Cops & Docs^SM

Working Handcuff-in-Glove to Reduce Violence

Colleen McCue, Ph.D.^1,2, Robyn L. Diehl, M.S.¹,

Rao Ivatury, M.D.², Jerry A. Oliver, M.P.A.

¹Crime Analysis Unit, Richmond Police Department

²Department of Surgery, MCV Hospitals at the Virginia Commonwealth University

³Chief of Police, Richmond Police Department

Richmond , VA

What is it?

Violent crime is not just a law enforcement problem or just a health care problem.  It is a multidisciplinary problem that requires multidisciplinary solutions.  In other words, the only meaningful, long-lasting solutions to the problem of violent crime will come from the cooperation of, and collaboration between all of the professions directly impacted by the problem.  The Cops & Docs^SM program described below is a novel approach to addressing the entire cycle of violence by combining the strengths and resources of the various and diverse professional groups currently responding to the problem.  The examples provided below should begin to highlight the wide array of unique tools available to the death investigator through nontraditional partnerships with their health care colleagues.  Victim interviews, forensic evidence and meaningful narcotics surveillance data, common sources of conflict between law enforcement and health care providers, can become more readily available to the death investigator when partnerships are formed with health care providers.  By working “handcuff-in-glove” to reduce violent crime, “cops” and “docs” can cross the traditional professional boundaries and work together to identify overlapping or even conflicting programming, while developing creative solutions to common problems.  Ultimately, each group is able to do their own job better, while helping their colleagues on the other side of the crime scene tape achieve success, as well.

How can it help?

A good working relationship between health care and law enforcement professionals can help each group do their own job better.  A few examples of how effective these health care and law enforcement partnerships can be are described below.  It is important to remember, though, that these are just examples employed to illustrate the potential of the Cops & Docs^SM program.  The type of crime prevalent in a community, as well as the availability of personnel resources and interest should guide implementation.  We have found that the opportunity for collaboration and cooperation will be unique to each community, the type of crime encountered, and the partners involved.

Interviews

After a violent assault, time frequently is of the essence, either because a victim is dying, and/or because a violent suspect remains at large.  In our experience, the time to develop the relationships necessary to interview key victims or witnesses is prior to when they are needed, not when they are being wheeled into the operating room.  A good working relationship with the health care providers can provide the opportunity for law enforcement to convey the importance of interviews in the hospital setting, while reducing any animosity or concerns about potential confidentiality issues or conflict of interest.  In turn, health care providers can work with law enforcement to determine the situations and times when law enforcement professionals can approach a victim for an interview, without compromising any medical care or treatment issues.  Health care providers who understand the importance of hospital interviews, particularly to the victim, may have a unique opportunity to counsel patients regarding their participation in the investigation.  These health care providers also can provide specific law enforcement contact information should a victim wish to speak with the detective assigned to his or her case.

In addition, there are certain points along the hospital continuum where a patient may be more or less open to discussing the events precipitating the injury as well as the assault itself.  A good working relationship with hospital personnel can make the process of gaining access to patients for interview purposes easier for all involved, including law enforcement, health care providers, and most importantly the patient.  There also may be times where a patient may be more candid with the health care providers regarding the cause of their injury, or involvement in other risk factors.  Again, health care providers who understand the importance of hospital interviews and witness cooperation to identifying and apprehending the suspect make better partners to law enforcement and patient advocates.

Cross training

Cross training is not only the most visible activity of the Cops & Docs^SM program, but perhaps the most valuable.  Cross training is where the health care providers begin to get an understanding of the unique duties, obligations, and responsibilities associated with a career in law enforcement; and when law enforcement can gain an understanding of the role that health care providers play by “walking a mile in their scrubs.”  In many cross training scenarios, however, it is difficult to determine who are the teachers and who are the students as we have found that the opportunity to view one’s own job through the eyes of another can be both enlightening and invigorating.

As discussed under “interviews” above, the opportunity to establish a good working relationship with the health care professionals can be essential to law enforcement, and the time to establish these relationships is before they are needed.  Cross training provides a great opportunity for all involved to get to know each other, exchange business cards, and discuss the responsibilities and obligations unique to their profession in an informal, educational situation, rather than the high stress environment frequently associated with a critically injured victim or witness.  Because law enforcement professionals frequently do their work in the hospital environment, familiarizing them with the hospital ahead of time and defining their role in that setting minimizes their potential interference in health care while ensuring that their investigative needs will be met.  It also provides an opportunity to establish ground rules and boundaries in a nonconfrontational setting, particularly where patient confidentiality is concerned.  Frequently, many of these issues can be resolved through creative problem solving that uses input from all of the professions involved.  This ultimately helps everyone do his or her own job better.

Drug surveillance

Illegal drug use impacts both health care and law enforcement professionals as individuals seek medical attention for substance use and drug overdoses, while law enforcement professionals are tasked with reducing both the supply and demand for illegal drugs.  Unfortunately, law enforcement and health care surveillance data alone frequently are incomplete.  In other words, while each professional group may see an important piece of the illegal drug world, neither has access to the entire universe of narcotics data.  By combining data resources, however, law enforcement and health care providers can significantly enhance their drug surveillance capabilities, which allows them to monitor and track local trends more efficiently.  Sharing local drug surveillance data also may help investigators other than those assigned specifically to narcotics.  Given the strong relationship between illegal drug markets and violent crime, detectives responsible for investigating homicide and violent crimes also can benefit from the enhanced narcotics intelligence that multidisciplinary data sharing would support.

New or emerging drug markets may come to the attention of health care providers before traditional, law enforcement narcotics surveillance identifies them.  Hospital personnel may note changes in substance use trends and patterns earlier than the criminal justice community because individuals may get into trouble medically with new drugs due to inexperience.  On the other hand, information pertaining to drug seizures or other drug intelligence possesses great utility to the medical community.  Intelligence data indicating the arrival of a new drug in the community can suggest either that someone may be trying to introduce a new drug to the community, or that a local taste has developed.  Law enforcement can save lives by giving health care providers the critical narcotics intelligence information they may need to correctly identify a drug and provide necessary medical treatment, particularly when time is of the essence.  In turn, knowledge of current drug trends and patterns can result in better narcotics surveillance for law enforcement.  If the health care providers know what to look for, they can better document it and provide more meaningful data to law enforcement.  Ultimately, each group is then able to respond to the problems associated with illegal drugs and drug markets more efficiently.

Security issues

Death investigators understand that most nonlethal violence represents either a poorly planned or incomplete homicide.  Unfortunately, many health care providers do not.  Therefore, the death investigator, in partnership with other violent crimes detectives, can provide a valuable educational service to hospital personnel while protecting victims and/or witnesses in the hospital setting.  Again, it is not unusual for retaliatory strikes or second attempts to either be planned, or actually occur within hospital walls.  Therefore, informal discussions or actual cross training on the cycle of violence and victim risk factors (e.g., substance use) can be valuable information that law enforcement professionals can share with their health care colleagues.

Forensic evidence

When a patient dies from an assault or a drug overdose, the hospital may become a crime scene.  Unfortunately, this is not an area in which doctors or nurses traditionally receive training.  While it is inappropriate for health care providers to serve in a law enforcement capacity, the medical personnel at our Trauma Center have acquired an increased sensitivity to the importance of forensic evidence, and their potential role in preserving and collecting it.  Through cross training and education, health care providers now understand that the preservation and collection of forensic evidence does not need to interfere with life saving efforts.  Rather, it actually may play a significant role in promoting a healthy community by increasing the likelihood that violent offenders will be identified, apprehended and successfully prosecuted.  Health care providers, local law enforcement, and criminal justice professionals currently are working to establish formal protocols to ensure these functions.  Members of the Cops & Docs^SM working group have been key participants in this endeavor.

How Does it Work?

Cost

The Cops & Docs^SM program required little or no start-up costs no start-up costs, relying exclusively on in-kind personnel contributions from the participating organizations and the creative utilization of existing resources.  For example, all cross training has been conducted by volunteer mentors from the participating organizations.  These unique features afford any community, regardless of size or economic resources, the opportunity to establish a similar program with little or no initial cost.

Membership

Our working group is comprised of a variety of individuals representing a diverse array of professional fields.  The law enforcement, criminal justice, and health care domains are represented.  These are only suggestions, however.  Interest and availability will determine the partners in each community.  For example, we are currently working with the Chaplain’s Academy run through our Department in an effort to recruit clergy to respond to homicides and other scenes of violence.

A word of caution.  Our experience has underscored the need to choose “charter” members wisely.  As described above, the Cops & Docs^SM program requires work outside traditional professional boundaries.  Therefore, it may be wise, at least initially, to involve fewer, very committed active members than a large group of individuals who may be either unwilling or unable to work outside their chosen profession.

Cross training

In our experience, the use of a “facilitator” can be an asset to any cross training exercise.  This individual should be someone who can take a global view of both fields, and highlight similarities and common points of interest during the training.  They also should posses the ability to guide the participants in creative problem solving when issues arise during the training exercise.  For example, this can be as simple as suggesting that the participants exchange business cards in an effort to ensure that each individual leaves the exercise with at least one point of contact who works in, or is familiar with the other setting.  This individual can then be called on in the future to answer questions or provide assistance from the “inside,” when the need arises.  It is also important to debrief the participants in an effort to ensure that the experience was positive and educational, and to identify and correct any issues or misconceptions before they return to their own workplace. 

Hospital

The cross training exercise begins with a brief tour of the Emergency Department (ED), with an emphasis on the Trauma Service as this is the part of the ED most frequently encountered by law enforcement professionals.  Small groups work best because all of the participants have an opportunity to ask questions and interact directly with the health care providers.  During the tour, the health care providers offer a general survey of the ED, highlighting areas of general interest.  Again, because law enforcement professionals frequently find themselves doing their job in the hospital environment, the cross training offers a unique opportunity for both law enforcement and the health care providers to specifically outline their expectations, needs and requirements.  For law enforcement, the need to access the patient for statements or dying declarations is generally the most important issue.  For the health care providers, saving lives and maintaining patient confidentiality take precedence.  In our experience, these potentially competing issues are best resolved during the relative calm of a cross training experience, rather than during a frantic effort to save a life.  We also have found that sometimes, the simplest solutions are the best.  For example, during the tour physicians can show law enforcement exactly where to stand in the ED so that they can make their presence known and monitor progress, without interfering with any ongoing medical efforts. 

Law enforcement professionals also have been taken on multidisciplinary hospital rounds.  In contrast to medical rounds, these rounds are open to a variety of professionals involved in patient care.  We have found that law enforcement input can be helpful in terms of identifying the circumstances preceding an injury, as well as providing valuable information regarding lifestyle and home life that can be an asset to effective discharge planning.  In addition, law enforcement professionals may be more familiar with situations unique to the community (e.g., cycles of revenge/retaliation, neighborhood beefs, etc.) that may have an impact on the patient’s ongoing health and safety, particularly when they are discharged.  It is critical to remember, though, that the information flow needs to be one way, coming in from law enforcement but not going out.  Patient confidentiality must be respected at all times.  Confidential medical information (e.g., drug screens), and any information pertaining to private conversations between the patient and any health care provider or hospital representative must remain confidential.

On the other hand, our experience has demonstrated that a good working relationship between health care and law enforcement professionals can have unintended benefits.  For example, patients may be more likely to share specific information pertaining to an assault or a suspect within the context of the hospital or health care setting.  While it would be both unethical and illegal to use or violate this trust, health care providers may have the opportunity to suggest that the victim share this information with law enforcement.  In anticipation of these opportunities, all cross-training participants are encouraged to exchange business cards and contact information so that health care providers encountering these situations can offer specific contact information, rather than referring the victim to the often cumbersome process of going through a central dispatch system.  This activity not only empowers the victims, but it increases the likelihood that a violent offender will be taken off the street.  Given the high rate of re-injury for victims of violent crime, this may represent a unique, multidisciplinary form of crime prevention.

Law enforcement

We have found that “matching” based on approximate “rank” works well, with hospital administrators or “chiefs” receiving a global survey of the community or areas of interest from command staff, while the hospital “line staff” seem to benefit from a tour with patrol.  If possible, additional matching based on assignment or specialty can enhance the ride-along experience for both the participant and the guide.  Many health care providers have limited daily exposure to the communities providing most of their work.  Therefore, a brief survey of the drug hot spots, or other locations associated with increased calls for service can be very educational.  Again, the use of an educated facilitator can be very helpful in highlighting features of the community that may be commonplace to law enforcement.  For example, open air drug markets and the opportunity to see spinal cord injury victims selling drugs from their wheelchairs made a strong impression on the trauma surgeons in our community.  As with all ride along programs, however, it is essential to remember that safety of the civilian participants is paramount.

Additional training

Additional training can be provided on an ad hoc basis.  For example, individuals from the Emergency Department responded to a request for information pertaining to “date rape” drugs.  During this informal training, an emergency department physician and a pharmacist presented information on date rape drugs to the violent crimes detectives.  The detectives were able to ask specific questions regarding signs and symptoms that would help them distinguish between intentional misuse, an unfounded claim, or a case where the drug was slipped into the drink of an unsuspecting victim.  Additional, informal training has been provided on “club drugs” (e.g., ecstasy, GHB), and the potentially serious medical consequences that can be associated with adulterated drugs, or overdoses.  Again, it is important to note that the mentors frequently become students.  In both of these training situations, the nature of the questions and informal observations made by the law enforcement professionals represented a unique educational experience for the doctors that enhanced their ability to respond to patients with substance use issues in the future.

Finally, one unique cross training exercise involved the use of the Firearms Training Simulator (FATS).  After an officer had been killed in the line of duty, several questions from the health care providers arose regarding the use of force and body armor.  They were particularly disturbed by the fact that body armor was not mandatory for law enforcement.  The FATS machine was used to demonstrate a variety of law enforcement scenarios where lethal force and body armor may be factors, and to provide the starting point for a discussion of officer safety issues.  The health care providers donned body armor and a full duty belt, and were instructed to utilize cover, if needed, during the exercise.  The law enforcement participants served both as mentors and critics, asking all participants to defend their actions during a short debriefing session after each scenario.  At the conclusion of the exercise, the health care providers had gained added insight and understanding regarding the use of force, and several other officer safety issues.  In addition, the opportunity for law enforcement to serve as mentors to the physicians, coaching them and offering support as they made mistakes, further strengthened the relationship between the two groups.

It is important to note that the cross training protocols and scenarios discussed above are offered only as suggestions.  As demonstrated by the last “use of force/officer safety” scenario, any cross training should be matched to the unique needs and assets of each community, both long-term and situational.  The only hard and fast rules should be the strict protection of patient confidentiality and the assurance of personal safety.

Surveillance data

Health care providers and law enforcement professionals frequently encounter and collect data and information that would be of use to other professionals.  One area of mutual interest is narcotics data.  For the death investigator encountering a suspected overdose, local drug surveillance data, particularly data documenting other recent overdoses in the area, can be an important investigative tool.  Lethal and nonlethal overdoses traditionally come to the attention of a variety of different agencies.  For example, the local police department or sheriff’s office, the hospital emergency department, the medical examiner or coroner’s office, and the local poison control center all may encounter victims of lethal and nonlethal drug overdoses.  Unfortunately, each of these agencies rarely has access to all of the data so the “big picture” may be lost.  Consequently, potential problems with a local market or drug source (e.g., adulterated drugs, changes in purity, etc.) may be missed.  By sharing overdose data, however, each agency has access to complete information, thereby allowing potential problems to be identified early and addressed.

We have found that narcotics data are relatively easy to collect and analyze, once each agency has committed to providing the data.  Over time, the participation rate in our group has increased to nearly one hundred percent.  Poison control center data can be a valuable resource for collecting trend data and establishing baseline use rates in a community.  Individual providers or agencies, on the other hand, frequently provide very good, unique single case or incident reports.  These data can be extremely important in identifying a rapidly emerging trend such as a series of overdoses.  In turn, all agencies in the area, regardless of whether they are able or willing to contribute data, have access to the local trends documented through Cops & Docs^SM surveillance.  We find that this approach increases participation, while providing data to agencies that may need it but are unable to provide anything either due to unavailability of resources or data.  Data are gathered and disseminated through a variety of sources (e.g., existing databases, e-mail, telephone), and we currently are establishing a single e-mail source to receive information and send briefs.  Finally, crime analysts can survey national, historical and geographic information and trends, providing relevant information to the program participants through the form of briefs and reports.

Again, it is essential to emphasize that patient confidentiality and operational integrity must be maintained at all times.  As helpful as it would be to have access to all patient data, inappropriate disclosure of confidential medical information, even informal discussion, has serious medical and legal implications, and must be strictly prohibited.  Protection of patient confidentiality, ongoing operations and confidential informants is critical.  All information shared must be sufficiently disguised or in aggregate form.  In other words, no one should be able to identify any individual based on any data provided.

Summary

In summary, violent crime is not just a law enforcement problem or just a health care problem.  It is a problem that belongs to all professionals called to respond to the epidemic of violence in a community.  Because violence is a problem that belongs to a diverse array of professionals, the only meaningful and long-lasting solutions will come from novel partnerships involving all of the professions directly impacted by the problem.  By working “handcuff-in-glove” to reduce violent crime, death investigators, narcotics detectives, doctors, nurses, EMTs, lawyers, funeral directors and other concerned professionals can work together to identify and correct overlapping or even conflicting programming, while capitalizing on the unique strengths of each profession and developing creative, multidisciplinary solutions.  By joining together to work on a common problem, the various professional groups represented in the Cops & Docs^SM working group have made an effort to address the entire cycle of violence.  Our experience has demonstrated that when law enforcement professionals come out from behind the crime scene tape, and health care providers step outside the trauma bay to work together, they can achieve the common goal of a healthier environment through increased public safety.

The Center for the Study and Prevention of Youth Violence
1200 East Broad Street P.O. Box 980439 Richmond, VA 23298 
Tel: 804.628.SAFE Fax: 804.628.2164 
Robert Cohen, Ph.D. 
Aleta Meyer, Ph.D.