If you’ve ever worked in an emergency room, you’ve likely treated a victim of human trafficking.

We all have, often without knowing it.

With nearly thirty million people in modern-day slavery around the world, there are more slaves today than at any point in history.

Human trafficking is defined as “the recruitment, harboring, transportation, provision, or obtaining a person for labor or services, through the use of force, fraud, or coercion” for the purpose of serving in the sex trade or in forced labor. It’s the third largest criminal industry in the world, outranked only by arms and drug dealing. Human trafficking is most commonly known for the severe forms of violence it entails — such as incarceration, rape, torture, and sexual enslavement. Up to 95% of victims experience some form of sexual and/or physical abuse during trafficking.

Human trafficking doesn’t just occur in rural India or urban Thailand. It occurs right here at home. There are approximately 100,000 children involved in the sex trade every year in the United States.  In fact, according to the Huffington Post, the Super Bowl is the occasion for the single largest incident of human trafficking in this country. With thousands of people visiting the host city, this sporting event becomes a prime breeding ground for sexual exploitation; trafficking victims are often forced to have sex with up to thirty visitors a day.

Given the prevalence of human trafficking, there is no doubt that we come across victims of sexual exploitation or forced labor in our everyday practice. Emergency physicians, advanced practice clinicians, and nurses are in a prime position to identify victims of human trafficking. According to the Family Violence Prevention Fund, 28% of trafficking survivors had contact with a health care provider, but the abuse wasn’t recognized.

It is therefore critical for us to maintain a high level of suspicion during our clinical shifts. Identifying these individuals can mean the difference between life and death.

Here are some telltale signs to assist you in recognizing potential victims of human trafficking. The patient may:

• be accompanied by someone who attempts to control the patient interview (e.g., by answering questions for the patient)
• have downcast eyes or diminished eye contact with the medical provider
• have a flat or fearful affect, and engage in minimal conversation with provider
• have multiple injuries in different stages of healing, or signs of self-mutilation
• offer vague or conflicting stories about how injuries were obtained
• have poor hygiene

The victim is usually accompanied by someone older who dominates the conversation. The patient will appear to cower or defer to them. They will appear withdrawn, frightened, agitated, or anxious.

However, as we all know from working in the emergency department, patients often don’t present like textbook cases. At times, the victims of human trafficking may be violent, either physically or verbally, and can be abusive to the staff. As stated earlier, many of the victims have been beaten, incarcerated, kidnapped, and/or sold to multiple sexual partners. They may be fearful of being integrated back into mainstream society or hopeless about their future, and so may act out to express their frustration. Therefore, it is critical we treat these patients with compassion.

As Mary De Chasney relates in Sex Trafficking, it is imperative that providers voice their concerns to patients in an attempt to identify victims of human trafficking in the clinical setting. Asking our patients direct questions can often lead to an open and honest discussion. In her book, De Chasney relates an incident early in her nursing career regarding an eleven-year-old girl with an ectopic pregnancy. When asked about the baby’s father, the girl responded: “It could be my father, my four brothers, or the men who come to party on the weekend.”

An encounter in the emergency department may be the only opportunity for these victims to be rescued from their oppressors. If you suspect someone of being a victim of human trafficking, it is critical to keep these points in mind:

• Get the patient alone before asking questions about their situation. Do not try to question them in the presence of the person accompanying the patient.
• Contact child protective services and the police if the patient is underage.
• If the patient refuses assistance, make sure they are aware that there are resources available to them.

The Polaris Project has a twenty-four hour National Human Trafficking Resource Center hotline (1-888-373-7888), or you can text INFO or HELP to BeFree (233733).

In an era when hospital administrators demand us to do more in less time, it is critical to take a moment to stop and think, to listen to that feeling in our guts indicating that something is wrong, to get more information, to delve into the case further, and to seek help.

Unless the patient refuses assistance, the police, CPS, social services, or human trafficking services should be notified. We should consult them, just like we consult cardiology for acute myocardial infarctions or gastroenterology for GI bleeds. Human trafficking is common, prevalent, and real — and it is just as deadly as any other life-threatening medical emergency — with potentially much more dire consequences.

Alberto Hazan is an emergency physician and author of Dr. Vigilante and The League of Freaks series.