As an Emergency Medicine Physician and EMS provider, I get a lot of questions about my job. #1 “What’s the worst thing you’ve ever seen?” #2 is “How do you stay motivated and not let it get to you?” And #3 is what I’ll address in this post, “How do you take care of murderers, rapists and other people who have done horrible things?”
It’s an unfortunately common scenario: high-speed MVC, multiple vehicles, one DOA (dead on arrival), two adults in critical condition, being flown by helicopter as the highest level trauma alert, alcohol involved. And all too often, Paramedics, Nurses and Physicians have to take care of everyone involved, including the intoxicated driver that caused the mayhem. How do you have compassion, empathy and care for someone that by all evidence just killed someone in a completely preventable way? I’ve been in Emergency Medicine for 11 years, and I still struggle with this. It’s never easy, but I’ve found a few strategies to help cope.
1. Don’t Ask, Don’t Tell
A few months back I was taking care of an ICU patient that I knew was a prisoner in a maximum security prison due to the vigilant watch by 2-3 armed security guards at all times. Clearly he had done something bad, but for me, knowing exactly what would only potentially worsen the medical care I could give him, not improve it. So I didn’t ask, I didn’t Google. Unfortunately someone else did, and shared it with the whole team.
Turns out he beheaded a total stranger, a husband and a father of two, because he didn’t have cash in his wallet when he tried to rob him. Once I learned that, I couldn’t unknow it. I struggled to walk in his room each morning with a smiling face and open, non-judging mind. For the human in me, it was a battle I had to consciously fight. My advice to anyone who might care for inmates or anyone in police custody, don’t ask, and encourage the whole team not to ask. And if you find out, don’t tell. 99% of the time it’s not relevant to patient care, and can only cause you (and everyone else on the team) to make mistakes.
2. Be an Advocate
Incarcerated people have difficulty accessing medical care. Although prisons and jails have a medical clinic, studies show that prisoners get less frequent and timely care for both chronic and acute conditions. A 2009 report published in the American Journal of Public Health, unearthed some worrisome stats:
“Among inmates with a persistent medical problem, 13.9% of federal inmates, 20.1% of state inmates, and 68.4% of local jail inmates had received no medical examination since incarceration.
Prior to incarceration, slightly more than 1 in 7 inmates were taking a prescription medication for an active medical problem routinely requiring medication (as defined in the Methods section). Of these, 3314 federal (20.9%), 43 679 state (24.3%), and 28 473 local jail inmates (36.5%) stopped the medication following incarceration.
Only a small portion of prison inmates (3.9% of federal and 6.4% of state inmates) with an active medical problem for which laboratory monitoring is routinely indicated had not undergone at least 1 blood test since incarceration. However, most local jail inmates with such a condition (60.1% [SE = 1.8%]) had not undergone a blood test.
Following serious injury, 650 federal inmates (7.7%), 12 997 state inmates (12.0%), and 3183 local jail inmates (24.7%) were not seen by medical personnel.“
Incarcerated persons have to “prove” to prison staff they are truly sick and need to go to the Emergency Department. Yes, many prisoners fake or exaggerate symptoms for the secondary gain of getting a break from behind bars: better eye candy, different food, and maybe some good pain medication. But, 38-43% of inmates have chronic medical conditions, which by all evidence, may not be properly addressed and managed by the prison clinic. When these patients present to the ED, I play it safe and assume they have been sick a few days longer than a regular person, as they probably had to fight to make their case to prison staff. Guilty or innocent, these patients all need an advocate for their medical care. I take pride in being that person, which allows me to keep my personal judgements out of the encounter.
3. We are guilty, too
Last week I took care of a woman addicted to IV heroin. By all accounts, she was pitiful looking – shivering, sweating, unable to sit still. She was also curt, demanding and liked to cuss at us. The medical student with me asked how someone could make such poor choices and then be so demanding. I didn’t disagree, and I found myself starting to judge. I had to redirect my thoughts and remember that prescription opioids can be a gateway to heroin for many people. Heroin is 1/10th the cost of prescription drugs bought on the street. People get hurt or have surgery, and we (doctors, NPs and PAs) prescribe them pain medication. When people can’t afford their prescription drug addictions, they turn to the cheaper alternative. And who writes the most prescriptions for these drugs? Us. We contribute to this, so we need to accept treating it.
That’s my limited advice. It’s still a daily struggle, with some days easier than others. Do you have any tips to offer on how to approach this difficult patient population? If so, I’d love to hear them. I encourage you to comment below.
3 thoughts on “Caring for criminals: How to provide good medical care to people who have done bad things”
……… well…….. my unsolicited 2 cents on it……. this is one of those situations where ignorance is bliss. I do not want to know what they have done or why they are there. When I get their packet of information from their facility I skip over the offender information sheet. This helps me not to glance at their offense so that I can focus on the person lying on the stretcher in front of me and not the offense they commited. I have often found that prisoners are fairly well behaved if you treat them with respect and satisfy their needs. Otherwise, you can have a very long, intense shift was a very dangerous and crafty individual. Lastly, I try to remember that they are human beings. As cliche as that sounds, I have to remember that I still have a human being lying in front of me. The nurse in me cannot purposefully watch another human being suffer and not offer my expertise. I have taught continued education classes in a Level 1 prison for the nursing staff there. This is a very scary place. The worst of the worst criminals are housed here. Let’s just say that the offender treatment stories I have heard and witnessed are sometimes just as horrific as the crimes they have committed. Lastly, I believe in reform. Often times, the people who have committed these crimes are not the same person who is lying in the stretcher in front of me. Abuse of drugs and alcohol are often the main contributors that have landed the offender where they are, coupled with imaturity and poor judgment . Additionally, noncompliance with their mental health regiment is also a leading contributor as well. When the offender has a long stretch of time to “sober” up (years), it provides perspective and an opportunity for clarity that during their “binging” phase, they where too impaired to imagine. So, call me optimistic, but I do believe that people can change and turn their life around. I do believe offenders can pay their debt to society and are able to reform. Will this ideology apply to all….. absolutely not, but I do believe people deserve a second chance or the opportunity to make it right. A former offender once told me….. “Prison will teach you two things, either you never want to go back, or it is where you belong”. I try to treat my patients like they are the ones that never want to go back and are paying their debt to society in the meantime.
All great points Ms. Brown – thanks for commenting and sharing your advice and experience. Another thing I thought of was to ensure the patient is accessible for a proper exam and associated therapies. Often there’s reluctance to remove or reposition handcuffs, but it needs to happen to ensure a proper assessment can be made.
A very thoughtful post on such a difficult topic. I’m obviously not in the medical profession, but this was still an interesting read with a unique perspective.