Prisoners, guns can be deadly combination in the emergency room
Experts recommend prompt action to minimize impact on staff, patients
In recent weeks, two violent episodes involving inmates inside EDs have left managers wondering if they should take special precautions when they know a prisoner is coming to their department. Also, when violence does occur, how do you counsel the patients, staff, and visitors who may have witnessed the event? And how do you deal with the inevitable media attention?
Consider these recent events:
• On the evening of Sept. 29, 2005, a police DUI suspect was brought in handcuffs to the triage room at the St. Mary Medical Center ED in Langhorne, PA, accompanied by two police officers. The cuffs were removed so hospital personnel could draw blood from the suspect’s arm for the test to determine if he was driving under the influence of alcohol.
He was then taken to a bathroom to give urine samples, which one of the two officers collected. The previously calm and cooperative suspect then struggled with the officer and grabbed his gun. He apparently gained control of the officer’s gun, and shot both officers and one ED technician.
One of the police officers subsequently died. The other police officer and the technician were in good condition. They were treated in the ED and subsequently released. The suspect, who had dropped his gun once it stopped firing, fled the hospital in the direction of the parking garage, where he was apprehended. He also was treated and ultimately released into police custody.
• On Sept. 14, 2005, a prisoner being treated in the ED at Grady Memorial Hospital in Atlanta wrestled a gun away from a Fulton County (GA) sheriff’s deputy. Shortly thereafter, a second deputy shot the inmate in the shoulder. While no one else was hurt, local media reports said the gunshot sent some patients running outside the ED’s waiting area.
"Obviously, a number of people saw the event," says Leon Haley, MD, MHSA, chief of emergency medicine at Grady Health System, who happened to be on duty that night. "Someone screamed on the [intercom system] overhead and called for security backup, but the other officer shot the prisoner." After the shooting, the patient was cared for in the ED, says Haley. He was admitted for observation and eventually discharged back to the deputies.
Immediately after the event at Grady, "We essentially shut down the ED and put ourselves on diversion as much as possible," says Haley. "During the situation, the main areas in the ED were cleared of patients. We tried to put them behind closed doors."
Debriefing team send to help staff
When the incident was over, Grady’s crisis intervention team — a group of psychiatrists and psychiatric counselors — was sent to debrief with the staff and offer help to anyone else who wanted it.
"Visitation was shut down to allow staff and patients the opportunity to regroup," adds Haley. In addition, he notes, "the area where the incident occurred was now a crime scene, which meant we didn’t want patients, staff, or visitors contaminating the scene." After a short time, visitation was allowed again.
Staff was the primary concern of the debriefing team, says Haley. Individuals who felt traumatized by the event were told they could go home. "We did not specifically ask visitors and patients if they were traumatized and if we could talk to them," he adds. "Patients were asked how they were feeling, and we were able to counsel them if they asked." After talking to staff, the intervention team members went to the waiting area to make themselves available to patients or family.
John L. Hick, MD, medical director for emergency preparedness at Hennepin County Medical Center in Minneapolis, agrees that the mental health of the staff should take priority. Years ago, a shooting involving a prisoner occurred at Hennepin County, although it didn’t involve the ED.
"If gunfire goes off, there is definitely a psychological impact," Hick says. "You have to get on top of that right away." Meet the psychological support and crisis intervention needs of your staff first and then the patients, he suggests. "Tell them what did and did not happen," Hick says. "Ease their fears."
In terms of the media, Haley advises, "The best thing to do is to address the incident right up front — as soon as possible after the prisoner is apprehended. Hopefully, this will mitigate circumstantial rumors and innuendo." During this particular incident, he says, the CEO came to the hospital and was the spokesperson.
Haley and other ED managers note that certain precautions are taken when prisoners are in the ED. However, they don’t always have a warning they are about to receive such a patient, he says.
Within the confines of the ED, behind a locked door, there is a "mini-jail," Haley says. "If the patient is stable, they are brought through the jail door, which has a separate entrance," he reports. "Once they are cleared, they are brought to the ED to be triaged."
Of course, the prisoners are escorted by officers, Haley says. In the ED setting, it is to be a one-to-one [prisoner-to-guard] situation," he says.
At Norman (OK) Regional Hospital, "any time law enforcement officers bring in prisoners, they bring them in through the ambulance entry, and they are taken directly to a room, says Joan Greenleaf, RN, director of the ED. "The officer who brings the patient in stays with them at all times," she says.
Norman recently had its own incident, although it did not directly affect the ED.
According to local media reports, an Oklahoma City police officer shot and killed a robbery suspect as he fled from the hospital and attempted to steal a car. He reportedly had been in custody of officers at the hospital on charges involving a series of robberies, and he checked into the facility to be treated for numerous stab wounds. However, a hospital spokesperson said he was never actually in the ED and simply fled through its entrance before he was shot.
The hospital would not comment on the incident. However, in terms of general policy, Greenleaf notes that "when we know we will have a prisoner, we alert our own security department so they are on standby and aware." Members of the security staff don’t carry guns, she says, but they have nonlethal weapons and extensive training on how to restrain violent individuals.
An unusual situation
As potentially serious as these incidents are, having a prisoner with a gun in your ED is a very rare occurrence, says Hick. "My feeling is that prisoners are actually among the safest patients we deal with," he says.
That’s because, in most cases, they’re not armed, says Hick. However, as these recent incidents indicate, prisoners can, and do, obtain weapons. Also, mentally disturbed patients can, and sometimes do, have weapons. "We had a guy recently who was fairly up’ on something," Hick recalls. "We said, Are you feeling OK?’ He said, I’m going to kill a lot of people.’ We said, Do you have a plan?’ It turns out that in his bag he had a semi-automatic he had converted to an automatic weapon." Hospital policy for such situations is to confiscate weapons and call the police.
Because very few hospitals have armed security staff, and most don’t use metal detectors, that "one-in-a-million" armed prisoner does present a big problem, Hicks concedes. "The availability of Tasers [nonlethal stun devices] or other less-than-lethal methods for your security staff may be a good idea," he advises.
The incident at Grady certainly has caused Haley and his staff to take a hard look at their security procedures. "One of the things we’re looking at is whether or not the officers in direct supervision of the patient should be armed," he says. "Our own security is typically unarmed, and we may have to think about alternative means of defense."
A hospital can tell an officer not to bring their guns in if they are there to support patient care, Haley explains. "My understanding is that there are examples around the country where this is being enforced."
A prisoner is unlikely to have a weapon of his own, Haley notes, and because he is generally chained, it is unlikely he would be able to do anything with it. "In our ED, we generally have security officers at the two main entrances who man metal detectors," he notes. "So in this case, the incident would not have happened if the police officer had not been armed."
As for St. Mary, the hospital has since identified a designated "public safety room" specifically for patients in police custody, which is separate from other ED care. The room, which was based on consultations with local law enforcement officials, is approximately 12 x 16 feet and is located just inside the ambulance entrance. The room has secure access to an ED restroom that has been fitted with an autolock mechanism. It is equipped with a security bench, an intercom system and call button, and has blood draw kits readily available. The room was ready for use in October.
Sources
For more information on how to deal with prisoners in the ED, contact:
- Joan Greenleaf, RN, ED Director, Norman Regional Hospital, 901 N. Porter, Norman, OK 73071. Phone: (405) 307-1000.
- Leon L. Haley Jr., MD, MHSA, Chief of Emergency Medicine, Vice Chairman of Clinical Affairs, Grady Health System, Atlanta; Associate Professor, Department of Emergency Medicine, Emory University, Atlanta. Phone: (404) 616-6419. E-mail: [email protected].
- John L. Hick, MD, Medical Director, Emergency Preparedness, Hennepin County Medical Center, 701 Park Ave. S., Minneapolis, MN 55415. Phone: (612) 873-3020. Fax: (612) 904-4241. E-mail: [email protected].
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