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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:

Martin Herman <[log in to unmask]>

Reply-To:

Martin Herman <[log in to unmask]>

Date:

Mon, 19 Feb 2018 19:43:53 +0000

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (1 lines)

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)

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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









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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)

http://apps.chicagotribune.com/news/local/young_victims/

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.


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
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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://en.wikipedia.org/wiki/Garen_Wintemute

If you are interested in his program or donating, here is the link: http://www.ucdmc.ucdavis.edu/vprp/

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<http://www.aap.org><http://www.aap.org>
<https://linkprotect.cudasvc.com/url?a=http://www.mmsend70.com/link.cfm%3fr%3dP1AWQRX2DH6KpZKp05dazA~~%26pe%3dBH4KXYJXftdV7_OrPTTyUbVAzQsfgoRvleBm2XUVQ6AiEVwuBNacQ0AWbz2OcXguY6Y2i1bNdCMkiPdWG-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:  http://www.roguedadmd.com/2018/02/how-many-people-and-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://en.wikipedia.org/wiki/List_of_countries_by_incarceration_rate (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
http://www.slredglobalhealth.org

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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<http://www.aap.org><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
The URL for the PED-EM-L Web Page is:
              http://listserv.brown.edu/ped-em-l.html


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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."

http://behavioralscientist.org/myth-mental-illness-causes-mass-shootings/

I will add few links of my own:

https://www.theatlantic.com/health/archive/2017/10/why-better-mental-health-care-wont-stop-mass-shootings/541965/

https://www.vox.com/policy-and-politics/2017/11/9/16618472/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:
              http://listserv.brown.edu/ped-em-l.html


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

http://apps.chicagotribune.com/news/local/young_victims/

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]<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
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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.


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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://en.wikipedia.org/wiki/
Garen_Wintemute

If you are interested in his program or donating, here is the link:
http://www.ucdmc.ucdavis.edu/vprp/

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<http://www.aap.org><http://www.aap.org>
<https://linkprotect.cudasvc.com/url?a=http://www.mmsend70.
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:
http://www.roguedadmd.com/2018/02/how-many-people-and-
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://en.wikipedia.org/wiki/List_of_countries_by_incarceration_rate
(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...







<http://listserv.brown.edu/ped-em-l.html>

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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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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 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
http://www.slredglobalhealth.org

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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=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<http://www.aap.org><https://urldefense.proofpoint.com/v2/
url?u=http-3A__www.aap.org&d=DwIGaQ&c=Pk_HpaIpE_jAoEC9PLIWoQ&r=PgyaJu_-
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<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.


For more information, send mail to [log in to unmask]<mailto:[log in to unmask]> with
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              http://listserv.brown.edu/ped-em-l.html


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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."

http://behavioralscientist.org/myth-mental-illness-
causes-mass-shootings/

I will add few links of my own:

https://www.theatlantic.com/health/archive/2017/10/why-
better-mental-health-care-wont-stop-mass-shootings/541965/

https://www.vox.com/policy-and-politics/2017/11/9/
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
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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]<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









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 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)

http://apps.chicagotribune.com/news/local/young_victims/

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://en.wikipedia.org/wiki/Garen_Wintemute

If you are interested in his program or donating, here is the link: http://www.ucdmc.ucdavis.edu/vprp/

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<http://www.aap.org><http://www.aap.org>
<https://linkprotect.cudasvc.com/url?a=http://www.mmsend70.com/link.cfm%3fr%3dP1AWQRX2DH6KpZKp05dazA~~%26pe%3dBH4KXYJXftdV7_OrPTTyUbVAzQsfgoRvleBm2XUVQ6AiEVwuBNacQ0AWbz2OcXguY6Y2i1bNdCMkiPdWG-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:  http://www.roguedadmd.com/2018/02/how-many-people-and-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://en.wikipedia.org/wiki/List_of_countries_by_incarceration_rate (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

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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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________________________________

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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
http://www.slredglobalhealth.org

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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<http://www.aap.org><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."

http://behavioralscientist.org/myth-mental-illness-causes-mass-shootings/

I will add few links of my own:

https://www.theatlantic.com/health/archive/2017/10/why-better-mental-health-care-wont-stop-mass-shootings/541965/

https://www.vox.com/policy-and-politics/2017/11/9/16618472/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.


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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

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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________________________________

Electronic mail from Children's Mercy Kansas City. This communication
is intended only for the use of the addressee. It may contain information
that is privileged or confidential under applicable law. If you are not the
intended recipient or the agent of the recipient, you are hereby notified
that any dissemination, copy or disclosure of this communication is
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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









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

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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