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Patient Care

Arms and ‘The Man’

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It has been a violent weekend evening, and the Attack One crew has just finished cleaning and resupplying its unit from the last trauma call. They are dispatched to a report of a “person injured.” They arrive in the nightclub area of the city to find police officers controlling an unruly patient. He is down on the sidewalk, two officers restraining his extremities.

The crew gets a rapid briefing: The police asked for EMS assistance after the patient was incapacitated with an electronic stun gun during his arrest. The officers say the man was intoxicated on some substance, assaulted another person on the street and became violent as they attempted to place him in a police cruiser. The stun gun barbs struck the man in the abdomen, and they brought him under control and removed the barbs. Bystanders report the man may have smoked “bath salts” during the evening.

The paramedic attempts to interview the man, but he gives limited information. He reports he is 28, has no medical problems and is not injured except where the stun gun struck his abdomen. He will not report taking any substances, but the paramedic notes he has widely dilated pupils, is sweating in the cool night air and has an elevated pulse.

The paramedic obtains basic vital signs and examines the man in his clothing. He feels the man’s behavior is unpredictable, and the man is uncooperative as the paramedic attempts to move his clothing and examine his back and extremities. The man has handcuffs on, his arms behind him.

The law enforcement officers step back away from the patient to clean themselves up, report to their supervisor who has just arrived and let the Attack One crew finish their evaluation. When that’s complete, the paramedic has found no injuries, and the patient is not requesting transportation to a hospital. The medic asks if the officers want to transport the patient to the hospital or jail. They have a policy that a patient who is potentially intoxicated and receives a stun gun application must be evaluated at a hospital, so they request the patient go there by ambulance.

The Attack One crew thus begins to load the patient and move toward the ambulance. As they get ready to move the stretcher in, the paramedic asks the officers, “This patient has been cleared already, correct?”

The officers look at each other. It appears neither has checked the patient for weapons. “Why don’t we stay here outside the ambulance until you guys do that?” the paramedic suggests.

The officers both approach and begin to pat the patient down. “Gun on board!” one announces.

The patient has a pistol in the waistband of his pants, and the other officer finds a knife in a lower-leg pocket. The officers secure the weapons. Under the watch of their unhappy supervisor, it’s decided they will both accompany the patient into the back of the ambulance, undress him completely and search every part of him and his clothing.

The Attack One crew members stand by as the officers do their work, and the paramedic conducts an examination as they expose the patient’s body. No further injuries, weapons or drugs are found. The man is then handcuffed and restrained to the stretcher using the seat belts. One of the officers will ride in the ambulance to the hospital; he sits on the bench in the patient compartment.

The police supervisor asks the officer to come out of the ambulance. After a brief private discussion, the officer removes his firearm, gives it to the supervisor and takes a stun gun in return. The supervisor advises the paramedic that he will drive behind the ambulance to the hospital, accompanied by the second officer, so that if the patient becomes violent again, there will be enough resources to regain control. They have the firearm of the first officer and will get assistance from hospital security once the patient arrives there.

Hospital Course

The transport to the hospital is safe and uneventful. On arrival in the ED, the patient is stable and receives rehydration and observation. Subsequent investigation by law enforcement finds the man has felony warrants and a history of violence. He is discharged to jail.

Case Discussion

This case involved a patient with a potentially dangerous medical condition and policies for safely processing persons who may have weapons. Most EMS agencies train providers to evaluate for and remove weapons from patients for safe transportation to a hospital. There are also policies regarding securing law enforcement weapons.

There is a critical need for safety in the transport of patients in the custody of law enforcement. Public safety cooperation is the basis for this. Public safety personnel who are not peace officers do not have the right to remove civil liberties, although they have the responsibility to restrain patients for medical reasons (e.g., the patient who is hypoglycemic due to an insulin reaction or suffers from severe dementia). So fire and EMS providers must be accompanied by a law enforcement officer in situations where a person is under arrest or has had civil liberties suspended by a court order, as that LEO is the only one who can enforce criminal restraint. If the patient is left in the custody of EMS personnel only and able to slip out of his handcuffs and walk out the side door of the ambulance, there is no legal basis for EMTs to restrain him.

With that legal underpinning, it is necessary for EMS organizations to have planned arrangements with local law enforcement agencies regarding the transport of individuals under the control of peace officers. Some agencies formalize those arrangements so field personnel have clear direction and protocols that guide patient care and responsibilities. That must be followed by training of both sets of personnel on the specifics of implementation.

Some EMS protocols allow ambulance transport without law enforcement accompaniment of less-dangerous offenders or those facing only misdemeanor or nonviolent felony charges. However, many EMS and law enforcement officials do not believe the nature of the offense and the outward behavior of the arrestee are accurate predictors of who can be safely transported. Sending an arrestee in an ambulance without police presence also carries the risk of potential violence by others wishing to harm the patient or EMS personnel. If there is an unarmed officer in the ambulance, he/she alone cannot protect from, for instance, gang members who attack an ambulance, looking to finish off the patient they injured, or a family member coming to break a patient free. For the patient who has a violent history or a great potential to attempt an escape, there is a need for a number of law enforcement personnel to support secure transportation.

The EMS policy may have language such as this:

EMS personnel are neither legally permitted nor operationally trained to maintain legal and physical custody of an arrestee. All patients under arrest should be accompanied in the back of the transport unit by a law enforcement officer or officers from the arresting agency or agency responsible for custody of the prisoner (local, state, federal, military) except under extraordinary circumstances. [An example of extraordinary circumstances negating the need for an accompanying officer would be a patient in cardiac arrest who is clearly incapable of assaulting EMS personnel or becoming a flight risk.] This officer (or officers) will be responsible for physical custody of the patient, as well as the safety and security of the patient and EMS personnel.

Therefore, anytime EMS transports a patient in the custody of law enforcement, the EMS officer shall request that a law enforcement officer accompany the patient in the rear of the transport unit. The law enforcement officer shall not have a firearm in the transport unit, and management of all firearms shall be done per law enforcement policy. The accompanying officer shall possess keys or release devices for any restraints being used on the patient. A sufficient contingent of law enforcement officers shall be in another vehicle driving in tandem with the ambulance to provide safe transit of the patient to the hospital. If there is to be any deviation from this policy, a police and an EMS supervisor must be contacted for approval by both parties.

James J. Augustine, MD, is an emergency physician and the director of clinical operations at EMP in Canton, OH. He serves on the clinical faculty in the Department of Emergency Medicine at Wright State University and as an EMS medical director for fire-based systems in Atlanta, GA; Naples, FL; and Dayton, OH. Contact him at jaugustine@emp.com.

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