The patient arrived in the trauma bay with gunshot wounds to his chest and abdomen. “Doctor, please don’t let me die today,” he begged me.
But I couldn’t give him my full attention, because he was accompanied by two armed officers who were interrogating him and searching his clothing as their body-worn cameras recorded.
I asked them to step out of the room. They refused.
The patient’s blood pressure dropped. His lungs were chock-full of blood that needed to be drained. He received an emergency transfusion as we inserted chest tubes. All the while, the officers moved in and out of our sterile field, capturing additional photos.
The emergency department reflects America’s deepest and most entrenched problems while offering a critical safety net for individuals with psychiatric illness, unstable housing, substance use disorders, and many other chronic structural vulnerabilities. It’s also the entry point to medical care for patients affiliated with the criminal justice system. The ubiquity of law enforcement presence in the ED is a major health equity issue impacting patient care, privacy, and trust. Yet few institutional policies exist to regulate their presence or guide medical providers in navigating interactions with officers.
As is true in other parts of life in the U.S., non-white and low-income communities are disproportionately exposed to law enforcement when visiting the emergency department. Police are a ubiquitous presence in emergency rooms, particularly in county hospitals and trauma centers located in urban, metropolitan areas. These hospitals often hire local law enforcement to provide on-site security services, and in some cases, patrol the ED waiting room. Physicians have witnessed officers collecting stickers (labels that contain personal demographic information) of patients who are not in custody and running background checks to see there is a warrant for someone. Patients may walk into the hospital with medical needs, and leave handcuffed with police.
All of that exacerbates mistrust in the medical system and may violate patients’ privacy and constitutional rights. But we can’t simply ban law enforcement from the emergency department. Law enforcement need to enter the emergency department when accompanying patients in custody, investigating a crime, or if they are called to the scene by the hospital. This results in the convergence of law enforcement and medical staff in the ED, presenting a conflict of interest for patients, health care staff, and hospitals.
Police and medical staff have distinct priorities. Law enforcement’s primary obligations are protecting public safety, preventing the escape of patients in custody, collecting and preserving evidence, and documenting injuries. Physicians who have sworn to uphold the Hippocratic Oath are focused on preserving the humanity, dignity, and privacy of patients. Doctors must also comply with the Health Insurance Portability and Accountability Act, which dictates how, why, and with whom a patient’s protected health information is shared. Hospitals and medical staff violating HIPAA may face financial penalties or imprisonment. With conflicting priorities, this delicate relationship raises unique challenges that impact the delivery of emergency care and/or infringe on a patient’s privacy and constitutional rights.
For example, when faced with resuscitating someone injured by gun violence, doctors must make clinical decisions expeditiously, yet law enforcement’s investigation disrupts medical care. In an exception to HIPAA, state laws commonly require medical staff to share protected health information with law enforcement when the case involves gunshots and/or stab wounds. But in the absence of hospital policies dictating how or when this information should be disclosed, I’m left uncertain with what to do when an investigation occurs during the lifesaving resuscitation of the patient and the officer refuses to leave.
By jeopardizing the sanctity of the patient-provider relationship, the routine presence of law enforcement in the ED compromises trust in the health care system. I’ve felt intimidated and cornered by police in many situations, and I can’t imagine how my patients feel in these uncomfortable scenarios. The perception of a doctor-law enforcement alliance is unsettling for communities that have negative experiences with police. Police use-of-force is a leading cause of death for Black men. Black children are more likely to be injured by law enforcement than any other group. Representing only 13% of the total U.S. population, Black people represent 40% of the incarcerated population. Fearing retaliation and/or deportation, undocumented immigrants who rely on the ED for medical needs may similarly question our allegiance and/or avoid the medical system altogether.
A safety net in a broken health care system serving medically and socially vulnerable populations, the ED must remain a place of hope and healing. So health care institutions and providers need to establish interdisciplinary and equitable policies that emphasize patients’ dignity and autonomy. Everyone needs to get a seat at the table when developing these protocols — frontline workers, community and patient advocates, law enforcement, hospital leadership, and risk management.
For instance, hospital protocols might require that law enforcement minimize disruptions to the resuscitation of an unstable patient, step out of the treatment area when providers perform a physical exam, and routinely turn off body cameras upon entering spaces where care is being rendered. In an effort to uphold accountability, hospitals should have a portal where health care staff document incidents involving specific law enforcement personnel that may have adversely impacted patient care and/or privacy. And hospitals should invest in non-carceral, trauma-informed approaches to de-escalation and crisis management. This investment should be directed towards increasing unarmed hospital security personnel, behavioral response teams, social workers, legal advocates and building robust hospital-based violence intervention programs.
I had another uncomfortable encounter with police the other night when a young man walked into the emergency department after he was shot. I asked the officers to stand outside of the trauma bay to respect this patient’s privacy while we stabilized him.
“This man is a criminal. Criminals have no privacy rights,” the officer said as he refused to move.
Once again, the lack of clear guidelines left me in a vulnerable position and could have led to conflict with law enforcement. I shouldn’t have to handle these issues on a case-by-case basis, and neither should my colleagues. Hospitals need to clearly delineate the roles of law enforcement in the emergency care setting.
Sally Mahmoud-Werthmann is an emergency medicine physician at Stanford Medicine. She is also a part-time emergency physician at Zuckerberg San Francisco General Hospital. She specializes in social emergency medicine, a discipline that examines the intersection of emergency care and social and structural forces that influence health outcomes.