Jumpsuits & Pinstripes

   It is 2 a.m. when your unit is dispatched to the medical unit of the state prison for a "possible stroke." As you approach the facility, the brightly lit prison and grounds are juxtaposed against the dark backdrop of the night sky. Beyond a sign that reads "No unauthorized vehicles or personnel beyond this point...State Department of Corrections...State Prison," a vehicle awaits to escort you to your point of entry into the facility.

   You pull the ambulance into a large garage bay and, as the door closes, corrections officers approach and ask you and your partner for your names, unit number and employee IDs. You are led through a door into an entryway, where you are asked the same questions again by an officer seated behind a desk and double-paned bulletproof glass. For the next few minutes, you are led through countless doors and hallways, and then to a door that opens up to the outside. More officers join the group as you walk across a large field and toward a building labeled "Medical Unit," where you are asked for your name and unit number a third time. Finally, you hear the loud, unmistakable sound of the lock on the heavy metal door in front of you being disengaged and as it slowly slides open, you are confronted with the familiar smell of disinfectant.

   You and your partner are directed to prisoner "Bob," age 62, who is wheelchair-bound and lives permanently in the medical unit. He has a significant medical history including hypertension, several MIs, several pulmonary emboli and two past CVAs. Upon assessment, you find Bob exhibiting a neurological status different from his baseline. Four officers surround you and your partner as you attempt to transfer the feeble man onto your stretcher. Bob is extremely nice, respectful and cooperative during treatment and transport, which lasts a little less than an hour. After transferring care at the hospital, you make sure Bob is comfortable before leaving his room and wishing him a quick recovery.

   "Bob" is just one example of the many types of patients in custody of law enforcement for whom you may be called. Law enforcement officers are authorized by federal, state and local lawmakers to arrest and confine persons suspected of crimes. The judicial system is authorized to confine persons convicted of crimes. This confinement, whether before or after a criminal conviction, is called incarceration.

A CHALLENGING RESPONSE

   Caring for an incarcerated patient poses several challenges for responders. Logistical and operational problems may arise, and treatment modalities may need to be adjusted. More important, your entire mind-set may need to be modified in order to appropriately care for such a patient. There are many factors that can interfere with providing adequate patient care to the incarcerated population, including the potential for intangible moral, psychological and personal issues to surface. These ever-present interpersonal issues are more complex than the logistical and operations concerns you may encounter in caring for these patients, such as extended times to initial patient contact or providing care for a patient restrained in handcuffs and leg irons. Careful consideration of all these potential problems is essential in providing appropriate care to the incarcerated population, and they should be addressed together, each related to--and dependent upon--the next.

GOING INSIDE

   There are many types of facilities where you may encounter an incarcerated patient, varying greatly depending on your response area.

   Logistical concerns regarding the passage in and out of correctional facilities can be especially pronounced for county and state facilities due to their size, capacity and configuration. The specific configuration of a facility varies based on the prison model used. The congregate system of confinement of the early 19th century later evolved to become the basis for United States penitentiaries today, and prisons built based on this congregate system are constructed in several ways. In order to minimize confusion while navigating in and out of the facility, familiarize yourself with the layout and procedures of the correctional facilities within your primary response area. This will maximize your efficiency in time management and ultimately your patient care.

   Have your identification and credentials ready, and be able to furnish them upon request during entrance into the facility and at guard posts and checkpoints while inside. Get to know what items are considered contraband within the prison prior to being sent there. While policies and procedures vary from facility to facility, prohibited items may include a large range of objects from knives, shears and other multifunction work tools, such as Swiss Army knives and Leathermans, to cell phones, keys, open packs of cigarettes and even sunglasses. Armed with this knowledge, leave these items inside your ambulance when possible. At the very least, anticipate and prepare to surrender them upon entrance into the facility.

   Most, if not all, corrections and other law enforcement agencies would look positively upon you or your EMS agency's desire to learn more about their systems and procedures so you can provide appropriate and seamless care. You, or someone within your agency who is authorized and an appropriate representative to do so, should contact any agency or facility that might fall within your response area and communicate with them your desire to be familiarized with their agency and facility. They may send a designated interagency liaison to provide you with this information, or even invite you to visit the facility to gather priceless first-hand specifics, for which there is truly no substitute.

   You can also gather information via the Internet that would otherwise be unavailable to you. Visitor guidelines are available online for many county and state correctional facilities, and the list of prohibited items provided for potential visitors can be used as a guide for responding EMS personnel as well. In some states, copies of all public and government records, including standard operating procedures, policies and any proposed amendments to such, are mandated by law to be available to the public. This is accomplished by either providing access to view documents of public record directly online or by filing a written request for the records. Additionally, even if such a law or practice is not in place in your state, agencies can still provide copies of their SOPs for your familiarization at their discretion. These and any other steps you can take toward becoming more educated and familiar with all aspects involving facilities where you might be providing care for the incarcerated patient ensure that you fulfill your task of providing excellent patient care at all times.

   Larger cities have the potential to house branch offices of FBI, DEA and other federal law enforcement agencies, which each have cells to house their own prisoners. Though your contact with these agencies may be limited, if there is any chance that you may be required to respond there, become familiar with that facility or facilities and the unique challenges they pose.

   State- and county-level juvenile correctional facilities pose their own set of legal issues, as they relate to custodial and parental rights, guardianship and whether the officers have a right to consent to treatment and procedures for the patient. Incarceration can take place in an institution designated to deal with psychological problems or in one for sexual offenders.

   There are also minimum-security county correctional facilities to absorb overflow of nonviolent criminals and incarcerated individuals.

   If an international airport or U.S. border crossing is within your primary response area, you may come in contact with detainees in the custody of U.S. Customs and Border Protection and the U.S. Border Patrol, as well as deportees who remain in the custody of Immigration and Customs Enforcement awaiting return transport to other countries. Be aware that these prisoners may subject you and others to infectious epidemic and pandemic diseases like malaria, SARS, parasites, or even mutated forms of the flu. You may also be called to provide medical care to visitors and law enforcement officers, not just prisoners.

LOCAL FACILITIES

   As a prehospital provider, you will most commonly encounter incarcerated patients in the custody of local law enforcement agencies. In larger towns or cities, different precincts or districts may have the capability to hold their own prisoners aside from a centralized city cellblock. Prisoners may be transferred to a central cellblock later on for further processing, holding, or in preparation for transfer into the custody of another agency. Smaller towns may only have one combined facility that handles the intake of arrestees for detention until they enter the court system.

   Prisoners of local law enforcement come from a variety of environments. As a result, these prisoners are typically unscreened, meaning that EMS providers will encounter them without any knowledge of their medical history or chronic illnesses, and potentially still affected by an event or drug they encountered prior to being taken into custody. In the event a prisoner is under the influence of a substance, he may be experiencing symptoms of abuse or overdose, as well as withdrawal.

   Cities hold prisoners for as long as necessary based on the needs of the local criminal justice system, coupled with space and availability in county correctional facilities. Therefore, incarcerated patients addicted to one or more substances can experience an immediate and sometimes violent "detox" period. They may experience an entire withdrawal cycle in their cell with symptoms that may mimic or accompany symptoms of other disease processes, such as nausea and vomiting, chest pain and seizures. Not all patients will be forthcoming about their substance abuse history. When possible, ask the patient about his or her level of dependence on a substance or substances. Knowing the type and amount of substance a prisoner typically uses regularly and the time of last use may help anticipate the severity of withdrawal.

   Vagrants, the homeless, and any persons with poor personal hygiene pose several risks for providers. Within this population, it becomes an increasingly significant finding upon incarceration that access to medical care has otherwise been minimal. The screening, treating and identifying of basic diseases for this populace are essentially non-existent. They pose a risk of being carriers of, or affected by, treatable yet highly communicable diseases such as tuberculosis, and may carry lice or other parasitic infestations. Lacking the proper means to clean and disinfect a wound or sore, problems such as localized infections, MRSA, gangrene and even maggots may be present.

   Due to a recent refocusing on crime control, there have been subsequent upgrades to many criminal justice complexes and jails, with construction of entirely new facilities. Despite this, the current economic climate nationwide finds local precincts or cities that still house detainees in older facilities, simply because they are unable to spare the funds for necessary renewals. Some buildings date back to the '60s, '70s or earlier, with several cities even operating out of condemned facilities. As a result, prisoners find themselves in facilities with peeling lead paint, mold, asbestos and cockroaches. All of these factors can contribute to an exacerbation of pre-existing medical conditions, such as asthma.

   These outdated institutions often lack modern security measures, particularly electronic video and audio monitoring capabilities. In these facilities, periodic cell checks performed by officers are especially crucial. Combined with confiscation of any potentially harmful personal property from detainees prior to their initial placement in a cell, these checks are another important measure in preventing self-inflicted injury. Absence of a modern monitoring system increases the chance that you will be called to care for a prisoner who has experienced an unwitnessed trauma or attempted suicide. No system is perfect, and even with state-of-the-art prisoner monitoring capabilities, these events may occur. Other contributing factors may include prisoner-on-prisoner violence, accidental injury, or even sudden cardiac arrests caused by a number of different pathologies. Frequently, EMS may be called for a prisoner who normally self-administers one or more medications, but, while incarcerated, does not immediately have access to these medications. In some instances, deficiencies in therapeutic levels may precipitate an acute medical emergency. Examples include seizures due to lack of anti-convulsants, hypertensive emergencies in patients who normally control their blood pressure with a strict regimen of combination antihypertensive therapy, or hyperglycemia in the absence of oral hypoglycemics and insulin.

COUNTY SYSTEMS

   Prisons and correctional systems worldwide vary greatly in their organization. In New Jersey, for example, persons serving sentences of one year or less are incarcerated in county correctional facilities. In county facilities, some of the same concerns and considerations that we just discussed apply. Unwitnessed trauma, drug withdrawal and overdoses do occur.

   No matter how effectively security measures are enforced at the facilities set to hold prisoners for extended lengths of time (county and state), the practice of allowing supervised visits from outside persons inevitably poses a threat that is not seen in most local cell blocks. Visitors can give incarcerated persons access to everything from drugs to weapons to cell phones, which can further complicate your interaction with and treatment of your patient.

   The patients in these facilities have access to baseline medical care, including undergoing a thorough medical screening exam upon arrival. Pertinent medical information for these patients is more accessible compared to that of prisoners newly placed into custody. County correctional facilities house medical units staffed by nurses and doctors, so you are less likely to be called into one of these facilities to provide basic care.

   These jails have additional security incarcerated patients not seen in municipal facilities. The process of physically accessing a patient incarcerated in a county facility may require more time and passage through a more complex security system. Time between onset of symptoms and receiving some form of medical treatment may be the same whether the patient is at a county or local facility, due to the in-house care available within the county jails and quick 9-1-1 response to municipal facilities. Consequently, for patients incarcerated at county jails, the time from onset of symptoms to arrival at a definitive care facility, and ultimately to surgical intervention, may be increased as prehospital providers attempt to gain initial access to the patient. This is compounded by the often lengthy process of leaving a secure facility, and additional delays are incurred while securing an escort of correctional officers for transport to the hospital.

STATE FACILITIES

   State prisons typically house people convicted of more serious crimes, and often violent offenses. These prisoners are slated to be incarcerated for longer periods of time, sometimes indefinitely. They not only pose an increased security risk, but a significant flight risk as well.

   During transport out of the facility, patients will be, at the very least, handcuffed. Depending upon the protocols of the agency under whose jurisdiction you will operate throughout the duration of your assignment, prisoners may also be in leg shackles. In extreme cases, they may be fitted with additional cuffs or restraints. Ultimately, the officer or officers responsible for your escort are not only accountable for the security and safety of the prisoner, but are held responsible for the actions of all of the surrounding healthcare providers. Accordingly, if you have a pair of shears or a knife in your possession, preventing the prisoner's access to these items becomes the responsibility of the accompanying correctional officers.

   Regardless of the type of facility to which you are responding, these safety and security precautions may sometimes interfere with your ability to initiate some BLS or ALS interventions. Provider safety is paramount, and if removing or reconfiguring the patient's restraints would put you at risk, it should not be attempted. However, if it will not endanger your safety, an attempt should be made whenever possible to safely secure the patient in such a way that would allow initiation of care and indicated treatments. For example, if the patient requires an IV, but establishing IV access is not possible because the patient's hands are secured together at the level of his stomach or chest, communicate your concern with the officer or officers escorting you. A compromise may be reached that allows you access to the patient's arm while maintaining the integrity of the restraints, such as securing the patient's arm to the metal side rail of the stretcher. Keep in mind, though, that some correctional agencies may have rules that prohibit officers from removing or reconfiguring the patient's restraints regardless of the circumstance. Metal restraints may pose a problem for patients who need defibrillation or synchronized cardioversion. In such cases, inquire about plastic or other alternative restraints.

   A state prison's medical unit is a comprehensive, self-contained operation, much like a hospital ward, and is designed to provide many facets of care by healthcare providers of all levels. Prisoners may reside there for weeks at a time, or may be serving the latter part of an extended sentence in the unit. Other healthcare providers and law enforcement officials working within the facilities can be very useful in helping you form a complete history of present illness. If anything, the fact that your patient is incarcerated may highlight the need to obtain a more complete, detailed medical and SAMPLE history. Before leaving the facility, find out exactly what care the patient received prior to your arrival and any treatment that may have been initiated.

   Whether an incarcerated individual is part of the general prison population or resides in the medical unit, be cognizant of your surroundings and anticipate some of the challenges you may encounter. Correctional facilities have volumes of policy and procedure manuals that delineate what steps and actions must be taken in virtually every possible contingency. Interagency cooperation with correctional staff is crucial. Once locked inside the prison, EMS has entered a different environment with a different set of rules and is no longer in control. It can be useful to contact your surrounding correctional agencies and facilities in order to research their standard operating procedures for any plan that could affect your patient care or safety. Look for policies regarding facility lockdown procedures, AED and CPR initiation outside designated medical areas, and prisoner transport rules and regulations. While situational awareness is important, it's also important to remember that your incarcerated patient is just that--a patient. He is a human being like any other person you encounter and, as such, has a right to be treated respectfully.

   It is your responsibility to try to treat everyone objectively and with respect, and provide everyone with equal medical care. I say "try" because every one of us is human and, despite our best attempts, personal beliefs may at some point interfere with how we interact with an incarcerated patient. There exists a potential for the provider to judge the patient based on the nature of his offenses. Different providers may employ a variety of personal strategies for dealing with this issue. One suggestion is to not look at paperwork regarding the nature of your patient's incarceration (and don't ask the officers who are with you at the time, either). You may not be tempted to judge the patient based on something he has done if you don't know the nature of that "something."

CONCLUSION

   A few weeks after caring for "Bob," I ran into one of the officers who had accompanied the BLS unit and Bob to the hospital that day. He pulled me aside to ask why I had been "so nice" to Bob, and asked if I knew why Bob had initially been incarcerated. I said I had absolutely no idea why and that it didn't matter, because I treat every patient with the same amount of respect as long as they respect me in return. "He's a serial killer, you know. Been locked up since the mid-'70s," he said, and waited to gauge my reaction. But the look of horror or surprise or disgust that he expected never came. I shrugged and walked away. As I did, I heard him say to no one particular, "Paramedics, I'll never understand you guys."

   "In custody" of law enforcement on any level is not equal to "not sick," but there is potential to become complacent while caring for an incarcerated patient. You may be frequently dispatched to the same correctional facility for the same patient or for the same chief complaint, which you write off in your head as "sick-of-cell" behavior or "incarceritis." This implies that no matter what the patient's actual complaint or symptoms are, he is just tired of being incarcerated and nothing more. This is dangerous for both you and your patient. If the patient's complaint is assumed to be something less severe and a comprehensive assessment is not performed, the patient's actual condition may go undiscovered and untreated, leaving you responsible for overlooking what was wrong with the patient when you deviated from your standard assessment and/or protocols. When time and location allow, assess your incarcerated patient thoroughly to the best of your scope of practice, just as you would any other patient. Never assume what is wrong or not wrong with the patient based on the fact that he or she is incarcerated.

   No matter where your response takes you to care for an incarcerated patient, always be aware of your environment and try to anticipate potential problems before they arise. Try to familiarize yourself with these facilities and their policies before you encounter a problem while providing care. Something as simple as a fistfight inside a correctional facility can quickly escalate into a riot, and you won't want to be providing care to a patient while locked inside a prison with no idea how to get out or what to do in case something goes wrong. The words of Roman military strategist Flavius Vegetius Renatus more than 1,600 years ago still apply today: "If you want peace, prepare for war."

SIDEBAR: PRISON STATS

• In 2008, more than 7.3 million people (3.2% of all U.S. adult residents) were on probation, in jail or prison, or on parole at yearend.¹
• At midyear 2008, state and federal prison authorities had jurisdiction over 1,610,446 prisoners; 1,409,166 in state jurisdiction and 201,280 in federal jurisdiction.¹
• The average inmate age is 38--93.5% male, 6.5% female.²
• In 2002, an estimated 229,000 jail inmates reported having a current medical problem other than a cold or virus. Medical problems reported by inmates included arthritis (13%), hypertension (11%), asthma (10%) and heart problems (6%). Less than 5% of inmates reported cancer, paralysis, stroke, diabetes, kidney problems, liver problems, hepatitis, sexually transmitted diseases, tuberculosis or HIV.³
• In California in 2008-2009, inmate healthcare cost on average 12,442, $8,768 of which was for medical care.⁴

References

1. Office of Justice Programs, Bureau of Justice Statistics

2. U.S. Department of Justice, Federal Bureau of Prisons

3. U.S. Department of Justice, Office of Justice Programs

4. California Legislative Analyst's Office

REFERENCES

1. West's Encyclopedia of American Law, Edition 2, Copyright 2008. The Gale Group. https://legal-dictionary.thefreedictionary.com/incarceration.

2. Dressler J, ed. Encyclopedia of Crime and Justice, Second Edition, Volume 3, pp. 1168-1175. MacMillan Reference, New York, NY, 2002.

   Yael Nelson, MICP, is a paramedic in Newark, NJ, and an instructor of several EMS-related disciplines. Contact her at Judges5.27@gmail.com.