Behind ER Doors: Police, Patients, and Privacy

So maybe I should be talking about my healthcare experience a little bit more , which was what the podcast was intended for from the very beginning . So this week I'm going to kind of continue that conversation , based off of a listener's questions around that . So if you want to hear more about the ER experience and the listener's questions , then this .

Welcome back to another episode . So this is a continuance of last week somewhat .

So I haven't really advertised this or discussed this a lot , but the hosting site for my podcast started a few months back allowing what they call quote unquote fan mail , and you can find that by going to the show notes on any platform , whether you're listening on Spotify , apple , wherever you're listening .

You just go to the show notes and it says send fan mail and you can send questions in that way and they're completely anonymous . So I don't even know who it is sending them . It just gives me a state where it's coming from . So I know this person who sent in a few questions is from Tennessee . So maybe one of my high school friends that listens , possibly .

So if you do want me to know who you are and your questions , definitely send them to me via my Instagram that way . But if you want to remain anonymous and you want to send in either comments or questions about episodes or something you want me to do , an episode on this is a great way to do it . You can also give me constructive criticism .

Please don't be mean . We don't need that in our lives right now . The world is already in enough chaos . But if you want to give me constructive criticism or notes that you want me to do , or just guests you want me to have on , it's a perfect opportunity to do that . You can still send me questions through my Instagram account . That's fine too .

That's where most of my questions come from . But I didn't realize that last week's episode talking about the ER would spark so much interest and have y'all all kind of engaged , so I really enjoyed that .

I actually was talking to one of my friends , val , who's been on this podcast before , worked in the ER with me , and she would like to do a follow up on that as well and just tell kind of stories that we've experienced so that one would kind of be a fun one to do . So whenever we can get our schedules coincide , I think we'll do that .

But anyways , that was a long winded response . To say , I got a few questions about last week's well , not about last week's episode , but to continue , last week's episode talking about the ER . So I'm going to read the questions and then I'm going to kind to kind of dive into that a little bit .

So the questions were if I could discuss how law enforcement is involved in the hospital , how do you balance the information police need to conduct their investigation versus what you need to know medically ? For example , is it medically relevant to know if they've taken drugs but the patient doesn't want to discuss that with cops ?

How do you handle a combative patient and how do you handle a patient transferred from jail or prison ? So we'll start with the first ones about law enforcement in the hospital

. And again , when I talk about stuff like this it is my experience , what I was told in training and then I did do a little bit of research because I didn't want to state any non-factual information . But if you hear anything that I state that you that I misstate , definitely reach out , let me know .

I'm just going to read off to you part of my research and then I'll kind of explain in examples of what we dealt with when I worked in the emergency room . So there are laws regarding police , as presidents in the ER , depending on federal and state regulations .

So each state will be different , obviously and I am here in Alabama , so this is just from my experience here . But , number one and first and foremost , there is patient privacy and HIPAA laws .

So if you're not familiar with HIPAA , that stands for the Health Insurance Portability and Accountability Act and it just means that the patient has a right to their own privacy . And if people are spilling quote , unquote their privacy , whether they're talking out in public to their friends about it or anybody that does not need to know the information .

So what they consider need to know information is the people working on you in that moment . So again , I'm referencing the emergency room , and you have a doctor , a nurse practitioner , physician's assistant , you have a nurse , a technician , pharmacy , consulting surgeons , whatever it may be .

If they are working on your case , then they have a need to know ability with your chart . So that is not breaking HIPAA because you're sharing information with people that need to know . That is not breaking HIPAA because you're sharing information with people that need to know .

When you break HIPAA , it's like if I were to leave the hospital , go talk to my friend about it , say your name , your date of birth , giving patient identifying information then that is breaking HIPAA .

When you give like if I give examples on this podcast , it's not breaking HIPAA if you're not giving patient identifying factors so you can't give too much information where someone could go oh , I know exactly who you're talking about because that then would be considered breaking HIPAA .

So under this HIPAA Act , hospital staff cannot disclose patient information to law enforcement without patient consent , so the patient would have to consent to do that , unless there are some exceptions , and the exceptions would be the police have a court order , a subpoena or a warrant for your arrest and they show that and provide that .

So then we have to obviously abide by those federal and state regulations on giving need to know information .

If the patient is suspected in a crime , so like gunshot wounds are mandated reporting and I know that it was for us in Alabama , so like if a level one trauma came in and it was a gunshot wound or a stab wound or something like that , and it didn't necessarily have to be a level one trauma .

It like even if you got grazed or something like that , gunshots had to be reported , because then it becomes a public safety issue . So that is reported to police and they become the need to know information as well . Other examples would be if the patient is unconscious or incapacitated and disclosure is in the best interest of public safety .

So again , if it was something that was trying to think , so like we don't know . So , for example , it's not like if you come in with a drug overdose and you're unconscious , we're not calling the police and saying , hey , you might want to get up here , someone had a drug overdose . We don't do that .

It's only when it's like a patient safety thing or it's a need to know information . It's only when it's like a patient safety thing or it's a need to know information . But then the second ruling , and where police enforcement would be involved , would be with the EMTALA and Patient Care Act .

So EMTALA stands for Emergency Medical Treatment and Labor Act , and hospitals must provide stabilizing treatment before law enforcement can take custody of a patient . So , for example , going back to the gunshot wound , if you are a level one , trauma like that's the worst trauma you can be in .

Right , you're the most critical and you have a gunshot wound to the chest , like usually a level one is considered when you're having like a gunshot wound to very vital organs the chest , where your heart is , your lungs are , the abdomen , where you have your aorta and large vessels that could cause you to bleed out without emergent intervention .

And then some like in the legs , where your femoral artery is and stuff like that . So anything that's going to cause you critical access and you need stabilizing immediately . And there are certain criteria to meet a level one . But usually if it's in those areas , you do meet criteria to meet a level one .

But usually if it's in those areas , you do meet criteria . Um , so if you come in and you let's say it was a gunshot wound and the police were already with you because they were on scene at the time , then yes , the police have a need to know and that's a mandated reporting .

So we would cooperate with police investigation and there's certain things that have to be done when it is like um , like let's say it's a gun shootout or something like that , then you know you have to be done .

When it is like like let's say it's a gun shootout or something like that , then you know you have to be very careful about how you cut the clothes off of the patient . You have to bag them for evidence , stuff like that . And then there's certain protocols that you have to do to follow compliance with investigative , like the investigation that's going on .

Like certain drug screens have to be a certain way just to see , like so we have to follow protocol there as well . But with the mtala and patient care you still have to stabilize the patient first . We're not just going to say , okay , take them , you know , take them to jail .

No , you have to stabilize the patient and police cannot interfere with the necessary medical care . So they couldn't come in and say , well , he's , he's under arrest , I'm going to handcuff him to the bed . That can't be done if it's against , like their patient safety .

So patient safety is always first , even though hospital staff are required to be compliant with the police investigation at that point . The third thing would be warrants and consent . So police cannot force entry into the ER or patient rooms without a warrant or exigent circumstances or the patient's consent .

So , for example , going back to what I said earlier , if you come in with a drug overdose , like we know , drugs are illegal we're not just automatically calling the police and saying , hey , you should know , this person took so much fentanyl , right ?

Because that is going against the HIPAA Privacy Act , because it is your right for us to talk about that together as a collaborative team . That is not a reportable event to the police .

So let's just , for example , say the police were already in the ER because of a level one trauma gunshot wound , so they were already there and then they see someone they had a warrant for roll by . This does not give them immediate access to your care or what's going on with you .

They are not allowed to forcefully enter your room and ask you questions because they don't have a warrant for the hospital . So I hope that makes sense . So just because a police officer has a warrant for a person and they happen to see them in the emergency room does not give them access to you because they did not go obtain a warrant to the hospital .

So , for example , a warrant for a person's arrest allows police to take them into custody after they are medically clear , but it does not give them access to medical records or details about their condition . So they cannot ask the nursing staff like , hey , did you do a drug screen on them ? What did it say ?

Because the hospital staff are not required to answer that question . Because it is not about even

though they have a warrant for the person and they've been medically cleared , they do not have a warrant for the hospital and the medical records . So until they present with a hospital like a warrant for a hospital and medical records , then nursing staff are still not to break HIPAA . Okay , so that's how that works .

But there are mandated things that have to be reported and it's very state by state . So I can only speak about Alabama , since that's where I worked for most of my career . But in Alabama , emergency room personnel are legally required to report certain types of abuse .

We already talked about the stab wounds and the gunshot wounds that are also mandated to be reporting . But the primary abuse that Alabama ERs are required to report is child abuse and neglect . So there's a Alabama code for this that healthcare professionals , including those in the ERs , must report any known or suspected cases of child abuse or neglect .

That can include physical , emotional or sexual abuse , as well as neglect such as failure to provide adequate food , medical treatment , clothing or shelters . Reports should be made immediately by the telephone or direct communication and followed by a written report to the authorities . The second one is abuse , neglect or exploitation of elderly or disabled adults .

The Adult Protective Service Act of 1976 mandates that health care providers report any known or suspected abuse , neglect or exploitation of elderly or disabled adults . This includes physical harm , financial exploitation or failure to provide necessary care . And then we talked about the gunshots and stab wounds .

So yes , so when I said earlier some states do burns , that's not on the Alabama reporting .

So the gunshot and stab wounds require well , actually it says , while Alabama law does not explicitly require the reporting of gunshot and stab wounds by healthcare providers , it is common practice for hospitals to notify law enforcements when treating such injuries , especially if they are related to criminal activities , which is what we always did .

Typically , when it was stuff like that , like level one traumas , gunshot wounds , the police were already there , like sometimes they were bringing them in for medical care and then sometimes they were following right behind the ambulance because they were on scene . So usually it's not even the fact that we have to report it .

It's already been reported and they're there and we have to cooperate in the investigation . Another type of abuse Alabama law requires is domestic violence .

It does say that Alabama law does not specifically mandate health care providers to report cases of domestic violence unless they involve injuries that fall under other mandatory reporting categories , such as child abuse or vulnerable adult abuse . Courage to offer support and resources to victims of domestic violence , which is typically what we do .

If you are worried about domestic abuse , then you would get a social worker involved . You would get them like certain situations um pamphlets or stuff like that . For example , if you do watch the Pit , after listening to it there was . This was actually a good . This is why I actually liked this show , because it had a really great example .

There was someone that was . You could tell they were being abused by their employer and whether it was , I think . I think in this situation they thought they were being human trafficked , but there was nothing they could do if the person didn't want help , like , hey , give me two winks if you need help , you know .

But this person was adamant that she was fine , that her employer quote unquote employer was not abusing her . But she was just acting very strangely . And so this woman , you know , kept trying and trying and trying . She even separated them by taking her to CAT scan and try to talk to her individually , and the person was still adamant , like no , I'm fine .

And try to talk to her individually , and the person was still adamant , like no , I'm fine , there's nothing wrong . All this stuff , right ? So you also have to do what the patient wants . So you can't force someone to get help if they don't want to help , because then that's going against their rights as well .

But you can try to talk to someone and do everything you can . So ultimately she just handed her a pin that when the pin opened up , there was a phone number for a hotline to get help if you wanted it .

So that way it wasn't an obvious pamphlet on abuse , but there was a secret way to be like , hey , if you ever feel like you want to talk to someone and you're ready to talk to someone , here's a way to do that . But I want to look up specifically human trafficking in Alabama , because that is something else .

I'm not sure if it's reportable or not , but let me look . Okay , so in Alabama the law does not explicitly mandate health care providers to report suspected human trafficking cases involving adults , it is considered best practice to do so . Health care professionals are encouraged to report any suspicions of human trafficking to the appropriate authorities .

So it's saying adult , so I'm not sure if it's a minor , that goes back to child abuse and neglect . So you probably would be mandated because all of this is intertwined . So that's why a lot of hospitals have social workers to let you know the rules and help you kind of navigate that .

So if you're suspecting something , I know we would always go speak with our social workers to be like , hey , this is kind of off Like can you come help me talk to this patient , can you help me follow the law ? And there's so many people to help you .

So those are the things that I know are reportable where you have to follow you know investigative reports and police officers . But the one where you absolutely do not is the one I spoke about earlier .

So , like I said , if you're a drug overdose or you know you use drugs and you you're having side effects , don't be afraid to go to the ER because you're like well , what if someone gets a hold of my medical records ? They're not allowed to do that .

They have to have a warrant for your medical records , like we can't , for I mean we can't even call your job and say hey , by the way , you should let so , and so know that they do drugs . That's illegal with the HIPAA Act . So you wouldn't have to worry about that . So I hope that answers that question about the police enforcement in the hospital .

Oh , one thing else I wanted to touch on , since I'm not getting too political . One day again maybe I'll sit down and talk about politics , but today's not the day when it comes to immigration in the ER .

If an illegal immigrant comes into an emergency room and then gets admitted to the hospital , ice nor the police , like if they find out that someone is at the hospital and they're illegal immigrants , they cannot come in and ask about the patient . They cannot take the patient Again . That goes against HIPAA , that goes against EMTALA

, because EMTALA protects all patients . Hospitals must provide emergency care to anyone regarding immigration status and that would fall under the HIPAA Act . If , because hospitals cannot share a patient's immigration status with that would fall under the HIPAA Act .

If , because hospitals cannot share a patient's immigration status with law enforcement unless the patient consents , there is a valid warrant or subpoena for the medical records , or if there is a patient public safety threat due to this patient , like a suspected violent crime , like this person was shooting someone else you know something like that .

So hospitals are considered sensitive locations . So under ICE's sensitive locations policy enforcement action should not take place in hospitals again , except in rare cases , such as you know , public safety , national security threats , imminent danger , or if they have a warrant or subpoena to do so .

So I know there was a lot of things going around recently about how ICE was invading hospitals and healthcare workers were just letting them in and letting them know that the patients were there . This is actually illegal . So you need to look up the law in your specific state . This is specific to Alabama , but I'm pretty sure it's a federal law .

So you need to look up the law in your specific state . This is specific to Alabama , but I'm pretty sure it's a federal law . So I would just make sure you're looking that up , because it doesn't say like per Alabama , it just says federally .

So when it comes to working in the ER , hospitals do not have a legal duty to check or report a patient's immigration status . Asking about immigration status could discourage patients from seeking care . So we don't even ask , like that was never something we asked . We never knew at all , period .

Someone's legal , not legal we don't ask , we don't ask for , you know , green cards , we don't ask for that . Most of the time they ask for a driver's license if they have one . If they don't like , and there's some people that are citizens that don't have their driver's license , like I know .

I went to the ER with my friend a few days ago to sit with her and she forgot her driver's license at her house because obviously she needed to go to the ER .

She was stressed out , she forgot her wallet on the counter and she didn't have it , and so it's not required to have those documents when you go into the ER and we can't say well , if you don't have this , we're not treating you , because again , we have to take care of every patient .

So now I'll say I hope I answered that question about the law enforcement in the hospital . That was a long winded response . I'm sorry , but I just wanted to make sure I gave you factual information . And then the second question was how do you handle a competitive patient ? So this could be nuanced and again you have to follow hospital policy .

Every hospital is going to be different . Our hospital offered a class called MOAB , which stands for management of aggressive behavior . It's a training for hospital staff . Basically , you're trying to prevent or deescalate an aggressive or violent situation or combative patient before it gets to a level of where you're having to take you know care .

I will say that our hospital in particular would say that you know , if someone's being combative and you're doing everything to deescalate or prevent it and they still become combative , that we're still not allowed to use what's the word self-defense measures , like okay , if someone gets to me , punches me , like I'm not allowed then to then punch back .

That's just hospital policy . The policy is to call you know security and try to get someone to what's the word intervene , I guess . So a lot of times we would have , we would call security . A lot of the doctors you know obviously are male .

So they would come in and the male nurses would then , if they had to get the patient away , pin them down using Moab techniques . They would pin them down waiting for security to come or get them back into the hospital bed and use restraints . Those type situations is how we handled it at our hospital .

They just say that we're not supposed to use self-defense and that's due to limitations , right ? So there's still legal and ethical and professional standards , even though you're trying to defend yourself . So there's , and I'll read off to you , like the different things that they say for this reason . Number one would be duty of care versus self-defense .

So healthcare workers have a duty of care to the patients , even if they are aggressive or violence . Unlike law enforcement , hospital staff are expected to use de-escalation techniques . That's why we have the MOAB training . Number two there's legal and liability issues .

Many hospitals prohibit staff from retaliating physically due to legal risks , and I know that was the case at our hospital . We were not allowed to retaliate physically .

You cannot use force against a patient , even in self-defense , because it could potentially lead to lawsuits to the hospital , termination of you from the hospital or criminal charges , which is honestly crazy if you think about it . Because , again , as last week when I used the example

of you know there's no other place of business that you can walk into and physically assault someone . But when it comes to medical care , there are certain things you just cannot do , because you cannot turn someone away from medical care , because that's a whole liability in itself .

And then sometimes patients are being aggressive or agitative or combative because it is a medical reason , like so , for example , sometimes if you're having a head bleed , you are a completely different person and you could become combative or whatnot , very easily . There was one time I was working , which we were very fortunate because it was okay .

I just so we were working and a patient came in unconscious . And when someone comes in unconscious you have to , you know , go through your differential list like is this drug overdose ? Is it electrolyte abnormality ? You just kind of have to go through your differentials .

So the first thing and the quickest thing and easiest thing to do is give some Narcan to see if they wake up , which is going to counteract any opioid it's not going to counteract benzos , but it'll counteract the opioid and then they're going to wake up and then you've solved the issue , they're now awake and then you just have to monitor them right .

So that's the quickest and easiest way to test that theory , without waiting on a UDS to come , which is a urine drug screen .

And so this one time we gave Narcan to a patient and because he came in unconscious and he didn't go through like walk in through the ER where there was metal detectors , and when you're a critical patient , obviously you're not going to stop and be one down by security because you're unconscious and you need ventilation , support , respiratory support , because you don't

know what's going on at that moment . And he came in by ambulance and so that was the first thing we did . You know we do like we do cut the clothes off , put the IVs in , put them on the cardiac monitor and then the first thing we did was , hey , let's give some Narcan , see if it wakes him up .

If not , then we're moving on to the next step , which is intubation , trying to figure out the cause , right ? So this patient we gave Narcan to immediately woke up , didn't know where he was , so he was terrified and unfortunately for us , he had a gun in his pocket and that's immediately where he went to grab .

But fortunately for us , security was there and was immediately able to stop before anything occurred .

So sometimes , when patients are combative or aggressive , there could be an underlying medical cause , like you know , if they're , if they don't know why they're there , and we wake them up , if it's a psychiatric patient , like a true schizophrenic bipolar , and that's something that they cannot control .

But but then again there are some patients that are just combative because they're mad at the staff , they're mad at the wait times and again , still not . And again it all goes back to hospital policy . But I would assume 99% of hospitals are going to say you cannot physically retaliate .

So the third one again since we're going through this checklist , is hospital policy and training , training focusing on deescalation , which most hospitals use the Moab that I talked about .

There's another training called CPI , which is Crisis Prevention Institute , and then there is PMAB Prevention and Management of Aggressive Behavior and all of these are just working and teaching you . You know de-escalation techniques , calling security and then using safe restraint methods , which is typically what we did . Like , again , you try to de-escalate them .

You're not going to start yelling back like if they're yelling profanities at you . You're not going to turn around and start doing the same thing , because that's going to agitate them even more . This is where you have to really focus on patience and not worrying about what someone is saying about you .

Sometimes you have to turn around and walk out and just shut the door and let them calm down . Maybe it's sometimes getting a new nurse , because y'all just aren't jiving . But if it does get to that physical point . That's when you have to like , and usually like if someone's starting to yell , we immediately call security .

So we're not waiting until they're physical , because then security is there and they have different policies for them , because it's security and law enforcement . At that point our particular er always had a law enforcement enforcement agent on duty . Well , I wouldn't say always , but most of the time . Most of the time there was a law enforcement agent on duty .

Well , I wouldn't say always , but most of the time , most of the time there was a law enforcement agent that sat at the front like in triage and kind of just monitor people coming in and out and if things went south , they they would come with security and number four . The reason why we can't is because it's security and law enforcement role .

So most hospitals expect staff to call security or police instead of using force , because security teams have different policies and they are trained to physically intervene when necessary . And then exceptions when self-defense may be justified would be if a patient is actively assaulting a nurse and there is no other escape .

Minimal and reasonable force to protect oneself may be allowed . But this would have to be like your only option pretty much . Self-defense must be proportional , like blocking or escaping , rather than striking back . So sometimes that's what we would have to do .

Sometimes it's you run as fast as you can , you get out of the room and you shut the doors and leave them in the room to destroy the room and not someone else . Sometimes we use that tactic as well . Some states provide workplace violence protections for healthcare workers , but the laws vary . So that's the explanation on that question . I hope that answers .

I know it's not direct , but it's just crazy because we know that there is a lot of nurse abuse out there and these policies are in place . But I can understand them because of it being different than just walking into , like a restaurant or Walmart or something like that .

But at the same time , it's like you also sometimes fare for your safety at your job , and who wants to do that ? And then the last question was how do you handle a patient transferred from jail

or prison ? So ? So basically , you're just going to handle them like you would any other patient , right ? So you're going to treat them with respect .

You are going to um protect their HIPAA rights , their EMTALA rights , any other rights that they have while they're in the hospital , and you're just going to treat them like they're any other person , and sometimes it's , sometimes it's scary .

Sometimes you know you have people coming in from prison for you know capital one murder and you're scared , but there's always a police officer with them . So the police officer stays in the room with them or right outside the door with them .

Usually they have them handcuffed either at both ankles or you know one wrist to the stretcher , unless it's something where that has to come off , like if they're having seizures or let's say they got in a fight in jail and now they need stitches and it's actually you know , and the handcuffs are then going to prevent , or if the handcuffs become a safety issue .

So if it's a safety issue , those have to go . We can use softer strengths if needed , but you just treat them like anyone else and most of the time they're very nice . They're , you know , just like any other patient and you have to just treat them . And that's one thing about being a nurse , right ?

And that's one of the things that I talked to the other day . It was a political statement with a friend . Like my job , no matter what my politics are , no matter what my religion is , no matter what my belief system is you have to check it at the door . Being in healthcare , you you do not deny care .

You do not treat someone differently just because of the color of their skin , the religion they believe in , if their immigration status is illegal or not . You treat everyone the same .

And if you can't do that , then you should not be in healthcare , in my personal opinion , because everyone deserves the same respect when it comes to treating them and trying to find out their diagnosis .

And that goes for like if you do or don't have insurance , like we're not going to not see you , we're not going to deny your care , we're not going to not run tests unless you ask . So some patients will be like , hey , I don't have insurance , can we keep the testing to minimum ? And then you're respecting their boundaries but you're also providing care .

So you just that for that question , that you just treat them like any other person , like you would if they weren't in custody or in jail . So I hope that answers all

your questions . Again , I appreciate the fan mail that you sent in . If anyone else has any more questions or wants me to continue this type of content , then definitely shoot me some fan mail or go to my Instagram . So it's quote , that's what it's called . It's called fan mail .

But if you go like to the actual episode , on whatever platform you're listening to , you just click on the episode and scroll to the bottom and there's like a purple link . Well , this is the Apple app . There's a purple link that says you can now send us a text to ask a question .

So you just click on that and it takes you to the place where it would text and it sends it to me via email and again , it's completely anonymous , so I don't even know who it is . It just tells me like , hey , this person from Tennessee is asking these questions .

So if you want again , like I said at the beginning , if you want me to know who you are and you want me to give you a shout out happy to do that just send me an Instagram link which my Instagram link is in the show notes as well or a direct message , and I will do my best to get all your questions answered . Sometimes I'm not the expert .

It would have been great if I had a law enforcement agent on here with me to kind of discuss this with me , but by the time I sat down , I do have a friend that is a police officer that would have gladly sat down and talked to talked about this episode with me , but time's been time constraints and stuff like that , so I hope that I answered all your

questions without boring you to death , and I hope that I answered them all accurately . If I misspoke at any point , I do apologize . I can only speak from my personal experience and the research that I conducted prior to this episode . So , as always , guys , thank you for listening and until next time . Bye , thank you .