may need active rehabilitation. It is never good to return to cheerleading too early; it may make their full recovery longer.  If a cheerleader has any signs or symptoms of a concussion, they should not be allowed to return to cheerleading until cleared by a physician.  Cheerleaders are 3-6 times more likely to have a second impact concussion after having their first concussion;  the second impact concussion can have more severe complications.

American Academy of Pediatrics recommendations for preventing injuries:                                              

• Cheerleading should be designated as a sport in all states, allowing for benefits such as qualified coaches, better access to medical care and injury surveillance.
• All cheerleaders should have a pre-season physical, and access to qualified strength and conditioning coaches.
• Cheerleaders should be trained in all spotting techniques and only attempt stunts after demonstrating appropriate skill progression. 
• Pyramid and partner stunts should be performed only on a spring/foam floor or grass/turf. Never perform stunts on a hard, wet or uneven surface. Pyramids should not be more than 2 people high.
• Coaches, parents and athletes should have access to a written emergency plan.
• Any cheerleader suspected of having a head injury should be removed from event and not allowed to return until cleared by a health care professional.

Related links

• The Cook Children's SPORTS program
• Cheerleading Injury Prevention
• Top 10 questions parents have about sports injuries

Corwin Warmink, M.D., medical director of the Emergency Department at Cook Children’s, knows that guns will be a popular gift this holiday season for not only children, but for adults too.

According to the journal Injury Prevention more than one-third of American adults own a gun. Last year, Cook Children’s saw 10 total injuries related to shootings of a gun (ranging from a BB to rifle). Since 2009, Cook Children’s has seen 104 shootings and three deaths.

Dr. Warmink asks parents to explain to children that BB guns can be dangerous, with harm ranging from severe eye damage to liver and kidney injuries.

Dr. Warmink says it’s important that parents educate their children about gun safety and make sure kids know to leave the area if another child, or someone other than their parent, has a gun.

“We live in Texas and I know many kids are raised hunting and have guns in the home,” Dr. Warmink said. “But if you give your child a gun for the holidays or if the adult in the house is given a gun, it’s important to take the proper precautions. The thing we want parents to remember is to keep guns locked, unloaded and separate from ammunition”

1. Lock the gun and keep it out of reach of kids. Hiding the gun is not enough.

2. Unload your gun. Take all ammunition out of the firearm.

3. Store the keys for the gun in a cabinet or safe different from your household keys. Keep the keys out of the reach of children.

Along with guns and replica firearms, such as airsoft guns that use hydraulics to shoot pellets, Dr. Warmink lists these gifts as dangerous and even life threatening:

• Ripstik Casterboard, Skateboards, roller skates …
• Pull toys with strings over 12 inches
• Trampolines
• Backyard playground equipment
• Hard plastic swords

Sharon Evans, Trauma/Injury Prevention coordinator at Cook Children’s, knows that owning a bike or scooter is part of growing up. But she encourages parents to take the proper precautions before placing wheeled gifts under the tree.

“Parents, please don’t forget a helmet for all riding toys,” Evans said. “Make sure the helmet is on properly and read the instructions.”

For younger children, Dana Walraven, manager of Community Health Outreach at Cook Children's and coordinator of the Safe Kids Tarrant County Coalition, warns parents to be aware of any small parts or potential choking hazards from their own toys or perhaps older siblings.

“The holidays can be an especially dangerous time for the little ones,” Walraven said. “Pick out toys and activities that will be appropriate for their age. On Christmas, designate an adult to supervise the children. It’s surprisingly easy to lose track of small children and with just a little planning we can keep choking hazards away from them. When it comes to young children, preparation is key.”

Richard Roberts, M.D., a neurosurgeon at Cook Children’s, wonders what it’s worth for your child to play sports with a reputation for head trauma.

“I think the fact that when the NFL players sued the league initially and won, the judge said the settlement (more than $700 million) wasn’t big enough,” Dr. Roberts said. “That says a lot about this growing issue more so than anything else.”

The issue discussed in the NFL cases has been CTE (chronic traumatic encephalopathy), a progressive, degenerative brain disease that has been found in some athletes with repetitive brain trauma.

Research is currently being done to study just how playing contact sports such as football mainly, but also soccer, can cause damage to an athlete’s head. But is it worth it for parents to wait for the results of this work.

“Amateur sports are different than professional sports because no one is feeding their family with the activity that they are doing,” Dr. Roberts said. We need to look beyond the short term and really understand what could happen in the long term. That potential for long term problems should be the primary thought, not the secondary thought.

“What is the actual incidence? We don’t know. But if it was your kid, how much would you be willing to risk? Even if it was 1 in 10, would you roll the dice on your own kid?”

Dr. Roberts has previously worked at Children’s Hospital in Philadelphia and Charity Hospital in New Orleans. While he saw concussions at the other hospitals, he’s never seen parents argue with him about concussions as he has seen at Cook Children’s.

“Part of what I’ve seen which is different here than other places is that I do get push back from parents who I think underestimate the severity of some of these injuries,” Dr. Roberts said. “Some of it is that they want their kids to play and I think some of it is the short term nature of some concussions.”

Children get concussions and they do well relatively quick, so opposed to having a broken arm which is in a cast or needing surgery and having stitches for three weeks, kids hurt their heads, they are knocked unconscious for five minutes, but then feel essentially better soon after. This apparent sign of improvement makes it difficult for some parents to grasp that their child may have a fairly significant brain injury.

“The more we understand concussions and the more we see people who have hurt their heads for various reasons, soldiers, professional athletes, anyone who has suffered a head injury, I think that we are seeing that in adulthood they are starting to have more cognitive issues,” Dr. Roberts said. “Now the science is not perfect yet. We can’t say to a football player you had three concussions and that’s why you have dementia. We can’t say to the soldier you were exposed to be a bomb blast and that’s why you have dementia because it could be multifactorial. It could be that you have the right genes to make you this way later on. But the percentage seems higher in people who have had traumatic brain injuries.”

Dr. Roberts says parents should be concerned after head injury one. He knows you have to let kids live their lives and be kids, but the brain wasn’t made to get beat up like happens sometimes in sports.

It’s not known for sure that after one concussion, people are more likely to get more, but Dr. Roberts’ suspicion is that it is likely the case.

And when does he have a serious heart-to-heart with the parents and the athlete?

“After two. We discuss no longer participating in the activities which could cause further injury because the likelihood of you having a head injury in your lifetime is still pretty high,” Dr. Robert said. “You are going to hit your head on a tree branch or you are going to fall off your bicycle or someone is going to run into you. You are going to be stepping out of the car and slip or walking across ice and fall down. My opinion after behavior has shown us that you are going to get injuries in a particular sport, you should probably not be playing in that sport because you are not able to protect your head.”

Dr. Roberts has seen strong reactions from both the parents and the kids after being told he or she should quit playing their respective sport. And it’s not just football as most people expect. It’s with the gymnast who has fallen off the bars and knocked herself out or the soccer player who has headed the ball and gotten knocked unconscious.

But football still remains king in Texas – in popularity and in concussions.

So what can be done about it?

Dr. Roberts is not sure there’s a good answer to that question. Building better equipment helps, but then armoring players probably makes them feel invincible and they hit harder. If you take away the facemasks or hard shell football helmets, he expects you will return to the old days – less concussions, but more skull fractures and in the process, immediate deaths on the playing field.

For now, Dr. Roberts wants parents to monitor their kids closely and to take the recommendations from their doctor closely. If they say it’s time to stop – stop!

“All the steps that sports are taking to make it safer are positive,” he said. “I think that everybody involved has to think less about return to play and more about long term health.”

About the source

Richard Roberts, M.D., is a neurosurgeon at Cook Children's. When a child with a neurological disorder requires surgery, the experts at Cook Children's Medical Center offer comprehensive care and state-of-the-art technology. With the help of such state-of-the-art equipment as the revolutionary intraoperative MRI (iMRI), our neurosurgeons are able to determine effectiveness of surgical procedures for cranial and spinal nerve disorders and tailor the treatment to each child's unique needs.

Water sports are great because it allows one to exercise at a high intensity, there is not that much stress on the back and legs. It is great for a whole body work out and allows someone, in one hour, to be able to burn as many calories as in a one-hour run.

Typically, one doesn’t think of swimming as a sport that leads to many injuries. Swimming is an overhead sport and the human body is not made to handle a lot of overhead activities. Swimming too much can lead to overuse injuries. The main ones are shoulders pain and occasionally knee pain.

The training for competitive swimmers has changed in recent years. Training now requires swimming a lot of laps. All this swimming leads to more overuse injuries, like the ones we see in baseball pitchers and runners. Shoulder pain is the major problem swimmers will “swim” into because using the same muscles over and over can lead to the muscles in the chest and back being unequally strong. These muscles not being equal can lead to bad swimming form which will then lead to shoulder pain. Swimming strokes that can lead to shoulder pain are freestyle, back stroke and butterfly. Swimmers that participate in breast stroke are as at risk as other strokes for shoulder pain, but can also develop knee pain. This comes from the knee cap shifting and rubbing on other parts of the knee joint leading to knee pain.

It is important for coaches and parents to know how to keep their young swimmers safe, what to look for, and what questions to ask their kids to ensure that they are staying safe and not injuring themselves.

KNOW WHAT’S BEST FOR YOUR YOUNG SWIMMER:

Parents and coaches can help their swimmers by being an extra pairs of eyes, because the young athletes don’t know any better.

Rest: Athletes participating in overhead activities should not participate in these activities for at least three months out of the year. This means that it is good for parents to encourage their child to try different sports, specifically ones that don’t involve overhead activities.

Warmup: Ensure that your swimmer is warmed up properly. It is never good to get into a pool cold. The type of warm up is important too. Make sure that the warm ups are active and not passive stretches. There are a lot of traditional stretches that swimmers do to warm up their arms. These warm ups target parts of the shoulders that keep the joint stable. It is important to warm up and actively stretch the muscles themselves and not the shoulder joint.

Hydration: Lastly, make sure to drink a lot of water. Being in a pool dehydrates the body on top of the sweating that occurs while working out.

THINGS TO AVOID:

• Incorrect swimming form
• Excessive training without rest days
• Swimming the same stroke every time

WHAT TO WATCH FOR:

• GREEN LIGHT- Good: Muscle soreness is OK if it last 2-3 days
• RED LIGHT- Bad: If soreness last more than 2-3 days, or gets worse, and/or is sharp

(If it is a red light item one should seek help from a medical professional)

NOW WHAT:

Young Kids AGE: 5-9

• Training should not exceed 60 minutes and no more than three times a week.
• Learn how to properly perform the basics of the strokes.

Older Kids AGE: 10-16

• Training should not exceed 120 minutes and no more than 6 times a week.
• Learning how to decrease wasted energy with strokes.

PROPER WARM UP:

• 5 minutes of light swimming
• 15 minutes of active stretching
• 10 minutes of stroke and breathing exercises in the pool

At Cook Children’s, our SPORTS physical therapists are trained in proper rehabilitation of overuse injuries and work to restore full function and safely guide return to athletic activities. If your child has a history of injuries from swimming or you are concerned about risk of future injury, talk to your pediatrician about a referral to physical therapy.

Learn more here:

• USA Swimming
• Ovoiding overuse injuries
• Swimming Injury Prevention

As parents before we just shrug off our children’s injury as nothing too serious, it helps to know exactly what a sprain is.

The American Academy of Orthopedic surgeons define a sprain as a stretch and/or tear of a ligament, the fibrous band of connective tissue that joins the end of one bone to another.

Technically a torn ACL or a torn MCL in the knee is a sprained knee, but we never shrug those injuries off. So why are we so dismissive of ankle sprains? Admittedly a sprained ankle is typically not as severe of an injury as a torn ACL, because an ACL when torn will not heal on its own and requires a surgical reconstruction, but that is a topic for another blog.

Just as with any injury when dealing with an ankle sprain we need to start by determining the severity of these injuries. Ankle sprains are typically divided into three grades based on the severity and presentation of the injury.

Grade 1: Ligaments are stretched, but not torn, ligaments are tender to touch, but no laxity is noted, and the patient is able to walk with little to no pain.

Grade 2: Ligaments are stretched and at least partially ruptured, there is moderate pain and swelling, mild to moderate bruising, some range of motion loss, the patient has pain with walking, and there is mild to moderate laxity noted.

Grade 3: Ligaments are completely torn, there is severe swelling, severe bruising, significant loss of motion, the patient is unable to bear weight or walk on the ankle, and there is significant laxity noted.

The severity of the sprain will definitely influence how we treat these injuries.

So why is it important for my child to rehab an ankle sprain?

The number one predictor of ankle injuries is a previous ankle injury. So what this tells me is that more often than not we aren’t addressing that initial injury effectively. Each ligament sends information to the brain letting us know if our joints are in good alignment or not. This is why we don’t have to look at our feet when we walk to know that our foot is in a good position to take a step. Any time a ligament is torn or stretched we lose some of our awareness of where the joint is in space. If a ligament is completely torn or stretched we aren’t getting those signals until our joint is potentially already in a bad position. After injury we have to do something to make sure that we re-establish that joint awareness, and that is where Physical Therapy comes in.

How can physical therapy help my child recover from an ankle sprain?

Initial focus in physical therapy will reduce swelling and inflammation with RICE (rest, ice, compression, and elevation), and regaining ROM. While this first phase is very important, the portion of rehab that really helps to prevent recurring injuries is the strengthening and proprioceptive (or balance) training. The balance exercises are the exercises designed to retrain joint position awareness by training the muscles to recognize and stabilize where our joint is in space. The balance and strengthening exercises are what will truly help a patient return to higher level activities like jumping and cutting in sports.

When do I get help for my child who has an ankle sprain?

• Any time an injury causes notable laxity or instability on exam.
• Any time a patients is unable to walk without pain.
• Any time balance is negatively affected.
• That means grade 2 sprains and above should automatically get help and any grade 1 sprain with balance deficits should also do rehab. If there is ever any doubt, error on the side of caution and contact your physician.

At Cook Children’s, our SPORTS physical therapists are trained in proper rehabilitation of all grades of ankle sprains and work to restore full function and safely guide return to athletic activities. If your child has a history of frequent ankle sprains or you are concerned about risk of future injury, talk to your doctor about a referral to physical therapy.

SPORTS resources

• Ankle sprains
• Top 10 questions parents have about sports injuries
• Injury Prevention Guide
• Strength training in children/adolescents
• Young athlete's injury prevention guide
• Rise of overuse injuries in school-age athletes
• The basics of sports injury prevention for kids
• Preventing children's sports injuries
• Pain that won't go away

Evans is concerned because at Cook Children’s:

• In 2013, there were three motor vehicle crash deaths (compared to 0 in 2012).
• There has been a 10 percent increase in injuries due to unrestrained kids and a 4 percent increase in ejections.

“This is the time of the summer when a lot of families will be traveling on the road,” Evans said. “I’m very concerned about the amount of unrestrained children we are seeing. I would ask all parents to make sure their children are buckled up correctly to prevent a tragedy to their family.”

Graco car seat recall, what you need to know

To see if your model may be covered, or for additional information, call Graco at 1-877-766-7470, or visit www.gracobucklerecall.com, or email consumerservices@gracobaby.com. Sharon Evans, Trauma/Injury Prevention outreach coordinator at Cook Children’s, stresses to parents to register car seats when purchasing them so they will be notified of recalls.

Posture
Posture is often overlooked with athletes. Posture is the result of a balanced muscular system that can control various aspects of timing and force to generate power needed for throwing and hitting. Breakdowns in posture will lead to increases in injury. Good posture is the optimal position for your muscles to work effectively without creating a risk for injury.

It is common for athletes to concentrate on the muscles in their chest and arms, while forgetting about the muscles in their backs. Weakness in your mid and upper back and tightness in the chest leads to the shoulders rounding forward, which puts the rotator cuff muscles around your shoulders in an ineffective and dangerous position. The muscles in a baseball player’s back, along with the rotator cuff, are essential in maintaining control of the shoulder during throwing.  During off days it’s good for all baseball players to strengthen the mid and upper back muscles.

Strength
With throwers, it is important to remember that strength and control in your legs and core are just as important as in your shoulders. Most of the power for throwing begins in your legs and core. By improving your core strength and activation you can throw harder without your shoulder and arm working harder. Working on your strength in your core and legs on off days will help you with performance and lower the risk of injury.  Flexibility in your hips and legs allows them to use their available strength.

Warm-ups
Before games use active warm-ups to prepare the muscles in both your arms and legs for the stresses of a baseball game. After the game always stretch your calves, hamstrings, quadriceps, hips, shoulder internal rotation and shoulder cross body adduction to prevent loss of motion. Remember that post-game stretches should be held for 30 seconds and should be steady with no bouncing.

Pitch counts
Pitch counts are an important way to prevent injury in pitchers. It’s important to note that increased performance and speed of pitching, actually increases the stress put on the body of a pitcher. Every pitch puts small amounts of damage on the elbow and shoulder. The body needs time to be able to heal this damage. I am not advocating that pitchers should not throw to their full potential. However, they should not pitch too much during a game or too frequently without adequate rest days. The following pitch counts are recommended by the American Academy of Orthopedic Surgery:

• 8-10 year olds - 50 pitches/game, 75 pitches/week
• 11-12 year olds - 75 pitches/game, 100 pitches/week
• 13-14 year olds - 75 pitches/game, 125 pitches/week
• 15-16 year olds - 90 pitches/game, 150/160 pitches/week
• 17/18 year olds - 105 pitches/game, 150-160 pitchesweek

The more times a baseball player pitches in a single game, the longer the player should rest. While resting from pitching, baseball players should not play catcher. The two players that throw the most during a baseball game are pitchers and catchers, and for both positions, the most important component of healing is the rest time.

Throwing technique
Pitch counts are not the only reason that pitchers should stop pitching during a game. With youth pitchers, throwing form is a huge factor in preventing injuries. Throwing form should not suffer from fatigue. When pitchers start to sacrifice form, they should be taken out of the game and rested. Common issues that arise from fatigue are dropping the elbow, leaning away from the throwing arm and the elbow lagging behind the shoulder. Quality pitching coaches are important to establishing good throwing form. Safety should always be the number one priority, when deciding between keeping a player in the game and resting them.