• Prevention Quarter

    Dr. Leah Tatebe

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    Building Collaborative Relationships with Law Enforcement in the Trauma Bay

    Optimal care of the injured patient involves creating a safe place for physical and mental healing in the hospital and during convalescence at home. Trauma Units often serve as the intersection of community services: medical, legal, social, and spiritual. While the patient is a focus of all, the goal of each service line varies and thus priorities need to be established and understood. Silo thinking frequently occurs and conflict can result when interests overlap and priorities are unclear or misunderstood. Trauma patients often arrive with law enforcement in tow for various reasons. Whether the patient is a victim, bystander or offender is irrelevant until stability is established and confirmed. The AAST Injury Prevention committee is seeking to address the often encountered intersection between law enforcement and trauma care during early management of trauma patients. When the patient is hemodynamically normal and willing to converse, there is frequently a benefit to a timely interview with law enforcement. This is especially important for victims of violence where exigent circumstances and the safety and security of others may be a concern. On the other side, when the patient is hemodynamically unstable, the medical priority is clear and law enforcement must yield. The intervening space of the trauma bay is a crossroads for public safety and hospital providers where understanding of each other’s jobs and actions are frequently underappreciated and or misunderstood. When boundaries are unclear, when communication is suboptimal, when pressures exist on both sides, prejudices can appear and conflict can ensue.

     

    During the upcoming AAST Virtual Grand Rounds, “Intersection of Law Enforcement & Health Care. Delineating the blurred lines,” the Injury Prevention committee will address practical ways that we can keep the patient’s best interest paramount while not hindering protection of the community’s interest. Much conflict can be avoided with strong lines of communication between public safety and hospital staff. This starts with a common understanding of each’s needs and priorities so that a partnership can be built instead of, far too common, antagonism. The overall goal is service to the patient, the circumstances and the community.

     

    There are unfortunate cases where law enforcement oversteps bounds in the name of investigation priority while violating patient and staff rights in the wake. Similarly, there are times where prejudice to law enforcement by healthcare staff can create unnecessary barriers for police. Acknowledging this, the scope of this effort is to work to find ethical solutions to common situations. Local and state laws can vary widely, so we cannot provide universal guidance as to specific recommended policies. A universal common ground, however, are the principles of bioethics that can be used to create a framework. It is up to individual hospitals to work with their local law enforcement partners to draft equitable, applicable, and transparent polices that are agreeable to both and service the needs of both healthcare and the law. Escalation of many conflicts could be avoided by real-time knowledge and reference to such hospital policies that have been acknowledged by law enforcement leadership and communicated down the ranks.

     

    We recommend a multi-pronged approach. The first is the establishment of strong lines of communication via liaisons from both the healthcare institution and from the law enforcement agency. We also recommend cross-education for both healthcare workers and for law enforcement. The more each understands about the roles and responsibilities of each other the more likely a strong working relationship. Healthcare workers need to be familiar with the laws and requirements that add pressure to law enforcement. This will also assist them in better advocating for patients when necessary. Similarly, law enforcement needs to be respectful of the priorities and stressors to the healthcare workers and to the patients during and after traumatic events. Although we perceive the trauma unit as “our house, our rules,” it is truly a shared environment and everyone needs to work collaboratively. We also suggest building relationships with all pre-hospital public safety professionals as this reliably serves to decrease confrontation.

     

    When it comes to advocacy, hospital policy and the law will serve as guidelines to work within, but the humanitarian considerations should also be considered. We suggest referencing the four primary principles of bioethics and determining how they can be applied in a variety of situations.

    Beneficence: Do Good

    Victims of violence may wish to speak to law enforcement to facilitate the judicial process, to protect others or to protect themselves. If the injury occurred in or around the home, the discharge plan should include assessing the safety of returning to the environment. Taking intimate partner violence as an example, a patient may be able to be discharged home if the offender is in custody, otherwise an alternative discharge plan may be needed. A prompt interview by law enforcement may also ease the mind of a victim of violence.

    Nonmaleficence: Do No Harm

    The need to protect our patients from harm extends beyond just physical injury. There may be patients who do not wish to speak to law enforcement, and in cases where it is not compulsory to do so, medical staff should support such a patient’s wishes. It may be in the patient’s best interests to control the ebb and flow of information to and from officers. Notifying a patient of a death may be better delayed until the patient’s medical workup is complete so the psychological injury does not mask or impede treatment. It may not be entirely clear to officers why we might request to delay an interview. Similarly, if an officer is standing outside of a curtain surrounding the patient’s gurney, the patient may not feel safe to honestly disclose protected health information or key factors surrounding their injury to the healthcare team and this may impact their treatment or disposition. Collaborative communication and understanding between the trauma team and law enforcement is essential to preserve the patient-clinician relationship.

    Autonomy: Power of Self-Determination

    Patient autonomy is held sacred within the world of medicine. Conflict and moral injury can result when law enforcement requests medical information or intervention without patient consent. For example, most states statutorily require compulsory blood draws when a suspected intoxicated driver causes injury to another. This has long presented as a dilemma to healthcare providers when the patient refuses the blood draw as it frequently puts the providers at odds with law enforcement based on supporting patient autonomy. Hospitals should have a clear understanding of their requirements to comply with such a request, particularly when the patient refuses or is non-decisional. Algorithmic policies covering each of these situations should be developed with hospital counsel, ethics review and in conjunction with law enforcement. Once written, they should be disseminated widely and easily accessible.

    Justice: Fair and Equitable Treatment

    We must protect our patients from discriminatory care within our walls, whether it be from our staff or others. A sex worker who presents with a sexual assault and battery is as entitled to a forensic rape kit collection as a college student. An intoxicated driver involved in a crash that injured the family in another vehicle has the same right to privacy as the family does. A man with gang-affiliated tattoos and a spent weapon on him deserves to have his wounds documented as much as a child hit by crossfire. We must be ever vigilant to ensure that neither implicit nor explicit biases interfere with patient treatment.

     

    The issues are vast and although many are common among institutions, many will be unique due to location and circumstance. These guiding ethical principles can be used as a compass when and if policy is lacking or falling short but should not be used in place of such guidance when it exists. For example, consider how one might approach further issues of informed consent, confidentiality, and right to disclosure. If an officer tries to speak to a patient who had just received significant pain medication or has a known traumatic brain injury, at what point should one step in and advocate for the patient’s right to consent to questioning or inform the officer of such considerations as they may be unaware? What if the patient is a minor? What if officers ask for patient belongings without patient consent? What if they ask for the results of toxicology screens or what the patient said about the situation surrounding the injury before they were intubated for emergent surgery? What we say and do can have legal implications for the patient as well as for ourselves and others. Informed actions backed up by policy and mutual understanding of privacy laws and exemptions will always be the best path.

     

    Outside of the development and dissemination of hospital policies surrounding interactions with law enforcement, one effective adjunctive solution is the integration of hospital-based violence intervention programs (HVIP) to the resuscitative team. Having trained HVIP specialists present during the initial resuscitation and evaluation can be profoundly helpful on several levels. First, they can focus on the patient’s psychological wellbeing during what can be a confusing and terrifying time. Second, they can act as a patient advocate to the medical team and to law enforcement. Third, they are increasingly becoming experts in trauma-informed care and through this approach can build rapport and gain trust of patients facilitating more effective and comprehensive care. By initiating this relationship as early as possible in the trauma care process, it optimizes opportunity for impact on the patient’s physical and emotional state. This can be carried through to more structured interventions during admission and increases the likelihood of continued outpatient involvement with the program. With the medical team prioritizing physical health and law enforcement prioritizing the judicial process, the HVIP specialist can help the patient prioritize their concerns.

     

    Ultimately, hospital policies only help if staff know they exist and where to rapidly find them. HVIP specialists can only help if administration recognizes their significant value and adequately supports their involvement. Trauma staff must prepare for inevitable overlapping interests with law enforcement. As with any conflict that may arise, resolution begins and ends with open and respectful communication. By keeping the patient’s best interests at the focus, acknowledging the importance of protecting community wellbeing, and acting within the bounds of ethical principles, trauma care teams and law enforcement officers can work collaboratively to achieve our respective goals.

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