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in a safe environment and all information is confidential; it is the patient’s choice to report an incident (Coppola & Cantwell, 2016). Screening questions may include the following: (a) Tell me about your living situation; (b) “Has anyone ever asked you to have sex in exchange for money, food, shelter, or other items?”; (c) “Has anyone ever threatened violence if you attempted to leave?”; (d) “Has anyone ever threatened your family if you leave?” Table 3 lists additional screening questions to assist practitioners with a sensitive evaluation. The provider should remain cognizant of the patient’s verbal and nonverbal responses to questions. Hypervigilant, hesitant, agitated, fearful, or inconsistent responses and behaviors may provide clues to the patient’s emotional state. Care approaches that provide accurate information and explain medical procedures in detail foster safety and independence during the clinical encounter (see Table 4; Borland & Zimmerman, 2009). A complete and thorough physical examination is imperative; signs of trauma or assault may indicate an exploitive situation regardless of the presenting complaint. The physical examination should progress from the least to the most intrusive procedures, leaving the pelvic, speculum, and reproductive system examination for last (Coppola & Cantwell, 2016). Detailed documentation of injuries involving the genital, anal, oral, and cutaneous areas include a written description of size, shape, color, location, and patterning of Table 3. Assessment questions to assist with screening for human trafficking Safety Is it safe for you to talk to me right now? Are there times you do not feel safe? Do you feel like you may be in danger for speaking with me? Is there anything that would help you feel safer? Fraud What were you told about the job before you started? What promises were you made? Have you ever felt you were deceived or lied to about your work or relationship? Has anything ever surprised you about your job/relationship? Coercion Have you ever felt pressured to do something you didn’t want to do? Or uncomfortable? What would happen if you didn’t do what you were told? Has anyone ever threatened or intimidated you? Has anyone taken/kept your legal papers or identification? Monetary Do you have access to money? Has anyone ever taken your money? Do you owe money to anyone? Can you spend your money the way you wanted to? Force Has someone controlled, supervised, or monitored your work? Has your communication restricted? Have you ever felt you had no other options? Are you able to access medical care? Are you allowed to leave the place you were living/working? Sex Has anyone ever pressured you to engage in sexual acts against your will? Have you ever been forced to engage in sex? Who decided if you could use a condom? Have you ever been required to earn a certain amount of money/meet a quota? Have you ever sexually assaulted or abused by anyone? Note. From National Human Trafficking Resource Center (2011). Used with permission. Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. Article: AENJ-D-16-00027 Date: January 18, 2017 Time: 0:13 42 Advanced Emergency Nursing Journal Table 4. Recommended management of a human trafficking situation in health care Assisting victims Prioritize safety of the patient, practitioner, staff, and other patients. Trafficker may present as an intimate partner, relative, or friend. Use certified translator or phone translation service. Do not have visitor interpret or present during the history and physical. Speak with the person alone. Ask a few questions related to the symptoms to ascertain the situation. Focus on the presenting complaint and not the cause of the injury or illness. Do not offer mental health services in the clinic. Management Adhere to HIPAA (Health Insurance Portability and Accountability Act) and exercise discretion with private information. Assess safety risks with person and experts in the field (e.g., social services or shelter staff). Offer to provide information or refer the person for shelter and services (e.g., hotline number). Communicate clearly at eye level (appreciate cultural communication differences). Use age- and culturally appropriate language. Act only with informed consent unless mandated by law. Know state-mandated reporting laws (minor, vulnerable adult, weapons-related). Know how the first contact will be arranged. Communicate relevant information to service providers only with patient consent. Do not inquire about trafficking-related details. Do not disclose your address, personal information, or attempt to shelter the patient. Do not contact the authorities (law enforcement, immigration) without consent unless legally mandated. Avoid making promises. National Human Trafficking Resource Center Hotline 1-888-373-7888 Note. Data obtained from Alpert et al. (2014); Borland and Zimmerman (2012); NHTRC (2011). bruising, contusions, scars, lacerations, or other evidence of physical or psychological trauma (Coppola & Cantwell, 2016; Greenbaum & Crawford-Jakubiak, 2015). Victims of labor trafficking may have injuries consistent with occupational hazards or neglect. Table 5 provides examples of examination findings associated with the physical and psychological trauma experienced across the various forms of human trafficking. An important management aspect of care is the clear documentation of physical injuries and the patient’s response during an examination. For patients who disclose sexual violence or assault, sexual assault nurse examiners (SANEs) are trained to conduct evidentiary examinations and appropriately document findings using sexual assault kits, photography, and written word (Williamson, Dutch, & Clawson, 2010). As an integral part of the multidisciplinary health care team, SANEs have the necessary training to assist patients who report sexual violence or assault with interviews, forensic examinations, collection of evidence, and facilitate community-based referrals (Alpert et al., 2014). Although an in-depth discussion of forensic evaluation is beyond the scope of this article, it is important to note that Sexual Assault Response Teams are available in some hospitals and provide valuable services in certain trafficking situations. The goal is to provide patient-centered support, avoid retraumatization, and describe injuries in a comprehensive, objective, and precise manner. When possible, it is advisable to use the patient’s own words to describe events and document the examination findings from a medicolegal perspective (Williamson et al., 2010). Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. Article: AENJ-D-16-00027 Date: January 18, 2017 Time: 0:13 January–March 2017 Vol. 39, No. 1 Human Trafficking Victims in the Emergency Department 43 Table 5. Potential examination findings associated with the trauma of human trafficking System Subjective complaints and objective clinical findings Associated physical and psychological trauma General Evidence of malnutrition, weight loss, anorexia, fatigue, febrile, poor skin turgor, nausea/vomiting Poor nutritional status (starvation, malnutrition, dehydration, eating disorder), sleep deprivation, insomnia, infectious disease, anxiety, substance use/addiction, withdrawal symptoms Cutaneous/ dermatological Ecchymosis, burns, bites, scratches, tattoos, contusions, scars, lacerations, ligature marks, track marks/cellulitis Physical trauma (slap, beat, kick, punch, burn, restraint), strangulation, confinement, torture, labor industrial injury/ exposure, branding Head, ears, eyes, nose, throat (HEENT), mouth Ecchymosis, scars, lacerations, ligature marks, petechiae of eyes and face, missing hair, nail damage, visual disturbances, broken/missing teeth, hearing loss Physical trauma, strangulation, suffocation, hair pulled, facial and jaw trauma, malnutrition, lack of medical and dental care, untreated chronic medical conditions Neurological Headache, dizziness, disorientation, memory loss, vertigo, concentration difficulty Traumatic brain injury, starvation, frequent relocation, isolation, anxiety, depression, complex trauma, PTSD Pulmonary/ cardiovascular Cough, SOB, arrhythmias, fever, asthma, tuberculosis, tachycardia, hypertension Unsanitary or crowded living conditions, industrial exposure, trauma, dehydration, infectious disease, substance use/addiction, stress, untreated chronic medical conditions Musculoskeletal Fractures, back pain, joint pain, loss of extremities Traumatic injuries (abuse, assault), industrial injuries, stress, repetitive injury, prolonged work hours Gastrointestinal Abdominal pain, trauma, irritable bowel syndrome, constipation Abdominal trauma,