Emergency Departments (EDs) regularly evaluate and treat individuals in custody by law enforcement, local jails as well as state and federal prisons. An emergency physician can be asked to evaluate a patient prior to that individual being incarcerated. Alternatively, an individual who has already been incarcerated for a period of time may be brought for an evaluation and/or treatment of an acute medical issue, an exacerbation of an underlying chronic condition or an acute traumatic injury. Both of these circumstances are forms of a medical clearance examination. The evaluation and treatment of prisoners can be challenging. Serious medical, legal, and ethical errors can occur if the emergency physician is unaware of the rules and standards that guide the care of detained and incarcerated individuals. A prisoner medical clearance expert witness can be utilized to evaluate if a prisoner has been provided care deviating from the standard of care and/or if failure to receive standard of care has caused harm.
Reasons for Presentations of Detainees and Prisoners to the Emergency Department
While data on the reasons for ED visits by incarcerated individuals is limited, a study published in 2020 out of The University of Tennessee at Chattanooga found that 69% of such ED visits were for medical issues or psychiatric issues needing medical clearance and 31% were for trauma-related pathology. Among those presenting for trauma related complaints, 42.5% were accidental vs 47.8% as being related to assault or intentional self-harm (1). Incarcerated patients are also more likely to have medical and psychiatric illness than the general population. HIV prevalence among the incarcerated population is approximately 5 times higher than the general population. Hepatitis C rates are 9-10 times higher. Rates of chronic illness including diabetes, hypertension and other chronic conditions are also higher than the general population, accounting for between 39%-43% of inmates. Documented rates of substance dependence or abuse among inmate populations vary significantly but are broadly above 50% (2,4). A prisoner medical clearance expert witness may be asked during relevant litigation if chronic and psychiatric issues were addressed withing the standard of care.
Legal Framework for Evaluation and Treatment of Patients in Custody at an Emergency Department
The Emergency Medicine Treatment and Labor Act (EMTALA), passed in 1986, established the right to a medical screening evaluation and appropriate stabilizing treatment for any emergent condition identified during that evaluation. EMTALA fully applies to those who are incarcerated (3). An emergency provider failing to recognize an incarcerated individual’s rights to a medical screening exam, to refuse medical care, and designate their own proxy decision makers can result in litigation requiring testimony from a prisoner medical clearance expert witness.
Healthcare providers may also be prone to providing substandard care to incarcerated individuals secondary to conscious or unconscious bias (4). Detainees who have committed particularly egregious actions such as murder, sexual violence, or violence against children are especially vulnerable to being rendered treatment that falls below the standard of care. An example of such bias is an emergency provider failing to order adequate treatment of pain. The American College of Emergency Physicians (ACEP) has established “General Guidelines for Emergency Medical Staff in Providing Care for Detainees”. These guidelines emphasize the importance of informed consent, providing unbiased care, and preserving patient privacy to the maximal extent that is possible (5). A prisoner medical clearance expert witness may be utilized in litigation regarding alleged breaches of the standard of care by emergency department providers dealing with detainees who have been accused of convicted of heinous acts.
Challenges in the Emergent Care of Prisoners and Detainees
The emergency physician can face significant obstacles to performing an appropriate medical screening evaluation of a prisoner (4). Prisoners present in restraints and often in a jumpsuit which may hinder physical examination. Prisoners are also frequently unaware of their medical history and may be poor historians for their current medical complaint (6). In relevant litigation a prisoner medical clearance expert witness may be called to address whether the history and physical complied with the standard of care.
Prisoners can also be agitated, combative or simply uncooperative while in the emergency department (6). This can be secondary to intoxicating substances, underlying psychiatric illnesses, or behavioral disorders. When a prisoner is demonstrating aggressive or violent behaviors, the emergency physician may be asked to determine if the prisoner has capacity to make their medical decisions. If a prisoner is deemed to have capacity the emergency physician should provide the same standard of care as would be given to a non-incarcerated individual. If the prisoner with capacity refuses evaluation and/or treatment, the emergency physician should inform law enforcement/prison staff of the patient’s right of refusal. Issues of capacity may also be addressed by a prisoner medical clearance expert witness.
Prisoners can also present in an incapacitated state secondary to trauma or substance use. Prisoners for whom a surrogate decision-maker cannot be identified should be treated using the best interest standard. This standard requires the physician to provide care that is most likely to promote the patient’s well-being (7). Compliance with this best interest standard may also be a subject of testimony from a prisoner medical clearance expert witness.
The evaluation and management of incarcerated patients is a common and often challenging clinical scenario. If emergency department evaluation and care provided to an inmate is concerning for deviation from the standard of care, a prisoner medical clearance expert witness can assist legal counsel.
- Martin RA, Couture R, Tasker N, Carter C, Copeland DM, Kibler M, et al. (2020) Emergency medical care of incarcerated patients: Opportunities for improvement and cost savings. PLoS ONE 15 (4): e0232243. https://doi.org/10.1371/journal. pone.0232243
- Dumont, D., Brockmann, B., Dickman, S., Alexander, N. and Rich, J., 2012. Public Health and the Epidemic of Incarceration. Annual Review of Public Health, 33(1), pp.325-339.
- State Operations Manual Appendix V – Interpretive Guidelines – Responsibilities of Medicare Participating Hospitals in Emergency Cases (2019).
- Gage MD, D., & Goldfrank MD, L. (1985). A setting which evokes the entire range of human emotions: prisoner health care. Urban Health, 26–28.
- Recognizing the Needs of Incarcerated Patients in the Emergency Department. (2006). American College of Emergency Physicians. https://www.acep.org/administration/resources/recognizing-the-needs-of-incarcerated-patients-in-the-emergency-department/
- Treat prisoners in ED with caution, dignity. (1996). ED Management, 117–120.
- AMA J Ethics. 2017;19(7):675-677. doi: 10.1001/journalofethics.2017.19.7.coet1-1707.
About the author
Brian Pisula, MD, FAAEM is an award-winning physician who has been practicing full-time in Emergency Medicine for over 8 years and has cared for over 30,000 patients in the Emergency Department setting. Dr. Pisula has extensive experience evaluating and treating detained individuals in the ED. He is board certified by the American Board of Emergency Medicine. He completed his Doctor of Medicine at the University of Rochester School of Medicine and Dentistry and completed residency training in Emergency Medicine at the University of North Carolina-Chapel Hill. He is experienced in multiple practice settings including level-one trauma centers, academic institutions, and low-resource facilities without broad specialty support. Dr. Pisula also has a passion for teaching with over 2,000 hours of teaching experience with medical students. He holds academic positions in Emergency Medicine at Mercer University and Edward Via College of Osteopathic Medicine.