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

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Emergency Medical Services Bioterrorism Bomb, Blast, and Crush Injuries Chronic Pain Postrepair Wound Care Puncture Wounds and Bites

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