Chapter 301: Prison Medicine

An established principle in civilized societies is that prisoners are entitled to the same level of medical health care as the law-abiding community.¹ Other ethical considerations involve the issue of prisoners' human rights.² The exact medical service provided will vary between countries and, in the United States, varies between states.² The concept of prison health care in general is the subject of debate and outside the remit of this chapter.

EDs may have to provide emergency health care to prisoners. Prisoners could be inmates of a local prison or recently arrested and detained in police custody. Many prisons have internal medical services of varied capability. There may be a ward or bedded observation unit for the management of uncomplicated medical conditions. Nursing staff are on duty for the full 24 hours working on a shift pattern. Doctors are present mainly for normal working hours, providing night, weekend, and holiday coverage on an on-call basis. Facilities will vary from site to site but may include radiography, a minor surgical treatment room, and consulting rooms for ambulatory care visits by local specialists. On-site or frequent access medical specialties can include a general prison medical officer(s), psychiatrists, psychologists, alcohol and drug abuse counselors, and social workers.³

The population of a prison is not representative of the general population; typical characteristics are listed in Table 301-1.^4,5

Within the prison, there exists a pool of chronic disease and drug misuse that can lead to significant morbidity and acute medical problems.³ Disease profiling of prison inmates exhibits higher prevalence rates of certain diseases than those reported for the general population. The most common disease groups are infectious diseases (hepatitis, tuberculosis, human immunodeficiency virus/acquired immunodeficiency syndrome), diseases of the circulatory systems (ischemic heart disease, hypertension), diseases of the respiratory system (asthma, chronic obstructive pulmonary disease), and musculoskeletal and psychiatric conditions.⁶ A study of prisoner mortality (while incarcerated) attributed the most common causes of death to ischemic heart disease, followed by cerebrovascular disease, neoplasms, and pneumonia.⁷ Upon release, former prisoners are at significant risk for suicide or accidental drug overdose within the first year.⁸ With the prison population increasing, in particular elderly prisoners and those from an ethnic minority group,^9,10 the prevalence of chronic disease rises, increasing the likelihood of acute medical problems.

Persons in police custody are often intoxicated with alcohol and/or drugs. Common presenting complaints are injuries (sustained prior to or during arrest), exposure to police incapacitants (handcuffs, tear gas or pepper spray, electronic weaponry, batons), complications of substance misuse, and acute behavioral disturbance.

The demographics of police detainees are similar to those in prison; important differences to note are a higher incidence of females, and around 30% of detainees are not registered with a primary care doctor.^11,12 Adherence to treatment for long-term medical and psychiatric illness is very poor among those in police custody.¹²

ACUTE MEDICAL EMERGENCIES

Prison medical emergencies should be managed according to standard treatment guidelines and protocols. If the prisoner requires admission after treatment, the prison authorities must make the necessary security arrangements at the facility of presentation or the referral location (Table 301-2).³

TRAUMA

Prison is a violent place. Violence among inmates is common. Minor injuries may be treated at the prison medical center. In one study, 18% of prison-related visits to the ED were due to violence.³ Penetrating stab wounds, head injuries, fractures, soft tissue injuries, and wounds may result from violence. In severe cases, trauma resuscitation, emergency surgery, and admission may be required.

Injuries Associated with Police Restraint

Persons in police custody often attempt to resist arrest; the police then may deploy tactics and equipment to aide in restraint and control. As a result, a variety of injuries may occur, including skin wounds, minor head injury, and joint dislocation.¹³ Injuries secondary to a handcuff application include neuropathy (in particular, the superficial branch of the radial nerve), and fractures of the ulna styloid. The use of a baton commonly results in soft tissue bruising; however, lacerations and fractures may occur.

Conducted electrical weapons (TASER®) have two methods of application: "drive-stun," whereby direct contact to the skin by the device is used, and "shooting," whereby two small darts attached to wires are fired into the skin to deliver the electric current. Complications associated with the use of such devices relate primarily to dart penetration (e.g., the trachea,¹⁴ brain,¹⁵ eye,¹⁶ and chest wall), resulting in pneumothorax.¹⁷ The proarrhythmogenicity of a conducted energy weapon is subject to debate^18,19; however, there has been a report of atrial fibrillation following its use.²⁰ Clinical management of individuals subjected to such devices is aimed at treating any complications secondary to penetrating injury. Electrocardiograms are advised, and for patients with pacemakers or internal defibrillators, device interrogation is warranted. Finally, the predisposing condition necessitating the requirement for the use of a conducted energy weapon should be assessed and, if necessary, treated.

DRUG ABUSE

It is estimated that 70% to 80% of prison inmates have been involved in some form of drug abuse before detention, with one-fifth being injecting opiate abusers.^3,21 Many inmates are on drug rehabilitation programs and maintained on regular doses of methadone or a similar opiate substitute. The main problem for emergency care is the provision of adequate analgesia. Due to the high level of opiate tolerance, standard doses of opiates (morphine, hydromorphone) may produce no analgesic effect. This can lead to high doses of opiate being given before producing an adequate analgesic effect.²² If a prisoner is placed on a controlled opiate detoxification program sustained by the use of naltrexone, a long-acting opiate receptor blocker, opiate analgesia will have no effect regardless of the dose given.²³ An alternative form of analgesia will be required (e.g., nonsteroidal anti-inflammatory drugs, which may or may not be effective). Ketamine is another option for pain relief.

Concealed Drugs

A person detained in custody may be suspected of concealing drugs in the rectum or vagina. Within the United Kingdom, unless the patient consents to the examination and removal of any such substances, any action is against the policy of the British Medical Association, even if the practitioner is protected legally by a warrant issued from the appropriate jurisdiction.²⁴ Legal practice may differ between countries. If the patient's ability to make an informed decision regarding their health care is compromised, then removal of drugs from the body is warranted should signs of drug toxicity be evident.

PSYCHIATRIC CONDITIONS

Within the prison population, there is a high prevalence of psychiatric illness. The most common is a personality disorder, found in 65% of men and 42% of women.⁶ The main ED contact with psychiatric problems will be related to deliberate self-harm and personality disorders, manifesting as manipulative behavior, fictitious illness, and Munchausen-type behavior. Other presentations include deliberate insertion of foreign bodies or alleged ingestion of objects or substances.

EXCITED DELIRIUM SYNDROME

Excited delirium is a condition that has been formally recognized by the American College of Emergency Physicians as "a unique syndrome which may be identified by the presence of a distinctive group of clinical and behavioral characteristics that can be recognised in the pre-mortem state."²⁵ Once the domain of the forensic literature, recognition of excited delirium in the premorbid state is increasing.

Attempts to apply strict diagnostic criteria are hampered by a lack of quality research. By the very nature of the presentation, patients are in extremis both mentally and physically. Table 301-3²⁵ reports the frequencies of the presenting signs and symptoms.

The pathophysiology underlying excited delirium has yet to be fully elucidated; a background of stimulant drug use (predominantly cocaine) or, rarely, psychiatric illness is a consistent feature. Individuals exhibit confusion and agitation. Attempts to reason with patients and transport to medical facilities are met with resistance and aggression, often necessitating physical restraint. It is then observed that the detainee has pronounced tactile hyperthermia, struggles violently, and suffers cardiac arrest, from which successful resuscitation is rare. Severe metabolic acidosis, bradycardia, asystole, and pulseless electrical activity are the predominant preterminal findings.²⁶

Treatment of excited delirium syndrome is predominantly aimed at reducing agitation. This can prove problematic, with issues regarding the safety of medical and law enforcement personnel, administration of parental medications, and the relative urgency necessary to reduce mortality. Physical restraint should be for as short duration as possible to reduce agitation and muscle activity–driven heat production. Intravenous access may prove difficult, and the intramuscular route for sedation is a viable, although slower onset, alternative.

Pharmacologic sedation is recommended: benzodiazepines (first line), antipsychotics (should not be used if long QT syndrome is suspected), and the dissociative anesthetic ketamine.²⁷ The choice of drug used will depend on user experience and route available; combination therapy allows reduced doses of each class of drug, minimizing the side effect profile.

As with any sedation, the ability to manage sudden loss of the patient's airway and facilities for resuscitation must be available. In some cases, rapid sequence induction of anesthesia may be necessary due to the large doses of sedation required and for definitive airway protection.

Supportive treatment is vital for patients with excited delirium, including cooled IV fluids, whole-body cooling (antipyretics are ineffective), and treatment of any electrolyte disturbance. Hypoglycemia, hyperkalemia, and rhabdomyolysis may be encountered. Metabolic acidosis is invariably present and may improve with fluid administration and cooling.

HEPATITIS C

Hepatitis C prevalence in prisoners is higher than in the general population, with studies demonstrating a prevalence of 25% to 39%.^6,28,29 Contrasting the range of values for hepatitis C prevalence within the community against the prevalence of hepatitis C in prisons, there is a theoretical risk of a several hundred–fold greater chance that a prisoner may be a hepatitis C carrier compared with a member of the general public. This raises issues regarding possible needlestick injuries or contamination with infected body fluids. All emergency personnel must be aware of the increased risk of contracting hepatitis C infection when dealing with prisoners and exert extreme vigilance in their clinical procedures.

SAFETY OF STAFF AND PATIENTS

The management of even one prisoner, disruptive or otherwise, will interfere with the running of the ED. The hospital has a duty to ensure that members of staff are not placed in undue danger. If possible, the management of the prisoner should be expedited to minimize disruption. This, in turn, allows the responsible officers the opportunity to return the prisoner to a more secure environment as soon as possible. Staff may be exposed to the risk of violence, but this should be minimal due to the use of restraints by prison officers. The presence of a restrained prisoner may alarm other patients or relatives within the ED, as they may erroneously assume the prisoner is either violent or dangerous. Examining the patient in a quieter area of the ED can help minimize other patients' natural anxieties.

USE OF RESTRAINTS

Prisoners will be restrained when arriving at the ED by virtue of the fact that they are in state custody. The physical mechanism of restraint will be variable but can include handcuffs, hand and foot cuffs with connecting shackles, or handcuffs with a chain attached to the prison officer (escort chains). Many doctors feel uncomforTable in dealing with prisoners who are shackled and are either unaware of the ability or unwilling to approach this issue with the prison officers.³⁰

Legislation regarding the shackling or restraint of prisoners will vary between states and countries. In Scotland, for example, the prisoner must remain restrained to two prison officers at all times in the ED and throughout the course of the hospital admission period. Law governs the situations where the removal of restraints is acceptable. Restraints can be removed if the patient is unconscious, anesthetized, being resuscitated, or for "other good medical reasons."³

Cases have been highlighted in which female prisoners have given birth while restrained with chains, raising issues regarding the welfare and human rights of prisoners. Even when restraints are removed, the prison officers must maintain a line of sight with the prisoner and must be present at clinical emergencies such as resuscitation. Staff may be uncomforTable working with prison officers in close proximity, and restraints can present a mechanical obstruction to treatment.

Prisoners are not restrained in all countries. With the issue of human rights being raised, the British Medical Association produced a set of guidelines for doctors dealing with prisoners in the hospital setting.³¹ The main points raised in these guidelines include advising doctors that they can request the prison officers to remove restraints to examine a patient fully and facilitate treatment, unless there is a high risk of escape or violence. In hospitals that treat prisoners on a regular basis, an area of the department should be modified into a secure area for examination. No blanket policy can exist, and all prisoners should be managed on a case-by-case basis.

However, these concerns must be balanced with the state's public and legal responsibility to carry out a prison sentence and ensure the safety of the general public. Management of prisoner patients requires consultation at a local level between the hospital and prison authorities.

MEDICAL CONFIDENTIALITY

Prison officers will be present at the consultation and during treatment. This raises issues regarding the doctor–patient relationship and medical confidentiality. There is a difficult balancing act between confidentiality for the prisoner and the legal responsibility to protect the public. In cases of nonviolent or minor offenders, the police or prison officers may step outside the room to allow a private consultation to take place. However, in the case of serious criminal offenses, the need for public safety will override medical confidentiality. A prisoner may have the right to challenge this in court, an argument best reserved for the legal profession.

COMMUNICATION

If prisoners are referred to the ED by a prison medical officer, they should be accompanied by a referral letter detailing the nature of the complaint, past medical history, medication, and whether the prisoner is high risk for violence. A medical chart from the prison will occasionally accompany the patient. If insufficient information is delivered with the prisoner, contact the prison medical officer. Once the consultation is complete, the prison medical officer should be advised of the outcome and any investigation results with electronic, paper, or telephone communication, as appropriate. In certain situations, liaison between the medical teams may avoid admission because the prison ward may have the facilities to handle continuing care.

When discharging from the ED back to the prison or police custody suite, consideration for the safety of the detainee is warranted. Police custody is no substitute for observation or administration of treatment for individuals who would otherwise be admitted to a hospital.