Dr Rosie RileyAll patient identifiable information and some details have been changed.
I pick up the notes for the next patient to be seen and my heart sinks. Aron is a 56-year-old man, intoxicated, antagonistic and upsetting other staff and patients in the waiting room.
He has come in by ambulance when a passerby noticed that he was having a seizure in the street. His face is red, he’s sweaty, agitated and clearly withdrawing from alcohol. Next to him is a slightly younger man who tells me he is Aron’s cousin. He smiles, helpfully offers information, and gets Aron a glass of water. I bring him into the cubicle and try to take a history.
Aron’s cousin comes with him and quickly tells me Aron doesn’t speak good English but not to worry, he will translate for him. I ask which country Aron is from. Albania, he says.
The cousin tells me that Aron has a problem with alcohol, that he had a seizure this morning and hit his head as he fell. He doesn’t know of any other symptoms and no other past medical history of note.
So far, this is quite a familiar story in the Emergency Department, but there are a few red flags here which alert me to the potential risk of exploitation and modern slavery.
I go and get the ECG machine and a portable telephone. I lead them round to a separate area of the department with consultations rooms, where there are doors that close rather than bays with curtains. I need a distraction. I want to get Aron alone in a safe clinical area and call a translation service, but I don’t want the cousin within earshot. So far, the cousin doesn’t know that I’m assessing for any safeguarding issues. That’s exactly what I want – everything must remain routine, natural, a normal experience in the Emergency Department as far as he’s concerned. An ECG and examination will give me an excuse and some time to talk to Aron alone.
“Right, I’m going to check Aron’s heart trace and do an examination, so please wait in the waiting room and I’ll call you back in 10-15 minutes.” He looks at Aron and then wanders off, oblivious. I double-check if Aron can indeed speak English, but he can’t so I call our telephone translation service and within a few minutes, we have an Albanian male translator on the end of the line.
My priority is to build a rapport, use my communication skills, keep eye contact, pick up on cues, and do anything to create a safe, confidential environment. I ask some clinical questions about the seizure, then “what do you do for work?”. An unusual question perhaps. He tells me he works in construction, building driveways and tiling roofs. “Are you paid for the work you do?” He looks at me and answers yes, quite quickly. He seems a bit agitated. I try and ask gentle medically-relevant questions – “you’re coughing a bit, do you have a window in your room? Do you share a room with others?” He tells me he lives in a caravan with 4 others. I ask about his alcohol intake. He mainly drinks spirits like Vodka.
I’m working very hard to gain a rapport, a real challenge when using a translator. I ask my key questions – “do you feel safe?” “Is there anyone you feel threatened by?” He denies everything but looks uncomfortable.
“Ok, well, if you ever feel unsafe, or threatened, you can always tell us. We’re safe and want to help.”
I then move on to the examination.
Let’s find out about Aron’s background – this isn’t my patient’s real story but was taken from a real case of forced labour within the UK.
Aron is from Albania. When he was looking for work, he met a man who offered him a job in the UK. The employment package included flights and accommodation; he would be given a loan to cover the costs. When he arrived, his passport was taken by his new boss. He was made to sleep in a small dirty caravan with four other young men from Eastern Europe and around the UK and was told he had a debt of £10,000 to pay off with work.
Each day a van would come to collect the men to take them to work on construction sites paving driveways and tiling roofs. He would be given a safety hat and vest, but no goggles or gloves. He worked for 12-16 hours a day, 6-7 days a week, was frequently beaten with tools, humiliated and never given any money for his labour. One-time Aron was forced to watch as another one of the men was hosed down with freezing water for trying to run away.
He was fed plain bread and pasta, but often his bosses forgot, and the men had to scavenge in bins for food. He was given daily vodka as a method of control and went on to develop alcohol dependency.
Aron has had prolonged exposure to stress and trauma. His body and brain will have made natural and appropriate neurobiological, physiological, and behavioural adaptations to survive, e.g. fight, flight, freeze and appease mode. It’s important that I recognise these responses when he’s with me in the Emergency Department and that I prioritise creating a safe, confidential environment, giving him choice and agency while considering capacity. This is trauma-informed care.
My heart always races when I’m concerned about safeguarding with a patient. These consultations can be the most challenging in many ways. I debrief with my consultant and discuss the case with a colleague. Sometimes I forget, even after hearing considerably traumatic life experiences from patients, that I’m a human too.