Criminal Patients The dilemma of the Hippocratic Oath: Giving criminal patients unprejudiced medical care, while protecting oneself and others from harm. Delaware Today, October 2003 The young man lay on the table, thrashing and screaming at the doctor and nurses who hovered over him. The mix of PCP and cocaine had kicked in. As doctors tried to sedate him, he wrenched his arms and legs. No use. His wrists and ankles were bound tightly with cuffs. He changed his strategy. When one nurse got close enough, he sunk his teeth into her. When she pulled away, he spat at the doctor and the nurses who were tending to him. One of the staff members covered his mouth with a mask. Then they turned back to their task at hand: fixing this kid up. Minutes earlier, he was dragged into Kent General Hospital's emergency department under police custody. Still a minor, he had been picked up on two outstanding warrants. It's not every day, but even in a small-town hospital like Kent General, emergency physicians occasionally work on patients brought in under police custody, as this young man was. Dr. Kelly Abbrescia, the physician who treated him, says she's seen about a handful of other patients brought in under arrest since she began working at Kent General in June. (She transferred there from a hospital in San Antonio, Tex., where patients were brought in from crime scenes almost daily.) Treating a patient who's been charged with a crime presents a number of challenges to hospital staff besides simply tending to the person's injuries. "Sometimes [patients] can be violent," Abbrescia says. "When I was pregnant, that was something I was afraid about, that someone would kick me or punch me. "But I've found the police officers to be very protective of physicians. And we welcome them to be very protective." Dr. Ben Corbalis, a former president and chairman of the Delaware-based Doctors for Emergency Services, says doctors and police officers must strike a fine balance between protecting themselves and protecting the patient's rights. Physicians and police officers can take measures to restrain hostile patients, but "all within reason of the patient's rights and good medical care." "When I was an intern, the police brought a guy in that they had subdued," Corbalis says. "He had two or three lacerations on his scalp for me to sew up. The policeman asked, 'Are you going to give him anesthesia?' I said yes. He said, 'Well I'll help you out,' and gave him a pop on the head, creating another laceration that I had to sew up, I might add. "That's not the kind of thing that can be done." Nowadays, emergency departments are vigilant about protecting themselves from liability. Over the past few years, Abbrescia says, hospitals have changed the rules and guidelines about how doctors may restrain violent patients. Physicians used to use leather straps to tie the person down; Kent General now uses only fabric straps. Physicians must also regularly, sometimes hour by hour, re-evaluate the means and necessity of restraint, to prevent excessive or unlawful confinement. Sometimes, a patient who arrives under police custody just needs stitching up, but if a suspect's injuries are severe enough that he or she must be admitted to the hospital, the police often book the suspect right in the hospital, says New Castle County Police spokesman Trinidad Navarro. "If we're going to charge someone who's going to be admitted [to a hospital], we'd bring a judge in and arraign that person," he says. Once a secured bail is set, the suspect is turned over to the Department of Corrections. Beth Welch, chief of media relations for the Delaware Department of Corrections, says defendants and offenders are restrained at all times, usually with hand and ankle cuffs, during their stays. They're guarded 24 hours a day by two correctional officers: one armed and one unarmed. "The unarmed officer is the one that would come into close proximity with the offender, so the offender won't be able to reach for a weapon," she says. These officers monitor who enters the patient's room. Typically, only medical staff are permitted, although a patient's family may be allowed to visit if the patient is near death. Down in the emergency department, physicians and other hospital staff have even more to worry about, since family and friends often congregate in a common area to await news of a patient's condition. This can present problems when the hospital treats multiple patients coming from the same crime or accident scene. Abbrescia completed her residency training in Philadelphia, where the emergency department would often admit both victim and assailant — for instance, a police officer and a suspect, both with gunshot wounds. Not only must the two patients be separated, but their families must be kept apart in the waiting area so they don't cause disturbances. In Philadelphia, particularly with gang warfare, Abbrescia says, visitors posed a problem. "Gangs would come back to the E.R. to settle a job," she says. Fortunately, she says, Dover doesn't have nearly the amount of crime as some of the bigger cities she's worked in, "but it's the only hospital in Kent County," she notes, so with any major accident or crime with injuries, all parties involved would most likely be transported there. Whatever the patient's guilt or innocence, Corbalis says, physicians must treat him or her with the same diligence as anyone else. "The keystone is that whoever the person is, they're still a patient," he says. "We are not law enforcement officers. It's not up to us [to decide] whether they're guilty or innocent. The perfect example is someone accused of rape. We don't know whether they're guilty or not. We shouldn't inject any of our own opinions into things. "You can't go into those kind of judgments. That's what's so important — that we just remember we're doctors." Shaun Gallagher is Delaware Today's managing editor.