Tuesday, June 14, 2016

Worst Mass Shooting in US History

I got up Sunday morning and the CNN headlines stated: "50 dead, 53 injured.....".  What appears to have been a single shooter entered an Orlando nightclub last night  at about 2AM and shot 92 people with an assault rifle.  I saw Dr. Michael Cheatham  of Orlando Regional Medical Center say that a mass casualty incident was declared and an additional 6 trauma surgeons and a pediatric trauma surgeon were brought in.  The FBI is investigating it as an act of terror or a hate crime.  The shooter was a 29 year old man who had been investigated by the FBI for possible ties to Islamic extremism.  He had been working as a security guard for a company who provides services to the federal government.  He was licensed to purchase firearms.  He purchased two firearms shortly before the shooting - a Sig Sauer MCX Carbine 0.223 cal on June 4 and a Glock 19  9mm pistol on June 9 from the same gun shop.  Some reports suggest he was also carrying a Walther P22 .22LR pistol, purchase date unknown.  Prior to this incident the worst mass shooting incident was the Virginia Tech incident in 2007 that killed 32 people.  

At the time of the attack the shooter called 911 and pledged allegiance to ISIS and mentioned the Boston bombers.  President Obama came on the networks at 2PM and referred to the incident:  "This was an act of terror or hate."  He pointed out that this was an attack on all Americans and he encouraged solidarity.  In an earlier commentary (posted above) he discussed solutions.  He used the example of highway traffic fatalities and how they were approached from a scientific and public health standpoint.  Vehicle safety improved.  Driver behaviors especially driving while intoxicated was confronted.  Although he did not mention it, the drinking age in the United States was increased to age 21 largely by political leverage using federal highway money granted to individual states.  He pointed out that these same public health measures cannot be used in the case of firearm violence because Congress has blocked research on firearm deaths and violence. He discussed a situation that he had just encountered, where people being tracked by the FBI for frequenting ISIL web sites could be put on the no-fly list but they could not be prohibited from purchasing firearms. That legislation is blocked by a gun lobby with a primary thesis that some members of the government want to take away Second Amendment rights and firearms from law-abiding citizens.   The President points out that nothing could be further from the truth and cited the fact that more firearms have been sold during his administration that practically any other time of the Republic.  I think the manufacturing statistics might back up that claim at least based on a chart I created during the first half of his administration.  Further information corroborating this statement is available at the document Firearms Commerce in the United States 2015 on the ATF website.  There is plenty of data there to corroborate both the President's remarks and the potential financial conflict of interest of the firearms lobby.  I am sure that the gun advocates will be the first to say they deserve credit for gun commerce rather than the President.  My speculation is that they would deflect the conflict of issue by either wrapping themselves in the Second Amendment or as advocates for all of the law-abiding gun owners.

I think that most physicians agree with a public health approach to gun violence and would like to see more data and strategies.  The existing data shows that gun availability is the single largest determinant when it comes to firearm deaths either due to suicide or homicide.  It accounts for the greatest correlation with adverse outcomes from gun violence.  By comparison psychiatric diagnosis does not.

The President's comments on the further political aspects of gun control legislation in the US especially people being investigated by the FBI, like the perpetrator was on two occasions cannot be prohibited from obtaining firearms.  That speaks directly to the pro-gun argument that all we have to do is focus on existing laws and get the guns out of the hands of the bad guys.  This law potentially puts guns directly into the hands of the bad guys and nothing is being done about it.  The Obama video was posted 10 days prior to the Orlando attack.

I won't belabor the points I have already made in a series of posts on this blog.  We are still seeing the same microanalysis and political opportunism that has become a routine part of mass shootings.  We are still seeing the lack of solutions like we have seen in the past.  The way it looks I can continue to post on the issue on out into the future it will probably be a problem long after I am gone.  I heard a gun advocate on public radio this morning and what he said after this incident was not only depressing and disingenuous, but it typifies a rigid illogical stance that no place in science, medicine, or the 21st century.  It illustrates why the gun lobby has Congress enact laws to stifle funding for epidemiological work on gun mortality and morbidity.   I suppose at this point it is just a question of when we hit the tipping point.  When will the majority of Americans start to reject this illogical philosophy?

If the gun advocates hit the street with this hard line attitude after the scope of a mass shooting like we witnessed in Orlando - I shudder to think of what the eventual human cost is going to be.

George Dawson, MD, DFAPA


Embedded video per PBS and the instruction on their site.  Original video was from June 2, 2016


  1. A mass shooting at a Philadephia hospital was stopped by a psychiatrist with a gun, Dr. Silverman.


    That hospital was a gun free zone. He ignored it. I wish someone else at Pulse had too.

    Let's be honest, if you're in that club when that happens what you are hoping and praying for is an off duty cop or a civilian with a concealed weapon.

    There are over 300 million guns in circulation, and government that is too incompetent to stop this guy from working security at the DHS after investigating him isn't going to be able to remove them.

    Any attempt to disarm the US will likely result in mass bloodshed and likely a second civil war.

    BTW, the assertion that gun ownership is correlated to crime in the US is objectively false. The murder rate is down while gun ownership has doubled.


    Chicago has strict gun control and the murder rate is through the roof. Houston, not so much.

    It will never happen and every time people clamor for it, sales go up.

    I know that it is practically a requirement of a psychiatric board certification that one be anti-gun, but the dominant paradigm is wrong in this case.

    1. In all of my previous arguments about gun violence and mass shooting, I suggested that the entire pro vs. anti-gun issue could be ignored and there could be a singular focus on homicide prevention. I seem to be the only person of that mindset, so I might as well engage you on the self-defensive gun issue. I think the evidence is pretty clear that guns in and of themselves are a problem. The sheer number of guns in the US compared to anywhere else and independent of the pro-gun lobby makes it more difficult to solve and that is why a focus on the mental state of the perpetrator seems like a more logical focus to me.

      In the Orlando incident, the man who may have saved the most lives was a US Marine veteran who served in Afghanistan. He recognized the problem immediately, saw dozens of people frozen when they recognized what happens and lead an estimated 60-70 people to safety. He was unarmed. I would attribute his success to combat training, immediate recognition of what was going on, and coming up with a viable plan and being able to execute it. That is a far superior plan than standing around with a gun in your pocket.

      The public health literature makes the following observations of self-defensive gun use:

      For property crimes, in situations where an intended victim is armed with a gun:

      4.2% of the unarmed versus 4.1% of the armed victims was injured (NS)
      39% of the unarmed using a weapon other than a gun lost property versus 35% of the armed victims.

      For assaults:

      Persons carrying guns are 4.46 times more likely to be shot than those not carrying.

      In cases where the victim carrying the gun had a chance to resist the odds ratio of the armed victim being shot increased to 5.45.

      Analyzing firearm deaths in 38 concealed carry states from 2007-2015; there were 544 incidents including 29 mass shooting incidents (defined as 4 or more people shot in the same incident). The results were 442 homicides, 223 suicides, 21 deaths to accidental discharges, and only 12 deaths due to legal self defense. There were 48 murder-suicides. The homicides also included 17 law enforcement officers.

      None of that data suggests that armed defenders make a dent in crime, protect anyone from mass shooters or protect his/her self against property or violent crime. It is far more likely that an armed citizen will experience harm to themselves or others in their household from firearm access than they will experience any benefits. In fact there is a well know graphic on a number of sites that shows the tight correlation between gun possession, suicide and homicide across the US and 14 OECD countries. The US has by far the highest rates of possession and gun deaths by suicide and homicide.

      The available epidemiology points out the fallacies of the guns as self-defense arguments. There have also been laboratory approaches where students are trained to shoot and user laser weapons to defend against a mass shooter entering a classroom. In the simulation I saw there were no instances where the armed student can successfully defend the classroom. My analysis is that people who are not trained to shoot human beings are too hesitant to use deadly force and during that hesitation become easy targets for heavily armed gunmen bent on homicide.

      Your observation about violent crime actually being at a 30 year low was covered in one of my previous posts (click on the table in the post below).


      I think that concealed carry law advocates have capitalized on that 30 year trend and suggested that concealed carry laws were causal when in fact other major societal trends (high incarceration rates, trends in abortion) were cited as being more likely. The concealed carry laws did not occur until well into the cycle.


    2. Independent of the epidemiology, the pro-gun position based on the sanctity of the Second Amendment is illogical in many regards. Just like some free speech advocates believe they can say anything, pro-gun advocates believe they should have unrestricted access to firearms and anything less than that is a violation of their rights. They have actually succeeded in politically advancing that skewed position. It has gotten to the absurd point that the well know conservative Bill O’Reilly came out today in support of reasonable gun laws and plans to discuss his points with the NRA. I think he was probably appalled hat terrorist suspects n the no-fly zone could still purchase firearms in an unrestricted manner. I had the good fortune to have a gun advocate explain to me why that rule exists. You would not want your name on a list anywhere as a gun owner because then “the government” can come to your home, kick the door down, and confiscate all of your guns. That is a stunning rationale for allowing potential terrorists access to unlimited amounts of high-powered semiautomatic weapons and ammunition.


      When that happens – it can’t be much clearer that things need to change.



      1. Preventive Med. 2015: Apr 21. National Crime Victimization Surveys 2007–2011. Multivariate analyses controlled for age, gender of offender and victim, if offender had a gun, urbanicity, and thirteen types of self-protective action.

      2. Am J Public Health. 2009 Nov;99(11):2034-40.

      3. Violence Policy Center Data as of 2/5/2015

    3. I also wanted to add that as a clinical psychiatrist who has treated thousands of people with suicidal and homicidal thoughts and actions that there is an undeniable human factor in these arguments. I have talked with people after they have shot themselves or other people and it is clearly something that they did not want to do. It happened only in the context of severe mental illness and gun availability. In trying to resolve that crisis and prevent future incident - to the person - they were relieved to have no further gun access. In many cases, I saw the person intent on suicide who could not get their hands on a gun. In some cases their survival was just based on chance - the gun merchant picking up on erratic behavior or their not being able to acquire that gun for some other reason. To the person they were relieved that they had no access to that firearm in retrospect after their psychiatric disorder was treated. Making access an unassailable rights issue - ignores that part of the human equation that psychiatrists are supposed to address.

  2. I didn't claim it had anything to do with CCW, I only claimed that the more guns more crime argument was wrong.

    Exactly what law would have stopped this crime from happening?

    The DHS secretary doesn't know either:


    There are 800K defensive uses of firearms every year, and a shot is fired in only 10 percent of cases.

    There is no practical way to achieve a gun ban without massive social chaos and violence. Many blue states (I live in one too) are ghettos of like minded people reinforcing each others biases, but in large parts of the country the mentality is quite the opposite and any attempt at this will fail horribly and I wouldn't be surprised if Texas leaves the union over it.

    The absolute freedom argument is a straw man. Of course, I don't believe you can scream fire in a crowded theatre and I don't believe the second amendment covers nuclear weapons. Neither does the NRA.

    The President has pretty much forfeited his right to talk about regulating sidearms after that nuclear deal with Iran. He was AOK with letting the most dangerous people have the most dangerous weapon. Also, he has made it abundantly clear he is anti-gun through his subordinates including the stumped DHS secretary in that vid.

    1. The law that would have stopped this is a law saying that if you are being investigated by the FBI for terrorist connections you cannot purchase firearms would have stopped this. The marker so far is the no fly list, but even this morning Mitch McConnell is saying that there has to be another step in place to keep people off a list who want to acquire weapons (the old list argument). I don't know what happened to the waiting period for guns but I have talked to several people who were saved from suicide by waiting periods and that sounds useful as well.

      The statistic of defensive guns uses that you posted is overblown and there is contradictory data.

      I am not even talking about a gun ban that would be impossible in this country. I am talking about a tweak to keeps guns out of the hands of mass shooters and terrorists and impulsive people.

      The absolute freedom argument would be a straw man if that was not in fact exactly what most pro-gun advocates are arguing. It was only a matter of time before their gamesmanship got to the the absurd point that a journalist had to come up with a strategy that Donald Trump and the heads of the Republican party have started to echo today. Many Americans I think will be surprised to learn that background checks are a moving target and you can never be sure exactly what is going on thanks to American politics. On any given day is there a background check? Is there a waiting period? Can I buy as many high capacity magazines as I want? Can I buy an assault rifle and body armour?

      Time to stop all of the chicanery and level with people about whether anyone is serious about gun violence.

  3. I know (and practice with) a lot of pro-gun people and I assure you none of them are absolutists. Every single one of them is against gun ownership by the mentally ill and felons. Again, this is the problem with living in a bubble and reading the New York Times (look how wrong they got Duke lacrosse), it's easy to believe what you are told about the other side of an argument. I suppose you can find someone who is an extremist like you say but that isn't representative. I can find people on the anti-gun side who throw kids out of school for a Pop-Tart that looks like a gun.

    On the issue of keeping guns away from those hospitalized for suicide or homicide, you will get next to no argument from the pro-gun side. BTW, it's intellectually dishonest for the pundits in the throwaway journals to claim to be anti-stigma and advocate this policy. Their revealed intentions betray their stated platitudes. I'm being intellectually honest in saying that in some cases their has to be a stigma for certain behaviors.

    So we are really not in that much of a disagreement. I do not want bloodshed over an attempted ban that would fail. The problem with the no-fly list is one of due process...someone could simply put their enemies on the list..Ted Kennedy was actually on the list because of a screw-up (he should have been on the no-drive list but that's another topic.)

    What I will say about the FBI and policy in general is once you are found to pledge allegiance to ISIS or Taliban or Al Qaeda, you should be charged with treason, and once convicted, be on the no firearms list if not deported.

    His father is pro-Taliban and should be charged with treason tomorrow.

    I just believe as mental health professionals we should focus on psychology first, and not tools. Most psychologists and psychiatrists have little knowledge of firearms. I have seen opeds in the throwaways that are just embarrassing for the authors, who don't even understand what a semiautomatic is.

    The cause of this tragedy was the warped ideology of someone in a homosexual panic who believed it was a sin punishable by death. I predicted before it even came out that he would be a closet case judging himself harshly by his fathers standards. The motivation here is obvious as the killer declared it in no uncertain terms. The Colorado case illustrates that involuntary commitment laws are too lax, but in this case no mental health law would have done anything.

    We don't have an epidemic of gun violence, it is down for many reasons, including demographic. What we do have is one side of a conflict fighting a war and the other side trying to pretend we aren't.

  4. "I suppose you can find someone who is an extremist like you say but that isn't representative."

    My argument is that the extremists are the representatives - the elected officials. It is one thing to poll gun owners and find out that most of them support background checks and then find that background checks and other reasonable measures have disappeared. If is quite easy to say that you are a reasonable gun owner when the gun lobby and Congress is so over the top that they have to be reigned in by Bill O'Reilly.

    I have posted here that the stigma argument is bullshit, but I also acknowledge that it is fueled in part by the pro-gum advocates claim that as long as you are NOT mentally ill, nothing bad will happen to you as a result of firearm access. I like to call that the myth of the concealed carry owner as a superhuman. That is the way it plays out in many states and in many states the statistics are collected to bias it in that direction.

    If we are not really in disagreement - where are the reasonable gun laws? If nothing happens in Congress or even if the no fly list gun ban is watered down - it is likely the mass shootings by people who should not have guns will continue.

  5. There are many ways a person with no mental illness can mess up their lives with a gun, no doubt. The much vilified NRA is a strong supporter of proper firearms training and safety courses. Any gun owner who doesn't have their weapon properly secured or learn how to shoot properly is irresponsible and self-negating their own personal safety argument.

    This is also true of alcohol consumption, even more so, which was viewed as a public health issue as well as a moral issue in the teens. We saw the solution make the original problem even worse. Punishing responsible drinkers is worse than tolerating some alcohol related deaths. There really is no ideal solution there.

    I prefer the carrot rather than stick approach to safety and training courses...the state can create an incentive by waiving some fees if the owner shows certification.

    Many people in mental health (not you) stereotype gun owners as ignorant hillbilly rednecks with anger issues. I am pretty much the opposite of that mold, having been board certified in psychiatry since 28, living all my life in blue states. I hated guns and hunters growing up but once I learned to use it properly (interestingly I found I shoot better left handed...its an eye dominance issue) I understood. Its a cultural thing with a sharp divide. I'm sure if you travelled north to Ely the opinions on this would be vastly different from Minneapolis but those citizens are not backward and many of them are quite scholarly on this subject.