Emergency response, a fact of life in healthcare, has some interesting aspects to consider in a custody setting. Correctional nurses are called upon to respond to a wide range of injuries and emergencies, from inmate scuffles in the yard, suicide attempts, and unresponsive inmates in the housing units. Are you prepared for the next emergency you will encounter during your shift?

Preparation is Key

Preparation is most important when it comes to a rapid emergency response. Be sure there is someone assigned to lead an emergency intervention on each shift, and that staff know where the supplies are kept. Since nurses typically must bring the needed equipment to the yard or the housing units, it needs to be portable and easy to move through corridors and brought up stairs.

Determine what is needed to stabilize a patient while outside EMS services are enroute and ensure that it readily available with your emergency response equipment.  This includes equipment to obtain vital signs and test blood glucose; to control bleeding, such as bandages, to immobilize patients, such as cervical collars; the AED; oxygen, and perhaps intravenous fluid administration supplies.  The secure nature of a jail or prison can make access by outside services difficult and time-consuming; often outside vehicles and persons must be checked and must go through multiple security checkpoints and doors in order to reach the patient.  Thus, activating EMS as soon as it is determined that the injuries/situation warrant a higher level of care will expedite that care.

Never Leave until Relieved

There are many instances where the correctional nurse arrived, assessed the patient, and then left the area to obtain needed equipment or treatment supplies. Never leave a patient in an emergency situation if you are the only healthcare staff on the scene. Ask correctional officers or other staff members to retrieve needed supplies. If the only healthcare professional leaves a patient in a life-threatening situation, it is considered patient abandonment. Be sure the patient is being cared for by a qualified healthcare staff member before leaving an emergency scene.

Know Your Protocols

Before you get into an emergency situation, know your responsibilities and protocols for managing an emergency until a provider arrives or is contacted by phone. Some facilities allow the initiation of various emergency medications and treatments, while others require that a provider be contacted for orders. Be ready to fully implement everything needed and available to you while awaiting further assistance and direction.

Risky Situations in Corrections

The following situations are of high concern in a correctional setting due to the nature of the environment and patient population.

• Anaphylaxis Treatment: Epinephrine is the gold-standard treatment for an anaphylactic allergic reaction. Highly allergic individuals typically carry on their person an epinephrine auto-injector at all times to self-administer a life-saving dose. For safety reasons, however, inmates cannot have personal possession of needles. How does your facility handle the need for immediate access to epinephrine? Are you aware of all highly allergic inmates in your patient population?
• Drug Overdose: Illicit drug use in some correctional facilities means that drug overdose should be considered in emergency situations. Even in prison, inmates can get access to contraband drugs. A classic sign of opioid overdose in an unconscious patient is constricted pupils; however, do not exclude other medical conditions like traumatic head injury.  Narcan (naloxone) should be available with a protocol for administration in suspected overdose situations.  The administration of naloxone to a patient not experiencing an opioid drug overdose will not harm him/her.
• Neck Injury: I know of several  emergency responses where the patient was found lying unconscious on the floor of his/her cell. The nurse performed the ABC’s of initial response but did not consider a possible neck injury from a preceding fall and did not take steps to protect the neck/c-spine. In more than one such case, the patient sustained a C-spine fracture and was permanently paralyzed. In an unknown situation, always remember to protect the spine, including the cervical spine until cleared.
• Hangings: Hanging is the most frequent suicide method behind bars. No matter what the assumed hang time, immediately cut down the patient and evaluate and initiate necessary resuscitation efforts while protecting the cervical spine. Do not assume it is too late, unless there are clear signs of prolonged death (pulseless and not breathing, dependent lividity, very cold body temperature and pupils that are fixed and dilated). Many facilities require that resuscitative efforts are initiated in all cases and are not stopped until EMS staff determine death.  Do you know where your hanging cut-down tool is located? Is this a custody or healthcare responsibility?

List of Emergent Conditions

Many facilities/Departments of Correction have established a list of emergent conditions that correctional nurses should be prepared to handle at their facilities. Below please find a compilation of the most commonly listed conditions.  Use this as a guide to develop and prepare your response for man-down emergencies.

• Acute altered mental status
• Airway related problems 
• Alteration in body temperature, hyperthermia and hypothermia
• Anaphylaxis
• Cardiac related chest pain (unresponsive to treatment)
• Cerebrovascular Accident (Stroke)
• Continuous decreased LOC
• Unresponsive Diabetic Patient
• Diabetic Ketoacidosis
• Drug overdose
• Eclampsia
• Fractures to the maxillary jaw
• Rectal Bleeding and vomiting blood with altered vital signs
• Head injury with GCS < 13, cerebrospinal fluid leakage, more than one episode of vomiting.
• Hypertensive Crisis
• Hypotension, Symptomatic
• Major burns
• Neuro compromise
• Open abdominal wound
• Open chest wound
• Penetrating foreign body of the eye
• Suspected Poisoning
• Precipitous or breech birth
• Puncture wound of the neck or torso (or that of an artery)
• Respiratory or cardiac arrest
• Seizure activity (first, sustained or change in previous)
• Sucking chest wound
• Uncontrolled hemorrhage

Keep Calm!

It is perhaps most important that you respond to an emergency calm and in control, which can only occur if you know what to do and are prepared. This requires training and forethought before you are put in an emergency response situation, and this should be part of the first day orientation at all facilities. Knowing how to call a code (telephone or radio – “Man-Down”; 10-14; 10-52; etc) seems like a simple thing, but every facility is different. Knowing what is in the emergency bag, and checking it every shift to ensure nothing has been taken out is vitally important. Finally, a successful emergency response requires that we work closely with our correctional colleagues to address the patient care and security aspects of the situation. Everyone should know his/her/their role and should respect the role of others responding.

How do you manage response for man-down emergencies in your setting? Share your experiences in the comments section of this post.