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Minimizing gang violence in the emergency department
CASE REPORT
gangs violence
Minimizing Gang Violence in the Emergency Department From Los Angeles County/ University of Southern California Medical Center, Los Angeles. Received for publication May 20, 1992. Acceptedfor publication June 9, 1992.
H Range Hutson,MD Deirdre Anglin, MD William Mallon, MD
Street gang members are frequently injured, and the violence of their subculture may fellow 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 gangrelated 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. [Hutson HR, Anglin D, Mallon W: Minimizing gang violence in the emergency department. Ann EmergMed October 1992;21:1291-1293.] INTRODUCTION Gangs are a violent subculture in America whose members frequently require medical attention. In Los Angeles County alone there are more than 950 different street gangs with more than 100,000 members, 10% of whom are women. Trauma secondary to gang violence is soaring. In Los Angeles County in 1991 there were 771 gang-related homicides and more than 5,100 injuries caused by gang violence (gang-related homicides increased 12% over 1990). 1 I n addition to traumatic injuries, medical problems are also common among gang members. Thus, the gang subculture generates a large n u m b e r of emergency department visits. The County of Los Angeles may be atypical in the degree to which gang violence has an impact on the health care system. However, street gangs have been documented in more than 300 cities across the United States. 2 The violence of gang subculture is no longer limited to the streets, parks, and homes of suspected gang members. Gang violence and its associated injuries are now spilling over into the hospital setting. Health care providers, particularly those in the ED, are appropriately concerned for their own safety and the safety of their patients when i n j u r e d gang members present to the ED. We present four cases in which in-hospital gang-related violence occurred or was prevented. Strategies to protect health care providers from gang violence are proposed. These strategies begin in the prehospital phase and continue into the ED and inpatient setting.
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ANNALS OF EMERGENCY MEDICLNE 21:10
OCTOBER1992
GANG VIOLENCE Hutson, Anglin & Mallon
CASE 1 A 19-year-old male gang member was brought by paramedics to the ED with a gunshot wound to the head sustained in a drive-by shooting. On arrival he was comatose, with fixed and dilated pupils, agonal respirations, and decerebrate posturing. He had an entrance wound in the left frontal region, with gray matter extruding from the wound. He was immediately intubated, placed on a ventilator, and hyperventilated. Emergency neurosurgical consultation and head computed tomography were requested. During the patient's emergency care, his fellow gang members and pregnant girlfriend were in the waiting room pending news of his condition. While driving by the hospital, rival gang members spotted them and opened fire on the waiting area and the ED. A hail of bullets shattered glass and sent the ED staff, patients, and waiting gang members scattering for cover. Although none of the ED staff or patients sustained any physical t r a u m a , the patient's girlfriend was i n j u r e d by flying shards of glass. She sustained several minor facial lacerations, which were repaired. No one else in the waiting area was injured. The entire ED staff remains psychologically traumatized from the experience, and several members refuse to work night shifts out of fear for their safety. CASE
2
Patient l , a 23-year-old man, was brought to the ED by p a r a medics after being shot at close range by an "unknown" assailant. On arrival he had stable vital signs. Physical examination revealed a through-and-through gunshot wound of the left u p p e r extremity and an entrance wound to the left chest. The chest wound was superficial with a palpable foreign body n e a r the wound. His initial chest r a d i o g r a p h was normal. Neurovascular examination of the left u p p e r extremity was intact. Twenty minutes later the paramedics arrived with Patient 2, a 17-year-old man with a superficial gunshot wound to the back. While being t r a n s f e r r e d to a guruey for evaluation, Patient 2 became angry and hostile, demanding to be moved away from Patient 1. Patient 2 stated that Patient 1 was the individual who h a d shot him. To prevent f u r t h e r violence, the patients were quickly separated and hospital security was called to help control the scene (including the waiting area and the hospital perimeter). It became evident that the two patients were rival gang members who had been involved in the same gang-related shootout. CASE
3
A hospitalized 27-year-old man who h a d been shot in gangrelated activity was visited by several of his fellow gang members. At the same time, another patient who had injuries caused by gang violence was undergoing evaluation by a surgical team. She also had several nonfamily visitors. The two groups of visitors recognized each other as rival
OCTOBER 1992 21:18 ANNALSOF EMERGENCYMEDICINE
gang members and challenged each other openly within the hospital. Initially, there was no gunfire, but after the second shouting matcb¢ hand signs were flashed and shooting erupted within the hospital stairwell. A gang member was shot in the face. Hospital security was not notified until shots were fired. Once called, security quickly a p p r e h e n d e d the gang member responsible for the shooting. His arrest occurred on the hospital grounds while he attempted to flee. The i n j u r e d gang member was immediately taken to the ED for evaluation and treatment. CASE
4
A nurse on a surgical ward noticed six gang members visiting a hospitalized fellow gang member. This identification was based solely on her awareness of gang attire. Believing she saw a weapon and realizing the potential for violence, she alerted security. Security responded immediately and the resultant search yielded a fully loaded, bullet-in-chamber, semi-automatic weapon partially hidden in a waistband beneath baggy gang apparel. There were no injuries associated with this incident. BlSCUSSlON
As gang violence increases across the country, health care providers have become vulnerable to injury and death secondary to in-hospital gang-related incidents. Cases 1 and 3 show what can h a p p e n when there is a lack of awareness of gangs in the hospital setting and the violence that may result. Cases 2 and 4 provide contrast with heightened awareness and early involvement of hospital security. To safeguard health care providers, patients, and visitors, we recommend the development of guidelines for the prevention of this type of violence. The guidelines we propose begin in the prehospital care setting and continue throughout the patient's hospital course. Prehospital Care Guidelines In areas in which gang activity is high we recommend the following measures. 3 1. Education of prchospital care personnel about gangs and gang violence should include the root causes of gang formation, effects of gang violence on the community, recognition and identification of local gangs, the nature of gang violence, and the prevention of gang-related trauma. Recognition and awareness of local street gangs is i m p o r t a n t if prehospital care personnel are to know when they may be in danger. 2. Safety of prehospital care personnel should be a high priority. Emergency medicine technicians and paramedics should be advised not to enter a combat zone until the police have secured the area. (Prehospital care response time may be less than police response time.) 3. F l a k jackets (bulletproof vests) should be worn or be readily available as s t a n d a r d equipment for prehospital care personnel. 4. Whenever a patient is t r a n s p o r t e d for a suspected gang-related i n j u r y or is a gang member (this may be more
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a p p a r e n t at the scene J. this information must be communicated to the receiving ED staff. 5. If known rival gang members have injuries, they should when possible be t r a n s p o r t e d to different hospitals. If this is not practical, the receiving ED must be alerted.
Emergency Department Guidelines 1. On arrival of known or suspected gang members, hospital security and local law enforcement should become involved (including surveillance of the waiting area and hospital perimeter). 2. As p a r t of the p r i m a r y survey, the patient should be disrobed, with attention to the possibility of concealed weapons. 3. ED staff, like paramedics, must be educated about gangs and gang violence. Recognition of local gangs is particularly important and may be possible by 4-5 tattoos: "colors" teg, blue for Crips, red for Bloods); typical clothing (baggy split seam pants, Pendleton plaid shirts and d a r k athletic team jackets); h a n d signs; accessories (eg, sneakers, caps, bandannas); evidence of p r i o r m a j o r t r a u m a (eg, healed exploratory laparotomy, thoracotomy, thoracostomy scars). 4. ED staff should seek a history of gang involvement from the patient in a nonjudgmental fashion. 5. It is especially i m p o r t a n t not to challenge or disrespect patients who are gang members. In gang culture this type of attitude often results in physical confrontation. 6. While in the ED, access to the patient should be limited. Preferably, the only visitors should be the patient's parents. Other relatives and friends should be denied access to the patient. They may be informed of the patient's progress with periodic updates by the medical staff. 7. On admission, all gang members should receive a " J o h n or Jane Doe" status. This is to protect their identity and prevent them from being f u r t h e r i n j u r e d by rival gang members while hospitalized. 8. Hospital security should be available 24 hours a day and should be prominent whenever gang members are present in the ED. Security personnel should also be educated with regard to local gangs. 9. Community activists who have experience with gangs can act as liaisons between gang members, the ED, and rival gang members. These liaisons should be involved whenever possible to help decompress any hostility that may arise. 10.All EDs should develop specific evacuation plans to enact when extreme violence erupts within the department.
3. All hospital personnel exposed to in-hospital gang violence in the hospital setting should be debriefed, and the need for further counseling should be addressed. 4. Emergency physicians, t r a u m a surgeons, nurses, and other health care providers who work with gang members should become involved with injury prevention programs in their communities. SUMMARY
Gang membership is increasing, and the violence associated with gangs is escalating. As gang members present to the ED, the violence of their subculture often follows them. We suggest that these guidelines can protect health care providers, patients, and visitors from i n j u r y caused by gang violence in the hospital setting. Emphasis on awareness, identification, and early involvement of hospital security and law enforcement is crucial. To u n d e r s t a n d gangs a n d gang violence, educational programs for health care providers (and others) are strongly recommended. Education regarding the root causes of gang formation may aid the health care p r o v i d e r in maintaining a nonjudgmental a p p r o a c h to these patients. As long as street gangs continue to exist, health care providers must provide compassionate care while minimizing their own risk of injury. REFERENCES 1. Los Angeles CountySheriff's Department Gang Related Homicide Report 1990- 1991.
2. Spergel IA: Youth gangs: Continuity and change, in Morris N, Tanry M (eds): Crime and Justice: An Annual Review of Research. Chicago, University of Chicago Press, 1990, vo112, p 171-275. 3. Meade DM, Relf RH: When colors kill. EmergMed Serv1992;21:20-26. 4. Lyman MD: Gangland. Springfield, Illinois, Charles C Thomas, 1989, p 100. 5. Jackson RK, McBride WD: Understanding Street Gangs. PlaeerviNe,California, Custom Publishing Co, 1991, p 34. Address for reprints: H Range Hutson, MD Los Angeles County/University of Southern California Medical Center Department of EmergencyMedicine Room 1011 1200 North State Street Los Angeles, California 90033
Hespitalwide Guidelines 1. Access and egress to the hospital should be by securitymonitored entrances and exits. EDs and hospitals in some areas should consider the use of metal detectors and bulletproof glass for the protection of health care providers as well as patients and visitors. 2. Hospital security should have close linkage with local law enforcement, especially the.gang control units.
1B6/1293
ANNALS OF EMERGENCY MEDICINE 21:10 OCTOBER1992
gangs violence
Minimizing Gang Violence in the Emergency Department From Los Angeles County/ University of Southern California Medical Center, Los Angeles. Received for publication May 20, 1992. Acceptedfor publication June 9, 1992.
H Range Hutson,MD Deirdre Anglin, MD William Mallon, MD
Street gang members are frequently injured, and the violence of their subculture may fellow 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 gangrelated 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. [Hutson HR, Anglin D, Mallon W: Minimizing gang violence in the emergency department. Ann EmergMed October 1992;21:1291-1293.] INTRODUCTION Gangs are a violent subculture in America whose members frequently require medical attention. In Los Angeles County alone there are more than 950 different street gangs with more than 100,000 members, 10% of whom are women. Trauma secondary to gang violence is soaring. In Los Angeles County in 1991 there were 771 gang-related homicides and more than 5,100 injuries caused by gang violence (gang-related homicides increased 12% over 1990). 1 I n addition to traumatic injuries, medical problems are also common among gang members. Thus, the gang subculture generates a large n u m b e r of emergency department visits. The County of Los Angeles may be atypical in the degree to which gang violence has an impact on the health care system. However, street gangs have been documented in more than 300 cities across the United States. 2 The violence of gang subculture is no longer limited to the streets, parks, and homes of suspected gang members. Gang violence and its associated injuries are now spilling over into the hospital setting. Health care providers, particularly those in the ED, are appropriately concerned for their own safety and the safety of their patients when i n j u r e d gang members present to the ED. We present four cases in which in-hospital gang-related violence occurred or was prevented. Strategies to protect health care providers from gang violence are proposed. These strategies begin in the prehospital phase and continue into the ED and inpatient setting.
164/1291
ANNALS OF EMERGENCY MEDICLNE 21:10
OCTOBER1992
GANG VIOLENCE Hutson, Anglin & Mallon
CASE 1 A 19-year-old male gang member was brought by paramedics to the ED with a gunshot wound to the head sustained in a drive-by shooting. On arrival he was comatose, with fixed and dilated pupils, agonal respirations, and decerebrate posturing. He had an entrance wound in the left frontal region, with gray matter extruding from the wound. He was immediately intubated, placed on a ventilator, and hyperventilated. Emergency neurosurgical consultation and head computed tomography were requested. During the patient's emergency care, his fellow gang members and pregnant girlfriend were in the waiting room pending news of his condition. While driving by the hospital, rival gang members spotted them and opened fire on the waiting area and the ED. A hail of bullets shattered glass and sent the ED staff, patients, and waiting gang members scattering for cover. Although none of the ED staff or patients sustained any physical t r a u m a , the patient's girlfriend was i n j u r e d by flying shards of glass. She sustained several minor facial lacerations, which were repaired. No one else in the waiting area was injured. The entire ED staff remains psychologically traumatized from the experience, and several members refuse to work night shifts out of fear for their safety. CASE
2
Patient l , a 23-year-old man, was brought to the ED by p a r a medics after being shot at close range by an "unknown" assailant. On arrival he had stable vital signs. Physical examination revealed a through-and-through gunshot wound of the left u p p e r extremity and an entrance wound to the left chest. The chest wound was superficial with a palpable foreign body n e a r the wound. His initial chest r a d i o g r a p h was normal. Neurovascular examination of the left u p p e r extremity was intact. Twenty minutes later the paramedics arrived with Patient 2, a 17-year-old man with a superficial gunshot wound to the back. While being t r a n s f e r r e d to a guruey for evaluation, Patient 2 became angry and hostile, demanding to be moved away from Patient 1. Patient 2 stated that Patient 1 was the individual who h a d shot him. To prevent f u r t h e r violence, the patients were quickly separated and hospital security was called to help control the scene (including the waiting area and the hospital perimeter). It became evident that the two patients were rival gang members who had been involved in the same gang-related shootout. CASE
3
A hospitalized 27-year-old man who h a d been shot in gangrelated activity was visited by several of his fellow gang members. At the same time, another patient who had injuries caused by gang violence was undergoing evaluation by a surgical team. She also had several nonfamily visitors. The two groups of visitors recognized each other as rival
OCTOBER 1992 21:18 ANNALSOF EMERGENCYMEDICINE
gang members and challenged each other openly within the hospital. Initially, there was no gunfire, but after the second shouting matcb¢ hand signs were flashed and shooting erupted within the hospital stairwell. A gang member was shot in the face. Hospital security was not notified until shots were fired. Once called, security quickly a p p r e h e n d e d the gang member responsible for the shooting. His arrest occurred on the hospital grounds while he attempted to flee. The i n j u r e d gang member was immediately taken to the ED for evaluation and treatment. CASE
4
A nurse on a surgical ward noticed six gang members visiting a hospitalized fellow gang member. This identification was based solely on her awareness of gang attire. Believing she saw a weapon and realizing the potential for violence, she alerted security. Security responded immediately and the resultant search yielded a fully loaded, bullet-in-chamber, semi-automatic weapon partially hidden in a waistband beneath baggy gang apparel. There were no injuries associated with this incident. BlSCUSSlON
As gang violence increases across the country, health care providers have become vulnerable to injury and death secondary to in-hospital gang-related incidents. Cases 1 and 3 show what can h a p p e n when there is a lack of awareness of gangs in the hospital setting and the violence that may result. Cases 2 and 4 provide contrast with heightened awareness and early involvement of hospital security. To safeguard health care providers, patients, and visitors, we recommend the development of guidelines for the prevention of this type of violence. The guidelines we propose begin in the prehospital care setting and continue throughout the patient's hospital course. Prehospital Care Guidelines In areas in which gang activity is high we recommend the following measures. 3 1. Education of prchospital care personnel about gangs and gang violence should include the root causes of gang formation, effects of gang violence on the community, recognition and identification of local gangs, the nature of gang violence, and the prevention of gang-related trauma. Recognition and awareness of local street gangs is i m p o r t a n t if prehospital care personnel are to know when they may be in danger. 2. Safety of prehospital care personnel should be a high priority. Emergency medicine technicians and paramedics should be advised not to enter a combat zone until the police have secured the area. (Prehospital care response time may be less than police response time.) 3. F l a k jackets (bulletproof vests) should be worn or be readily available as s t a n d a r d equipment for prehospital care personnel. 4. Whenever a patient is t r a n s p o r t e d for a suspected gang-related i n j u r y or is a gang member (this may be more
1292/ 165
GANG VIOLENCE Hutson, Anglin & Mallon
a p p a r e n t at the scene J. this information must be communicated to the receiving ED staff. 5. If known rival gang members have injuries, they should when possible be t r a n s p o r t e d to different hospitals. If this is not practical, the receiving ED must be alerted.
Emergency Department Guidelines 1. On arrival of known or suspected gang members, hospital security and local law enforcement should become involved (including surveillance of the waiting area and hospital perimeter). 2. As p a r t of the p r i m a r y survey, the patient should be disrobed, with attention to the possibility of concealed weapons. 3. ED staff, like paramedics, must be educated about gangs and gang violence. Recognition of local gangs is particularly important and may be possible by 4-5 tattoos: "colors" teg, blue for Crips, red for Bloods); typical clothing (baggy split seam pants, Pendleton plaid shirts and d a r k athletic team jackets); h a n d signs; accessories (eg, sneakers, caps, bandannas); evidence of p r i o r m a j o r t r a u m a (eg, healed exploratory laparotomy, thoracotomy, thoracostomy scars). 4. ED staff should seek a history of gang involvement from the patient in a nonjudgmental fashion. 5. It is especially i m p o r t a n t not to challenge or disrespect patients who are gang members. In gang culture this type of attitude often results in physical confrontation. 6. While in the ED, access to the patient should be limited. Preferably, the only visitors should be the patient's parents. Other relatives and friends should be denied access to the patient. They may be informed of the patient's progress with periodic updates by the medical staff. 7. On admission, all gang members should receive a " J o h n or Jane Doe" status. This is to protect their identity and prevent them from being f u r t h e r i n j u r e d by rival gang members while hospitalized. 8. Hospital security should be available 24 hours a day and should be prominent whenever gang members are present in the ED. Security personnel should also be educated with regard to local gangs. 9. Community activists who have experience with gangs can act as liaisons between gang members, the ED, and rival gang members. These liaisons should be involved whenever possible to help decompress any hostility that may arise. 10.All EDs should develop specific evacuation plans to enact when extreme violence erupts within the department.
3. All hospital personnel exposed to in-hospital gang violence in the hospital setting should be debriefed, and the need for further counseling should be addressed. 4. Emergency physicians, t r a u m a surgeons, nurses, and other health care providers who work with gang members should become involved with injury prevention programs in their communities. SUMMARY
Gang membership is increasing, and the violence associated with gangs is escalating. As gang members present to the ED, the violence of their subculture often follows them. We suggest that these guidelines can protect health care providers, patients, and visitors from i n j u r y caused by gang violence in the hospital setting. Emphasis on awareness, identification, and early involvement of hospital security and law enforcement is crucial. To u n d e r s t a n d gangs a n d gang violence, educational programs for health care providers (and others) are strongly recommended. Education regarding the root causes of gang formation may aid the health care p r o v i d e r in maintaining a nonjudgmental a p p r o a c h to these patients. As long as street gangs continue to exist, health care providers must provide compassionate care while minimizing their own risk of injury. REFERENCES 1. Los Angeles CountySheriff's Department Gang Related Homicide Report 1990- 1991.
2. Spergel IA: Youth gangs: Continuity and change, in Morris N, Tanry M (eds): Crime and Justice: An Annual Review of Research. Chicago, University of Chicago Press, 1990, vo112, p 171-275. 3. Meade DM, Relf RH: When colors kill. EmergMed Serv1992;21:20-26. 4. Lyman MD: Gangland. Springfield, Illinois, Charles C Thomas, 1989, p 100. 5. Jackson RK, McBride WD: Understanding Street Gangs. PlaeerviNe,California, Custom Publishing Co, 1991, p 34. Address for reprints: H Range Hutson, MD Los Angeles County/University of Southern California Medical Center Department of EmergencyMedicine Room 1011 1200 North State Street Los Angeles, California 90033
Hespitalwide Guidelines 1. Access and egress to the hospital should be by securitymonitored entrances and exits. EDs and hospitals in some areas should consider the use of metal detectors and bulletproof glass for the protection of health care providers as well as patients and visitors. 2. Hospital security should have close linkage with local law enforcement, especially the.gang control units.
1B6/1293
ANNALS OF EMERGENCY MEDICINE 21:10 OCTOBER1992