H. Range Hutson

Taser Use in Restraint-Related Deaths

Objective. The Taser is an electric weapon capable of releasing significant amounts of electricity in rapid pulses, causing uncontrollable muscle contraction. Use of this weapon has dramatically increased over the past decade, andit is now commonly used by law enforcement officers nationwide. Emergency medical services providers are, likewise, seeing more patients who have recently been subjected to application of a Taser. We examined the autopsy reports of patients who died after application of a Taser in an attempt to identify high-risk interactions. Methods. This is a case series of Taser-related deaths. Fatalities occurring over four years beginning in January 2001 were identified through an Internet search, andautopsy reports were requested. Reports were analyzed for patient demographics, preexisting cardiac disease, toxicology, evidence of excited delirium, restraint techniques used, andlisted cause of death. Results. Of 75 cases identified, 37 (49.3%) had autopsy reports available for review. All cases involved men, with ages ranging from 18 to 50 years. Cardiovascular disease was found in 54.1%. Illegal substance use was found on toxicology screening for 78.4%; within that group, 86.2% were found to have been using stimulants. A diagnosis of excited delirium was given for 75.7% of the cases. Use of a Taser was considered a potential or contributory cause of death in 27%. Conclusions. This is the largest review of Taser-related fatalities reported in the medical literature. The findings are consistent with prior studies, suggesting a high frequency of restraint-related andexcited delirium–related fatalities. Key words: emergency medical services; restraint; physical; fatal outcome; law enforcement.

Lisfranc fracture-dislocation: a frequently missed diagnosis in the emergency department.

Lisfranc fracture-dislocations are rare, and their correct diagnosis is important. Misdiagnosis is common and can lead to grave, chronic disability. We present two cases of Lisfranc fracture-dislocation to highlight the mechanisms of injury, clinical presentation, diagnosis, and treatment. Accurate diagnosis by emergency physicians with early orthopedic referral and evaluation are essential because surgery is often necessary for optimal results.

Adolescents and children injured or killed in drive-by shootings in Los Angeles.

BACKGROUND Drive-by shootings by violent street gangs contribute to early morbidity and mortality among adolescents and children in Los Angeles. This study attempted to determine the frequency of this problem and the population at greatest risk. We also studied the most frequently injured areas of the body, the seasons in which the most shootings occurred, the most common sites for drive-by shootings, and the types of firearms used. METHODS We retrospectively reviewed the files of the Gang Information Section of the Los Angeles Police Department to identify all drive-by shootings in Los Angeles in 1991 in which a child or adolescent under the age of 18 was shot at, injured, or killed. RESULTS A total of 677 adolescents and children were shot at, among whom 429 (63 percent) had gunshot wounds and 36 (5.3 percent) died from their injuries. Three hundred three of those with gunshot wounds (71 percent) were gang members. Arms and legs were the areas of the body most commonly injured. Handguns were the most frequently used type of firearm. All the homicide victims were African American or Hispanic, and 97 percent were boys. African American and Hispanic children and adolescents, especially male gang members, had a significantly higher risk than their Asian and white counterparts of injury and death from drive-by shootings in Los Angeles (P < 0.001). CONCLUSIONS Drive-by shootings involving adolescents and children are frequent in Los Angeles. Although Los Angeles may be an atypical case, understanding why violent street gangs form, preventing causes of violence, and limiting access to firearms are essential steps in preventing this serious problem.

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.

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.

Minimizing Gang Violence in the Emergency Department

Street gang members are frequently injured, and the violence of their subculture may follow them from the streets into the emergency department. We present four cases in which in-hospital gang violence occurred or was prevented. To decrease the risk of injury from gang-related violence within the hospital, we offer guidelines for patient care and health care provider safety. Emphasis is on education, awareness, and early hospital security involvement.

Academic Emergency Physicians’ Experiences With Patient Death

OBJECTIVES There is a growing awareness of the effects of patient death on physician well-being, and the importance of cultural and educational changes to improve coping mechanisms. The objective of this study was to explore both the effects of patient death on academic emergency physicians (EPs) and the coping mechanisms they use to deal with these events. METHODS Faculty at a convenience sample of four emergency medicine (EM) residency programs were questioned about their responses to patient death in a 15-question on-line survey. Descriptive analysis of the data was performed. Independent variables were analyzed for differences in complaints of physical symptoms or consideration of important life changes after patient death. RESULTS Of 207 EPs surveyed, 145 (70%) responded. Patient death was experienced frequently, with 95 (66%) witnessing a death at least every month. No training on coping with patient death had occurred for 35 (24%); 93 (64%) had less than 6 hours of training. The most common coping mechanisms included talking with colleagues (113; 78%) or friends and family (100; 69%), as well as simply continuing to work (89; 61%). Postdeath debriefing occurred rarely or never for 93 (64%) of respondents. Most EPs had experienced physical responses to patient death, the most common being insomnia (54; 37%) and fatigue (21; 14%). Common emotional responses included sadness (112; 70%) and disappointment (55; 38%). No significant differences in response rates for physical symptoms or consideration of life changes were found for any of the variables. CONCLUSIONS Patient death was reported to lead to both physical and emotional symptoms in academic EPs. Postdeath debriefing appears to happen infrequently in teaching settings, and most respondents reported that they themselves received limited training in coping with patient death. Further study is needed to both identify coping mechanisms that are feasible and effective in emergency department settings and develop teaching strategies to incorporate this information into EM residency training.

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.

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, andthose 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) andmechanism 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 andadolescents. Mean age of death was 24 years. African–Americans 1,154 (24%) andNative 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 andfatalities. All states should record the total number of police pursuits, pursuit crashes, injuries andfatalities for annual review. The findings in this study have important operational implications for EMS care.

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.