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.

Growth hormone and low dose estrogen in Turner syndrome: results of a United States multi-center trial to near-final height.

A cardinal clinical feature of Turner syndrome (TS) is linear growth failure resulting in extreme short stature: the median adult height of untreated women with TS is 143 cm, 20 cm (8 in.) below that of the general female population. In the largest multicenter, randomized, long-term, dose-response study conducted in the United States, 232 subjects with TS received either 0.27 or 0.36 mg/kg.wk of recombinant human GH with either low dose ethinyl E2 or oral placebo. The study was placebo-controlled for both GH and estrogen for the first 18 months and remained placebo-controlled for estrogen for its duration. The near-final height of the 99 subjects whose bone age was at least 14 yr was 148.7 +/- 6.1 cm after 5.5 +/- 1.8 yr of GH started at a mean age of 10.9 +/- 2.3 yr; this represents an average increase of 1.3 +/- 0.6 SD scores from baseline (TS standard). Height was greater than 152.4 cm (60 in.) in 29% of subjects compared with the expected 5% of untreated patients. Mean near-final heights of subjects who received the lower GH dose, with or without estrogen, were 145.1 +/- 5.4 and 149.9 +/- 6.0 cm, respectively; those who received the higher GH dose with or without estrogen achieved mean near-final heights of 149.1 +/- 6.0 and 150.4 +/- 6.0 cm, respectively. Factors that most impacted outcome were younger age, lower bone age/chronological age ratio, lower body weight, and greater height SD score at study entry. This study demonstrates significant GH-induced improvement in height SD score, with correction of height to within the normal channels for a significant number of patients, and provides evidence of a GH dose-response effect. These data also indicate that early administration of estrogen, even at relatively low doses, does not improve gain in near-final height in patients with TS.

Inhibition of in vitro pre-mRNA splicing in S. cerevisiae by branched oligonucleotides.

A series of V- and Y-shaped nucleic acids, related to the splicing intermediates derived from S. cerevisiae actin pre-mRNA, were prepared. The effects of such branched nucleic acids (bNAs) on the efficiency of in vitro pre-mRNA splicing in yeast were studied. The exogenous bNAs each effect the efficiency of splicing, yet to different degrees, depending on the sugar composition and topology of the molecules. Y-shaped RNAs inhibited the formation of mRNA (i.e. RNA splicing) to the greatest extent.

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.

Pharmacokinetics of midazolam in critically ill pediatric patients.

Midazolam is frequently used to produce sedation in critically ill pediatric patients. We studied the pharmacokinetics of midazolam in 22 patients (age 8 days to 16 years). The intravenous infusion rate to produce sedation ranged from 49-385 mcg/kg/hr. The blood samples were obtained at steady-state and midazolam was measured by gas chromatography with electron capture. The steady-state plasma concentrations of midazolam ranged from 49-385 ng/mL. The total clearance, apparent volume of distribution, and elimination half-life ranged from 0.1-3.1 L/kg/hr, 0.2-3.5 L/kg, and 0.3-10.9 hours, respectively. The marked interpatient variability in pharmacokinetics explains in part, the substantial variation in dosage requirements of midazolam to produce sedation in critically ill pediatric patients.

Risk factors for injury to women from domestic violence.

BACKGROUND: Domestic violence is the most common cause of nonfatal injury to women in the United States. To identify risk factors for such injuries, we examined the socioeconomic and behavioral characteristics of women who were victims of domestic violence and the men who injured them. METHODS: We conducted a case-control study at eight large, university-affiliated emergency departments. The 256 intentionally injured women had acute injuries resulting from a physical assault by a male partner. The 659 controls were women treated for other conditions in the emergency department. Information was collected with a standardized questionnaire; no information was obtained directly from the male partners. RESULTS: The 256 intentionally injured women had a total of 434 contusions and abrasions, 89 lacerations, and 41 fractures and dislocations. In a multivariate analysis, the characteristics of the partners that were most closely associated with an increased risk of inflicting injury as a result of domestic violence were alcohol abuse (adjusted relative risk, 3.6; 95 percent confidence interval, 2.2 to 5.9); drug use (adjusted relative risk, 3.5; 95 percent confidence interval, 2.0 to 6.4); intermittent employment (adjusted relative risk, 3.1; 95 percent confidence interval, 1.1 to 8.8); recent unemployment (adjusted relative risk, 2.7; 95 percent confidence interval, 1.2 to 6.5); having less than a high-school-graduate's education (adjusted relative risk, 2.5; 95 percent confidence interval, 1.4 to 4.4); and being a former husband, estranged husband, or former boyfriend (adjusted relative risk, 3.5; 95 percent confidence interval, 1.5 to 8.3). CONCLUSIONS: Women at greatest risk for injury from domestic violence include those with male partners who abuse alcohol or use drugs, are unemployed or intermittently employed, have less than a high-school-graduate's education, and are former husbands, estranged husbands, or former boyfriends of the women.

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.

Emergency department-based study of risk factors for acute injury from domestic violence against women.

STUDY OBJECTIVES: To evaluate the associations between selected socioeconomic risk factors and acute injury from domestic violence against women. METHODS: We conducted a preliminary matched case-control study to measure the association of selected predictor variables with acute injury from domestic, violence against women. Patients identified as cases were Hispanic or white female emergency department patients, 16 to 65 years of age, with acute injury sustained from physical assault by an intimate male partner. Cases were selected for inclusion in the study if they reported or admitted acute physical assault by their male partners. Controls were selected from non-case female ED patients so as to represent the base population of the cases and enhance comparability. Two controls were matched to each case. The socioeconomic predictor variables examined were the education level, employment status, history of alcohol abuse, and history of drug abuse of the male partner and the education level and cohabitation status of the female partner. RESULTS: Forty-six cases were identified and included in the study. The age range was 16 to 51 years (mean, 33 years). There were 26 (57%) Hispanic and 20 (43%) white cases. The strongest predictor for acute injury from domestic violence in these patients was a history of alcohol abuse by the male partner, as reported by the female partner (odds ratio, 12.9). The remaining predictor variables were weakly associated or not associated with domestic violence. One half of the cases stated that their male partners were intoxicated with alcohol at the time of assault. CONCLUSION: Of the socioeconomic variables examined in this preliminary study, a history of alcohol abuse by the male partner, as reported by the female partner, was the strongest predictor for acute injury from domestic violence. A large-scale, multicenter, ED-based study is needed to clarify the relation between alcohol abuse, other socioeconomic factors, and acute physical assaults against women by their intimate male partners.

Penetrating neck trauma.

Penetrating neck trauma can pose significant diagnostic and therapeutic challenges for emergency physicians. Factors contributing to these problems are complex anatomy, proximity of vital structures, and potential for rapid deterioration of airway, vascular, or neurologic injuries. Other contributing factors are the lack of consensus in the literature regarding appropriate evaluation and management of penetrating neck injuries, and insufficient resources or experienced personnel at some institutions. This review focuses on the key components of the history and physical examinations that allow for an assessment of the severity and type of structures involved. In addition, current methods of airway management, as well as ways to manage penetrating neck trauma efficiently and cost effectively, are discussed.

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.