Send letter to journal:
Re: Flawed Study

The Supreme Court stated in Graham v. Conner "The test of reasonableness under the 4th Amendment is not capable of precise definition or mechanical application." That means it is very difficult to judge a use of force (a better term being response to resistance) without knowing all the information known to the officer at the time the force was used. While your study may indicate a number of injuries resulting from contacts with police officers, I do not see how you can represent these injuries as being the result of excessive force when you had no information to judge whether the force used was justified or not.

It would be no different than taking a survey of patients asking them if they felt the doctor treating them overcharged them or not. While each patient may indeed have an opinion, that opinion would be of little value without some objective facts upon which to evaluate the question.

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Re: Good Work: Take the Next Step

Send letter to journal:
Re: Original Authors' Response to Dr. Ford’s e-Letter

Dear Editor,

We appreciate Dr. Ford’s letter in response to our article entitled “Excessive Use of Force by Police: A Survey of Academic Emergency Physicians.”[1] As he pointed out, almost all respondents to our randomized survey of academic emergency physicians in the US believed that excessive use of force by law enforcement does occur. This is substantiated by statistics from the US Department of Justice in their Special Report - Citizen Complaints about Police Use of Force, in which data from 2002 revealed that 8% of 26,556 citizen complaints of police use of force were sustained. In addition, 34% of the complaints were not sustained due to insufficient evidence to prove that excessive use of force actually occurred.[2] Further in recent years the US Department of Justice has investigated the law enforcement agencies of numerous cities, including Los Angeles, Cincinnati, Washington DC, New York, New Orleans, Detroit, Cleveland, Pittsburgh, Oakland, as well as US Virgin Islands and the New Jersey State Police, for excessive use of force.[3]

However, we disagree with Dr. Ford’s assessment that police use of force is strictly a “rubric of criminal justice policy.” We believe that police use of force crosses other sectors, and is also a healthcare issue. This is not the only healthcare issue that is also a criminal justice problem and is regularly evaluated in emergency departments nationwide. Child abuse, sexual assault, intimate partner violence, elder abuse, and other forms of assaultive violence (i.e. injuries from stab wounds, gunshot wounds, and hate crimes) are also examples of issues that involve both health care and the criminal justice system. As with suspected excessive use of force by law enforcement, in all these situations emergency physicians cannot determine the circumstances of the events that lead to the patients’ injuries. In our article we clearly stated this. However, it is within our scope of practice, and is considered standard of care to ask about the mechanism of injury and to assess injury patterns for signs of intentional injury and injuries that do not fit with the reported mechanism of injury by either law enforcement or the patient.

We are mandated by law to report cases in which we suspect injuries due to family violence, in order that law enforcement may investigate the circumstances of the events and make a determination as to whether a crime occurred. Patients who present to the emergency department for evaluation, in whom the healthcare provider has a suspicion of excessive use of force by law enforcement officers, should similarly be reported to an authority responsible for investigating the circumstances of the event resulting in the injuries. Patient presentations which may be particularly concerning are those in which the patient has significant injuries, injuries that are not consistent with the medical history, and significant injuries despite not being arrested. Even Dr. Ford agrees that injuries inconsistent with the history provided should be reported to “the authorities” by the physician.

We are not aware of any regulations requiring healthcare providers to report injuries from suspected excessive use of force by law enforcement officers. Legislation is necessary to permit healthcare providers to report significant injuries to the authorities in good faith and without legal repercussions. The goal is to prevent unnecessary injuries to individuals during physical encounters with officers, while acknowledging that the amount of force needed will vary from encounter to encounter.

1. Hutson HR, Anglin D, Rice P, et al. Excessive use of force by police: A survey of academic emergency physicians. Emerg Med J 2009;26:20- 22.

2. Hickman MJ. Special Report - Citizen Complaints About Police Use of Force, NCJ210296. Washington DC: US Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, June 2006. Accessed 2/19/2009. http://www.ojp.usdoj.gov/bjs/pub/pdf/ccpuf.pdf.

Send letter to journal:
Re: Emergency Physicians and Police Brutality

Hutson et. al's survey of 393 academic emergency physicians (EP's) demonstrated their almost universal sense that the police engage in excessive force.[1] While this result is provocative, it is not as informative as one might think. The opinions of such doctors would certainly be expected to carry great weight in discussions regarding health care issues. However, determinations of the appropriateness of police "use of force" is not such an issue and rather falls under the rubric of criminal justice policy.

Even if physicians had the necessary training to make such assessments (in this study, 93.7% admit to lacking such training), a detailed investigation reviewing police reports, interviewing witnesses, etc. would be required to come to anything resembling an informed conclusion. In fact, EP's, not being witnesses to the events leading to injured suspects, bring no additional insight to the causes of such injury than any other "after-the-fact" care provider.

Certainly, physicians of all specialties have a responsibility to identify child, partner, and elder abuse and frequently receive training to this end. This is not, as some might think, analogous to recognizing cases of police brutality. Children, partners, and the elderly should never be the victims of physical or emotional abuse by those close to them. The mere existence of such physical or emotional injuries (which many physicians are certainly able to detect) clearly raises the possibility or even likelihood of such abuse. A suspect brought into the emergency department by law enforcement however falls into a different category.

The police have an extraordinarily difficult job often interacting with very dangerous criminal suspects. When such suspects are hurt, their injuries may arise out of the normal and appropriate application of physical force. EP's seldom, if ever, possess the information necessary to judge the appropriateness of that force.

The authors have concluded that their results "...suggest that national emergency medicine organizations in the USA should become involved, jointly developing and advocating for guidelines to manage this complex issue."

Obviously, if a police officer's history of the events leading to suspect's constellation of injuries is completely inconsistent with what is observed on physical exam, the physician's course is self-evident: he or she must report it to the authorities. Neither additional "study" nor "guidelines" are required to establish this.

1. Hutson HR, Anglin D, Rice P, et al. Excessive use of force by police: a survey of academic emergency physicians. Emerg Med J 2009;26:20-22.

John S. Ford, M.D., M.P.H.

Assistant Professor of Medicine

David Geffen School of Medicine at UCLA

Harbor-UCLA Medical Center

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Re: Respectful disagreement

To Distinguished Physicians,

I have read excerpts form you article “ Police Use Excessive Force, ER Docs Say” January 1 2009, Volume 26, Issue 1 . Although I haven’t read the whole article, I do believe your study is flawed. For the purposes of this study, how did you define excessive force? Did you allow the individual doctors to subjectively define the term excessive force. Law enforcement officers are authorized to use force in apprehending a criminal. The definition of justifiable force employed by most agencies is minimum amount force necessary to effect a lawful arrest. This is a very easy definition when you have a compliant person who doesn’t resist. What about when the person does resists? Tries to assault the officer? If an officer defends himself from that assault and injures the criminal, what do you think the criminal is going to say to the ER personnel? I don’t think you will hear the criminal say “I violently resisted being arrested and tried to assault the officer” rather I believe you will here “The officer hit me for no reason.” There are an infinite amount of variables that determine the minimum amount of force used in the field all of which the ER staff is not privy to. An unintentional false allegation based upon what the criminal tells the doctor can stall a dedicated officers career, preventing promotions and pay raises. If the patient feels they are the victim of excessive police force, there are many legal routes for them to file a complaint. The role of the ER staff is not to judge if there is a victim of suspected excessive police force, but to treat and document the patient’s injuries. If the patient files a complaint, those records will without a doubt be subpoenaed.

As for the handcuffs, they are not constructed to be “user friendly”. They are made to ratchet closed. If the handcuffs are not double locked, the prisoner themselves can make them tighter either accidentally or intentionally. Prisoners have been known to tighten the handcuffs to bolster there claim of excessive force. Even if the handcuffs are double locked, the radius and ulna can be pinched in the oval open of the handcuffs causing pain and making it look like they are too tight. This is caused by the prisoner trying to move around in the handcuffs and trying to slip out of them.

Sincerely,