Date: Sun, 9 Jul 1995 09:54:09 -0700 (PDT) From: "Edgar A. Suter" <[s--t--r] at [crl.com]> To: [firearms alert] at [shell.portal.com] Cc: Multiple recipients of list <[n--b--n] at [mainstream.com]> Subject: Censorship and incompetence at the Journal of Trauma (fwd) Message-ID: <[Pine SUN 3 91 950709093155 20086 D 100000] at [crl5.crl.com]> Here's the kind of junk science and censorship that is being used to destroy our civil rights. I also received some private e-mail from a medical librarian who had independently written a letter to Dr. Pruitt about the dangerous and discredited treatment advice recommended by Trask et al. in their article. Pruitt's response was to write a letter to the President of the librarian's university attempting to cause trouble for the librarian. So... Pruitt is also, as typical for cowards, a bully. Particularly in the Journal of Trauma beware of the work of Dr. Ordog at Martin Luther King Medical Center in LA. He is among the worst of the junk scientists. In a short article by Ordog a few years ago, Dr. Fackler discovered _54_ errors. Despite a detailed letter chronicling the errors, J. Trauma refused to publish the letter. Dr. Pruitt's claim that my letter with Fackler (see below) need not be published because it doesn't relate to improving patient care is ridiculous. Trask et al. recommended that surgeons routinely "extensively debride" (meaning "chop off lots of flesh") on the mistaken assumption that, simply because the wound is from an "assault weapon," that _even if the tissue looks good_, there is "massive necrosis" (meaning "dead flesh"). In other words, Trask et al. are suggesting that surgeons chop off good flesh on a mistaken assumption. It seems quite bizarre that Pruitt doesn't see correcting that dangerous notion as improving patient care. I would hope that members of this list would see fit to write Dr. Pruitt _AND_ the other members of the J. Trauma editorial Board (so that Pruitt's behavior is known to the other editors) about (1) Trask et al.'s dangerous recommendations (you may cite the references in my letter with Fackler) and (2) emphasize the importance in relation to patient care. We will deal with his efforts to bully the librarian later. Besides Pruitt: John H. Davis, MD Associate Editor, Journal of Trauma Department of Surgery DQ319 Given Bldg. University of Vermont College of Medicine Burlington, VT 05405 David B. Pilcher, MD Associate Editor, Journal of Trauma University of Vermont College of Medicine Burlington, VT 05405 Larry Floersch, BA Assistant Editor, Journal of Trauma University of Vermont College of Medicine Burlington, VT 05405 Ernest E. Moore, MD Associate Editor, Journal of Trauma Dept. of Surgery Denver General Hospital 777 Bannock Street Denver, CO 80204 ---------- Forwarded message ---------- Date: Wed, 5 Jul 1995 22:15:56 -0700 (PDT) From: Edgar A. Suter <[s--t--r] at [crl.crl.com]> To: [firearms alert] at [portal.shell.com] Cc: "John Latz, M.D." <[70641 3422] at [compuserve.com]>, [H K MP 5 A 3] at [aol.com], [D R GOT W W] at [aol.com], [C h ristieH] at [aol.com] Subject: Censorship and incompetence at the Journal of Trauma If readers, particularly those with scientific training, are moved to obtain a copy of the Trask article and to send their own critiques to the Journal of Trauma, perhaps the wall of censorship erected by the new editor, Dr. Pruitt, can be broken. A massive resonse to J. Trauma could deservedly humiliate Trask, his co-authors, and the obstinate and prejudiced Dr. Pruitt. ************************************************************************* * Edgar A. Suter, MD [s--t--r] at [crl.com] * * Chair, DIPR Doctors for Integrity in Policy Research, Inc.* ************************************************************************* April 11, 1995, revised as requested May 15, 1995 Doctors for Integrity in Research & Public Policy 5201 Norris Canyon Road - Suite 140 San Ramon, CA 94583 USA Voice 510-277-0333 FAX 510-277-1283 Basil A. Pruitt, Jr. MD Editor, Journal of Trauma 7330 San Pedro Avenue #336 San Antonio TX 78216 Voice 210-342-7903 FAX 210-342-2966 "Re: Trask AL, Richards FD, Schwartzbach CC, and Kurtzke RN. Massive Orthopedic, Vascular, and Soft Tissue Wounds from Military Type Assault Weapons: A Case Report." J. Trauma. 1995; 38(3):428-431. Dear Dr. Pruitt, Treatment of any wound should be based upon severity, extent, and amount of tissue damaged. It is particularly risky to base treatment upon inaccurate generalizations. In their report of a single case of wounding by a projectile from the 7.62x39mm cartridge, the cartridge of the AK-47 rifle, Trask et al. made discredited and dangerous recommendations for wound management. The authors opined that "The management of wounds caused by these weapons is considerably different from the wounds caused by low or medium velocity missiles... 1. Even though surface wounds appear minor, the degree of internal tissue necrosis is usually massive. 2. Management of the bone and vascular tissue differs from that of low velocity projectile wounds, requiring more extensive debridement... 3. In contrast to low velocity projectile wounds, a high-velocity wound to the torso is likely to be fatal...." Massive evidence shows all these points to be in error. Interestingly, the authors' own reference[1] for their claims does not support or even address their claims. The Trooskin study, wrongfully cited, did not even mention the types of weapons causing the wounds let alone compare wound care of different weapon or velocity types. >From the current edition of Emergency War Surgery - NATO Handbook we learn that "The widespread belief that every wound caused by 'high-velocity' projectiles must be treated with 'radical debridement' is incorrect and results from failure to recognize the role of other variables, such as bullet mass and construction, in the projectile-tissue interaction."[2] Specifically regarding performance of the AK-47 rifle bullet, the NATO Handbook notes that "The long path through tissue before marked yaw begins (about 25cm) explains the clinical significance that many wounds from this weapon resemble much lower velocity handguns."[2] Additionally, depending upon the bullet type, bullets fired from the AK-47 attain velocity of 2,200 to 2,350 ft/sec,[2,3] not the 2,800 ft/sec claimed by the authors. Reports from Vietnam confirmed the often minimal wounds caused by AK-47 bullets: "Uncomplicated perforating soft-tissue wounds were the most common bullet wounds of the extremities; They showed small entry and exit wounds and a clean soft tissue track with little or no devitalization of tissue. They usually healed if left alone."[4] In the proceedings of the Tri-Service War Surgery Conferences, in which those who were treating the war surgery casualties met to report and discuss their findings, all three of Trask et al.'s conclusions were shown to be in error.[5] More recent reports from Afghanistan concur: "Wounds with the greatest tendency to spontaneous healing were the through and through gunshot wounds. Of note were the number of patients in this group with gunshot wounds, the bullet passing through the body, who did not have the massive tissue destruction that one expects, even when bone had been fragmented."[6] Over two dozen studies on the criminal use of military-style weapons undercut the authors' "800% increase" claim. We direct readers to a review of those studies (including a review of lethality, firepower, and constitutional issues).[7] The authors, like many before them, inappropriately relied upon gun trace data. Gun traces are not representative of the criminal prevalence of gun use any more than the index of a research journal reflects the prevalence of disease. Journal indices and gun traces reflect a level of interest in the topic or the gun. For example, in 1989 in Los Angeles, a hotbed of drug gangs and violent crime, "assault weapons" represented approximately 3% of guns seized, but 19% of gun traces.[8] The Congressional Research Service and the Bureau of Alcohol, Tobacco and Firearms (BATF) have acknowledged that the gun trace system is inappropriate for statistical purposes: "The [B]ATF tracing system is an operational system designed to help law enforcement agencies identify the ownership path of individual firearms. It was not designed to collect statistics... "Two significant limitations should be considered when tracing data are used for statistical purposes: "* First, the firearms selected for tracing do not constitute a random sample and cannot be considered representative of the larger universe of all firearms used by criminals, or of any subset of that universe. As a result, data from the tracing system may not be appropriate for drawing inferences such as which makes or models of firearms are used for illicit purposes; "* Second, standardized procedures do not exist to ensure that officers use consistent definitions or terms in the reports of circumstances that lead to each trace request. Some trace requests do not even identify the circumstances that resulted in the request."[9] No crime need be involved to initiate a gun trace. For example, efforts to return stolen guns to rightful owners and guns found incidental to other investigations are included amongst gun traces. The statistically unreliable nature of gun traces should be clear. Additionally, in the period 1986-1992 cited by the authors, increased media attention and changing definitions of "assault weapon" further complicate interpretation of gun trace data. In the worst areas of gang and drug crime, the studies show that military-style, semiautomatic guns account for generally 0% to 3% of crime guns and, nationally, represent less than 1% of crime guns, far less than their proportion amongst American guns. More pointedly, ten times more Americans die annually from attacks using hands and feet than die from military-style rifles.[6] We hope that this information helps put the authors' unusual case report in perspective. Sincerely, Edgar A. Suter, MD National Chair, Doctors for Integrity in Research & Public Policy Member, International Wound Ballistics Association Col. Martin L. Fackler MD, US Army (retired) President, International Wound Ballistics Association Former Director, US Army Wound Ballistics Laboratory [1] Trooskin SZ, Winfield J, Duncan AO et al. "The Management of Vascular Injuries of the Extremities Associated with Civilian Firearms." Surg. Gyn. Obstr. 1993; 176:350-354. [2] Bowen TE. Emergency War Surgery - NATO Handbook. 2nd. US Revision. Washington DC: Government Printing Office. 1988. pp 24,33. [3] Fackler ML, Malinowski JA, Hoxie SW, and Jason A. "Wounding Effects of the AK-47 Rifle Used by Patrick Purdy in the Stockton, California, Schoolyard Shooting of January 17, 1989." Am J Forensic Medicine and Path. 1990; 11(3): 185-90. [4] King KF. "Orthopedic Aspects of War Wounds in South Vietnam." J. Bone and Joint Surg. 1969; 51B:112-117. [5] Commander in Chief Pacific (CINCPAC). War Surgery. in Proceedings of the Commander in Chief Pacific Fifth Conference on War Surgery, 29 March - 2 April 1971, Tokyo, Japan. 1971: 33. (available from CINCPAC, Attn: Surgeon, FPO San Francisco CA 96610). [6] Coupland RM and Howell PR. An Experience of War Surgery and Wounds Presenting After 3 Days on the Border of Afghanistan." Injury. 1988; 19:259-262. [7] Suter EA. "'Assault Weapons' Revisited - An Analysis of the AMA Report." Journal of the Medical Association of Georgia. May1994; 83: 281-89. [8] Kleck G. Point Blank: Guns and Violence in America. New York: Aldine de Gruyter. 1991. [9] Bea K. "CRS Report for Congress P 'Assault Weapons': Military-Style Semiautomatic Firearms Facts and Issues." Washington DC: Congressional Research Service, The Library of Congress; May 13, 1992 (Technical Revisions, June 4, 1992). Appendix B. pp. 65-76. ********************** Dr. Pruitt's responses to our initial and revised letter is evident from our two letters below ********************** May 17 1995 Basil A. Pruitt, Jr. MD Editor, Journal of Trauma 7330 San Pedro Avenue #336 San Antonio TX 78216 Dear Dr. Pruitt, We have revised and shortened our letter in accordance with your helpful suggestions. We agree with you that "treatment of any wound should be based upon severity, extent, and amount of tissue damaged." Our revised letter states such. It was precisely for this reason that our short letter calls attention to the dangerous generalizations of Trask et al. regarding AK47 wound care, generalizations that are thoroughly rebutted in the peer-reviewed literature. We have cited peer-reviewed literature that documents that, far from "usually massive" tissue necrosis as claimed by Trask et al., AK47 wounds more closely approximate handgun injuries with non-expanding bullets. Because of this finding, the peer reviewed literature does not support Trask et al.'s generalized recommendation for "extensive debridement" even when bone is involved. We cited evidence from the largest experience with AK47 wounds to date, the Vietnam War. We did not recommend that AK47 wounds be "left alone," but we did note that, from the Vietnam experience, "Uncomplicated perforating soft-tissue wounds... of the extremities... usually healed if left alone." We cited peer-reviewed literature, the American Journal of Forensic Medicine and Pathology, that confirms the relatively low lethality of the AK47 cartridge [even when children were the targets]. We also draw attention to Trask et al.'s false citation of the Trooskin article. We made passing note that the velocity of the AK47 projection is 21% lower than claimed by Trask et al. We also note that the actual projectile construction is an important determinant of tissue destruction. This is often overlooked by those who are inappropriately and simplistically fixated upon velocity. Though Dr. Kleck's Point Blank was not peer-reviewed prior to publication, Dr. Kleck was awarded the American Society of Criminology's prestigious Hindelang Award in 1994 for Point Blank as "the most important contribution to criminology in the preceding three years." Even the most ardent of Dr. Kleck's opponents, Dr. Phil Cook, has, in a book review, described Point Blank as a monumental and essential contribution to the understanding of gun control research. Particularly in view of the extensive peer acclaim, it seems inaccurate and unnecessarily argumentative to discount Point Blank as "unrefereed statements of opinion." Additionally, the Proceedings of the Commander in Chief Pacific Fifth Conference on War Surgery involved approximately fifty peer reviewers before publication rather than the currently typical two or three for most journals. At the request of Congress, the Congressional Research Service of The Library of Congress conducted a review of some data on military-style semiautomatic firearms. The report explained precisely why BATF gun trace data cannot be used for statistical purposes. To allow Trask et al.'s non-peer-reviewed gun trace data reference for their "800% increase" claim, but rejecting our Congressional Research Service citation seems to be a "double-standard" and unnecessarily argumentative, particularly when our citation is buttressed with referenced data from more than two dozen studies that are reviewed in a peer-reviewed journal, the Journal of the Medical Association of Georgia. As apropos, our letter attacks only dangerous patient care recommendations and other mistakes. As always, we avoid ad hominem invective of any kind. We hope for publication of our revised letter. Warmest personal regards, Edgar A. Suter MD ********************** July 5, 1995 Basil A. Pruitt, Jr. MD Editor, Journal of Trauma 7330 San Pedro Avenue #336 San Antonio TX 78216 Dear Dr. Pruitt, Your characterization of our revised letter as "[offering] no information that will increase the reader's understanding of pathogenesis, improve the diagnosis of injury, or enhance patient management" is quite mistaken. In fact, our letter draws attention to the dangerous treatment recommendations made by Trask et al. The peer-reviewed literature explicitly contradicts Trask et al.'s claims and recommendations. In distinction from their report of a single case, the literature cited in our letter is based on large series of patients. In exposing dangerous patient care recommendations, we are certainly "enhancing patient care." We also drew attention to the mistaken claims of Trask et al. regarding the prevalence of military-style, semi-automatic firearms amongst crime guns and their inappropriate use of gun trace data for statistical purposes. Not only did we cite a reference that reviews the subject in its entirety, presenting over two dozen studies that rebut Trask et al.'s claims, but we also cited the Congressional Research Service's description of the Bureau of Alcohol, Tobacco and Forearms" tracing system and their explanation of it's inability to provide a statistically significant sample of crime guns. The citation of gun trace data is common in the medical literature. We have offered the most authoritative and unbiased evidence available demonstrating how gun trace data may not be accurately used for statistical purposes. For this reason, our letter most certainly enhances your reader's abilities to interpret the data presented in medical journals. It seems unethical to turn a blind eye when inappropriate data or methodology and dangerous recommendations are presented in any journal. While it may be some embarrassment to the authors and to your journal that their mistakes (particularly their false citation of the Trooksin study) may be made public, that embarrassment seems a small price to pay for improved patient care. Trask et al.'s errors are exposed in our letter, but no personal attacks or insults were made in our letter. There is, therefore, no substance in your claim that our letter is "laden with emotional freight and does not meet the standards of civility...." In view of your own strongly held and publicly known opinions regarding guns and the likelihood that you are projecting your own emotionalism upon our letter, we respectfully suggest that our letter be reviewed by someone who does not hold tendentious views on guns and gun control. We believe that an objective comparison of Trask et al.'s recommendations with the balance of the peer-reviewed literature will find their recommendations deficient and dangerous. Please also note our incorporation and the new name of our national medical think tank. Sincerely, Edgar A. Suter, MD National Chair, Doctors for Integrity in Research & Public Policy Member, International Wound Ballistics Association