CASE #1
A 43-year-old man presents with a chief complaint of a fingertip amputation while using a saw at work. You introduce yourself to the patient, and ask how he knows the accompanying visitor, who is talking to the registration clerk. He replies this is his boss. You overhear the employer say there is no insurance form or card but he will pay for the visit.
What do you do now?
You introduce yourself to the supervisor, and smile. You thank him for filling out the paperwork and ask him to finish the registration while you examine the patient and then walk him over to X-ray. He looks at the patient and says, “Ok. Where should I go?” You ask registration clerk to finish the paperwork with him in the waiting room, and as they leave you pull the curtain. You check pulses and the cap refill of the other fingers; you assess strength and movement of the digits and then undress the wound as you ask more about the mechanism of injury. There is some small bloody ooze but, for the most part, this is a clean amputation, involving the nail bed. The patient is unsure of his last tetanus shot but was initially vaccinated. You offer him pain control, re-wrap his finger, and order the X-ray. When you return to the bedside you ask him if he was wearing work gloves and other protection while working. He replies that he does not always have protective gear, and does not have work gloves. You ask why his site supervisor is here in the ED with you. He explains that the supervisor has all of his documents. You ask why his boss has his identification, and the patient looks confused. “Because he is my boss.”
It is not traditional for employers to control workers’ identification documents; how do you inquire about this patient’s safety and agency at work?
Answer: Respectful, nonjudgmental, and honest communication is usually acceptable and appreciated. Explain that in most work places, employers do not have possession of staff’s identification. You can ask about what he does on his days off and about what he thinks will happen when he has to miss work.
The patient replies he gets Sunday afternoons off and usually he runs errands. He does not think he can miss work, because he is on a work visa. You ask what he means, and he explains that his documentation status allows him to work only for this company while he is in the United States. The transporter comes to take him to X-ray, and you go to the computer to write up the chart.
You are starting to be concerned about workplace safety violations, and maybe labor trafficking. What should you do now?
Answer: When he returns, have a frank and respectful conversation with the patient. You can ask about his feeling of safety at work, about what he thinks would happen if asked for protective gear, or what would happen if he decided to leave his job. If you are familiar with local community organizations or local governmental regulatory agents, you can offer to connect him to them (even while in the ED, potentially).
Your patient returns from X-ray. The injury includes the bone, so you call hand surgery and ask the nurse to start an IV for his antibiotics. While you are waiting for surgery to call back, the site supervisor returns to the bedside.
You have more questions you want to ask the patient and need the site supervisor to leave again. What do you do?
Answer: It is best for the patient that you avoid a tense or hostile situation. Continue to be polite to the site supervisor; it will be easier to work with him that way, and safer for your patient.
You welcome him back, and let him know you are waiting for a specialist to consult on the case. You tell him it could be “a while, probably a few hours at least” and suggest he get something to eat. You tell him how to get to the hospital cafeteria. He stops to chat to the patient, and then says he will be back.
You ask the patient if it is ok to talk with his supervisor about the extent of the injury, if he asks. The patient gives permission. You ask if there is anyone else he would like to tell that he is in the hospital. He replies that he would like to call his daughter but he does not know her number and his cell phone battery is dead. You offer to look for a charger he can use while he is in the ED. You sit down and ask him about his safety in his current job. Specifically, you ask him if he is concerned about his safety or anyone else’s safety if he needs to stop working, or talk with regulatory authorities about his lack of workplace protection. He tells you that he would get in big trouble if he did any of those things. He knows his boss has had other workers deported.
You have a high concern for labor trafficking now. What do you do?
Answer: Offer that you are concerned that he is in a bad situation, and you would like to help connect him to resources that may be able to help. You can offer that he can speak with the social worker (if available), or you can connect him with an appropriate anti-trafficking agency directly.
You tell him you are concerned that he may be experiencing a form of work exploitation, and ask if he would like support or assistance in dealing with the situation. He says, “Ok, but I have nowhere to go. The boss provides our housing. If I make trouble, where will I live? And he has my papers.” You explain that you do not know all the answers, but would like to connect him some resources to see what is possible. It may take some time; you ask if he is willing to be admitted to the hospital to for the care of his open fracture. He is. Hand surgery still has not called back. The supervisor returns with a meal for the patient.
What do you do now?
Answer: The patient has given you permission to speak with the supervisor about his condition. It is simplest to be as honest as is safe, and speak with the supervisor in front of the patient so he knows exactly what you have told his boss.
You ask the patient not to eat until the specialist has evaluated him, in case they need to do a procedure today. You inform the supervisor that the patient needs to be admitted because he has “an open fracture” and requires intravenous antibiotics. You ask if there is a phone number at which he can be reached, and thank him for his help so far.
When the hand surgeon calls back, you explain the situation to him. Because you have permission from the patient, you (or the social worker) also speak with a local anti-trafficking organization about the patient’s situation. They do not have staff to send to the hospital today, but will send someone tomorrow. You let the inpatient social worker, admitting team, and patient know. You follow any other protocols that your hospital has instituted around admitting patients with a possible trafficking experience.