There is an old piece of printer paper taped to the wall in one of the work rooms at Elmhurst Hospital in Queens, New York that contains a scribbled number to the physician at Rikers Island, New York City’s largest jail. I often dial this number and am met with a helpful voice on the other end, giving me details about a patient’s history or what happened prior to their transfer to the emergency department (ED). Whenever I hang up the phone, I try to picture the person on the other end.

Beyond the orange jumpsuits, metal cuffs, and groups of surrounding officers, I feel that there is so much I do not know, but really should, about the patient from Rikers Island who awaits treatment.

I set out to learn more about the care of incarcerated patients by speaking with three experts who have extensive experience in this field. They helped shed light on what we as emergency physicians should consider when we care for these patients, and how we can improve our practice going forward.

Dr. Utsha Khatri, an emergency medicine physician and researcher in New York City, focuses on substance use disorders and involvement with the criminal legal system. She practices at a hospital that receives patients in custody and has also worked within a carceral facility, giving her unique perspective on both sides of the system.

Dr. Incognito, a physician with extensive experience working with incarcerated patients in New York City and beyond, spoke to ACEP Now on condition of anonymity. Their name in this article is Incognito.

Sarah Lexcen, the lead advanced practice practitioner at the Hennepin County Jail in Minneapolis, provides general medical care as well as more focused care for patients with opioid use disorder and other substance use.

The conversations have been presented as a Q&A, edited for clarity and length.

Q: What are the most common conditions you see daily?

Incognito: The most pervasive issues are mental illness and substance use disorders. The prevalence is so high that it can almost fade into the background, but it fundamentally shapes everything else we do. Many patients struggle with both, often with incomplete or imperfect treatment. That makes managing any other medical condition more complicated.

From an addiction standpoint, opioid-use disorder is something we treat robustly. We operate a federally qualified opioid treatment program, so access to methadone and long-acting injectable buprenorphine is often easier here than in the community.

Where we struggle more is with non-opioid substance use disorders, particularly stimulant use disorders, which lack effective pharmacologic treatments. We also have significant challenges with synthetic cannabinoids, which have proven far more dangerous than many initially appreciated. We’re seeing substantial physical and psychiatric consequences from their use.

We also see very advanced chronic diseases. Many individuals have had limited access to preventive care. As a result, diagnoses often occur late — advanced diabetes, heart disease, and even late-stage cancers.

Q: When patients are acutely ill, where are they evaluated?

Sarah Lexcen: If someone is very sick, we often go to their housing unit to evaluate them, sometimes in their cell or the day room, because they may not be stable enough to be transported to the clinic. Others can be brought to the clinic, depending on their condition.

Q: Can you describe the medical resources available in your facility?

Incognito: I always frame the facility as an ambulatory setting. We have more resources than a typical outpatient clinic, but it is not an ED, hospital, or nursing home. Each jail essentially functions as a primary care clinic. We have plain film X-rays, ultrasound, wound care services, nursing, and treatment rooms for intravenous or intramuscular injections. We can place IVs, but only temporarily for infusions; they cannot remain in place long-term. We have physicians and physician assistants 24 hours a day, including emergency medicine physicians. In some respects, we are more medically staffed than many community environments. However, if a condition in the community would require ED evaluation, it should also require ED evaluation here.

Sarah Lexcen: This is where there’s often a disconnect between jail and ED emergency department expectations. We cannot routinely run IV fluids in our jail. That’s very different from how I would manage something like hyperglycemia in an outpatient clinic, where we might give fluids and insulin and avoid an ED visit. In the jail, because of nurse staffing, security requirements, monitoring needs, and limited infirmary space, we generally cannot place IVs for ongoing management. We can perform minor procedures, like incision and drainage. We can provide oral medications and IM injections. We have X-ray capability, but it’s limited. Imaging is available once daily at a scheduled time, so we can’t obtain urgent films at 3 p.m. if needed. Our limitations are driven by security structure, staffing, and monitoring capacity as much as by medical resources.

Q: What are the most common reasons you transfer patients to the emergency department?

Incognito: The most common categories include drug intoxications, trauma, and psychiatric decompensation. Trauma is frequent; not always severe, but persistent and common enough to be concerning. Psychiatric decompensation is another large category, and it can be challenging to determine whether symptoms are purely psychiatric or have an organic component requiring medical evaluation. Beyond those, it’s the full spectrum of acute medicine: heart failure exacerbations, sepsis, diabetic ketoacidosis—essentially the bread-and-butter emergencies.

Sarah Lexcen: It’s a broad mix, similar to the general population. Common reasons include prolonged seizures or postictal states, overdose requiring naloxone (per protocol, these are transferred), withdrawal not responding to symptomatic treatment and especially when IV fluids would be indicated, acute abdominal pain, infections not responding to oral antibiotics, large dental abscesses with facial swelling, and acute cardiac concerns. Because we cannot provide IV fluids or continuous monitoring, certain cases that might be managed in a clinic elsewhere require ED transfer from the jail.

Q: How do you decide when to transfer someone to the emergency department?

Incognito: I encourage clinicians to think clearly about the setting. If you are not 100 percent certain the patient will remain stable over the next 24 hours, they should go to the emergency department. There can be pressure not to overutilize emergency resources, and some worry about reputational concerns if transfers seem unnecessary. But sometimes we send patients simply because it is safer and allows for more monitoring. Even if 99 out of 100 transfers turn out to be low acuity, that one case where something deteriorates unexpectedly is far better managed in the emergency department than in a jail clinic.

Q: How do you communicate with the emergency department when transferring a patient?

Sarah Lexcen: We share the same Epic system with our hospital, but the jail chart has additional security layers. Some ED [clinicians] report being able to see our notes; others say they cannot. They can usually see medication lists and medical history. Our nurses call ahead and give report to ED nursing staff. Deputies escort the patient and know the reason for transfer. Provider-to-provider communication happens in more specific circumstances. For example, if a patient has been sent multiple times for the same issue, but it’s not routine.

Incognito: Ideally, the transferring [clinician] writes a summary and sends it with the patient. However, that depends on individual practices. Then there’s the question of whether the paperwork reliably makes it to the receiving team. One important development is movement toward giving emergency departments read-only access to our medical records. That would significantly improve continuity, especially because patients may not be able to provide reliable histories, and the transferring [clinician] may no longer be on shift by the time the patient arrives. Often, the communication is brief and focused on immediate stability rather than a nuanced differential. So having chart access would make a substantial difference.

Q: What should emergency physicians keep in mind when caring for patients from jail?

Dr. Khatri: First and foremost, patients in custody retain autonomy. They have the right to make their own medical decisions. Correctional officers cannot override that. Patients also retain their right to privacy. Their medical information is protected by HIPAA just like anyone else’s. Whenever possible, ask officers to step away or provide as much privacy as feasible during examinations and discussions. Often, we don’t even ask because we assume it’s not possible, but many officers will accommodate if it’s safe to do so.

Sarah Lexcen: First, recognize that these patients enter the medical system differently. They arrive in uniform, escorted by deputies, often restrained. That alone shapes how they are perceived and how they perceive the interaction. Some patients may not feel comfortable sharing their full history in front of deputies. In some cases, deputies may provide the history. There’s a balance between safety and ensuring the patient’s voice is heard. When possible and safe, it’s important to ensure the patient can speak for themselves. There’s also the reality that working in a jail environment changes how [we] think. Most patients are safe and appropriate to care for, but violence does occur. That awareness affects how we practice. [Emergency physicians] are balancing similar concerns — security, safety, chaotic environments — and it’s a complicated dynamic.

Some patients have deep mistrust of medical systems or prior trauma. Being in restraints, in an orange uniform, surrounded by security, and then evaluated in a public ED hallway can compound that. Some may feel that no one will listen to them anyway. That dynamic can affect history-taking and engagement.

Q: Can physicians ask for restraints, such as handcuffs, to be removed for medical care?

Dr. Khatri: You can absolutely ask. The decision ultimately rests with the correctional officers, as they are responsible for safety. In high-acuity settings, like trauma bays, where restraints may interfere with lifesaving care, it’s appropriate to request removal. It’s not our job to assume what is or isn’t allowed. If it’s medically necessary, ask and allow the officers to make the determination.

Q: What are common barriers to caring for incarcerated patients in the emergency department?

Dr. Khatri: One of the biggest barriers is lack of information. Often, we don’t have a clear understanding of why the patient was transferred. Sometimes the patient cannot provide a full history due to altered mental status, psychiatric concerns, or cognitive limitations. There may also be mistrust or limited medical literacy. The presence of correctional officers can also complicate history-taking. Clinicians may rely on officers for information, or patients may withhold information due to privacy concerns. All of this can make it difficult to obtain an accurate and complete clinical picture.

Q: What common mistakes or pitfalls do you see physicians, especially trainees, make when caring for incarcerated patients?

Dr. Khatri: The most concerning pitfall is downplaying symptoms. Stigma associated with incarceration can lead to assumptions about malingering or secondary gain. [Physicians] may also underestimate risk because many patients are young. What many people don’t realize is how difficult it is to get transferred from a jail to an ED. Typically, the patient has already been evaluated and deemed in need of hospital-level care. Sometimes symptoms have been present for days before transfer. Assuming that an 18-year-old arriving from jail has the same risk profile as an 18-year-old coming from home can be a dangerous assumption.

Q: How do you determine what follow-up is available when deciding on discharge versus admission?

Dr. Khatri: Over time, I’ve learned what services are available at the facilities that send patients to our hospital; whether infirmary units exist, what medications or infusions can be administered, and how follow-up works. However, for trainees, this is very challenging. You cannot rely on the patient or the correctional officers to tell you whether something like a stress test can be arranged in 72 hours. If you cannot confirm follow-up with a clinician at the facility, it may be safer to admit the patient. When possible, call the facility early in the encounter. Be aware that clinics often operate during business hours, but there should be someone available to provide information.

Q: Does communication happen in reverse when patients return from the emergency department?

Sarah Lexcen: Not typically in real time. We review ED documentation in Epic when available and receive the after-visit summary. When patients return, the charge nurse reviews documentation, reconciles medications, and ensures follow-up steps are entered into our system. We are working to improve this process by placing all returning patients on a review list within 24 hours. However, if someone is not placed on that list, follow-up items, like repeat labs, can fall through the cracks. That’s an ongoing systems issue we’re trying to improve.

Q: After patients return from the emergency department, are they reevaluated?

Incognito: They are supposed to be seen by a physician upon return. However, operational realities can interfere, for example, housing logistics or shift changes. Care ideally should be standardized and predictable, but variability exists. Some patients return to structured follow-up, while others may experience gaps in care.

Q: What would improve the relationship between jail and emergency departments?

Sarah Lexcen: Most people understand what a clinic or ED looks like. Fewer understand what providing care in a jail entails. Facility tours or cross-exposure—even brief ones—can build perspective. Not full rotations, but enough to understand the operational realities on both sides. Sometimes ED staff may think, “Why didn’t they just give fluids?” or “Why was this sent?” Without understanding staffing, security, monitoring limits, or weekend coverage constraints it’s hard to appreciate those decisions. Similarly, jail [clinicians] may not appreciate ED crowding, hallway care, and patient volume. That understanding reduces defensiveness and improves empathy.

Q: Are there additional operational realities that emergency physicians should know about?

Sarah Lexcen: We do not always have on-site [clinicians] overnight or on weekends; sometimes only on-call coverage. Evaluating chest pain in person during the day is different than making decisions remotely at night. Jails are also high-risk and highly scrutinized environments. There is significant legal exposure. Even when following protocol, [we] may face complaints or legal review. That risk environment influences decision-making and contributes to a lower threshold for transfer in some cases. Providing care in custody is a constant balance—medical judgment, security realities, staffing limitations, patient advocacy, and legal risk. Understanding that balance can help [emergency physicians] contextualize why certain patients arrive the way they do.

Q: Do you think trainees are adequately prepared to care for this population?

Dr. Khatri: No. During my training, there was no formal education on the ethical principles involved in caring for incarcerated patients or on how health care systems function within carceral facilities. These encounters involve complex power dynamics. Trainees may feel deferential to law enforcement authority. Understanding what rights patients have and what you can appropriately request is often missing from training. Another gap is understanding what health care services are actually available within specific facilities. Without knowing what follow-up or monitoring is possible, your threshold for admission may need to be lower.

Q: What can residency programs do to better prepare trainees?

Dr. Khatri: Simulation is an excellent tool to practice the interpersonal and ethical complexities of these encounters; directing questions to the patient, requesting privacy, navigating conversations with officers. Programs should also explicitly teach the ethical principles involved: autonomy, privacy, beneficence, and nonmaleficence. The concept of the “third party”—the state or custodial authority—adds complexity to the physician–patient relationship.

I often conceptualize the health risks in this population as a triangle: poor baseline health, harmful environmental exposures, and fragmented or limited access to health care. Understanding this framework is essential. This population has higher rates of chronic disease, mental illness, substance use disorder, and infectious disease. The environment itself is unhealthy and access to care is inconsistent.

Q: Any final thoughts?

The walls of a correctional facility can feel very high, but when it comes to caring for patients across those boundaries, they don’t have to be.

Dr. Khatri: This is an extremely vulnerable and underserved population. Building rapport and trust may be more challenging, but that means you must work harder, not less. You are caring for people with high health care needs and limited access to care. You’re sending them back to an environment most of us do not truly understand. That raises the stakes. Rather than being dismissive, maintain a high index of suspicion. Perform thorough evaluations. Gather as much information as possible. And always respect patient autonomy.

Incognito: Emergency medicine is inherently chaotic work; taking chaotic situations and imposing order. I sometimes worry that clinicians assume our facility is less chaotic because it is an institutional setting. In reality, patients are often coming from very chaotic environments and may be returning to chaotic environments. When you discharge an elderly patient home to a family who will ensure follow-up and medication adherence, that’s one scenario. Discharging someone back into a setting with instability or limited access to follow-up is different. I wish trainees would keep that context at the forefront, ensuring that patients are truly stable and prepared to return to the environment they’re going back to.

Make every effort to understand the specific discharge challenges faced by incarcerated patients. This asks something beyond what is strictly required, but the more familiar you become with the realities of jail, prison, and the criminal legal system more broadly, the better positioned you are to advocate meaningfully for the people caught up in it. Seek out connections with medical professionals working in your local jails or prisons. Even a casual professional acquaintance can open an important line of communication that meaningfully improves continuity of care. The walls of a correctional facility can feel very high,but when it comes to caring for patients across those boundaries, they don’t have to be.

Dr. Zvonar is a third-year resident at The Mount Sinai-Elmhurst Emergency Residency Program in New York City. Her interests include medical education, immigrant and refugee health, and global health.