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of law enforcement officers in the ICU could have
on the other pediatric patients and families who are
there for critical care.
Discussion of options
With the patient’s tenuous hemodynamic status
in mind, the pediatric surgeon is presented with a
number of ethical concerns and has four potential
options:
•Perform the initial operation, and then transfer the
patient to the adjacent adult hospital (where additional
protocols regarding police interaction are more commonly used) after he is stabilized
•Perform all necessary operations and postoperative care
at the children’s hospital and allow the officers to remain
at the patient’s bedside
•Express concern regarding the officers’ role and request
an ethics consult
•Ask the officers to wait in the designated waiting area
away from the OR and away from the patient’s bedside
until the patient has been declared clinically stable, citing
the best interests of the patient, in particular the patient’s
safety, the need for timely surgical and medical intervention, and the patient’s health information privacy
Option 1: Perform the initial operation, and then transfer
the patient to the adjacent adult hospital (where additional protocols regarding police interaction are more
commonly used) after he is stabilized
This may be an appealing option, especially given the
patient’s age in this scenario. Gunshot victims are often
brought to the adult ED simply because of proxim-
ity or because the exact age of the patient is initially
unknown. Adult hospitals and EDs may have a more
streamlined process for caring for victims of violence,
as this problem is more common in the adult popula-
tion. Adult hospitals and EDs often work closely with
local police departments and may also have an in-house
security.
However, the prevalence of youth violence argues
against the feasibility of this option as a routine solution. Youth violence is an important health care issue
across the U. S. Injured victims and perpetrators of violence are frequently seen in pediatric EDs. Homicide is
the third leading cause of death for young people ages
15− 24 years old. 2 In 2012, 4,787 young people were killed
by homicide, which is equivalent to approximately 13
cases per day, and more than 599,000 young people ages
10 to 24 were treated in U.S. EDs for physical assault
injuries. 2 Youth homicides and assault-related injuries
result in $16 billion in combined medical and work loss
costs every year. 2 Violent injuries are often repeated;
among youths who suffer a penetrating injury, nearly
45 percent are victims of violence again in the five years
following the first injury, and 20 percent will die in
the same time frame. 3, 4 Given the high rate of violent
trauma, especially in urban settings, ideally pediatric
EDs and trauma bays should be equipped to care for
patients who arrive with police accompaniment.
Initiating a patient’s care in one hospital and then
transferring the patient to another hospital creates its
own set of both practical and ethical complications.
Electronic or non-electronic health record communication barriers often exist between hospitals even
when they are physically nearby or associated with one
another. These communications issues become compounded and even dangerous in situations where the
patient requires multiple operations or complex ICU
care. Fracturing patient care in this way can be detrimental to the patient, possibly resulting in avoidable
medical errors. Transfer from a pediatric facility to an
adult facility can also result in poorer outcomes if the
adult facility lacks up-to-date pediatric algorithms. For
example, pediatric trauma literature supports significantly less invasive surgical management for abdominal
trauma with splenic injury than is recommended to
treat a similar situation in an adult with abdominal
trauma.
Moving the patient to a different surgical team also
hinders communication between the surgeon and
the patient. When dealing with critically ill patients,
