When my family and I moved to Maine in 1989, one of the things I liked best about our new home was how safe we felt. 

Our family had just spent four years in Fresno, California where I did my residency.  In those days, there was an advantage to doing an emergency medicine residency in a place like Fresno, which then had the highest per capita violent crime rate in California. 

For a Minnesota boy, it was an eye-opening experience.

In Fresno we had drive-by drop-offs. A car would speed up to the emergency department’s ambulance doors, roll somebody out of the back seat, honk three times and speed away.

Most often, the person lying on the concrete had been shot, stabbed or suffered a heroin overdose.

Injuries caused by shootings or stabbings were difficult to manage but the patients would cooperate because they understood you were trying to help them and they were at risk of dying from their injuries.

If the problem was a heroin overdose, the overdose itself was usually easy to treat, but the patients were incredibly difficult. Sometimes they had an abscess in their arm or an infected heart valve caused by the use of dirty needles. 

Even though we explained they could lose their arm, die of sepsis or a number of other things, they weren’t listening.  The only thing that mattered to them was the next fix.

Living in Fresno, I began to understand how much harder it is to treat patients when their community is sick.

The heroin use was part of the problem but the underlying drug culture and drug dealing led to a lot of gang violence

The Bulldogs, a notoriously brutal gang that took their name from the Fresno State University mascot, is a nationally known crime syndicate. They used violence to protect their turf and their hold on the drug market.

The drugs fed the gangs and the gangs fed the drugs. The result was a culture of fear that affected everybody.

As a physician, I was a noncombatant, but not above the fray. Once I was called into the emergency department waiting room to speak to a patient who was demanding to be seen ahead of the 50 people who were waiting in front of him. He was a large angry man who demanded a prescription for narcotic pain medications. I told him he would have to wait his turn to be seen.

He called me several names, one of which was new to me, and left after telling me he would be back to kill me. Since a fellow emergency medicine resident at a nearby hospital had recently been shot to death after receiving a similar threat, I spent the rest of my shift with an eye on the entrance.

I recall an interesting conversation with a man who had been shot execution style in the back of his head. As I was examining the gunshot wound, I asked how it happened.

“I was just lying down on my living room floor when I heard a pop.” He answered.

The bullet had entered the back of the head and miraculously glanced off the skull and lodged in the jaw.

“Did you see them?” I asked.

“No, I was just sleeping with my face down like this.” He demonstrated the position holding his hands above his head.

“You sleep face down on the living room floor with your hands above your head?” I asked skeptically.

“Sometimes.”

He told the same story to the police and eventually went home, more willing to take his chances with the people who had tried to kill him than to trust the authorities.

Compared to Fresno and much of the rest of California, Maine was incredibly safe. Home invasions rarely happened. People often didn’t lock their homes or their cars. In the 1990’s, our emergency medicine residents might work for three years in the emergency department and never treat a heroin overdose.

That has changed dramatically over the past 10 to 15 years.

Today, Maine is still a safe place but people now lock their doors and emergency medicine residents have more than enough experience treating heroin overdoses.

Gunshot wounds and stabbings are still fairly rare, but not as rare as they were, and to those of us who have watched things change in emergency departments, the trends are incredibly concerning.

Part of the problem is a history of doctors over prescribing narcotic pain medications. We have gotten much better about that, but as prescription narcotics have become more difficult to obtain, people have moved on to heroin which is cheaper and more potent.

More police would help slow the flow of drugs, but history shows that once a market is well established, interdiction is at best only a partial remedy.

The most fundamental problem is the economic ills that are eroding our society. Young people who could once find work in the woods or in paper mills are now stranded with neither the skills nor jobs they need to support the kind of lifestyle their parents had.

Any solution will have to do more than put additional law enforcement on the streets and better controls on narcotic pain medications; it will need to develop treatment strategies and shore up our economy. It will have to give people hope.

Mark Fourre, MD, is an emergency physician and chief medical officer of LincolnHealth. He also serves on their board of trustees. Prior to joining LincolnHealth, Dr. Fourre was an attending faculty at Maine Medical Center where he developed the Emergency Medicine Residency Program and served as residency director.