Best practice guidelines for evaluating patients in custody in the emergency department.

Patients in custody due to arrest or incarceration are a vulnerable population that present a unique ethical and logistical challenge for emergency physicians (EPs). People incarcerated in the United States have a constitutional right to health care. When caring for these patients, EPs must balance their ethical obligations to the patient with security and safety concerns. They should refer to their institutional policy for guidance and their local, state, and federal laws, when applicable. Hospital legal counsel and risk management also can be helpful resources. EPs should communicate early and openly with law enforcement personnel to ensure security and emergency department staff safety is maintained while meeting the patient's medical needs. Physicians should consider the least restrictive restraints necessary to ensure security while allowing for medical evaluation and treatment. They should also protect patient privacy as much as possible within departmental constraints, promote the patient's autonomous medical decision-making, and be mindful of ways that medical information could interact with the legal system.

Human Rights in Hospitals: an End to Routine Shackling.

Medical students (NSB, NM, JDW) spearheaded revision of the policy and clinical practice for shackling incarcerated patients at Boston Medical Center (BMC), the largest safety net hospital in New England. In American hospitals, routine shackling of incarcerated patients with metal restraints is widespread-except for perinatal patients-regardless of consciousness, mobility, illness severity, or age. The modified policy includes individualized assessments and allows incarcerated patients to be unshackled if they meet defined criteria. The students also formed the Stop Shackling Patients Coalition (SSP Coalition) of clinicians, public health practitioners, human rights advocates, and community members determined to humanize the inpatient treatment of incarcerated patients. Changes pioneered at BMC led the Mass General Brigham health system to follow suit. The Massachusetts Medical Society adopted a resolution authored by the SSP Coalition, which condemned universal shackling and advocated for use of the least restrictive alternative. This will be presented to the American Medical Association in June 2024. The Coalition led a similar effort to coauthor a policy statement on the issue, which was formally adopted by the American Public Health Association in November 2023. Most importantly, in an unprecedented human rights victory, a BMC patient who was incarcerated, sedated, and intubated was unshackled by correctional officers for the purpose of preserving human dignity.

Training Among Noncustodial Health Care Workers Caring for Patients Experiencing Incarceration: A Preliminary Investigation.

People experiencing incarceration in the United States receive much of their health care outside of custodial settings. Optimizing care in this setting requires further understanding of the training and experiences of noncustodial health care workers. We conducted a cross-sectional, exploratory survey of health care workers at a single academic institution to assess their training and experiences related to caring for this patient population. Of 333 respondents, 94.1% had cared for patients experiencing incarceration but only 22.5% had received any formal training, with 94.6% somewhat or very interested in further training. Common challenges included lack of privacy, difficulty obtaining patient history or completing an examination, and patient distress. Health care workers frequently experience challenges and report strong interest in further training to address knowledge gaps, and further detailed investigation is needed.

Comprehensive Reform Urgently Needed in Hospital Shackling Policy for Incarcerated Patients in the United States.

Approximately 2.2 million people are incarcerated in the United States. The carceral population is aging due to strict sentencing laws, which has increased the frequency and acuity of off-site medical care. Inpatient providers must follow departments of correction procedures when treating incarcerated patients, which often prevents adherence to standards of care and puts the health of patients at risk. Shackling is a common requirement during hospitalization and is associated with increased risk for complications. Current state and federal policies regarding shackling lack specifics to prevent patient harm. Incarcerated people have a constitutionally protected right to health care, but with current policy, we are not meeting this essential responsibility. Updates to policy are needed to ensure that patients receive compassionate, safe, and constitutionally mandated health care.

Forensic evaluation of alleged wrist restraint/handcuff injuries in survivors of torture utilizing the Istanbul Protocol.

Despite being a common form of abuse, there is a paucity of literature describing shackling and wrist restraint injuries among survivors of torture. Forensic evaluation of alleged wrist restraint/handcuff injuries in survivors of torture presents challenges to the evaluator, especially if the injuries are remote and do not leave lasting marks nor neurologic deficits. Thorough history-taking and physical examination are critical to effective forensic documentation. Guidance is provided in The Manual on Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (Istanbul Protocol), the gold standard for the medicolegal documentation of torture. This guidance relies primarily on physical findings, with less direction provided on how to interpret historical evidence or when historical evidence provided by the patient can be interpreted as highly consistent with alleged injury in the absence of current physical findings. Through a case-based review, we present diagnostic strategies for the evaluation of alleged abuse involving wrist restraints/handcuffs, focusing on skin, neurologic, and osseous injuries. We highlight key findings from both the history and physical examination that will allow the evaluator to improve the accuracy of their expert medical opinion on the degree to which medical findings correlate with the patient's allegations of wrist restraint injuries.

Effect of transportation and shackling on plasma concentrations of corticosterone and heterophil to lymphocyte ratios in market weight male turkeys in a commercial operation.

There is limited information on the effects of stress and/or physiological manipulation on either plasma concentrations of corticosterone (CORT) and/or heterophil: lymphocyte (H : L) ratios in turkeys. The present studies examine the effects of catching/transportation/lairage in a holding shed and shackling on plasma concentrations of CORT and H : L ratios in male market weight turkeys. Plasma concentrations of CORT were increased after transportation and lairage but not further elevated by shackling, irrespective of its duration up to 240 s. In one study, there were increased H : L ratios following catching/placing birds into transportation cages/transportation/lairage. In one study, H : L ratios declined following shackling. It is concluded that while moving turkeys from the farm to immediately before the shackling line is stressful, shackling for up to 4 min was not perceived as more stressful in turkeys. There were also differences between farms/houses for both plasma concentrations of CORT and H : L ratios.

Effects of putative stressors and adrenocorticotropic hormone on plasma concentrations of corticosterone in market-weight male turkeys.

There is limited information on the effects of stress and/or physiological manipulation on plasma concentrations of corticosterone (CORT) in turkeys. Under basal conditions, there was evidence for episodic release of CORT in turkeys. The present studies determine the effects of handling, herding, herding, the administration of Escherichia coli endotoxin, and challenge with turkey adrenocorticotropic hormone (ACTH) on plasma concentrations of CORT in market-weight male turkeys. Plasma concentrations of CORT were increased after challenge with turkey ACTH, handling together with saline injection or herding (moving birds from one pen to another). There were no effects on plasma concentrations of CORT of the following putative stressors: handling per se, endotoxin challenge, or of placing in an inverted position on simulated shackles.

Effects of preslaughter shackling on postmortem glycolysis, meat quality, changes of water distribution, and protein structures of broiler breast meat.

The objective of this study was to investigate the effects of preslaughter shackling on stress, postmortem glycolysis, meat quality, water distribution, and protein structures of pectoralis majors. Before slaughter, Arbor Acres broilers (n = 105, 42 days old, 2.0 to 2.5 kg) were randomly categorized into 3 treatment groups: (I) control group without shackling (NS); (II) 2.5 min shackling (SS); (III) 4.5 min shackling (LS). Each treatment group consisted of 5 replicates with 7 broilers each. Results indicated that preslaughter shackling increased (P < 0.05) plasma corticosterone and adrenocorticotropic hormone concentrations in comparison with the control group. Antemortem shackling increased (P < 0.05) activity of glycogen phosphorylase and phosphofructokinase-1 (PFK-1) accompanying with rapid glycolysis and pH decline at early postmortem. LS treatment led to myosin denaturation, decreased (P < 0.05) α-helix content, and increased (P < 0.05) ß-sheet structures proportion in the myofibrillar proteins. Furthermore, meat from LS treatment had higher (P < 0.05) lightness, redness, and poorer water-holding capacity. These results indicated that the longer shackling duration (4.5 min) increased stress and the rate of glycolysis, causing myosin denaturation and changes of the secondary structure in the myofibrillar proteins, which aggravated the deterioration of meat quality.

Where Does Your State Stand on Shackling of Pregnant Incarcerated Women?

Pregnant incarcerated women have been identified as a particularly high-risk group and among the most vulnerable women in the United States. The use of shackling or restraints poses health risks to pregnant women and their fetuses. Currently, only 22 states have legislation prohibiting or limiting the shackling of pregnant women. Here we provide an overview of the potential negative health outcomes that can result from shackling pregnant women, especially during labor and birth, and suggest strategies for nurses who wish to promote optimal health care for incarcerated women and to advocate for anti-shackling legislation in their states.

Developing control points for halal slaughtering of poultry.

Halal (permissible or lawful) poultry meat production must meet industry, economic, and production needs, and government health requirements without compromising the Islamic religious requirements derived from the Qur'an and the Hadiths (the actions and sayings of the Prophet Muhammad, peace and blessings be upon him). Halal certification authorities may vary in their interpretation of these teachings, which leads to differences in halal slaughter requirements. The current study proposes 6 control points (CP) for halal poultry meat production based on the most commonly used halal production systems. CP 1 describes what is allowed and prohibited, such as blood and animal manure, and feed ingredients for halal poultry meat production. CP 2 describes the requirements for humane handling during lairage. CP 3 describes different methods for immobilizing poultry, when immobilization is used, such as water bath stunning. CP 4 describes the importance of intention, details of the halal slaughter, and the equipment permitted. CP 5 and CP 6 describe the requirements after the neck cut has been made such as the time needed before the carcasses can enter the scalding tank, and the potential for meat adulteration with fecal residues and blood. It is important to note that the proposed halal CP program is presented as a starting point for any individual halal certifying body to improve its practices.