Excessive use of force by police: a survey of academic emergency physicians.

OBJECTIVE: To determine the clinical experience, management and training of emergency physicians in the suspected use of excessive force by law enforcement officers. METHODS: Surveys were mailed to a random sample of academic emergency physicians in the USA. RESULTS: Of 393 emergency physicians surveyed, 315 (80.2%) responded. Of the respondents, 99.8% (95% CI 98.2% to 100.0%) believed excessive use of force actually occurs and 97.8% (95% CI 95.5% to 99.1%) replied that they had managed patients with suspected excessive use of force. These incidents were not reported by 71.2% (95% CI 65.6% to 76.4%) of respondents, 96.5% (95% CI 93.8% to 98.2%) had no departmental policies and 93.7% (95% CI 90.4% to 96.1%) had not received training in the management of these cases. CONCLUSIONS: Suspected excessive use of force is encountered by academic emergency physicians in the USA. There is only limited training or policies for the management of these cases.

Police deaths in New York and London during the twentieth century.

OBJECTIVES: To describe the incidences and causes of occupational police deaths in New York City in the United States and Greater London in the United Kingdom during the twentieth century. To assess the relation between overall societal violence and violence directed toward police officers in these metropolitan areas. DESIGN AND SETTING: Ecological study of New York and London from 1900 through 1999. MAIN OUTCOME MEASURES: Intentional and unintentional occupational police mortality rates for New York and London were estimated for each decade. The general population homicide rates of both New York and London were assessed for their correlation with their respective intentional occupational police mortality rates. RESULTS: During the 20th century, 585 police officers in New York and 160 police officers in London died while participating in law enforcement activities. New York had markedly greater intentional police mortality rates compared to London throughout most of the 20th century, but these differences decreased significantly by the end of the century. Intentional gunshot wounds comprised 290 police deaths in New York, but only 14 police deaths in London. In New York, gun shot wounds (both intentional and unintentional) accounted for more occupational police deaths (51.6%) than did all other injury mechanisms combined. In London, motor vehicle collision was the most common cause (47.5%) of occupational police death. There were no apparent correlations between the general population homicide rates and intentional police mortality rates in either New York (r(2) = 0.05, 95% CI -0.77 to 0.81) or London (r(2) = 0.34, 95% CI -0.61 to 0.89). CONCLUSIONS: During the 20th century, both intentional and unintentional occupational police mortality rates were significantly greater in New York compared to London. These differences are likely from several socioeconomic, cultural, and occupational factors. The declines in police deaths in New York during the latter part of the 20th century indicate that at least some measures taken by the New York Police Department have been successful at significantly reducing the incidence of both intentional and unintentional police deaths.

Emergency medical services providers and weapons in the prehospital setting.

OBJECTIVES: To investigate emergency medical services (EMS) providers' experience with weapons encountered while working, and evaluate the training they have received regarding searching for and confiscating weapons in the field. METHODS: This was a descriptive, cross-sectional survey anonymously completed by a convenience sample of EMS providers in the metropolitan Boston and Los Angeles (LA) areas. RESULTS: Of 2,672 surveys distributed, 2,224 (83%) were returned. Forty-two percent of the respondents (39% of Boston and 46% of LA) reported searching patients for weapons, and 62% (51% of Boston and 76% of LA) reported finding weapons. The LA respondents were more likely than the Boston respondents to have found a firearm. Twenty-seven percent of the respondents reported they had found more than five weapons in their careers. One thousand seven hundred seventy-two (80%) providers replied that they would report discovered weapons, most frequently to law enforcement personnel. Providers with higher EMS education and ones who received weapons-related training were more likely to search for, find, and report weapons. Four hundred fifty-one (20%) respondents reported receiving formal weapons-related training, 291 (13%) considered their initial EMS training on weapons-related topics to be adequate, and 292 (13%) considered their continuing education in these areas adequate. CONCLUSIONS: These data suggest that weapons encountered in the field are a widespread problem for EMS providers. Although many EMS providers search for and find weapons on their patients, most of them feel they have been inadequately trained in this area. Prospective studies are needed to document the actual incidence of weapon encounters in the prehospital setting. Multidisciplinary discussions are needed to address the above issues.

Caring for the patient with mental retardation in the emergency department.

There are approximately 6 million individuals with a diagnosis of mental retardation in the United States. Because of deinstitutionalization of patients with mental retardation, coupled with an increase in their life expectancy, emergency physicians are increasingly encountering and managing patients with mental retardation in the emergency department. Many emergency physicians are uncomfortable when interacting with individuals with mental retardation, which often carries over to the assessment and management of these patients in the ED. The purpose of this review is to aid the emergency physician in understanding the patient with mental retardation, their comorbid conditions, and the approach to evaluating and managing these patients in the ED.

Emergency physicians and biological terrorism.

Recent developments, such as the bombings of the World Trade Center in 1993 and the Alfred P. Murrah Federal Building in Oklahoma City in 1995, the sarin attacks in Tokyo and Matsumoto, Japan, and US Embassy bombings in Kenya and Tanzania in 1998, have heightened fears of terrorist attacks. Future terrorist activities will continue to involve bombs and firearms, but may also include weapons of mass destruction, including biological agents. Recent US government initiatives have recognized the threats to our country from these weapons and have funded planning and response programs. These preparedness programs are being built on existing infrastructure of EMS and fire services' plans for hazardous materials response. Appropriate emergency department and hospital response, guided by public health principles, could significantly limit the morbidity and mortality of biological warfare agents. Inappropriate response by the medical community may worsen a chaotic and potentially devastating situation. This article discusses planning and response issues central to a potential bioterrorism event.

The relationship between socioeconomic factors and gang violence in the City of Los Angeles.

OBJECTIVE: To investigate the relationship between community-level socioeconomic factors and the incidence of gang-related homicide in the city of Los Angeles. METHODS: An ecological group-level analysis was conducted to correlate the 5-year incidence rates (from 1988 through 1992) of gang-related homicide with community-level socioeconomic statistics for the 18 geographically distinct Los Angeles Police Department divisions. Eight socioeconomic factors were examined: (1) log mean per capita income, (2) proportion employed, (3) proportion high school graduates, (4) proportion single-parent families, (5) proportion male, (6) proportion younger than 20 years of age, (7) proportion African American, and (8) proportion Hispanic. Pearson correlation coefficients were calculated for the interrelationships among the study variables and gang-related homicide. Adjusted regression estimates were calculated from a multiple linear regression model. RESULTS: The overall 5-year gang-related homicide rate for the city was 48.8 per 100,000, with a range of 5.2 to 173.5 per 100,000 among the different Los Angeles Police Department divisions. Pearson correlation coefficients revealed that the strongest negative correlations with gang-related homicide were log mean per capita income and proportion employed, and the strongest positive correlations were proportion single-parent families and proportion younger than 20 years of age. With mutual adjustment of all variables, only log mean per capita income and proportion employed were significantly associated with gang-related homicide. CONCLUSION: At the community level, gang-related homicide in Los Angeles is most closely associated with lower income and unemployment. These relationships may provide important insights into the causes of gang formation and gang violence.

Suicide by cop.

STUDY OBJECTIVE: "Suicide by cop" is a term used by law enforcement officers to describe an incident in which a suicidal individual intentionally engages in life-threatening and criminal behavior with a lethal weapon or what appears to be a lethal weapon toward law enforcement officers or civilians to specifically provoke officers to shoot the suicidal individual in self-defense or to protect civilians. The objective of this study was to investigate the phenomenon that some individuals attempt or commit suicide by intentionally provoking law enforcement officers to shoot them. METHODS: We reviewed all files of officer-involved shootings investigated by the Los Angeles County Sheriff's Department from 1987 to 1997. Cases met the following criteria: (1) evidence of the individual's suicidal intent, (2) evidence they specifically wanted officers to shoot them, (3) evidence they possessed a lethal weapon or what appeared to be a lethal weapon, and (4) evidence they intentionally escalated the encounter and provoked officers to shoot them. RESULTS: Suicide by cop accounted for 11% (n=46) of all officer-involved shootings and 13% of all officer-involved justifiable homicides. Ages of suicidal individuals ranged from 18 to 54 years; 98% were male. Forty-eight percent of weapons possessed by suicidal individuals were firearms, 17% replica firearms. The median time from arrival of officers at the scene to the time of the shooting was 15 minutes with 70% of shootings occurring within 30 minutes of arrival of officers. Thirty-nine percent of cases involved domestic violence. Fifty-four percent of suicidal individuals sustained fatal gunshot wounds. All deaths were classified by the coroner as homicides, as opposed to suicides. CONCLUSION: Suicide by cop is an actual form of suicide. The most appropriate term for this phenomenon is law enforcement-forced-assisted suicide. Law enforcement agencies may be able to develop strategies for early recognition and handling of law enforcement-forced-assisted suicide (suicide by cop). Health care providers involved in the evaluation of potentially suicidal individuals and in the resuscitation of officer-involved shootings should be aware of law enforcement-forced-assisted suicide as a form of suicide.

Acute right lower quadrant pain in a patient with leukemia.

Typhlitis or neutropenic enterocolitis is a life-threatening, necrotizing process of the cecum whose incidence is increasing. It is usually encountered in patients with leukemia who have recently undergone chemotherapy. Neutropenic enterocolitis presents as fever, abdominal pain, and diarrhea in neutropenic patients. As the incidence of neutropenic enterocolitis increases, emergency physicians must be aware of this rapidly progressive and potentially fatal disease.

Intracranial hemorrhage associated with tangential gunshot wounds to the head.

UNLABELLED: Tangential gunshot wounds (TGSWs) to the head are gunshot wounds in which the bullet or bullet fragments do not penetrate the inner table of the skull. OBJECTIVES: To determine the occurrence of intracranial hemorrhage (ICH) associated with TGSW to the head and to assess the ability of selected clinical criteria to predict ICH in this patient population. METHODS: A retrospective chart review of patients diagnosed as having TGSWs to the head presenting to the ED of Los Angeles County + University of Southern California Medical Center from October 1, 1993, to May 31, 1996. RESULTS: Four hundred twenty patients with gunshot wounds to the head presented to the ED. CT confirmed the diagnosis of TGSWs in 154 patients (36.7%). Head CT of patients with TGSWs revealed 25 (16.2%) skull fractures and 37 (24.0%) ICHs. Fourteen (56.0%) skull fractures were depressed. Of patients with a CT-documented TGSW to the head, 23 (16.1%) had a history of a loss of consciousness (LOC), 129 (84.3%) had a normal neurologic examination in the ED, 17 (11.1%) had a Glasgow Coma Scale score (GCS) < 15, and 75 (48.7%) had retained extracranial bullets or bullet fragments. Of all patients with TGSWs to the head, 113 had a GCS of 15 with no LOC and a normal neurologic examination, with 17 of these 113 patients (15.0%) having ICH. One patient died while hospitalized. Fifty-six (36.6%) patients were released home directly from the ED. Five clinical criteria (history of LOC, GCS < 15 on ED presentation, skull fracture, location of TGSW on the skull, and presence of extracranial bullet fragments) were examined to determine their ability to predict ICH. None of these criteria either alone or in combination were adequately predictive of ICH. CONCLUSION: In this series, 1 in 4 patients with a TGSW to the head had an ICH. All patients with TGSWs to the head should undergo head CT to rule out depressed skull fractures and ICH.

Hate crime violence and its emergency department management.

As the 21st century approaches, the United States is moving, toward a more pluralistic society with regard to race, ethnicity, and national origin. With this increase in diversity has come a resurgence of hate crime violence. Scant information is available in the medical literature about hate crime violence, hate groups, hate crime violence legislation, or the physical and psychologic sequelae of hate crime violence on the individual and its effects on the community. Guidelines for the treatment of victims of hate crime violence in the prehospital care setting, ED, and inpatient setting are proposed.

Law enforcement K-9 dog bites: injuries, complications, and trends.

STUDY OBJECTIVE: To quantify the number of individuals bitten, the number of bites per patient, and the types of injuries and complications caused by law enforcement K-9 dog bites treated in the Jail Ward Emergency Department of the Los Angeles County-University of Southern California Medical Center. These variables were compared before and after a change in K-9 police policy from the "bite-and-hold" to the "find-and-bark" technique or stricter controls were instituted over the K-9 teams. METHODS: A retrospective chart review of all patients in police custody with K-9 dog bites who presented to the Jail Ward ED between January 1, 1988, and December 31, 1995, was conducted. Demographic data of patients with K-9 dog bites, the number and location of bites, complications, procedures performed, and management of bites were recorded and compared between the periods 1988-1991 (before the policy changes) and 1992-1995 (after the changes). RESULTS: Between 1988 and 1995 790 in-custody patients were treated for K-9 dog bites in the Jail Ward ED; 705 charts were available for review. Nearly all the patients (98.6%) were male, with a mean age of 25; 85.0% were Hispanic or black. More than half (57.2%) sustained three or more bites, mainly to the extremities. Complications ensued in 19.3%: vascular in 7.0%, infection in 5.0%, fracture or cortical violation in 4.0%, nerve injury in 1.9%, and tendon injury in 1.1%. Half (49.9%) were hospitalized, with a median stay of 3 days. After the change in K-9 policy, the number of patients with K-9 dogs bites presenting to the Jail Ward ED decreased from 639 (1988-1991) to 66 (1992-1995). The proportion of patients who sustained three or more bites decreased from 58.4% to 45.5%. The rate of vascular complications decreased from 7.5% to 1.6%, the rate of fractures decreased from 2.4% to 0, and the rate of cortical violations increased from 1.4% to 6.3%. The proportion of patients hospitalized decreased from 52.0% to 33.8%. CONCLUSION: K-9 dog bites are associated with significant injuries and complications. In this study, changes in law enforcement K-9 policy contributed to a significant decrease in the overall number of individuals bitten, the number of injuries and complications, and the proportion of patients hospitalized.

Flunitrazepam and its involvement in date or acquaintance rape.

An estimated 1 in 4 women in the United States will be raped in their lifetimes. Approximately 75% of all rapes are date or acquaintance rapes. Recently the illegal use of flunitrazepam (Rohypnol), a benzodiazepine, as a prelude to the assault has been reported. Flunitrazepam readily dissolves, and once in solution, is colorless, odorless, and tasteless. The predominant clinical manifestations are drowsiness, impaired motor skills, and anterograde amnesia. Due to the amnestic effects of flunitrazepam, historical clues of the rape event are difficult to obtain. Patients with a complaint of sexual assault who appear intoxicated or have anterograde amnesia should be suspected of unknowingly ingesting flunitrazepam. In addition to adhering to standard rape protocols, a urine specimen should be analyzed for flunitrazepam metabolites using gas chromatography/mass spectrometry. If the hospital, local, or forensic laboratory is unable to analyze for flunitrazepam, Hoffmann-La Roche Inc., the manufacturer of Rohypnol, should be contacted. Hoffmann-La Roche has a mechanism for definitive testing for flunitrazepam, at no cost, for health care providers, rape treatment centers, and law enforcement agencies. A network of organizations is attempting to reduce the abuse of flunitrazepam in association with date rape.

Emergency medicine residents' perspectives on injury prevention.

STUDY OBJECTIVE: To determine emergency medicine residents' perspectives and opinions concerning the relevance of injury prevention to emergency medicine and their exposure to formal instruction and readings in this subspecialty area. METHODS: A survey was mailed between November 1992 and February 1993 to all 461 residents and 1992 graduates of the 13 emergency medicine residency programs in California. RESULTS: Three hundred ninety questionnaires (85%) were returned. Ninety-seven percent of respondents said they believed injury prevention is pertinent to emergency medicine. Sixty-two percent said they believed inadequate time in residency is devoted to this subject, and 70% said there should be a greater focus on injury prevention in their training. Only 44% of the respondents said they had received lectures and 28% of the respondents said they consistently read journal articles on injury prevention. There were no statistically significant differences between the level of the respondents' training and their answers to the questions. CONCLUSION: Although most emergency medicine residents consider injury prevention pertinent to emergency medicine and important to their training, most perceived a lack of formal instruction on injury prevention during their training and did not consistently read articles on this subspecialty area.

Managing law enforcement (K-9) dog bites in the emergency department.

OBJECTIVE: To review the types of injuries due to law enforcement (K-9) dog bites and address related management issues. METHODS: A case series of law enforcement dog bite victims is reported and related literature reviewed. RESULTS: Law enforcement dogs are taught a bite-and-hold technique for subduing individuals suspected of felony crimes. This bite-and-hold technique's greater applied force results in a unique spectrum of injuries, including deep puncture wounds, severe crush injuries, large tissue avulsions and lacerations, wounds necessitating surgical débridement, bony injuries ranging from cortical violations to displaced fractures, neurovascular damage, and other wounds at high risk for infection. The four reported cases highlight the types of injuries and complications associated with law enforcement dog bites. CONCLUSION: Attention to potential deep injuries of nerves, vessels, and the musculoskeletal system is essential with law enforcement dog bites. Injuries associated both with pursuit and arrest and with the bites themselves must be identified and assessed. Guidelines for the ED treatment of patients with law enforcement dog bite injuries are proposed.