Use of force by law enforcement: an evaluation of safetyand injury.

BACKGROUND: Little is known about the frequency and types of injuries sustained from law enforcement use of force (UOF). The purpose of this study was to examine injury patterns and subject conditions after law enforcement UOF under real-life conditions. METHODS: A retrospective cohort design was used to examine every UOF by a single police department from January through December, 2006. Data were collected from law enforcement UOF forms as well as medical records and included conditions surrounding the UOF, medical histories, and data from emergency department (ED) evaluations and hospital admissions. RESULTS: Of 888 individuals subjected to force during the study period, 86.9% were men and the average body mass index was 25.8. Ages ranged from 10 to 77 years; juveniles comprised 5.6%. Of the types of force used by police, 73.7% were blows with arms or legs; 15.9% were Taser, 4.6% were capsicum spray, 1.7% were K-9, 0.7% were impact weapons, and 0.2% were firearms. Of the 630 (70.9%) with medical records, 78.7% had a substance abuse or psychiatric history. ED evaluations occurred for 187 (21.1% of) incidents. When laboratory workup occurred, 75.5% had positive urine toxicology and 45.9% had positive ethanol levels. Admission occurred in 15.5% (29) of ED presentations (3.3% of all subjects); of these, 9 (31.0%) were for UOF-related injury. Two subjects in the study died: one as a result of firearm injury and one by suicide after UOF; both were declared dead on scene. DISCUSSION: Significant injuries related to law enforcement UOF in one city were rare and the only deaths were related to firearm use. A large percentage of those subjected to UOF had diagnoses of substance abuse and/or psychiatric conditions, and most hospital admissions were for problems unrelated to the UOF.

Conducted electrical weapon use by law enforcement: an evaluation of safety and injury.

INTRODUCTION: Controversy persists over the safety of conducted electrical weapons (CEWs), which are increasingly used by law enforcement agencies around the world. The purpose of this study was to examine injury patterns and physiologic conditions after CEW use under real life conditions. METHODS: A retrospective, cohort design was used, examining all CEW uses by one police department during a 6-year period. Data were collected from use-of-force forms and medical records and included conditions surrounding the use of force, medical histories, and data from emergency department evaluations and hospital admissions. RESULTS: Of 1,101 individuals subjected to (Taser M26 and X26) CEW use during the study period, 92.6% were male, the average body mass index was 26.2, and the age range was 9 to 73 years. Of the 886 (80.5%) with medical records, 46.8% had a psychiatric history and 72.9% had a substance abuse history. Emergency department (ED) evaluations occurred for 295 (26.8%) incidents. Of chief complaints, 41.7% were trauma related, 26.8% were for altered mental status, and 21.7% were for psychiatric evaluation. On presentation, 17.6% had a pulse >120, 1.7% were febrile, and 30.9% were altered; 1.4% met criteria associated with "excited delirium." When laboratory workup occurred, 70.6% had positive urine toxicology and 44.8% had positive alcohol levels. Troponin I was positive for one patient. Other laboratory abnormalities were rare, although extensive evaluations were infrequently done. Admission occurred in 24.4% of ED presentations (6.5% of all subjects); of discharge diagnoses for these patients, 59.7% were psychiatric, 22.2% were for unrelated trauma, 11.1% were for restraint-related trauma, and 6.9% were for unrelated medical diagnoses. No patients died. CONCLUSIONS: Significant injuries related to 6 years of law enforcement CEW use in one city were rare. A large percentage of those subjected to CEW use had diagnoses of substance abuse and/or psychiatric conditions. Most admissions after CEW use were unrelated to law enforcement restraint.

Emergency department evaluation and management of peripartum cardiomyopathy.

Peripartum cardiomyopathy (PPCM) affects 1000-1300 women in the United States each year. We present three cases of PPCM seen in our Emergency Department (ED) that cover the entire spectrum of disease from mild heart failure to sudden cardiac death. Without previous heart disease, these women develop cardiomyopathy with impairment of left ventricular function in the last month of pregnancy, or during the first 5 months postpartum. The etiology of PPCM is not clear, although various mechanisms have been proposed, including infection, autoimmune response, prolonged tocolysis during labor, and maladaptive responses to the hemodynamic changes of pregnancy. The initial presentation of these patients is frequently to the ED. The differential diagnosis and key characteristics of PPCM are discussed. ED management should focus on three elements: reduction in pre-load, reduction in afterload, and increase in inotropy. Key differences between the antepartum and postpartum states are highlighted.

A review of police pursuit fatalities in the United States from 1982-2004.

BACKGROUND: High-speed police pursuits are common in the United States (US). Most states do not gather statistics on police pursuits, pursuit crashes, injuries or fatalities for annual review. OBJECTIVE: The objective of this study is to determine the number of pursuit fatalities to officers, those in the chased vehicle, and those uninvolved in pursuits from 1982-2004. METHODS: A review of police pursuit fatalities reported to the National Highway Traffic Safety Administration (NHTSA) Fatality Analysis Reporting System (FARS) database from 1982-2004. The data was reviewed for fatalities, demographic data, alcohol involvement, road surface type (rural versus urban) and mechanism of collision leading to a pursuit fatality. RESULTS: From 1982-2004, 881,733 fatal crashes were reported to NHTSA, leading to 987,523 fatalities. Of fatal crashes, 6,336 (0.7%) were secondary to pursuits, leading to 7,430 (0.8%) fatalities, a mean of 323 per year. Among these fatalities, chased vehicle occupants accounted for 5,355 (72%); police for 81 (1%); those uninvolved for 1994 (27%). Of fatalities, 6074 (82%) were male, 2,092 (28%) were children and adolescents. Mean age of death was 24 years. African-Americans 1,154 (24%) and Native Americans 101 (2%) died at a higher proportion than their percentage of the US population. Collisions with solid objects accounted for 3,175 (59%) of fatalities in the chased vehicles. Collisions with other moving vehicles accounted for 1,434 (80%) of fatalities of vehicular occupants uninvolved in pursuits. Most fatal crashes, 3,130 (62%), occurred on urban roadways. Alcohol was involved in 4,628 (62%) fatalities. Of police fatalities, 20 (25%) were intoxicated. CONCLUSIONS: Police pursuits results in a small yet significant number of fatal motor vehicular crashes and fatalities. All states should record the total number of police pursuits, pursuit crashes, injuries and fatalities for annual review. The findings in this study have important operational implications for EMS care.

The United States twenty-year experience with bombing incidents: implications for terrorism preparedness and medical response.

BACKGROUND: Terrorist bombings remain a significant threat in the United States. However, minimal longitudinal data exists regarding the medical and public health impact because of bombings. METHODS: We conducted a retrospective analysis of the number of incidents, injuries, and deaths because of explosive, incendiary, premature, and attempted bombings from January 1983 to December 2002. Morbidity and mortality by motives, target locations, and materials used were evaluated. RESULTS: In the United States, 36,110 bombing incidents, 5,931 injuries, and 699 deaths were reported. There were 21,237 (58.8%) explosive bombings, 6,185 (17.1%) incendiary bombings, 1,107 (3.1%) premature bombings, and 7,581 (21.0%) attempted bombings. For explosive bombings with known motives, 72.9% of injuries and 73.8% of deaths were because of homicide. For incendiary bombings with known motives, 68.2% of injuries were because of extortion and revenge, and 53.5% of deaths were due to homicide. Private residences accounted for 29.0% of incidents, 31.5% of injuries, and 55.5% of deaths. Government installations accounted for 4.4% of incidents but were the site of 12.7% of injuries and 25.5% of deaths. In bombings with known materials, nitrate-based fertilizers accounted for 36.2% of injuries and 30.4% of deaths, and smokeless powder and black powder accounted for 33.2% of injuries and 27.1% of deaths. CONCLUSIONS: Illegal bombings and related injuries commonly occur in the United States. Because of the easy availability of bombing materials, government agencies and healthcare providers should prepare for potential mass-casualty bombings.

Communicating life-threatening diagnoses to patients in the emergency department.

Disclosing a new, life-threatening diagnosis to a patient is difficult for the physician, the patient, and the family. The disclosure provokes a wide range of reactions from both the patient and family, to which the emergency physician must respond. This interaction is further complicated by the limited time the emergency physician can spend with the patient, the strained resources of a busy emergency department (ED), and, oftentimes, the inability to make a definitive diagnosis based on the ED workup and evaluation. We present a case seen recently in the ED in which a new, life-threatening illness requires disclosure. We offer guidelines for the emergency physician that emphasize patient- and family-centered disclosure of the worrisome diagnostic findings. Additionally, we discuss the essential roles of other allied health professionals in addressing the patient's nonmedical concerns (eg, health insurance, social issues) and in creating a smooth transition for the patient from the ED to further inpatient or outpatient care.