Picture this scenario: A 55-year-old Spanish-speaking man presents to your emergency department with wheezing, dyspnea, and fatigue. His English-speaking nephew reports that his uncle hasn’t worked for three days, but that he must return to work in order to stay in the United States.

The patient describes fevers, cough, chest pain, and leg swelling. His physical examination reveals mildly increased work of breathing, with mild tachypnea, oxygen saturation of 93 percent, and diffuse expiratory wheezes. You ask if he smokes or has asthma, but the translation leads to a heated exchange between the nephew and uncle, during which the nephew barely allows the uncle to speak. You let this slide, assuming perhaps the patient is a smoker despite family wishes. You order a chest X-ray, nebulized albuterol, and oral prednisone. Discharge with inhaler and prednisone prescriptions is anticipated, provided he improves.

The chest X-ray is negative. After completing 3 nebs, your patient’s wheezing has significantly decreased and the nephew reports subjective improvement. You provide them with prescriptions, review proper inhaler use, counsel the patient about smoking cessation through the nephew, and recommend prompt follow-up. The nephew thanks you and turns to leave. The patient interjects in Spanish, but the nephew responds tersely, brusquely grabs his arm, and leads him toward the exit.

The nurse, who understands some Spanish, tells you that the patient asked about his fatigue and weight loss, but the nephew told him to get back to work. As they depart, you notice for the first time that your patient is wearing a loose, fully buttoned-up long-sleeved shirt and baggy pants, which seem warm for the summer. In that moment, you’re summoned for a new patient—off you go.

A Second Look

The patient subsequently returns alone, and, through a medical interpretive service, reports worsening symptoms and expresses fear for his safety and for that of his family back home. He has been identified as a labor trafficking victim, toiling 12-hour days in the agricultural industry without compensation to “pay off” the cost of having been brought to the United States, despite having paid the recruiter in his country for job placement, a work visa, and travel costs. The purported “nephew” had, in fact, been trafficked himself and had worked his way up to foreman, in charge of keeping new workers in line. The oversized clothing he wore concealed signs of physical abuse and weight loss from restricted food access.

He denies a history of asthma or tobacco use, and reports that the foreman repeatedly threatened him and accused him of having lied about his health to the recruiter. With more history and diagnostics, you believe the wheezing to be related to chronic pesticide fume exposure without personal protective equipment, and the fatigue to be a combination of heat cramps, malnutrition, and anemia.

Hospital Preparedness: Identifying and Assisting

Human trafficking, whether for forced manual labor or commercial sexual exploitation, is a violent form of modern-day slavery with devastating physical and mental health effects on adults and children.^1,2 The exact prevalence of human trafficking is unknown. However, cases of human trafficking have been reported in all 50 states, and a large proportion of victims are U.S. citizens and lawful residents.³ The U.S. Department of Justice found that among nearly 460 confirmed sex trafficking victims, 83 percent were citizens, and 55 percent were 17 years old or younger (87 percent were 24 years or younger).⁴ Among a cohort of 98 sex trafficking survivors, 87.8 percent reported having been evaluated in a health care facility at least once while exploited, and 63 percent reported seeking care in a hospital ED.⁵

Emergency providers are uniquely positioned to identify and assist trafficking victims. This case highlights the importance of long-established patient-centered care recommendations such as professional language interpretation, private patient interviews, and detailed history-taking and physical examinations. While the multiple red flags here may have been more easily recognized following specialized training, our unconscious biases and assumptions and the demands for our time and attention can interfere with our ability to provide patient-centered care that will foster the trust and sense of safety that trafficking victims need to request help.

To effectively assist these highly traumatized patients, emergency providers must not only receive training on how to recognize human trafficking, but must also be patient-centered in the approach to care, and survivor-centered in response to identification and disclosures.

There are specific steps you can take to enhance your practice and improve identification and assistance of trafficked persons:

1. Go back to basics. Recall why you chose your profession and commit to making your clinical practice more patient-centered. Identify a list of concrete behaviors you wish to incorporate and commit to a reasonable time frame to implement them. These behaviors include:

• Ensuring privacy during examinations.
• Collaborating with professional interpreters.
• Active listening and being fully present in the moment.
• Sharing decision-making with the patient.
• Taking the time to explain diagnoses and treatment options.
• Demonstrating patience and compassion.

2. Seek educational opportunities. Complete an in-person or online educational activity for health care professionals to enhance your knowledge and skills about human trafficking. Consider the content and ensure that it includes information about health impacts, red flags, screening, and responding to an identification or disclosure. The National Human Trafficking Resource Center offers assessment information for physicians.
3. Maintain a high index of suspicion. For patients with multiple red flags, be ready to screen for human trafficking and know your state’s mandatory reporting laws. Even if human trafficking is not a mandated reporting event, the commercial sexual exploitation of children is considered child abuse and may require reporting to local officials.
4. Be prepared to respond. Familiarize yourself with your hospital’s policies and protocols for human trafficking. If no guidelines are in place, identify relevant hospital and community resources; the National Human Trafficking Resource Center can help locate resources in your community. For patients who desire assistance and communicate the possibility of life-threatening danger, consider involving hospital security personnel early on in the examination.
5. Catalyze change through advocacy. Educate hospital administrators, colleagues, and your community about the health impact of human trafficking and how they can assist in developing protocols to safely and effectively respond to trafficked persons presenting to the ED.

The authors are the Chair of the ACEP Trauma and Injury Prevention Section (TIPS) Task Force on Human Trafficking and the Chair of TIPS.

Dr. Macias-Konstantopoulos,is director of the MGH Human Trafficking Initiative, the medical and executive director of the MGH Freedom Clinic, Division of Global Health and Human Right, Department of Emergency Medicine, Massachusetts General Hospital, and an assistant professor of emergency medicine at Harvard Medical School. Dr. Raja is vice chair of the Department of Emergency Medicine at Massachusetts General Hospital, and an associate professor of emergency medicine at Harvard Medical School.

References
1. Oram S, Stöckl H, Busza J, Howard LM, Zimmerman C. Prevalence and risk of violence and the physical, mental, and sexual health problems associated with human trafficking: Systematic review. PLoS Medicine. 2012;9(5):e1001224. doi: 10.1371/journal.pmed.1001224.

2. Kiss L, Pocock NS, Naisanguansri V, Suos S, Dickson B, Thuy D, et al. Health of men, women, and children in post-trafficking services in Cambodia, Thailand, and Vietnam: an observational cross-sectional study. Lancet Glob Health. 2015 Mar;3(3):e154-61. Erratum in: Lancet Glob Health, 2015 Apr;3(4):e198. doi: 10.1016/S2214-109X(15)70016-1.

3. Polaris Project. State map. 2014.

4. Banks D, Kyckelhahn T. Characteristics of suspected human trafficking incidents, 2008-2010. Washington, DC: U.S. Department of Justice, Bureau of Justice Statistics; 2011.[PDF]

5.Lederer LJ, Wetzel CA. The health consequences of sex trafficking and their implications for identifying victims in healthcare facilities. Ann Health Law. 2014 Winter;23(1):61-91.[PDF]