By Sarah Riley-Burnett, DO
Her eyes were crazed and glassy when she finally opened them. She had been writhing in the gurney, gyrating her jaw with clinched teeth and breathing heavily. When she answered questions, all her movement would stop, and she would respond in a clipped staccato formal way as though she were a lieutenant responding to a commanding officer and then she would start her forceful panicked breathing that set her whole body to its rhythm. She never opened her eyes, as if by having them open would only confirm the nightmare she was in.
We had all rolled our eyes when the ER clerk briefed us of the incoming patient, “24 year old female with chest pain. Apparently after being arrested for heroin possession, started complaining of 10/10 chest pain.” She arrived 10 minutes later with two police officers trailing behind the crew of EMTs and the ER nurse wheeling her in.
They were polite, smiling at us respectfully appearing perhaps slightly amused as we passed between them through the doorway to her room. She was reticent during the interview, often moaning,“I don’t know”. Her physical exam was benign, heart rate was slightly fast at 102. Her work up was as expected: chemistry panel, blood count, cardiac enzymes, urinalysis, EKG and chest x ray, all normal. Her drug screen came back positive for amphetamine and opioid. I stepped into the room to discuss the results with her, “Good news, the chest pain doesn’t seem like it’s coming from your heart.”
She began to sob as she faced away from me, “I can’t go back to jail! I can’t go back again … I don’t even know why this is happening to me … Please,” she abruptly turned towards me, eyes suddenly open. The whites of her eyes reminded me of a spooked horse, panicked. “Please, do something. I’m sick.” She went on, “I need to see a psychiatrist. I need to get back on my medications! I’ve been in the hospital before, to the psych ward … Please, you’ll see. Look up my records, you can see what medications I’ve been on … Please.”
“Do you have plans to hurt yourself, to end your life? Are you hearing voices that others cannot hear or seeing things that others cannot see? Do you have plans to hurt someone else?”
She was quiet again, facing away from me. She nodded her head slightly to indicate no.
Then, in a hushed very matter of fact voice, she stated, “I was raped yesterday.” Her voice betrayed no emotion, but the words hung in the room, tense, like a trip wire threatening to sound an alarm. “Two men held me down”.
I breathed in, “I’m so sorry.” She said nothing, her body was very still. “This wasn’t your fault.” Silence in the room was heavy and disorienting. Years ago, I had volunteered in a shelter for women fleeing violence, I had been trained to be patient, allowing the women to tell their story at their own pace, to be sensitive to their privacy. Here in the ER, I could hear the bustle of new patients being hooked up to monitors and being triaged by nurses, I knew it was getting busy. Feeling the pressure of time, I broke the long pause, “Do you know the men?” I asked gently. Her nod signaled yes. “Did you take a shower?” Yes. “Do you still have the clothes you wore” Yes. “Did you tell anyone?” No. With each answer, I felt she was closing herself off more, becoming smaller in the bed, so small she would disappear.
I sighed, “We have to call in a special nurse to examine you. To try to collect any evidence that is there. It may take a while.”
She had turned slightly, so that I could partially see her face, her eyes were open, she seemed to be calculating her options. “No.” she answered, then more firmly, “No.”
I hesitated, “This wasn’t your fault.” I repeated.
“Yes, it is!” Her head snapped around, her voice suddenly shrill. “It’s always my fault. Everything!” Her hands were clinched and she punched them into the mattress. “I can’t keep living like this.” She moaned. “Please, don’t send me to jail. I don’t belong there … I can’t, I just can’t.” She gritted her teeth and turned away from me, breathing heavy with her whole body.
“I’m sorry” I said. I wanted to reach out and touch her, give her a reassuring hand squeeze, I reconsidered and instead excused myself from the room, promising to return.
I glanced at the computer and took note of three new patients and one being checked in. I found my attending. “She says that she was raped, but I don’t think she will allow an examination.”
My attending sighed. “We still have to call the forensic nurse in.” He picked up the phone, “It’ll probably take 2 hours for someone to get here.” He mumbled, “You wanna see room 8?” I nodded and moved on to the next patient waiting to be seen.
I thought about the time I had been working at the pediatric hospital ER and a forensic nurse was called in to evaluate a 13 year old girl who had been raped by her stepfather. The nurse was amiable and sensitive but also slow and methodical. Although she was careful about the girl’s comfort, I felt it was not possible to collect evidence without some form of repeated violation. Necessary, yes, but never benign. I had forced back the rising panic and nausea I’d felt as I helped the girl into the lithotomy position so the camera could capture the proof of the violence at her introitus and the swabs to collect semen, blood and hair.
I could not blame the patient for not wanting to be examined and I wondered if we were doing a disservice towards her by calling in the forensic nurse. My shift ended and I signed out the remaining patients to my attending and went home. Later, I found out that the patient had refused the exam and was taken off to jail. I felt deflated, had we done anything for the patient? Her pleading and huge eyes bothered me and I couldn’t shake the feeling that I hadn’t done enough for her.
She didn’t belong in jail, nor did she belong in the streets, she needed treatment, she needed compassion.
A few months later, in Southern Utah, I was buzzed through a series of locked doors, slid my driver’s license into a revolving drawer that closed and then reopened with a guest pass. I followed a PA down a drab grey concrete hallway to a small room, the size of a large closet with a single exam table from the 1950s. We shuffled through patient charts that had been pulled with their medical requests clipped to the front. Grown men and women with emotional appeals for pain and anxiety medications scrawled out with the lexicon and handwriting of a 6th grade student.
“This one is requesting his gabapentin”. I showed the chart to the PA, and she frowned down at the name and flipped through a few pages of the chart. “No,” she replied, “He was caught abusing it, diverting it. Lost his privileges, he can have Tylenol or Ibuprofen.”
“This one has a history of asthma, wants an inhaler.”
“No, if she needs a breathing treatment, has to come here to use a nebulizer. They use the inhaler to get high.”
And so it went. We saw the patients with acute complaints: cough or skin rash. They were polite and diffident in their questions. Some would work up the nerve to ask for a new mattress, or something for back pain.
I slowly turned pages in charts, looking for the reason for arrest, most were for violating parole or probation, petty crimes, intoxication, drug possession.
Are these the people we wish to punish? I thought through some statistics: 1 in 100 people are locked up in the US. Half a million people are locked up for a drug offense, fewer than 15% of inmates in need of drug treatment receive it during incarceration. 63-71% of inmates report symptoms or diagnoses of mental illness. One third of incarcerated women were subject to physical abuse and one third to sexual abuse prior to being imprisoned.
I imagined the girl from the ER in a jail like this one. Was she also putting in medical requests for anxiety and depression medications? “Please, I need to restart my medications”. Would she ever find help? Is it possible to live through continued trauma and then the shame of paying for lapses in judgement or impairment by sitting in a concrete room, with locked doors and few windows, pleading your case to an unknown physician, a judge, an officer, and then be a normal human afterwards?
If the girl gets out of jail, will she be able to pay the required fees of probation, drug testing, courts? Will she find a job, get a home, go to school? In most states, a prison record eliminates eligibility for public assistance (food stamps, public housing, student loans). Would she be stuck in a cycle of punishment, for being young, stupid, addicted, ravaged and alone?
“I can’t keep living like this … Please.”
“Don’t send me back. I don’t belong there.”
*Some details of the story were changed to respect the privacy of the patients.
Sarah Riley-Burnett, DO is a third year Family Medicine Resident in the Department of Family & Preventive Medicine at the University of Utah School of Medicine
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