Care of the Forensic Patient in Hyperbaric Oxygen Therapy
A forensic patient is one who is under the legal custody of law enforcement or correction facility. The United States has over 2 million individuals who are incarcerated.1 Of these individuals, 800,000 were found to have chronic conditions requiring medical care. Comparatively, incarcerated patients have double the chronic disease burden than that of the general population.2 The Supreme Court Ruling in Estelle v. Gamble (1976) ensures that all incarcerated patients have a right to medical care. This right has required the correctional health system to send more patients to local hospitals for care which, ultimately, could include hyperbaric for acute or chronic conditions. Some of the chronic conditions identified at high levels in the incarcerated patient population are diabetes and cancer–two conditions that often precipitate the need for hyperbaric therapy.
“The proportion of inmates reporting having ever had diabetes or high blood sugar in 2011–12 was 899 per 10,000 prisoners, almost twice the rate reported in 2004 (483 per 10 000).”3
“Incarcerated individuals were diagnosed with cancer at a later stage more frequently compared to those recently released or never incarcerated.”4 “Cancers originating from the gastrointestinal system...were the most common cancers in all three groups (incarcerated, 25.5%; recently released, 32.8%; and never incarcerated, 17.8%, respectively). Other cancers commonly diagnosed among those incarcerated included those in the thoracic region (97% of which lung), the male reproductive organs (62% were prostate), and leukemia and lymphomas.”4
In the United States, we need to be proactive in providing safe, efficient, high-quality care for this specialized patient population to reduce evident disparities. In this article, we will discuss: care of the forensic patient in the multiplace hyperbaric chamber, challenges in this population and recommendations for standard of care and policy creation. Once a referral for hyperbaric therapy is initiated, the consultation should be initiated in a timely fashion, comparable to the general population. These patients may come to the hyperbaric facility as an inpatient or outpatient.
During consultation, the hyperbaric staff discusses the risks and benefi ts with the forensic patient. Also, one must be cognizant that these patients still maintain the right to refuse treatment if desired.
“All patients, including prisoners and their appointed surrogate medical decision-makers, have the right to be properly informed of medical conditions, prognosis, diagnosis, risk and treatment alternatives through the process of informed consent.”5
After completing the consultation, if treatment is deemed necessary and desired, discussion will occur with the correctional facility point of contact for coordination of transport times and/or availability of transport to the chamber for treatments. Based on the security level of the forensic patient, conversations will occur between chamber staff and the correctional facility regarding safety and security measures. Receiving medical treatment at outside facilities creates a high-risk situation in the transport of the forensic patient, which is why there are regulations and procedures to ensure no unnecessary harm occurs.6 During transport, every eff ort should be made to avoid co-mingling between the forensic patient and the general population.
Throughout the duration of transport and treatment, the accompanying law enforcement officer should maintain direct line of sight of the forensic patient. Although the officer will not be in the chamber with the patient, all measures will be taken to ensure the safety of the forensic patient, staff, and other patients during the treatment.
Working with a forensic patient presents unique considerations which need to be addressed prior to the start of treatment. During consultation, discussions about emergency procedures with the forensic patient should be limited to just the basics to eliminate potential security breaches and damage to equipment. Patient safety should always be in the forefront of the medical professional’s mind, but may need to be adjusted slightly to ensure that forensic patients do not maliciously cause undue harm during a hyperbaric treatment.
The restraint process should be predetermined; specialized plastic restraints should be used in leu of traditional metal handcuffs. This will eliminate the possibly of sparks therefore mitigating fire risk. Restraint policies for patients in custody will be determined by the correctional facility’s restraint policy, which is different from the hospital restraint policies for patients who are agitated or combative.
The hyperbaric clinician should determine whether appropriate care can be delivered with restraints in place. For example, during the compression stage of the hyperbaric treatment where restraints are implemented, discussion on how the forensic patient must be able to complete a Valsalva maneuver should be discussed.
A particularly challenging portion of forensic patient care in the multiplace hyperbaric chamber is limited by immediate staff availability should a security breach occur. Depending on the dive profile utilized, it may take up to five minutes for secondary staff to be able to provide assistance. To create a controlled environment where all parties feel safe the following must be considered: safety protocols should be developed and followed, staffing guidelines should be adjusted for level of security, education for staff on effective communication, and comingling should be minimized with staff and other patients.
Should a situation present where the forensic patient is threatening or hostile during the hyperbaric treatment, the inside hyperbaric attendant should first notify topside staff. Then, the inside staff can attempt de-escalation techniques learned through effective communication training. If these attempts are unsuccessful, an emergency security response should be initiated. The forensic patient should be removed from treatment through an adjacent chamber with secondary staff and escorted off the premises by the correctional facility offi cers with assistance from hospital-based security. With safety being paramount, further treatment after high-risk behavioral situations will be determined collaboratively between the correctional facility and hyperbaric staff.
As chronic illnesses increase, the number of forensic patients we encounter in hospital and clinic-based settings will become more prevalent. Hyperbaric clinics need to be proactive in creating policies and standards of care prior to encountering this specialized population. Being prepared with these policies and standardizations in place ensures the safety of the patients and the hyperbaric staff and equipment.
It is vital to develop a good rapport with local, state, and federal corrections institutions. Collaboration of care between the correctional facility and the hyperbaric center is necessary for safe and effective hyperbaric therapy. It develops and maintains open lines of communication with the correctional facility and ensures that if a safety concern arises, it is escalated and addressed appropriately.
The objective of this article is to educate the hyperbaric community on the increasing incidence of forensic patients requiring hyperbaric treatment. We acknowledge there is little data on the care of the patient in the hyperbaric chamber. We recommend a proactive approach in your hyperbaric facility, by developing policies and procedures to be better prepared to serve this vulnerable population.