By Michael T. Puerini, MD, CCHP-A, and Dean P. Rieger, MD, MPH, CCHP
Posted on June 15, 2011 – Jails and prisons house many inmates with histories of violence, sometimes unprovoked. Facilities prepare for the eventuality of individual violence by establishing some sort of emergency response teams, a kind of internal SWAT team, often known by the initials ERT. After force is used to respond to violence, and sometimes simply to respond to resistance, clinical personnel are routinely asked to review an inmate’s health status, to provide treatment, to screen for serious mental illness, or simply to let custodial personnel know that placement of the inmate in a segregation environment is unlikely to result in clinical deterioration or worse. The process sometimes skates perilously close to clinical personnel participating in the physical interventions necessary to maintain a safe environment. And what can we do when the ERT response appears to be disproportionate to the challenge posed?
The principle of beneficence can properly be applied to the care of individuals and to the care of groups. In the case of violence inside a facility, these concerns may conflict. Force is used appropriately to preserve order and security; this creates safer conditions for employees and inmates (our other patients). But the force required may create injuries to the individual patient, and the more force required or used, the more likely that the individual will be hurt. Being conscious of the conflict when concerns for beneficence are applied to violent force utilized to preserve overall safety can help us to understand when the lines are crossed. Consider an inmate who refuses to follow custodial directions. The ERT is mobilized and arrives, dressed in black uniforms, thick protective vests, protective helmets with plastic protective visors, sticks, capsaicin sprays, and other tools. The inmate is rushed and forced to the ground, where he is immobilized and struck multiple times, resulting in injury. You subsequently examine the patient, and the extent of the bruising in the context of about a dozen trained ERT members subduing a single inmate suggests that the ERT may have gone too far. The inmate, not surprisingly, tells you that once he hit the ground the ERT continued to beat him with their firsts. His facial injuries suggest that he may be telling you the truth. Clearly you need to treat this patient, but what else should you do? Should you ask the officers what happened, in effect initiating your own investigation? Should you put your head down and trust that the custodial experts will handle this appropriately? Should you risk antagonizing your custodial partners? This is a difficult position to be in, in part because we are not experts in the application of force. Just as we would look askance at correctional officers wondering why an incision was made just so long and not longer or shorter, the correctional officers look askance at clinical personnel telling them how force should be utilized. Despite that, the principle of beneficence extends not only to the provision of direct patient care, but also to the creation and maintenance of an environment in which risk for injury is kept appropriately to a minimum while safety is maintained. One appropriate response could be to approach a trusted member of the command staff and share your concerns. Command staff also operate under the principle of beneficence, and if you have no command staff that you can trust to have the best interests of the facility at heart, both employees and inmates, then you may have to question your continued service in that setting.
Dr. Puerini is the Chief Medical Officer for the Oregon State Correctional Insitution in Salem, Oregon. Dr. Rieger is the Corporate Medical Director for Correct Care Solutions in Nashville, Tennessee. Readers may contact the authors at mike.t.puerini@doc.state.or and drieger@correctcaresolutions.com.
