Correspondence

Firearm Violence Among Youth

David E Davies, MD

Martin L Fackler, MD

Reply

Elizabeth C Powell, MD

Karen M 5heehan, MD, MPH

Katherine Kaufer Christoffel, MD, MPH

Scombroid Poisoning Revisited

Menty Downs, MD

Roland B Clark, MD

Reply

Joan McInerney, MD

Mechanical Hyperinflation and PEA

M Neville Pohl, MD

Cross-Gender Violence

Donald Vasquez, DO

Robert E Falcon< MD

Copy@t © by the American College of Emergency Physicians.

Firearm Violence Among Youth To the Editor:

Any emergency physician who has had the heartrending task of informing a mother that her teenage son has died of gunshot wounds could not help applauding the recently pub- lished call by Powell et al for a firearm injury tracking system [August 1996;28:204-212] to study the mayhem that rolls through our emer- gency department doors daily.

As the authors note in their Figure 3, the vari- ables of the firearms-violence equation are many leg, characteristics of the injury event, victim-offender relationshi p , geography). Col- lection of data on "firearm type.., ammunition used" for the proposed firearm violence track- ing system may be difficult unless law enforce- ment actually recovers the weapon used to inflict the injury. Without the weapon, infer- ences would have to be drawn from the wound's characteristics. This practice is highly unreliable. 1 One important factor not clearly mentioned is gang affiliation. Did the injury event involve a gang member as "victim" or "offender?" Was the "victim" caught in a gun- fire exchange between rivals on gang turf?

Was the "victim" residing with someone affil- iated with a gang? Perhaps a more inclusive approach would be to study blunt as well as firearm violence by expanding the "firearm type, make.., ammunition used" data field to "weapon" and subcategorizing types.

The authors thoroughly list the myriad legis- lative and educational remedies that have been proposed to solve the epidemic of violence. Persons younger than 18 years have been pro- hibited from buying firearms for years, and in California and New York (for example)only persons older than 21 years may purchase handguns legally. Because such purchases are already illegal, further legislation prohibiting gun ownership by persons younger than 21 years would be meaningless.

Visual emphasis that "firearm violence is a public health emergency unique to the United States" was provided by the authors in their Figure 1. Subsequent implications about the presence of firearms in the home being unique to the United States and causal with respect to violence are tenuous. Members of the mili- tary in Switzerland and Israel maintain their duty weapons at home as a component of mili- tary readiness. These military-issue weapons have greater lethal potential than our "store- bought" firearms in the United States, yet the

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CORRESPONDENCE

homicide rates in these countries are negligible. Clearly we do not fully understand the violence equation.

Education has been overlooked as a remedy for firearms violence. The medical community has worked wonders in publicizing the dangers of tobacco, the danger of mixing alcohol and driving, and "unsafe sex" as a risk factor for sexually transmitted disease. Universal precau- tions have become commonplace in prehospital and hospital practice to reduce the risk of bloodborne pathogens. "Universal precautions" for firearms have existed for years as well: (1) Every firearm should be considered loaded and ready to fire until proved otherwise, (2)never point a firearm at anything you do not intend to kill, and (3) no firearm can be presumed safe until it is opened and demonstrated to be empty of ammunition. Although I don't advocate teaching the last precaution to personnel out- side the military and law enforcement, we must teach the first two to all citizens. We teach our children how to safely cross the street, how to say no to drugs, and to beware of strangers. We need to add, "Don't touch guns." The pro- found curiosity of children and their need to be taught survival skills must become everyone's responsibility.

The authors open their article with eyecatch- ing statistics about the scope of the effect of firearms violence on our "children and adoles- cents;" however, the data presented are strati- fied such that the oldest group comprises persons aged 15 to I9 years. The inclusion of 18- and 19-year-old adults (in the legal sense) may skew interpretation of these data. Eighty- six percent of the homicide deaths and 88% of the suicide deaths listed in the authors' Table 1 involved members of this oldest stra- tum; how many occurred in the 15- to 17-year- old subgroup and how many actually involved "adults?" Until the American College of Emer- gency Physicians adopts a standard violence reporting system with carefully defined data fields such as that suggested by the authors, we cannot effectively study violence, whatever its cause.

David E Davies, MD Department of Emergency Medicine Naval Medical Center San Diego, California

1. Fackler ML: Gunshot wound review. Ann Emerg Med August 1996;28:I94-203.

To the Editor:

In their recent Annals article, Powell et al mis- represented and distorted the problem and pro- posed unsound solutions.

The authors used "child" falsely to represent their entire sample. In common usage, and according to standard reference works 1, only the two youngest age groups listed by Powell et al in their Table 1 are children; these groups comprised less than 1/25 of the deaths. Exag- gerating the number of "children" killed in- creases emotional impact and is a common propaganda ploy by antigun political activists.

Powell et al also followed the customs of some public health physicians by adding sui- cides and justified homicides to inflate their death statistics. The problem of firearm vio- lence in the United States is one of felonious homicides.

The authors cited a series (their reference 11 ) comprising subjects aged younger than 17 years (despite a median age of 15.8 years, the entire group is referred to as "children"). In this series it was reported that slightly more than half of those killed or wounded were shot by a "friend, acquaintance, or family member" (one wonders whether members of opposing gangs and drug-trade rivals were included as acquaintances). They purport to have gotten this information from the victims (one wonders about drive-by shootings and victims who died at the scene). No method of verifying this infor- mation was mentioned. Anyone who has been involved in law enforcement or the forensic aspects of shootings knows that, more often than not, victims falsify the circumstances sur- rounding a shooting. This same false interpre- tation was used by the dean of the Harvard School of Public Health to deny that the illicit drug trade is a major cause of firearm-related deaths2; she stated that most such deaths were the result of disputes between family members, friends, and neighbors.

When political correctness and emotional bias are put aside and the violence problem examined rationally, it is clear that firearm- related deaths are largely the direct result of the illicit drug trade and crime. McGonigal et al 3 noted in their study of firearm-related deaths in the US urban population, "Overall, 84% of firearm deaths in 1990 had antemortem drug use or criminal history. "3 In reference 11 cited by Powell et ai it was also noted that 75% of perpetrators had criminal records; one sus-

pects this percentage is an underestimate be- cause the criminal records of juvenile offenders are usually sealed.

The solution promoted by Powell et al, re- duced access to handguns, would reduce ac- cess only among honest citizens, leaving them more vulnerable to assaults by criminals, on whom legislative efforts to limit firearms have no effect. Increased availability of permits for honest and productive members of society to carry concealed handguns has been shown to reduce firearm-related violence and deaths, as well as rapes and other crimes. 4

Under their heading "Public Health Ap- proach," Powell et al revealed that they lack knowledge on basic wound ballistics. When they wrote, "Even if the number of violent events remained unchanged, reduced access to handguns would decrease the lethality of violence . . . . "they apparently did not realize that most of the shotguns and rifles that would be substituted for handguns are far more lethal than handguns. The authors demonstrated fur- ther that they sorely need the advice and guid- ance of someone conversant with wound ballistics in their other suggestions for reducing firearm lethality such as ammunition modifica- tion and regulation of the bullet-manufacturing process. They apparently have never heard of handloading and do not appear to understand that firearms need to be lethal for many valid, necessary, and legal purposes.

Pewell et al have completely ignored the positive use of firearms in the prevention of deaths and other crimes. They have completely ignored the fact that legislative attempts to restrict firearms have more often than not re- sulted in huge promotion of their sales (such as that which occurred after the California "assault rifle" frenzy in the early 1990s). It is distressing to find in the references cited by Powell et al 34 that include authors whose work has been found, on scholarly review, to lack the tenets of science and scholarship. 3,5

Firearm-related injuries and deaths in the United States are a serious problem that must be analyzed honestly by researchers with the scientific training and integrity to rise above emotional bias and to rationally consider all the facts on both sides of the issue.

Martin L Fackler, MD President, International Wound Ballistics

Association

MARCH 1997 29:3 ANNALS OF EMERGENCY MEDICINE 42 5

CORRESPONDENCE

1. Dorland's Illustrated Medical Dictionary, ed 27. PhiIadelphia: Saunders, •988. 2. Dr Deborah Prothrow-Stith, Face the Nation, January 2, 1994. 3. Kates DB, Schaffer HE, Lattimer JK, et at: Guns and public health: Epidemic of violence or pandemic of propa- ganda? Tenn Law Rev 1995;62:513-596. 4. Lott dR Jr: More guns, less violent crime. Wall Street Journal August 28, 1996:A13. 5. Surer EA: Guns in the medical literature: A failure o.f peer review. J Med Assoc Ga 1994;83:133-148.

In roof)/'.

Dr Fackler raises many objections to our article. We would like to address a few of the more substantive points.

(1) He believes we misrepresented the prob- lem of firearm violence among youth because we used the word "child." As pediatricians we relearn daily the fact that a particular teen age and an adult body do not make an adolescent a citizen with mature knowledge, experience, or judgment. Nonetheless, in the manuscript we used the terms "child," "children and ado- lescents," "adolescents," and "youth;" to limit confusion we stated specific ages in many places in the text and provided tabular firearm death data by age.

(2) He believes our inclusion of suicide and unintentional firearm deaths (as well as firearm homicides by age)is misleading. Most readers will understand that we do not include suicide to "inflate death statistics." Rather, we present the data on all types of firearm deaths to pro- vide a full picture of this epidemic.

(3) He challenges the validity of the methods and results of a series we reference, under- scoring that there is much that we still must learn about the circumstances of all firearm deaths and injuries. Along the same lines, the information he implicitly seeks on the propor- tion of firearm injury victims aged 19 years and younger with a drug or criminal history is not yet well studied.

(4) He suggests that the only victims of gun death and injury are "bad guys," ignoring the important and recognized roles of anger, de- pression, fear, and happenstance in these events.

(5) He cites a recent study that suggests that carrying a concealed weapon reduces the inci- dence of violence and death from firearms. 1 This study has been heavily criticized for its methodologic flaws, which include use of sta- tistical techniques that assume data used in the study (such as crime rates in consecutive years or in adjacent counties) are not related

to each other, use of arrest rates to predict crime rates, and failure to use appropriate anal- ytic techniques that would allow true effect of the law to be distinguished from an expected downward drift toward average levels. 2,3

(6) He leaps to the conclusion that "reduced access to handguns" will inevitably mean in- creases in use of other firearms. The differ- ences between handguns and long guns are many (eg, purpose for ownership, storage habits, size), and these differences likely ex- plain why handguns are overrepresented in firearm deaths and injuries. It seems to us that small, easily hidden handguns are not likely to be replaced by rifles and shotguns; clearly such replacement is not certain to occur.

Dr Davis raises a different set of issues. (1) He cites international differences in gun

injury and claims that these occur despite com- parable handgun access. We do not believe this is true. 4 Furthermore, because guns turn volatile situations lethal, the international dif- ferences in social problems and violence con- found any gun-access effect.

(2) We agree with Dr Davis that it is useful to know whether an injury event is gang re- lated (as shown in our Figure 3).

(3) We also agree that education is a key intervention in reducing firearm violence; such interventions must be evaluated.

(4) Dr Davis is concerned that the inclusion of 18- and 19-year-olds skews the data. We believe their experience is part of the problem we described. We used standard National Center for Health Statistics age groupings for ease of presentation. (5)We welcome Dr Davis' support for systematic tracking of critical data on the US handgun epidemic.

Elizabeth C Powell, AdD Karen M Sheehan, MD, MPH Katherine Kaufer Christoffel, MD, MPH Children's Memorial Hospital Chicago, Illinois

1. Lott JR Jr, Mustard DB: Crime, deterrence, and right-to- carry concealed handguns. J Legal Stud, in press. 2. Ludwig J: "Crime, Deterrence, and Right-to-Carry Concealed Handguns": A Critique. Washington DC: Georgetown University Graduate Public Policy Program, August 1996. 3. Critical Commentary on a Paper by Lott and Mustard. Baltimore: Johns Hopkins Center for Gun Policy and Research, School of Public Health, August 1996. 4. Killtas M: International correlations between gun owner- ship and rates of homicide and suicide. Can Med Assoc J 1993;148:1721-I 725.

Scombroid Poisoning Revisited To the Editor.

I practice emergency medicine in a region where fresh fish is a dietary staple and have had occasion to treat several cases of scom- broid poisoning. In these cases I have not encountered the vision loss described by Mclnerney et al [August 1996;28:235-238], and I enjoyed and appreciated their report.

However, the authors omitted a key part of the treatment of scombroid poisoning: ipecac- induced emesis. They note that their patient was seen 3.5 hours after ingestion of the fish and its toxin. Although I am not sure at what point after ingestion emesis should be con- sidered ineffective or not indicated, in my ex- perience it would still be effective 3.5 hours after ingestion.

I have observed the bright red rash and headache disappear as the patient is vomiting. This unpleasant but often effective treatment is also rewarding for the physician, who knows that continued absorption of the toxin is minimized.

in other cases, severe headache can persist for 3 or 4 days after ingestion; continued treat- ment with an H 2 blocker can ameliorate this problem.

Monty Downs, MD Kauai, Hawafi

To the Editor:

I found the recent case report by Mclnerney et al on scombroid poisoning to be an intriguing discussion of unusual ocular and cardiac mani- festations of this toxidrome. However, the arti- cle gave rise to three questions.

First, the authors noted that the patient sub- jectively reported his vision to be reduced to the point where he " . , , suddenly could no longer see except for shadows." Objective ex- amination revealed " . . . bare hand motion in both eyes." Yet the examiner reported the pupils to be " . . . reactive to light and accom- modation . . . " How could accommodation be tested adequately when visual acuity was re- duced to near-blindness?

Second, the authors discuss the possible neuroanatomic sites of lesions that could cause transient near-blindness, including the retina and optic nerve. Why are prechiasmal lesions

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