Dr Meng Aw-Yong
468 Fulham Palace Road
London SW6 6Hy
11th May 2009
Letter in response to
Booker RJ, Smith JE Rodger M. Packers, pushers and stuffers- managing
patients with concealed drugs in UK emergency departments: a clinical and
medicolegal review. EMJ Vol 26 No 5 May 2009. Pages 316-320
Dear Sirs,
The article in EMJ May 2009 on packers, pushers and stuffers by Booker et al is an invaluab...
Dr Meng Aw-Yong
468 Fulham Palace Road
London SW6 6Hy
11th May 2009
Letter in response to
Booker RJ, Smith JE Rodger M. Packers, pushers and stuffers- managing
patients with concealed drugs in UK emergency departments: a clinical and
medicolegal review. EMJ Vol 26 No 5 May 2009. Pages 316-320
Dear Sirs,
The article in EMJ May 2009 on packers, pushers and stuffers by Booker et al is an invaluable and timely one especially for those involved with this particular group of patients. I must outline my conflict of interest as I am a Forensic Medical Examiner (FME) in the Metropolitan police and have examined a high caseload, probably close to 15,000 over the years. I am also in the unique position to be working as a Staff Grade in EM in the main receiving hospital for the drug packers flying in via Heathrow.
There are several issues, which I would like to clarify and expand upon. These are the minimal reference to body stuffers, the consequences of an investigation by the Independent Police Complaints Commission (IPCC) and Coroner’s inquest arising from of any custodial death and the ethics of discharging a patient with the potential risk of sudden death. In the medical jurisprudence environment drug pushers are referred to as “stuffers”. The maximum sentence for possession with intent to supply class A drugs is life imprisonment and an unlimited fine. Henceforth many body packers or stuffers are likely to refuse to divulge any incriminatory evidence, refuse treatment and/or admission. Furthermore they face severe punishment or death from the drug dealers should they fail to deliver the goods. On the issue of conservative management of body packers, I will quote from a series of presentations at the Royal Society of Medicine in 2008 on body packer and stuffers. Mr Mohsen, consultant surgeon, presented the results of a review of 2508 suspected body packers, in a period between January 2000 and January 2005, presenting to Hillingdon Hospital. The patients were from the HM Revenue and Custom detention Unit (HMRC) at Heathrow. Those with a negative abdominal x-rays were returned to Customs in Heathrow and only symptomatic body packers (61) were kept as inpatients. Abdominal pain was the commonest presenting complaint with 4 presenting with symptoms of cocaine toxicity. There was an 8% failure rate in conservative management with 0.3% rate of surgical intervention similar to that reported in previous studies.
We are unable to detain patients with capacity in hospital against their wishes but the ethical dilemma is whether we should allow patients to go home or return under arrest to a customs facility with no medical backup, where there may be considerable risk to their health. If admitted in hospital, they may be disruptive to the daily workings, as they require 24-hour one to one supervision, as many will swallow any emerging drugs to eliminate the evidence and the security risk posed from the dealers. Customs officials tend not to like the inconvenience and loss of officers on hospital guard.
Police officers and FMEs fear a death in custody. Any death in custody quite rightly is rigorously examined and will ensure the closure of a custody site, the banning of police officers from any contact with the public, the possible involvement of the doctor in negligence claims, dismissal from work or a GMC referral. The costs alone are estimated at about £1 million per case.
Drugs stuffers refer to those who swallow illicit drugs to evidence while on the verge of being arrested. This is a much more serious situation as it is unplanned with often inadequate packaging. Doses can be significantly higher than what the stuffer normally takes, together with poly-drug overdose and the unknown effect of adulterants. This is a regular occurrence presenting to FMEs and subsequently ED. Although Booker refers to scant evidence of deaths from drugs stuffers, a review of the Deaths in Custody data reveals 12 deaths from drugs in 1999 with 4 alone from airway obstruction. Havis et al found 43 drug related deaths in police custody (England and Wales) between 1997-2002. Of those 16 cases involved internal drug concealment, 8 were witnessed swallowing/concealing drugs and 5-showed airway obstruction. The Good Practice Guidelines for FMEs in the Metropolitan Police stipulate that if “A prisoner who has or is suspected of having swallowed drugs, must be treated as having taken an overdose and an ambulance should be called”. . The caveat to the ED doctor is when the police bring a “stuffer” to hospital soon after arrest. The stuffer will usually deny swallowing any drugs for the reasons outlined above. And there may little or no signs of drug intoxication. However several hours later as the wrapping becomes unwrapped or is dissolved by stomach acid dissolves there may be a sudden rush of drugs to the body potentially resulting in death. Furthermore as these cases are medicolegal in nature accurate and copious documentation is essential. Therefore the discretionary factor in Booker’s advice is that stuffers should be asymptomatic with a minimum 6 hours FROM the time of ingestion irrespective of any denial of drug swallowing. What if the detainee refuses to stay wishing to expedite the criminal process and be released? If discharged we merely displace the risk and responsibility to the hapless Custody Sergeant and FME who face serious risk? Although there is strong evidence supporting the conservative management of body packers there still remains the questions of sending them home or to custody with little or no medical facilities. I suggest that police authorities and the HMRC collaborate and built special units attached to ED thereby providing continuous and immediate medical care should the need arise. There also remains an opportunity for researching the safe parameters for stuffers and developing guidelines for Emergency Departments.
Sentencing Guidelines. http://www.sentencing-guidelines
.gov.uk/guidelines/other/courtappeal/default.asp?
T=Cases&catID=6&subject=POSSESSION%20WITH%20INTENT%20TO%20SUPPL
Y
Shamir OC, Williams EW, Evans NR and Johnson P. Occupational hazard:
Treating cocaine body packers in Caribbean countries International Journal
of
Drug Policy.
Vol 20, Issue 4, July 2009, P 377-380.
http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6VJX-
4THB4C8-
1&_user=10&_coverDate=07%2F31%2F2009&_alid=915345136&_rdoc=1&_f
mt=high&_orig=search&_cdi=6106&_sort=d&_docanchor=&view=c&_ct=301
&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=05b793
3fbd7fd30cda8309a1a9fdc1d4
Goertemoeller H and Behrman A. The Risky Business of Body Packers and
Body Stuffers.. Journal of Emergency Nursing. Vol 32, Issue 6, Dec 2006, P
541-544
http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WJ5-
4MD8SYX-P&_user=5932406&_origUdi=B8CY1-4RSHRC2-
4&_fmt=high&_coverDate=12%2F31%2F2006&_rdoc=1& Concealment of drugs by
police detainees: lessons learned from adverse
incidents and from routine clinical practice. S Havis, D Best and J
Carter.
JCFM Vol 12 No 5 p237-241
I am impressed with your article, because in our country, the major part of surgeons still believe analgesics would mask the physical findings and delay the time of accurate diagnosis.
In your article, I have a question that patients were examined by surgeons not involved in their care while they were waiting for operation. I wondered if the surgeons had already known the diagnosis of patients or...
I am impressed with your article, because in our country, the major part of surgeons still believe analgesics would mask the physical findings and delay the time of accurate diagnosis.
In your article, I have a question that patients were examined by surgeons not involved in their care while they were waiting for operation. I wondered if the surgeons had already known the diagnosis of patients or if they were concealed? The other question is that if the patients before being scheduled to receive operation had any analgesic or not.
I will be glad to know and that will help me do my job well.
We greatly enjoyed reading the ACES ultrasound protocol by Atkinson
et al. to evaluate patients with hypotension of unknown etiology.[1] We
have been using a similar protocol for a few years with the addition of
pneumothorax windows to examine for spontaneous or iatrogenic pneumothorax
as the cause for shock.[2]
We call our protocol the RUSH exam, an acronym for Rapid Ultrasound
for Shock/Hypotension. We find th...
We greatly enjoyed reading the ACES ultrasound protocol by Atkinson
et al. to evaluate patients with hypotension of unknown etiology.[1] We
have been using a similar protocol for a few years with the addition of
pneumothorax windows to examine for spontaneous or iatrogenic pneumothorax
as the cause for shock.[2]
We call our protocol the RUSH exam, an acronym for Rapid Ultrasound
for Shock/Hypotension. We find this title acts as a mnemonic tie-in with
the FAST exam for trauma. When teaching our protocol, we use the acronym
HI-MAP to remember the steps of the exam. (Heart, IVC, Morison’s/abdominal
views, Aorta, Pneumothorax). This also describes the sequencing of the
examination. While we believe ACES is aces, we submit that adoption may be
quicker with RUSH.
1. Atkinson PRT, McAuley DJ, et al. Abdominal and Cardiac Evaluation
with Sonography
in Shock (ACES): an approach by emergency physicians for the use of
ultrasound in patients with undifferentiated hypotension. Emerg. Med. J.
2009;26;87-91.
2. Weingart SD, Duque D, Nelson B. Rapid Ultrasound for
Shock/Hypotension. EMCrit.org.
[http://emcrit.org/ultrasound/The%20RUSH%20Examfinal.htm]. accessed
3/5/2009 2141.
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
contac...
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.
I fail to see the benefit to anyone of publishing this study.
Thank you for your effort. The most important revelation is that
there are no requirements to report obvious abuse, and there is no data
collected. Most claims of abuse by police are not objectively
investigated by the police themselves, few ever reach a criminal
prosecution, and the only realistic "investigation" and prosecution of
excessive force and gratitutious violence is by private lawyers in civil
cases. This,...
Thank you for your effort. The most important revelation is that
there are no requirements to report obvious abuse, and there is no data
collected. Most claims of abuse by police are not objectively
investigated by the police themselves, few ever reach a criminal
prosecution, and the only realistic "investigation" and prosecution of
excessive force and gratitutious violence is by private lawyers in civil
cases. This, unfortunately, is the only open window into the well oiled
system of concealment of incidents of escessive force by U.S. police.
John Ryan raises an interesting question from an editorial point of
view. Like
him
I suspect that I refer to my own department as an emergency department,
and
see myself as an emergency physician. I am a proud member of the College
of
Emergency Medicine and despite familial protestations refuse to watch
historically named BBC dramas on principles of nomenclature.
John Ryan raises an interesting question from an editorial point of
view. Like
him
I suspect that I refer to my own department as an emergency department,
and
see myself as an emergency physician. I am a proud member of the College
of
Emergency Medicine and despite familial protestations refuse to watch
historically named BBC dramas on principles of nomenclature.
Hau on the other hand uses the terms terms 'Accident and Emergency',
and
indeed 'Casualty'. As the handling editor for that issue of the journal I
must
accept the criticism for allowing it to pass. In the past I have
challenged such
historical terms as a reviewer and as an editor. However, on this occasion
I
did
not as the authors are referring to their own department and arguably have
a
right to refer to their own department in any way they choose.
Your recently published Best Evidence Topic (BET) report regarding
the reduction of dislocated hip prosthesis outlines a comparison of
general anaesthesia with “conscious sedation”.[1] However, of the four
included papers one used methohexital with or without opioids to
facilitate reduction, whilst another was a prospective cohort study of
patients receiving intravenous morphine followed by propofol. In...
Your recently published Best Evidence Topic (BET) report regarding
the reduction of dislocated hip prosthesis outlines a comparison of
general anaesthesia with “conscious sedation”.[1] However, of the four
included papers one used methohexital with or without opioids to
facilitate reduction, whilst another was a prospective cohort study of
patients receiving intravenous morphine followed by propofol. In the third
paper a proportion of patients also received propofol sedation.
Conscious sedation is defined as “a technique in which the use of a
drug or drugs produces a state of depression of the central nervous system
enabling treatment to be carried out, but during which verbal contact with
the patient is maintained throughout the period of sedation”.[2] However
it seems highly implausible that all the patients receiving methohexital
or propofol fulfilled this definition throughout the procedure. Indeed,
propofol sedation in the doses described is likely to produce a state of
deep sedation,[3] during which the patient does not respond to verbal or
simple physical stimuli,[2] and perhaps even a brief period of general
anaesthesia. Furthermore, the chance of successful reduction appears, from
this BET, to be related to the depth of sedation or anaesthesia achieved:
this is problematic for the emergency physician since the deeper the level
of sedation the greater the chance of procedural success, but also the
greater the chance of anaesthetic complications.
Whilst the published evidence to date would support the overall
safety of deep procedural sedation administered in the Emergency
Department,[4] further progress in this important area of our practice
will be potentially undermined if we pretend that the use of propofol
reliably produces nothing more than a state of “conscious sedation”. In
practical terms, deep sedation is difficult to distinguish from general
anaesthesia, and the Academy of Royal Colleges recommends that supervision
of these two states, in terms of the training and skill of the clinician,
should be identical.[2] Unfortunately this somewhat undermines the premise
of this particular BET, in that the comparison becomes one of general
anaesthesia in the emergency department versus general anaesthesia in the
operating theatre. However, providing that the safety of the procedure is
identical regardless of its location then earlier reduction in the
emergency department confers clear patient benefit, with a reduced period
of time spent in discomfort and pain.
Yours faithfully,
Jonathan Benger.
1. Payne N, Jones S. General anaesthesia or conscious sedation for
reducing a dislocated hip prosthesis? Emerg Med J2009;26:204-5.
2. Implementing and ensuring safe sedation practice for healthcare
procedures in adults. Academy of Medical Royal Colleges. November 2001.
Available at: http://www.rcoa.ac.uk/docs/safesedationpractice.pdf
(accessed 5th March 2009).
3. Gürses E, Sungurtekin H, Tomatir E, Dogan H. Assessing propofol
induction of anesthesia dose using bispectral index analysis. Anesth Analg
2004;98:128-131.
4. Smally AJ, Nowicki TA. Sedation in the emergency department
[Anaesthesia outside the operating room]. Current Opinion in
Anaesthesiology 2007;20:379-383.
We read with interest the clinically based study, on the use of
propofol to sedate patients for relocation of hip prostheses in the
emergency department [1]. The authors rightly point out that there are
problems with the safety and efficacy of using midazolam, and conclude
that the described technique is both effective and safe. In another paper
by the same authors they demonstrate this technique of “sedation” has a
bet...
We read with interest the clinically based study, on the use of
propofol to sedate patients for relocation of hip prostheses in the
emergency department [1]. The authors rightly point out that there are
problems with the safety and efficacy of using midazolam, and conclude
that the described technique is both effective and safe. In another paper
by the same authors they demonstrate this technique of “sedation” has a
better success than midazolam, reduces the delay in these patients going
to theatre, and therefore the patients discomfort (although there is no
mention of pain scores of these patients)[2]. However we disagree strongly
with the conclusions that adverse effects were acceptably uncommon, and
argue that the authors have not demonstrated the safety of this technique.
Firstly, we would like to comment on the sedation protocol.
Disappointingly there is no attempt to describe the depth of sedation
provided. The report of the Academy of Royal Colleges on Safe Sedation
Practice states clearly that “verbal contact with the patient is
maintained throughout the period of sedation” [3]. To us, 1mg.kg-1 of
propofol in this age group is a dose close to that required for induction
of anaesthesia [4], and without documentation of the maintenance of verbal
contact it cannot be termed sedation. By your own admission, many of the
patients in this study were, in fact, anaesthetised. The Academy of Royal
Colleges document (to which the Faculty of Accident and Emergency Medicine
were party) again is quite clear that “provision of sedation deeper than
this (verbal contact)… is bordering on anaesthesia. As such, this depth of
sedation must be supervised by those with the same level of training and
skills necessary to provide general anaesthesia”[4] Given that many of
these patients may have been anaesthetised, we have several concerns
regarding this protocol pertaining to training, monitoring, and fasting:
Training: the staff responsible for this procedure had only undergone
one hour of in-house training. The Royal College of Anaesthetists mandate
to its own trainees that they should undergo an initial assessment of
competency before being allowed to give any anaesthetic not directly
supervised. This assessment is usually after a full three months [5].
Monitoring: the level of monitoring recommended for patients undergoing
general anaesthesia should include capnography[6].
Fasting: we find it disappointing that in emergency patients suffering
pain that you stated that fasting guidelines were used “as a guide and not
a rule”. Evidence on the necessity of fasting for elective procedures are
clear after almost 40 years of evidence [7]. Guidelines are less clear for
emergency cases as normal fasting times may be insufficient, necessitating
protection of the patients’ airway.
More worryingly we refute the interpretation of these data as
evidencing safety. It would have been useful to present the incidence of
adverse events with confidence intervals (CI). This allows one to estimate
the true population incidence of a rare event, which could be as much as
the upper level of the 95% CI [8]. We have taken the liberty of doing this
for you: 8% (95% CI 2.6 to 13.4) of patients suffered arterial oxygen
desaturation, 4% (95%CI 0.2-8) required bag-valve-mask ventilation and 4%
(95%CI 0.2 to 2.8) required vasopressors.
Therefore your actual population rate may be anywhere between 2.6%
and 13.4%. This rate of airway/respiratory events equates to 80/1000 (but
could be anywhere between 26 and 134/1000 patients). This compares very
unfavourably with those of other non anaesthetic groups (Australian GPs)
of 4.1 (95%CI 3.3 to 4.9) /1000 and even less favourably with
anaesthetists of 2.6 (95%CI 1.6 to 4.2) /1000 [9]. Our department has
trained non-medical sedationists to provide true conscious sedation for a
different painful procedure (oocyte retrieval for assisted conception),
and have audited experience of 3000 patients with an adverse incidence
rate of 0.3 (95%CI -0.3 to +0.9) /1000 patients. In this context your
described results cannot be remotely construed as demonstrating safety.
In conclusion we are not surprised that the hip relocation rate is
higher with your technique as you have compared propofol anaesthesia with
midazolam sedation. We can entirely understand the desire to reduce delays
for your patients waiting in pain for hip relocation in theatre. However,
our answer to the title of your article “Is propofol a safe and effective
sedative for relocating hip protheses?” is a resounding no. It is our
interpretation that this technique has not been demonstrated as safe, and
would be difficult to justify in the event of a permanent serious
complication.
References
1.Mathieu N, Jones L, Harris A, et al. Is propofol a safe and effective
sedative for relocating hip prostheses? Emerg Med J 2009;26:37–38.
2.Gagg J, Jones L, Shingler G, et al. Door to relocation time for
dislocated hip prosthesis: multicentre comparison of emergency department
procedural sedation versus theatre-based general anaesthesia. Emerg Med J
2009;26:39–40.
3.UK Academy of Medical Royal Colleges and their Faculties. Implementing
and ensuring Safe Sedation Practise for healthcare procedures in adults.
http://www.rcoa.ac.uk/docs/safesedationpractice.pdf
4.Dundee JW, Robinson FP, McCollum JSC, Patterson CC. Sensitivity to
propofol in the elderly. Anaesthesia 1986;41:482–485.
5.http://www.rcoa.ac.uk/docs/CCTptii.pdf
6.http://www.aagbi.org/publications/guidelines/docs/standardsofmonitoring07.pdf
7.Practice guidelines for preoperative fasting and the use of
pharmacological agents for the prevention of pulmonary aspiration:
application to healthy patients undergoing elective procedures.
Anesthesiology 1999; 90; 896-905.
8.Eypasch E, Lefering R,Kum CK, Troidl H. Education and debate.
Probability of adverse events that have not yet occurred: a statistical
reminder. BMJ 1995;311:619-620
9.Clarke AC, Chiragakis l, HillmanLC, Kaye GL. Sedation for endoscopy: the
safe use of propofol by general practitioner sedationists. Med J of Aust
2002;176:158-61
I read with interest the article by Skinner, Carter and Haxton
assessing whether case management of frequent attenders to an urban
emergency department reduces frequency of subsequent attendances.1 The
case for multidisciplinary management of frequent attenders is well-made
and the reported practice of case review and implementation of care plans
highly commendable.
I read with interest the article by Skinner, Carter and Haxton
assessing whether case management of frequent attenders to an urban
emergency department reduces frequency of subsequent attendances.1 The
case for multidisciplinary management of frequent attenders is well-made
and the reported practice of case review and implementation of care plans
highly commendable.
However, a possible considerable limitation to this study is not
fully elucidated in the authors’ discussion. While mention is made that
the reduction seen in attendances by frequent attenders following case
review “may be due to the natural ebb and flow in the presentations of
these patients”1, comment is not made on the potential substantial effects
of the differing seasons in which the study was conducted (October 2006 to
March 2007 control, compared to April 2007 to September 2007 post-
intervention).
Watters et al have previously observed that the number of patient
attendances to the Emergency Department at the Royal Infirmary Edinburgh
is subject to monthly variation.2 Chi-squared analysis of the total
numbers of patients presenting each month presented by Watters et al
confirms variation in numbers of patients by month (chi2 = 105.24, p
<0.001) even when the varying numbers of days in each month is taken
into account (chi2 = 57.03, p <0.001).
Further to this variation in total attendances is the seasonal
variation in presentations of different clinical conditions. The most
common documented diagnoses in this group of frequent attenders was stated
to include “alcohol-related problems (46%), mental health problems (37%)
and chronic complaints such as abdominal or chest pain (40%)”. Other
diagnoses included COPD / asthma and drug abuse. However, the
presentations of many of these conditions have been shown to be subject to
seasonal variation. Arkfen et al’s study of frequent visitors to
psychiatric emergency services found that admission was more frequent in
inclement weather 3; Halpern et al observed a seasonal variation in
emergency department “psychiatric visits” with results supporting the
“existence of a Christmas effect”, they also noted that substance abusers
were more likely to attend the emergency department during the weeks
surrounding Christmas 4.
It is also known that patients with ischaemic heart disease are more
likely to become severely symptomatic during colder temperatures, and
“cold stress” contributes to a higher mortality rate from this condition
during the winter 5. Winter predominance seasonal variation in
presentation rates for abdominal pain is also suspected, and has been
demonstrated in children 6. Ballester et al observed “clear temporal
patterns of COPD emergency” with more emergencies in winter 7.
With more than half of the frequent attenders’ documented diagnoses
subject to seasonal variation with increased presentations during winter
months, it would appear that there is an as yet unaddressed confounding
bias in the observed decreased number of subsequent attendances in the
(summer) months following case management intervention. I eagerly await
the mentioned follow-up study, and will be interested to ascertain whether
the results seen so far are indeed sustainable over time.
E Bateman
Competing interests: None
REFERENCES
1. Skinner J, Carter L, Haxton C. Case management
of patients who frequently present to a Scottish emergency department.
Emerg Med J 2009; 26: 103-105.
2. Watters DA, Brooks S, Elton RA, et al. Sports
injuries in an accident and emergency department. Emerg Med J 1984; 1: 105
-111.
3. Arfken C, Zeman LL, Yeager L, et al. Frequent
visitors to psychiatric emergency services: staff attitudes and temporal
patterns. J Behav Health Serv Res 2002; 29(4): 490-496.
4. Halpern SD, Doraiswamy PM, Tupler LA, et al.
Emergency department patterns in psychiatric visits during the holiday
season. Ann Emerg Med 1994; 24(5): 939-943.
5. Houdas Y, Deklunder G, Lecroart JL. Cold
exposure and ischemic heart disease. Int J Sports Med 1992; 13 Suppl1:
S179-81.
6. Saps M, Blank C, Khan S, et al. Seasonal
variation in the presentation of abdominal pain. J Pediatr Gastroenterol
Nutr 2008; 46(3): 279-84.
7. Ballester F, Pérez-Hoyos S, Rivera ML, et al.
[The patterns of use and factors associated with the patient admission of
hospital emergencies for asthma and chronic obstructive pulmonary
disease]. Arch Bronconeumol 1999; 35(1): 20-26.
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...
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.
3. Other Justice Probes. USA Today. 4/16/2001. Accessed 2/19/2009.
www.usatoday.com.
Dr Meng Aw-Yong 468 Fulham Palace Road London SW6 6Hy 11th May 2009
Letter in response to Booker RJ, Smith JE Rodger M. Packers, pushers and stuffers- managing patients with concealed drugs in UK emergency departments: a clinical and medicolegal review. EMJ Vol 26 No 5 May 2009. Pages 316-320
Dear Sirs,
The article in EMJ May 2009 on packers, pushers and stuffers by Booker et al is an invaluab...
Dear authors:
I am impressed with your article, because in our country, the major part of surgeons still believe analgesics would mask the physical findings and delay the time of accurate diagnosis.
In your article, I have a question that patients were examined by surgeons not involved in their care while they were waiting for operation. I wondered if the surgeons had already known the diagnosis of patients or...
We greatly enjoyed reading the ACES ultrasound protocol by Atkinson et al. to evaluate patients with hypotension of unknown etiology.[1] We have been using a similar protocol for a few years with the addition of pneumothorax windows to examine for spontaneous or iatrogenic pneumothorax as the cause for shock.[2]
We call our protocol the RUSH exam, an acronym for Rapid Ultrasound for Shock/Hypotension. We find th...
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 contac...
Thank you for your effort. The most important revelation is that there are no requirements to report obvious abuse, and there is no data collected. Most claims of abuse by police are not objectively investigated by the police themselves, few ever reach a criminal prosecution, and the only realistic "investigation" and prosecution of excessive force and gratitutious violence is by private lawyers in civil cases. This,...
John Ryan raises an interesting question from an editorial point of view. Like him I suspect that I refer to my own department as an emergency department, and see myself as an emergency physician. I am a proud member of the College of Emergency Medicine and despite familial protestations refuse to watch historically named BBC dramas on principles of nomenclature.
Hau on the other hand uses the terms terms 'A...
Editor,
Your recently published Best Evidence Topic (BET) report regarding the reduction of dislocated hip prosthesis outlines a comparison of general anaesthesia with “conscious sedation”.[1] However, of the four included papers one used methohexital with or without opioids to facilitate reduction, whilst another was a prospective cohort study of patients receiving intravenous morphine followed by propofol. In...
We read with interest the clinically based study, on the use of propofol to sedate patients for relocation of hip prostheses in the emergency department [1]. The authors rightly point out that there are problems with the safety and efficacy of using midazolam, and conclude that the described technique is both effective and safe. In another paper by the same authors they demonstrate this technique of “sedation” has a bet...
Dear Editor,
I read with interest the article by Skinner, Carter and Haxton assessing whether case management of frequent attenders to an urban emergency department reduces frequency of subsequent attendances.1 The case for multidisciplinary management of frequent attenders is well-made and the reported practice of case review and implementation of care plans highly commendable.
However, a possible c...
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...
Pages