A 44-year old female is transported to the county jail and is placed in a cell with others waiting to be processed through the correctional system. She complains to several officers that she is short of breath. Six hours later, she is evaluated by a physician assistant and sent to the emergency department (ED) at the jail. Once in the jail's ED, she reports that her boyfriend stabbed her in the neck. She states she was seen at a hospital after being arrested and discharged. The patient was found to have a significant pneumothorax and transported to the nearest external ED.

Scope of the Problem

Although emergency departments are witnessing increases in virtually all sections of the patient population,^1,2 perhaps no group poses as much of a challenge for rapid assessment and treatment as incarcerated patients. America is "the world's most aggressive jailer" with roughly 2 million Americans in jail, 4.5 million on parole or probation, and 3 million ex-convicts in 2002.^3,4 Not only are these individuals more likely to come in with more serious problems (ie, serious injuries from beatings or rape, higher STD rates, high tuberculosis infection, etc),^5-9 they are also often viewed differently from other, non-incarcerated patients because of their perceived "criminality."¹⁰ Additionally, an ever-growing number of incarcerated patients have serious mental health issues that may impede their ability to attain adequate healthcare services.^11-13 Whether the patient has been brought in from a local municipal lockup, a county jail facility, or a prison, he or she likely has limitations of access to healthcare compared to "free-world" patients.^11,14,15 Normally unable to seek alternative healthcare or treatment options, the detainee depends on many individuals - from officers to healthcare technicians to physicians - to assess the urgency of her condition.^16,17

Barriers to Access to Healthcare

When the patient's situation is deemed sufficiently emergent, he or she may be transported from correctional medical facilities to the nearest hospital ED.¹⁷ However, such transport is not simple. Incarcerated patients frequently undergo careful scrutiny of their conditions by both correctional medical healthcare providers and security personnel and must gain clearance from both prior to transport to the ED.¹⁷ Indeed, with calls for reducing prisoner healthcare costs growing ever more vociferous, ^18,19 many detention facilities are implementing even stricter parameters before the incarcerated can obtain permission to approach external EDs, including the use of on-call physicians for case-by-case screenings.^17,20 Personal barriers may also prevent patients from accessing healthcare. In the jail environment - a location lacking in privacy - incarcerated individuals may be hesitant to admit that they have a medical problem or illness (eg, the anxiety of an HIV or TB detainee seeking care).^21,22 Fear of correctional officers and fellow detainees may also play a significant role in delaying or preventing patient access to healthcare. More than one HIV/AIDS-infected inmate has been ridiculed or worse due to his or her condition.²² If a patient does seek attention, he or she may have only limited time to explain the problem with language, mental health status, and situational barriers (ie, few jail personnel, limited supervision of patients) further diminishing opportunities.^15,22-24 The detainee may or may not understand or be able to effectively communicate a complex set of symptoms. An additional barrier is the lack of information. Many incarcerated individuals may not even be cognizant of their healthcare rights as detainees.^6,15 Worse, many inmates may feel abandoned by society and "not entitled" to any healthcare option that may palliate or end their pain/medical problem. Although dispelling and reducing such barriers may require significant patience, effort, and time, obstructions to adequate healthcare for the incarcerated should be dealt with swiftly when noted.

Preconceived Opinions

If an incarcerated patient does manage to enter an ED, his chances of obtaining equal treatment compared to non-incarcerated patients may be jeopardized by the very fact that he or she is incarcerated.¹¹ In many EDs, the incarcerated patient is usually escorted by officers, cuffed and/or shackled, triaged quickly and brought to the treatment area.²⁵ Whether they are brought into a large tertiary care center or a community hospital, detainees do not take a seat in the waiting room.¹⁰ Many healthcare providers (including nurses, physicians, and technicians) view incarcerated patients as unreliable (especially with regard to providing honest personal histories), dangerous, and manipulative malingerers.^10,20,25 Even more troublesome are beliefs by some healthcare workers that the incarcerated are essentially "social outcasts" whose diseases are "well deserved."¹⁰ Physicians and healthcare staff of all EDs must keep in mind that, "although these patients have lost their rights to move freely in society, they have not lost their rights to secure appropriate care and treatment.¹⁰

Historical Perspective: Protection of Healthcare Rights for the Incarcerated

The legal rights of incarcerated patients seeking healthcare are many and not to be taken lightly. Most importantly, incarcerated persons have the right to receive sufficient and accessible healthcare. In 1976, the United States Supreme Court established the first of many constitutional standards for correctional healthcare in the Texas case of Estelle v. Gamble when it acknowledged that "deliberate indifference" to suffering of the incarcerated violated the Eight Amendment.^11,15 Estelle further recognized that the state was responsible for providing adequate care for the incarcerated since the state had "restricted completely the inmate's ability to secure medical or mental healthcare on his own behalf."¹⁴ Such standards were deemed necessary to combat widespread ill-treatment of the incarcerated and the dangerous concept of penal harm medicine, the belief that imprisonment alone is not sufficient punishment for criminals.^15,22

The Supreme Court and many lower courts (in response to numerous patient lawsuits) have since chiefly used the Eighth and Fourteenth Amendments to the U.S. Constitution to protect the rights of incarcerated persons.^11,15 Additionally, laws passed by Congress have banned many of the worst aspects of pre-Estelle correctional healthcare, including the use of prisoners in medical experiments and forcing prisoners to accept unwanted treatment.15 The American judiciary has outlined a series of basic rights for all incarcerated individuals seeking healthcare, including but not limited to the right of access to care, the right to the care that is ordered, the right to professional medical judgment, the right to have proper medical records, the right to confidentiality, and the right to refuse treatment.¹¹ Although the main negative effect of so much legislation has been the subsequent litigation,^14,23,26 the primary and overwhelmingly positive effect of judicial involvement has been to promote basic human rights in correctional facilities.^11,15,22,27

Provisions for Healthcare: Municipality vs. State

The thought that all patients presenting to the ED who are in shackles are "prisoners" and will ultimately serve a sentence is incorrect.^15,25 Depending on the offense, the detainee will appear in court and a bond set, or he will be released until a future court date. Of those detained or unable to post bond, the county or federal jail will be the final destination.¹⁵ It is at the county or federal jail where the incarcerated individual will usually go through an "intake process" where medical problems are identified through a rapid evaluation. The correctional officers primarily control the environment and, thus, those who are ill may or may not be identified.^18,20,22 The purpose of the intake process is to sort through the detainees and disperse them to locations where they will stay for the remainder of their time. If at this time an individual is sick from heroin withdrawal or is pregnant and experiencing acute abdominal pain, she may need to wait until she is allowed to go through the intake process. There is no guarantee that a healthcare provider will be available during the intake process depending on the jail.^11,20 Once identified as needing evaluation, a physician, physician assistant, and/or RN may be available to assist the detainee. While an acute illness or injury may be diagnosed at this initial encounter, the patient may or may not receive care the following day depending on the sick-call system.

Additional Considerations

A further and even more controversial challenge for ED providers lies in the question of what follow-up care the incarcerated patient should receive upon leaving the ED. Many ED providers have cultivated an "in-and-out" mindset emphasizing quick treatment of patients and referral of serious cases to specialists. While such a mentality is generally fine for patients with freedom of movement and the ability to access better care, the incarcerated often receive substandard care at correctional facilities^10,22,27 and face a unique set of personal and environmental challenges not least of which are high suicidal tendencies and mental health issues.^{12,13,24,28-31} As such, emergency departments must seriously consider, not whether, but how, when, and how often to ascertain whether physician-mandated orders and prescriptions are being followed/utilized by correctional staff and patients. In addition, even if aftercare is arranged, the correctional facility may not be able or willing to allow follow-up care in a timely fashion. For example, for a pregnant woman, additional prenatal care as recommended in the ED may not occur.

General Guidelines for Emergency Medical Staff in Providing Care for Detainees

1. Complete a thorough physical medical exam.
2. Care provided or needed must be unbiased and must not be influenced by officers.
3. If safety is an issue, allow the officer to be in clear view. The healthcare provider should not jeopardize his or her own safety. The shackles and restraints may or may not need to be removed.
4. Listen carefully to the complaints and, if the detainee continues to express complaints, reassess as needed.
5. Provide the detainee with information about required tests, results, discharge instructions, prescriptions, etc as you would for any other patient, recognizing that follow-up and compliance may be impossible. Consider calling the correctional facility to update the healthcare provider of the detainee's medical management needs and to assure adequate follow-up.
6. Instruct the accompanying officer on any medical or physical limitations that the detainee (ie, shoulder dislocation) may have that would influence the way the detainee is positioned or shackled.
7. If frequent observation of the detainee is necessary or concern exists about the progression of a medical problem that would require that the patient return in a relatively short amount of time, the patient should be admitted. The disposition of the patient must always be communicated as early as possible to the accompanying officer.
8. Communication options with the correctional facility and the healthcare services available at the detention facility must be known by all ED staff who service the inmate population in the area.
9. As with all patients, maximum patient privacy to the extent possible should be maintained.

Created by members of the ACEP Public Health Committee
April 2006

References

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