Violence: Recognition, Management and Prevention

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1 doi: /s (03) The Journal of Emergency Medicine, Vol. 25, No. 2, pp , 2003 Copyright 2003 Elsevier Inc. Printed in the USA. All rights reserved /03 $ see front matter Violence: Recognition, Management and Prevention INJURY PATTERNS RELATED TO USE OF LESS-LETHAL WEAPONS DURING A PERIOD OF CIVIL UNREST Joe Suyama, MD, Peter D. Panagos, MD, Matthew D. Sztajnkrycer, MD, PhD, Denis J. FitzGerald, MD, and Dawn Barnes, BS Department of Emergency Medicine, University of Cincinnati Medical Center, Cincinnati, Ohio Reprint Address: Joe Suyama, MD, Department of Emergency Medicine, University of Pittsburgh, 269 Quantum One Building, 2 Hot Metal Bridge Street, Pittsburgh, PA e Abstract This case series documents injury patterns related to beanbag and other less-lethal (LL) weapons during a period of civil unrest in a major U.S. city. A retrospective review of injuries related to LL weapons usage presenting to an urban Emergency Department (ED) from April 10, 2001 to April 18, 2001 was performed. Patients under 18 years of age and those without signed consent to treat were excluded. Twenty-seven patients were identified. Two were excluded due to lack of signed consent for treatment. Mean age was years; 76% of patients were male. Significant morbidity was found in 7 (28%) cases with no fatalities. Three (12%) individuals, with the diagnoses of pulmonary contusion, liver laceration, and Achilles tendon rupture, required admission. Two (8%) individuals had delayed complications of pneumonia and post-concussive syndrome. Reports of injury patterns associated with beanbag munitions in the medical literature are limited. Physicians should be aware of the injuries and delayed sequelae associated with their use Elsevier Inc. e Keywords less lethal; beanbag; civil unrest; injury pattern INTRODUCTION Less-lethal (LL) technology refers to the broad category of devices designed to incapacitate individuals without lethal injury (1). This technology includes a number of specialty impact munitions known to the general public as plastic bullets, rubber bullets and beanbag rounds. The term less-lethal reflects the recognized potential for serious injury even when these devices are properly deployed (2). For this reason, LL weapons are regarded within the police use-of-force continuum immediately below the use of deadly force. In civil unrest situations, the use of LL technology is considered preferable to alternative techniques for violent and potentially hazardous crowd dispersal. Recent international episodes have spotlighted the widespread use of LL weapons to control civil unrest. During the 1999 World Trade Organization Meeting in Seattle, police deployed pepper gas and rubber bullets to manage violent protestors among the 35,000 individuals attempting to disrupt the conference. In Quebec City, security forces for the 2001 Summit of the Americas mobilized approximately 6,000 police officers and 1,200 military personnel to control 30,000 protestors who marched through Quebec City (3). During the ensuing demonstrations, 320 plastic bullets and 1700 tear-gas canisters were fired by the Surete du Quebec, one of the police forces present at the summit (4). In Tucson, police were equipped with LL weapons to help disperse expected crowds after the 2001 NCAA Championship Game (5). More than 300 rounds of LL ammunition were fired during riots after the game. A subsequent inquiry RECEIVED: 21 February 2001; FINAL SUBMISSION RECEIVED: 11 September 2002; ACCEPTED: 15 October

2 220 J. Suyama et al. Figure 1. Beanbag rounds. into Special Response Plan NCAA Tournament 2001 documented the presence of three police marksmen on the rooftops armed with conventional rifles, in case the LL munitions did not suffice (6). During a period of recent civil unrest in Cincinnati, Ohio, police utilized three main types of impact LL weapons: 1. Square beanbag projectiles fired by shotgun (Figure 1). 2. Round beanbag projectiles with fin-type tails designed for improved in-flight stabilization. 3. Large foam rubber bullets launched from special 40-mm rifles. The purpose of this article is to document the injury patterns related to LL weapon injuries presenting to an urban, tertiary care, Level One Trauma Center that received patients during a state of emergency declared from April 10 17, It is intended to be an objective review of the types of injuries that can result from LL weapons and to serve as a guide to those who may encounter these injuries in their practice. MATERIALS AND METHODS A retrospective chart review of individuals presenting to an urban Emergency Department (ED), The University Hospital (TUH), a Level One Trauma Center, was performed for the period April 10, 2001 to April 18, TUH ED does not routinely accept pediatric patients due to close proximity of a tertiary care, Level One Pediatric Trauma Center. All ED records were reviewed. Discharge or Admit diagnoses were used as an initial screen to determine eligibility for the study. Medical records with diagnoses related to physical injury or pain were subsequently analyzed. Inclusion criteria for the study were: 1. The injury or pain documented was a direct result of a beanbag round or other LL ammunition. 2. The patient was 18 years or older. 3. The patient provided signed consent for treatment. If these criteria were met, the patient was enrolled into the database. The last two inclusion criteria were required by TUH Risk Management Department due to pending civil litigation, not involving TUH, regarding injured parties during the period of civil unrest. TUH Risk Management Department did not allow minors to be included in the database. All patients were recorded by numerical identifiers to maintain patient confidentiality. Demographic and medical information was retrieved from LASTWORD and WEB- VIEW online medical record databases. No patients were contacted for this study. The study was reviewed by the institutional review board (IRB) and found to be exempt from IRB review with Risk Management oversight.

3 Less-Lethal Weapons 221 Table 1. Less-Than-Lethal Weapons Injury Patterns and Disposition # Date Injury Diagnosis Disposition 1 4/10 RB to R shoulder R shoulder contusion Discharged 2 4/10 RB to face Facial laceration Discharged 3 4/10 RB to face Facial lacerations Discharged BB to R LE, abdomen, and chest Multiple contusions Discharged 4 4/10 5A 4/10 RB to head 8 cm lac, no LOC Discharged 6 4/10 RB to lower chest RUQ abd wall contusion Discharged 7 4/10 RB to R LE R Achilles tendon rupture/laceration Admitted 8 4/10 RB to head LOC, stellate laceration 1 2 in Discharged 9A 4/11 BB to L chest Pulmonary contusion, hypoxia Discharged 10 4/11 BB to R shoulder R shoulder contusion Discharged 11 4/11 RB to L chest L chest wall contusion Discharged 12 4/11 BB to back Multiple back contusions Discharged 13 4/11 BB to R LE and abdomen Abdominal wall contusion, L LE contusion Discharged 14 4/11 BB to head Complex forehead laceration Discharged 15 4/11 BB to L hand L 3rd finger laceration Discharged 16 4/12 BB to L LE and groin Foley for inability to void, L LE contusion Discharged 17 4/12 BB to back, L LE, L hand Multiple abrasions Discharged 18 4/12 BB to R abdomen, L buttock, and chest R chest 4 4 cm abrasion, R rectus shealth hematoma, L buttock contusion Discharged 19 4/12 RB to R UE and back Multiple contusions Discharged 9B* 4/12 BB to L chest Pulmonary contusion vs. pneumonia, hypoxia Admitted 20 4/12 RB to L UE, L buttock, and L neck Multiple contusions Discharged 21 4/12 RB to L UE L UE contusion Discharged 22 4/13 BB to abdomen Grade I liver laceration Admitted 23 4/13 BB to L UE L UE contusion Discharged 24 4/16 BB to L buttock Contusion L buttock Discharged 25 4/16 BB to R buttock Contusion R buttock Discharged 5B* 4/18 RB to head Post concussive syndrome Discharged * repeat visit; BB bean-bag; RB rubber bullet; UE upper extremity; LE lower extremity; L left; R right; LOC loss of consciousness; lac laceration; RUQ right upper quadrant; adb abdominal. RESULTS During the study period, a total of 27 individuals were evaluated for LL weapon injuries at TUH ED. Of these, 25 individuals met criteria for entry into the database; 2 individuals were excluded due to lack of signed consent to treat in the ED. No patients were excluded based on age criteria. Two individuals were re-evaluated in the ED after initial discharge, for a total of 27 patient encounters (Table 1).The mean age was years (range years). The majority, 19 of 25 (76%), of patients were male. Injuries per age group were broken down as follows: years old, 14 (56%); years old, 5 (20%); years old, 2 (8%); and 45 years old, 4 (16%). Although eight patients (32%) had more than one injury related to either a single or multiple LL rounds, most (68%) had a single anatomical impact site. The impact sites, reflecting pattern of injury, were designated as extremity, chest, head/neck, abdomen, back/buttock, and groin (Table 2).There was a predilection for extremity injury (36%), and back/buttock and extremity injuries combined comprised the majority of impact sites (55%). A minority of patient encounters, 6 of 27 (24%), involved Emergency Medical Services (EMS) transport directly from the scene (Table 3). Only 2 (7%) patients were transported in police custody. When prehospital time was recorded (25 of 27 patient encounters), the mean elapsed time before ED arrival was h. When considering patients presenting less than 24 h after injury, the mean elapsed time before ED arrival was h (19 patient encounters) compared to h (6 patient encounters) for those presenting 24 h after injury. Of those transported by EMS, the mean elapsed time before arrival was h. No patient that was admitted was transported by EMS. Information regarding type of LL munition used was obtained from the EMS Table 2. Anatomic Impact Sites: Pattern of Injury Site Number of hits (% total) Extremity 13 (36%) Head/neck 6 (17%) Back/buttock 7 (19%) Chest 5 (14%) Abdomen 4 (11%) Groin 1 (3%)

4 222 J. Suyama et al. Table 3. Prehospital Information # EMS Prehospital Time (Hours) Identification Source of LL Weapon Police Custody 1 Yes 1.0 EMS No 2 Yes 0.5 EMS No 3 No 2.0 Patient No 4 No 2.0 Patient No 5A Yes 1.5 EMS No 6 No 1.5 Patient No 7 No 1.0 MD No 8 Yes 2.0 MD No 9A No 1.0 MD No 10 No 24.0 Patient No 11 No 24.0 Patient No 12 Yes 1.0 Patient Yes 13 No 1.0 Patient No 14 No 1.5 MD No 15 No 1.5 Patient No 16 No 2.0 Patient No 17 No 2.0 Patient No 18 No 2.0 Patient Yes 19 No 48.0 Patient No 9B* No N/A MD No 20 No 72.0 Patient No 21 No 24.0 Patient No 22 No 2.0 Patient No 23 Yes 1.5 Patient No 24 No 24.0 Patient No 25 No 2.5 Patient No 5B* No N/A EMS No LL less-lethal; EMS emergency medical services; N/A not available; * repeat visit. provider on three occasions, the patient 18 times, and inferred by the treating physician five times (Table 3). In the ED, patients underwent medical and trauma evaluation, with most receiving plain radiographs or computed tomography (CT) scan. Twelve patients (48%) received plain radiographs and seven patients (28%) received CT scans. CT scans were performed of the head (3), abdomen (3), and chest (1). Nine patients (36%) received no radiographic studies. After evaluation, no wounds were documented to be contaminated with foreign material consistent with LL munition debris. Of the 25 individuals, 23 (92%) were discharged home after initial ED management. Two individuals required repeat evaluation for complications of the LL round injury and one individual was subsequently admitted on the second visit. No fatalities were observed. No patient suffered hemodynamic compromise as a result of a LL munition injury, although one patient did develop hypoxia requiring supplemental oxygen. Beanbag injuries accounted for 61% of all injuries (Table 4). Ninetyone percent of beanbag injuries were contusions or abrasions, compared to 64% of rubber bullet injuries. Rubber bullets were almost four times as likely to cause laceration-type injuries. From this small sample of patients, it Table 4. Bean-bag vs. Rubber Bullet Injury Patterns Bean-bag Round (% total) is noted that beanbag related injuries were more likely to be contusions than lacerations, whereas rubber bullets did not show so large a difference between the two types of injuries. This difference did not reach statistical significance (p 0.064, Fischer s Exact Test, Table 4). Significant morbidity was defined as patients requiring admission, specialty consultation, prolonged work-up or management in the ED, or requiring reevaluation for the same injury within the study period. Significant morbidity was noted in seven cases (28%). Three patients required admission (12%), and one required operative intervention (4%). These seven cases are reviewed in detail in the following section. CASE REPORTS Case 1: Pulmonary Contusion Rubber Bullet (% total) Total injuries Contusion/abrasion 20 (91%) 9 (64%) Laceration 2 (9%) 5 (36%) Significant morbidity 4 (18%) 3 (21%) Admission 2 (9%) 1 (7%) A 35-year-old man with a past medical history significant for non-insulin-dependent diabetes mellitus presented to the TUH ED with a complaint of difficulty breathing after being struck by a beanbag round in the left chest. He originally presented to an outside ED and was noted to be hypoxic with oxygen saturations of 90% on room air. The diagnosis of pulmonary contusion was made and the patient was transferred to TUH ED for specialty trauma evaluation. Vital signs on arrival to the TUH were: blood pressure 134/70 mm Hg, pulse 96 beats/min 1, respiratory rate 18 breaths/min 1, oral temperature 36.1 C (98.1 F), and ambient oxygen saturation of 94%. On physical examination, a left anterior/inferior chest wall contusion in the mid-axillary line was noted. No crepitus or deformities were noted. Breath sounds were present and equal. Chest radiograph demonstrated bullet fragments from a previous gunshot wound, and a left lower lobe consolidation consistent with a pulmonary contusion (Figure 2). After evaluation by the trauma service, the patient was deemed medically stable for discharge home that evening. The patient returned to TUH ED 1 day later with a complaint of increased difficulty breathing, chest pain, and hemoptysis. Vital signs were: blood pressure 127/78 mm Hg, pulse 114

5 Less-Lethal Weapons 223 Figure 2. Chest X-ray showing pulmonary contusion (arrowhead). beats/min 1, respiratory rate 40 breaths/min 1 and shallow, and oral temperature 39.3 C (102.8 F). Oxygen saturation on room air was 96%. Physical examination demonstrated bilateral rales and a normal cardiac examination. White blood cell count was elevated at 16.8 cell/mm 3. He was diagnosed with a pulmonary contusion, possibly complicated by pneumonia, and admitted for intravenous antibiotics and aggressive pulmonary toilet. CT scan of the chest showed complete consolidation of the left lower lobe with air bronchograms and narrowing of the left lower lobe bronchus consistent with an inflammatory process. After 2 days his clinical condition improved, and the patient was discharged on oral antibiotics and analgesics. Case 2: Rectus Sheath Hematoma An otherwise healthy 18-year-old youth presented to TUH ED 2 h after being struck in the right abdomen, left buttock, and left lower chest with beanbag rounds. The patient reported abdominal pain at the site of the right abdominal impact site. On arrival, vital signs were: blood pressure 120/60 mm Hg, pulse 79 beats/min 1, respiratory rate 18 breaths/min 1, and oxygen saturation 99% on room air. Abdominal examination demonstrated a 4 cm 4 cm abrasion over the right lower chest and upper abdomen with soft tissue swelling and focal tenderness. Chest radiograph was unremarkable. Computed tomography of the abdomen and pelvis demonstrated a right rectus sheath hematoma, but no intraperitoneal or retroperitoneal injuries (Figure 3). The patient was observed in the ED for 6 h, and subsequently discharged home. Case 3: Liver Laceration An otherwise healthy 19-year-old man presented to TUH ED after being struck in the abdomen with a beanbag round. He complained of abdominal pain at the site of impact. Initial vital signs were: 121/56 mm Hg, heart rate 87 beats/min 1, respiratory rate 16 breaths/min 1, and temperature 36.1 C (97 F). Secondary survey was remarkable for an abrasion and contusion in the left-upper quadrant of the abdomen. The patient had diffuse abdominal tenderness to palpation. CT scan of the abdomen and pelvis demonstrated a 2-cm hepatic contusion in the lateral segment of the left hepatic lobe, a grade I liver laceration, and a left rectus muscle contusion (Figure 4). The patient was admitted by the trauma service for observation. The patient was subsequently discharged home after 1 day in good condition with pain adequately controlled.

6 224 J. Suyama et al. Figure 3. CT scan of abdomen showing rectus sheath hematoma (arrowhead). Figure 4. CT scan of abdomen showing liver laceration (arrowhead).

7 Less-Lethal Weapons 225 Case 4: Abdominal Wall Contusion An otherwise healthy 27-year-old man presented to TUH ED less than 2 h after being struck in the mid lower thorax by a rubber bullet. He complained of chest and abdominal pain. Vital signs on presentation were: blood pressure 103/56 mm Hg, pulse 99 beats/min 1, respiratory rate 16 breaths/min 1, and oxygen saturation 98% on room air. The physical examination was remarkable fora3cm 3 cm erythematous abrasion located in the lower sternum just right of midline. Breath sounds were present and equal. No palpable deformities or crepitus were noted. The abdomen was diffusely tender with voluntary guarding, but no rebound tenderness. Chest radiograph demonstrated no acute cardiopulmonary disease. CT scan of the abdomen and pelvis was significant for a right anterior-upper abdominal wall soft tissue contusion. The patient was discharged home in stable condition after a period of 6 h of observation in the ED. Case 5: Scalp Laceration and Closed Head Injury An otherwise healthy 21-year-old man presented to TUH ED after being struck in the posterior scalp by a rubber bullet. The patient noted pain at the back of his head, nausea, generalized fatigue, lethargy, and a brief (described as several second ) loss of consciousness at the time of injury. Vital signs upon arrival were: blood pressure 123/60 mm Hg, pulse 110 beats/min 1, respiratory rate 16 breaths/min 1, and temperature 37.8 C (100.0 F). Neurological examination documented a Glasgow Coma Scale score of 15, without focal neurological deficits. Head examination was remarkable for a 3cm 5 cm stellate laceration to the posterior right occipital area. No Battle s sign, raccoon eyes, or hemotympanum were noted. CT scan of the head was negative for intracranial injury. After wound closure and neurological observation in the ED for 4 h, the patient remained stable and was discharged home. Case 6: Traumatic Laceration of the Right Achilles Tendon A 20-year-old woman with a past medical history of asthma presented to TUH ED after being struck in the right calf with a rubber bullet. The patient reported falling to the ground secondary to the pain, and noted a large, open wound to the distal posterior right calf with profuse bleeding. Vital signs were: blood pressure 148/68 mm Hg, pulse 116 beats/min 1, respiratory rate 16 breaths/min 1, and temperature 37.1 C (98.8 F). Physical examination was remarkable only for a large tissue defect in the distal posterior right calf 3 4 cm superior to the insertion of the Achilles tendon with the proximal portion of the tendon exposed. Although dorsiflexion was normal, the patient was unable to plantarflex the foot. Thompson s test was positive. Neurovascular examination of the right lower extremity was within normal limits. Radiographs demonstrated an area of soft tissue injury but no acute bony abnormality or retained foreign body. The patient was evaluated by the orthopedic surgery service and explored in the operating suite, where she was found to have a traumatic laceration of the right gastrocnemius and Achilles tendon. She underwent primary operative repair of the tendon defect. Her post-operative course was unremarkable and she was discharged on hospital day number two. Outpatient follow-up 2 weeks later revealed a well-healing wound. Case 7: Scalp De-gloving Injury and Post-Concussive Syndrome An otherwise healthy 51-year-old woman presented to TUH after being struck in the head by a beanbag round, resulting in a large right parietal scalp laceration. She complained of headache, but denied loss of consciousness, visual changes, or nausea. Vital signs on arrival were: blood pressure 140/105 mm Hg, pulse 86 beats/ min 1, respiratory rate 22 breaths/min 1, and temperature 37.7 C (99.8 F). Physical examination revealed a 9-cm scalp laceration involving the right parietal region, with exposed galea aponeurotica. No depression or deformity was noted on visual or manual inspection. The neurological examination was unremarkable, with a Glasgow Coma Scale score of 15. The laceration was repaired while the patient was in the ED. The patient refused a CT scan of the head, was observed in the ED, and subsequently discharged home with closed head injury instructions. Eight days later, she returned to the ED complaining of persistent headaches. History and physical examination were consistent with a post-concussive syndrome and no CT scan was performed. The patient was educated, reassured and discharged home. Her wound was noted to be healing well. Beanbag rounds were just as likely as rubber bullets to cause significant injury, with 4 of 22 (18%) beanbag injuries and 3 of 14 (21%) rubber bullet injuries designated as significant. Injuries associated with the use of beanbag versus rubber bullet did not demonstrate statistically significant differences in rates of significant morbidity (p 0.57, Fischer s Exact Test, Table 4) or admission (p 0.67, Fischer s Exact Test, Table 4). Although not classified as significant morbidity, seven additional patients (28%) sustained lacerations requiring closure. All these individuals had the potential for wound

8 226 J. Suyama et al. infections, long-term cosmetic concerns, and the need for a subsequent follow-up visit for suture removal. One patient who sustained an injury to the groin was discharged home with an in-dwelling Foley catheter and urology follow-up. DISCUSSION The typical plastic bullet is a blunt-ended cylindrical projectile made of polyvinyl chloride. It measures 10 cm 3.7 cm and weighs 135 grams. It is discharged from a specially designed riot-control gun at a low muzzle velocity (229.7 ft/s). It is more accurate than a rubber bullet and travels along its long axis to strike the target end on (7). The typical 40-mm rubber bullet is a 2.2-inch foam projectile that weighs 30 grams and is housed in a 4-inch shell case. It is fired from a 40 mm launcher at an average velocity of 325 feet/second to an effective range of 100 feet, but with tumbling movement and high wind resistance it loses energy very rapidly. It fits loosely into the barrel of a riot gun and is highly unstable in flight, resulting in a diverse and unpredictable injury pattern. The typical beanbag projectile is a 2 2-inch square filled with lead shot that weighs 40 grams and is housed in a 2 3/4-inch cartridge. It is fired from a 12-gauge shotgun at a velocity of approximately feet/ second with an effective range up to approximately 50 feet. These projectiles are designed to cause blunt trauma on impact, not to penetrate into the body. Optimally, these devices are deployed at least 30 feet away from the target with an aim point for large muscle groups to reduce the likelihood of internal injury. Historically, the global medical community has a greater experience with the management of injuries resulting from the use of earlier generation LL crowd dispersal agents. Since the start of civil disturbances in Northern Ireland in 1969, rubber, then plastic bullets have been deployed. In July 1970, Millar et al. described injury patterns among 90 patients struck by rubber bullets in Northern Ireland. During the study period, 33,000 rubber bullets were fired, resulting in two deaths and 17 people with permanent disabilities or deformities (8). From April to August 1981, Rocke described 99 consecutive patients presenting to Northern Ireland EDs for injuries alleged from plastic or rubber bullets. During this study period, 29,000 plastic bullets were fired. Seven deaths occurred and 31 individuals sustained moderate to severe injuries to the head (9). Ritchie further described 123 patients who sustained 126 plastic bullet injuries in Belfast over a 14-year period from He clearly demonstrated a significant association of serious injury or death from plastic bullets if the impact was above the level of the diaphragm (7,10). During the week beginning July 7, 1996, Steele et al. detailed the injuries attributed to plastic bullets and found a total of 172 injuries in 155 patients with a 25% admission rate and no fatalities (11). The Israeli Defense Forces utilized rubber and plastic bullets between 1987 and 1993 as a deterrent to aggression by the Palestinian civilian population in occupied territories. Extensive injuries and more than 20 deaths were directly attributed to injuries inflicted by rubber bullets and plastic bullets (12,13). Austria and South Africa also have reported similar injury patterns with the use of earlier generation LL weapons (14,15). A single case report in France describes a close range self-inflicted rubber bullet wound to the chest, which resulted in death (16). Although earlier generation weapons were designed to inflict non-penetrating blunt trauma to immobilize rather than kill, fatalities and serious injury have occurred. In our series, the majority of injuries were noted to involve the extremities and back/buttocks. This pattern of injury proved less likely to necessitate admission (1 of 18, 6%) when compared with chest (1 of 5, 20.0%) and abdomen (1 of 4, 25%). A reduced number of wounds with significant morbidity was also demonstrated with this pattern of injury. Only 1 of 18 (6%) extremity/back/ buttock injuries was designated significant in comparison to 3 of 4 (75%) abdominal injuries, 2 of 6 (33%) head/ neck injuries, and 1 of 5 (20.0%) chest injuries. However, the only operative candidate in this case series was an individual with a traumatic Achilles tendon rupture secondary to an extremity injury. No ophthalmologic injuries were noted during the current review. As a retrospective study, this review has inherent limitations. This case series highlights a handful of individuals injured during a period of civil unrest in a major U.S. city and is therefore subject to selection bias. We cannot determine the number of patients who did not seek medical attention regardless of the extent of their injuries. For example, a highly publicized case involved one individual, initially injured during the riots and evaluated by pre-hospital care providers, who subsequently was released to seek medical treatment in a different state. This individual was noted to have a cracked rib, bruised lung and bruised spleen requiring hospitalization in another city, but was not included in this series (17). Further selection bias involved limiting the study to only one of four adult EDs within the city limits. The other hospitals may have treated LL weapon injuries as well. Moreover, this study deliberately excluded children. Children have been well documented to have a different pattern of injury than adults, and are far more likely to suffer significant morbidity and mortality from LL technology (18). It is unlikely, however, given the close public and media scrutiny during the unrest, that a

9 Less-Lethal Weapons 227 beanbag-related mortality was missed in the data collection. Formal review of pediatric cases was not performed, and the true number of pediatric causalities from this civil disturbance is unknown. No minors (age 18) with LL weapon injuries, however, presented to the TUH for evaluation during the study period. Finally, we were unable to identify, with certainty, the type of LL ammunition that caused each injury. The medical records reflect the use of some type of LL ammunition documented as either a beanbag round or rubber bullet. This categorization by healthcare workers may not be accurate due to the vernacular use of rubber bullet to describe many potentially different types of LL rounds available. Due to the limited amount of previous medical literature available regarding beanbag injury patterns, we cannot retrospectively confirm the type of LL ammunition used based upon the clinical presentation of the patient. In a recent case series from Los Angeles, 40 individuals over a 4-year period of time were noted to have significant traumatic injuries as a result of blunt and penetrating injuries related to beanbag injuries (19). Our series reflects similar blunt and penetrating pathology that, according to de Brito et al., can be completely attributed to the beanbag round alone. In the end, we still cannot identify the type of weapon used by the injury pattern produced. The actual number of individuals injured by LL weapons during this period of civil unrest remains unknown, making it impossible to determine the true incidence of significant injury. The purpose of this article, however, was to document the injury patterns associated with the use of LL munitions and to supplement the current literature regarding injuries related to modern LL technology. The current study suggests that the pattern of injury from beanbag rounds is largely minor in nature, although the potential for significant morbidity and possible mortality remains. SUMMARY Governmental and law enforcement agencies have employed less-lethal weapons since the late 1970s. Review of the medical literature reveals a consistent injury pattern related to the use of plastic and rubber bullets. The newest weapon system, the beanbag gun, has an injury pattern with limited documentation in the medical literature. As we have demonstrated, the newest generation of less-lethal weapons can produce significant morbidity, but has not yet been shown to produce the mortality associated with earlier generation rounds. REFERENCES 1. Non-lethal weapons. emerging requirements for security strategy. Washington, DC: Institute for Foreign Policy Analysis; Coupland RM. Non-lethal weapons: precipitating a new arms race (editorial). BMJ 1997;315: CBC News, Indepth. Summit of the Americas, 2001 [press release]. CBC News Web site. Available at: indepth/summit/security.html. Accessed June 13, Amstrong P. CBC Montreal. CBC News Web site. Available at: Montreal.cbc.ca/cgi-bin/templates/view.cgi?/news/2001/04/26/ singh0104. Accessed June 13, Barrios J, Arizona Daily Star. Police has snipers on rooftops at riot. Yahoo News Web site. Available at. htx/azstar/200.../police_had_snipers_on_rooftops_at_riot_1. Accessed June 13, Barrios J. Report. police snipers on roofs during riot. Arizona Daily Star; May 21, 2001:A1. 7. Ritchie AJ, Gibbons JRP. Life threatening injuries to the chest caused by plastic bullets. BMJ 1990;301: Millar R, Rutherford W, Johnson S, Malhotra VJ. Injuries caused by rubber bullets: a report on 90 patients. Br J Surg 1975;62: Rocke L. Injuries caused by plastic bullets compared with those caused by rubber bullets. Lancet 1983;l: Ritchie AJ. Plastic bullets: significant risk of serious injury above the diaphragm. Injury 1992;23: Steele JA, McBride SJ, Kelly J, Dearden CH, Rocke LG. Plastic bullet injuries in Northern Ireland: experiences during a week of civil disturbance. J Trauma 1999;46: Balouris C. Rubber and plastic bullet eye injuries in Palestine. Lancet 1990;335: Hiss J, Hellman FN, Kahana T. Rubber and plastic ammunition lethal injuries: the Israeli experience. Med Sci Law 1997;37: Missliwetz J, Lindermann A. Gunshot wounds caused by Fiocchi Anticrime cartridges (plastic bullets). Am J Forensic Med Pathol 1991;12: Cohen M. Plastic bullet injuries of the face and jaws. S Afr Med J 1985;68: Voiglio EJ, Fanton L, Caillot JL, Neidhardt JP, Malicier D. Suicide with non-lethal firearm. Lancet 1998;352: Prendergast J. Bean-bag shooting unprovoked, says ex-cop, now city official. The Cincinnati Enquirer Web site. Available at: enquirer.com/editions/2001/04/16/loc_bean-bag.html. Accessed September 14, Shaw J. Pulmonary contusion in children due to rubber bullet injuries. Br Med J 1972;4: de Brito D, Challoner KR, Sehgal A, Mallon W. The injury pattern of a new law enforcement weapon: the police bean bag. Ann Emerg Med 2001;38: