Gun control: A simple answer to the wrong question

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anterior axillary line with multiple surrounding excoriations. Breath sounds were reported as equally bilateral by both the emergency physician and surgical consultant. There were multiple bites to the upper extremities without neurovascular deficit. The remainder of the examination was normal. The patient was placed on a cardiac monitor, an intravenous (IV) line of normal saline was established, and supplemental oxygen administered via nasal canula. The patient was given a tetanus booster, morphine sulfate, and IV cefazolin. Blood was typed and cross-matched, and a manual spun hematocrit was determined to be 37%. During the ED course, the patient began to complain of difficulty breathing and shortness of breath. A portable AP chest x-ray was obtained and showed a right-sided pneumothorax. The patient’s symptoms subsided after the uncomplicated placement of a 36-F chest tube. The patient was admitted to the general surgical service. A normal carotid angiogram was performed to evaluate his neck hematoma. Otolaryngological consultation was obtained for repair of his facial lacerations. The chest tube was removed on hospital day 3, and the patient was discharged after 4 days of IV antibiotics and initiation of rabies prophylaxis. At follow-up clinic appointments, the patient was completely asymptomatic, repeat chest x-rays were normal, and the rabies vaccinations were completed. Reports of fatal and near-fatal dog bites show that patients younger than 10 years of age are most at risk.4*5.7Lethal bites are predominantly to the head and neck, and the listed cause of death is most frequently hemorrhage, lacerations, punctures, or “unknown.“‘*’ Pneumothorax has never been reported secondary to a dog bite, and is a possible cause of death in dog bite injuries. The importance of a complete evaluation and reassessment of seemingly minor penetrating chest and zone I and 2 neck injuries is illustrated by this case. Auscultation may be an unreliable means of diagnosing a pneumothorax, especially in a thin person (caused by transmitted breath sounds from the unaffected lung) in a noisy ED. This patient had minimal symptoms and normal breath sounds bilaterally. The seemingly benign mechanism of injury could have precluded recognition of the pneumothorax. Infants and children are particularly susceptible to pneumothorax secondary to chest injuries and zone 1 neck injuries because the cupola of the lung is superior to the clavicle and there is a relative paucity of subcutaneous tissue and muscle compared with adults. In this patient the diagnosis was made only after the chest x-ray was obtained. Observation and chest x-ray are indicated to rule out a pneumothorax in any nonsuperficial penetrating injury to the chest and zone 1 of the neck before discharge. If initial studies are normal, consideration should be given to obtain expiratory chest x-rays and delayed repeat chest x-rays. This is the first reported case in the western literature of a dog bite resulting in pneumothorax. Dog bites are a major public health problem and fatal cases have been reported. Pneumothorax is a potential cause of morbidity and mortality in dog bites to the neck and chest. FRANTZ MELIO,

MD

Wake Medical Center Raleigh, NC TRACY CONRAD,

MD

University of Southern Los Angeles, CA

California Medical Center

References 1. Beck AM, Loring H, Lockwood R: The ecology of dog bite injury in St Louis, Missouri. Public Health Rep 1975;90:262 2. Underman AE: Bite wounds inflicted by dogs and cats. Vet Clin N Am Small Anim Pratt 1987:17:195-207 3. Winkler WG: Human deaths’induced by dog bites, United States, 1974-1975. Public Health Rep 1977;92:425-429 4. Sacks JJ, Sattin RW, Bonzo SE: Dog bite-related fatalities from 1979 through 1988. JAMA 1989;269:1489-1492 5. Pickney LE, Kennedy LA: Traumatic deaths from dog attacks in the United States. Pediatrics 1982;69:193-196 6. Wright JC: Severe attacks by dogs: Characteristics of the

dogs, the victims, and the attack settings. Public Health Rep 1985;100:55-61 7. Brown PF, Christian LP, Panagiotis SN, et al: Management of the asymptomatic patient with a stab wound to the chest. South Med J 1991;84(5):591-593

GUN CONTROL: A SIMPLE ANSWER TO THE WRONG QUESTION To the Editor:-No one has any need to own a handgun or an assault weapon. Only the police and the Army should have them. We need to ban guns because they are used for nothing but killing people. Such is the incessant banter of the anti-gun groups and some politicians across our country. Assisted by the constant replay of every firearm-related violent crime by every television station that by the 11 PM news we believe we have heard about thousands of dead and wounded. It is no wonder we feel overwhelmed, and that the only answer is in banning all guns? Have we really examined this problem, or have we just jumped on the politically correct bandwagon, because from a medical viewpoint it is easier than trying to explain even a neutral stand on firearms? Do editorials such as “Taking Aim at Firearm Injuries,” which appeared in the March 1993 issue (Vol. 11, No. 2) of The American Journal ofEmergency Medicine give us enough evidence to call on the medical community, and emergency physicians in particular, to advocate the total ban of firearms? The medical community has always required proof of everything presented as fact, and has been suspect of assumptions, or proof by common sense. Why do we assume that because firearms sometimes cause death and injury that they must be banned? Do we have years of statistics and experience that proves that gun control works? Do we have proof that violence is caused by firearms, or are people responsible? Biologically we are the same people today as walked the Earth a thousand years ago. We may well have a technology that is advanced far beyond that period of history, but we have no greater ability to transcend our human emotions or dependencies. We all still have the same limitations. One of those unfortunate limitations is that some of us occasionally lose control, or make conscious decisions to do violence to others for various, and many times, unwarranted reasons. This is the result of our being human, and there is little we can do to avoid it. Many have tried various schemes to limit the violence in our country. They usually involve two methods: (I) threatening to punish criminals and (2) removing firearms from civilians. We say threatening to punish because it is clear criminals are fully aware they are very unlikely to be caught, and even less likely to serve any significant jail time.’ Because criminals are unaffected by our attempts to scare them, and building hundreds of additional prisons is politically unpopular, some take the second choice, and attempt to remove or restrict firearms. Toward that end, many politicians, supported in no small degree by the vast majority of the media, have marched a myriad of different gun control schemes onto congressional floors, both federal and state. The failure of these types of laws has been shown many times in the past,’ but because it looks good politically, we find our politicians, and the anti-gun lobby trudging ahead promising that the next law will be the one to show some results. They insist that the 20,000 plus other gun laws already on the books were just not strong enough, even though many are virtual firearms bans like Washington, DC, and New York City.3 Wright, Rossi, and Daly have shown proof that there is no evidence to show that gun control works and that it may cause increases in crime.4 Over the past few years we have seen a number of physicians’ organizations and publications fall in line on the same gun control path. Possibly this is because it is the expected stand from those of us in the medical community. It is very telling, that the positive uses of firearms are totally ignored. If we are to be objective, don’t we have to consider the other side of each issue? Virtually every city that has tried firearm bans or strict restrictions has ended up with massive increases in their violent crime rates?’ Proponents of gun bans have been unable

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to give any example of one city that has seen a decrease in violent crime due to initiating a ban on firearms. It would seem that the following statistics comparing cites with gun bans to those with relative gun availability, support the ownership of firearms as a deterrent to violent crime (Table 1). If we look at the suggested proof that is presented in the editorial by Cheng and Lowe, it can be shown that there are many holes in their evidence. They also totally neglect to consider the positive role of firearms in our society. They point out that more than half of the homicides are caused by firearms, but this also means that nearly half are caused without firearms. Current records also do not distinguish between homicides that are justifiable by honest citizens’ self defense or police intervention; therefore, these figures are very misleading. Clearly, as emergency department personnel we are required to treat patients aggressively regardless of injury source or legality, and this necessarily makes us consider all sources of injury for minimization. However, we must also concede that there are times when self defense is not only permissible but required. If this is so, then we must also accept that until we can change the emotional, sociological, and economic structure of humans, we are forced to accept some number of violent injuries as honest people and police defend themselves against the criminals in our society. The only other choice is to submit to the idea that only honest people are being injured and are dying in our emergency departments. Removing firearms from the hands of honest people would certainly increase the number of honest people being injured, while decreasing the number of criminals hurt. It is very clear that criminals will always have firearms, regardless of the strictness of the laws.6 Their statement that firearms account for more than half of our suicides again is quite misleading. If all firearms were eliminated, the suicide rates would shortly return to the same level. As proof, we need only look at Japan, which has a suicide rate twice that of our country, and firearms are totally banned.’ Suicide rates are not related to firearm availability.8 Suicides represent 54% of all firearm deaths in our country.’ We must be objective enough to admit we have few answers for those with severe depression. A certain percentage of these people, patients or not, will succeed in their attempts at suicide regardless of the availability of any specific means. There are numerous ways to commit suicide detailed in many books available at the nearest bookstore. Since suicides will occur in any case, it is unreasonable to use the availability of firearms as a cause of these deaths. It would seem our national firearms “public health crisis” has just been cut in half. The assertion that firearms in the home are many more times likely to kill friends, or family rather than be used to kill an intruder TABLE1. 1990 FBI Uniform Crime Report Homicide Rates for US Cities per 100,000 Population Cities Tough Washington, DC Detroit Baltimore Newark New York City Chicago Boston Lenient Austin Tucson El Paso Wichita Omaha Colorado Springs

Rate 77.8 65.6 41.4 40.7 30.7 30.6 24.9 9.9 7.4 6.6 5.9 3.3 3.2

is also inaccurate. The Kellerman and Reay’O study has been shown to be flawed in many areas. Its most notable error is the exclusion of all outside home uses, and it ignores all positive uses of firearms that do not result in death. It should be clear that honest people do not intend to kill to defend themselves. To consider that all legitimate uses of firearms for self defense will end in death is very unrealistic. The investigators give the estimate of 180 to 200 million firearms in our country, and that fully half of American households have weapons.“-‘* If one adds all firearm deaths known in our country, whether accidental, homicide, suicide, or legal intervention by police or honest citizens you end up with about 36,073 according to the most recent information for 1991 from the National Health Center. Considering the 200,000,000 firearms kept in private hands that means only 0.018% were used for killing. (If we deduct those suicides we know will occur regardless of firearms we have with less than 0.009%). Consequently, this means that miraculously 99.99% of all firearms are owned without any danger of killing anyone in any particular year. We submit that if we had such a good result with any medication or procedure available to us lo tight disease we would be delighted. Obviously, although misuse of firearms is certainly a problem, it is far from being the “public health crisis” the authors contend. It is also obvious that the mere availability of firearms does not cause any violence to erupt automatically from its owner. Even if one multiplies the percentage of firearm deaths (.009%) by a factor of 10 to represent possible injury resulting from firearms, it would not approach 1% of those firearms in our country. Considering that the authors invoked the “common sense” argument, we will do the same in saying that it is common sense that criminals do not, and never will obey any gun bans,6 and thus will always be a source of firearm injury and death to our citizens. We submit that if violence from firearms is inevitable, then we would rather treat the wounded criminals in our emergency departments, than the wounded and dying honest citizens that would result if honest people are disarmed. The authors quote Freedman, in that there are three mechanisms of increasing violence due to the availability of guns: (1) guns instigate violence, (2) guns facilitate violence, and (3) guns intensify violence. I3 Guns are more likely to cause the avoidance of violence by concluding attacks without a shot being fired. Honest people are not quick to kill, they just want to be left alone, and they use their firearms only to that end. If an attack can be stopped by showing a firearm, or just shooting into the ground they will gladly do so to avoid killing. They are not so foolish as to think their use of a firearm will not be closely scrutinized by the authorities, and that they are at risk if that use is not justifiable. The public, however, will never hear of these cases because the media deems them uninteresting-no one was killed. Just as NBC made up a study concerning the GM trucks, “news” stories need not be true to be seen on our major networks. Professor Kleck, an admitted anti-gun liberal, has completed the most timely, and detailed study of gun control. It has become the standard of legitimate firearm research. He has found that at least 645,000 times a year a handgun alone is used to protect the lives of innocent people, and when long guns are included the number exceeds 1 million.5 Professor Kleck estimates that 95% of these episodes never require the weapon to be fired. As a result these episodes will never be seen on any records kept by police.5 Firearms do not instigate, facilitate, or intensify violence-people do. Regardless of the availability of firearms, these actions still occur. Whether with baseball bats, knives, fists, or feet they still occur. If one truly wishes to assign these qualities to firearms, then we must also say that firearms instigate, facilitate, and intensify-self defense. The authors quote another study that purports that the restrictions put in place in Washington, DC caused “. . a prompt decline in homicides, and suicides by firearms. .” Do we seriously believe that the murder capitol has seen a prompt decrease in violence? FBI Unified Crime Reports for 1991 disagree, as shown in Table 2. Perhaps, the authors picked rates from 1984 and 1985 for their example. but I think the pattern clearly shows a dramatic increase in

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TABLE2. Violent Crime Rates per 100,000 in the District of Columbia

Year

Violent Crime

Homicide

Rape

Robbery

Assault

1991 1990 1989 1988 1987 1986 1985 1984 1983

2453.3 2458.2 2141.9 1921.6 1610.3 1505.3 1626.0 1799.8 1985.4

80.6 77.8 71.9 59.5 36.2 31.0 23.5 28.6 29.4

35.8 49.9 30.8 26.6 39.4 52.4 53.8 63.7 69.5

1215.6 1213.5 1083.1 917.7 717.4 754.0 836.4 1014.3 1275.9

1121.4 1117.0 956.1 917.7 817.4 667.9 712.3 693.3 610.6

homicides after gun control began. Early estimates for 1992 give a homicide rate of 88/100,000. This points toward the success of banning guns? The authors do note some answers to the problem of gun violence that are worth while, but they do not go far enough. To suggest that physicians should inform their patients about the dangers of firearm ownership is reasonable, but if the patient intends to keep the lirearm, are we doing our job if we fail to inquire if they have taken a safety course, and do we refer them to qualified instructors? It would be even better to call for every school in our country to have mandatory firearm safety classes. Regardless of your stand on tirearm ownership, firearms are a fact of life in our country. We have, for far too long, ignored the needs of our children in this area. We teach them how to avoid drugs, and how to use a condom, but we ignore giving them any information on being safe around firearms, possibly in (as stated by the authors) 50% of the homes in America. Education does not need to promote one side or the other. Not to call for this instruction is neglecting a true method to limit firearm accidents, and possibly to instill enough knowledge in our children to allow them to understand that the violence on television does not represent acceptable behavior. We can not afford to let our children learn their safety habits from television, whether it concerns drugs, sex, or firearms. Stem calls on the media as a whole to clean up their programming are obligatory on us all. Why do we assume that because firearms sometimes cause death, and injury, that they must be banned? If a surgical procedure has a mortality rate of 3%. but is beneficial in decreasing morbidity and mortality of a certain disease, it is likely to be continually used until a better procedure is found. Can we not also say that firearms, although causing some tragic deaths, often result in decreased morbidity and mortality of the honest citizen. Indeed, the available statistics, even from present anti-gun researchers strongly suggest the benefits of firearm ownership far outweigh the risks.5 In summary, the factors surrounding the ownership of firearms in our country are much more intricate than the simple notion that they have no purpose but to kill. The vast majority of legitimate researchers have shown that gun control does not work.’ Many previously enamored of gun control, such as Wright et al, have reversed their position on its effectiveness.3 We can acknowledge that we have a problem with criminal homicide, suicides, and accidents, (legal intervention and self defense stop with the preceding); however, there is no significant evidence that the damage done by owning firearms outweighs the benefits4 Indeed, it would seem that there is much evidence to support the ownership of firearms as a significant deterrent to violence, and a much higher benefit than a risk to our society. The body of verifiable research supporting the firearm as a positive influence in our society is much greater than any that supports their ban. If we are to find the true cost of firearms in our society, we must consider both sides of this question. For every criminal that uses a firearm, there are hundreds of honest people who use tirearms for self defense.’ We all realize that our patient populations include

both the honest and the criminal. If we direct our efforts at control of firearms instead of controlling the criminals we will end up disarming the honest citizen, who are the majority of our patients. As medical professionals, we cannot be responsible for illegal actions by patients who may be criminals. We also can not prevent their injury and deaths. Shortsighted evaluations of the role of firearms in our country without close attention to the fact that they are used for many legitimate purposes leads us to prescribe for a minor symptom rather than effect a cure. As Centerwall commented on his research, “If you are surprised by my findings, so am I. I did not begin this research with any intent to exonerate handguns, but there it is-a negative finding, to be sure, but a negative finding is nevertheless a positive contribution. It directs us where not to aim public health resources.“i4 We have a responsibility to our patients, and our various communities to endorse actions that will enhance the public health. As responsible medical care providers, can you really put your credibility on the line by supporting gun control? The answer is in criminal control. It is a lot more difficult, but less expensive in terms of lives, disability, and expense, than trying to implement firearm restrictions and bans which will only adversely affect our honest patients.

GARY R. BATOK,MD, JAMESF.SCOTT,PA-C References 1. Reynolds M: Why Does Crime Pay? Dallas, TX, National Center for Policy Analysis, 1991 2. Kates DB (ed): Firearms and Violence: Issues of Public Policy 3. Wright, Rossi, Daly: Report for the National Institute of Justice. 1982 4. Wright, Rossi, Daly: Under the Gun: Weapons, Crime, and Violence in America. Aldine de Gryter, 5. Kleck G: FBI 1990 Uniform Crime Reports. Point Blank: Guns and Violence in America. Aldine de Gruyter, 1991 6. Armed and Dangerous: A Survey of Felons and Their Firearms. Aldine de Gruyter, 1986 7. National Rifle Association Firearms Fact Book, ed 3. 1993 8. Newton G, Zimring F: Firearms and Violence in American Life. Washington, DC, Government Printing Office, 1969 9. Accident Facts: 1991. Washington, DC, National Safety Council, 0000 10. Kellerman AL, Reay DT: Protection or peril? N Engl J Med, 1986 11. Alviani JD, Drake WR, Karline MD: Handgun control issues and alternatives. 1983 12. NRA Fact Card. Washington, DC, Institute for Legislative Action, 1986 13. Freedmand W: The Privilege to Keep and Bear Arms: The Second Amendment and its Interpretation. 1989 14. Centerwall: Homicide and the prevalence of handguns: Canada and the United States, 1976 to 1980. Am J Epidemiol 134:1245-1265 The authors rep/y:-Thank you for the opportunity to respond to the letter by Scott and Batok addressing our editorial “Taking Aim at Firearm Injuries,” which appeared in the March 1993 issue of The American Journal of Emergency Medicine. We feel that they misunderstand or misrepresent our argument on several counts. Most importantly, we do not suggest that gun control be viewed as a panacea or a step to be taken in isolation. Quite the contrary, we explicitly call for an integrated strategy for dealing with gun-related violence, supported by education, research, and a shift in social attitudes, as well as gun-control legislation. Admittedly, gun control only speaks to the supply side of a complex problem driven by factors of both supply and demand. This does not mean that supplyside restrictions cannot be effective, particularly when used in conjunction with efforts that address the root causes of rampant vio-