Social EM Teaching Modules

Learning Objectives

1. Promote the use of respectful and person-centered language to describe patients in custody.
2. Describe special concerns and considerations when interacting with law enforcement.
3. Describe ways to advocate for the rights of patients in custody.

Case Presentation

Discussion Questions

1. Is the patient allowed privacy from the officers? What steps can you take to ensure patient privacy and autonomy?
2. When is it appropriate to remove shackles for exams or procedures? How do you promote safety for the patient and medical staff?
3. Are incarcerated patients allowed to refuse care?
4. What information, if any, must be shared with prison system staff? What unique considerations must be made when documenting this patient encounter?

Privacy

• All patients, incarcerated or not, are entitled to privacy of their health information under HIPAA.
• Correctional officers are not medical staff and should only learn privileged health information if it directly impacts them or their transport (e.g., a tuberculosis diagnosis).
• If officers learn that a patient uses drugs or alcohol behind bars, there can be legal consequences for the patient.
• Officers generally must maintain "line-of-sight" with a patient in custody but can step outside of the room or out of earshot.

Forensic Restraints / Shackles

• Forensic restraints are placed by officers to lower escape/harm risk — distinct from medical restraints ordered by physicians.
• Restraints should not limit medical care; physicians can ask officers to move or remove restraints when needed.
• Patients in custody are generally low-risk; if concerned about safety, consider moving shackles to another extremity rather than removing entirely.
• The American Public Health Association recommends policies to limit shackling of patients receiving medical care.
• Most states, including Illinois, have laws limiting or prohibiting shackles for pregnant patients outside of clear extenuating circumstances.

Right to Care

• Individuals who are incarcerated have a right to medical care under the 8th Amendment — leaving someone to suffer from untreated medical conditions is considered cruel and unusual punishment.

Consent

• Patients generally retain the right to consent or refuse treatment; officers are not allowed to be surrogate decision-makers.
• You can often speak with family or emergency contacts, coordinated through officers to establish a secure line and avoid providing a care location for security purposes.

Documentation

• If noting a patient's carceral status, use person-first and respectful language (e.g., "man in custody" not "inmate" or "convict") in alignment with National Commission on Correctional Health Care guidance.
• Only document information that is necessary for medical care.

Discharge Planning

• Facilities often have a restricted number of medications on formulary — consider calling the facility to verify availability.
• Writing a prescription for OTC medications allows patients to receive them for free from the medical unit.
• Patients are not allowed to keep discharge instructions — explain instructions and return precautions verbally in detail.
• Provide clear follow-up care recommendations to support continuity of care at the facility.
• Consider writing discharge instructions and sealing them in an envelope for delivery to medical personnel at the facility to prevent accidental disclosure to correctional officers.
• Patients have an increased risk of death in the first few weeks following release — drug overdoses contribute; referral to treatment programs should be considered if they have a history of substance use disorder.

Health Disparities

• People experiencing incarceration face higher rates of communicable diseases such as HIV, Hepatitis C, tuberculosis, and certain STIs — consider medical screening if appropriate.
• Studies suggest that hospitalized patients in custody may receive less care than other patients; addressing biases may help ensure more equitable care.

Patient-Centered / Trauma-Informed Care

• Recognize and address the impact of trauma in carceral settings.
• Seek to avoid practices that may cause retraumatization.
• Provide trauma-informed care by fostering safety, trustworthiness, collaboration, and empowerment.

Learning Objectives

1. Recognize torture — including state-sanctioned violence — as a social driver impacting health.
2. Apply trauma-informed, safety-centered management for survivors of torture in the emergency department.
3. Integrate ethical and professional obligations when state violence is suspected.

Case Presentation

Discussion Questions

1. When a patient presents with injuries and alleges assault by law enforcement, what are the clinical, ethical, and professional responsibilities of the emergency physician?
2. How can an emergency physician create psychological and physical safety when uniformed officers are present? What should you do if officers resist stepping out of earshot?
3. How should injuries and patient disclosures be documented when police violence is alleged? What are the consequences of vague or minimizing documentation?
4. What information is legally required to be shared with law enforcement in the emergency department, and what information remains protected health information?
5. If you believe a patient is at risk of ongoing harm after discharge back to custody, what institutional pathways exist to escalate concerns?

Definition & Conceptual Framework

• Torture is defined under international law as the intentional infliction of severe physical or psychological pain or suffering for purposes such as coercion, punishment, intimidation, or obtaining information, when carried out by or with the consent or acquiescence of a public official.
• State-sanctioned violence, including police brutality, may meet this definition when force is used in a manner intended to coerce, punish, or intimidate.
• Exposure to torture or severe state violence constitutes a significant structural determinant of health and is associated with both acute and long-term medical and psychiatric morbidity.

Professional Scope

• Emergency medicine frequently serves as the first point of contact for individuals exposed to violence, including state violence. Recognition, stabilization, documentation, and appropriate escalation of suspected torture fall within the scope of emergency practice.
• These actions reflect adherence to professional, ethical, and patient-centered standards of care.

Clinical Manifestations in the ED

• Survivors of torture or police violence may present with blunt force injuries (contusions, fractures, rib injuries), head trauma or facial injuries, multiple injuries in various stages of healing, symptoms of acute stress (tachycardia, hyperventilation, tremor), or hypervigilance and reluctance to speak in the presence of law enforcement.
• A discrepancy between the initial reported mechanism and the patient's private disclosure warrants careful clinical evaluation and documentation.

Privacy & Confidentiality

• All patients, including those in custody, retain the right to confidential medical care under HIPAA and relevant state law.
• When clinically appropriate, law enforcement officers should be asked to step out of earshot during medical history taking. Only information necessary for immediate safety or transport should be shared.
• Disclosure of allegations or sensitive history should not occur in the presence of officers unless required by law. Maintaining confidentiality is a clinical obligation and may directly affect patient safety and disclosure.

Trauma-Informed Clinical Approach

• Trauma-informed care has been shown to improve patient engagement and reduce retraumatization in survivors of violence.
• Seek consent prior to examination and explain each component of the evaluation.
• Minimize authoritative or confrontational language. Provide choices when feasible.
• Recognize that mistrust of institutions may be adaptive.

Documentation Standards

• Thorough and objective documentation is essential when evaluating suspected assault, including allegations involving law enforcement.
• Describe injuries precisely (location, size, color, configuration). Document patient statements verbatim when relevant. Avoid speculative or minimizing language. Consider institutional protocols for photographic documentation.
• Medical documentation may later serve as an important objective record of injury. Incomplete or imprecise documentation may limit future clinical, legal, or protective actions.

Reporting & Institutional Pathways

• Mandatory reporting requirements vary by jurisdiction and should be reviewed in accordance with Illinois law and institutional policy.
• Professional ethical standards affirm that physicians must not participate in or conceal torture and must take appropriate steps when such abuse is identified.
• When allegations of police violence arise, clinicians should notify supervising physicians, involve social work early, contact hospital risk management, and follow established institutional procedures for suspected assault. Providers may consider reporting to the Civilian Office of Police Accountability.
• Emergency physicians are not investigators; however, they have a responsibility to follow appropriate reporting pathways when credible harm is disclosed.

Disposition Considerations

• In situations where it is medically indicated, clinicians should admit patients and provide appropriate management and treatment.
• Document expressed fear of return to custody and assess for ongoing risk.
• Provide appropriate trauma-informed mental health referrals.