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PED-EM-L  February 2018

PED-EM-L February 2018

Subject:

Re: PED-EM-L Digest - 18 Feb 2018 to 19 Feb 2018 - Special issue (#2018-42)

From:

"Chen, Lei" <[log in to unmask]>

Reply-To:

Chen, Lei

Date:

Tue, 20 Feb 2018 04:48:04 +0000

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (1 lines)

I love buckyballs. I believe I am entitled to own buckyballs. I believe they have educational and entertainment values. I believe I am a responsible owner of buckyballs.

What about others? Well, some others stockpile them, and may even misuse them, to the harm of themselves and others. Each year buckyballs cause 13,000 to 15,000 deaths in the US.

When I am out of the country people always ask me to explain two things when they find out that I am American. "What's it with Trump and buckyballs?" With regard to Trump I tell them to read JD Vance's book.

Members of this listserv know what happened with the buckyballs.



Lei Chen, MD MHS

Associate Professor of Pediatrics
Section of Emergency Medicine
Department of Pediatrics
Faculty, Global Health Initiative
Yale University School of Medicine


________________________________
From: Pediatric Emergency Medicine Discussion List <[log in to unmask]> on behalf of Martin Herman <[log in to unmask]>
Sent: Monday, February 19, 2018 2:43 PM
To: [log in to unmask]
Subject: Re: PED-EM-L Digest - 18 Feb 2018 to 19 Feb 2018 - Special issue (#2018-42)

so glad I stopped sending my money to this left ist organization.





there are mean people in this world.

they do bad things



you can’t legislate bad things away



want to do something to prevent school shootings?



Try finding those kids in your community that are being bullied and help them!



do something to prevent gangs.



let me defend myself, my family and home as I see fit. you aren’t going to help me if I am mugged, you aren’t going to be there if my home is invaded, and the police won’t be able to help for at least 6-7 minutes, if I can make the call.



doubt me? call 911 and see how long it takes to get through the questions and then get a car to your home. a lot of bad things can happen in the time it takes to get help.



btw, assault weapons are already banned.



Focus on mental health, finding those who are abused, bullied, marginalized and those who are deranged. they live among us, find them!









[X]



Martin (Marty) Herman

USAPA Ambassador for Pickleball , North Mississippi.

Tupelo Pickleball ( facebook)

[log in to unmask]<mailto:[log in to unmask]>

901 219 9202

Sent from my iPhone





On Feb 19, 2018, at 10:03 AM, PED-EM-L automatic digest system <[log in to unmask]<mailto:[log in to unmask]>> wrote:



There are 4 messages totaling 10581 lines in this issue.



Topics in this special issue:



1. School shootings.......

2. PED-EM-L Digest - 17 Feb 2018 to 18 Feb 2018 (#2018-41) (3)



For more information, send mail to [log in to unmask]<mailto:[log in to unmask]> with the message: info PED-EM-L

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----------------------------------------------------------------------



Date: Sun, 18 Feb 2018 22:08:25 -0700

From: Julian Orenstein <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: School shootings.......



Exactly, Jill. The anti-gun movement needs a Lincoln, a King.... and if I had my wish it’d be for Obama. Either one of them.



Jb0





On Feb 18, 2018, at 6:03 PM, Jill C Obremskey <[log in to unmask]<mailto:[log in to unmask]>> wrote:



Great discussion but what are WE going to do about it as an organization?

How do we become relentless about the need for gun control, the need for mental health services, and for preventing toxic stress in children.



We need to ask leaders in the AAP and AAEM to organize us into a uniified voice that will not quit.



On February 18, 2018 at 5:05 PM "Chamberlain, James" <[log in to unmask]<mailto:[log in to unmask]>> wrote:





I'd be happy with sensible regulations, required training, and licensure so that guns don't get into the hands of criminals and people with mental illness.



But the NRA is against sensible regulations.







Sent from my Verizon, Samsung Galaxy smartphone





-------- Original message --------

From: Robert Finkelstein <[log in to unmask]<mailto:[log in to unmask]>>

Date: 2/18/18 12:17 (GMT-05:00)

To: [log in to unmask]<mailto:[log in to unmask]>

Subject: Re: School shootings.......



Just because people will find a way to break laws does not mean that we shouldn’t have them. By that logic, we expect that all of us who are currently law abiding don’t need any laws to make us so. Human nature being what it is, we all need laws and structure. Yes, gun regulation would not stop all gun violence, but it could reduce it. Also, I don’t think the majority want prohibition of guns, just regulation; the same way alcohol is regulated by age and penalties for driving under the influence. Or, the way cars are regulated with licensing, registration, having to pass a driving test and citations for violations.







On Feb 18, 2018, at 8:42 AM, Horst D. Weinberg, MD <[log in to unmask]<mailto:[log in to unmask]>> wrote:







Yes, automatic weapons should be banned by our government, but most of the discussions posted blame the guns, the NRA, the 2nd amendment and our 'laws'. Nobody gets to the meat of the matter: If there is a demand (for guns), regardless of the laws passed, someone will fill that demand. This is no different from Prohibition, where there was no shortage of available booze or the 'war' on drugs, where you can get them at most street corners in any city. What needs to change: There has been a steady decline over the past 20 or so years in our country's moral fiber, personal and work ethic, and yes, child rearing. Cause: unmarried or one parent families, poverty, and absence of any discipline both in the home and in the schools, for 'political correctness'. Parents want to be friends with their children rather than running their homes like 'benevolent dictator ships'. Nothing is denied the child: the child wants $150.00 sneakers or a new cell-phone: no problem. So you can blame the gun all you want, but unless there is a real change in the populations personal morality and ethics, these school tragedies will continue.



We pediatricians should look at our own practices in teaching good child rearing ways to the families we serve. Horst D. Weinberg, MD



















For more information, send mail to [log in to unmask]<mailto:[log in to unmask]> with the message: info PED-EM-L



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------------------------------



Date: Mon, 19 Feb 2018 09:25:18 -0500

From: Mick Work <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: PED-EM-L Digest - 17 Feb 2018 to 18 Feb 2018 (#2018-41)



https://urldefense.proofpoint.com/v2/url?u=http-3A__apps.chicagotribune.com_news_local_young-5Fvictims_&d=DwIGaQ&c=cjytLXgP8ixuoHflwc-poQ&r=iiLqIGJPj43rFwhy0umXiLW2YeM4w7OHtbhTpnjKXBI&m=t48oRvjGz5SVTSWYDRNskNM83f8PFATlPgGDaXkwwFA&s=X2M--MDdYYwsGrfHTv88WzYo6_er5JmsO6XsSZCiN0o&e=



10x the number of kids dying and they have stricter gun laws. Why do these deaths draw so little attention? Yet suburban school shootings and the shooter gets major coverage.



Is the media effectively and wisely moving public opinion around guns or opioids etc or is it about reaction and ratings?



The government can’t solve issues any more than the c-suite can claim to provide better care in hospitals through policy alone. Just my opinion.



Real solutions won’t come from laws or policy especially from those distant from the problem and solely developed to satisfy media hype or check a regulatory box.







Mick Connors







On Feb 19, 2018, at 12:00 AM, PED-EM-L automatic digest system <[log in to unmask]<mailto:[log in to unmask]>> wrote:



There are 17 messages totaling 3381 lines in this issue.



Topics of the day:



1. School shootings....... (4)

2. PED-EM-L Digest - 15 Feb 2018 to 16 Feb 2018 (#2018-39) (3)

3. The shooting in Florida (9)

4. A second, more settled, reflection on the Florida shooting



For more information, send mail to [log in to unmask]<mailto:[log in to unmask]> with the message: info PED-EM-L

The URL for the PED-EM-L Web Page is:

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----------------------------------------------------------------------



Date: Sat, 17 Feb 2018 21:57:25 -0500

From: "Horst D. Weinberg, MD"

<[log in to unmask]<mailto:[log in to unmask]>>

Subject: School shootings.......



Yes, automatic weapons should be banned by our government, but most of the discussions posted blame the guns, the NRA, the 2nd amendment and our 'laws'. Nobody gets to the meat of the matter: If there is a demand (for guns), regardless of the laws passed, someone will fill that demand. This is no different from Prohibition, where there was no shortage of available booze or the 'war' on drugs, where you can get them at most street corners in any city. What needs to change: There has been a steady decline over the past 20 or so years in our country's moral fiber, personal and work ethic, and yes, child rearing. Cause: unmarried or one parent families, poverty, and absence of any discipline both in the home and in the schools, for 'political correctness'. Parents want to be friends with their children rather than running their homes like 'benevolent dictator ships'. Nothing is denied the child: the child wants $150.00 sneakers or a new cell-phone: no problem. So you can blame the gun all you want, but unless there is a real change in the populations personal morality and ethics, these school tragedies will continue.

We pediatricians should look at our own practices in teaching good child rearing ways to the families we serve. Horst D. Weinberg, MD









For more information, send mail to [log in to unmask]<mailto:[log in to unmask]> with the message: info PED-EM-L

The URL for the PED-EM-L Web Page is:

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------------------------------



Date: Sun, 18 Feb 2018 06:13:44 -0500

From: Mick Work <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: PED-EM-L Digest - 15 Feb 2018 to 16 Feb 2018 (#2018-39)



I respect the need for debate around guns. However, I think we are remiss as pediatric emergency physicians to not raise a deeper discussion around the mental illness crisis.



We all see kids who meet this persons profile across the country. We see disturbing mental illness and the many factors (including social media, broken families, child abuse) that lead a child to buy a gun to do harm. Or if not gun an explosive device etc..



We see kids who are socially isolated and warning signs ignored. Anyone else concerned that the kids we see with mental illness are recognized by schools or pediatric visit screening more often than by their own parents, friends or neighbors.



This persons desire to be a “school shooter” should raise attention around how the media covers these events. The fame brought to these shooters should be called into question. Are we fostering this copycat mentality?



The lack of respect for human life should call us to question more than the how but why.



A focus only on guns and gun laws is remiss to the bigger picture in my opinion and experience.



Mick







On Feb 17, 2018, at 12:01 AM, PED-EM-L automatic digest system <[log in to unmask]<mailto:[log in to unmask]>> wrote:



There are 4 messages totaling 391 lines in this issue.



Topics of the day:



1. Peds EM talk (2)

2. Bacterial meningitis

3. The shooting in Florida



For more information, send mail to [log in to unmask]<mailto:[log in to unmask]> with the message: info PED-EM-L

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----------------------------------------------------------------------



Date: Fri, 16 Feb 2018 11:50:44 -0500

From: Purva Grover <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: Peds EM talk



Thanks all for your help on this.

Best

Purva



Purva Grover , MD

Medical Director

Pediatric Emergency Department

Cleveland Clinic Health System

Email- [log in to unmask]<mailto:[log in to unmask]> <[log in to unmask]<mailto:[log in to unmask]>>g



On Thu, Feb 15, 2018 at 2:18 PM, <[log in to unmask]<mailto:[log in to unmask]>> wrote:



Hi All

I am giving an hour ppt to new PAs on Peds Emergencies. Clearly can not

cover ALL or even most. Any thoughts / talks / power points- you could

share would be appreciated.

Thanks

Purva



Sent from my mobile device



For more information, send mail to [log in to unmask]<mailto:[log in to unmask]> with the message: info PED-EM-L

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------------------------------



Date: Fri, 16 Feb 2018 14:34:20 +0000

From: "Chamberlain, James" <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: Peds EM talk



I would also cover unusual cases that you can't afford to miss, e.g.



Sternoclavicular dislocation

Conjunctivitis caused by penetrating FB

Septic joint presenting with only low-grade fever (we've had several Staph infections where temp was only 37.6 or 37.7 orally)

Myocarditis presenting as wheezing. Remind them that all "bronchiolitis" patients need a through cardiac exam, including distal pulses

NAT

The "sleepy" baby who has hypoglycemia

The "sleepy" baby who has intussusception

The appendicitis patient who presents with vomiting and diarrhea (not all that unusual, actually)

Etc.



To me, this is the challenge of PEM. Finding the needle in the haystack, that one sick kid who is different than all the usual low acuity illness...



Jim



James Chamberlain

Division Chief, Emergency Medicine

Children’s National Health System

(202) 476-4177



-----Original Message-----

From: Pediatric Emergency Medicine Discussion List [mailto:[log in to unmask]] On Behalf Of Mojica, Michael

Sent: Thursday, February 15, 2018 5:29 PM

To: [log in to unmask]<mailto:[log in to unmask]>

Subject: Re: Peds EM talk



Purva







I would recommend "the critically ill infant".







It is the topic that scares the most people and you can cover a lot of causes through cases.







I like to use cases that include common presenting complaints (e.g. vomiting) that are associated with very bad things (e.g. midgut volvulus).







I'm attaching a ppt file for a talk I did a few years ago on this topic.







My goal is for them to develop a mental checklist of potentially life-saving interventions.







Michael







Michael Mojica, M.D



Director of Education, Division of Pediatric Emergency Medicine



Director, Pediatric Emergency Medicine Fellowship



Bellevue Hospital Center



Administration Building Room A528



New York, N.Y. 10016



[log in to unmask]<mailto:[log in to unmask]>



212-562-8147











On 2/15/18, 5:12 PM, "Pediatric Emergency Medicine Discussion List on behalf of Purva Grover" <[log in to unmask]<mailto:[log in to unmask]> on behalf of [log in to unmask]<mailto:[log in to unmask]>> wrote:







Hi All



I am giving an hour ppt to new PAs on Peds Emergencies. Clearly can not cover ALL or even most. Any thoughts / talks / power points- you could share would be appreciated.



Thanks



Purva







Sent from my mobile device



For more information, send mail to [log in to unmask]<mailto:[log in to unmask]> with the message: info PED-EM-L



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------------------------------



Date: Fri, 16 Feb 2018 18:29:38 -0500

From: Aline Baghdassarian <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: Bacterial meningitis



Scott,



Would love to hear more about the cases. How did they present? What was the

decision making process?



Thank you,



Aline



Aline Baghdassarian, MD, MPH, FAAP

Director, Pediatric Emergency Medicine Fellowship Program

Assistant Professor, Department of Emergency Medicine

Virginia Commonwealth University School of Medicine



Children's Hospital of Richmond at VCU

Email [log in to unmask]<mailto:[log in to unmask]>





On Thu, Feb 15, 2018 at 12:40 PM, Julian Orenstein <[log in to unmask]<mailto:[log in to unmask]>>

wrote:



In a recent case at our institution, there was a present but subtle degree

of meningismus — I’ve found over the years there is always some elicitable

sign — but as importantly there’s a degree of irritability or altered

behavior that has everyone concerned: mom, RN’s, me.

If mama ain't happy, I ain't happy. I’ll make liberal use of the term

cerebritis or encephalopathic behavior until there’s a consent signed.



I’m not such a good scientist anymore, but I’ve tried to be an attentive

clinician.



Julian Orenstein





On Feb 14, 2018, at 3:30 PM, JAY FISHER <[log in to unmask]<mailto:[log in to unmask]>> wrote:



Scott - Bacterial meningitis is alive and well here in LV - we have seen

it in a variety of age groups. There is good evidence that there has been

an increase in pneumococcal serotypes not covered by the polyvalent

vaccines since there widespread use, such that the burden of pneumococcal

meningitis (as opposed to H. flu type b) has not decreased nearly as much.



Brouwer MC, van de Beek D. Epidemiology of community-acquired bacterial

meningitis. Curr Opin Infect Dis. 2018;31(1):78-84.



Also, the absence of meningismus in older kids with bacterial meningitis

is well described and occurs in a substantial subset.



Geiseler J, Nelson, K.E. Bacterial meningitis without clinical signs of

meningeal irritation. . Southern Med J 1982;75(4):448-450.



Much of the data on the sensitivity of the neck exam is of the

retrospective variety. I have only read one really good prospective study

on the sensitivity of PE for bacterial meningitis and it was a single

center variety as I recall.



Walsh-Kelly C, Nelson DB, Smith DS, et al. Clinical predictors of

bacterial versus aseptic meningitis in childhood. Ann Emerg Med.

1992;21(8):910-914.



Tough case.





Jay



Jay D. Fisher MD FAAP FACEP

Medical Director, Pediatric EM

Children's Hospital of Nevada at UMC

Clinical Professor of Emergency Medicine and Pediatrics

UNLV School of Medicine

















On February 14, 2018 at 4:18 PM "Conners, Gregory, P" <

[log in to unmask]<mailto:[log in to unmask]>> wrote:





I shared this with our ID director (Dr. Mary Anne Jackson), who pointed

out that bacterial meningitis appears at this time of year as a

complication of influenza:

"Both pneumococcal and meningococcal meningitis can occur post flu as

well as GAS and S aureus invasive disease and TSS."



She also addressed Jim's question: "We do know that new serotypes [of

pneumococcus] have emerged but this is not waning immunity because the teen

only got PCV7".





Greg Conners



Gregory P. Conners, MD, MPH, MBA, FAAP, FACEP



Director, Division of Emergency Medicine

Associate Chair of Pediatrics

Professor of Pediatrics and Emergency Medicine

Children’s Mercy Hospital, Kansas City

University of Missouri, Kansas City

[log in to unmask]<mailto:[log in to unmask]>









-----Original Message-----

From: Pediatric Emergency Medicine Discussion List [mailto:

[log in to unmask]<mailto:[log in to unmask]>] On Behalf Of 000001679b145c30-dmarc-

[log in to unmask]<mailto:[log in to unmask]>

Sent: Wednesday, February 14, 2018 2:25 PM

To: [log in to unmask]<mailto:[log in to unmask]>

Subject: Re: Bacterial meningitis



*** This message was sent to you from an External Source. Please do not

open untrusted links or attachments. ***



________________________________





Could you share with us the clinical findings and history that prompted

the LP?





Shiu-Lin









Shiu-Lin Tsai, MD

Division of Pediatric Emergency Medicine



Department of Emergency Medicine

Columbia University Medical Center







-----Original Message-----

From: Scott Freedman <[log in to unmask]<mailto:[log in to unmask]>>

To: PED-EM-L <[log in to unmask]<mailto:[log in to unmask]>>

Sent: Wed, Feb 14, 2018 2:44 pm

Subject: Bacterial meningitis



ALL:

Since Jan 1st this year, we have seen 3 cases of culture + bacterial

meningitis come through are ED; 2 with *Strep pneumoniae* and 1 with

*Neisseria meningiditis*. All 3 were in older children/ teens who received

their Prevnar 13 vaccines as well as the Menactra series in the patient

with Neisseria. Anyone else seeing cases of this sort? I do not recall 3

cases of bacterial meningitis in older kids in a community setting such as

ours in quite a long time. Is this random bad luck or do we all need to

be more vigilant? Incidentally, none had neck pain or meningismus as a

clinical finding.



--

Kind regards,



Scott

Scott Freedman, MD

Medical Director, Pediatric Emergency Dept Rockville MD



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------------------------------



Date: Fri, 16 Feb 2018 18:29:08 -0500

From: Martin Pusic <[log in to unmask]<mailto:[log in to unmask]>>

Subject: The shooting in Florida



Hi colleagues,



As I sit in my office late on a Friday, I've gotten myself into a state about the 17 children gunned down in a school. For the umpteenth time.



I think the thing that has me so upset, is that this state of gun complaisance is an affront to everything a pediatric emergency physician stands for. We sweat whether it's too risky when the WBC is 15.1 and not 14.9. We study 40,000 children in order sort out who deserves the x-ray risk of a maybe brain tumor 30 years from now. We work in difficult, burnout inducing conditions so that we can personally save, say, one life a year.



Today it feels to me like someone with an AK-whatever just wiped out 17 years of my work. In minutes. I want to cry. We SHOULD cry. Try and watch that Parkland mother on CNN. I dare you.



Today is not a day like all the others. It's just not.



--Martin Pusic



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------------------------------



End of PED-EM-L Digest - 15 Feb 2018 to 16 Feb 2018 (#2018-39)

**************************************************************



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------------------------------



Date: Sun, 18 Feb 2018 12:42:58 +0000

From: Terence Bergmann <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: The shooting in Florida



Hi Joe



I disagree about ‘strict gun control laws’ here having anything to do with it . Either you or I could have a new hunting rifle in a week or two in Canada. If you look at the school shootings or the Vegas massacre these are not people who acquired their guns and went slaughtering. These guns were acquired and the armamentarium prepped and the plans made. Canadian laws would not stop this.



We have a different culture here in Canada. Guns are not toted around in public. Thankfully the 49th parallel prevented the ‘western’ mentality from flourishing on our side of the border. I don’t know why.



The challenge to end ‘their’ problem is that once the bad guys are armed with illegal guns how do you stop the populace from wanting to have legal guns?



Somehow other countries can have legal weapons, such as Swiss adults all keeping their weapons at home after their years of mandatory service, yet they don’t kill each other with them. Somehow a well armed militia there does not lead to violence.



I have lots of questions, but I don’t know the answers.



Terence



On Feb 17, 2018, at 2:43 PM, Joe Nemeth, Dr <[log in to unmask]<mailto:[log in to unmask]><mailto:[log in to unmask]>> wrote:



Disclaimer: I live in Canada and love our very strict gun control laws.





For more information, send mail to [log in to unmask]<mailto:[log in to unmask]> with the message: info PED-EM-L

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------------------------------



Date: Sun, 18 Feb 2018 14:31:22 +0000

From: "Habib, David" <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: The shooting in Florida



Repeal and replace the second amendment with a clear and contemporary document. Dave Habib



________________________________________

From: Pediatric Emergency Medicine Discussion List [[log in to unmask]<mailto:[log in to unmask]>] on behalf of Terence Bergmann [[log in to unmask]<mailto:[log in to unmask]>]

Sent: Sunday, February 18, 2018 7:42 AM

To: [log in to unmask]<mailto:[log in to unmask]>

Subject: Re: The shooting in Florida







Hi Joe



I disagree about ‘strict gun control laws’ here having anything to do with it . Either you or I could have a new hunting rifle in a week or two in Canada. If you look at the school shootings or the Vegas massacre these are not people who acquired their guns and went slaughtering. These guns were acquired and the armamentarium prepped and the plans made. Canadian laws would not stop this.



We have a different culture here in Canada. Guns are not toted around in public. Thankfully the 49th parallel prevented the ‘western’ mentality from flourishing on our side of the border. I don’t know why.



The challenge to end ‘their’ problem is that once the bad guys are armed with illegal guns how do you stop the populace from wanting to have legal guns?



Somehow other countries can have legal weapons, such as Swiss adults all keeping their weapons at home after their years of mandatory service, yet they don’t kill each other with them. Somehow a well armed militia there does not lead to violence.



I have lots of questions, but I don’t know the answers.



Terence



On Feb 17, 2018, at 2:43 PM, Joe Nemeth, Dr <[log in to unmask]<mailto:[log in to unmask]><mailto:[log in to unmask]>> wrote:



Disclaimer: I live in Canada and love our very strict gun control laws.





For more information, send mail to [log in to unmask]<mailto:[log in to unmask]> with the message: info PED-EM-L

The URL for the PED-EM-L Web Page is:

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For more information, send mail to [log in to unmask]<mailto:[log in to unmask]> with the message: info PED-EM-L

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------------------------------



Date: Sun, 18 Feb 2018 14:04:25 +0000

From: Nathan Kuppermann <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: The shooting in Florida



Jeffrey and colleagues:



My colleague Garen Wintemute is an EM physician at UC Davis and has been doing seminal work on firearm violence prevention for decades - doggedly and with great impact



He is the director of the Violence Prevention Research Program (VPRP) at UC Davis, and has been named a "hero of medicine" by Time Magazine in the past for his work. He is as smart and accomplished as they come, and there is nobody in the country who has been doing this longer or with greater impact. And he has weathered the political and funding crises for this type of work for years, frequently funding his own work when the political climate for this work was bleak. But he has also received substantial foundation money and federal grants during more supportive political times.



He recently received $5 million from the California state legislature to lead the University of California Firearm Violence Research Center, the first state-funded gun violence research center in the country.



Here is his entry in Wikipedia: https://urldefense.proofpoint.com/v2/url?u=https-3A__en.wikipedia.org_wiki_Garen-5FWintemute&d=DwIGaQ&c=cjytLXgP8ixuoHflwc-poQ&r=iiLqIGJPj43rFwhy0umXiLW2YeM4w7OHtbhTpnjKXBI&m=t48oRvjGz5SVTSWYDRNskNM83f8PFATlPgGDaXkwwFA&s=NLb0pWX2zSNtCCtxb8sbfq2eU5kwLSJ1K01CUSRclBU&e=



If you are interested in his program or donating, here is the link: https://urldefense.proofpoint.com/v2/url?u=http-3A__www.ucdmc.ucdavis.edu_vprp_&d=DwIGaQ&c=cjytLXgP8ixuoHflwc-poQ&r=iiLqIGJPj43rFwhy0umXiLW2YeM4w7OHtbhTpnjKXBI&m=t48oRvjGz5SVTSWYDRNskNM83f8PFATlPgGDaXkwwFA&s=y6AkLoGvtzbgZgJDAeqhImP2Ae_P1GrSzIOuDmcuDyo&e=



Full disclosure: I serve as the Chair of EM at UC Davis where Garen works, but the only benefit to me for getting Garen more exposure or money to the VPRP program that he oversees is my children and family whom I desperately want to protect, my many friends throughout this great country about whom I deeply care, and a country about which I am deeply concerned.



Nate Kuppermann

UC Davis







On Feb 17, 2018, at 3:03 PM, Jeffrey Oestreicher <[log in to unmask]<mailto:[log in to unmask]><mailto:[log in to unmask]>> wrote:



Thanks for this cathartic thread, Dr. Pusic and others. Hope fellows are allowed to chime in. Like many on here my gut reaction is to focus on politics, ie an assault weapons ban, the 2nd amendment etc. If Americans were being killed by the same type of airplane that kept crashing, congress would act. Why the same isn’t done with the AR-15 given that it keeps being used to murder kids (in Sandy Hook, Aurora, Orlando, Las Vegas and now Parkland) is maddening. But I wonder if we could do more by taking the lead on another key gun violence issue on which physicians are experts. The problem was encapsulated by the first few hours after the parkland shooting when media outlets were literally arguing over how many school shootings there have been in 2018. We don't even know! We don't know because there are very little data on firearm injury/death in this country on account of Congress blocking gun violence research funding since 1996. And this funding block (the "Dickey amendment," named for the NRA point person in Congress at the time) has created a political chill on research that has trickled down even to academic medical centers. When I tried to examine NY EMS data to look at pre-hospital intervention in pediatric firearm injury, the city blocked it on account of the study being "too political." Where is the research? When SIDs reached epidemic numbers in the 70’s, Congress allocated funds for aggressive research leading to Back to Sleep campaign and SIDS rates plummeted. Similar research campaigns produced life-saving interventions for lead poisoning and car crashes. Yet no research crusade has been directed at the epidemic of pediatric firearm death because Congress essentially prohibits it. The hard part is trying to figure out what to do about it. In my state of New York, A.2977/S.4363, sponsored by New York State Assemblymember Jo Anne Simon and Senator Roxanne Persaud, would create a Firearm Violence Research Institute in New York and I along with some colleagues are trying to support this in a few different ways; if others on here want to discuss or have other ideas pls be in touch. This is not meant to discourage us from yelling from rooftops and writing senators about background checks, assault weapons ban etc. That is so important. But we have a unique vantage point with regard to public health research and we're allowed to do it for every other public health problem except this one. Thanks so much for allowing me to add my 2 cents



Sent from my iPhone



On Feb 17, 2018, at 3:43 PM, Joe Nemeth, Dr <[log in to unmask]<mailto:[log in to unmask]><mailto:[log in to unmask]>> wrote:



Martin,



As I sit in my living room on this Saturday morning, I’ve also gotten my self in a state about how we tend to focus in on the small picture and neglect an exponentially bigger one.



Spoiler Alert: this will NOT be a politically laced nor personally biased post...as opposed to some of the previous posts on this issue - I'm actually quite disappointed that politics had to rear its ugly head.



Disclaimer: I live in Canada and love our very strict gun control laws.

Don't claim to be a gun control policy expert



Now, allow me to expound:



1. A troubled young man AND inappropriate access to crazy weapons is what caused this catastrophe.



Colleagues, I think we all agree that it would be too simplistic and frankly naive to think that stricter gun control would solve all of these gun related deaths...many examples of this false and misleading association of tighter gun control means safer society here are just a few below...many more:

-explore New Hampshire and Illinois...NH has very liberal gun control, Chicago instead has very strict ones...look up who has more gun related violent crime per capita...

-the Swiss gov't actually encourages gun ownership.. has one of the highest rates of gun ownership in the world, but little gun-related street crime

-Britain has more violent crime then the US (ban on guns since 1997)



From my viewpoint, attention is being focused in the wrong direction. I think we as powerful respected advocates of "public health" should focus at the root causes of the problem, starting with the breakdown of the family (young males who are deprived of an active father figure are far more likely to commit violent crimes), the relentless stream of violent promoting behaviour from Hollywood, the exponential increase in mental illness in youth to start with.



How come we don't lambast the horrendous violence coming out of Hollywood which our youth are imbibing with negative consequences?



2. As per the CDC, in 2016, ~900 000 legal induced abortions were reported from 49 reporting areas...likely a significant underestimate since CA among other states does not report its numbers (BTW ~ 1.5% for rape/incest, 3% for fetal health issues).



Without going into the classic arguments re pro/con, how can we not, how do we not stand up for these children? I agree with the AAP's stance on gun control but what I have trouble understanding is how the AAP does not weigh in on the abortion issue (~10% of abortions are reported in females <19)?



17 children violently, meaninglessly murdered. An incredible tragedy. How is this different then close to 1 million kids per year mentioned above.



I agree with the AAP's stance on gun control but what I have trouble understanding is how the AAP does not weigh in on the abortion issue?





Joe











Joe Nemeth MD FCFP EM

Associate Professor

McGill University





________________________________________

From: Pediatric Emergency Medicine Discussion List <[log in to unmask]<mailto:[log in to unmask]><mailto:[log in to unmask]>> on behalf of Barry Nathan <[log in to unmask]<mailto:[log in to unmask]><mailto:[log in to unmask]>>

Sent: February 17, 2018 7:23:57 AM

To: [log in to unmask]<mailto:[log in to unmask]><mailto:[log in to unmask]>

Subject: Re: The shooting in Florida



In case you don't get emails from the AAP:



[image: AAP_400_61.jpg]







*Statement on School Shooting in Parkland, Florida*



from *Colleen A. Kraft, MD, FAAP, President, American Academy of Pediatrics*



"Yesterday just before the dismissal bell rang, 17 children and adults were

shot and killed and 15 were injured inside Marjory Stoneman Douglas High

School in Parkland, Fla. We find ourselves once again filled with grief and

horror, and we mourn alongside all those impacted by the shooting. As our

hearts are in Parkland, our eyes are on Congress.



"This is the eighteenth school shooting in 2018, the equivalent of one

every two and a half days so far this year. Shootings have an indelible

impact on entire communities, on the families who lost children and loved

ones, and on the children who survived. Columbine. Virginia Tech. Newtown.

Orlando. Las Vegas. And now, Parkland. Children are dying from gun violence

and Congress is failing to act. Every one of our 100 U.S. senators, and all

435 U.S. representatives bear a responsibility to take meaningful action to

protect our children, our families, and our communities. Our elected

leaders cannot continue to fail at this most essential task.



"We can start by working to advance meaningful legislation that keeps

children safe. The American Academy of Pediatrics advocates for stronger

state and federal gun laws that protect children, including a ban on

assault weapons like the one used in yesterday's school shooting. We also

call for stronger background checks, solutions addressing firearm

trafficking, and encouraging safe firearm storage. We will also continue to

work to ensure that children and their families have access to appropriate

mental health services, particularly to address the effects of exposure to

violence.



"Although these mass shootings command our attention, our children remain

at risk daily for suicide, homicide, and unintentional injury because of

the current policy regarding access to guns in the United States. Gun

violence is a public health threat to children, and one the American

Academy of Pediatrics will continue to take on, in state capitals across

the country and in the halls of Congress. Parents across the United States

send their children to school every day, and hope and trust they will be

safe. As long as children continue to be injured and killed by guns in this

country, pediatricians will not rest in our pursuit to keep them safe."



*The American Academy of Pediatrics is an organization of 66,000 primary

care pediatricians, pediatric medical subspecialists and pediatric surgical

specialists dedicated to the health, safety and well-being of infants,

children, adolescents and young adults. For more information, visit *

www.aap.org<https://urldefense.proofpoint.com/v2/url?u=http-3A__www.aap.org&d=DwIGaQ&c=cjytLXgP8ixuoHflwc-poQ&r=iiLqIGJPj43rFwhy0umXiLW2YeM4w7OHtbhTpnjKXBI&m=t48oRvjGz5SVTSWYDRNskNM83f8PFATlPgGDaXkwwFA&s=GYHJ2Trg6KbD5HWur2hhBM8okfIlyE-J85UX7orhmA4&e=><https://urldefense.proofpoint.com/v2/url?u=http-3A__www.aap.org&d=DwIGaQ&c=cjytLXgP8ixuoHflwc-poQ&r=iiLqIGJPj43rFwhy0umXiLW2YeM4w7OHtbhTpnjKXBI&m=t48oRvjGz5SVTSWYDRNskNM83f8PFATlPgGDaXkwwFA&s=GYHJ2Trg6KbD5HWur2hhBM8okfIlyE-J85UX7orhmA4&e=>

<https://urldefense.proofpoint.com/v2/url?u=https-3A__linkprotect.cudasvc.com_url-3Fa-3Dhttp-3A__www.mmsend70.com_link.cfm-253fr-253dP1AWQRX2DH6KpZKp05dazA-7E-7E-2526pe-253dBH4KXYJXftdV7-5FOrPTTyUbVAzQsfgoRvleBm2XUVQ6AiEVwuBNacQ0AWbz2OcXguY6Y2i1bNdCMkiPdWG-2DfHRg-7E-7E-2526t-253dP2O93UltqkjSP1tT62-5FPaA-7E-7E-26c-3DE-2C1-2CEDnzTesKajviC9Rbq687pz7yfFyRgC2WBFw6mF1beQyzL2WYF-5FfPWMjWxOixG1eagtp40GaUhhxZ8IL4zNcR4weeC1DLvkbbpHQsmMSnszDC-26typo-3D1&d=DwIGaQ&c=cjytLXgP8ixuoHflwc-poQ&r=iiLqIGJPj43rFwhy0umXiLW2YeM4w7OHtbhTpnjKXBI&m=t48oRvjGz5SVTSWYDRNskNM83f8PFATlPgGDaXkwwFA&s=nx187qR_lU1zgduq5D6pufobUc2LvOfMjUy_CKFqY-w&e=>*

and

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On Fri, Feb 16, 2018 at 9:22 PM, Chamberlain, James <

[log in to unmask]<mailto:[log in to unmask]>> wrote:



I think we need to move to repeal the second amendment. It's the only way

the NRA can be stopped. They resist all reasonable attempts to limit the

carnage and then hide behind a misinterpretation of the second amendment.



Very well, let's repeal it. I know many people agree that we don't need

militias any longer.



Jim Chamberlain







-----Original Message-----

From: Pediatric Emergency Medicine Discussion List [mailto:

[log in to unmask]<mailto:[log in to unmask]>] On Behalf Of Martin Pusic

Sent: Friday, February 16, 2018 6:29 PM

To: [log in to unmask]<mailto:[log in to unmask]>

Subject: The shooting in Florida



Hi colleagues,



As I sit in my office late on a Friday, I've gotten myself into a state

about the 17 children gunned down in a school. For the umpteenth time.



I think the thing that has me so upset, is that this state of gun

complaisance is an affront to everything a pediatric emergency physician

stands for. We sweat whether it's too risky when the WBC is 15.1 and not

14.9. We study 40,000 children in order sort out who deserves the x-ray

risk of a maybe brain tumor 30 years from now. We work in difficult,

burnout inducing conditions so that we can personally save, say, one life a

year.



Today it feels to me like someone with an AK-whatever just wiped out 17

years of my work. In minutes. I want to cry. We SHOULD cry. Try and

watch that Parkland mother on CNN. I dare you.



Today is not a day like all the others. It's just not.



--Martin Pusic



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------------------------------



Date: Sun, 18 Feb 2018 10:20:42 -0500

From: Martin Pusic <[log in to unmask]<mailto:[log in to unmask]>>

Subject: A second, more settled, reflection on the Florida shooting



After my amygdala-based email of Friday, a clarification:



It is right and fit and proper that Pediatric Emergency Medicine physicians bring the full force of our research and clinical armementarium to bear on the problems of our patients. That means sweating thresholds of WBC for their predictive value in infections. That means mounting massive 10 year PECARN/PERC/PERN level research efforts to understand in detail the mechanisms of our patients' problems in order to benefit them in any way we can. That's our laudable job. We should be proud of taking on the problem of brain tumours 30 years from now. In no way did I mean to denigrate those efforts. Instead, the complete opposite -- I think they provide us with the moral authority to speak out against government policies that harm children.



What is neither right nor fit nor proper is the ease with which a gun violence proponent can wreak havoc at a scale that, on a given schoolday, trivializes my efforts and those of my PEM colleagues. It feels like a personal affront that we live in a nation in which somehow the NRA has better government support than CHIP does. My point is not to devalue our day/evening/night/weekend job.... we are doing MORE than our part in society.......but rather to express that I, as a PEM physician, am rocked to the core by the moral imbalance that makes it possible to routinely leave 17 children dead. And that this is some sort of normal.



Some notes:

If you need an example of how routine this has become, one PEM colleague wrote that he is going to his son's elementary school next week to instruct the teachers on external control of hemorrhage

A Scot described the positive example of the way the Dunblane massacre provoked a re-writing of their laws. They haven't had another in 22 years since.

Fahd Ahmad from WashU had already written on this: https://urldefense.proofpoint.com/v2/url?u=http-3A__www.roguedadmd.com_2018_02_how-2Dmany-2Dpeople-2Dand-2Dwhich-2Dpeople-2Dshould-2Ddie-2Dfor-2Dwhich-2Drights_&d=DwIGaQ&c=cjytLXgP8ixuoHflwc-poQ&r=iiLqIGJPj43rFwhy0umXiLW2YeM4w7OHtbhTpnjKXBI&m=t48oRvjGz5SVTSWYDRNskNM83f8PFATlPgGDaXkwwFA&s=gBTmwrSDR2Xj4YokS_BOxGaLGBc1Xiq3jhEmCjkra6M&e=

I learned of the positive examples of EM physicians taking this on including Garen Wintemute of UC Davis and Eric Fleegler/Lois Lee at Boston Children's.

thank you posting the AAP statement which properly represents our values

The majority of people who wrote back are mothers.



Finally, I commit to writing back, constructively, every 3 months on this topic until there's nothing to write about





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------------------------------



Date: Sun, 18 Feb 2018 16:56:19 +0000

From: Doc Holiday <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: The shooting in Florida



Before I continue, I must say how much more comfortable this on-line debate feels as compared to previous ones on other ListServs. I know it's a generalising comment, but I keep finding that the insertion into the mix of people who work with children makes everything so much more polite and patient. If I recall correctly, there was a lot of anger and short sentences last time I was involved in a debate on this topic on an "adult" list....





From: Joe Nemeth, Dr <[log in to unmask]<mailto:[log in to unmask]>>

As I sit in my living room on this Saturday morning





--> My living room. Sunday afternoon. What else is there to do on a weekend, eh?





I live in Canada and love our very strict gun control laws





--> As people know, I live in the UK at this time and I also like the gun laws here (as well as ones on knives, etc). I don't feel as positive about drug laws, but that's a different thread. Still, the point I made before and make again now is that I don't think our gun laws are THE cause of our statistics. I think they are but one (be it major) factor contributing, but on the background of a culture which rejects gun violence! I don't think that any society will change sufficiently merely by their introduction - no matter how strict. I have lived for many years in more than one country in which guns were far more common than they are in the UK and these countries differed markedly in terms of gun violence. One was actually on the same scale as the USA!





A troubled young man AND inappropriate access to crazy weapons is what caused this catastrophe... too simplistic and frankly naive to think that stricter gun control would solve all of these gun related deaths





--> I agree. And I would add that there are factors beyond the two you mentioned. It's not even ONLY two factors. We can probably add to this:

- the lack of major societal backlash to inappropriate comments

- the tolerance of lack of free psychiatric care

- the overwhelming number of similar cases which will "drown" the efforts of law enforcement to identify the cases which eventually go on to this sort of event from among so many others, etc

- there will be more factors identified as this case gets investigated





One more point, though - a HUGE factor might be, as in past cases, if the outrage dies down! The NRA and those who profit from guns will push their politicians, including some of the more publicly-prominent ones and they will keep things as quiet as possible. Possibly, even the next similar event somehow will be used to make this one "disappear". You can recognise the "silencing tactics" by indicator phrases such as:

- "Now is not the time..."

- "Country/state/city X ... bla-bla-bla ... And they have more/fewer guns and more/fewer gun deaths and this random statistic thus means we should stop looking into gun control"

- "My child just falls a lot" (sorry - had to put that in, as it's on the same level)

- "The USA is a unique country and yet, when it suits me, I will find some other one with which to make comparisons to prove my point"





Britain has more violent crime then the US (ban on guns since 1997)





--> I realise that I am picking up just one of the many points which were listed together. I am only choosing this one because it's one I have been familiar with for a very long time. It has been much "used" in order to "prove" to Americans how the introduction of gun laws in the UK has left it with a higher violent crime rate than the USA and should thus be avoided by the USA. Now, I won't trouble the List by arguments about this. Instead, I would appreciate it if y'all satisfy your own curiosities, each to his/her own level, by going to a favourite search engine and searching for the phrase "Britain has more violent crime then the US". You can read for yourselves and save me from having to type up the actual facts...





But I can't stop myself from mentioning something which has come up in a past discussion I was accidentally drawn into on a visit to the USA 3-4 years ago. This same myth was raised. That, in itself, was no surprise, but it had been raised by someone who had already impressed me with how many "facts" he had absorbed from social media sources and how confidently he spoke of these despite appearing to be far less eloquent whenever questioned in detail about anything. I.e., he appeared to me to have been "brainwashed". Despite knowing better, I challenged him on why he thought the USA was "doing so much better" than the UK in terms of violent crime. He gave me the answer. He then mistook my look of disbelief to indicate I did not believe the facts he had mentioned. He was wrong - what I did not believe is that someone could be that easy to "sell" to. He pulled out his phone and showed me the "evidence". No idea what you're sitting on as you read this, but I hope it has handles for you to hang onto, so that you don't fall to the ground laughing. The reason, according to this "expert" for how the USA got to have what he claimed was 10 times less violent crime than the UK is because the USA has taken the excellent pre-emptive step of imprisoning those who would otherwise have engaged in violent crime! I kid you not - he attributed the high level of violent crime he believed the UK had, not to the fact that the UK records a huge number of offences which the USA does not include in its statistics. What he showed me was: https://urldefense.proofpoint.com/v2/url?u=https-3A__en.wikipedia.org_wiki_List-5Fof-5Fcountries-5Fby-5Fincarceration-5Frate&d=DwIGaQ&c=cjytLXgP8ixuoHflwc-poQ&r=iiLqIGJPj43rFwhy0umXiLW2YeM4w7OHtbhTpnjKXBI&m=t48oRvjGz5SVTSWYDRNskNM83f8PFATlPgGDaXkwwFA&s=U4gHJAeNgKwFDK4WRfsLUPol7JAm8n3364MaZLG1Co4&e= (the version which was on line then). He had been "educated" to believe that the fact that the USA had around a 10-time higher number of prisoners than the UK per million of population correlated with how it achieved a 10-time lower rate of violent crime...





I expect one requires whole armies of people who can be thus educated in order to perpetuate certain "facts"... Such people can be convinced of many things...















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------------------------------



Date: Sun, 18 Feb 2018 12:00:26 -0500

From: Michael Falk <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: The shooting in Florida



While I get the despair and anger given the lose of 17 people in another

senseless mass shooting, I would caution people to not give up hope. When

I first came to New York City in 1989, it was averaging about 2,000

homicides a year. If take our statistics for nonlethal injuries per

homicide, roughly 7:1, the city was seeing another 10,000 plus penetrating

traumas and I have not even mentioned the assaults with fists or blunt

objects. Last year in NYC, we had less than 400 homicides and the city is

safer than it has been in years. Why? Well, there was a concerted effort

to change the culture of policing and law enforcement in the city, and

there was a massive crackdown on guns and getting them off the streets.

The laws were changed around gun ownership and licensing, and there you

have it....



Also, many of you are forgetting that we had an assault weapons law in the

US and Bush/Congress let it lapse in 2003. Now it's record is a mixed bag

but I think that if we learn from the mistakes we made the last time, and

write a better law, we can actually have a significant impact.



Just my two cents..

Mike Falk

NYC.



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------------------------------



Date: Sun, 18 Feb 2018 17:09:24 +0000

From: Robert Finkelstein <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: PED-EM-L Digest - 15 Feb 2018 to 16 Feb 2018 (#2018-39)



Other countries have the same level of mental illness as the United States, but not nearly the number of gun deaths. The mental health issue is important but access to weapons that can kill a large number of people in seconds allows the results we see. In addition, access to guns plays a huge role in suicides since many who attempt suicide and do not succeed will get help and not attempt again. However, access to a gun makes it much more likely that the first attempt will result in death.



Robert Finkelstein



On Feb 18, 2018, at 8:42 AM, Mick Work <[log in to unmask]<mailto:[log in to unmask]>> wrote:



I respect the need for debate around guns. However, I think we are remiss as pediatric emergency physicians to not raise a deeper discussion around the mental illness crisis.



We all see kids who meet this persons profile across the country. We see disturbing mental illness and the many factors (including social media, broken families, child abuse) that lead a child to buy a gun to do harm. Or if not gun an explosive device etc..



We see kids who are socially isolated and warning signs ignored. Anyone else concerned that the kids we see with mental illness are recognized by schools or pediatric visit screening more often than by their own parents, friends or neighbors.



This persons desire to be a “school shooter” should raise attention around how the media covers these events. The fame brought to these shooters should be called into question. Are we fostering this copycat mentality?



The lack of respect for human life should call us to question more than the how but why.



A focus only on guns and gun laws is remiss to the bigger picture in my opinion and experience.



Mick







On Feb 17, 2018, at 12:01 AM, PED-EM-L automatic digest system <[log in to unmask]<mailto:[log in to unmask]>> wrote:



There are 4 messages totaling 391 lines in this issue.



Topics of the day:



1. Peds EM talk (2)

2. Bacterial meningitis

3. The shooting in Florida



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----------------------------------------------------------------------



Date: Fri, 16 Feb 2018 11:50:44 -0500

From: Purva Grover <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: Peds EM talk



Thanks all for your help on this.

Best

Purva



Purva Grover , MD

Medical Director

Pediatric Emergency Department

Cleveland Clinic Health System

Email- [log in to unmask]<mailto:[log in to unmask]> <[log in to unmask]<mailto:[log in to unmask]>>g



On Thu, Feb 15, 2018 at 2:18 PM, <[log in to unmask]<mailto:[log in to unmask]>> wrote:



Hi All

I am giving an hour ppt to new PAs on Peds Emergencies. Clearly can not

cover ALL or even most. Any thoughts / talks / power points- you could

share would be appreciated.

Thanks

Purva



Sent from my mobile device



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------------------------------



Date: Fri, 16 Feb 2018 14:34:20 +0000

From: "Chamberlain, James" <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: Peds EM talk



I would also cover unusual cases that you can't afford to miss, e.g.



Sternoclavicular dislocation

Conjunctivitis caused by penetrating FB

Septic joint presenting with only low-grade fever (we've had several Staph infections where temp was only 37.6 or 37.7 orally)

Myocarditis presenting as wheezing. Remind them that all "bronchiolitis" patients need a through cardiac exam, including distal pulses

NAT

The "sleepy" baby who has hypoglycemia

The "sleepy" baby who has intussusception

The appendicitis patient who presents with vomiting and diarrhea (not all that unusual, actually)

Etc.



To me, this is the challenge of PEM. Finding the needle in the haystack, that one sick kid who is different than all the usual low acuity illness...



Jim



James Chamberlain

Division Chief, Emergency Medicine

Children’s National Health System

(202) 476-4177



-----Original Message-----

From: Pediatric Emergency Medicine Discussion List [mailto:[log in to unmask]] On Behalf Of Mojica, Michael

Sent: Thursday, February 15, 2018 5:29 PM

To: [log in to unmask]<mailto:[log in to unmask]>

Subject: Re: Peds EM talk



Purva







I would recommend "the critically ill infant".







It is the topic that scares the most people and you can cover a lot of causes through cases.







I like to use cases that include common presenting complaints (e.g. vomiting) that are associated with very bad things (e.g. midgut volvulus).







I'm attaching a ppt file for a talk I did a few years ago on this topic.







My goal is for them to develop a mental checklist of potentially life-saving interventions.







Michael







Michael Mojica, M.D



Director of Education, Division of Pediatric Emergency Medicine



Director, Pediatric Emergency Medicine Fellowship



Bellevue Hospital Center



Administration Building Room A528



New York, N.Y. 10016



[log in to unmask]<mailto:[log in to unmask]>



212-562-8147











On 2/15/18, 5:12 PM, "Pediatric Emergency Medicine Discussion List on behalf of Purva Grover" <[log in to unmask]<mailto:[log in to unmask]> on behalf of [log in to unmask]<mailto:[log in to unmask]>> wrote:







Hi All



I am giving an hour ppt to new PAs on Peds Emergencies. Clearly can not cover ALL or even most. Any thoughts / talks / power points- you could share would be appreciated.



Thanks



Purva







Sent from my mobile device



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------------------------------



Date: Fri, 16 Feb 2018 18:29:38 -0500

From: Aline Baghdassarian <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: Bacterial meningitis



Scott,



Would love to hear more about the cases. How did they present? What was the

decision making process?



Thank you,



Aline



Aline Baghdassarian, MD, MPH, FAAP

Director, Pediatric Emergency Medicine Fellowship Program

Assistant Professor, Department of Emergency Medicine

Virginia Commonwealth University School of Medicine



Children's Hospital of Richmond at VCU

Email [log in to unmask]<mailto:[log in to unmask]>





On Thu, Feb 15, 2018 at 12:40 PM, Julian Orenstein <[log in to unmask]<mailto:[log in to unmask]>>

wrote:



In a recent case at our institution, there was a present but subtle degree

of meningismus — I’ve found over the years there is always some elicitable

sign — but as importantly there’s a degree of irritability or altered

behavior that has everyone concerned: mom, RN’s, me.

If mama ain't happy, I ain't happy. I’ll make liberal use of the term

cerebritis or encephalopathic behavior until there’s a consent signed.



I’m not such a good scientist anymore, but I’ve tried to be an attentive

clinician.



Julian Orenstein





On Feb 14, 2018, at 3:30 PM, JAY FISHER <[log in to unmask]<mailto:[log in to unmask]>> wrote:



Scott - Bacterial meningitis is alive and well here in LV - we have seen

it in a variety of age groups. There is good evidence that there has been

an increase in pneumococcal serotypes not covered by the polyvalent

vaccines since there widespread use, such that the burden of pneumococcal

meningitis (as opposed to H. flu type b) has not decreased nearly as much.



Brouwer MC, van de Beek D. Epidemiology of community-acquired bacterial

meningitis. Curr Opin Infect Dis. 2018;31(1):78-84.



Also, the absence of meningismus in older kids with bacterial meningitis

is well described and occurs in a substantial subset.



Geiseler J, Nelson, K.E. Bacterial meningitis without clinical signs of

meningeal irritation. . Southern Med J 1982;75(4):448-450.



Much of the data on the sensitivity of the neck exam is of the

retrospective variety. I have only read one really good prospective study

on the sensitivity of PE for bacterial meningitis and it was a single

center variety as I recall.



Walsh-Kelly C, Nelson DB, Smith DS, et al. Clinical predictors of

bacterial versus aseptic meningitis in childhood. Ann Emerg Med.

1992;21(8):910-914.



Tough case.





Jay



Jay D. Fisher MD FAAP FACEP

Medical Director, Pediatric EM

Children's Hospital of Nevada at UMC

Clinical Professor of Emergency Medicine and Pediatrics

UNLV School of Medicine

















On February 14, 2018 at 4:18 PM "Conners, Gregory, P" <

[log in to unmask]<mailto:[log in to unmask]>> wrote:





I shared this with our ID director (Dr. Mary Anne Jackson), who pointed

out that bacterial meningitis appears at this time of year as a

complication of influenza:

"Both pneumococcal and meningococcal meningitis can occur post flu as

well as GAS and S aureus invasive disease and TSS."



She also addressed Jim's question: "We do know that new serotypes [of

pneumococcus] have emerged but this is not waning immunity because the teen

only got PCV7".





Greg Conners



Gregory P. Conners, MD, MPH, MBA, FAAP, FACEP



Director, Division of Emergency Medicine

Associate Chair of Pediatrics

Professor of Pediatrics and Emergency Medicine

Children’s Mercy Hospital, Kansas City

University of Missouri, Kansas City

[log in to unmask]<mailto:[log in to unmask]>









-----Original Message-----

From: Pediatric Emergency Medicine Discussion List [mailto:

[log in to unmask]<mailto:[log in to unmask]>] On Behalf Of 000001679b145c30-dmarc-

[log in to unmask]<mailto:[log in to unmask]>

Sent: Wednesday, February 14, 2018 2:25 PM

To: [log in to unmask]<mailto:[log in to unmask]>

Subject: Re: Bacterial meningitis



*** This message was sent to you from an External Source. Please do not

open untrusted links or attachments. ***



________________________________





Could you share with us the clinical findings and history that prompted

the LP?





Shiu-Lin









Shiu-Lin Tsai, MD

Division of Pediatric Emergency Medicine



Department of Emergency Medicine

Columbia University Medical Center







-----Original Message-----

From: Scott Freedman <[log in to unmask]<mailto:[log in to unmask]>>

To: PED-EM-L <[log in to unmask]<mailto:[log in to unmask]>>

Sent: Wed, Feb 14, 2018 2:44 pm

Subject: Bacterial meningitis



ALL:

Since Jan 1st this year, we have seen 3 cases of culture + bacterial

meningitis come through are ED; 2 with *Strep pneumoniae* and 1 with

*Neisseria meningiditis*. All 3 were in older children/ teens who received

their Prevnar 13 vaccines as well as the Menactra series in the patient

with Neisseria. Anyone else seeing cases of this sort? I do not recall 3

cases of bacterial meningitis in older kids in a community setting such as

ours in quite a long time. Is this random bad luck or do we all need to

be more vigilant? Incidentally, none had neck pain or meningismus as a

clinical finding.



--

Kind regards,



Scott

Scott Freedman, MD

Medical Director, Pediatric Emergency Dept Rockville MD



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------------------------------



Date: Fri, 16 Feb 2018 18:29:08 -0500

From: Martin Pusic <[log in to unmask]<mailto:[log in to unmask]>>

Subject: The shooting in Florida



Hi colleagues,



As I sit in my office late on a Friday, I've gotten myself into a state about the 17 children gunned down in a school. For the umpteenth time.



I think the thing that has me so upset, is that this state of gun complaisance is an affront to everything a pediatric emergency physician stands for. We sweat whether it's too risky when the WBC is 15.1 and not 14.9. We study 40,000 children in order sort out who deserves the x-ray risk of a maybe brain tumor 30 years from now. We work in difficult, burnout inducing conditions so that we can personally save, say, one life a year.



Today it feels to me like someone with an AK-whatever just wiped out 17 years of my work. In minutes. I want to cry. We SHOULD cry. Try and watch that Parkland mother on CNN. I dare you.



Today is not a day like all the others. It's just not.



--Martin Pusic



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------------------------------



Date: Sun, 18 Feb 2018 10:17:05 -0500

From: Deepti Thomas-Paulose <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: The shooting in Florida



The year speed limit laws went into effect-->traffic deaths down 17%.

Mothers against Drunk Driving, stricter DUI enforcement laws-->cut deaths

due to drunk driving by half every year since 1980. Seat belt safety laws,

traffic laws-all created to protect the public. As a public health trained

physician, it seems so illogical to me that we would not create stricter

gun laws especially against military style guns for the civilian

population. Let's start there.



Problem- Mass shootings

Prevention- Ban assault rifles





On Sun, Feb 18, 2018 at 7:42 AM, Terence Bergmann <

[log in to unmask]<mailto:[log in to unmask]>> wrote:



Hi Joe



I disagree about ‘strict gun control laws’ here having anything to do with

it . Either you or I could have a new hunting rifle in a week or two in

Canada. If you look at the school shootings or the Vegas massacre these

are not people who acquired their guns and went slaughtering. These guns

were acquired and the armamentarium prepped and the plans made. Canadian

laws would not stop this.



We have a different culture here in Canada. Guns are not toted around in

public. Thankfully the 49th parallel prevented the ‘western’ mentality

from flourishing on our side of the border. I don’t know why.



The challenge to end ‘their’ problem is that once the bad guys are armed

with illegal guns how do you stop the populace from wanting to have legal

guns?



Somehow other countries can have legal weapons, such as Swiss adults all

keeping their weapons at home after their years of mandatory service, yet

they don’t kill each other with them. Somehow a well armed militia there

does not lead to violence.



I have lots of questions, but I don’t know the answers.



Terence



On Feb 17, 2018, at 2:43 PM, Joe Nemeth, Dr <[log in to unmask]<mailto:[log in to unmask]><mailto:j

[log in to unmask]<mailto:[log in to unmask]>>> wrote:



Disclaimer: I live in Canada and love our very strict gun control laws.





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--

Deepti Thomas-Paulose, MD, MPH

Fellowship Director

Global Health Division

Mt. Sinai St.Luke's Roosevelt Hospital Center

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------------------------------



Date: Sun, 18 Feb 2018 17:15:53 +0000

From: Robert Finkelstein <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: School shootings.......



Just because people will find a way to break laws does not mean that we shouldn’t have them. By that logic, we expect that all of us who are currently law abiding don’t need any laws to make us so. Human nature being what it is, we all need laws and structure. Yes, gun regulation would not stop all gun violence, but it could reduce it. Also, I don’t think the majority want prohibition of guns, just regulation; the same way alcohol is regulated by age and penalties for driving under the influence. Or, the way cars are regulated with licensing, registration, having to pass a driving test and citations for violations.



On Feb 18, 2018, at 8:42 AM, Horst D. Weinberg, MD <[log in to unmask]<mailto:[log in to unmask]>> wrote:



Yes, automatic weapons should be banned by our government, but most of the discussions posted blame the guns, the NRA, the 2nd amendment and our 'laws'. Nobody gets to the meat of the matter: If there is a demand (for guns), regardless of the laws passed, someone will fill that demand. This is no different from Prohibition, where there was no shortage of available booze or the 'war' on drugs, where you can get them at most street corners in any city. What needs to change: There has been a steady decline over the past 20 or so years in our country's moral fiber, personal and work ethic, and yes, child rearing. Cause: unmarried or one parent families, poverty, and absence of any discipline both in the home and in the schools, for 'political correctness'. Parents want to be friends with their children rather than running their homes like 'benevolent dictator ships'. Nothing is denied the child: the child wants $150.00 sneakers or a new cell-phone: no problem. So you can blame the gun all you want, but unless there is a real change in the populations personal morality and ethics, these school tragedies will continue.

We pediatricians should look at our own practices in teaching good child rearing ways to the families we serve. Horst D. Weinberg, MD









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------------------------------



Date: Sun, 18 Feb 2018 17:26:11 +0000

From: Robert Flood <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: The shooting in Florida



Dear Colleagues:





This conversation gives me some hope that we can and will address the issue of gun violence through the scientific approach, rather than "beliefs" and "feelings", similar to the way that Dr. Wintemute has done for the past several decades. While I fully support a "re-evaluation/clarification" of the second amendment, a "Children's Rights Amendment", and other legislation to help curb gun violence in the US, we can and and should evaluate potential interventions now in the context of over 350 million guns, with unlimited ammunition, available to the US public.





So, if we are going to use the scientific approach to this huge public health emergency that clearly endangers our children, we really should break up the huge scope of "gun violence" into unique subsets, including but not limited to the following:





1) Mass Shootings: Unfortunately, the US leads the entire world in the number of mass shootings, which may be more properly categorized as "mass suicides" since these shooters usually have no intention of surviving their murderous rampages. Clearly, the evidence shows a direct correlation with the elimination on the band on assault rifles and the increase in the number and deaths in these incidents. So, everyone's comments on the access to better mental health should be just one aspect of the study of all potential interventions. For instance, even pediatricians must admit that if we had armed security in every school, perhaps with the national guard, we would likely decrease the number of gun related deaths/year in our schools. However, we would need to study that model to prove our hypothesis rather than saying "I believe this will work". Still, Mass Shooting Deaths are only a tiny percentage of gun deaths in the US in any given year. In fact, if we eliminated every single mass shooting gun death and injury in the US, it would have a negligible impact on gun related death and injury rates.





2) Intentional Hand Gun Violence: We continue to have disturbing data regarding intentional handgun injuries, especially in the inner city African American communities. With over 100 K gun related injuries/year, and over 10 k non-suicidal gun related deaths/year, this is a very different problem than "Mass Shootings" and needs to be studied in very different ways. Within this category there are both domestic (ie, in the home) and non-domestic sub-categories, which will likely require very different interventions. For instance, in Saint Louis, MO, we are participating in a 4 hospital (all level 1 trauma centers), 2 university intervention program whereby social worker mentors will be paired with willing participants who present as victims of gun violence with the goal of preventing recidivism as either a victim or a perpetrator.





3) Suicides: The data is consistent and very alarming: over 20 K deaths/year from suicides with a gun. The overwhelming majority of these deaths are due to access to handguns and ammunition in the homes. So, while our limited data allows us to recommend that guns and ammunition be stored and locked separately, we don't know for sure whether this would have significant impact on intentional suicides by teenagers, who often have access to both of these locked items. So, we need to study this in much greater detail, and offer viable solutions to well intentioned individuals who are trying to "protect their families".





4) Accidental Shootings: As we all have friends who own one or more weapons, it is often difficult to convince them that the weapon in the home greatly increases the risk of one of their loved ones being the victim of that weapon. Rather, these often well intentioned families in the suburban and rural areas, who honestly believe that having a loaded gun will protect their families from the very, very unlikely chance of a home invasion, will actually endanger their loved ones simply by bringing guns into the home. On the other hand, in the inner city where gun violence is part of everyday life, families believe having the loaded gun readily available (unlocked, fully loaded) allows them to better protect their loved ones from the reality of their situation. So, when we, as healthcare providers, care for the young children who "accidentally" shoot themselves, we are particularly frustrated and angered by the tragedy of the entire plight of these families. The point is this: these very different groups may require very different approaches with respect to interventions.







I look forward to the continued dialogue, and, more importantly, continued research in these areas.





Bob Flood



Saint Louis University







________________________________

From: Pediatric Emergency Medicine Discussion List <[log in to unmask]<mailto:[log in to unmask]>> on behalf of Nathan Kuppermann <[log in to unmask]<mailto:[log in to unmask]>>

Sent: Sunday, February 18, 2018 8:04:25 AM

To: [log in to unmask]<mailto:[log in to unmask]>

Subject: Re: The shooting in Florida



Jeffrey and colleagues:







My colleague Garen Wintemute is an EM physician at UC Davis and has been doing seminal work on firearm violence prevention for decades - doggedly and with great impact







He is the director of the Violence Prevention Research Program (VPRP) at UC Davis, and has been named a "hero of medicine" by Time Magazine in the past for his work. He is as smart and accomplished as they come, and there is nobody in the country who has been doing this longer or with greater impact. And he has weathered the political and funding crises for this type of work for years, frequently funding his own work when the political climate for this work was bleak. But he has also received substantial foundation money and federal grants during more supportive political times.







He recently received $5 million from the California state legislature to lead the University of California Firearm Violence Research Center, the first state-funded gun violence research center in the country.







Here is his entry in Wikipedia: https://urldefense.proofpoint.com/v2/url?u=https-3A__en.wikipedia.org_wiki_Garen-5FWintemute&d=DwIGaQ&c=Pk_HpaIpE_jAoEC9PLIWoQ&r=PgyaJu_-6fURaaWELlGskCQzpkXWZSDQU-w6tbGwwMM&m=kjmFQ1KpfStKxhcvfi4QpgjqumdRH2TVpCIOAggcCW0&s=MwtCq_L-kQIs3_poo8ESXJUfQXyAfM2mv3_BCZ2sBPo&e=







If you are interested in his program or donating, here is the link: https://urldefense.proofpoint.com/v2/url?u=http-3A__www.ucdmc.ucdavis.edu_vprp_&d=DwIGaQ&c=Pk_HpaIpE_jAoEC9PLIWoQ&r=PgyaJu_-6fURaaWELlGskCQzpkXWZSDQU-w6tbGwwMM&m=kjmFQ1KpfStKxhcvfi4QpgjqumdRH2TVpCIOAggcCW0&s=km0yMXq80C4DGUQlje9yL-_xAQ5OiKQNooiyry9xUC0&e=







Full disclosure: I serve as the Chair of EM at UC Davis where Garen works, but the only benefit to me for getting Garen more exposure or money to the VPRP program that he oversees is my children and family whom I desperately want to protect, my many friends throughout this great country about whom I deeply care, and a country about which I am deeply concerned.







Nate Kuppermann



UC Davis















On Feb 17, 2018, at 3:03 PM, Jeffrey Oestreicher <[log in to unmask]<mailto:[log in to unmask]><mailto:[log in to unmask]>> wrote:







Thanks for this cathartic thread, Dr. Pusic and others. Hope fellows are allowed to chime in. Like many on here my gut reaction is to focus on politics, ie an assault weapons ban, the 2nd amendment etc. If Americans were being killed by the same type of airplane that kept crashing, congress would act. Why the same isn’t done with the AR-15 given that it keeps being used to murder kids (in Sandy Hook, Aurora, Orlando, Las Vegas and now Parkland) is maddening. But I wonder if we could do more by taking the lead on another key gun violence issue on which physicians are experts. The problem was encapsulated by the first few hours after the parkland shooting when media outlets were literally arguing over how many school shootings there have been in 2018. We don't even know! We don't know because there are very little data on firearm injury/death in this country on account of Congress blocking gun violence research funding since 1996. And this funding block (the "Dickey amendment," named for the NRA point person in Congress at the time) has created a political chill on research that has trickled down even to academic medical centers. When I tried to examine NY EMS data to look at pre-hospital intervention in pediatric firearm injury, the city blocked it on account of the study being "too political." Where is the research? When SIDs reached epidemic numbers in the 70’s, Congress allocated funds for aggressive research leading to Back to Sleep campaign and SIDS rates plummeted. Similar research campaigns produced life-saving interventions for lead poisoning and car crashes. Yet no research crusade has been directed at the epidemic of pediatric firearm death because Congress essentially prohibits it. The hard part is trying to figure out what to do about it. In my state of New York, A.2977/S.4363, sponsored by New York State Assemblymember Jo Anne Simon and Senator Roxanne Persaud, would create a Firearm Violence Research Institute in New York and I along with some colleagues are trying to support this in a few different ways; if others on here want to discuss or have other ideas pls be in touch. This is not meant to discourage us from yelling from rooftops and writing senators about background checks, assault weapons ban etc. That is so important. But we have a unique vantage point with regard to public health research and we're allowed to do it for every other public health problem except this one. Thanks so much for allowing me to add my 2 cents







Sent from my iPhone







On Feb 17, 2018, at 3:43 PM, Joe Nemeth, Dr <[log in to unmask]<mailto:[log in to unmask]><mailto:[log in to unmask]>> wrote:







Martin,







As I sit in my living room on this Saturday morning, I’ve also gotten my self in a state about how we tend to focus in on the small picture and neglect an exponentially bigger one.







Spoiler Alert: this will NOT be a politically laced nor personally biased post...as opposed to some of the previous posts on this issue - I'm actually quite disappointed that politics had to rear its ugly head.







Disclaimer: I live in Canada and love our very strict gun control laws.



Don't claim to be a gun control policy expert







Now, allow me to expound:







1. A troubled young man AND inappropriate access to crazy weapons is what caused this catastrophe.







Colleagues, I think we all agree that it would be too simplistic and frankly naive to think that stricter gun control would solve all of these gun related deaths...many examples of this false and misleading association of tighter gun control means safer society here are just a few below...many more:



-explore New Hampshire and Illinois...NH has very liberal gun control, Chicago instead has very strict ones...look up who has more gun related violent crime per capita...



-the Swiss gov't actually encourages gun ownership.. has one of the highest rates of gun ownership in the world, but little gun-related street crime



-Britain has more violent crime then the US (ban on guns since 1997)







From my viewpoint, attention is being focused in the wrong direction. I think we as powerful respected advocates of "public health" should focus at the root causes of the problem, starting with the breakdown of the family (young males who are deprived of an active father figure are far more likely to commit violent crimes), the relentless stream of violent promoting behaviour from Hollywood, the exponential increase in mental illness in youth to start with.







How come we don't lambast the horrendous violence coming out of Hollywood which our youth are imbibing with negative consequences?







2. As per the CDC, in 2016, ~900 000 legal induced abortions were reported from 49 reporting areas...likely a significant underestimate since CA among other states does not report its numbers (BTW ~ 1.5% for rape/incest, 3% for fetal health issues).







Without going into the classic arguments re pro/con, how can we not, how do we not stand up for these children? I agree with the AAP's stance on gun control but what I have trouble understanding is how the AAP does not weigh in on the abortion issue (~10% of abortions are reported in females <19)?







17 children violently, meaninglessly murdered. An incredible tragedy. How is this different then close to 1 million kids per year mentioned above.







I agree with the AAP's stance on gun control but what I have trouble understanding is how the AAP does not weigh in on the abortion issue?











Joe























Joe Nemeth MD FCFP EM



Associate Professor



McGill University











________________________________________



From: Pediatric Emergency Medicine Discussion List <[log in to unmask]<mailto:[log in to unmask]><mailto:[log in to unmask]>> on behalf of Barry Nathan <[log in to unmask]<mailto:[log in to unmask]><mailto:[log in to unmask]>>



Sent: February 17, 2018 7:23:57 AM



To: [log in to unmask]<mailto:[log in to unmask]><mailto:[log in to unmask]>



Subject: Re: The shooting in Florida







In case you don't get emails from the AAP:







[image: AAP_400_61.jpg]















*Statement on School Shooting in Parkland, Florida*







from *Colleen A. Kraft, MD, FAAP, President, American Academy of Pediatrics*







"Yesterday just before the dismissal bell rang, 17 children and adults were



shot and killed and 15 were injured inside Marjory Stoneman Douglas High



School in Parkland, Fla. We find ourselves once again filled with grief and



horror, and we mourn alongside all those impacted by the shooting. As our



hearts are in Parkland, our eyes are on Congress.







"This is the eighteenth school shooting in 2018, the equivalent of one



every two and a half days so far this year. Shootings have an indelible



impact on entire communities, on the families who lost children and loved



ones, and on the children who survived. Columbine. Virginia Tech. Newtown.



Orlando. Las Vegas. And now, Parkland. Children are dying from gun violence



and Congress is failing to act. Every one of our 100 U.S. senators, and all



435 U.S. representatives bear a responsibility to take meaningful action to



protect our children, our families, and our communities. Our elected



leaders cannot continue to fail at this most essential task.







"We can start by working to advance meaningful legislation that keeps



children safe. The American Academy of Pediatrics advocates for stronger



state and federal gun laws that protect children, including a ban on



assault weapons like the one used in yesterday's school shooting. We also



call for stronger background checks, solutions addressing firearm



trafficking, and encouraging safe firearm storage. We will also continue to



work to ensure that children and their families have access to appropriate



mental health services, particularly to address the effects of exposure to



violence.







"Although these mass shootings command our attention, our children remain



at risk daily for suicide, homicide, and unintentional injury because of



the current policy regarding access to guns in the United States. Gun



violence is a public health threat to children, and one the American



Academy of Pediatrics will continue to take on, in state capitals across



the country and in the halls of Congress. Parents across the United States



send their children to school every day, and hope and trust they will be



safe. As long as children continue to be injured and killed by guns in this



country, pediatricians will not rest in our pursuit to keep them safe."







*The American Academy of Pediatrics is an organization of 66,000 primary



care pediatricians, pediatric medical subspecialists and pediatric surgical



specialists dedicated to the health, safety and well-being of infants,



children, adolescents and young adults. For more information, visit *



www.aap.org<https://urldefense.proofpoint.com/v2/url?u=http-3A__www.aap.org&d=DwIGaQ&c=cjytLXgP8ixuoHflwc-poQ&r=iiLqIGJPj43rFwhy0umXiLW2YeM4w7OHtbhTpnjKXBI&m=t48oRvjGz5SVTSWYDRNskNM83f8PFATlPgGDaXkwwFA&s=GYHJ2Trg6KbD5HWur2hhBM8okfIlyE-J85UX7orhmA4&e=><https://urldefense.proofpoint.com/v2/url?u=http-3A__www.aap.org&d=DwIGaQ&c=Pk_HpaIpE_jAoEC9PLIWoQ&r=PgyaJu_-6fURaaWELlGskCQzpkXWZSDQU-w6tbGwwMM&m=kjmFQ1KpfStKxhcvfi4QpgjqumdRH2TVpCIOAggcCW0&s=3Oc_7pCeJFj4KZ9QlF0MpVKwh-Xixr5f2-x4dFOOgHk&e=>



<https://urldefense.proofpoint.com/v2/url?u=https-3A__linkprotect.cudasvc.com_url-3Fa-3Dhttp-3A__www.mmsend70.com_link.cfm-253fr-253dP1AWQRX2DH6KpZKp05dazA-7E-7E-2526pe-253dBH4KXYJXftdV7-5FOrPTTyUbVAzQsfgoRvleBm2XUVQ6AiEVwuBNacQ0AWbz2OcXguY6Y2i1bNdCMkiPdWG-2DfHRg-7E-7E-2526t-253dP2O93UltqkjSP1tT62-5FPaA-7E-7E-26c-3DE-2C1-2CEDnzTesKajviC9Rbq687pz7yfFyRgC2WBFw6mF1beQyzL2WYF-5FfPWMjWxOixG1eagtp40GaUhhxZ8IL4zNcR4weeC1DLvkbbpHQsmMSnszDC-26typo-3D1&d=DwIGaQ&c=Pk_HpaIpE_jAoEC9PLIWoQ&r=PgyaJu_-6fURaaWELlGskCQzpkXWZSDQU-w6tbGwwMM&m=kjmFQ1KpfStKxhcvfi4QpgjqumdRH2TVpCIOAggcCW0&s=IjSKeAbtNO1UyfAxfonG3YrPW35X2WKiPCyGj3YfSnQ&e=>*



and



follow us on Twitter @AmerAcadPeds.*







On Fri, Feb 16, 2018 at 9:22 PM, Chamberlain, James <



[log in to unmask]<mailto:[log in to unmask]>> wrote:







I think we need to move to repeal the second amendment. It's the only way



the NRA can be stopped. They resist all reasonable attempts to limit the



carnage and then hide behind a misinterpretation of the second amendment.







Very well, let's repeal it. I know many people agree that we don't need



militias any longer.







Jim Chamberlain















-----Original Message-----



From: Pediatric Emergency Medicine Discussion List [mailto:



[log in to unmask]<mailto:[log in to unmask]>] On Behalf Of Martin Pusic



Sent: Friday, February 16, 2018 6:29 PM



To: [log in to unmask]<mailto:[log in to unmask]>



Subject: The shooting in Florida







Hi colleagues,







As I sit in my office late on a Friday, I've gotten myself into a state



about the 17 children gunned down in a school. For the umpteenth time.







I think the thing that has me so upset, is that this state of gun



complaisance is an affront to everything a pediatric emergency physician



stands for. We sweat whether it's too risky when the WBC is 15.1 and not



14.9. We study 40,000 children in order sort out who deserves the x-ray



risk of a maybe brain tumor 30 years from now. We work in difficult,



burnout inducing conditions so that we can personally save, say, one life a



year.







Today it feels to me like someone with an AK-whatever just wiped out 17



years of my work. In minutes. I want to cry. We SHOULD cry. Try and



watch that Parkland mother on CNN. I dare you.







Today is not a day like all the others. It's just not.







--Martin Pusic







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------------------------------



Date: Sun, 18 Feb 2018 12:18:07 -0500

From: Jeff Pender <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: The shooting in Florida



I have a desire to put in my 2 cents as well, considering this is perhaps one of the issues I feel most passionately about. This is a multi-factorial problem, obviously. Not only is it a problem with “quality and quantity”, but also with “culture".



By quality and quantity, I am speaking about what people own, and how much they own. Does anyone outside the military need a semi automatic weapon for anything? No. Does anyone need a bump stock? No. Does anyone need an extended magazine? No. If you require any of these things for the lame ass excuse of “home defense”, you either need to move, or take some classes and become a far better shot with a handgun. Further, do people need the insane quantity of weapons and ammunition they tend to accumulate? No, but this is a secondary problem to the types of weapons they own. We can’t own a bazooka, so “we” understand that limits can exist, so we need to extend those limits to the things listed above.



The culture issue, to me, is even worse. In the spirit of full disclosure, I despise guns. I don’t own one, and have no plans on ever owning one. I won’t allow one in my home, period. I feel pretty damn safe with my 3 large dogs, thank you. I will admit that I pull away socially from people once I learn they are big time gun enthusiasts. I won’t spend time with people that I know are carrying a gun on their person, or in their car. I can’t help it, and I don’t feel bad about it for even 1 second. We just see the world too differently, although I don’t think it makes them a bad person. In my anecdotal experience, these serious “enthusiasts” share some similar traits - they own a shit ton of guns, ridiculous ammunition that no target shooter or home defense person really needs, but most importantly perhaps, a “macho” response to their guns. This is the thing that needs to change.



Guns are celebrated in our country as both cool and macho. Decide where to place the blame - video games, movies, athletes, musicians, etc. But, our politicians are part of this problem, and perhaps the largest part. Since they are the ones that make the laws (and take the bribes…err…donations), we need them to stop believing this more than anyone else. They will never change the gun laws until the culture of how we view guns changes. Think back to that insane video Ted Cruz made where he wrapped bacon around the muzzle of an AR-15, and after shooting for a while, ate the bacon that the hot muzzle cooked. It was horrifying how he celebrated that AR-15….just so he could get another donation from gun lovers. Change the culture of how they are viewed (and then campaign finance laws) and the needle can be moved on this issue.



Israel and Swiss citizens own guns at incredibly high rates, but they are viewed as a fact of life, not as a point of pride or machismo. Culture changes are very slow to occur, but that is what is needed first, I think. Without it, laws won’t change, and neither will the desire to own these weapons and accessories. Think of other social changes/regulations….they were slow — seat belt laws, speed limits, voting rights, marriage equality, marijuana legalization, etc etc. They take decades, sadly. We are a country that seems to have extreme difficulty doing the right thing without it taking insanely long. It drives me crazy.



I truly hope that this school shooting has occurred around student’s ages that can possibly make a difference in that these students are at an age to become true activists, unlike when it happens to younger children. A wave has to start, and I think it is most likely to start with these young people, as long as we “older” people support them…both financially and vocally…and in our voting patterns.



Jeff











On Feb 18, 2018, at 7:42 AM, Terence Bergmann <[log in to unmask]<mailto:[log in to unmask]>> wrote:



Hi Joe



I disagree about ‘strict gun control laws’ here having anything to do with it . Either you or I could have a new hunting rifle in a week or two in Canada. If you look at the school shootings or the Vegas massacre these are not people who acquired their guns and went slaughtering. These guns were acquired and the armamentarium prepped and the plans made. Canadian laws would not stop this.



We have a different culture here in Canada. Guns are not toted around in public. Thankfully the 49th parallel prevented the ‘western’ mentality from flourishing on our side of the border. I don’t know why.



The challenge to end ‘their’ problem is that once the bad guys are armed with illegal guns how do you stop the populace from wanting to have legal guns?



Somehow other countries can have legal weapons, such as Swiss adults all keeping their weapons at home after their years of mandatory service, yet they don’t kill each other with them. Somehow a well armed militia there does not lead to violence.



I have lots of questions, but I don’t know the answers.



Terence



On Feb 17, 2018, at 2:43 PM, Joe Nemeth, Dr <[log in to unmask]<mailto:[log in to unmask]><mailto:[log in to unmask]>> wrote:



Disclaimer: I live in Canada and love our very strict gun control laws.





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------------------------------



Date: Sun, 18 Feb 2018 12:34:05 -0500

From: Michael Falk <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: The shooting in Florida



Friend just posted this interesting rebuttal to the "mental illness"

response whenever there is a mass shooting:



"Believing that mental illness causes mass shootings can feel reassuring.

It helps to believe that only a mentally ill person could do something so

horrific. We also think that if someone is mentally ill, they can be

identified. But the evidence suggests that mental illness only causes a

small fraction of gun violence. And even if some shooters have undiagnosed

mental illness, there is no evidence to suggest that they could have been

diagnosed prior to their gun violence or that such a diagnosis would

increase the predictive validity of a diagnosis on gun violence."



https://urldefense.proofpoint.com/v2/url?u=http-3A__behavioralscientist.org_myth-2Dmental-2Dillness-2Dcauses-2Dmass-2Dshootings_&d=DwIGaQ&c=cjytLXgP8ixuoHflwc-poQ&r=iiLqIGJPj43rFwhy0umXiLW2YeM4w7OHtbhTpnjKXBI&m=t48oRvjGz5SVTSWYDRNskNM83f8PFATlPgGDaXkwwFA&s=Ij2AVYkN8_dOohEUJqTc3oK3dja0ogb2DxwZquooPUg&e=



I will add few links of my own:



https://urldefense.proofpoint.com/v2/url?u=https-3A__www.theatlantic.com_health_archive_2017_10_why-2Dbetter-2Dmental-2Dhealth-2Dcare-2Dwont-2Dstop-2Dmass-2Dshootings_541965_&d=DwIGaQ&c=cjytLXgP8ixuoHflwc-poQ&r=iiLqIGJPj43rFwhy0umXiLW2YeM4w7OHtbhTpnjKXBI&m=t48oRvjGz5SVTSWYDRNskNM83f8PFATlPgGDaXkwwFA&s=iuN1ZZWvSku4__pWqqZGs88CZl8aLR4AGeH1wrVCdO8&e=



https://urldefense.proofpoint.com/v2/url?u=https-3A__www.vox.com_policy-2Dand-2Dpolitics_2017_11_9_16618472_mental-2Dillness-2Dgun-2Dhomicide-2Dmass-2Dshootings&d=DwIGaQ&c=cjytLXgP8ixuoHflwc-poQ&r=iiLqIGJPj43rFwhy0umXiLW2YeM4w7OHtbhTpnjKXBI&m=t48oRvjGz5SVTSWYDRNskNM83f8PFATlPgGDaXkwwFA&s=fpNtmUdDXtNXjh9vJuCsoZOzpctDlZD2qEwlDx4cgyQ&e=



The mentally ill are stigmatized enough, blaming them for these killings

seems unfair.



Mike Falk



On Sun, Feb 18, 2018 at 12:18 PM, Jeff Pender <[log in to unmask]<mailto:[log in to unmask]>> wrote:



I have a desire to put in my 2 cents as well, considering this is perhaps

one of the issues I feel most passionately about. This is a

multi-factorial problem, obviously. Not only is it a problem with

“quality and quantity”, but also with “culture".



By quality and quantity, I am speaking about what people own, and how much

they own. Does anyone outside the military need a semi automatic weapon

for anything? No. Does anyone need a bump stock? No. Does anyone need

an extended magazine? No. If you require any of these things for the lame

ass excuse of “home defense”, you either need to move, or take some classes

and become a far better shot with a handgun. Further, do people need the

insane quantity of weapons and ammunition they tend to accumulate? No, but

this is a secondary problem to the types of weapons they own. We can’t

own a bazooka, so “we” understand that limits can exist, so we need to

extend those limits to the things listed above.



The culture issue, to me, is even worse. In the spirit of full

disclosure, I despise guns. I don’t own one, and have no plans on ever

owning one. I won’t allow one in my home, period. I feel pretty damn safe

with my 3 large dogs, thank you. I will admit that I pull away socially

from people once I learn they are big time gun enthusiasts. I won’t spend

time with people that I know are carrying a gun on their person, or in

their car. I can’t help it, and I don’t feel bad about it for even 1

second. We just see the world too differently, although I don’t think it

makes them a bad person. In my anecdotal experience, these serious

“enthusiasts” share some similar traits - they own a shit ton of guns,

ridiculous ammunition that no target shooter or home defense person really

needs, but most importantly perhaps, a “macho” response to their guns.

This is the thing that needs to change.



Guns are celebrated in our country as both cool and macho. Decide where

to place the blame - video games, movies, athletes, musicians, etc. But,

our politicians are part of this problem, and perhaps the largest part.

Since they are the ones that make the laws (and take the

bribes…err…donations), we need them to stop believing this more than anyone

else. They will never change the gun laws until the culture of how we view

guns changes. Think back to that insane video Ted Cruz made where he

wrapped bacon around the muzzle of an AR-15, and after shooting for a

while, ate the bacon that the hot muzzle cooked. It was horrifying how he

celebrated that AR-15….just so he could get another donation from gun

lovers. Change the culture of how they are viewed (and then campaign

finance laws) and the needle can be moved on this issue.



Israel and Swiss citizens own guns at incredibly high rates, but they are

viewed as a fact of life, not as a point of pride or machismo. Culture

changes are very slow to occur, but that is what is needed first, I think.

Without it, laws won’t change, and neither will the desire to own these

weapons and accessories. Think of other social changes/regulations….they

were slow — seat belt laws, speed limits, voting rights, marriage equality,

marijuana legalization, etc etc. They take decades, sadly. We are a

country that seems to have extreme difficulty doing the right thing without

it taking insanely long. It drives me crazy.



I truly hope that this school shooting has occurred around student’s ages

that can possibly make a difference in that these students are at an age to

become true activists, unlike when it happens to younger children. A wave

has to start, and I think it is most likely to start with these young

people, as long as we “older” people support them…both financially and

vocally…and in our voting patterns.



Jeff











On Feb 18, 2018, at 7:42 AM, Terence Bergmann <

[log in to unmask]<mailto:[log in to unmask]>> wrote:



Hi Joe



I disagree about ‘strict gun control laws’ here having anything to do

with it . Either you or I could have a new hunting rifle in a week or two

in Canada. If you look at the school shootings or the Vegas massacre these

are not people who acquired their guns and went slaughtering. These guns

were acquired and the armamentarium prepped and the plans made. Canadian

laws would not stop this.



We have a different culture here in Canada. Guns are not toted around

in public. Thankfully the 49th parallel prevented the ‘western’ mentality

from flourishing on our side of the border. I don’t know why.



The challenge to end ‘their’ problem is that once the bad guys are armed

with illegal guns how do you stop the populace from wanting to have legal

guns?



Somehow other countries can have legal weapons, such as Swiss adults all

keeping their weapons at home after their years of mandatory service, yet

they don’t kill each other with them. Somehow a well armed militia there

does not lead to violence.



I have lots of questions, but I don’t know the answers.



Terence



On Feb 17, 2018, at 2:43 PM, Joe Nemeth, Dr <[log in to unmask]<mailto:[log in to unmask]>

<mailto:[log in to unmask]>> wrote:



Disclaimer: I live in Canada and love our very strict gun control laws.





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------------------------------



Date: Sun, 18 Feb 2018 12:52:28 -0500

From: Mick Work <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: PED-EM-L Digest - 15 Feb 2018 to 16 Feb 2018 (#2018-39)



I appreciate the passion around gun legislation and not opposed. I don’t think laws will end this countries obsession with guns or limit access to those who want to perform unlawful acts. But again I am not arguing against reasonable legislation.



I have heard proposed that we need to arm principals and add more security in schools. I just wonder if we added mental health counselors instead if we wouldn’t make a greater impact.



My point is our prevention should be multi-modal like all effective strategies.





Mick







On Feb 18, 2018, at 12:09 PM, Robert Finkelstein <[log in to unmask]<mailto:[log in to unmask]>> wrote:



Other countries have the same level of mental illness as the United States, but not nearly the number of gun deaths. The mental health issue is important but access to weapons that can kill a large number of people in seconds allows the results we see. In addition, access to guns plays a huge role in suicides since many who attempt suicide and do not succeed will get help and not attempt again. However, access to a gun makes it much more likely that the first attempt will result in death.



Robert Finkelstein



On Feb 18, 2018, at 8:42 AM, Mick Work <[log in to unmask]<mailto:[log in to unmask]>> wrote:



I respect the need for debate around guns. However, I think we are remiss as pediatric emergency physicians to not raise a deeper discussion around the mental illness crisis.



We all see kids who meet this persons profile across the country. We see disturbing mental illness and the many factors (including social media, broken families, child abuse) that lead a child to buy a gun to do harm. Or if not gun an explosive device etc..



We see kids who are socially isolated and warning signs ignored. Anyone else concerned that the kids we see with mental illness are recognized by schools or pediatric visit screening more often than by their own parents, friends or neighbors.



This persons desire to be a “school shooter” should raise attention around how the media covers these events. The fame brought to these shooters should be called into question. Are we fostering this copycat mentality?



The lack of respect for human life should call us to question more than the how but why.



A focus only on guns and gun laws is remiss to the bigger picture in my opinion and experience.



Mick







On Feb 17, 2018, at 12:01 AM, PED-EM-L automatic digest system <[log in to unmask]<mailto:[log in to unmask]>> wrote:



There are 4 messages totaling 391 lines in this issue.



Topics of the day:



1. Peds EM talk (2)

2. Bacterial meningitis

3. The shooting in Florida



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----------------------------------------------------------------------



Date: Fri, 16 Feb 2018 11:50:44 -0500

From: Purva Grover <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: Peds EM talk



Thanks all for your help on this.

Best

Purva



Purva Grover , MD

Medical Director

Pediatric Emergency Department

Cleveland Clinic Health System

Email- [log in to unmask]<mailto:[log in to unmask]> <[log in to unmask]<mailto:[log in to unmask]>>g



On Thu, Feb 15, 2018 at 2:18 PM, <[log in to unmask]<mailto:[log in to unmask]>> wrote:



Hi All

I am giving an hour ppt to new PAs on Peds Emergencies. Clearly can not

cover ALL or even most. Any thoughts / talks / power points- you could

share would be appreciated.

Thanks

Purva



Sent from my mobile device



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------------------------------



Date: Fri, 16 Feb 2018 14:34:20 +0000

From: "Chamberlain, James" <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: Peds EM talk



I would also cover unusual cases that you can't afford to miss, e.g.



Sternoclavicular dislocation

Conjunctivitis caused by penetrating FB

Septic joint presenting with only low-grade fever (we've had several Staph infections where temp was only 37.6 or 37.7 orally)

Myocarditis presenting as wheezing. Remind them that all "bronchiolitis" patients need a through cardiac exam, including distal pulses

NAT

The "sleepy" baby who has hypoglycemia

The "sleepy" baby who has intussusception

The appendicitis patient who presents with vomiting and diarrhea (not all that unusual, actually)

Etc.



To me, this is the challenge of PEM. Finding the needle in the haystack, that one sick kid who is different than all the usual low acuity illness...



Jim



James Chamberlain

Division Chief, Emergency Medicine

Children’s National Health System

(202) 476-4177



-----Original Message-----

From: Pediatric Emergency Medicine Discussion List [mailto:[log in to unmask]] On Behalf Of Mojica, Michael

Sent: Thursday, February 15, 2018 5:29 PM

To: [log in to unmask]<mailto:[log in to unmask]>

Subject: Re: Peds EM talk



Purva







I would recommend "the critically ill infant".







It is the topic that scares the most people and you can cover a lot of causes through cases.







I like to use cases that include common presenting complaints (e.g. vomiting) that are associated with very bad things (e.g. midgut volvulus).







I'm attaching a ppt file for a talk I did a few years ago on this topic.







My goal is for them to develop a mental checklist of potentially life-saving interventions.







Michael







Michael Mojica, M.D



Director of Education, Division of Pediatric Emergency Medicine



Director, Pediatric Emergency Medicine Fellowship



Bellevue Hospital Center



Administration Building Room A528



New York, N.Y. 10016



[log in to unmask]<mailto:[log in to unmask]>



212-562-8147











On 2/15/18, 5:12 PM, "Pediatric Emergency Medicine Discussion List on behalf of Purva Grover" <[log in to unmask]<mailto:[log in to unmask]> on behalf of [log in to unmask]<mailto:[log in to unmask]>> wrote:







Hi All



I am giving an hour ppt to new PAs on Peds Emergencies. Clearly can not cover ALL or even most. Any thoughts / talks / power points- you could share would be appreciated.



Thanks



Purva







Sent from my mobile device



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------------------------------



Date: Fri, 16 Feb 2018 18:29:38 -0500

From: Aline Baghdassarian <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: Bacterial meningitis



Scott,



Would love to hear more about the cases. How did they present? What was the

decision making process?



Thank you,



Aline



Aline Baghdassarian, MD, MPH, FAAP

Director, Pediatric Emergency Medicine Fellowship Program

Assistant Professor, Department of Emergency Medicine

Virginia Commonwealth University School of Medicine



Children's Hospital of Richmond at VCU

Email [log in to unmask]<mailto:[log in to unmask]>





On Thu, Feb 15, 2018 at 12:40 PM, Julian Orenstein <[log in to unmask]<mailto:[log in to unmask]>>

wrote:



In a recent case at our institution, there was a present but subtle degree

of meningismus — I’ve found over the years there is always some elicitable

sign — but as importantly there’s a degree of irritability or altered

behavior that has everyone concerned: mom, RN’s, me.

If mama ain't happy, I ain't happy. I’ll make liberal use of the term

cerebritis or encephalopathic behavior until there’s a consent signed.



I’m not such a good scientist anymore, but I’ve tried to be an attentive

clinician.



Julian Orenstein





On Feb 14, 2018, at 3:30 PM, JAY FISHER <[log in to unmask]<mailto:[log in to unmask]>> wrote:



Scott - Bacterial meningitis is alive and well here in LV - we have seen

it in a variety of age groups. There is good evidence that there has been

an increase in pneumococcal serotypes not covered by the polyvalent

vaccines since there widespread use, such that the burden of pneumococcal

meningitis (as opposed to H. flu type b) has not decreased nearly as much.



Brouwer MC, van de Beek D. Epidemiology of community-acquired bacterial

meningitis. Curr Opin Infect Dis. 2018;31(1):78-84.



Also, the absence of meningismus in older kids with bacterial meningitis

is well described and occurs in a substantial subset.



Geiseler J, Nelson, K.E. Bacterial meningitis without clinical signs of

meningeal irritation. . Southern Med J 1982;75(4):448-450.



Much of the data on the sensitivity of the neck exam is of the

retrospective variety. I have only read one really good prospective study

on the sensitivity of PE for bacterial meningitis and it was a single

center variety as I recall.



Walsh-Kelly C, Nelson DB, Smith DS, et al. Clinical predictors of

bacterial versus aseptic meningitis in childhood. Ann Emerg Med.

1992;21(8):910-914.



Tough case.





Jay



Jay D. Fisher MD FAAP FACEP

Medical Director, Pediatric EM

Children's Hospital of Nevada at UMC

Clinical Professor of Emergency Medicine and Pediatrics

UNLV School of Medicine

















On February 14, 2018 at 4:18 PM "Conners, Gregory, P" <

[log in to unmask]<mailto:[log in to unmask]>> wrote:





I shared this with our ID director (Dr. Mary Anne Jackson), who pointed

out that bacterial meningitis appears at this time of year as a

complication of influenza:

"Both pneumococcal and meningococcal meningitis can occur post flu as

well as GAS and S aureus invasive disease and TSS."



She also addressed Jim's question: "We do know that new serotypes [of

pneumococcus] have emerged but this is not waning immunity because the teen

only got PCV7".





Greg Conners



Gregory P. Conners, MD, MPH, MBA, FAAP, FACEP



Director, Division of Emergency Medicine

Associate Chair of Pediatrics

Professor of Pediatrics and Emergency Medicine

Children’s Mercy Hospital, Kansas City

University of Missouri, Kansas City

[log in to unmask]<mailto:[log in to unmask]>









-----Original Message-----

From: Pediatric Emergency Medicine Discussion List [mailto:

[log in to unmask]<mailto:[log in to unmask]>] On Behalf Of 000001679b145c30-dmarc-

[log in to unmask]<mailto:[log in to unmask]>

Sent: Wednesday, February 14, 2018 2:25 PM

To: [log in to unmask]<mailto:[log in to unmask]>

Subject: Re: Bacterial meningitis



*** This message was sent to you from an External Source. Please do not

open untrusted links or attachments. ***



________________________________





Could you share with us the clinical findings and history that prompted

the LP?





Shiu-Lin









Shiu-Lin Tsai, MD

Division of Pediatric Emergency Medicine



Department of Emergency Medicine

Columbia University Medical Center







-----Original Message-----

From: Scott Freedman <[log in to unmask]<mailto:[log in to unmask]>>

To: PED-EM-L <[log in to unmask]<mailto:[log in to unmask]>>

Sent: Wed, Feb 14, 2018 2:44 pm

Subject: Bacterial meningitis



ALL:

Since Jan 1st this year, we have seen 3 cases of culture + bacterial

meningitis come through are ED; 2 with *Strep pneumoniae* and 1 with

*Neisseria meningiditis*. All 3 were in older children/ teens who received

their Prevnar 13 vaccines as well as the Menactra series in the patient

with Neisseria. Anyone else seeing cases of this sort? I do not recall 3

cases of bacterial meningitis in older kids in a community setting such as

ours in quite a long time. Is this random bad luck or do we all need to

be more vigilant? Incidentally, none had neck pain or meningismus as a

clinical finding.



--

Kind regards,



Scott

Scott Freedman, MD

Medical Director, Pediatric Emergency Dept Rockville MD



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------------------------------



Date: Fri, 16 Feb 2018 18:29:08 -0500

From: Martin Pusic <[log in to unmask]<mailto:[log in to unmask]>>

Subject: The shooting in Florida



Hi colleagues,



As I sit in my office late on a Friday, I've gotten myself into a state about the 17 children gunned down in a school. For the umpteenth time.



I think the thing that has me so upset, is that this state of gun complaisance is an affront to everything a pediatric emergency physician stands for. We sweat whether it's too risky when the WBC is 15.1 and not 14.9. We study 40,000 children in order sort out who deserves the x-ray risk of a maybe brain tumor 30 years from now. We work in difficult, burnout inducing conditions so that we can personally save, say, one life a year.



Today it feels to me like someone with an AK-whatever just wiped out 17 years of my work. In minutes. I want to cry. We SHOULD cry. Try and watch that Parkland mother on CNN. I dare you.



Today is not a day like all the others. It's just not.



--Martin Pusic



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------------------------------



End of PED-EM-L Digest - 15 Feb 2018 to 16 Feb 2018 (#2018-39)

**************************************************************



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------------------------------



Date: Sun, 18 Feb 2018 23:05:03 +0000

From: "Chamberlain, James" <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: School shootings.......



I'd be happy with sensible regulations, required training, and licensure so that guns don't get into the hands of criminals and people with mental illness.



But the NRA is against sensible regulations.







Sent from my Verizon, Samsung Galaxy smartphone





-------- Original message --------

From: Robert Finkelstein <[log in to unmask]<mailto:[log in to unmask]>>

Date: 2/18/18 12:17 (GMT-05:00)

To: [log in to unmask]<mailto:[log in to unmask]>

Subject: Re: School shootings.......



Just because people will find a way to break laws does not mean that we shouldn’t have them. By that logic, we expect that all of us who are currently law abiding don’t need any laws to make us so. Human nature being what it is, we all need laws and structure. Yes, gun regulation would not stop all gun violence, but it could reduce it. Also, I don’t think the majority want prohibition of guns, just regulation; the same way alcohol is regulated by age and penalties for driving under the influence. Or, the way cars are regulated with licensing, registration, having to pass a driving test and citations for violations.







On Feb 18, 2018, at 8:42 AM, Horst D. Weinberg, MD <[log in to unmask]<mailto:[log in to unmask]>> wrote:







Yes, automatic weapons should be banned by our government, but most of the discussions posted blame the guns, the NRA, the 2nd amendment and our 'laws'. Nobody gets to the meat of the matter: If there is a demand (for guns), regardless of the laws passed, someone will fill that demand. This is no different from Prohibition, where there was no shortage of available booze or the 'war' on drugs, where you can get them at most street corners in any city. What needs to change: There has been a steady decline over the past 20 or so years in our country's moral fiber, personal and work ethic, and yes, child rearing. Cause: unmarried or one parent families, poverty, and absence of any discipline both in the home and in the schools, for 'political correctness'. Parents want to be friends with their children rather than running their homes like 'benevolent dictator ships'. Nothing is denied the child: the child wants $150.00 sneakers or a new cell-phone: no problem. So you can blame the gun all you want, but unless there is a real change in the populations personal morality and ethics, these school tragedies will continue.



We pediatricians should look at our own practices in teaching good child rearing ways to the families we serve. Horst D. Weinberg, MD



















For more information, send mail to [log in to unmask]<mailto:[log in to unmask]> with the message: info PED-EM-L



The URL for the PED-EM-L Web Page is:



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------------------------------



Date: Sun, 18 Feb 2018 19:03:20 -0600

From: Jill C Obremskey <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: School shootings.......



Great discussion but what are WE going to do about it as an organization?

How do we become relentless about the need for gun control, the need for mental health services, and for preventing toxic stress in children.



We need to ask leaders in the AAP and AAEM to organize us into a uniified voice that will not quit.



On February 18, 2018 at 5:05 PM "Chamberlain, James" <[log in to unmask]<mailto:[log in to unmask]>> wrote:





I'd be happy with sensible regulations, required training, and licensure so that guns don't get into the hands of criminals and people with mental illness.



But the NRA is against sensible regulations.







Sent from my Verizon, Samsung Galaxy smartphone





-------- Original message --------

From: Robert Finkelstein <[log in to unmask]<mailto:[log in to unmask]>>

Date: 2/18/18 12:17 (GMT-05:00)

To: [log in to unmask]<mailto:[log in to unmask]>

Subject: Re: School shootings.......



Just because people will find a way to break laws does not mean that we shouldn’t have them. By that logic, we expect that all of us who are currently law abiding don’t need any laws to make us so. Human nature being what it is, we all need laws and structure. Yes, gun regulation would not stop all gun violence, but it could reduce it. Also, I don’t think the majority want prohibition of guns, just regulation; the same way alcohol is regulated by age and penalties for driving under the influence. Or, the way cars are regulated with licensing, registration, having to pass a driving test and citations for violations.







On Feb 18, 2018, at 8:42 AM, Horst D. Weinberg, MD <[log in to unmask]<mailto:[log in to unmask]>> wrote:







Yes, automatic weapons should be banned by our government, but most of the discussions posted blame the guns, the NRA, the 2nd amendment and our 'laws'. Nobody gets to the meat of the matter: If there is a demand (for guns), regardless of the laws passed, someone will fill that demand. This is no different from Prohibition, where there was no shortage of available booze or the 'war' on drugs, where you can get them at most street corners in any city. What needs to change: There has been a steady decline over the past 20 or so years in our country's moral fiber, personal and work ethic, and yes, child rearing. Cause: unmarried or one parent families, poverty, and absence of any discipline both in the home and in the schools, for 'political correctness'. Parents want to be friends with their children rather than running their homes like 'benevolent dictator ships'. Nothing is denied the child: the child wants $150.00 sneakers or a new cell-phone: no problem. So you can blame the gun all you want, but unless there is a real change in the populations personal morality and ethics, these school tragedies will continue.



We pediatricians should look at our own practices in teaching good child rearing ways to the families we serve. Horst D. Weinberg, MD



















For more information, send mail to [log in to unmask]<mailto:[log in to unmask]> with the message: info PED-EM-L



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------------------------------



End of PED-EM-L Digest - 17 Feb 2018 to 18 Feb 2018 (#2018-41)

**************************************************************



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------------------------------



Date: Mon, 19 Feb 2018 10:04:13 -0500

From: Michael Falk <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: PED-EM-L Digest - 17 Feb 2018 to 18 Feb 2018 (#2018-41)



Yes, Chicago has a unique problem with homicide. But if you actually look

at the list of the top 10 cities for homicide, and the same holds true for

states, you will find that the vast majority are in states with lax gun

laws. In fact, Chicago ranks 25 as of 2016 for homicide and if you look at

the full list I get that 4/30 are in states with tougher gun laws. I maybe

overreaching here, but that hardly seems like a "media hype" issue to me.



As for Chicago....they have one of the worst and most entrenched gang

cultures in the US. Given that, it's hardly the norm in this country and

should not be thought of as such. Finally, it happens to been within an

hour drive from a number of other states that have incredibly loose gun

laws and where it's very, very easy to purchase a gun and then transport it

back to Chicago and sell for a large profit.



Just my 2 cents....and a few public health facts.



On Mon, Feb 19, 2018 at 9:25 AM, Mick Work <[log in to unmask]<mailto:[log in to unmask]>> wrote:



https://urldefense.proofpoint.com/v2/url?u=http-3A__apps.chicagotribune.com_news_local_young-5Fvictims_&d=DwIGaQ&c=cjytLXgP8ixuoHflwc-poQ&r=iiLqIGJPj43rFwhy0umXiLW2YeM4w7OHtbhTpnjKXBI&m=t48oRvjGz5SVTSWYDRNskNM83f8PFATlPgGDaXkwwFA&s=X2M--MDdYYwsGrfHTv88WzYo6_er5JmsO6XsSZCiN0o&e=



10x the number of kids dying and they have stricter gun laws. Why do

these deaths draw so little attention? Yet suburban school shootings and

the shooter gets major coverage.



Is the media effectively and wisely moving public opinion around guns or

opioids etc or is it about reaction and ratings?



The government can’t solve issues any more than the c-suite can claim to

provide better care in hospitals through policy alone. Just my opinion.



Real solutions won’t come from laws or policy especially from those

distant from the problem and solely developed to satisfy media hype or

check a regulatory box.







Mick Connors







On Feb 19, 2018, at 12:00 AM, PED-EM-L automatic digest system <

[log in to unmask]<mailto:[log in to unmask]>> wrote:



There are 17 messages totaling 3381 lines in this issue.



Topics of the day:



1. School shootings....... (4)

2. PED-EM-L Digest - 15 Feb 2018 to 16 Feb 2018 (#2018-39) (3)

3. The shooting in Florida (9)

4. A second, more settled, reflection on the Florida shooting



For more information, send mail to [log in to unmask]<mailto:[log in to unmask]> with the

message: info PED-EM-L

The URL for the PED-EM-L Web Page is:

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----------------------------------------------------------------------



Date: Sat, 17 Feb 2018 21:57:25 -0500

From: "Horst D. Weinberg, MD"

<[log in to unmask]<mailto:[log in to unmask]>>

Subject: School shootings.......



Yes, automatic weapons should be banned by our government, but most of

the discussions posted blame the guns, the NRA, the 2nd amendment and our

'laws'. Nobody gets to the meat of the matter: If there is a demand (for

guns), regardless of the laws passed, someone will fill that demand. This

is no different from Prohibition, where there was no shortage of available

booze or the 'war' on drugs, where you can get them at most street corners

in any city. What needs to change: There has been a steady decline over the

past 20 or so years in our country's moral fiber, personal and work ethic,

and yes, child rearing. Cause: unmarried or one parent families, poverty,

and absence of any discipline both in the home and in the schools, for

'political correctness'. Parents want to be friends with their children

rather than running their homes like 'benevolent dictator ships'. Nothing

is denied the child: the child wants $150.00 sneakers or a new cell-phone:

no problem. So you can blame the gun all you want, but unless there is a

real change in the populations personal morality and ethics, these school

tragedies will continue.

We pediatricians should look at our own practices in teaching good child

rearing ways to the families we serve. Horst D. Weinberg, MD









For more information, send mail to [log in to unmask]<mailto:[log in to unmask]> with the

message: info PED-EM-L

The URL for the PED-EM-L Web Page is:

https://urldefense.proofpoint.com/v2/url?u=http-3A__listserv.brown.edu_ped-2Dem-2Dl.html&d=DwIGaQ&c=cjytLXgP8ixuoHflwc-poQ&r=iiLqIGJPj43rFwhy0umXiLW2YeM4w7OHtbhTpnjKXBI&m=t48oRvjGz5SVTSWYDRNskNM83f8PFATlPgGDaXkwwFA&s=WbnKabvCDEZlGP3t3JnZVQzkVoGMTS4hApYsWUL2GLY&e=



------------------------------



Date: Sun, 18 Feb 2018 06:13:44 -0500

From: Mick Work <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: PED-EM-L Digest - 15 Feb 2018 to 16 Feb 2018 (#2018-39)



I respect the need for debate around guns. However, I think we are

remiss as pediatric emergency physicians to not raise a deeper discussion

around the mental illness crisis.



We all see kids who meet this persons profile across the country. We see

disturbing mental illness and the many factors (including social media,

broken families, child abuse) that lead a child to buy a gun to do harm.

Or if not gun an explosive device etc..



We see kids who are socially isolated and warning signs ignored. Anyone

else concerned that the kids we see with mental illness are recognized by

schools or pediatric visit screening more often than by their own parents,

friends or neighbors.



This persons desire to be a “school shooter” should raise attention

around how the media covers these events. The fame brought to these

shooters should be called into question. Are we fostering this copycat

mentality?



The lack of respect for human life should call us to question more than

the how but why.



A focus only on guns and gun laws is remiss to the bigger picture in my

opinion and experience.



Mick







On Feb 17, 2018, at 12:01 AM, PED-EM-L automatic digest system <

[log in to unmask]<mailto:[log in to unmask]>> wrote:



There are 4 messages totaling 391 lines in this issue.



Topics of the day:



1. Peds EM talk (2)

2. Bacterial meningitis

3. The shooting in Florida



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----------------------------------------------------------------------



Date: Fri, 16 Feb 2018 11:50:44 -0500

From: Purva Grover <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: Peds EM talk



Thanks all for your help on this.

Best

Purva



Purva Grover , MD

Medical Director

Pediatric Emergency Department

Cleveland Clinic Health System

Email- [log in to unmask]<mailto:[log in to unmask]> <[log in to unmask]<mailto:[log in to unmask]>>g



On Thu, Feb 15, 2018 at 2:18 PM, <[log in to unmask]<mailto:[log in to unmask]>> wrote:



Hi All

I am giving an hour ppt to new PAs on Peds Emergencies. Clearly can not

cover ALL or even most. Any thoughts / talks / power points- you could

share would be appreciated.

Thanks

Purva



Sent from my mobile device



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------------------------------



Date: Fri, 16 Feb 2018 14:34:20 +0000

From: "Chamberlain, James" <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: Peds EM talk



I would also cover unusual cases that you can't afford to miss, e.g.



Sternoclavicular dislocation

Conjunctivitis caused by penetrating FB

Septic joint presenting with only low-grade fever (we've had several

Staph infections where temp was only 37.6 or 37.7 orally)

Myocarditis presenting as wheezing. Remind them that all

"bronchiolitis" patients need a through cardiac exam, including distal

pulses

NAT

The "sleepy" baby who has hypoglycemia

The "sleepy" baby who has intussusception

The appendicitis patient who presents with vomiting and diarrhea (not

all that unusual, actually)

Etc.



To me, this is the challenge of PEM. Finding the needle in the

haystack, that one sick kid who is different than all the usual low acuity

illness...



Jim



James Chamberlain

Division Chief, Emergency Medicine

Children’s National Health System

(202) 476-4177



-----Original Message-----

From: Pediatric Emergency Medicine Discussion List [mailto:

[log in to unmask]<mailto:[log in to unmask]>] On Behalf Of Mojica, Michael

Sent: Thursday, February 15, 2018 5:29 PM

To: [log in to unmask]<mailto:[log in to unmask]>

Subject: Re: Peds EM talk



Purva







I would recommend "the critically ill infant".







It is the topic that scares the most people and you can cover a lot of

causes through cases.







I like to use cases that include common presenting complaints (e.g.

vomiting) that are associated with very bad things (e.g. midgut volvulus).







I'm attaching a ppt file for a talk I did a few years ago on this topic.







My goal is for them to develop a mental checklist of potentially

life-saving interventions.







Michael







Michael Mojica, M.D



Director of Education, Division of Pediatric Emergency Medicine



Director, Pediatric Emergency Medicine Fellowship



Bellevue Hospital Center



Administration Building Room A528



New York, N.Y. 10016



[log in to unmask]<mailto:[log in to unmask]>



212-562-8147











On 2/15/18, 5:12 PM, "Pediatric Emergency Medicine Discussion List on

behalf of Purva Grover" <[log in to unmask]<mailto:[log in to unmask]> on behalf of

[log in to unmask]<mailto:[log in to unmask]>> wrote:







Hi All



I am giving an hour ppt to new PAs on Peds Emergencies. Clearly can

not cover ALL or even most. Any thoughts / talks / power points- you could

share would be appreciated.



Thanks



Purva







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------------------------------



Date: Fri, 16 Feb 2018 18:29:38 -0500

From: Aline Baghdassarian <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: Bacterial meningitis



Scott,



Would love to hear more about the cases. How did they present? What was

the

decision making process?



Thank you,



Aline



Aline Baghdassarian, MD, MPH, FAAP

Director, Pediatric Emergency Medicine Fellowship Program

Assistant Professor, Department of Emergency Medicine

Virginia Commonwealth University School of Medicine



Children's Hospital of Richmond at VCU

Email [log in to unmask]<mailto:[log in to unmask]>





On Thu, Feb 15, 2018 at 12:40 PM, Julian Orenstein <[log in to unmask]<mailto:[log in to unmask]>>

wrote:



In a recent case at our institution, there was a present but subtle

degree

of meningismus — I’ve found over the years there is always some

elicitable

sign — but as importantly there’s a degree of irritability or altered

behavior that has everyone concerned: mom, RN’s, me.

If mama ain't happy, I ain't happy. I’ll make liberal use of the term

cerebritis or encephalopathic behavior until there’s a consent signed.



I’m not such a good scientist anymore, but I’ve tried to be an

attentive

clinician.



Julian Orenstein





On Feb 14, 2018, at 3:30 PM, JAY FISHER <[log in to unmask]<mailto:[log in to unmask]>> wrote:



Scott - Bacterial meningitis is alive and well here in LV - we have

seen

it in a variety of age groups. There is good evidence that there has

been

an increase in pneumococcal serotypes not covered by the polyvalent

vaccines since there widespread use, such that the burden of

pneumococcal

meningitis (as opposed to H. flu type b) has not decreased nearly as

much.



Brouwer MC, van de Beek D. Epidemiology of community-acquired

bacterial

meningitis. Curr Opin Infect Dis. 2018;31(1):78-84.



Also, the absence of meningismus in older kids with bacterial

meningitis

is well described and occurs in a substantial subset.



Geiseler J, Nelson, K.E. Bacterial meningitis without clinical signs

of

meningeal irritation. . Southern Med J 1982;75(4):448-450.



Much of the data on the sensitivity of the neck exam is of the

retrospective variety. I have only read one really good prospective

study

on the sensitivity of PE for bacterial meningitis and it was a single

center variety as I recall.



Walsh-Kelly C, Nelson DB, Smith DS, et al. Clinical predictors of

bacterial versus aseptic meningitis in childhood. Ann Emerg Med.

1992;21(8):910-914.



Tough case.





Jay



Jay D. Fisher MD FAAP FACEP

Medical Director, Pediatric EM

Children's Hospital of Nevada at UMC

Clinical Professor of Emergency Medicine and Pediatrics

UNLV School of Medicine

















On February 14, 2018 at 4:18 PM "Conners, Gregory, P" <

[log in to unmask]<mailto:[log in to unmask]>> wrote:





I shared this with our ID director (Dr. Mary Anne Jackson), who

pointed

out that bacterial meningitis appears at this time of year as a

complication of influenza:

"Both pneumococcal and meningococcal meningitis can occur post flu as

well as GAS and S aureus invasive disease and TSS."



She also addressed Jim's question: "We do know that new serotypes

[of

pneumococcus] have emerged but this is not waning immunity because the

teen

only got PCV7".





Greg Conners



Gregory P. Conners, MD, MPH, MBA, FAAP, FACEP



Director, Division of Emergency Medicine

Associate Chair of Pediatrics

Professor of Pediatrics and Emergency Medicine

Children’s Mercy Hospital, Kansas City

University of Missouri, Kansas City

[log in to unmask]<mailto:[log in to unmask]>









-----Original Message-----

From: Pediatric Emergency Medicine Discussion List [mailto:

[log in to unmask]<mailto:[log in to unmask]>] On Behalf Of 000001679b145c30-dmarc-

[log in to unmask]<mailto:[log in to unmask]>

Sent: Wednesday, February 14, 2018 2:25 PM

To: [log in to unmask]<mailto:[log in to unmask]>

Subject: Re: Bacterial meningitis



*** This message was sent to you from an External Source. Please do

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________________________________





Could you share with us the clinical findings and history that

prompted

the LP?





Shiu-Lin









Shiu-Lin Tsai, MD

Division of Pediatric Emergency Medicine



Department of Emergency Medicine

Columbia University Medical Center







-----Original Message-----

From: Scott Freedman <[log in to unmask]<mailto:[log in to unmask]>>

To: PED-EM-L <[log in to unmask]<mailto:[log in to unmask]>>

Sent: Wed, Feb 14, 2018 2:44 pm

Subject: Bacterial meningitis



ALL:

Since Jan 1st this year, we have seen 3 cases of culture + bacterial

meningitis come through are ED; 2 with *Strep pneumoniae* and 1 with

*Neisseria meningiditis*. All 3 were in older children/ teens who

received

their Prevnar 13 vaccines as well as the Menactra series in the

patient

with Neisseria. Anyone else seeing cases of this sort? I do not

recall 3

cases of bacterial meningitis in older kids in a community setting

such as

ours in quite a long time. Is this random bad luck or do we all need

to

be more vigilant? Incidentally, none had neck pain or meningismus as a

clinical finding.



--

Kind regards,



Scott

Scott Freedman, MD

Medical Director, Pediatric Emergency Dept Rockville MD



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------------------------------



Date: Fri, 16 Feb 2018 18:29:08 -0500

From: Martin Pusic <[log in to unmask]<mailto:[log in to unmask]>>

Subject: The shooting in Florida



Hi colleagues,



As I sit in my office late on a Friday, I've gotten myself into a state

about the 17 children gunned down in a school. For the umpteenth time.



I think the thing that has me so upset, is that this state of gun

complaisance is an affront to everything a pediatric emergency physician

stands for. We sweat whether it's too risky when the WBC is 15.1 and not

14.9. We study 40,000 children in order sort out who deserves the x-ray

risk of a maybe brain tumor 30 years from now. We work in difficult,

burnout inducing conditions so that we can personally save, say, one life a

year.



Today it feels to me like someone with an AK-whatever just wiped out 17

years of my work. In minutes. I want to cry. We SHOULD cry. Try and

watch that Parkland mother on CNN. I dare you.



Today is not a day like all the others. It's just not.



--Martin Pusic



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------------------------------



End of PED-EM-L Digest - 15 Feb 2018 to 16 Feb 2018 (#2018-39)

**************************************************************



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------------------------------



Date: Sun, 18 Feb 2018 12:42:58 +0000

From: Terence Bergmann <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: The shooting in Florida



Hi Joe



I disagree about ‘strict gun control laws’ here having anything to do

with it . Either you or I could have a new hunting rifle in a week or two

in Canada. If you look at the school shootings or the Vegas massacre these

are not people who acquired their guns and went slaughtering. These guns

were acquired and the armamentarium prepped and the plans made. Canadian

laws would not stop this.



We have a different culture here in Canada. Guns are not toted around

in public. Thankfully the 49th parallel prevented the ‘western’ mentality

from flourishing on our side of the border. I don’t know why.



The challenge to end ‘their’ problem is that once the bad guys are armed

with illegal guns how do you stop the populace from wanting to have legal

guns?



Somehow other countries can have legal weapons, such as Swiss adults all

keeping their weapons at home after their years of mandatory service, yet

they don’t kill each other with them. Somehow a well armed militia there

does not lead to violence.



I have lots of questions, but I don’t know the answers.



Terence



On Feb 17, 2018, at 2:43 PM, Joe Nemeth, Dr <[log in to unmask]<mailto:[log in to unmask]>

<mailto:[log in to unmask]>> wrote:



Disclaimer: I live in Canada and love our very strict gun control laws.





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------------------------------



Date: Sun, 18 Feb 2018 14:31:22 +0000

From: "Habib, David" <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: The shooting in Florida



Repeal and replace the second amendment with a clear and contemporary

document. Dave Habib



________________________________________

From: Pediatric Emergency Medicine Discussion List [

[log in to unmask]<mailto:[log in to unmask]>] on behalf of Terence Bergmann [

[log in to unmask]<mailto:[log in to unmask]>]

Sent: Sunday, February 18, 2018 7:42 AM

To: [log in to unmask]<mailto:[log in to unmask]>

Subject: Re: The shooting in Florida







Hi Joe



I disagree about ‘strict gun control laws’ here having anything to do

with it . Either you or I could have a new hunting rifle in a week or two

in Canada. If you look at the school shootings or the Vegas massacre these

are not people who acquired their guns and went slaughtering. These guns

were acquired and the armamentarium prepped and the plans made. Canadian

laws would not stop this.



We have a different culture here in Canada. Guns are not toted around

in public. Thankfully the 49th parallel prevented the ‘western’ mentality

from flourishing on our side of the border. I don’t know why.



The challenge to end ‘their’ problem is that once the bad guys are armed

with illegal guns how do you stop the populace from wanting to have legal

guns?



Somehow other countries can have legal weapons, such as Swiss adults all

keeping their weapons at home after their years of mandatory service, yet

they don’t kill each other with them. Somehow a well armed militia there

does not lead to violence.



I have lots of questions, but I don’t know the answers.



Terence



On Feb 17, 2018, at 2:43 PM, Joe Nemeth, Dr <[log in to unmask]<mailto:[log in to unmask]>

<mailto:[log in to unmask]>> wrote:



Disclaimer: I live in Canada and love our very strict gun control laws.





For more information, send mail to [log in to unmask]<mailto:[log in to unmask]> with the

message: info PED-EM-L

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------------------------------



Date: Sun, 18 Feb 2018 14:04:25 +0000

From: Nathan Kuppermann <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: The shooting in Florida



Jeffrey and colleagues:



My colleague Garen Wintemute is an EM physician at UC Davis and has been

doing seminal work on firearm violence prevention for decades - doggedly

and with great impact



He is the director of the Violence Prevention Research Program (VPRP) at

UC Davis, and has been named a "hero of medicine" by Time Magazine in the

past for his work. He is as smart and accomplished as they come, and there

is nobody in the country who has been doing this longer or with greater

impact. And he has weathered the political and funding crises for this type

of work for years, frequently funding his own work when the political

climate for this work was bleak. But he has also received substantial

foundation money and federal grants during more supportive political times.



He recently received $5 million from the California state legislature to

lead the University of California Firearm Violence Research Center, the

first state-funded gun violence research center in the country.



Here is his entry in Wikipedia: https://urldefense.proofpoint.com/v2/url?u=https-3A__en.wikipedia.org_wiki_&d=DwIGaQ&c=cjytLXgP8ixuoHflwc-poQ&r=iiLqIGJPj43rFwhy0umXiLW2YeM4w7OHtbhTpnjKXBI&m=t48oRvjGz5SVTSWYDRNskNM83f8PFATlPgGDaXkwwFA&s=1kh3nrCXjOO0hjwcfYtYQLnVHIMkK17coy088jgPWNw&e=

Garen_Wintemute



If you are interested in his program or donating, here is the link:

https://urldefense.proofpoint.com/v2/url?u=http-3A__www.ucdmc.ucdavis.edu_vprp_&d=DwIGaQ&c=cjytLXgP8ixuoHflwc-poQ&r=iiLqIGJPj43rFwhy0umXiLW2YeM4w7OHtbhTpnjKXBI&m=t48oRvjGz5SVTSWYDRNskNM83f8PFATlPgGDaXkwwFA&s=y6AkLoGvtzbgZgJDAeqhImP2Ae_P1GrSzIOuDmcuDyo&e=



Full disclosure: I serve as the Chair of EM at UC Davis where Garen

works, but the only benefit to me for getting Garen more exposure or money

to the VPRP program that he oversees is my children and family whom I

desperately want to protect, my many friends throughout this great country

about whom I deeply care, and a country about which I am deeply concerned.



Nate Kuppermann

UC Davis







On Feb 17, 2018, at 3:03 PM, Jeffrey Oestreicher <[log in to unmask]<mailto:[log in to unmask]>

<mailto:[log in to unmask]>> wrote:



Thanks for this cathartic thread, Dr. Pusic and others. Hope fellows are

allowed to chime in. Like many on here my gut reaction is to focus on

politics, ie an assault weapons ban, the 2nd amendment etc. If Americans

were being killed by the same type of airplane that kept crashing, congress

would act. Why the same isn’t done with the AR-15 given that it keeps being

used to murder kids (in Sandy Hook, Aurora, Orlando, Las Vegas and now

Parkland) is maddening. But I wonder if we could do more by taking the lead

on another key gun violence issue on which physicians are experts. The

problem was encapsulated by the first few hours after the parkland shooting

when media outlets were literally arguing over how many school shootings

there have been in 2018. We don't even know! We don't know because there

are very little data on firearm injury/death in this country on account of

Congress blocking gun violence research funding since 1996. And this

funding block (the "Dickey amendment," named for the NRA point person in

Congress at the time) has created a political chill on research that has

trickled down even to academic medical centers. When I tried to examine NY

EMS data to look at pre-hospital intervention in pediatric firearm injury,

the city blocked it on account of the study being "too political." Where is

the research? When SIDs reached epidemic numbers in the 70’s, Congress

allocated funds for aggressive research leading to Back to Sleep campaign

and SIDS rates plummeted. Similar research campaigns produced life-saving

interventions for lead poisoning and car crashes. Yet no research crusade

has been directed at the epidemic of pediatric firearm death because

Congress essentially prohibits it. The hard part is trying to figure out

what to do about it. In my state of New York, A.2977/S.4363, sponsored by

New York State Assemblymember Jo Anne Simon and Senator Roxanne Persaud,

would create a Firearm Violence Research Institute in New York and I along

with some colleagues are trying to support this in a few different ways; if

others on here want to discuss or have other ideas pls be in touch. This is

not meant to discourage us from yelling from rooftops and writing senators

about background checks, assault weapons ban etc. That is so important. But

we have a unique vantage point with regard to public health research and

we're allowed to do it for every other public health problem except this

one. Thanks so much for allowing me to add my 2 cents



Sent from my iPhone



On Feb 17, 2018, at 3:43 PM, Joe Nemeth, Dr <[log in to unmask]<mailto:[log in to unmask]>

<mailto:[log in to unmask]>> wrote:



Martin,



As I sit in my living room on this Saturday morning, I’ve also gotten my

self in a state about how we tend to focus in on the small picture and

neglect an exponentially bigger one.



Spoiler Alert: this will NOT be a politically laced nor personally

biased post...as opposed to some of the previous posts on this issue - I'm

actually quite disappointed that politics had to rear its ugly head.



Disclaimer: I live in Canada and love our very strict gun control laws.

Don't claim to be a gun control policy expert



Now, allow me to expound:



1. A troubled young man AND inappropriate access to crazy weapons is

what caused this catastrophe.



Colleagues, I think we all agree that it would be too simplistic and

frankly naive to think that stricter gun control would solve all of these

gun related deaths...many examples of this false and misleading association

of tighter gun control means safer society here are just a few below...many

more:

-explore New Hampshire and Illinois...NH has very liberal gun control,

Chicago instead has very strict ones...look up who has more gun related

violent crime per capita...

-the Swiss gov't actually encourages gun ownership.. has one of the

highest rates of gun ownership in the world, but little gun-related street

crime

-Britain has more violent crime then the US (ban on guns since 1997)



From my viewpoint, attention is being focused in the wrong direction. I

think we as powerful respected advocates of "public health" should focus at

the root causes of the problem, starting with the breakdown of the family

(young males who are deprived of an active father figure are far more

likely to commit violent crimes), the relentless stream of violent

promoting behaviour from Hollywood, the exponential increase in mental

illness in youth to start with.



How come we don't lambast the horrendous violence coming out of

Hollywood which our youth are imbibing with negative consequences?



2. As per the CDC, in 2016, ~900 000 legal induced abortions were

reported from 49 reporting areas...likely a significant underestimate since

CA among other states does not report its numbers (BTW ~ 1.5% for

rape/incest, 3% for fetal health issues).



Without going into the classic arguments re pro/con, how can we not, how

do we not stand up for these children? I agree with the AAP's stance on gun

control but what I have trouble understanding is how the AAP does not weigh

in on the abortion issue (~10% of abortions are reported in females <19)?



17 children violently, meaninglessly murdered. An incredible tragedy.

How is this different then close to 1 million kids per year mentioned above.



I agree with the AAP's stance on gun control but what I have trouble

understanding is how the AAP does not weigh in on the abortion issue?





Joe











Joe Nemeth MD FCFP EM

Associate Professor

McGill University





________________________________________

From: Pediatric Emergency Medicine Discussion List <

[log in to unmask]<mailto:[log in to unmask]><mailto:[log in to unmask]>> on

behalf of Barry Nathan <[log in to unmask]<mailto:[log in to unmask]><mailto:[log in to unmask]>>

Sent: February 17, 2018 7:23:57 AM

To: [log in to unmask]<mailto:[log in to unmask]><mailto:[log in to unmask]>

Subject: Re: The shooting in Florida



In case you don't get emails from the AAP:



[image: AAP_400_61.jpg]







*Statement on School Shooting in Parkland, Florida*



from *Colleen A. Kraft, MD, FAAP, President, American Academy of

Pediatrics*



"Yesterday just before the dismissal bell rang, 17 children and adults

were

shot and killed and 15 were injured inside Marjory Stoneman Douglas High

School in Parkland, Fla. We find ourselves once again filled with grief

and

horror, and we mourn alongside all those impacted by the shooting. As our

hearts are in Parkland, our eyes are on Congress.



"This is the eighteenth school shooting in 2018, the equivalent of one

every two and a half days so far this year. Shootings have an indelible

impact on entire communities, on the families who lost children and loved

ones, and on the children who survived. Columbine. Virginia Tech.

Newtown.

Orlando. Las Vegas. And now, Parkland. Children are dying from gun

violence

and Congress is failing to act. Every one of our 100 U.S. senators, and

all

435 U.S. representatives bear a responsibility to take meaningful action

to

protect our children, our families, and our communities. Our elected

leaders cannot continue to fail at this most essential task.



"We can start by working to advance meaningful legislation that keeps

children safe. The American Academy of Pediatrics advocates for stronger

state and federal gun laws that protect children, including a ban on

assault weapons like the one used in yesterday's school shooting. We also

call for stronger background checks, solutions addressing firearm

trafficking, and encouraging safe firearm storage. We will also continue

to

work to ensure that children and their families have access to

appropriate

mental health services, particularly to address the effects of exposure

to

violence.



"Although these mass shootings command our attention, our children remain

at risk daily for suicide, homicide, and unintentional injury because of

the current policy regarding access to guns in the United States. Gun

violence is a public health threat to children, and one the American

Academy of Pediatrics will continue to take on, in state capitals across

the country and in the halls of Congress. Parents across the United

States

send their children to school every day, and hope and trust they will be

safe. As long as children continue to be injured and killed by guns in

this

country, pediatricians will not rest in our pursuit to keep them safe."



*The American Academy of Pediatrics is an organization of 66,000 primary

care pediatricians, pediatric medical subspecialists and pediatric

surgical

specialists dedicated to the health, safety and well-being of infants,

children, adolescents and young adults. For more information, visit *

www.aap.org<https://urldefense.proofpoint.com/v2/url?u=http-3A__www.aap.org&d=DwIGaQ&c=cjytLXgP8ixuoHflwc-poQ&r=iiLqIGJPj43rFwhy0umXiLW2YeM4w7OHtbhTpnjKXBI&m=t48oRvjGz5SVTSWYDRNskNM83f8PFATlPgGDaXkwwFA&s=GYHJ2Trg6KbD5HWur2hhBM8okfIlyE-J85UX7orhmA4&e=><https://urldefense.proofpoint.com/v2/url?u=http-3A__www.aap.org&d=DwIGaQ&c=cjytLXgP8ixuoHflwc-poQ&r=iiLqIGJPj43rFwhy0umXiLW2YeM4w7OHtbhTpnjKXBI&m=t48oRvjGz5SVTSWYDRNskNM83f8PFATlPgGDaXkwwFA&s=GYHJ2Trg6KbD5HWur2hhBM8okfIlyE-J85UX7orhmA4&e=>

<https://urldefense.proofpoint.com/v2/url?u=https-3A__linkprotect.cudasvc.com_url-3Fa-3Dhttp-3A__www.mmsend70&d=DwIGaQ&c=cjytLXgP8ixuoHflwc-poQ&r=iiLqIGJPj43rFwhy0umXiLW2YeM4w7OHtbhTpnjKXBI&m=t48oRvjGz5SVTSWYDRNskNM83f8PFATlPgGDaXkwwFA&s=VaK7XBUaLqPzHU7BXZRNTyxta7pSZ7KSoKKmkkBHZbQ&e=.

com/link.cfm%3fr%3dP1AWQRX2DH6KpZKp05dazA~~%26pe%3dBH4KXYJXftdV7_

OrPTTyUbVAzQsfgoRvleBm2XUVQ6AiEVwuBNacQ0AWbz2OcXguY6Y2i1bNdC

MkiPdWG-fHRg~~%26t%3dP2O93UltqkjSP1tT62_PaA~~&c=E,1,

EDnzTesKajviC9Rbq687pz7yfFyRgC2WBFw6mF1beQyzL2WYF_

fPWMjWxOixG1eagtp40GaUhhxZ8IL4zNcR4weeC1DLvkbbpHQsmMSnszDC&typo=1>*

and

follow us on Twitter @AmerAcadPeds.*



On Fri, Feb 16, 2018 at 9:22 PM, Chamberlain, James <

[log in to unmask]<mailto:[log in to unmask]>> wrote:



I think we need to move to repeal the second amendment. It's the only way

the NRA can be stopped. They resist all reasonable attempts to limit the

carnage and then hide behind a misinterpretation of the second amendment.



Very well, let's repeal it. I know many people agree that we don't need

militias any longer.



Jim Chamberlain







-----Original Message-----

From: Pediatric Emergency Medicine Discussion List [mailto:

[log in to unmask]<mailto:[log in to unmask]>] On Behalf Of Martin Pusic

Sent: Friday, February 16, 2018 6:29 PM

To: [log in to unmask]<mailto:[log in to unmask]>

Subject: The shooting in Florida



Hi colleagues,



As I sit in my office late on a Friday, I've gotten myself into a state

about the 17 children gunned down in a school. For the umpteenth time.



I think the thing that has me so upset, is that this state of gun

complaisance is an affront to everything a pediatric emergency physician

stands for. We sweat whether it's too risky when the WBC is 15.1 and not

14.9. We study 40,000 children in order sort out who deserves the x-ray

risk of a maybe brain tumor 30 years from now. We work in difficult,

burnout inducing conditions so that we can personally save, say, one

life a

year.



Today it feels to me like someone with an AK-whatever just wiped out 17

years of my work. In minutes. I want to cry. We SHOULD cry. Try and

watch that Parkland mother on CNN. I dare you.



Today is not a day like all the others. It's just not.



--Martin Pusic



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------------------------------



Date: Sun, 18 Feb 2018 10:20:42 -0500

From: Martin Pusic <[log in to unmask]<mailto:[log in to unmask]>>

Subject: A second, more settled, reflection on the Florida shooting



After my amygdala-based email of Friday, a clarification:



It is right and fit and proper that Pediatric Emergency Medicine

physicians bring the full force of our research and clinical armementarium

to bear on the problems of our patients. That means sweating thresholds of

WBC for their predictive value in infections. That means mounting massive

10 year PECARN/PERC/PERN level research efforts to understand in detail the

mechanisms of our patients' problems in order to benefit them in any way we

can. That's our laudable job. We should be proud of taking on the

problem of brain tumours 30 years from now. In no way did I mean to

denigrate those efforts. Instead, the complete opposite -- I think they

provide us with the moral authority to speak out against government

policies that harm children.



What is neither right nor fit nor proper is the ease with which a gun

violence proponent can wreak havoc at a scale that, on a given schoolday,

trivializes my efforts and those of my PEM colleagues. It feels like a

personal affront that we live in a nation in which somehow the NRA has

better government support than CHIP does. My point is not to devalue our

day/evening/night/weekend job.... we are doing MORE than our part in

society.......but rather to express that I, as a PEM physician, am rocked

to the core by the moral imbalance that makes it possible to routinely

leave 17 children dead. And that this is some sort of normal.



Some notes:

If you need an example of how routine this has become, one PEM

colleague wrote that he is going to his son's elementary school next week

to instruct the teachers on external control of hemorrhage

A Scot described the positive example of the way the Dunblane massacre

provoked a re-writing of their laws. They haven't had another in 22 years

since.

Fahd Ahmad from WashU had already written on this:

https://urldefense.proofpoint.com/v2/url?u=http-3A__www.roguedadmd.com_2018_02_how-2Dmany-2Dpeople-2Dand-2D&d=DwIGaQ&c=cjytLXgP8ixuoHflwc-poQ&r=iiLqIGJPj43rFwhy0umXiLW2YeM4w7OHtbhTpnjKXBI&m=t48oRvjGz5SVTSWYDRNskNM83f8PFATlPgGDaXkwwFA&s=PYtNS5WrdFNmfcGiM27bq7m9FivmIIqEV3JCHNFWYk4&e=

which-people-should-die-for-which-rights/

I learned of the positive examples of EM physicians taking this on

including Garen Wintemute of UC Davis and Eric Fleegler/Lois Lee at Boston

Children's.

thank you posting the AAP statement which properly represents our values

The majority of people who wrote back are mothers.



Finally, I commit to writing back, constructively, every 3 months on

this topic until there's nothing to write about





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------------------------------



Date: Sun, 18 Feb 2018 16:56:19 +0000

From: Doc Holiday <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: The shooting in Florida



Before I continue, I must say how much more comfortable this on-line

debate feels as compared to previous ones on other ListServs. I know it's a

generalising comment, but I keep finding that the insertion into the mix of

people who work with children makes everything so much more polite and

patient. If I recall correctly, there was a lot of anger and short

sentences last time I was involved in a debate on this topic on an "adult"

list....





From: Joe Nemeth, Dr <[log in to unmask]<mailto:[log in to unmask]>>

As I sit in my living room on this Saturday morning





--> My living room. Sunday afternoon. What else is there to do on a

weekend, eh?





I live in Canada and love our very strict gun control laws





--> As people know, I live in the UK at this time and I also like the

gun laws here (as well as ones on knives, etc). I don't feel as positive

about drug laws, but that's a different thread. Still, the point I made

before and make again now is that I don't think our gun laws are THE cause

of our statistics. I think they are but one (be it major) factor

contributing, but on the background of a culture which rejects gun

violence! I don't think that any society will change sufficiently merely by

their introduction - no matter how strict. I have lived for many years in

more than one country in which guns were far more common than they are in

the UK and these countries differed markedly in terms of gun violence. One

was actually on the same scale as the USA!





A troubled young man AND inappropriate access to crazy weapons is what

caused this catastrophe... too simplistic and frankly naive to think that

stricter gun control would solve all of these gun related deaths





--> I agree. And I would add that there are factors beyond the two you

mentioned. It's not even ONLY two factors. We can probably add to this:

- the lack of major societal backlash to inappropriate comments

- the tolerance of lack of free psychiatric care

- the overwhelming number of similar cases which will "drown" the

efforts of law enforcement to identify the cases which eventually go on to

this sort of event from among so many others, etc

- there will be more factors identified as this case gets investigated





One more point, though - a HUGE factor might be, as in past cases, if

the outrage dies down! The NRA and those who profit from guns will push

their politicians, including some of the more publicly-prominent ones and

they will keep things as quiet as possible. Possibly, even the next similar

event somehow will be used to make this one "disappear". You can recognise

the "silencing tactics" by indicator phrases such as:

- "Now is not the time..."

- "Country/state/city X ... bla-bla-bla ... And they have more/fewer

guns and more/fewer gun deaths and this random statistic thus means we

should stop looking into gun control"

- "My child just falls a lot" (sorry - had to put that in, as it's on

the same level)

- "The USA is a unique country and yet, when it suits me, I will find

some other one with which to make comparisons to prove my point"





Britain has more violent crime then the US (ban on guns since 1997)





--> I realise that I am picking up just one of the many points which

were listed together. I am only choosing this one because it's one I have

been familiar with for a very long time. It has been much "used" in order

to "prove" to Americans how the introduction of gun laws in the UK has left

it with a higher violent crime rate than the USA and should thus be avoided

by the USA. Now, I won't trouble the List by arguments about this. Instead,

I would appreciate it if y'all satisfy your own curiosities, each to

his/her own level, by going to a favourite search engine and searching for

the phrase "Britain has more violent crime then the US". You can read for

yourselves and save me from having to type up the actual facts...





But I can't stop myself from mentioning something which has come up in a

past discussion I was accidentally drawn into on a visit to the USA 3-4

years ago. This same myth was raised. That, in itself, was no surprise, but

it had been raised by someone who had already impressed me with how many

"facts" he had absorbed from social media sources and how confidently he

spoke of these despite appearing to be far less eloquent whenever

questioned in detail about anything. I.e., he appeared to me to have been

"brainwashed". Despite knowing better, I challenged him on why he thought

the USA was "doing so much better" than the UK in terms of violent crime.

He gave me the answer. He then mistook my look of disbelief to indicate I

did not believe the facts he had mentioned. He was wrong - what I did not

believe is that someone could be that easy to "sell" to. He pulled out his

phone and showed me the "evidence". No idea what you're sitting on as you

read this, but I hope it has handles for you to hang onto, so that you

don't fall to the ground laughing. The reason, according to this "expert"

for how the USA got to have what he claimed was 10 times less violent crime

than the UK is because the USA has taken the excellent pre-emptive step of

imprisoning those who would otherwise have engaged in violent crime! I kid

you not - he attributed the high level of violent crime he believed the UK

had, not to the fact that the UK records a huge number of offences which

the USA does not include in its statistics. What he showed me was:

https://urldefense.proofpoint.com/v2/url?u=https-3A__en.wikipedia.org_wiki_List-5Fof-5Fcountries-5Fby-5Fincarceration-5Frate&d=DwIGaQ&c=cjytLXgP8ixuoHflwc-poQ&r=iiLqIGJPj43rFwhy0umXiLW2YeM4w7OHtbhTpnjKXBI&m=t48oRvjGz5SVTSWYDRNskNM83f8PFATlPgGDaXkwwFA&s=U4gHJAeNgKwFDK4WRfsLUPol7JAm8n3364MaZLG1Co4&e=

(the version which was on line then). He had been "educated" to believe

that the fact that the USA had around a 10-time higher number of prisoners

than the UK per million of population correlated with how it achieved a

10-time lower rate of violent crime...





I expect one requires whole armies of people who can be thus educated in

order to perpetuate certain "facts"... Such people can be convinced of many

things...















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------------------------------



Date: Sun, 18 Feb 2018 12:00:26 -0500

From: Michael Falk <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: The shooting in Florida



While I get the despair and anger given the lose of 17 people in another

senseless mass shooting, I would caution people to not give up hope.

When

I first came to New York City in 1989, it was averaging about 2,000

homicides a year. If take our statistics for nonlethal injuries per

homicide, roughly 7:1, the city was seeing another 10,000 plus

penetrating

traumas and I have not even mentioned the assaults with fists or blunt

objects. Last year in NYC, we had less than 400 homicides and the city

is

safer than it has been in years. Why? Well, there was a concerted

effort

to change the culture of policing and law enforcement in the city, and

there was a massive crackdown on guns and getting them off the streets.

The laws were changed around gun ownership and licensing, and there you

have it....



Also, many of you are forgetting that we had an assault weapons law in

the

US and Bush/Congress let it lapse in 2003. Now it's record is a mixed

bag

but I think that if we learn from the mistakes we made the last time, and

write a better law, we can actually have a significant impact.



Just my two cents..

Mike Falk

NYC.



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------------------------------



Date: Sun, 18 Feb 2018 17:09:24 +0000

From: Robert Finkelstein <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: PED-EM-L Digest - 15 Feb 2018 to 16 Feb 2018 (#2018-39)



Other countries have the same level of mental illness as the United

States, but not nearly the number of gun deaths. The mental health issue is

important but access to weapons that can kill a large number of people in

seconds allows the results we see. In addition, access to guns plays a

huge role in suicides since many who attempt suicide and do not succeed

will get help and not attempt again. However, access to a gun makes it much

more likely that the first attempt will result in death.



Robert Finkelstein



On Feb 18, 2018, at 8:42 AM, Mick Work <[log in to unmask]<mailto:[log in to unmask]>> wrote:



I respect the need for debate around guns. However, I think we are

remiss as pediatric emergency physicians to not raise a deeper discussion

around the mental illness crisis.



We all see kids who meet this persons profile across the country. We

see disturbing mental illness and the many factors (including social media,

broken families, child abuse) that lead a child to buy a gun to do harm.

Or if not gun an explosive device etc..



We see kids who are socially isolated and warning signs ignored.

Anyone else concerned that the kids we see with mental illness are

recognized by schools or pediatric visit screening more often than by their

own parents, friends or neighbors.



This persons desire to be a “school shooter” should raise attention

around how the media covers these events. The fame brought to these

shooters should be called into question. Are we fostering this copycat

mentality?



The lack of respect for human life should call us to question more than

the how but why.



A focus only on guns and gun laws is remiss to the bigger picture in my

opinion and experience.



Mick







On Feb 17, 2018, at 12:01 AM, PED-EM-L automatic digest system <

[log in to unmask]<mailto:[log in to unmask]>> wrote:



There are 4 messages totaling 391 lines in this issue.



Topics of the day:



1. Peds EM talk (2)

2. Bacterial meningitis

3. The shooting in Florida



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----------------------------------------------------------------------



Date: Fri, 16 Feb 2018 11:50:44 -0500

From: Purva Grover <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: Peds EM talk



Thanks all for your help on this.

Best

Purva



Purva Grover , MD

Medical Director

Pediatric Emergency Department

Cleveland Clinic Health System

Email- [log in to unmask]<mailto:[log in to unmask]> <[log in to unmask]<mailto:[log in to unmask]>>g



On Thu, Feb 15, 2018 at 2:18 PM, <[log in to unmask]<mailto:[log in to unmask]>> wrote:



Hi All

I am giving an hour ppt to new PAs on Peds Emergencies. Clearly can

not

cover ALL or even most. Any thoughts / talks / power points- you could

share would be appreciated.

Thanks

Purva



Sent from my mobile device



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------------------------------



Date: Fri, 16 Feb 2018 14:34:20 +0000

From: "Chamberlain, James" <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: Peds EM talk



I would also cover unusual cases that you can't afford to miss, e.g.



Sternoclavicular dislocation

Conjunctivitis caused by penetrating FB

Septic joint presenting with only low-grade fever (we've had several

Staph infections where temp was only 37.6 or 37.7 orally)

Myocarditis presenting as wheezing. Remind them that all

"bronchiolitis" patients need a through cardiac exam, including distal

pulses

NAT

The "sleepy" baby who has hypoglycemia

The "sleepy" baby who has intussusception

The appendicitis patient who presents with vomiting and diarrhea (not

all that unusual, actually)

Etc.



To me, this is the challenge of PEM. Finding the needle in the

haystack, that one sick kid who is different than all the usual low acuity

illness...



Jim



James Chamberlain

Division Chief, Emergency Medicine

Children’s National Health System

(202) 476-4177



-----Original Message-----

From: Pediatric Emergency Medicine Discussion List [mailto:

[log in to unmask]<mailto:[log in to unmask]>] On Behalf Of Mojica, Michael

Sent: Thursday, February 15, 2018 5:29 PM

To: [log in to unmask]<mailto:[log in to unmask]>

Subject: Re: Peds EM talk



Purva







I would recommend "the critically ill infant".







It is the topic that scares the most people and you can cover a lot of

causes through cases.







I like to use cases that include common presenting complaints (e.g.

vomiting) that are associated with very bad things (e.g. midgut volvulus).







I'm attaching a ppt file for a talk I did a few years ago on this

topic.







My goal is for them to develop a mental checklist of potentially

life-saving interventions.







Michael







Michael Mojica, M.D



Director of Education, Division of Pediatric Emergency Medicine



Director, Pediatric Emergency Medicine Fellowship



Bellevue Hospital Center



Administration Building Room A528



New York, N.Y. 10016



[log in to unmask]<mailto:[log in to unmask]>



212-562-8147











On 2/15/18, 5:12 PM, "Pediatric Emergency Medicine Discussion List on

behalf of Purva Grover" <[log in to unmask]<mailto:[log in to unmask]> on behalf of

[log in to unmask]<mailto:[log in to unmask]>> wrote:







Hi All



I am giving an hour ppt to new PAs on Peds Emergencies. Clearly can

not cover ALL or even most. Any thoughts / talks / power points- you could

share would be appreciated.



Thanks



Purva







Sent from my mobile device



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------------------------------



Date: Fri, 16 Feb 2018 18:29:38 -0500

From: Aline Baghdassarian <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: Bacterial meningitis



Scott,



Would love to hear more about the cases. How did they present? What

was the

decision making process?



Thank you,



Aline



Aline Baghdassarian, MD, MPH, FAAP

Director, Pediatric Emergency Medicine Fellowship Program

Assistant Professor, Department of Emergency Medicine

Virginia Commonwealth University School of Medicine



Children's Hospital of Richmond at VCU

Email [log in to unmask]<mailto:[log in to unmask]>





On Thu, Feb 15, 2018 at 12:40 PM, Julian Orenstein <[log in to unmask]<mailto:[log in to unmask]>>

wrote:



In a recent case at our institution, there was a present but subtle

degree

of meningismus — I’ve found over the years there is always some

elicitable

sign — but as importantly there’s a degree of irritability or altered

behavior that has everyone concerned: mom, RN’s, me.

If mama ain't happy, I ain't happy. I’ll make liberal use of the term

cerebritis or encephalopathic behavior until there’s a consent signed.



I’m not such a good scientist anymore, but I’ve tried to be an

attentive

clinician.



Julian Orenstein





On Feb 14, 2018, at 3:30 PM, JAY FISHER <[log in to unmask]<mailto:[log in to unmask]>> wrote:



Scott - Bacterial meningitis is alive and well here in LV - we have

seen

it in a variety of age groups. There is good evidence that there has

been

an increase in pneumococcal serotypes not covered by the polyvalent

vaccines since there widespread use, such that the burden of

pneumococcal

meningitis (as opposed to H. flu type b) has not decreased nearly as

much.



Brouwer MC, van de Beek D. Epidemiology of community-acquired

bacterial

meningitis. Curr Opin Infect Dis. 2018;31(1):78-84.



Also, the absence of meningismus in older kids with bacterial

meningitis

is well described and occurs in a substantial subset.



Geiseler J, Nelson, K.E. Bacterial meningitis without clinical signs

of

meningeal irritation. . Southern Med J 1982;75(4):448-450.



Much of the data on the sensitivity of the neck exam is of the

retrospective variety. I have only read one really good prospective

study

on the sensitivity of PE for bacterial meningitis and it was a single

center variety as I recall.



Walsh-Kelly C, Nelson DB, Smith DS, et al. Clinical predictors of

bacterial versus aseptic meningitis in childhood. Ann Emerg Med.

1992;21(8):910-914.



Tough case.





Jay



Jay D. Fisher MD FAAP FACEP

Medical Director, Pediatric EM

Children's Hospital of Nevada at UMC

Clinical Professor of Emergency Medicine and Pediatrics

UNLV School of Medicine

















On February 14, 2018 at 4:18 PM "Conners, Gregory, P" <

[log in to unmask]<mailto:[log in to unmask]>> wrote:





I shared this with our ID director (Dr. Mary Anne Jackson), who

pointed

out that bacterial meningitis appears at this time of year as a

complication of influenza:

"Both pneumococcal and meningococcal meningitis can occur post flu

as

well as GAS and S aureus invasive disease and TSS."



She also addressed Jim's question: "We do know that new serotypes

[of

pneumococcus] have emerged but this is not waning immunity because

the teen

only got PCV7".





Greg Conners



Gregory P. Conners, MD, MPH, MBA, FAAP, FACEP



Director, Division of Emergency Medicine

Associate Chair of Pediatrics

Professor of Pediatrics and Emergency Medicine

Children’s Mercy Hospital, Kansas City

University of Missouri, Kansas City

[log in to unmask]<mailto:[log in to unmask]>









-----Original Message-----

From: Pediatric Emergency Medicine Discussion List [mailto:

[log in to unmask]<mailto:[log in to unmask]>] On Behalf Of 000001679b145c30-dmarc-

[log in to unmask]<mailto:[log in to unmask]>

Sent: Wednesday, February 14, 2018 2:25 PM

To: [log in to unmask]<mailto:[log in to unmask]>

Subject: Re: Bacterial meningitis



*** This message was sent to you from an External Source. Please do

not

open untrusted links or attachments. ***



________________________________





Could you share with us the clinical findings and history that

prompted

the LP?





Shiu-Lin









Shiu-Lin Tsai, MD

Division of Pediatric Emergency Medicine



Department of Emergency Medicine

Columbia University Medical Center







-----Original Message-----

From: Scott Freedman <[log in to unmask]<mailto:[log in to unmask]>>

To: PED-EM-L <[log in to unmask]<mailto:[log in to unmask]>>

Sent: Wed, Feb 14, 2018 2:44 pm

Subject: Bacterial meningitis



ALL:

Since Jan 1st this year, we have seen 3 cases of culture + bacterial

meningitis come through are ED; 2 with *Strep pneumoniae* and 1 with

*Neisseria meningiditis*. All 3 were in older children/ teens who

received

their Prevnar 13 vaccines as well as the Menactra series in the

patient

with Neisseria. Anyone else seeing cases of this sort? I do not

recall 3

cases of bacterial meningitis in older kids in a community setting

such as

ours in quite a long time. Is this random bad luck or do we all

need to

be more vigilant? Incidentally, none had neck pain or meningismus as

a

clinical finding.



--

Kind regards,



Scott

Scott Freedman, MD

Medical Director, Pediatric Emergency Dept Rockville MD



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------------------------------



Date: Fri, 16 Feb 2018 18:29:08 -0500

From: Martin Pusic <[log in to unmask]<mailto:[log in to unmask]>>

Subject: The shooting in Florida



Hi colleagues,



As I sit in my office late on a Friday, I've gotten myself into a

state about the 17 children gunned down in a school. For the umpteenth

time.



I think the thing that has me so upset, is that this state of gun

complaisance is an affront to everything a pediatric emergency physician

stands for. We sweat whether it's too risky when the WBC is 15.1 and not

14.9. We study 40,000 children in order sort out who deserves the x-ray

risk of a maybe brain tumor 30 years from now. We work in difficult,

burnout inducing conditions so that we can personally save, say, one life a

year.



Today it feels to me like someone with an AK-whatever just wiped out

17 years of my work. In minutes. I want to cry. We SHOULD cry. Try and

watch that Parkland mother on CNN. I dare you.



Today is not a day like all the others. It's just not.



--Martin Pusic



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------------------------------



End of PED-EM-L Digest - 15 Feb 2018 to 16 Feb 2018 (#2018-39)

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------------------------------



Date: Sun, 18 Feb 2018 10:17:05 -0500

From: Deepti Thomas-Paulose <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: The shooting in Florida



The year speed limit laws went into effect-->traffic deaths down 17%.

Mothers against Drunk Driving, stricter DUI enforcement laws-->cut

deaths

due to drunk driving by half every year since 1980. Seat belt safety

laws,

traffic laws-all created to protect the public. As a public health

trained

physician, it seems so illogical to me that we would not create stricter

gun laws especially against military style guns for the civilian

population. Let's start there.



Problem- Mass shootings

Prevention- Ban assault rifles





On Sun, Feb 18, 2018 at 7:42 AM, Terence Bergmann <

[log in to unmask]<mailto:[log in to unmask]>> wrote:



Hi Joe



I disagree about ‘strict gun control laws’ here having anything to do

with

it . Either you or I could have a new hunting rifle in a week or two in

Canada. If you look at the school shootings or the Vegas massacre these

are not people who acquired their guns and went slaughtering. These

guns

were acquired and the armamentarium prepped and the plans made.

Canadian

laws would not stop this.



We have a different culture here in Canada. Guns are not toted around

in

public. Thankfully the 49th parallel prevented the ‘western’ mentality

from flourishing on our side of the border. I don’t know why.



The challenge to end ‘their’ problem is that once the bad guys are armed

with illegal guns how do you stop the populace from wanting to have

legal

guns?



Somehow other countries can have legal weapons, such as Swiss adults all

keeping their weapons at home after their years of mandatory service,

yet

they don’t kill each other with them. Somehow a well armed militia

there

does not lead to violence.



I have lots of questions, but I don’t know the answers.



Terence



On Feb 17, 2018, at 2:43 PM, Joe Nemeth, Dr <[log in to unmask]<mailto:[log in to unmask]>

<mailto:j

[log in to unmask]<mailto:[log in to unmask]>>> wrote:



Disclaimer: I live in Canada and love our very strict gun control laws.





For more information, send mail to [log in to unmask]<mailto:[log in to unmask]> with the

message: info PED-EM-L

The URL for the PED-EM-L Web Page is:

https://urldefense.proofpoint.com/v2/url?u=http-3A__listserv.brown.edu_ped-2Dem-2Dl.html&d=DwIGaQ&c=cjytLXgP8ixuoHflwc-poQ&r=iiLqIGJPj43rFwhy0umXiLW2YeM4w7OHtbhTpnjKXBI&m=t48oRvjGz5SVTSWYDRNskNM83f8PFATlPgGDaXkwwFA&s=WbnKabvCDEZlGP3t3JnZVQzkVoGMTS4hApYsWUL2GLY&e=









--

Deepti Thomas-Paulose, MD, MPH

Fellowship Director

Global Health Division

Mt. Sinai St.Luke's Roosevelt Hospital Center

https://urldefense.proofpoint.com/v2/url?u=http-3A__www.slredglobalhealth.org&d=DwIGaQ&c=cjytLXgP8ixuoHflwc-poQ&r=iiLqIGJPj43rFwhy0umXiLW2YeM4w7OHtbhTpnjKXBI&m=t48oRvjGz5SVTSWYDRNskNM83f8PFATlPgGDaXkwwFA&s=D3bvjwGdQp2RN9jDOl4BSMlphh63sYQrLWvNUrRTFAY&e=



For more information, send mail to [log in to unmask]<mailto:[log in to unmask]> with the

message: info PED-EM-L

The URL for the PED-EM-L Web Page is:

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------------------------------



Date: Sun, 18 Feb 2018 17:15:53 +0000

From: Robert Finkelstein <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: School shootings.......



Just because people will find a way to break laws does not mean that we

shouldn’t have them. By that logic, we expect that all of us who are

currently law abiding don’t need any laws to make us so. Human nature

being what it is, we all need laws and structure. Yes, gun regulation

would not stop all gun violence, but it could reduce it. Also, I don’t

think the majority want prohibition of guns, just regulation; the same way

alcohol is regulated by age and penalties for driving under the influence.

Or, the way cars are regulated with licensing, registration, having to pass

a driving test and citations for violations.



On Feb 18, 2018, at 8:42 AM, Horst D. Weinberg, MD <

[log in to unmask]<mailto:[log in to unmask]>> wrote:



Yes, automatic weapons should be banned by our government, but most of

the discussions posted blame the guns, the NRA, the 2nd amendment and our

'laws'. Nobody gets to the meat of the matter: If there is a demand (for

guns), regardless of the laws passed, someone will fill that demand. This

is no different from Prohibition, where there was no shortage of available

booze or the 'war' on drugs, where you can get them at most street corners

in any city. What needs to change: There has been a steady decline over the

past 20 or so years in our country's moral fiber, personal and work ethic,

and yes, child rearing. Cause: unmarried or one parent families, poverty,

and absence of any discipline both in the home and in the schools, for

'political correctness'. Parents want to be friends with their children

rather than running their homes like 'benevolent dictator ships'. Nothing

is denied the child: the child wants $150.00 sneakers or a new cell-phone:

no problem. So you can blame the gun all you want, but unless there is a

real change in the populations personal morality and ethics, these school

tragedies will continue.

We pediatricians should look at our own practices in teaching good

child rearing ways to the families we serve. Horst D. Weinberg, MD









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the message: info PED-EM-L

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------------------------------



Date: Sun, 18 Feb 2018 17:26:11 +0000

From: Robert Flood <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: The shooting in Florida



Dear Colleagues:





This conversation gives me some hope that we can and will address the

issue of gun violence through the scientific approach, rather than

"beliefs" and "feelings", similar to the way that Dr. Wintemute has done

for the past several decades. While I fully support a

"re-evaluation/clarification" of the second amendment, a "Children's Rights

Amendment", and other legislation to help curb gun violence in the US, we

can and and should evaluate potential interventions now in the context of

over 350 million guns, with unlimited ammunition, available to the US

public.





So, if we are going to use the scientific approach to this huge public

health emergency that clearly endangers our children, we really should

break up the huge scope of "gun violence" into unique subsets, including

but not limited to the following:





1) Mass Shootings: Unfortunately, the US leads the entire world in the

number of mass shootings, which may be more properly categorized as "mass

suicides" since these shooters usually have no intention of surviving their

murderous rampages. Clearly, the evidence shows a direct correlation with

the elimination on the band on assault rifles and the increase in the

number and deaths in these incidents. So, everyone's comments on the access

to better mental health should be just one aspect of the study of all

potential interventions. For instance, even pediatricians must admit that

if we had armed security in every school, perhaps with the national guard,

we would likely decrease the number of gun related deaths/year in our

schools. However, we would need to study that model to prove our hypothesis

rather than saying "I believe this will work". Still, Mass Shooting Deaths

are only a tiny percentage of gun deaths in the US in any given year. In

fact, if we eliminated every single mass shooting gun death and injury in

the US, it would have a negligible impact on gun related death and injury

rates.





2) Intentional Hand Gun Violence: We continue to have disturbing data

regarding intentional handgun injuries, especially in the inner city

African American communities. With over 100 K gun related injuries/year,

and over 10 k non-suicidal gun related deaths/year, this is a very

different problem than "Mass Shootings" and needs to be studied in very

different ways. Within this category there are both domestic (ie, in the

home) and non-domestic sub-categories, which will likely require very

different interventions. For instance, in Saint Louis, MO, we are

participating in a 4 hospital (all level 1 trauma centers), 2 university

intervention program whereby social worker mentors will be paired with

willing participants who present as victims of gun violence with the goal

of preventing recidivism as either a victim or a perpetrator.





3) Suicides: The data is consistent and very alarming: over 20 K

deaths/year from suicides with a gun. The overwhelming majority of these

deaths are due to access to handguns and ammunition in the homes. So, while

our limited data allows us to recommend that guns and ammunition be stored

and locked separately, we don't know for sure whether this would have

significant impact on intentional suicides by teenagers, who often have

access to both of these locked items. So, we need to study this in much

greater detail, and offer viable solutions to well intentioned individuals

who are trying to "protect their families".





4) Accidental Shootings: As we all have friends who own one or more

weapons, it is often difficult to convince them that the weapon in the home

greatly increases the risk of one of their loved ones being the victim of

that weapon. Rather, these often well intentioned families in the suburban

and rural areas, who honestly believe that having a loaded gun will protect

their families from the very, very unlikely chance of a home invasion, will

actually endanger their loved ones simply by bringing guns into the home.

On the other hand, in the inner city where gun violence is part of everyday

life, families believe having the loaded gun readily available (unlocked,

fully loaded) allows them to better protect their loved ones from the

reality of their situation. So, when we, as healthcare providers, care for

the young children who "accidentally" shoot themselves, we are particularly

frustrated and angered by the tragedy of the entire plight of these

families. The point is this: these very different groups may require very

different approaches with respect to interventions.







I look forward to the continued dialogue, and, more importantly,

continued research in these areas.





Bob Flood



Saint Louis University







________________________________

From: Pediatric Emergency Medicine Discussion List <

[log in to unmask]<mailto:[log in to unmask]>> on behalf of Nathan Kuppermann <

[log in to unmask]<mailto:[log in to unmask]>>

Sent: Sunday, February 18, 2018 8:04:25 AM

To: [log in to unmask]<mailto:[log in to unmask]>

Subject: Re: The shooting in Florida



Jeffrey and colleagues:







My colleague Garen Wintemute is an EM physician at UC Davis and has been

doing seminal work on firearm violence prevention for decades - doggedly

and with great impact







He is the director of the Violence Prevention Research Program (VPRP) at

UC Davis, and has been named a "hero of medicine" by Time Magazine in the

past for his work. He is as smart and accomplished as they come, and there

is nobody in the country who has been doing this longer or with greater

impact. And he has weathered the political and funding crises for this type

of work for years, frequently funding his own work when the political

climate for this work was bleak. But he has also received substantial

foundation money and federal grants during more supportive political times.







He recently received $5 million from the California state legislature to

lead the University of California Firearm Violence Research Center, the

first state-funded gun violence research center in the country.







Here is his entry in Wikipedia: https://urldefense.proofpoint.com/v2/url?u=https-3A__urldefense.proofpoint&d=DwIGaQ&c=cjytLXgP8ixuoHflwc-poQ&r=iiLqIGJPj43rFwhy0umXiLW2YeM4w7OHtbhTpnjKXBI&m=t48oRvjGz5SVTSWYDRNskNM83f8PFATlPgGDaXkwwFA&s=d0mALrOoha-lMmeSsKSDYyFao-oIcmA4DlVrUBl1KbE&e=.

com/v2/url?u=https-3A__en.wikipedia.org_wiki_Garen-

5FWintemute&d=DwIGaQ&c=Pk_HpaIpE_jAoEC9PLIWoQ&r=PgyaJu_-

6fURaaWELlGskCQzpkXWZSDQU-w6tbGwwMM&m=kjmFQ1KpfStKxhcvfi4QpgjqumdRH2

TVpCIOAggcCW0&s=MwtCq_L-kQIs3_poo8ESXJUfQXyAfM2mv3_BCZ2sBPo&e=







If you are interested in his program or donating, here is the link:

https://urldefense.proofpoint.com/v2/url?u=http-3A__www.

ucdmc.ucdavis.edu_vprp_&d=DwIGaQ&c=Pk_HpaIpE_jAoEC9PLIWoQ&r=PgyaJu_-

6fURaaWELlGskCQzpkXWZSDQU-w6tbGwwMM&m=kjmFQ1KpfStKxhcvfi4QpgjqumdRH2

TVpCIOAggcCW0&s=km0yMXq80C4DGUQlje9yL-_xAQ5OiKQNooiyry9xUC0&e=







Full disclosure: I serve as the Chair of EM at UC Davis where Garen

works, but the only benefit to me for getting Garen more exposure or money

to the VPRP program that he oversees is my children and family whom I

desperately want to protect, my many friends throughout this great country

about whom I deeply care, and a country about which I am deeply concerned.







Nate Kuppermann



UC Davis















On Feb 17, 2018, at 3:03 PM, Jeffrey Oestreicher <[log in to unmask]<mailto:[log in to unmask]>

<mailto:[log in to unmask]>> wrote:







Thanks for this cathartic thread, Dr. Pusic and others. Hope fellows are

allowed to chime in. Like many on here my gut reaction is to focus on

politics, ie an assault weapons ban, the 2nd amendment etc. If Americans

were being killed by the same type of airplane that kept crashing, congress

would act. Why the same isn’t done with the AR-15 given that it keeps being

used to murder kids (in Sandy Hook, Aurora, Orlando, Las Vegas and now

Parkland) is maddening. But I wonder if we could do more by taking the lead

on another key gun violence issue on which physicians are experts. The

problem was encapsulated by the first few hours after the parkland shooting

when media outlets were literally arguing over how many school shootings

there have been in 2018. We don't even know! We don't know because there

are very little data on firearm injury/death in this country on account of

Congress blocking gun violence research funding since 1996. And this

funding block (the "Dickey amendment," named for the NRA point person in

Congress at the time) has created a political chill on research that has

trickled down even to academic medical centers. When I tried to examine NY

EMS data to look at pre-hospital intervention in pediatric firearm injury,

the city blocked it on account of the study being "too political." Where is

the research? When SIDs reached epidemic numbers in the 70’s, Congress

allocated funds for aggressive research leading to Back to Sleep campaign

and SIDS rates plummeted. Similar research campaigns produced life-saving

interventions for lead poisoning and car crashes. Yet no research crusade

has been directed at the epidemic of pediatric firearm death because

Congress essentially prohibits it. The hard part is trying to figure out

what to do about it. In my state of New York, A.2977/S.4363, sponsored by

New York State Assemblymember Jo Anne Simon and Senator Roxanne Persaud,

would create a Firearm Violence Research Institute in New York and I along

with some colleagues are trying to support this in a few different ways; if

others on here want to discuss or have other ideas pls be in touch. This is

not meant to discourage us from yelling from rooftops and writing senators

about background checks, assault weapons ban etc. That is so important. But

we have a unique vantage point with regard to public health research and

we're allowed to do it for every other public health problem except this

one. Thanks so much for allowing me to add my 2 cents







Sent from my iPhone







On Feb 17, 2018, at 3:43 PM, Joe Nemeth, Dr <[log in to unmask]<mailto:[log in to unmask]>

<mailto:[log in to unmask]>> wrote:







Martin,







As I sit in my living room on this Saturday morning, I’ve also gotten my

self in a state about how we tend to focus in on the small picture and

neglect an exponentially bigger one.







Spoiler Alert: this will NOT be a politically laced nor personally

biased post...as opposed to some of the previous posts on this issue - I'm

actually quite disappointed that politics had to rear its ugly head.







Disclaimer: I live in Canada and love our very strict gun control laws.



Don't claim to be a gun control policy expert







Now, allow me to expound:







1. A troubled young man AND inappropriate access to crazy weapons is

what caused this catastrophe.







Colleagues, I think we all agree that it would be too simplistic and

frankly naive to think that stricter gun control would solve all of these

gun related deaths...many examples of this false and misleading association

of tighter gun control means safer society here are just a few below...many

more:



-explore New Hampshire and Illinois...NH has very liberal gun control,

Chicago instead has very strict ones...look up who has more gun related

violent crime per capita...



-the Swiss gov't actually encourages gun ownership.. has one of the

highest rates of gun ownership in the world, but little gun-related street

crime



-Britain has more violent crime then the US (ban on guns since 1997)







From my viewpoint, attention is being focused in the wrong direction. I

think we as powerful respected advocates of "public health" should focus at

the root causes of the problem, starting with the breakdown of the family

(young males who are deprived of an active father figure are far more

likely to commit violent crimes), the relentless stream of violent

promoting behaviour from Hollywood, the exponential increase in mental

illness in youth to start with.







How come we don't lambast the horrendous violence coming out of

Hollywood which our youth are imbibing with negative consequences?







2. As per the CDC, in 2016, ~900 000 legal induced abortions were

reported from 49 reporting areas...likely a significant underestimate since

CA among other states does not report its numbers (BTW ~ 1.5% for

rape/incest, 3% for fetal health issues).







Without going into the classic arguments re pro/con, how can we not, how

do we not stand up for these children? I agree with the AAP's stance on gun

control but what I have trouble understanding is how the AAP does not weigh

in on the abortion issue (~10% of abortions are reported in females <19)?







17 children violently, meaninglessly murdered. An incredible tragedy.

How is this different then close to 1 million kids per year mentioned above.







I agree with the AAP's stance on gun control but what I have trouble

understanding is how the AAP does not weigh in on the abortion issue?











Joe























Joe Nemeth MD FCFP EM



Associate Professor



McGill University











________________________________________



From: Pediatric Emergency Medicine Discussion List <

[log in to unmask]<mailto:[log in to unmask]><mailto:[log in to unmask]>> on

behalf of Barry Nathan <[log in to unmask]<mailto:[log in to unmask]><mailto:[log in to unmask]>>



Sent: February 17, 2018 7:23:57 AM



To: [log in to unmask]<mailto:[log in to unmask]><mailto:[log in to unmask]>



Subject: Re: The shooting in Florida







In case you don't get emails from the AAP:







[image: AAP_400_61.jpg]















*Statement on School Shooting in Parkland, Florida*







from *Colleen A. Kraft, MD, FAAP, President, American Academy of

Pediatrics*







"Yesterday just before the dismissal bell rang, 17 children and adults

were



shot and killed and 15 were injured inside Marjory Stoneman Douglas High



School in Parkland, Fla. We find ourselves once again filled with grief

and



horror, and we mourn alongside all those impacted by the shooting. As our



hearts are in Parkland, our eyes are on Congress.







"This is the eighteenth school shooting in 2018, the equivalent of one



every two and a half days so far this year. Shootings have an indelible



impact on entire communities, on the families who lost children and loved



ones, and on the children who survived. Columbine. Virginia Tech.

Newtown.



Orlando. Las Vegas. And now, Parkland. Children are dying from gun

violence



and Congress is failing to act. Every one of our 100 U.S. senators, and

all



435 U.S. representatives bear a responsibility to take meaningful action

to



protect our children, our families, and our communities. Our elected



leaders cannot continue to fail at this most essential task.







"We can start by working to advance meaningful legislation that keeps



children safe. The American Academy of Pediatrics advocates for stronger



state and federal gun laws that protect children, including a ban on



assault weapons like the one used in yesterday's school shooting. We also



call for stronger background checks, solutions addressing firearm



trafficking, and encouraging safe firearm storage. We will also continue

to



work to ensure that children and their families have access to

appropriate



mental health services, particularly to address the effects of exposure

to



violence.







"Although these mass shootings command our attention, our children remain



at risk daily for suicide, homicide, and unintentional injury because of



the current policy regarding access to guns in the United States. Gun



violence is a public health threat to children, and one the American



Academy of Pediatrics will continue to take on, in state capitals across



the country and in the halls of Congress. Parents across the United

States



send their children to school every day, and hope and trust they will be



safe. As long as children continue to be injured and killed by guns in

this



country, pediatricians will not rest in our pursuit to keep them safe."







*The American Academy of Pediatrics is an organization of 66,000 primary



care pediatricians, pediatric medical subspecialists and pediatric

surgical



specialists dedicated to the health, safety and well-being of infants,



children, adolescents and young adults. For more information, visit *



www.aap.org<https://urldefense.proofpoint.com/v2/url?u=http-3A__www.aap.org&d=DwIGaQ&c=cjytLXgP8ixuoHflwc-poQ&r=iiLqIGJPj43rFwhy0umXiLW2YeM4w7OHtbhTpnjKXBI&m=t48oRvjGz5SVTSWYDRNskNM83f8PFATlPgGDaXkwwFA&s=GYHJ2Trg6KbD5HWur2hhBM8okfIlyE-J85UX7orhmA4&e=><https://urldefense.proofpoint.com/v2/

url?u=http-3A__www.aap.org&d=DwIGaQ&c=Pk_HpaIpE_jAoEC9PLIWoQ&r=PgyaJu_-

6fURaaWELlGskCQzpkXWZSDQU-w6tbGwwMM&m=kjmFQ1KpfStKxhcvfi4QpgjqumdRH2

TVpCIOAggcCW0&s=3Oc_7pCeJFj4KZ9QlF0MpVKwh-Xixr5f2-x4dFOOgHk&e=>



<https://urldefense.proofpoint.com/v2/url?u=https-

3A__linkprotect.cudasvc.com_url-3Fa-3Dhttp-3A__www.

mmsend70.com_link.cfm-253fr-253dP1AWQRX2DH6KpZKp05dazA-7E-

7E-2526pe-253dBH4KXYJXftdV7-5FOrPTTyUbVAzQsfgoRvleBm2XUVQ6

AiEVwuBNacQ0AWbz2OcXguY6Y2i1bNdCMkiPdWG-2DfHRg-7E-7E-2526t-

253dP2O93UltqkjSP1tT62-5FPaA-7E-7E-26c-3DE-2C1-

2CEDnzTesKajviC9Rbq687pz7yfFyRgC2WBFw6mF1beQyzL2WYF-

5FfPWMjWxOixG1eagtp40GaUhhxZ8IL4zNcR4weeC1DLvkbbpHQsmMSnszDC

-26typo-3D1&d=DwIGaQ&c=Pk_HpaIpE_jAoEC9PLIWoQ&r=PgyaJu_-

6fURaaWELlGskCQzpkXWZSDQU-w6tbGwwMM&m=kjmFQ1KpfStKxhcvfi4QpgjqumdRH2

TVpCIOAggcCW0&s=IjSKeAbtNO1UyfAxfonG3YrPW35X2WKiPCyGj3YfSnQ&e=>*



and



follow us on Twitter @AmerAcadPeds.*







On Fri, Feb 16, 2018 at 9:22 PM, Chamberlain, James <



[log in to unmask]<mailto:[log in to unmask]>> wrote:







I think we need to move to repeal the second amendment. It's the only way



the NRA can be stopped. They resist all reasonable attempts to limit the



carnage and then hide behind a misinterpretation of the second amendment.







Very well, let's repeal it. I know many people agree that we don't need



militias any longer.







Jim Chamberlain















-----Original Message-----



From: Pediatric Emergency Medicine Discussion List [mailto:



[log in to unmask]<mailto:[log in to unmask]>] On Behalf Of Martin Pusic



Sent: Friday, February 16, 2018 6:29 PM



To: [log in to unmask]<mailto:[log in to unmask]>



Subject: The shooting in Florida







Hi colleagues,







As I sit in my office late on a Friday, I've gotten myself into a state



about the 17 children gunned down in a school. For the umpteenth time.







I think the thing that has me so upset, is that this state of gun



complaisance is an affront to everything a pediatric emergency physician



stands for. We sweat whether it's too risky when the WBC is 15.1 and not



14.9. We study 40,000 children in order sort out who deserves the x-ray



risk of a maybe brain tumor 30 years from now. We work in difficult,



burnout inducing conditions so that we can personally save, say, one

life a



year.







Today it feels to me like someone with an AK-whatever just wiped out 17



years of my work. In minutes. I want to cry. We SHOULD cry. Try and



watch that Parkland mother on CNN. I dare you.







Today is not a day like all the others. It's just not.







--Martin Pusic







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------------------------------



Date: Sun, 18 Feb 2018 12:18:07 -0500

From: Jeff Pender <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: The shooting in Florida



I have a desire to put in my 2 cents as well, considering this is

perhaps one of the issues I feel most passionately about. This is a

multi-factorial problem, obviously. Not only is it a problem with

“quality and quantity”, but also with “culture".



By quality and quantity, I am speaking about what people own, and how

much they own. Does anyone outside the military need a semi automatic

weapon for anything? No. Does anyone need a bump stock? No. Does anyone

need an extended magazine? No. If you require any of these things for the

lame ass excuse of “home defense”, you either need to move, or take some

classes and become a far better shot with a handgun. Further, do people

need the insane quantity of weapons and ammunition they tend to

accumulate? No, but this is a secondary problem to the types of weapons

they own. We can’t own a bazooka, so “we” understand that limits can

exist, so we need to extend those limits to the things listed above.



The culture issue, to me, is even worse. In the spirit of full

disclosure, I despise guns. I don’t own one, and have no plans on ever

owning one. I won’t allow one in my home, period. I feel pretty damn safe

with my 3 large dogs, thank you. I will admit that I pull away socially

from people once I learn they are big time gun enthusiasts. I won’t spend

time with people that I know are carrying a gun on their person, or in

their car. I can’t help it, and I don’t feel bad about it for even 1

second. We just see the world too differently, although I don’t think it

makes them a bad person. In my anecdotal experience, these serious

“enthusiasts” share some similar traits - they own a shit ton of guns,

ridiculous ammunition that no target shooter or home defense person really

needs, but most importantly perhaps, a “macho” response to their guns.

This is the thing that needs to change.



Guns are celebrated in our country as both cool and macho. Decide where

to place the blame - video games, movies, athletes, musicians, etc. But,

our politicians are part of this problem, and perhaps the largest part.

Since they are the ones that make the laws (and take the

bribes…err…donations), we need them to stop believing this more than anyone

else. They will never change the gun laws until the culture of how we view

guns changes. Think back to that insane video Ted Cruz made where he

wrapped bacon around the muzzle of an AR-15, and after shooting for a

while, ate the bacon that the hot muzzle cooked. It was horrifying how he

celebrated that AR-15….just so he could get another donation from gun

lovers. Change the culture of how they are viewed (and then campaign

finance laws) and the needle can be moved on this issue.



Israel and Swiss citizens own guns at incredibly high rates, but they

are viewed as a fact of life, not as a point of pride or machismo.

Culture changes are very slow to occur, but that is what is needed first,

I think. Without it, laws won’t change, and neither will the desire to own

these weapons and accessories. Think of other social

changes/regulations….they were slow — seat belt laws, speed limits, voting

rights, marriage equality, marijuana legalization, etc etc. They take

decades, sadly. We are a country that seems to have extreme difficulty

doing the right thing without it taking insanely long. It drives me crazy.



I truly hope that this school shooting has occurred around student’s

ages that can possibly make a difference in that these students are at an

age to become true activists, unlike when it happens to younger children.

A wave has to start, and I think it is most likely to start with these

young people, as long as we “older” people support them…both financially

and vocally…and in our voting patterns.



Jeff











On Feb 18, 2018, at 7:42 AM, Terence Bergmann <

[log in to unmask]<mailto:[log in to unmask]>> wrote:



Hi Joe



I disagree about ‘strict gun control laws’ here having anything to do

with it . Either you or I could have a new hunting rifle in a week or two

in Canada. If you look at the school shootings or the Vegas massacre these

are not people who acquired their guns and went slaughtering. These guns

were acquired and the armamentarium prepped and the plans made. Canadian

laws would not stop this.



We have a different culture here in Canada. Guns are not toted around

in public. Thankfully the 49th parallel prevented the ‘western’ mentality

from flourishing on our side of the border. I don’t know why.



The challenge to end ‘their’ problem is that once the bad guys are

armed with illegal guns how do you stop the populace from wanting to have

legal guns?



Somehow other countries can have legal weapons, such as Swiss adults

all keeping their weapons at home after their years of mandatory service,

yet they don’t kill each other with them. Somehow a well armed militia

there does not lead to violence.



I have lots of questions, but I don’t know the answers.



Terence



On Feb 17, 2018, at 2:43 PM, Joe Nemeth, Dr <[log in to unmask]<mailto:[log in to unmask]>

<mailto:[log in to unmask]>> wrote:



Disclaimer: I live in Canada and love our very strict gun control laws.





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------------------------------



Date: Sun, 18 Feb 2018 12:34:05 -0500

From: Michael Falk <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: The shooting in Florida



Friend just posted this interesting rebuttal to the "mental illness"

response whenever there is a mass shooting:



"Believing that mental illness causes mass shootings can feel reassuring.

It helps to believe that only a mentally ill person could do something so

horrific. We also think that if someone is mentally ill, they can be

identified. But the evidence suggests that mental illness only causes a

small fraction of gun violence. And even if some shooters have

undiagnosed

mental illness, there is no evidence to suggest that they could have been

diagnosed prior to their gun violence or that such a diagnosis would

increase the predictive validity of a diagnosis on gun violence."



https://urldefense.proofpoint.com/v2/url?u=http-3A__behavioralscientist.org_myth-2Dmental-2Dillness-2D&d=DwIGaQ&c=cjytLXgP8ixuoHflwc-poQ&r=iiLqIGJPj43rFwhy0umXiLW2YeM4w7OHtbhTpnjKXBI&m=t48oRvjGz5SVTSWYDRNskNM83f8PFATlPgGDaXkwwFA&s=CtasXvZEbtex9Ea_fevBMnEEw-UBePUkhQxlNWUuyVg&e=

causes-mass-shootings/



I will add few links of my own:



https://urldefense.proofpoint.com/v2/url?u=https-3A__www.theatlantic.com_health_archive_2017_10_why-2D&d=DwIGaQ&c=cjytLXgP8ixuoHflwc-poQ&r=iiLqIGJPj43rFwhy0umXiLW2YeM4w7OHtbhTpnjKXBI&m=t48oRvjGz5SVTSWYDRNskNM83f8PFATlPgGDaXkwwFA&s=DgOFazZZvWx1W9zS38nxvnf85y1QY0GmHdZ8Qtk9x7c&e=

better-mental-health-care-wont-stop-mass-shootings/541965/



https://urldefense.proofpoint.com/v2/url?u=https-3A__www.vox.com_policy-2Dand-2Dpolitics_2017_11_9_&d=DwIGaQ&c=cjytLXgP8ixuoHflwc-poQ&r=iiLqIGJPj43rFwhy0umXiLW2YeM4w7OHtbhTpnjKXBI&m=t48oRvjGz5SVTSWYDRNskNM83f8PFATlPgGDaXkwwFA&s=8Twdb2ih6ggxse1x0oGs4HY2-gbDf_9J8ceYrvCxwxY&e=

16618472/mental-illness-gun-homicide-mass-shootings



The mentally ill are stigmatized enough, blaming them for these killings

seems unfair.



Mike Falk



On Sun, Feb 18, 2018 at 12:18 PM, Jeff Pender <[log in to unmask]<mailto:[log in to unmask]>>

wrote:



I have a desire to put in my 2 cents as well, considering this is

perhaps

one of the issues I feel most passionately about. This is a

multi-factorial problem, obviously. Not only is it a problem with

“quality and quantity”, but also with “culture".



By quality and quantity, I am speaking about what people own, and how

much

they own. Does anyone outside the military need a semi automatic weapon

for anything? No. Does anyone need a bump stock? No. Does anyone

need

an extended magazine? No. If you require any of these things for the

lame

ass excuse of “home defense”, you either need to move, or take some

classes

and become a far better shot with a handgun. Further, do people need

the

insane quantity of weapons and ammunition they tend to accumulate? No,

but

this is a secondary problem to the types of weapons they own. We

can’t

own a bazooka, so “we” understand that limits can exist, so we need to

extend those limits to the things listed above.



The culture issue, to me, is even worse. In the spirit of full

disclosure, I despise guns. I don’t own one, and have no plans on ever

owning one. I won’t allow one in my home, period. I feel pretty damn

safe

with my 3 large dogs, thank you. I will admit that I pull away socially

from people once I learn they are big time gun enthusiasts. I won’t

spend

time with people that I know are carrying a gun on their person, or in

their car. I can’t help it, and I don’t feel bad about it for even 1

second. We just see the world too differently, although I don’t think

it

makes them a bad person. In my anecdotal experience, these serious

“enthusiasts” share some similar traits - they own a shit ton of guns,

ridiculous ammunition that no target shooter or home defense person

really

needs, but most importantly perhaps, a “macho” response to their guns.

This is the thing that needs to change.



Guns are celebrated in our country as both cool and macho. Decide where

to place the blame - video games, movies, athletes, musicians, etc.

But,

our politicians are part of this problem, and perhaps the largest part.

Since they are the ones that make the laws (and take the

bribes…err…donations), we need them to stop believing this more than

anyone

else. They will never change the gun laws until the culture of how we

view

guns changes. Think back to that insane video Ted Cruz made where he

wrapped bacon around the muzzle of an AR-15, and after shooting for a

while, ate the bacon that the hot muzzle cooked. It was horrifying how

he

celebrated that AR-15….just so he could get another donation from gun

lovers. Change the culture of how they are viewed (and then campaign

finance laws) and the needle can be moved on this issue.



Israel and Swiss citizens own guns at incredibly high rates, but they

are

viewed as a fact of life, not as a point of pride or machismo. Culture

changes are very slow to occur, but that is what is needed first, I

think.

Without it, laws won’t change, and neither will the desire to own these

weapons and accessories. Think of other social

changes/regulations….they

were slow — seat belt laws, speed limits, voting rights, marriage

equality,

marijuana legalization, etc etc. They take decades, sadly. We are a

country that seems to have extreme difficulty doing the right thing

without

it taking insanely long. It drives me crazy.



I truly hope that this school shooting has occurred around student’s

ages

that can possibly make a difference in that these students are at an

age to

become true activists, unlike when it happens to younger children. A

wave

has to start, and I think it is most likely to start with these young

people, as long as we “older” people support them…both financially and

vocally…and in our voting patterns.



Jeff











On Feb 18, 2018, at 7:42 AM, Terence Bergmann <

[log in to unmask]<mailto:[log in to unmask]>> wrote:



Hi Joe



I disagree about ‘strict gun control laws’ here having anything to do

with it . Either you or I could have a new hunting rifle in a week or

two

in Canada. If you look at the school shootings or the Vegas massacre

these

are not people who acquired their guns and went slaughtering. These

guns

were acquired and the armamentarium prepped and the plans made.

Canadian

laws would not stop this.



We have a different culture here in Canada. Guns are not toted around

in public. Thankfully the 49th parallel prevented the ‘western’

mentality

from flourishing on our side of the border. I don’t know why.



The challenge to end ‘their’ problem is that once the bad guys are

armed

with illegal guns how do you stop the populace from wanting to have

legal

guns?



Somehow other countries can have legal weapons, such as Swiss adults

all

keeping their weapons at home after their years of mandatory service,

yet

they don’t kill each other with them. Somehow a well armed militia

there

does not lead to violence.



I have lots of questions, but I don’t know the answers.



Terence



On Feb 17, 2018, at 2:43 PM, Joe Nemeth, Dr <[log in to unmask]<mailto:[log in to unmask]>

<mailto:[log in to unmask]>> wrote:



Disclaimer: I live in Canada and love our very strict gun control

laws.





For more information, send mail to [log in to unmask]<mailto:[log in to unmask]> with

the

message: info PED-EM-L

The URL for the PED-EM-L Web Page is:

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------------------------------



Date: Sun, 18 Feb 2018 12:52:28 -0500

From: Mick Work <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: PED-EM-L Digest - 15 Feb 2018 to 16 Feb 2018 (#2018-39)



I appreciate the passion around gun legislation and not opposed. I

don’t think laws will end this countries obsession with guns or limit

access to those who want to perform unlawful acts. But again I am not

arguing against reasonable legislation.



I have heard proposed that we need to arm principals and add more

security in schools. I just wonder if we added mental health counselors

instead if we wouldn’t make a greater impact.



My point is our prevention should be multi-modal like all effective

strategies.





Mick







On Feb 18, 2018, at 12:09 PM, Robert Finkelstein <

[log in to unmask]<mailto:[log in to unmask]>> wrote:



Other countries have the same level of mental illness as the United

States, but not nearly the number of gun deaths. The mental health issue is

important but access to weapons that can kill a large number of people in

seconds allows the results we see. In addition, access to guns plays a

huge role in suicides since many who attempt suicide and do not succeed

will get help and not attempt again. However, access to a gun makes it much

more likely that the first attempt will result in death.



Robert Finkelstein



On Feb 18, 2018, at 8:42 AM, Mick Work <[log in to unmask]<mailto:[log in to unmask]>> wrote:



I respect the need for debate around guns. However, I think we are

remiss as pediatric emergency physicians to not raise a deeper discussion

around the mental illness crisis.



We all see kids who meet this persons profile across the country. We

see disturbing mental illness and the many factors (including social media,

broken families, child abuse) that lead a child to buy a gun to do harm.

Or if not gun an explosive device etc..



We see kids who are socially isolated and warning signs ignored.

Anyone else concerned that the kids we see with mental illness are

recognized by schools or pediatric visit screening more often than by their

own parents, friends or neighbors.



This persons desire to be a “school shooter” should raise attention

around how the media covers these events. The fame brought to these

shooters should be called into question. Are we fostering this copycat

mentality?



The lack of respect for human life should call us to question more

than the how but why.



A focus only on guns and gun laws is remiss to the bigger picture in

my opinion and experience.



Mick







On Feb 17, 2018, at 12:01 AM, PED-EM-L automatic digest system <

[log in to unmask]<mailto:[log in to unmask]>> wrote:



There are 4 messages totaling 391 lines in this issue.



Topics of the day:



1. Peds EM talk (2)

2. Bacterial meningitis

3. The shooting in Florida



For more information, send mail to [log in to unmask]<mailto:[log in to unmask]> with

the message: info PED-EM-L

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------------------------------------------------------------

----------



Date: Fri, 16 Feb 2018 11:50:44 -0500

From: Purva Grover <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: Peds EM talk



Thanks all for your help on this.

Best

Purva



Purva Grover , MD

Medical Director

Pediatric Emergency Department

Cleveland Clinic Health System

Email- [log in to unmask]<mailto:[log in to unmask]> <[log in to unmask]<mailto:[log in to unmask]>>g



On Thu, Feb 15, 2018 at 2:18 PM, <[log in to unmask]<mailto:[log in to unmask]>> wrote:



Hi All

I am giving an hour ppt to new PAs on Peds Emergencies. Clearly can

not

cover ALL or even most. Any thoughts / talks / power points- you

could

share would be appreciated.

Thanks

Purva



Sent from my mobile device



For more information, send mail to [log in to unmask]<mailto:[log in to unmask]> with

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------------------------------



Date: Fri, 16 Feb 2018 14:34:20 +0000

From: "Chamberlain, James" <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: Peds EM talk



I would also cover unusual cases that you can't afford to miss, e.g.



Sternoclavicular dislocation

Conjunctivitis caused by penetrating FB

Septic joint presenting with only low-grade fever (we've had several

Staph infections where temp was only 37.6 or 37.7 orally)

Myocarditis presenting as wheezing. Remind them that all

"bronchiolitis" patients need a through cardiac exam, including distal

pulses

NAT

The "sleepy" baby who has hypoglycemia

The "sleepy" baby who has intussusception

The appendicitis patient who presents with vomiting and diarrhea (not

all that unusual, actually)

Etc.



To me, this is the challenge of PEM. Finding the needle in the

haystack, that one sick kid who is different than all the usual low acuity

illness...



Jim



James Chamberlain

Division Chief, Emergency Medicine

Children’s National Health System

(202) 476-4177



-----Original Message-----

From: Pediatric Emergency Medicine Discussion List [mailto:

[log in to unmask]<mailto:[log in to unmask]>] On Behalf Of Mojica, Michael

Sent: Thursday, February 15, 2018 5:29 PM

To: [log in to unmask]<mailto:[log in to unmask]>

Subject: Re: Peds EM talk



Purva







I would recommend "the critically ill infant".







It is the topic that scares the most people and you can cover a lot

of causes through cases.







I like to use cases that include common presenting complaints (e.g.

vomiting) that are associated with very bad things (e.g. midgut volvulus).







I'm attaching a ppt file for a talk I did a few years ago on this

topic.







My goal is for them to develop a mental checklist of potentially

life-saving interventions.







Michael







Michael Mojica, M.D



Director of Education, Division of Pediatric Emergency Medicine



Director, Pediatric Emergency Medicine Fellowship



Bellevue Hospital Center



Administration Building Room A528



New York, N.Y. 10016



[log in to unmask]<mailto:[log in to unmask]>



212-562-8147











On 2/15/18, 5:12 PM, "Pediatric Emergency Medicine Discussion List

on behalf of Purva Grover" <[log in to unmask]<mailto:[log in to unmask]> on behalf of

[log in to unmask]<mailto:[log in to unmask]>> wrote:







Hi All



I am giving an hour ppt to new PAs on Peds Emergencies. Clearly can

not cover ALL or even most. Any thoughts / talks / power points- you could

share would be appreciated.



Thanks



Purva







Sent from my mobile device



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------------------------------



Date: Fri, 16 Feb 2018 18:29:38 -0500

From: Aline Baghdassarian <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: Bacterial meningitis



Scott,



Would love to hear more about the cases. How did they present? What

was the

decision making process?



Thank you,



Aline



Aline Baghdassarian, MD, MPH, FAAP

Director, Pediatric Emergency Medicine Fellowship Program

Assistant Professor, Department of Emergency Medicine

Virginia Commonwealth University School of Medicine



Children's Hospital of Richmond at VCU

Email [log in to unmask]<mailto:[log in to unmask]>





On Thu, Feb 15, 2018 at 12:40 PM, Julian Orenstein <[log in to unmask]<mailto:[log in to unmask]>



wrote:



In a recent case at our institution, there was a present but subtle

degree

of meningismus — I’ve found over the years there is always some

elicitable

sign — but as importantly there’s a degree of irritability or altered

behavior that has everyone concerned: mom, RN’s, me.

If mama ain't happy, I ain't happy. I’ll make liberal use of the term

cerebritis or encephalopathic behavior until there’s a consent

signed.



I’m not such a good scientist anymore, but I’ve tried to be an

attentive

clinician.



Julian Orenstein





On Feb 14, 2018, at 3:30 PM, JAY FISHER <[log in to unmask]<mailto:[log in to unmask]>> wrote:



Scott - Bacterial meningitis is alive and well here in LV - we have

seen

it in a variety of age groups. There is good evidence that there has

been

an increase in pneumococcal serotypes not covered by the polyvalent

vaccines since there widespread use, such that the burden of

pneumococcal

meningitis (as opposed to H. flu type b) has not decreased nearly as

much.



Brouwer MC, van de Beek D. Epidemiology of community-acquired

bacterial

meningitis. Curr Opin Infect Dis. 2018;31(1):78-84.



Also, the absence of meningismus in older kids with bacterial

meningitis

is well described and occurs in a substantial subset.



Geiseler J, Nelson, K.E. Bacterial meningitis without clinical

signs of

meningeal irritation. . Southern Med J 1982;75(4):448-450.



Much of the data on the sensitivity of the neck exam is of the

retrospective variety. I have only read one really good prospective

study

on the sensitivity of PE for bacterial meningitis and it was a single

center variety as I recall.



Walsh-Kelly C, Nelson DB, Smith DS, et al. Clinical predictors of

bacterial versus aseptic meningitis in childhood. Ann Emerg Med.

1992;21(8):910-914.



Tough case.





Jay



Jay D. Fisher MD FAAP FACEP

Medical Director, Pediatric EM

Children's Hospital of Nevada at UMC

Clinical Professor of Emergency Medicine and Pediatrics

UNLV School of Medicine

















On February 14, 2018 at 4:18 PM "Conners, Gregory, P" <

[log in to unmask]<mailto:[log in to unmask]>> wrote:





I shared this with our ID director (Dr. Mary Anne Jackson), who

pointed

out that bacterial meningitis appears at this time of year as a

complication of influenza:

"Both pneumococcal and meningococcal meningitis can occur post flu

as

well as GAS and S aureus invasive disease and TSS."



She also addressed Jim's question: "We do know that new serotypes

[of

pneumococcus] have emerged but this is not waning immunity because

the teen

only got PCV7".





Greg Conners



Gregory P. Conners, MD, MPH, MBA, FAAP, FACEP



Director, Division of Emergency Medicine

Associate Chair of Pediatrics

Professor of Pediatrics and Emergency Medicine

Children’s Mercy Hospital, Kansas City

University of Missouri, Kansas City

[log in to unmask]<mailto:[log in to unmask]>









-----Original Message-----

From: Pediatric Emergency Medicine Discussion List [mailto:

[log in to unmask]<mailto:[log in to unmask]>] On Behalf Of 000001679b145c30-dmarc-

[log in to unmask]<mailto:[log in to unmask]>

Sent: Wednesday, February 14, 2018 2:25 PM

To: [log in to unmask]<mailto:[log in to unmask]>

Subject: Re: Bacterial meningitis



*** This message was sent to you from an External Source. Please

do not

open untrusted links or attachments. ***



________________________________





Could you share with us the clinical findings and history that

prompted

the LP?





Shiu-Lin









Shiu-Lin Tsai, MD

Division of Pediatric Emergency Medicine



Department of Emergency Medicine

Columbia University Medical Center







-----Original Message-----

From: Scott Freedman <[log in to unmask]<mailto:[log in to unmask]>>

To: PED-EM-L <[log in to unmask]<mailto:[log in to unmask]>>

Sent: Wed, Feb 14, 2018 2:44 pm

Subject: Bacterial meningitis



ALL:

Since Jan 1st this year, we have seen 3 cases of culture +

bacterial

meningitis come through are ED; 2 with *Strep pneumoniae* and 1 with

*Neisseria meningiditis*. All 3 were in older children/ teens who

received

their Prevnar 13 vaccines as well as the Menactra series in the

patient

with Neisseria. Anyone else seeing cases of this sort? I do not

recall 3

cases of bacterial meningitis in older kids in a community setting

such as

ours in quite a long time. Is this random bad luck or do we all

need to

be more vigilant? Incidentally, none had neck pain or meningismus

as a

clinical finding.



--

Kind regards,



Scott

Scott Freedman, MD

Medical Director, Pediatric Emergency Dept Rockville MD



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------------------------------



Date: Fri, 16 Feb 2018 18:29:08 -0500

From: Martin Pusic <[log in to unmask]<mailto:[log in to unmask]>>

Subject: The shooting in Florida



Hi colleagues,



As I sit in my office late on a Friday, I've gotten myself into a

state about the 17 children gunned down in a school. For the umpteenth

time.



I think the thing that has me so upset, is that this state of gun

complaisance is an affront to everything a pediatric emergency physician

stands for. We sweat whether it's too risky when the WBC is 15.1 and not

14.9. We study 40,000 children in order sort out who deserves the x-ray

risk of a maybe brain tumor 30 years from now. We work in difficult,

burnout inducing conditions so that we can personally save, say, one life a

year.



Today it feels to me like someone with an AK-whatever just wiped out

17 years of my work. In minutes. I want to cry. We SHOULD cry. Try and

watch that Parkland mother on CNN. I dare you.



Today is not a day like all the others. It's just not.



--Martin Pusic



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------------------------------



Date: Sun, 18 Feb 2018 23:05:03 +0000

From: "Chamberlain, James" <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: School shootings.......



I'd be happy with sensible regulations, required training, and licensure

so that guns don't get into the hands of criminals and people with mental

illness.



But the NRA is against sensible regulations.







Sent from my Verizon, Samsung Galaxy smartphone





-------- Original message --------

From: Robert Finkelstein <[log in to unmask]<mailto:[log in to unmask]>>

Date: 2/18/18 12:17 (GMT-05:00)

To: [log in to unmask]<mailto:[log in to unmask]>

Subject: Re: School shootings.......



Just because people will find a way to break laws does not mean that we

shouldn’t have them. By that logic, we expect that all of us who are

currently law abiding don’t need any laws to make us so. Human nature

being what it is, we all need laws and structure. Yes, gun regulation

would not stop all gun violence, but it could reduce it. Also, I don’t

think the majority want prohibition of guns, just regulation; the same way

alcohol is regulated by age and penalties for driving under the influence.

Or, the way cars are regulated with licensing, registration, having to pass

a driving test and citations for violations.







On Feb 18, 2018, at 8:42 AM, Horst D. Weinberg, MD <

[log in to unmask]<mailto:[log in to unmask]>> wrote:







Yes, automatic weapons should be banned by our government, but most of

the discussions posted blame the guns, the NRA, the 2nd amendment and our

'laws'. Nobody gets to the meat of the matter: If there is a demand (for

guns), regardless of the laws passed, someone will fill that demand. This

is no different from Prohibition, where there was no shortage of available

booze or the 'war' on drugs, where you can get them at most street corners

in any city. What needs to change: There has been a steady decline over the

past 20 or so years in our country's moral fiber, personal and work ethic,

and yes, child rearing. Cause: unmarried or one parent families, poverty,

and absence of any discipline both in the home and in the schools, for

'political correctness'. Parents want to be friends with their children

rather than running their homes like 'benevolent dictator ships'. Nothing

is denied the child: the child wants $150.00 sneakers or a new cell-phone:

no problem. So you can blame the gun all you want, but unless there is a

real change in the populations personal morality and ethics, these school

tragedies will continue.



We pediatricians should look at our own practices in teaching good

child rearing ways to the families we serve. Horst D. Weinberg, MD



















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------------------------------



Date: Sun, 18 Feb 2018 19:03:20 -0600

From: Jill C Obremskey <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: School shootings.......



Great discussion but what are WE going to do about it as an organization?

How do we become relentless about the need for gun control, the need for

mental health services, and for preventing toxic stress in children.



We need to ask leaders in the AAP and AAEM to organize us into a

uniified voice that will not quit.



On February 18, 2018 at 5:05 PM "Chamberlain, James" <

[log in to unmask]<mailto:[log in to unmask]>> wrote:





I'd be happy with sensible regulations, required training, and

licensure so that guns don't get into the hands of criminals and people

with mental illness.



But the NRA is against sensible regulations.







Sent from my Verizon, Samsung Galaxy smartphone





-------- Original message --------

From: Robert Finkelstein <[log in to unmask]<mailto:[log in to unmask]>>

Date: 2/18/18 12:17 (GMT-05:00)

To: [log in to unmask]<mailto:[log in to unmask]>

Subject: Re: School shootings.......



Just because people will find a way to break laws does not mean that we

shouldn’t have them. By that logic, we expect that all of us who are

currently law abiding don’t need any laws to make us so. Human nature being

what it is, we all need laws and structure. Yes, gun regulation would not

stop all gun violence, but it could reduce it. Also, I don’t think the

majority want prohibition of guns, just regulation; the same way alcohol is

regulated by age and penalties for driving under the influence. Or, the way

cars are regulated with licensing, registration, having to pass a driving

test and citations for violations.







On Feb 18, 2018, at 8:42 AM, Horst D. Weinberg, MD <

[log in to unmask]<mailto:[log in to unmask]>> wrote:







Yes, automatic weapons should be banned by our government, but most of

the discussions posted blame the guns, the NRA, the 2nd amendment and our

'laws'. Nobody gets to the meat of the matter: If there is a demand (for

guns), regardless of the laws passed, someone will fill that demand. This

is no different from Prohibition, where there was no shortage of available

booze or the 'war' on drugs, where you can get them at most street corners

in any city. What needs to change: There has been a steady decline over the

past 20 or so years in our country's moral fiber, personal and work ethic,

and yes, child rearing. Cause: unmarried or one parent families, poverty,

and absence of any discipline both in the home and in the schools, for

'political correctness'. Parents want to be friends with their children

rather than running their homes like 'benevolent dictator ships'. Nothing

is denied the child: the child wants $150.00 sneakers or a new cell-phone:

no problem. So you can blame the gun all you want, but unless there is a

real change in the populations personal morality and ethics, these school

tragedies will continue.



We pediatricians should look at our own practices in teaching good

child rearing ways to the families we serve. Horst D. Weinberg, MD



















For more information, send mail to [log in to unmask]<mailto:[log in to unmask]> with

the message: info PED-EM-L



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------------------------------



End of PED-EM-L Digest - 17 Feb 2018 to 18 Feb 2018 (#2018-41)

**************************************************************



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------------------------------



Date: Mon, 19 Feb 2018 15:07:35 +0000

From: "Joe Nemeth, Dr" <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: PED-EM-L Digest - 17 Feb 2018 to 18 Feb 2018 (#2018-41)



Mick-





Thank you.





This exactly was the point of my post. We see only what we want to see, what falls into our political agenda sadly.





BTW, wasn't going to write a separate post about this but since I'm "here"...





I am flabbergasted at the lack of ANY (pro or con) response to my abortion corollary...





More than ~3000 children "aborted" per day.







joe





________________________________

From: Pediatric Emergency Medicine Discussion List <[log in to unmask]<mailto:[log in to unmask]>> on behalf of Mick Work <[log in to unmask]<mailto:[log in to unmask]>>

Sent: February 19, 2018 9:25 AM

To: [log in to unmask]<mailto:[log in to unmask]>

Subject: Re: PED-EM-L Digest - 17 Feb 2018 to 18 Feb 2018 (#2018-41)



https://urldefense.proofpoint.com/v2/url?u=http-3A__apps.chicagotribune.com_news_local_young-5Fvictims_&d=DwIGaQ&c=cjytLXgP8ixuoHflwc-poQ&r=iiLqIGJPj43rFwhy0umXiLW2YeM4w7OHtbhTpnjKXBI&m=t48oRvjGz5SVTSWYDRNskNM83f8PFATlPgGDaXkwwFA&s=X2M--MDdYYwsGrfHTv88WzYo6_er5JmsO6XsSZCiN0o&e=



10x the number of kids dying and they have stricter gun laws. Why do these deaths draw so little attention? Yet suburban school shootings and the shooter gets major coverage.



Is the media effectively and wisely moving public opinion around guns or opioids etc or is it about reaction and ratings?



The government can’t solve issues any more than the c-suite can claim to provide better care in hospitals through policy alone. Just my opinion.



Real solutions won’t come from laws or policy especially from those distant from the problem and solely developed to satisfy media hype or check a regulatory box.







Mick Connors







On Feb 19, 2018, at 12:00 AM, PED-EM-L automatic digest system <[log in to unmask]<mailto:[log in to unmask]>> wrote:



There are 17 messages totaling 3381 lines in this issue.



Topics of the day:



1. School shootings....... (4)

2. PED-EM-L Digest - 15 Feb 2018 to 16 Feb 2018 (#2018-39) (3)

3. The shooting in Florida (9)

4. A second, more settled, reflection on the Florida shooting



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----------------------------------------------------------------------



Date: Sat, 17 Feb 2018 21:57:25 -0500

From: "Horst D. Weinberg, MD"

<[log in to unmask]<mailto:[log in to unmask]>>

Subject: School shootings.......



Yes, automatic weapons should be banned by our government, but most of the discussions posted blame the guns, the NRA, the 2nd amendment and our 'laws'. Nobody gets to the meat of the matter: If there is a demand (for guns), regardless of the laws passed, someone will fill that demand. This is no different from Prohibition, where there was no shortage of available booze or the 'war' on drugs, where you can get them at most street corners in any city. What needs to change: There has been a steady decline over the past 20 or so years in our country's moral fiber, personal and work ethic, and yes, child rearing. Cause: unmarried or one parent families, poverty, and absence of any discipline both in the home and in the schools, for 'political correctness'. Parents want to be friends with their children rather than running their homes like 'benevolent dictator ships'. Nothing is denied the child: the child wants $150.00 sneakers or a new cell-phone: no problem. So you can blame the gun all you want, but unless there is a real change in the populations personal morality and ethics, these school tragedies will continue.

We pediatricians should look at our own practices in teaching good child rearing ways to the families we serve. Horst D. Weinberg, MD









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------------------------------



Date: Sun, 18 Feb 2018 06:13:44 -0500

From: Mick Work <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: PED-EM-L Digest - 15 Feb 2018 to 16 Feb 2018 (#2018-39)



I respect the need for debate around guns. However, I think we are remiss as pediatric emergency physicians to not raise a deeper discussion around the mental illness crisis.



We all see kids who meet this persons profile across the country. We see disturbing mental illness and the many factors (including social media, broken families, child abuse) that lead a child to buy a gun to do harm. Or if not gun an explosive device etc..



We see kids who are socially isolated and warning signs ignored. Anyone else concerned that the kids we see with mental illness are recognized by schools or pediatric visit screening more often than by their own parents, friends or neighbors.



This persons desire to be a “school shooter” should raise attention around how the media covers these events. The fame brought to these shooters should be called into question. Are we fostering this copycat mentality?



The lack of respect for human life should call us to question more than the how but why.



A focus only on guns and gun laws is remiss to the bigger picture in my opinion and experience.



Mick







On Feb 17, 2018, at 12:01 AM, PED-EM-L automatic digest system <[log in to unmask]<mailto:[log in to unmask]>> wrote:



There are 4 messages totaling 391 lines in this issue.



Topics of the day:



1. Peds EM talk (2)

2. Bacterial meningitis

3. The shooting in Florida



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----------------------------------------------------------------------



Date: Fri, 16 Feb 2018 11:50:44 -0500

From: Purva Grover <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: Peds EM talk



Thanks all for your help on this.

Best

Purva



Purva Grover , MD

Medical Director

Pediatric Emergency Department

Cleveland Clinic Health System

Email- [log in to unmask]<mailto:[log in to unmask]> <[log in to unmask]<mailto:[log in to unmask]>>g



On Thu, Feb 15, 2018 at 2:18 PM, <[log in to unmask]<mailto:[log in to unmask]>> wrote:



Hi All

I am giving an hour ppt to new PAs on Peds Emergencies. Clearly can not

cover ALL or even most. Any thoughts / talks / power points- you could

share would be appreciated.

Thanks

Purva



Sent from my mobile device



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------------------------------



Date: Fri, 16 Feb 2018 14:34:20 +0000

From: "Chamberlain, James" <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: Peds EM talk



I would also cover unusual cases that you can't afford to miss, e.g.



Sternoclavicular dislocation

Conjunctivitis caused by penetrating FB

Septic joint presenting with only low-grade fever (we've had several Staph infections where temp was only 37.6 or 37.7 orally)

Myocarditis presenting as wheezing. Remind them that all "bronchiolitis" patients need a through cardiac exam, including distal pulses

NAT

The "sleepy" baby who has hypoglycemia

The "sleepy" baby who has intussusception

The appendicitis patient who presents with vomiting and diarrhea (not all that unusual, actually)

Etc.



To me, this is the challenge of PEM. Finding the needle in the haystack, that one sick kid who is different than all the usual low acuity illness...



Jim



James Chamberlain

Division Chief, Emergency Medicine

Children’s National Health System

(202) 476-4177



-----Original Message-----

From: Pediatric Emergency Medicine Discussion List [mailto:[log in to unmask]] On Behalf Of Mojica, Michael

Sent: Thursday, February 15, 2018 5:29 PM

To: [log in to unmask]<mailto:[log in to unmask]>

Subject: Re: Peds EM talk



Purva







I would recommend "the critically ill infant".







It is the topic that scares the most people and you can cover a lot of causes through cases.







I like to use cases that include common presenting complaints (e.g. vomiting) that are associated with very bad things (e.g. midgut volvulus).







I'm attaching a ppt file for a talk I did a few years ago on this topic.







My goal is for them to develop a mental checklist of potentially life-saving interventions.







Michael







Michael Mojica, M.D



Director of Education, Division of Pediatric Emergency Medicine



Director, Pediatric Emergency Medicine Fellowship



Bellevue Hospital Center



Administration Building Room A528



New York, N.Y. 10016



[log in to unmask]<mailto:[log in to unmask]>



212-562-8147











On 2/15/18, 5:12 PM, "Pediatric Emergency Medicine Discussion List on behalf of Purva Grover" <[log in to unmask]<mailto:[log in to unmask]> on behalf of [log in to unmask]<mailto:[log in to unmask]>> wrote:







Hi All



I am giving an hour ppt to new PAs on Peds Emergencies. Clearly can not cover ALL or even most. Any thoughts / talks / power points- you could share would be appreciated.



Thanks



Purva







Sent from my mobile device



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------------------------------



Date: Fri, 16 Feb 2018 18:29:38 -0500

From: Aline Baghdassarian <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: Bacterial meningitis



Scott,



Would love to hear more about the cases. How did they present? What was the

decision making process?



Thank you,



Aline



Aline Baghdassarian, MD, MPH, FAAP

Director, Pediatric Emergency Medicine Fellowship Program

Assistant Professor, Department of Emergency Medicine

Virginia Commonwealth University School of Medicine



Children's Hospital of Richmond at VCU

Email [log in to unmask]<mailto:[log in to unmask]>





On Thu, Feb 15, 2018 at 12:40 PM, Julian Orenstein <[log in to unmask]<mailto:[log in to unmask]>>

wrote:



In a recent case at our institution, there was a present but subtle degree

of meningismus — I’ve found over the years there is always some elicitable

sign — but as importantly there’s a degree of irritability or altered

behavior that has everyone concerned: mom, RN’s, me.

If mama ain't happy, I ain't happy. I’ll make liberal use of the term

cerebritis or encephalopathic behavior until there’s a consent signed.



I’m not such a good scientist anymore, but I’ve tried to be an attentive

clinician.



Julian Orenstein





On Feb 14, 2018, at 3:30 PM, JAY FISHER <[log in to unmask]<mailto:[log in to unmask]>> wrote:



Scott - Bacterial meningitis is alive and well here in LV - we have seen

it in a variety of age groups. There is good evidence that there has been

an increase in pneumococcal serotypes not covered by the polyvalent

vaccines since there widespread use, such that the burden of pneumococcal

meningitis (as opposed to H. flu type b) has not decreased nearly as much.



Brouwer MC, van de Beek D. Epidemiology of community-acquired bacterial

meningitis. Curr Opin Infect Dis. 2018;31(1):78-84.



Also, the absence of meningismus in older kids with bacterial meningitis

is well described and occurs in a substantial subset.



Geiseler J, Nelson, K.E. Bacterial meningitis without clinical signs of

meningeal irritation. . Southern Med J 1982;75(4):448-450.



Much of the data on the sensitivity of the neck exam is of the

retrospective variety. I have only read one really good prospective study

on the sensitivity of PE for bacterial meningitis and it was a single

center variety as I recall.



Walsh-Kelly C, Nelson DB, Smith DS, et al. Clinical predictors of

bacterial versus aseptic meningitis in childhood. Ann Emerg Med.

1992;21(8):910-914.



Tough case.





Jay



Jay D. Fisher MD FAAP FACEP

Medical Director, Pediatric EM

Children's Hospital of Nevada at UMC

Clinical Professor of Emergency Medicine and Pediatrics

UNLV School of Medicine

















On February 14, 2018 at 4:18 PM "Conners, Gregory, P" <

[log in to unmask]<mailto:[log in to unmask]>> wrote:





I shared this with our ID director (Dr. Mary Anne Jackson), who pointed

out that bacterial meningitis appears at this time of year as a

complication of influenza:

"Both pneumococcal and meningococcal meningitis can occur post flu as

well as GAS and S aureus invasive disease and TSS."



She also addressed Jim's question: "We do know that new serotypes [of

pneumococcus] have emerged but this is not waning immunity because the teen

only got PCV7".





Greg Conners



Gregory P. Conners, MD, MPH, MBA, FAAP, FACEP



Director, Division of Emergency Medicine

Associate Chair of Pediatrics

Professor of Pediatrics and Emergency Medicine

Children’s Mercy Hospital, Kansas City

University of Missouri, Kansas City

[log in to unmask]<mailto:[log in to unmask]>









-----Original Message-----

From: Pediatric Emergency Medicine Discussion List [mailto:

[log in to unmask]<mailto:[log in to unmask]>] On Behalf Of 000001679b145c30-dmarc-

[log in to unmask]<mailto:[log in to unmask]>

Sent: Wednesday, February 14, 2018 2:25 PM

To: [log in to unmask]<mailto:[log in to unmask]>

Subject: Re: Bacterial meningitis



*** This message was sent to you from an External Source. Please do not

open untrusted links or attachments. ***



________________________________





Could you share with us the clinical findings and history that prompted

the LP?





Shiu-Lin









Shiu-Lin Tsai, MD

Division of Pediatric Emergency Medicine



Department of Emergency Medicine

Columbia University Medical Center







-----Original Message-----

From: Scott Freedman <[log in to unmask]<mailto:[log in to unmask]>>

To: PED-EM-L <[log in to unmask]<mailto:[log in to unmask]>>

Sent: Wed, Feb 14, 2018 2:44 pm

Subject: Bacterial meningitis



ALL:

Since Jan 1st this year, we have seen 3 cases of culture + bacterial

meningitis come through are ED; 2 with *Strep pneumoniae* and 1 with

*Neisseria meningiditis*. All 3 were in older children/ teens who received

their Prevnar 13 vaccines as well as the Menactra series in the patient

with Neisseria. Anyone else seeing cases of this sort? I do not recall 3

cases of bacterial meningitis in older kids in a community setting such as

ours in quite a long time. Is this random bad luck or do we all need to

be more vigilant? Incidentally, none had neck pain or meningismus as a

clinical finding.



--

Kind regards,



Scott

Scott Freedman, MD

Medical Director, Pediatric Emergency Dept Rockville MD



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------------------------------



Date: Fri, 16 Feb 2018 18:29:08 -0500

From: Martin Pusic <[log in to unmask]<mailto:[log in to unmask]>>

Subject: The shooting in Florida



Hi colleagues,



As I sit in my office late on a Friday, I've gotten myself into a state about the 17 children gunned down in a school. For the umpteenth time.



I think the thing that has me so upset, is that this state of gun complaisance is an affront to everything a pediatric emergency physician stands for. We sweat whether it's too risky when the WBC is 15.1 and not 14.9. We study 40,000 children in order sort out who deserves the x-ray risk of a maybe brain tumor 30 years from now. We work in difficult, burnout inducing conditions so that we can personally save, say, one life a year.



Today it feels to me like someone with an AK-whatever just wiped out 17 years of my work. In minutes. I want to cry. We SHOULD cry. Try and watch that Parkland mother on CNN. I dare you.



Today is not a day like all the others. It's just not.



--Martin Pusic



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------------------------------



End of PED-EM-L Digest - 15 Feb 2018 to 16 Feb 2018 (#2018-39)

**************************************************************



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------------------------------



Date: Sun, 18 Feb 2018 12:42:58 +0000

From: Terence Bergmann <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: The shooting in Florida



Hi Joe



I disagree about ‘strict gun control laws’ here having anything to do with it . Either you or I could have a new hunting rifle in a week or two in Canada. If you look at the school shootings or the Vegas massacre these are not people who acquired their guns and went slaughtering. These guns were acquired and the armamentarium prepped and the plans made. Canadian laws would not stop this.



We have a different culture here in Canada. Guns are not toted around in public. Thankfully the 49th parallel prevented the ‘western’ mentality from flourishing on our side of the border. I don’t know why.



The challenge to end ‘their’ problem is that once the bad guys are armed with illegal guns how do you stop the populace from wanting to have legal guns?



Somehow other countries can have legal weapons, such as Swiss adults all keeping their weapons at home after their years of mandatory service, yet they don’t kill each other with them. Somehow a well armed militia there does not lead to violence.



I have lots of questions, but I don’t know the answers.



Terence



On Feb 17, 2018, at 2:43 PM, Joe Nemeth, Dr <[log in to unmask]<mailto:[log in to unmask]><mailto:[log in to unmask]>> wrote:



Disclaimer: I live in Canada and love our very strict gun control laws.





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------------------------------



Date: Sun, 18 Feb 2018 14:31:22 +0000

From: "Habib, David" <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: The shooting in Florida



Repeal and replace the second amendment with a clear and contemporary document. Dave Habib



________________________________________

From: Pediatric Emergency Medicine Discussion List [[log in to unmask]<mailto:[log in to unmask]>] on behalf of Terence Bergmann [[log in to unmask]<mailto:[log in to unmask]>]

Sent: Sunday, February 18, 2018 7:42 AM

To: [log in to unmask]<mailto:[log in to unmask]>

Subject: Re: The shooting in Florida







Hi Joe



I disagree about ‘strict gun control laws’ here having anything to do with it . Either you or I could have a new hunting rifle in a week or two in Canada. If you look at the school shootings or the Vegas massacre these are not people who acquired their guns and went slaughtering. These guns were acquired and the armamentarium prepped and the plans made. Canadian laws would not stop this.



We have a different culture here in Canada. Guns are not toted around in public. Thankfully the 49th parallel prevented the ‘western’ mentality from flourishing on our side of the border. I don’t know why.



The challenge to end ‘their’ problem is that once the bad guys are armed with illegal guns how do you stop the populace from wanting to have legal guns?



Somehow other countries can have legal weapons, such as Swiss adults all keeping their weapons at home after their years of mandatory service, yet they don’t kill each other with them. Somehow a well armed militia there does not lead to violence.



I have lots of questions, but I don’t know the answers.



Terence



On Feb 17, 2018, at 2:43 PM, Joe Nemeth, Dr <[log in to unmask]<mailto:[log in to unmask]><mailto:[log in to unmask]>> wrote:



Disclaimer: I live in Canada and love our very strict gun control laws.





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------------------------------



Date: Sun, 18 Feb 2018 14:04:25 +0000

From: Nathan Kuppermann <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: The shooting in Florida



Jeffrey and colleagues:



My colleague Garen Wintemute is an EM physician at UC Davis and has been doing seminal work on firearm violence prevention for decades - doggedly and with great impact



He is the director of the Violence Prevention Research Program (VPRP) at UC Davis, and has been named a "hero of medicine" by Time Magazine in the past for his work. He is as smart and accomplished as they come, and there is nobody in the country who has been doing this longer or with greater impact. And he has weathered the political and funding crises for this type of work for years, frequently funding his own work when the political climate for this work was bleak. But he has also received substantial foundation money and federal grants during more supportive political times.



He recently received $5 million from the California state legislature to lead the University of California Firearm Violence Research Center, the first state-funded gun violence research center in the country.



Here is his entry in Wikipedia: https://urldefense.proofpoint.com/v2/url?u=https-3A__en.wikipedia.org_wiki_Garen-5FWintemute&d=DwIGaQ&c=cjytLXgP8ixuoHflwc-poQ&r=iiLqIGJPj43rFwhy0umXiLW2YeM4w7OHtbhTpnjKXBI&m=t48oRvjGz5SVTSWYDRNskNM83f8PFATlPgGDaXkwwFA&s=NLb0pWX2zSNtCCtxb8sbfq2eU5kwLSJ1K01CUSRclBU&e=



If you are interested in his program or donating, here is the link: https://urldefense.proofpoint.com/v2/url?u=http-3A__www.ucdmc.ucdavis.edu_vprp_&d=DwIGaQ&c=cjytLXgP8ixuoHflwc-poQ&r=iiLqIGJPj43rFwhy0umXiLW2YeM4w7OHtbhTpnjKXBI&m=t48oRvjGz5SVTSWYDRNskNM83f8PFATlPgGDaXkwwFA&s=y6AkLoGvtzbgZgJDAeqhImP2Ae_P1GrSzIOuDmcuDyo&e=



Full disclosure: I serve as the Chair of EM at UC Davis where Garen works, but the only benefit to me for getting Garen more exposure or money to the VPRP program that he oversees is my children and family whom I desperately want to protect, my many friends throughout this great country about whom I deeply care, and a country about which I am deeply concerned.



Nate Kuppermann

UC Davis







On Feb 17, 2018, at 3:03 PM, Jeffrey Oestreicher <[log in to unmask]<mailto:[log in to unmask]><mailto:[log in to unmask]>> wrote:



Thanks for this cathartic thread, Dr. Pusic and others. Hope fellows are allowed to chime in. Like many on here my gut reaction is to focus on politics, ie an assault weapons ban, the 2nd amendment etc. If Americans were being killed by the same type of airplane that kept crashing, congress would act. Why the same isn’t done with the AR-15 given that it keeps being used to murder kids (in Sandy Hook, Aurora, Orlando, Las Vegas and now Parkland) is maddening. But I wonder if we could do more by taking the lead on another key gun violence issue on which physicians are experts. The problem was encapsulated by the first few hours after the parkland shooting when media outlets were literally arguing over how many school shootings there have been in 2018. We don't even know! We don't know because there are very little data on firearm injury/death in this country on account of Congress blocking gun violence research funding since 1996. And this funding block (the "Dickey amendment," named for the NRA point person in Congress at the time) has created a political chill on research that has trickled down even to academic medical centers. When I tried to examine NY EMS data to look at pre-hospital intervention in pediatric firearm injury, the city blocked it on account of the study being "too political." Where is the research? When SIDs reached epidemic numbers in the 70’s, Congress allocated funds for aggressive research leading to Back to Sleep campaign and SIDS rates plummeted. Similar research campaigns produced life-saving interventions for lead poisoning and car crashes. Yet no research crusade has been directed at the epidemic of pediatric firearm death because Congress essentially prohibits it. The hard part is trying to figure out what to do about it. In my state of New York, A.2977/S.4363, sponsored by New York State Assemblymember Jo Anne Simon and Senator Roxanne Persaud, would create a Firearm Violence Research Institute in New York and I along with some colleagues are trying to support this in a few different ways; if others on here want to discuss or have other ideas pls be in touch. This is not meant to discourage us from yelling from rooftops and writing senators about background checks, assault weapons ban etc. That is so important. But we have a unique vantage point with regard to public health research and we're allowed to do it for every other public health problem except this one. Thanks so much for allowing me to add my 2 cents



Sent from my iPhone



On Feb 17, 2018, at 3:43 PM, Joe Nemeth, Dr <[log in to unmask]<mailto:[log in to unmask]><mailto:[log in to unmask]>> wrote:



Martin,



As I sit in my living room on this Saturday morning, I’ve also gotten my self in a state about how we tend to focus in on the small picture and neglect an exponentially bigger one.



Spoiler Alert: this will NOT be a politically laced nor personally biased post...as opposed to some of the previous posts on this issue - I'm actually quite disappointed that politics had to rear its ugly head.



Disclaimer: I live in Canada and love our very strict gun control laws.

Don't claim to be a gun control policy expert



Now, allow me to expound:



1. A troubled young man AND inappropriate access to crazy weapons is what caused this catastrophe.



Colleagues, I think we all agree that it would be too simplistic and frankly naive to think that stricter gun control would solve all of these gun related deaths...many examples of this false and misleading association of tighter gun control means safer society here are just a few below...many more:

-explore New Hampshire and Illinois...NH has very liberal gun control, Chicago instead has very strict ones...look up who has more gun related violent crime per capita...

-the Swiss gov't actually encourages gun ownership.. has one of the highest rates of gun ownership in the world, but little gun-related street crime

-Britain has more violent crime then the US (ban on guns since 1997)



From my viewpoint, attention is being focused in the wrong direction. I think we as powerful respected advocates of "public health" should focus at the root causes of the problem, starting with the breakdown of the family (young males who are deprived of an active father figure are far more likely to commit violent crimes), the relentless stream of violent promoting behaviour from Hollywood, the exponential increase in mental illness in youth to start with.



How come we don't lambast the horrendous violence coming out of Hollywood which our youth are imbibing with negative consequences?



2. As per the CDC, in 2016, ~900 000 legal induced abortions were reported from 49 reporting areas...likely a significant underestimate since CA among other states does not report its numbers (BTW ~ 1.5% for rape/incest, 3% for fetal health issues).



Without going into the classic arguments re pro/con, how can we not, how do we not stand up for these children? I agree with the AAP's stance on gun control but what I have trouble understanding is how the AAP does not weigh in on the abortion issue (~10% of abortions are reported in females <19)?



17 children violently, meaninglessly murdered. An incredible tragedy. How is this different then close to 1 million kids per year mentioned above.



I agree with the AAP's stance on gun control but what I have trouble understanding is how the AAP does not weigh in on the abortion issue?





Joe











Joe Nemeth MD FCFP EM

Associate Professor

McGill University





________________________________________

From: Pediatric Emergency Medicine Discussion List <[log in to unmask]<mailto:[log in to unmask]><mailto:[log in to unmask]>> on behalf of Barry Nathan <[log in to unmask]<mailto:[log in to unmask]><mailto:[log in to unmask]>>

Sent: February 17, 2018 7:23:57 AM

To: [log in to unmask]<mailto:[log in to unmask]><mailto:[log in to unmask]>

Subject: Re: The shooting in Florida



In case you don't get emails from the AAP:



[image: AAP_400_61.jpg]







*Statement on School Shooting in Parkland, Florida*



from *Colleen A. Kraft, MD, FAAP, President, American Academy of Pediatrics*



"Yesterday just before the dismissal bell rang, 17 children and adults were

shot and killed and 15 were injured inside Marjory Stoneman Douglas High

School in Parkland, Fla. We find ourselves once again filled with grief and

horror, and we mourn alongside all those impacted by the shooting. As our

hearts are in Parkland, our eyes are on Congress.



"This is the eighteenth school shooting in 2018, the equivalent of one

every two and a half days so far this year. Shootings have an indelible

impact on entire communities, on the families who lost children and loved

ones, and on the children who survived. Columbine. Virginia Tech. Newtown.

Orlando. Las Vegas. And now, Parkland. Children are dying from gun violence

and Congress is failing to act. Every one of our 100 U.S. senators, and all

435 U.S. representatives bear a responsibility to take meaningful action to

protect our children, our families, and our communities. Our elected

leaders cannot continue to fail at this most essential task.



"We can start by working to advance meaningful legislation that keeps

children safe. The American Academy of Pediatrics advocates for stronger

state and federal gun laws that protect children, including a ban on

assault weapons like the one used in yesterday's school shooting. We also

call for stronger background checks, solutions addressing firearm

trafficking, and encouraging safe firearm storage. We will also continue to

work to ensure that children and their families have access to appropriate

mental health services, particularly to address the effects of exposure to

violence.



"Although these mass shootings command our attention, our children remain

at risk daily for suicide, homicide, and unintentional injury because of

the current policy regarding access to guns in the United States. Gun

violence is a public health threat to children, and one the American

Academy of Pediatrics will continue to take on, in state capitals across

the country and in the halls of Congress. Parents across the United States

send their children to school every day, and hope and trust they will be

safe. As long as children continue to be injured and killed by guns in this

country, pediatricians will not rest in our pursuit to keep them safe."



*The American Academy of Pediatrics is an organization of 66,000 primary

care pediatricians, pediatric medical subspecialists and pediatric surgical

specialists dedicated to the health, safety and well-being of infants,

children, adolescents and young adults. For more information, visit *

www.aap.org<https://urldefense.proofpoint.com/v2/url?u=http-3A__www.aap.org&d=DwIGaQ&c=cjytLXgP8ixuoHflwc-poQ&r=iiLqIGJPj43rFwhy0umXiLW2YeM4w7OHtbhTpnjKXBI&m=t48oRvjGz5SVTSWYDRNskNM83f8PFATlPgGDaXkwwFA&s=GYHJ2Trg6KbD5HWur2hhBM8okfIlyE-J85UX7orhmA4&e=><https://urldefense.proofpoint.com/v2/url?u=http-3A__www.aap.org&d=DwIGaQ&c=cjytLXgP8ixuoHflwc-poQ&r=iiLqIGJPj43rFwhy0umXiLW2YeM4w7OHtbhTpnjKXBI&m=t48oRvjGz5SVTSWYDRNskNM83f8PFATlPgGDaXkwwFA&s=GYHJ2Trg6KbD5HWur2hhBM8okfIlyE-J85UX7orhmA4&e=>

<https://urldefense.proofpoint.com/v2/url?u=https-3A__linkprotect.cudasvc.com_url-3Fa-3Dhttp-3A__www.mmsend70.com_link.cfm-253fr-253dP1AWQRX2DH6KpZKp05dazA-7E-7E-2526pe-253dBH4KXYJXftdV7-5FOrPTTyUbVAzQsfgoRvleBm2XUVQ6AiEVwuBNacQ0AWbz2OcXguY6Y2i1bNdCMkiPdWG-2DfHRg-7E-7E-2526t-253dP2O93UltqkjSP1tT62-5FPaA-7E-7E-26c-3DE-2C1-2CEDnzTesKajviC9Rbq687pz7yfFyRgC2WBFw6mF1beQyzL2WYF-5FfPWMjWxOixG1eagtp40GaUhhxZ8IL4zNcR4weeC1DLvkbbpHQsmMSnszDC-26typo-3D1&d=DwIGaQ&c=cjytLXgP8ixuoHflwc-poQ&r=iiLqIGJPj43rFwhy0umXiLW2YeM4w7OHtbhTpnjKXBI&m=t48oRvjGz5SVTSWYDRNskNM83f8PFATlPgGDaXkwwFA&s=nx187qR_lU1zgduq5D6pufobUc2LvOfMjUy_CKFqY-w&e=>*

and

follow us on Twitter @AmerAcadPeds.*



On Fri, Feb 16, 2018 at 9:22 PM, Chamberlain, James <

[log in to unmask]<mailto:[log in to unmask]>> wrote:



I think we need to move to repeal the second amendment. It's the only way

the NRA can be stopped. They resist all reasonable attempts to limit the

carnage and then hide behind a misinterpretation of the second amendment.



Very well, let's repeal it. I know many people agree that we don't need

militias any longer.



Jim Chamberlain







-----Original Message-----

From: Pediatric Emergency Medicine Discussion List [mailto:

[log in to unmask]<mailto:[log in to unmask]>] On Behalf Of Martin Pusic

Sent: Friday, February 16, 2018 6:29 PM

To: [log in to unmask]<mailto:[log in to unmask]>

Subject: The shooting in Florida



Hi colleagues,



As I sit in my office late on a Friday, I've gotten myself into a state

about the 17 children gunned down in a school. For the umpteenth time.



I think the thing that has me so upset, is that this state of gun

complaisance is an affront to everything a pediatric emergency physician

stands for. We sweat whether it's too risky when the WBC is 15.1 and not

14.9. We study 40,000 children in order sort out who deserves the x-ray

risk of a maybe brain tumor 30 years from now. We work in difficult,

burnout inducing conditions so that we can personally save, say, one life a

year.



Today it feels to me like someone with an AK-whatever just wiped out 17

years of my work. In minutes. I want to cry. We SHOULD cry. Try and

watch that Parkland mother on CNN. I dare you.



Today is not a day like all the others. It's just not.



--Martin Pusic



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------------------------------



Date: Sun, 18 Feb 2018 10:20:42 -0500

From: Martin Pusic <[log in to unmask]<mailto:[log in to unmask]>>

Subject: A second, more settled, reflection on the Florida shooting



After my amygdala-based email of Friday, a clarification:



It is right and fit and proper that Pediatric Emergency Medicine physicians bring the full force of our research and clinical armementarium to bear on the problems of our patients. That means sweating thresholds of WBC for their predictive value in infections. That means mounting massive 10 year PECARN/PERC/PERN level research efforts to understand in detail the mechanisms of our patients' problems in order to benefit them in any way we can. That's our laudable job. We should be proud of taking on the problem of brain tumours 30 years from now. In no way did I mean to denigrate those efforts. Instead, the complete opposite -- I think they provide us with the moral authority to speak out against government policies that harm children.



What is neither right nor fit nor proper is the ease with which a gun violence proponent can wreak havoc at a scale that, on a given schoolday, trivializes my efforts and those of my PEM colleagues. It feels like a personal affront that we live in a nation in which somehow the NRA has better government support than CHIP does. My point is not to devalue our day/evening/night/weekend job.... we are doing MORE than our part in society.......but rather to express that I, as a PEM physician, am rocked to the core by the moral imbalance that makes it possible to routinely leave 17 children dead. And that this is some sort of normal.



Some notes:

If you need an example of how routine this has become, one PEM colleague wrote that he is going to his son's elementary school next week to instruct the teachers on external control of hemorrhage

A Scot described the positive example of the way the Dunblane massacre provoked a re-writing of their laws. They haven't had another in 22 years since.

Fahd Ahmad from WashU had already written on this: https://urldefense.proofpoint.com/v2/url?u=http-3A__www.roguedadmd.com_2018_02_how-2Dmany-2Dpeople-2Dand-2Dwhich-2Dpeople-2Dshould-2Ddie-2Dfor-2Dwhich-2Drights_&d=DwIGaQ&c=cjytLXgP8ixuoHflwc-poQ&r=iiLqIGJPj43rFwhy0umXiLW2YeM4w7OHtbhTpnjKXBI&m=t48oRvjGz5SVTSWYDRNskNM83f8PFATlPgGDaXkwwFA&s=gBTmwrSDR2Xj4YokS_BOxGaLGBc1Xiq3jhEmCjkra6M&e=

I learned of the positive examples of EM physicians taking this on including Garen Wintemute of UC Davis and Eric Fleegler/Lois Lee at Boston Children's.

thank you posting the AAP statement which properly represents our values

The majority of people who wrote back are mothers.



Finally, I commit to writing back, constructively, every 3 months on this topic until there's nothing to write about





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------------------------------



Date: Sun, 18 Feb 2018 16:56:19 +0000

From: Doc Holiday <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: The shooting in Florida



Before I continue, I must say how much more comfortable this on-line debate feels as compared to previous ones on other ListServs. I know it's a generalising comment, but I keep finding that the insertion into the mix of people who work with children makes everything so much more polite and patient. If I recall correctly, there was a lot of anger and short sentences last time I was involved in a debate on this topic on an "adult" list....





From: Joe Nemeth, Dr <[log in to unmask]<mailto:[log in to unmask]>>

As I sit in my living room on this Saturday morning





--> My living room. Sunday afternoon. What else is there to do on a weekend, eh?





I live in Canada and love our very strict gun control laws





--> As people know, I live in the UK at this time and I also like the gun laws here (as well as ones on knives, etc). I don't feel as positive about drug laws, but that's a different thread. Still, the point I made before and make again now is that I don't think our gun laws are THE cause of our statistics. I think they are but one (be it major) factor contributing, but on the background of a culture which rejects gun violence! I don't think that any society will change sufficiently merely by their introduction - no matter how strict. I have lived for many years in more than one country in which guns were far more common than they are in the UK and these countries differed markedly in terms of gun violence. One was actually on the same scale as the USA!





A troubled young man AND inappropriate access to crazy weapons is what caused this catastrophe... too simplistic and frankly naive to think that stricter gun control would solve all of these gun related deaths





--> I agree. And I would add that there are factors beyond the two you mentioned. It's not even ONLY two factors. We can probably add to this:

- the lack of major societal backlash to inappropriate comments

- the tolerance of lack of free psychiatric care

- the overwhelming number of similar cases which will "drown" the efforts of law enforcement to identify the cases which eventually go on to this sort of event from among so many others, etc

- there will be more factors identified as this case gets investigated





One more point, though - a HUGE factor might be, as in past cases, if the outrage dies down! The NRA and those who profit from guns will push their politicians, including some of the more publicly-prominent ones and they will keep things as quiet as possible. Possibly, even the next similar event somehow will be used to make this one "disappear". You can recognise the "silencing tactics" by indicator phrases such as:

- "Now is not the time..."

- "Country/state/city X ... bla-bla-bla ... And they have more/fewer guns and more/fewer gun deaths and this random statistic thus means we should stop looking into gun control"

- "My child just falls a lot" (sorry - had to put that in, as it's on the same level)

- "The USA is a unique country and yet, when it suits me, I will find some other one with which to make comparisons to prove my point"





Britain has more violent crime then the US (ban on guns since 1997)





--> I realise that I am picking up just one of the many points which were listed together. I am only choosing this one because it's one I have been familiar with for a very long time. It has been much "used" in order to "prove" to Americans how the introduction of gun laws in the UK has left it with a higher violent crime rate than the USA and should thus be avoided by the USA. Now, I won't trouble the List by arguments about this. Instead, I would appreciate it if y'all satisfy your own curiosities, each to his/her own level, by going to a favourite search engine and searching for the phrase "Britain has more violent crime then the US". You can read for yourselves and save me from having to type up the actual facts...





But I can't stop myself from mentioning something which has come up in a past discussion I was accidentally drawn into on a visit to the USA 3-4 years ago. This same myth was raised. That, in itself, was no surprise, but it had been raised by someone who had already impressed me with how many "facts" he had absorbed from social media sources and how confidently he spoke of these despite appearing to be far less eloquent whenever questioned in detail about anything. I.e., he appeared to me to have been "brainwashed". Despite knowing better, I challenged him on why he thought the USA was "doing so much better" than the UK in terms of violent crime. He gave me the answer. He then mistook my look of disbelief to indicate I did not believe the facts he had mentioned. He was wrong - what I did not believe is that someone could be that easy to "sell" to. He pulled out his phone and showed me the "evidence". No idea what you're sitting on as you read this, but I hope it has handles for you to hang onto, so that you don't fall to the ground laughing. The reason, according to this "expert" for how the USA got to have what he claimed was 10 times less violent crime than the UK is because the USA has taken the excellent pre-emptive step of imprisoning those who would otherwise have engaged in violent crime! I kid you not - he attributed the high level of violent crime he believed the UK had, not to the fact that the UK records a huge number of offences which the USA does not include in its statistics. What he showed me was: https://urldefense.proofpoint.com/v2/url?u=https-3A__en.wikipedia.org_wiki_List-5Fof-5Fcountries-5Fby-5Fincarceration-5Frate&d=DwIGaQ&c=cjytLXgP8ixuoHflwc-poQ&r=iiLqIGJPj43rFwhy0umXiLW2YeM4w7OHtbhTpnjKXBI&m=t48oRvjGz5SVTSWYDRNskNM83f8PFATlPgGDaXkwwFA&s=U4gHJAeNgKwFDK4WRfsLUPol7JAm8n3364MaZLG1Co4&e= (the version which was on line then). He had been "educated" to believe that the fact that the USA had around a 10-time higher number of prisoners than the UK per million of population correlated with how it achieved a 10-time lower rate of violent crime...





I expect one requires whole armies of people who can be thus educated in order to perpetuate certain "facts"... Such people can be convinced of many things...















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------------------------------



Date: Sun, 18 Feb 2018 12:00:26 -0500

From: Michael Falk <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: The shooting in Florida



While I get the despair and anger given the lose of 17 people in another

senseless mass shooting, I would caution people to not give up hope. When

I first came to New York City in 1989, it was averaging about 2,000

homicides a year. If take our statistics for nonlethal injuries per

homicide, roughly 7:1, the city was seeing another 10,000 plus penetrating

traumas and I have not even mentioned the assaults with fists or blunt

objects. Last year in NYC, we had less than 400 homicides and the city is

safer than it has been in years. Why? Well, there was a concerted effort

to change the culture of policing and law enforcement in the city, and

there was a massive crackdown on guns and getting them off the streets.

The laws were changed around gun ownership and licensing, and there you

have it....



Also, many of you are forgetting that we had an assault weapons law in the

US and Bush/Congress let it lapse in 2003. Now it's record is a mixed bag

but I think that if we learn from the mistakes we made the last time, and

write a better law, we can actually have a significant impact.



Just my two cents..

Mike Falk

NYC.



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------------------------------



Date: Sun, 18 Feb 2018 17:09:24 +0000

From: Robert Finkelstein <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: PED-EM-L Digest - 15 Feb 2018 to 16 Feb 2018 (#2018-39)



Other countries have the same level of mental illness as the United States, but not nearly the number of gun deaths. The mental health issue is important but access to weapons that can kill a large number of people in seconds allows the results we see. In addition, access to guns plays a huge role in suicides since many who attempt suicide and do not succeed will get help and not attempt again. However, access to a gun makes it much more likely that the first attempt will result in death.



Robert Finkelstein



On Feb 18, 2018, at 8:42 AM, Mick Work <[log in to unmask]<mailto:[log in to unmask]>> wrote:



I respect the need for debate around guns. However, I think we are remiss as pediatric emergency physicians to not raise a deeper discussion around the mental illness crisis.



We all see kids who meet this persons profile across the country. We see disturbing mental illness and the many factors (including social media, broken families, child abuse) that lead a child to buy a gun to do harm. Or if not gun an explosive device etc..



We see kids who are socially isolated and warning signs ignored. Anyone else concerned that the kids we see with mental illness are recognized by schools or pediatric visit screening more often than by their own parents, friends or neighbors.



This persons desire to be a “school shooter” should raise attention around how the media covers these events. The fame brought to these shooters should be called into question. Are we fostering this copycat mentality?



The lack of respect for human life should call us to question more than the how but why.



A focus only on guns and gun laws is remiss to the bigger picture in my opinion and experience.



Mick







On Feb 17, 2018, at 12:01 AM, PED-EM-L automatic digest system <[log in to unmask]<mailto:[log in to unmask]>> wrote:



There are 4 messages totaling 391 lines in this issue.



Topics of the day:



1. Peds EM talk (2)

2. Bacterial meningitis

3. The shooting in Florida



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----------------------------------------------------------------------



Date: Fri, 16 Feb 2018 11:50:44 -0500

From: Purva Grover <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: Peds EM talk



Thanks all for your help on this.

Best

Purva



Purva Grover , MD

Medical Director

Pediatric Emergency Department

Cleveland Clinic Health System

Email- [log in to unmask]<mailto:[log in to unmask]> <[log in to unmask]<mailto:[log in to unmask]>>g



On Thu, Feb 15, 2018 at 2:18 PM, <[log in to unmask]<mailto:[log in to unmask]>> wrote:



Hi All

I am giving an hour ppt to new PAs on Peds Emergencies. Clearly can not

cover ALL or even most. Any thoughts / talks / power points- you could

share would be appreciated.

Thanks

Purva



Sent from my mobile device



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------------------------------



Date: Fri, 16 Feb 2018 14:34:20 +0000

From: "Chamberlain, James" <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: Peds EM talk



I would also cover unusual cases that you can't afford to miss, e.g.



Sternoclavicular dislocation

Conjunctivitis caused by penetrating FB

Septic joint presenting with only low-grade fever (we've had several Staph infections where temp was only 37.6 or 37.7 orally)

Myocarditis presenting as wheezing. Remind them that all "bronchiolitis" patients need a through cardiac exam, including distal pulses

NAT

The "sleepy" baby who has hypoglycemia

The "sleepy" baby who has intussusception

The appendicitis patient who presents with vomiting and diarrhea (not all that unusual, actually)

Etc.



To me, this is the challenge of PEM. Finding the needle in the haystack, that one sick kid who is different than all the usual low acuity illness...



Jim



James Chamberlain

Division Chief, Emergency Medicine

Children’s National Health System

(202) 476-4177



-----Original Message-----

From: Pediatric Emergency Medicine Discussion List [mailto:[log in to unmask]] On Behalf Of Mojica, Michael

Sent: Thursday, February 15, 2018 5:29 PM

To: [log in to unmask]<mailto:[log in to unmask]>

Subject: Re: Peds EM talk



Purva







I would recommend "the critically ill infant".







It is the topic that scares the most people and you can cover a lot of causes through cases.







I like to use cases that include common presenting complaints (e.g. vomiting) that are associated with very bad things (e.g. midgut volvulus).







I'm attaching a ppt file for a talk I did a few years ago on this topic.







My goal is for them to develop a mental checklist of potentially life-saving interventions.







Michael







Michael Mojica, M.D



Director of Education, Division of Pediatric Emergency Medicine



Director, Pediatric Emergency Medicine Fellowship



Bellevue Hospital Center



Administration Building Room A528



New York, N.Y. 10016



[log in to unmask]<mailto:[log in to unmask]>



212-562-8147











On 2/15/18, 5:12 PM, "Pediatric Emergency Medicine Discussion List on behalf of Purva Grover" <[log in to unmask]<mailto:[log in to unmask]> on behalf of [log in to unmask]<mailto:[log in to unmask]>> wrote:







Hi All



I am giving an hour ppt to new PAs on Peds Emergencies. Clearly can not cover ALL or even most. Any thoughts / talks / power points- you could share would be appreciated.



Thanks



Purva







Sent from my mobile device



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------------------------------



Date: Fri, 16 Feb 2018 18:29:38 -0500

From: Aline Baghdassarian <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: Bacterial meningitis



Scott,



Would love to hear more about the cases. How did they present? What was the

decision making process?



Thank you,



Aline



Aline Baghdassarian, MD, MPH, FAAP

Director, Pediatric Emergency Medicine Fellowship Program

Assistant Professor, Department of Emergency Medicine

Virginia Commonwealth University School of Medicine



Children's Hospital of Richmond at VCU

Email [log in to unmask]<mailto:[log in to unmask]>





On Thu, Feb 15, 2018 at 12:40 PM, Julian Orenstein <[log in to unmask]<mailto:[log in to unmask]>>

wrote:



In a recent case at our institution, there was a present but subtle degree

of meningismus — I’ve found over the years there is always some elicitable

sign — but as importantly there’s a degree of irritability or altered

behavior that has everyone concerned: mom, RN’s, me.

If mama ain't happy, I ain't happy. I’ll make liberal use of the term

cerebritis or encephalopathic behavior until there’s a consent signed.



I’m not such a good scientist anymore, but I’ve tried to be an attentive

clinician.



Julian Orenstein





On Feb 14, 2018, at 3:30 PM, JAY FISHER <[log in to unmask]<mailto:[log in to unmask]>> wrote:



Scott - Bacterial meningitis is alive and well here in LV - we have seen

it in a variety of age groups. There is good evidence that there has been

an increase in pneumococcal serotypes not covered by the polyvalent

vaccines since there widespread use, such that the burden of pneumococcal

meningitis (as opposed to H. flu type b) has not decreased nearly as much.



Brouwer MC, van de Beek D. Epidemiology of community-acquired bacterial

meningitis. Curr Opin Infect Dis. 2018;31(1):78-84.



Also, the absence of meningismus in older kids with bacterial meningitis

is well described and occurs in a substantial subset.



Geiseler J, Nelson, K.E. Bacterial meningitis without clinical signs of

meningeal irritation. . Southern Med J 1982;75(4):448-450.



Much of the data on the sensitivity of the neck exam is of the

retrospective variety. I have only read one really good prospective study

on the sensitivity of PE for bacterial meningitis and it was a single

center variety as I recall.



Walsh-Kelly C, Nelson DB, Smith DS, et al. Clinical predictors of

bacterial versus aseptic meningitis in childhood. Ann Emerg Med.

1992;21(8):910-914.



Tough case.





Jay



Jay D. Fisher MD FAAP FACEP

Medical Director, Pediatric EM

Children's Hospital of Nevada at UMC

Clinical Professor of Emergency Medicine and Pediatrics

UNLV School of Medicine

















On February 14, 2018 at 4:18 PM "Conners, Gregory, P" <

[log in to unmask]<mailto:[log in to unmask]>> wrote:





I shared this with our ID director (Dr. Mary Anne Jackson), who pointed

out that bacterial meningitis appears at this time of year as a

complication of influenza:

"Both pneumococcal and meningococcal meningitis can occur post flu as

well as GAS and S aureus invasive disease and TSS."



She also addressed Jim's question: "We do know that new serotypes [of

pneumococcus] have emerged but this is not waning immunity because the teen

only got PCV7".





Greg Conners



Gregory P. Conners, MD, MPH, MBA, FAAP, FACEP



Director, Division of Emergency Medicine

Associate Chair of Pediatrics

Professor of Pediatrics and Emergency Medicine

Children’s Mercy Hospital, Kansas City

University of Missouri, Kansas City

[log in to unmask]<mailto:[log in to unmask]>









-----Original Message-----

From: Pediatric Emergency Medicine Discussion List [mailto:

[log in to unmask]<mailto:[log in to unmask]>] On Behalf Of 000001679b145c30-dmarc-

[log in to unmask]<mailto:[log in to unmask]>

Sent: Wednesday, February 14, 2018 2:25 PM

To: [log in to unmask]<mailto:[log in to unmask]>

Subject: Re: Bacterial meningitis



*** This message was sent to you from an External Source. Please do not

open untrusted links or attachments. ***



________________________________





Could you share with us the clinical findings and history that prompted

the LP?





Shiu-Lin









Shiu-Lin Tsai, MD

Division of Pediatric Emergency Medicine



Department of Emergency Medicine

Columbia University Medical Center







-----Original Message-----

From: Scott Freedman <[log in to unmask]<mailto:[log in to unmask]>>

To: PED-EM-L <[log in to unmask]<mailto:[log in to unmask]>>

Sent: Wed, Feb 14, 2018 2:44 pm

Subject: Bacterial meningitis



ALL:

Since Jan 1st this year, we have seen 3 cases of culture + bacterial

meningitis come through are ED; 2 with *Strep pneumoniae* and 1 with

*Neisseria meningiditis*. All 3 were in older children/ teens who received

their Prevnar 13 vaccines as well as the Menactra series in the patient

with Neisseria. Anyone else seeing cases of this sort? I do not recall 3

cases of bacterial meningitis in older kids in a community setting such as

ours in quite a long time. Is this random bad luck or do we all need to

be more vigilant? Incidentally, none had neck pain or meningismus as a

clinical finding.



--

Kind regards,



Scott

Scott Freedman, MD

Medical Director, Pediatric Emergency Dept Rockville MD



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------------------------------



Date: Fri, 16 Feb 2018 18:29:08 -0500

From: Martin Pusic <[log in to unmask]<mailto:[log in to unmask]>>

Subject: The shooting in Florida



Hi colleagues,



As I sit in my office late on a Friday, I've gotten myself into a state about the 17 children gunned down in a school. For the umpteenth time.



I think the thing that has me so upset, is that this state of gun complaisance is an affront to everything a pediatric emergency physician stands for. We sweat whether it's too risky when the WBC is 15.1 and not 14.9. We study 40,000 children in order sort out who deserves the x-ray risk of a maybe brain tumor 30 years from now. We work in difficult, burnout inducing conditions so that we can personally save, say, one life a year.



Today it feels to me like someone with an AK-whatever just wiped out 17 years of my work. In minutes. I want to cry. We SHOULD cry. Try and watch that Parkland mother on CNN. I dare you.



Today is not a day like all the others. It's just not.



--Martin Pusic



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------------------------------



End of PED-EM-L Digest - 15 Feb 2018 to 16 Feb 2018 (#2018-39)

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------------------------------



Date: Sun, 18 Feb 2018 10:17:05 -0500

From: Deepti Thomas-Paulose <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: The shooting in Florida



The year speed limit laws went into effect-->traffic deaths down 17%.

Mothers against Drunk Driving, stricter DUI enforcement laws-->cut deaths

due to drunk driving by half every year since 1980. Seat belt safety laws,

traffic laws-all created to protect the public. As a public health trained

physician, it seems so illogical to me that we would not create stricter

gun laws especially against military style guns for the civilian

population. Let's start there.



Problem- Mass shootings

Prevention- Ban assault rifles





On Sun, Feb 18, 2018 at 7:42 AM, Terence Bergmann <

[log in to unmask]<mailto:[log in to unmask]>> wrote:



Hi Joe



I disagree about ‘strict gun control laws’ here having anything to do with

it . Either you or I could have a new hunting rifle in a week or two in

Canada. If you look at the school shootings or the Vegas massacre these

are not people who acquired their guns and went slaughtering. These guns

were acquired and the armamentarium prepped and the plans made. Canadian

laws would not stop this.



We have a different culture here in Canada. Guns are not toted around in

public. Thankfully the 49th parallel prevented the ‘western’ mentality

from flourishing on our side of the border. I don’t know why.



The challenge to end ‘their’ problem is that once the bad guys are armed

with illegal guns how do you stop the populace from wanting to have legal

guns?



Somehow other countries can have legal weapons, such as Swiss adults all

keeping their weapons at home after their years of mandatory service, yet

they don’t kill each other with them. Somehow a well armed militia there

does not lead to violence.



I have lots of questions, but I don’t know the answers.



Terence



On Feb 17, 2018, at 2:43 PM, Joe Nemeth, Dr <[log in to unmask]<mailto:[log in to unmask]><mailto:j

[log in to unmask]<mailto:[log in to unmask]>>> wrote:



Disclaimer: I live in Canada and love our very strict gun control laws.





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--

Deepti Thomas-Paulose, MD, MPH

Fellowship Director

Global Health Division

Mt. Sinai St.Luke's Roosevelt Hospital Center

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------------------------------



Date: Sun, 18 Feb 2018 17:15:53 +0000

From: Robert Finkelstein <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: School shootings.......



Just because people will find a way to break laws does not mean that we shouldn’t have them. By that logic, we expect that all of us who are currently law abiding don’t need any laws to make us so. Human nature being what it is, we all need laws and structure. Yes, gun regulation would not stop all gun violence, but it could reduce it. Also, I don’t think the majority want prohibition of guns, just regulation; the same way alcohol is regulated by age and penalties for driving under the influence. Or, the way cars are regulated with licensing, registration, having to pass a driving test and citations for violations.



On Feb 18, 2018, at 8:42 AM, Horst D. Weinberg, MD <[log in to unmask]<mailto:[log in to unmask]>> wrote:



Yes, automatic weapons should be banned by our government, but most of the discussions posted blame the guns, the NRA, the 2nd amendment and our 'laws'. Nobody gets to the meat of the matter: If there is a demand (for guns), regardless of the laws passed, someone will fill that demand. This is no different from Prohibition, where there was no shortage of available booze or the 'war' on drugs, where you can get them at most street corners in any city. What needs to change: There has been a steady decline over the past 20 or so years in our country's moral fiber, personal and work ethic, and yes, child rearing. Cause: unmarried or one parent families, poverty, and absence of any discipline both in the home and in the schools, for 'political correctness'. Parents want to be friends with their children rather than running their homes like 'benevolent dictator ships'. Nothing is denied the child: the child wants $150.00 sneakers or a new cell-phone: no problem. So you can blame the gun all you want, but unless there is a real change in the populations personal morality and ethics, these school tragedies will continue.

We pediatricians should look at our own practices in teaching good child rearing ways to the families we serve. Horst D. Weinberg, MD









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------------------------------



Date: Sun, 18 Feb 2018 17:26:11 +0000

From: Robert Flood <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: The shooting in Florida



Dear Colleagues:





This conversation gives me some hope that we can and will address the issue of gun violence through the scientific approach, rather than "beliefs" and "feelings", similar to the way that Dr. Wintemute has done for the past several decades. While I fully support a "re-evaluation/clarification" of the second amendment, a "Children's Rights Amendment", and other legislation to help curb gun violence in the US, we can and and should evaluate potential interventions now in the context of over 350 million guns, with unlimited ammunition, available to the US public.





So, if we are going to use the scientific approach to this huge public health emergency that clearly endangers our children, we really should break up the huge scope of "gun violence" into unique subsets, including but not limited to the following:





1) Mass Shootings: Unfortunately, the US leads the entire world in the number of mass shootings, which may be more properly categorized as "mass suicides" since these shooters usually have no intention of surviving their murderous rampages. Clearly, the evidence shows a direct correlation with the elimination on the band on assault rifles and the increase in the number and deaths in these incidents. So, everyone's comments on the access to better mental health should be just one aspect of the study of all potential interventions. For instance, even pediatricians must admit that if we had armed security in every school, perhaps with the national guard, we would likely decrease the number of gun related deaths/year in our schools. However, we would need to study that model to prove our hypothesis rather than saying "I believe this will work". Still, Mass Shooting Deaths are only a tiny percentage of gun deaths in the US in any given year. In fact, if we eliminated every single mass shooting gun death and injury in the US, it would have a negligible impact on gun related death and injury rates.





2) Intentional Hand Gun Violence: We continue to have disturbing data regarding intentional handgun injuries, especially in the inner city African American communities. With over 100 K gun related injuries/year, and over 10 k non-suicidal gun related deaths/year, this is a very different problem than "Mass Shootings" and needs to be studied in very different ways. Within this category there are both domestic (ie, in the home) and non-domestic sub-categories, which will likely require very different interventions. For instance, in Saint Louis, MO, we are participating in a 4 hospital (all level 1 trauma centers), 2 university intervention program whereby social worker mentors will be paired with willing participants who present as victims of gun violence with the goal of preventing recidivism as either a victim or a perpetrator.





3) Suicides: The data is consistent and very alarming: over 20 K deaths/year from suicides with a gun. The overwhelming majority of these deaths are due to access to handguns and ammunition in the homes. So, while our limited data allows us to recommend that guns and ammunition be stored and locked separately, we don't know for sure whether this would have significant impact on intentional suicides by teenagers, who often have access to both of these locked items. So, we need to study this in much greater detail, and offer viable solutions to well intentioned individuals who are trying to "protect their families".





4) Accidental Shootings: As we all have friends who own one or more weapons, it is often difficult to convince them that the weapon in the home greatly increases the risk of one of their loved ones being the victim of that weapon. Rather, these often well intentioned families in the suburban and rural areas, who honestly believe that having a loaded gun will protect their families from the very, very unlikely chance of a home invasion, will actually endanger their loved ones simply by bringing guns into the home. On the other hand, in the inner city where gun violence is part of everyday life, families believe having the loaded gun readily available (unlocked, fully loaded) allows them to better protect their loved ones from the reality of their situation. So, when we, as healthcare providers, care for the young children who "accidentally" shoot themselves, we are particularly frustrated and angered by the tragedy of the entire plight of these families. The point is this: these very different groups may require very different approaches with respect to interventions.







I look forward to the continued dialogue, and, more importantly, continued research in these areas.





Bob Flood



Saint Louis University







________________________________

From: Pediatric Emergency Medicine Discussion List <[log in to unmask]<mailto:[log in to unmask]>> on behalf of Nathan Kuppermann <[log in to unmask]<mailto:[log in to unmask]>>

Sent: Sunday, February 18, 2018 8:04:25 AM

To: [log in to unmask]<mailto:[log in to unmask]>

Subject: Re: The shooting in Florida



Jeffrey and colleagues:







My colleague Garen Wintemute is an EM physician at UC Davis and has been doing seminal work on firearm violence prevention for decades - doggedly and with great impact







He is the director of the Violence Prevention Research Program (VPRP) at UC Davis, and has been named a "hero of medicine" by Time Magazine in the past for his work. He is as smart and accomplished as they come, and there is nobody in the country who has been doing this longer or with greater impact. And he has weathered the political and funding crises for this type of work for years, frequently funding his own work when the political climate for this work was bleak. But he has also received substantial foundation money and federal grants during more supportive political times.







He recently received $5 million from the California state legislature to lead the University of California Firearm Violence Research Center, the first state-funded gun violence research center in the country.







Here is his entry in Wikipedia: https://urldefense.proofpoint.com/v2/url?u=https-3A__en.wikipedia.org_wiki_Garen-5FWintemute&d=DwIGaQ&c=Pk_HpaIpE_jAoEC9PLIWoQ&r=PgyaJu_-6fURaaWELlGskCQzpkXWZSDQU-w6tbGwwMM&m=kjmFQ1KpfStKxhcvfi4QpgjqumdRH2TVpCIOAggcCW0&s=MwtCq_L-kQIs3_poo8ESXJUfQXyAfM2mv3_BCZ2sBPo&e=







If you are interested in his program or donating, here is the link: https://urldefense.proofpoint.com/v2/url?u=http-3A__www.ucdmc.ucdavis.edu_vprp_&d=DwIGaQ&c=Pk_HpaIpE_jAoEC9PLIWoQ&r=PgyaJu_-6fURaaWELlGskCQzpkXWZSDQU-w6tbGwwMM&m=kjmFQ1KpfStKxhcvfi4QpgjqumdRH2TVpCIOAggcCW0&s=km0yMXq80C4DGUQlje9yL-_xAQ5OiKQNooiyry9xUC0&e=







Full disclosure: I serve as the Chair of EM at UC Davis where Garen works, but the only benefit to me for getting Garen more exposure or money to the VPRP program that he oversees is my children and family whom I desperately want to protect, my many friends throughout this great country about whom I deeply care, and a country about which I am deeply concerned.







Nate Kuppermann



UC Davis















On Feb 17, 2018, at 3:03 PM, Jeffrey Oestreicher <[log in to unmask]<mailto:[log in to unmask]><mailto:[log in to unmask]>> wrote:







Thanks for this cathartic thread, Dr. Pusic and others. Hope fellows are allowed to chime in. Like many on here my gut reaction is to focus on politics, ie an assault weapons ban, the 2nd amendment etc. If Americans were being killed by the same type of airplane that kept crashing, congress would act. Why the same isn’t done with the AR-15 given that it keeps being used to murder kids (in Sandy Hook, Aurora, Orlando, Las Vegas and now Parkland) is maddening. But I wonder if we could do more by taking the lead on another key gun violence issue on which physicians are experts. The problem was encapsulated by the first few hours after the parkland shooting when media outlets were literally arguing over how many school shootings there have been in 2018. We don't even know! We don't know because there are very little data on firearm injury/death in this country on account of Congress blocking gun violence research funding since 1996. And this funding block (the "Dickey amendment," named for the NRA point person in Congress at the time) has created a political chill on research that has trickled down even to academic medical centers. When I tried to examine NY EMS data to look at pre-hospital intervention in pediatric firearm injury, the city blocked it on account of the study being "too political." Where is the research? When SIDs reached epidemic numbers in the 70’s, Congress allocated funds for aggressive research leading to Back to Sleep campaign and SIDS rates plummeted. Similar research campaigns produced life-saving interventions for lead poisoning and car crashes. Yet no research crusade has been directed at the epidemic of pediatric firearm death because Congress essentially prohibits it. The hard part is trying to figure out what to do about it. In my state of New York, A.2977/S.4363, sponsored by New York State Assemblymember Jo Anne Simon and Senator Roxanne Persaud, would create a Firearm Violence Research Institute in New York and I along with some colleagues are trying to support this in a few different ways; if others on here want to discuss or have other ideas pls be in touch. This is not meant to discourage us from yelling from rooftops and writing senators about background checks, assault weapons ban etc. That is so important. But we have a unique vantage point with regard to public health research and we're allowed to do it for every other public health problem except this one. Thanks so much for allowing me to add my 2 cents







Sent from my iPhone







On Feb 17, 2018, at 3:43 PM, Joe Nemeth, Dr <[log in to unmask]<mailto:[log in to unmask]><mailto:[log in to unmask]>> wrote:







Martin,







As I sit in my living room on this Saturday morning, I’ve also gotten my self in a state about how we tend to focus in on the small picture and neglect an exponentially bigger one.







Spoiler Alert: this will NOT be a politically laced nor personally biased post...as opposed to some of the previous posts on this issue - I'm actually quite disappointed that politics had to rear its ugly head.







Disclaimer: I live in Canada and love our very strict gun control laws.



Don't claim to be a gun control policy expert







Now, allow me to expound:







1. A troubled young man AND inappropriate access to crazy weapons is what caused this catastrophe.







Colleagues, I think we all agree that it would be too simplistic and frankly naive to think that stricter gun control would solve all of these gun related deaths...many examples of this false and misleading association of tighter gun control means safer society here are just a few below...many more:



-explore New Hampshire and Illinois...NH has very liberal gun control, Chicago instead has very strict ones...look up who has more gun related violent crime per capita...



-the Swiss gov't actually encourages gun ownership.. has one of the highest rates of gun ownership in the world, but little gun-related street crime



-Britain has more violent crime then the US (ban on guns since 1997)







From my viewpoint, attention is being focused in the wrong direction. I think we as powerful respected advocates of "public health" should focus at the root causes of the problem, starting with the breakdown of the family (young males who are deprived of an active father figure are far more likely to commit violent crimes), the relentless stream of violent promoting behaviour from Hollywood, the exponential increase in mental illness in youth to start with.







How come we don't lambast the horrendous violence coming out of Hollywood which our youth are imbibing with negative consequences?







2. As per the CDC, in 2016, ~900 000 legal induced abortions were reported from 49 reporting areas...likely a significant underestimate since CA among other states does not report its numbers (BTW ~ 1.5% for rape/incest, 3% for fetal health issues).







Without going into the classic arguments re pro/con, how can we not, how do we not stand up for these children? I agree with the AAP's stance on gun control but what I have trouble understanding is how the AAP does not weigh in on the abortion issue (~10% of abortions are reported in females <19)?







17 children violently, meaninglessly murdered. An incredible tragedy. How is this different then close to 1 million kids per year mentioned above.







I agree with the AAP's stance on gun control but what I have trouble understanding is how the AAP does not weigh in on the abortion issue?











Joe























Joe Nemeth MD FCFP EM



Associate Professor



McGill University











________________________________________



From: Pediatric Emergency Medicine Discussion List <[log in to unmask]<mailto:[log in to unmask]><mailto:[log in to unmask]>> on behalf of Barry Nathan <[log in to unmask]<mailto:[log in to unmask]><mailto:[log in to unmask]>>



Sent: February 17, 2018 7:23:57 AM



To: [log in to unmask]<mailto:[log in to unmask]><mailto:[log in to unmask]>



Subject: Re: The shooting in Florida







In case you don't get emails from the AAP:







[image: AAP_400_61.jpg]















*Statement on School Shooting in Parkland, Florida*







from *Colleen A. Kraft, MD, FAAP, President, American Academy of Pediatrics*







"Yesterday just before the dismissal bell rang, 17 children and adults were



shot and killed and 15 were injured inside Marjory Stoneman Douglas High



School in Parkland, Fla. We find ourselves once again filled with grief and



horror, and we mourn alongside all those impacted by the shooting. As our



hearts are in Parkland, our eyes are on Congress.







"This is the eighteenth school shooting in 2018, the equivalent of one



every two and a half days so far this year. Shootings have an indelible



impact on entire communities, on the families who lost children and loved



ones, and on the children who survived. Columbine. Virginia Tech. Newtown.



Orlando. Las Vegas. And now, Parkland. Children are dying from gun violence



and Congress is failing to act. Every one of our 100 U.S. senators, and all



435 U.S. representatives bear a responsibility to take meaningful action to



protect our children, our families, and our communities. Our elected



leaders cannot continue to fail at this most essential task.







"We can start by working to advance meaningful legislation that keeps



children safe. The American Academy of Pediatrics advocates for stronger



state and federal gun laws that protect children, including a ban on



assault weapons like the one used in yesterday's school shooting. We also



call for stronger background checks, solutions addressing firearm



trafficking, and encouraging safe firearm storage. We will also continue to



work to ensure that children and their families have access to appropriate



mental health services, particularly to address the effects of exposure to



violence.







"Although these mass shootings command our attention, our children remain



at risk daily for suicide, homicide, and unintentional injury because of



the current policy regarding access to guns in the United States. Gun



violence is a public health threat to children, and one the American



Academy of Pediatrics will continue to take on, in state capitals across



the country and in the halls of Congress. Parents across the United States



send their children to school every day, and hope and trust they will be



safe. As long as children continue to be injured and killed by guns in this



country, pediatricians will not rest in our pursuit to keep them safe."







*The American Academy of Pediatrics is an organization of 66,000 primary



care pediatricians, pediatric medical subspecialists and pediatric surgical



specialists dedicated to the health, safety and well-being of infants,



children, adolescents and young adults. For more information, visit *



www.aap.org<https://urldefense.proofpoint.com/v2/url?u=http-3A__www.aap.org&d=DwIGaQ&c=cjytLXgP8ixuoHflwc-poQ&r=iiLqIGJPj43rFwhy0umXiLW2YeM4w7OHtbhTpnjKXBI&m=t48oRvjGz5SVTSWYDRNskNM83f8PFATlPgGDaXkwwFA&s=GYHJ2Trg6KbD5HWur2hhBM8okfIlyE-J85UX7orhmA4&e=><https://urldefense.proofpoint.com/v2/url?u=http-3A__www.aap.org&d=DwIGaQ&c=Pk_HpaIpE_jAoEC9PLIWoQ&r=PgyaJu_-6fURaaWELlGskCQzpkXWZSDQU-w6tbGwwMM&m=kjmFQ1KpfStKxhcvfi4QpgjqumdRH2TVpCIOAggcCW0&s=3Oc_7pCeJFj4KZ9QlF0MpVKwh-Xixr5f2-x4dFOOgHk&e=>



<https://urldefense.proofpoint.com/v2/url?u=https-3A__linkprotect.cudasvc.com_url-3Fa-3Dhttp-3A__www.mmsend70.com_link.cfm-253fr-253dP1AWQRX2DH6KpZKp05dazA-7E-7E-2526pe-253dBH4KXYJXftdV7-5FOrPTTyUbVAzQsfgoRvleBm2XUVQ6AiEVwuBNacQ0AWbz2OcXguY6Y2i1bNdCMkiPdWG-2DfHRg-7E-7E-2526t-253dP2O93UltqkjSP1tT62-5FPaA-7E-7E-26c-3DE-2C1-2CEDnzTesKajviC9Rbq687pz7yfFyRgC2WBFw6mF1beQyzL2WYF-5FfPWMjWxOixG1eagtp40GaUhhxZ8IL4zNcR4weeC1DLvkbbpHQsmMSnszDC-26typo-3D1&d=DwIGaQ&c=Pk_HpaIpE_jAoEC9PLIWoQ&r=PgyaJu_-6fURaaWELlGskCQzpkXWZSDQU-w6tbGwwMM&m=kjmFQ1KpfStKxhcvfi4QpgjqumdRH2TVpCIOAggcCW0&s=IjSKeAbtNO1UyfAxfonG3YrPW35X2WKiPCyGj3YfSnQ&e=>*



and



follow us on Twitter @AmerAcadPeds.*







On Fri, Feb 16, 2018 at 9:22 PM, Chamberlain, James <



[log in to unmask]<mailto:[log in to unmask]>> wrote:







I think we need to move to repeal the second amendment. It's the only way



the NRA can be stopped. They resist all reasonable attempts to limit the



carnage and then hide behind a misinterpretation of the second amendment.







Very well, let's repeal it. I know many people agree that we don't need



militias any longer.







Jim Chamberlain















-----Original Message-----



From: Pediatric Emergency Medicine Discussion List [mailto:



[log in to unmask]<mailto:[log in to unmask]>] On Behalf Of Martin Pusic



Sent: Friday, February 16, 2018 6:29 PM



To: [log in to unmask]<mailto:[log in to unmask]>



Subject: The shooting in Florida







Hi colleagues,







As I sit in my office late on a Friday, I've gotten myself into a state



about the 17 children gunned down in a school. For the umpteenth time.







I think the thing that has me so upset, is that this state of gun



complaisance is an affront to everything a pediatric emergency physician



stands for. We sweat whether it's too risky when the WBC is 15.1 and not



14.9. We study 40,000 children in order sort out who deserves the x-ray



risk of a maybe brain tumor 30 years from now. We work in difficult,



burnout inducing conditions so that we can personally save, say, one life a



year.







Today it feels to me like someone with an AK-whatever just wiped out 17



years of my work. In minutes. I want to cry. We SHOULD cry. Try and



watch that Parkland mother on CNN. I dare you.







Today is not a day like all the others. It's just not.







--Martin Pusic







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------------------------------



Date: Sun, 18 Feb 2018 12:18:07 -0500

From: Jeff Pender <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: The shooting in Florida



I have a desire to put in my 2 cents as well, considering this is perhaps one of the issues I feel most passionately about. This is a multi-factorial problem, obviously. Not only is it a problem with “quality and quantity”, but also with “culture".



By quality and quantity, I am speaking about what people own, and how much they own. Does anyone outside the military need a semi automatic weapon for anything? No. Does anyone need a bump stock? No. Does anyone need an extended magazine? No. If you require any of these things for the lame ass excuse of “home defense”, you either need to move, or take some classes and become a far better shot with a handgun. Further, do people need the insane quantity of weapons and ammunition they tend to accumulate? No, but this is a secondary problem to the types of weapons they own. We can’t own a bazooka, so “we” understand that limits can exist, so we need to extend those limits to the things listed above.



The culture issue, to me, is even worse. In the spirit of full disclosure, I despise guns. I don’t own one, and have no plans on ever owning one. I won’t allow one in my home, period. I feel pretty damn safe with my 3 large dogs, thank you. I will admit that I pull away socially from people once I learn they are big time gun enthusiasts. I won’t spend time with people that I know are carrying a gun on their person, or in their car. I can’t help it, and I don’t feel bad about it for even 1 second. We just see the world too differently, although I don’t think it makes them a bad person. In my anecdotal experience, these serious “enthusiasts” share some similar traits - they own a shit ton of guns, ridiculous ammunition that no target shooter or home defense person really needs, but most importantly perhaps, a “macho” response to their guns. This is the thing that needs to change.



Guns are celebrated in our country as both cool and macho. Decide where to place the blame - video games, movies, athletes, musicians, etc. But, our politicians are part of this problem, and perhaps the largest part. Since they are the ones that make the laws (and take the bribes…err…donations), we need them to stop believing this more than anyone else. They will never change the gun laws until the culture of how we view guns changes. Think back to that insane video Ted Cruz made where he wrapped bacon around the muzzle of an AR-15, and after shooting for a while, ate the bacon that the hot muzzle cooked. It was horrifying how he celebrated that AR-15….just so he could get another donation from gun lovers. Change the culture of how they are viewed (and then campaign finance laws) and the needle can be moved on this issue.



Israel and Swiss citizens own guns at incredibly high rates, but they are viewed as a fact of life, not as a point of pride or machismo. Culture changes are very slow to occur, but that is what is needed first, I think. Without it, laws won’t change, and neither will the desire to own these weapons and accessories. Think of other social changes/regulations….they were slow — seat belt laws, speed limits, voting rights, marriage equality, marijuana legalization, etc etc. They take decades, sadly. We are a country that seems to have extreme difficulty doing the right thing without it taking insanely long. It drives me crazy.



I truly hope that this school shooting has occurred around student’s ages that can possibly make a difference in that these students are at an age to become true activists, unlike when it happens to younger children. A wave has to start, and I think it is most likely to start with these young people, as long as we “older” people support them…both financially and vocally…and in our voting patterns.



Jeff











On Feb 18, 2018, at 7:42 AM, Terence Bergmann <[log in to unmask]<mailto:[log in to unmask]>> wrote:



Hi Joe



I disagree about ‘strict gun control laws’ here having anything to do with it . Either you or I could have a new hunting rifle in a week or two in Canada. If you look at the school shootings or the Vegas massacre these are not people who acquired their guns and went slaughtering. These guns were acquired and the armamentarium prepped and the plans made. Canadian laws would not stop this.



We have a different culture here in Canada. Guns are not toted around in public. Thankfully the 49th parallel prevented the ‘western’ mentality from flourishing on our side of the border. I don’t know why.



The challenge to end ‘their’ problem is that once the bad guys are armed with illegal guns how do you stop the populace from wanting to have legal guns?



Somehow other countries can have legal weapons, such as Swiss adults all keeping their weapons at home after their years of mandatory service, yet they don’t kill each other with them. Somehow a well armed militia there does not lead to violence.



I have lots of questions, but I don’t know the answers.



Terence



On Feb 17, 2018, at 2:43 PM, Joe Nemeth, Dr <[log in to unmask]<mailto:[log in to unmask]><mailto:[log in to unmask]>> wrote:



Disclaimer: I live in Canada and love our very strict gun control laws.





For more information, send mail to [log in to unmask]<mailto:[log in to unmask]> with the message: info PED-EM-L

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------------------------------



Date: Sun, 18 Feb 2018 12:34:05 -0500

From: Michael Falk <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: The shooting in Florida



Friend just posted this interesting rebuttal to the "mental illness"

response whenever there is a mass shooting:



"Believing that mental illness causes mass shootings can feel reassuring.

It helps to believe that only a mentally ill person could do something so

horrific. We also think that if someone is mentally ill, they can be

identified. But the evidence suggests that mental illness only causes a

small fraction of gun violence. And even if some shooters have undiagnosed

mental illness, there is no evidence to suggest that they could have been

diagnosed prior to their gun violence or that such a diagnosis would

increase the predictive validity of a diagnosis on gun violence."



https://urldefense.proofpoint.com/v2/url?u=http-3A__behavioralscientist.org_myth-2Dmental-2Dillness-2Dcauses-2Dmass-2Dshootings_&d=DwIGaQ&c=cjytLXgP8ixuoHflwc-poQ&r=iiLqIGJPj43rFwhy0umXiLW2YeM4w7OHtbhTpnjKXBI&m=t48oRvjGz5SVTSWYDRNskNM83f8PFATlPgGDaXkwwFA&s=Ij2AVYkN8_dOohEUJqTc3oK3dja0ogb2DxwZquooPUg&e=



I will add few links of my own:



https://urldefense.proofpoint.com/v2/url?u=https-3A__www.theatlantic.com_health_archive_2017_10_why-2Dbetter-2Dmental-2Dhealth-2Dcare-2Dwont-2Dstop-2Dmass-2Dshootings_541965_&d=DwIGaQ&c=cjytLXgP8ixuoHflwc-poQ&r=iiLqIGJPj43rFwhy0umXiLW2YeM4w7OHtbhTpnjKXBI&m=t48oRvjGz5SVTSWYDRNskNM83f8PFATlPgGDaXkwwFA&s=iuN1ZZWvSku4__pWqqZGs88CZl8aLR4AGeH1wrVCdO8&e=



https://urldefense.proofpoint.com/v2/url?u=https-3A__www.vox.com_policy-2Dand-2Dpolitics_2017_11_9_16618472_mental-2Dillness-2Dgun-2Dhomicide-2Dmass-2Dshootings&d=DwIGaQ&c=cjytLXgP8ixuoHflwc-poQ&r=iiLqIGJPj43rFwhy0umXiLW2YeM4w7OHtbhTpnjKXBI&m=t48oRvjGz5SVTSWYDRNskNM83f8PFATlPgGDaXkwwFA&s=fpNtmUdDXtNXjh9vJuCsoZOzpctDlZD2qEwlDx4cgyQ&e=



The mentally ill are stigmatized enough, blaming them for these killings

seems unfair.



Mike Falk



On Sun, Feb 18, 2018 at 12:18 PM, Jeff Pender <[log in to unmask]<mailto:[log in to unmask]>> wrote:



I have a desire to put in my 2 cents as well, considering this is perhaps

one of the issues I feel most passionately about. This is a

multi-factorial problem, obviously. Not only is it a problem with

“quality and quantity”, but also with “culture".



By quality and quantity, I am speaking about what people own, and how much

they own. Does anyone outside the military need a semi automatic weapon

for anything? No. Does anyone need a bump stock? No. Does anyone need

an extended magazine? No. If you require any of these things for the lame

ass excuse of “home defense”, you either need to move, or take some classes

and become a far better shot with a handgun. Further, do people need the

insane quantity of weapons and ammunition they tend to accumulate? No, but

this is a secondary problem to the types of weapons they own. We can’t

own a bazooka, so “we” understand that limits can exist, so we need to

extend those limits to the things listed above.



The culture issue, to me, is even worse. In the spirit of full

disclosure, I despise guns. I don’t own one, and have no plans on ever

owning one. I won’t allow one in my home, period. I feel pretty damn safe

with my 3 large dogs, thank you. I will admit that I pull away socially

from people once I learn they are big time gun enthusiasts. I won’t spend

time with people that I know are carrying a gun on their person, or in

their car. I can’t help it, and I don’t feel bad about it for even 1

second. We just see the world too differently, although I don’t think it

makes them a bad person. In my anecdotal experience, these serious

“enthusiasts” share some similar traits - they own a shit ton of guns,

ridiculous ammunition that no target shooter or home defense person really

needs, but most importantly perhaps, a “macho” response to their guns.

This is the thing that needs to change.



Guns are celebrated in our country as both cool and macho. Decide where

to place the blame - video games, movies, athletes, musicians, etc. But,

our politicians are part of this problem, and perhaps the largest part.

Since they are the ones that make the laws (and take the

bribes…err…donations), we need them to stop believing this more than anyone

else. They will never change the gun laws until the culture of how we view

guns changes. Think back to that insane video Ted Cruz made where he

wrapped bacon around the muzzle of an AR-15, and after shooting for a

while, ate the bacon that the hot muzzle cooked. It was horrifying how he

celebrated that AR-15….just so he could get another donation from gun

lovers. Change the culture of how they are viewed (and then campaign

finance laws) and the needle can be moved on this issue.



Israel and Swiss citizens own guns at incredibly high rates, but they are

viewed as a fact of life, not as a point of pride or machismo. Culture

changes are very slow to occur, but that is what is needed first, I think.

Without it, laws won’t change, and neither will the desire to own these

weapons and accessories. Think of other social changes/regulations….they

were slow — seat belt laws, speed limits, voting rights, marriage equality,

marijuana legalization, etc etc. They take decades, sadly. We are a

country that seems to have extreme difficulty doing the right thing without

it taking insanely long. It drives me crazy.



I truly hope that this school shooting has occurred around student’s ages

that can possibly make a difference in that these students are at an age to

become true activists, unlike when it happens to younger children. A wave

has to start, and I think it is most likely to start with these young

people, as long as we “older” people support them…both financially and

vocally…and in our voting patterns.



Jeff











On Feb 18, 2018, at 7:42 AM, Terence Bergmann <

[log in to unmask]<mailto:[log in to unmask]>> wrote:



Hi Joe



I disagree about ‘strict gun control laws’ here having anything to do

with it . Either you or I could have a new hunting rifle in a week or two

in Canada. If you look at the school shootings or the Vegas massacre these

are not people who acquired their guns and went slaughtering. These guns

were acquired and the armamentarium prepped and the plans made. Canadian

laws would not stop this.



We have a different culture here in Canada. Guns are not toted around

in public. Thankfully the 49th parallel prevented the ‘western’ mentality

from flourishing on our side of the border. I don’t know why.



The challenge to end ‘their’ problem is that once the bad guys are armed

with illegal guns how do you stop the populace from wanting to have legal

guns?



Somehow other countries can have legal weapons, such as Swiss adults all

keeping their weapons at home after their years of mandatory service, yet

they don’t kill each other with them. Somehow a well armed militia there

does not lead to violence.



I have lots of questions, but I don’t know the answers.



Terence



On Feb 17, 2018, at 2:43 PM, Joe Nemeth, Dr <[log in to unmask]<mailto:[log in to unmask]>

<mailto:[log in to unmask]>> wrote:



Disclaimer: I live in Canada and love our very strict gun control laws.





For more information, send mail to [log in to unmask]<mailto:[log in to unmask]> with the

message: info PED-EM-L

The URL for the PED-EM-L Web Page is:

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------------------------------



Date: Sun, 18 Feb 2018 12:52:28 -0500

From: Mick Work <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: PED-EM-L Digest - 15 Feb 2018 to 16 Feb 2018 (#2018-39)



I appreciate the passion around gun legislation and not opposed. I don’t think laws will end this countries obsession with guns or limit access to those who want to perform unlawful acts. But again I am not arguing against reasonable legislation.



I have heard proposed that we need to arm principals and add more security in schools. I just wonder if we added mental health counselors instead if we wouldn’t make a greater impact.



My point is our prevention should be multi-modal like all effective strategies.





Mick







On Feb 18, 2018, at 12:09 PM, Robert Finkelstein <[log in to unmask]<mailto:[log in to unmask]>> wrote:



Other countries have the same level of mental illness as the United States, but not nearly the number of gun deaths. The mental health issue is important but access to weapons that can kill a large number of people in seconds allows the results we see. In addition, access to guns plays a huge role in suicides since many who attempt suicide and do not succeed will get help and not attempt again. However, access to a gun makes it much more likely that the first attempt will result in death.



Robert Finkelstein



On Feb 18, 2018, at 8:42 AM, Mick Work <[log in to unmask]<mailto:[log in to unmask]>> wrote:



I respect the need for debate around guns. However, I think we are remiss as pediatric emergency physicians to not raise a deeper discussion around the mental illness crisis.



We all see kids who meet this persons profile across the country. We see disturbing mental illness and the many factors (including social media, broken families, child abuse) that lead a child to buy a gun to do harm. Or if not gun an explosive device etc..



We see kids who are socially isolated and warning signs ignored. Anyone else concerned that the kids we see with mental illness are recognized by schools or pediatric visit screening more often than by their own parents, friends or neighbors.



This persons desire to be a “school shooter” should raise attention around how the media covers these events. The fame brought to these shooters should be called into question. Are we fostering this copycat mentality?



The lack of respect for human life should call us to question more than the how but why.



A focus only on guns and gun laws is remiss to the bigger picture in my opinion and experience.



Mick







On Feb 17, 2018, at 12:01 AM, PED-EM-L automatic digest system <[log in to unmask]<mailto:[log in to unmask]>> wrote:



There are 4 messages totaling 391 lines in this issue.



Topics of the day:



1. Peds EM talk (2)

2. Bacterial meningitis

3. The shooting in Florida



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----------------------------------------------------------------------



Date: Fri, 16 Feb 2018 11:50:44 -0500

From: Purva Grover <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: Peds EM talk



Thanks all for your help on this.

Best

Purva



Purva Grover , MD

Medical Director

Pediatric Emergency Department

Cleveland Clinic Health System

Email- [log in to unmask]<mailto:[log in to unmask]> <[log in to unmask]<mailto:[log in to unmask]>>g



On Thu, Feb 15, 2018 at 2:18 PM, <[log in to unmask]<mailto:[log in to unmask]>> wrote:



Hi All

I am giving an hour ppt to new PAs on Peds Emergencies. Clearly can not

cover ALL or even most. Any thoughts / talks / power points- you could

share would be appreciated.

Thanks

Purva



Sent from my mobile device



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------------------------------



Date: Fri, 16 Feb 2018 14:34:20 +0000

From: "Chamberlain, James" <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: Peds EM talk



I would also cover unusual cases that you can't afford to miss, e.g.



Sternoclavicular dislocation

Conjunctivitis caused by penetrating FB

Septic joint presenting with only low-grade fever (we've had several Staph infections where temp was only 37.6 or 37.7 orally)

Myocarditis presenting as wheezing. Remind them that all "bronchiolitis" patients need a through cardiac exam, including distal pulses

NAT

The "sleepy" baby who has hypoglycemia

The "sleepy" baby who has intussusception

The appendicitis patient who presents with vomiting and diarrhea (not all that unusual, actually)

Etc.



To me, this is the challenge of PEM. Finding the needle in the haystack, that one sick kid who is different than all the usual low acuity illness...



Jim



James Chamberlain

Division Chief, Emergency Medicine

Children’s National Health System

(202) 476-4177



-----Original Message-----

From: Pediatric Emergency Medicine Discussion List [mailto:[log in to unmask]] On Behalf Of Mojica, Michael

Sent: Thursday, February 15, 2018 5:29 PM

To: [log in to unmask]<mailto:[log in to unmask]>

Subject: Re: Peds EM talk



Purva







I would recommend "the critically ill infant".







It is the topic that scares the most people and you can cover a lot of causes through cases.







I like to use cases that include common presenting complaints (e.g. vomiting) that are associated with very bad things (e.g. midgut volvulus).







I'm attaching a ppt file for a talk I did a few years ago on this topic.







My goal is for them to develop a mental checklist of potentially life-saving interventions.







Michael







Michael Mojica, M.D



Director of Education, Division of Pediatric Emergency Medicine



Director, Pediatric Emergency Medicine Fellowship



Bellevue Hospital Center



Administration Building Room A528



New York, N.Y. 10016



[log in to unmask]<mailto:[log in to unmask]>



212-562-8147











On 2/15/18, 5:12 PM, "Pediatric Emergency Medicine Discussion List on behalf of Purva Grover" <[log in to unmask]<mailto:[log in to unmask]> on behalf of [log in to unmask]<mailto:[log in to unmask]>> wrote:







Hi All



I am giving an hour ppt to new PAs on Peds Emergencies. Clearly can not cover ALL or even most. Any thoughts / talks / power points- you could share would be appreciated.



Thanks



Purva







Sent from my mobile device



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------------------------------



Date: Fri, 16 Feb 2018 18:29:38 -0500

From: Aline Baghdassarian <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: Bacterial meningitis



Scott,



Would love to hear more about the cases. How did they present? What was the

decision making process?



Thank you,



Aline



Aline Baghdassarian, MD, MPH, FAAP

Director, Pediatric Emergency Medicine Fellowship Program

Assistant Professor, Department of Emergency Medicine

Virginia Commonwealth University School of Medicine



Children's Hospital of Richmond at VCU

Email [log in to unmask]<mailto:[log in to unmask]>





On Thu, Feb 15, 2018 at 12:40 PM, Julian Orenstein <[log in to unmask]<mailto:[log in to unmask]>>

wrote:



In a recent case at our institution, there was a present but subtle degree

of meningismus — I’ve found over the years there is always some elicitable

sign — but as importantly there’s a degree of irritability or altered

behavior that has everyone concerned: mom, RN’s, me.

If mama ain't happy, I ain't happy. I’ll make liberal use of the term

cerebritis or encephalopathic behavior until there’s a consent signed.



I’m not such a good scientist anymore, but I’ve tried to be an attentive

clinician.



Julian Orenstein





On Feb 14, 2018, at 3:30 PM, JAY FISHER <[log in to unmask]<mailto:[log in to unmask]>> wrote:



Scott - Bacterial meningitis is alive and well here in LV - we have seen

it in a variety of age groups. There is good evidence that there has been

an increase in pneumococcal serotypes not covered by the polyvalent

vaccines since there widespread use, such that the burden of pneumococcal

meningitis (as opposed to H. flu type b) has not decreased nearly as much.



Brouwer MC, van de Beek D. Epidemiology of community-acquired bacterial

meningitis. Curr Opin Infect Dis. 2018;31(1):78-84.



Also, the absence of meningismus in older kids with bacterial meningitis

is well described and occurs in a substantial subset.



Geiseler J, Nelson, K.E. Bacterial meningitis without clinical signs of

meningeal irritation. . Southern Med J 1982;75(4):448-450.



Much of the data on the sensitivity of the neck exam is of the

retrospective variety. I have only read one really good prospective study

on the sensitivity of PE for bacterial meningitis and it was a single

center variety as I recall.



Walsh-Kelly C, Nelson DB, Smith DS, et al. Clinical predictors of

bacterial versus aseptic meningitis in childhood. Ann Emerg Med.

1992;21(8):910-914.



Tough case.





Jay



Jay D. Fisher MD FAAP FACEP

Medical Director, Pediatric EM

Children's Hospital of Nevada at UMC

Clinical Professor of Emergency Medicine and Pediatrics

UNLV School of Medicine

















On February 14, 2018 at 4:18 PM "Conners, Gregory, P" <

[log in to unmask]<mailto:[log in to unmask]>> wrote:





I shared this with our ID director (Dr. Mary Anne Jackson), who pointed

out that bacterial meningitis appears at this time of year as a

complication of influenza:

"Both pneumococcal and meningococcal meningitis can occur post flu as

well as GAS and S aureus invasive disease and TSS."



She also addressed Jim's question: "We do know that new serotypes [of

pneumococcus] have emerged but this is not waning immunity because the teen

only got PCV7".





Greg Conners



Gregory P. Conners, MD, MPH, MBA, FAAP, FACEP



Director, Division of Emergency Medicine

Associate Chair of Pediatrics

Professor of Pediatrics and Emergency Medicine

Children’s Mercy Hospital, Kansas City

University of Missouri, Kansas City

[log in to unmask]<mailto:[log in to unmask]>









-----Original Message-----

From: Pediatric Emergency Medicine Discussion List [mailto:

[log in to unmask]<mailto:[log in to unmask]>] On Behalf Of 000001679b145c30-dmarc-

[log in to unmask]<mailto:[log in to unmask]>

Sent: Wednesday, February 14, 2018 2:25 PM

To: [log in to unmask]<mailto:[log in to unmask]>

Subject: Re: Bacterial meningitis



*** This message was sent to you from an External Source. Please do not

open untrusted links or attachments. ***



________________________________





Could you share with us the clinical findings and history that prompted

the LP?





Shiu-Lin









Shiu-Lin Tsai, MD

Division of Pediatric Emergency Medicine



Department of Emergency Medicine

Columbia University Medical Center







-----Original Message-----

From: Scott Freedman <[log in to unmask]<mailto:[log in to unmask]>>

To: PED-EM-L <[log in to unmask]<mailto:[log in to unmask]>>

Sent: Wed, Feb 14, 2018 2:44 pm

Subject: Bacterial meningitis



ALL:

Since Jan 1st this year, we have seen 3 cases of culture + bacterial

meningitis come through are ED; 2 with *Strep pneumoniae* and 1 with

*Neisseria meningiditis*. All 3 were in older children/ teens who received

their Prevnar 13 vaccines as well as the Menactra series in the patient

with Neisseria. Anyone else seeing cases of this sort? I do not recall 3

cases of bacterial meningitis in older kids in a community setting such as

ours in quite a long time. Is this random bad luck or do we all need to

be more vigilant? Incidentally, none had neck pain or meningismus as a

clinical finding.



--

Kind regards,



Scott

Scott Freedman, MD

Medical Director, Pediatric Emergency Dept Rockville MD



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------------------------------



Date: Fri, 16 Feb 2018 18:29:08 -0500

From: Martin Pusic <[log in to unmask]<mailto:[log in to unmask]>>

Subject: The shooting in Florida



Hi colleagues,



As I sit in my office late on a Friday, I've gotten myself into a state about the 17 children gunned down in a school. For the umpteenth time.



I think the thing that has me so upset, is that this state of gun complaisance is an affront to everything a pediatric emergency physician stands for. We sweat whether it's too risky when the WBC is 15.1 and not 14.9. We study 40,000 children in order sort out who deserves the x-ray risk of a maybe brain tumor 30 years from now. We work in difficult, burnout inducing conditions so that we can personally save, say, one life a year.



Today it feels to me like someone with an AK-whatever just wiped out 17 years of my work. In minutes. I want to cry. We SHOULD cry. Try and watch that Parkland mother on CNN. I dare you.



Today is not a day like all the others. It's just not.



--Martin Pusic



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------------------------------



End of PED-EM-L Digest - 15 Feb 2018 to 16 Feb 2018 (#2018-39)

**************************************************************



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------------------------------



Date: Sun, 18 Feb 2018 23:05:03 +0000

From: "Chamberlain, James" <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: School shootings.......



I'd be happy with sensible regulations, required training, and licensure so that guns don't get into the hands of criminals and people with mental illness.



But the NRA is against sensible regulations.







Sent from my Verizon, Samsung Galaxy smartphone





-------- Original message --------

From: Robert Finkelstein <[log in to unmask]<mailto:[log in to unmask]>>

Date: 2/18/18 12:17 (GMT-05:00)

To: [log in to unmask]<mailto:[log in to unmask]>

Subject: Re: School shootings.......



Just because people will find a way to break laws does not mean that we shouldn’t have them. By that logic, we expect that all of us who are currently law abiding don’t need any laws to make us so. Human nature being what it is, we all need laws and structure. Yes, gun regulation would not stop all gun violence, but it could reduce it. Also, I don’t think the majority want prohibition of guns, just regulation; the same way alcohol is regulated by age and penalties for driving under the influence. Or, the way cars are regulated with licensing, registration, having to pass a driving test and citations for violations.







On Feb 18, 2018, at 8:42 AM, Horst D. Weinberg, MD <[log in to unmask]<mailto:[log in to unmask]>> wrote:







Yes, automatic weapons should be banned by our government, but most of the discussions posted blame the guns, the NRA, the 2nd amendment and our 'laws'. Nobody gets to the meat of the matter: If there is a demand (for guns), regardless of the laws passed, someone will fill that demand. This is no different from Prohibition, where there was no shortage of available booze or the 'war' on drugs, where you can get them at most street corners in any city. What needs to change: There has been a steady decline over the past 20 or so years in our country's moral fiber, personal and work ethic, and yes, child rearing. Cause: unmarried or one parent families, poverty, and absence of any discipline both in the home and in the schools, for 'political correctness'. Parents want to be friends with their children rather than running their homes like 'benevolent dictator ships'. Nothing is denied the child: the child wants $150.00 sneakers or a new cell-phone: no problem. So you can blame the gun all you want, but unless there is a real change in the populations personal morality and ethics, these school tragedies will continue.



We pediatricians should look at our own practices in teaching good child rearing ways to the families we serve. Horst D. Weinberg, MD



















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------------------------------



Date: Sun, 18 Feb 2018 19:03:20 -0600

From: Jill C Obremskey <[log in to unmask]<mailto:[log in to unmask]>>

Subject: Re: School shootings.......



Great discussion but what are WE going to do about it as an organization?

How do we become relentless about the need for gun control, the need for mental health services, and for preventing toxic stress in children.



We need to ask leaders in the AAP and AAEM to organize us into a uniified voice that will not quit.



On February 18, 2018 at 5:05 PM "Chamberlain, James" <[log in to unmask]<mailto:[log in to unmask]>> wrote:





I'd be happy with sensible regulations, required training, and licensure so that guns don't get into the hands of criminals and people with mental illness.



But the NRA is against sensible regulations.







Sent from my Verizon, Samsung Galaxy smartphone





-------- Original message --------

From: Robert Finkelstein <[log in to unmask]<mailto:[log in to unmask]>>

Date: 2/18/18 12:17 (GMT-05:00)

To: [log in to unmask]<mailto:[log in to unmask]>

Subject: Re: School shootings.......



Just because people will find a way to break laws does not mean that we shouldn’t have them. By that logic, we expect that all of us who are currently law abiding don’t need any laws to make us so. Human nature being what it is, we all need laws and structure. Yes, gun regulation would not stop all gun violence, but it could reduce it. Also, I don’t think the majority want prohibition of guns, just regulation; the same way alcohol is regulated by age and penalties for driving under the influence. Or, the way cars are regulated with licensing, registration, having to pass a driving test and citations for violations.







On Feb 18, 2018, at 8:42 AM, Horst D. Weinberg, MD <[log in to unmask]<mailto:[log in to unmask]>> wrote:







Yes, automatic weapons should be banned by our government, but most of the discussions posted blame the guns, the NRA, the 2nd amendment and our 'laws'. Nobody gets to the meat of the matter: If there is a demand (for guns), regardless of the laws passed, someone will fill that demand. This is no different from Prohibition, where there was no shortage of available booze or the 'war' on drugs, where you can get them at most street corners in any city. What needs to change: There has been a steady decline over the past 20 or so years in our country's moral fiber, personal and work ethic, and yes, child rearing. Cause: unmarried or one parent families, poverty, and absence of any discipline both in the home and in the schools, for 'political correctness'. Parents want to be friends with their children rather than running their homes like 'benevolent dictator ships'. Nothing is denied the child: the child wants $150.00 sneakers or a new cell-phone: no problem. So you can blame the gun all you want, but unless there is a real change in the populations personal morality and ethics, these school tragedies will continue.



We pediatricians should look at our own practices in teaching good child rearing ways to the families we serve. Horst D. Weinberg, MD



















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------------------------------



End of PED-EM-L Digest - 17 Feb 2018 to 18 Feb 2018 (#2018-41)

**************************************************************



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------------------------------



End of PED-EM-L Digest - 18 Feb 2018 to 19 Feb 2018 - Special issue (#2018-42)

******************************************************************************



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