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.

~Steph