1. Describe the operational, legal, and ethical justifications for the provision of appropriate medical treatment to persons in legal custody.

2. Describe medical concerns associated with assumption of custody, transport of the prisoner, and transfer of custody at the medical or booking facility.

3. Describe methods and potential hazards associated with patient restraint.

4. Identify situational and individual factors associated with increased risk of sudden death while in custody.

5. Describe elements of the medical preplan for a tactical operation.

The act of taking an individual into custody begins a relationship where the custodial officer assumes responsibility for the health and welfare of the individual taken into custody. This relationship should be viewed as a continuum, beginning with the act of taking the individual into custody and ending only when responsibility for the individual is assumed by another governmental agency or the individual is released.

Responsibility for the health and welfare of a prisoner may last only a brief period of time. It may simply entail ensuring that a prisoner is properly secured in a transporting patrol car with a seatbelt. However, it may also involve complex medical monitoring due to chronic medical conditions while the prisoner is transported over great distances. Considerations, such as fitness for confinement, the appropriateness of certain physical restraints, the potential for preexisting injury or illness, security of law enforcement personnel, medical preplanning, and documentation, should all be addressed.

The views expressed in this article are those of the authors and do not necessarily represent the views of the Federal Bureau of Investigation or of the United States Government.

This chapter will address the essential elements of medical support and medical preplanning as it relates to law enforcement agency responsibilities for individuals in custody. The period examined is from the point of initial interaction with tactical law enforcement until arrival at a medical treatment facility, or in the case of subjects without medical needs, at the initial arrest processing location. Medical support provided in military or correctional settings is beyond the scope of this discussion.

Upon receiving an individual in custody, it is the individual law enforcement officer’s responsibility to assure that provisions for United States standards of health care are available to the in-custody individual with appropriate consideration of security and tactical safety issues.

Appropriate medical treatment of subjects in custody is mandated for both operational and ethical reasons. Provision of medical care can positively impact the relationship between the prisoner and escort, potentially leading to beneficial intelligence or investigative outcomes. To do less risks potential complaints of withholding of medical care for punitive purposes. The withholding of adequate
medical care may be viewed as excessive force, an unconstitutional act in violation of the Fourth Amendment right to be free of unreasonable seizure. Federal courts have held that “a pretrial detainee’s constitutional right to medical care, whether in prison or other custody, flows from the procedural and substantive due process guarantees of the Fourteenth Amendment” (1). In a legal context, when a law enforcement officer takes custody of a prisoner, a duty to provide adequate health care may then arise. Failure to provide such health care may be viewed as a breach of that duty and expose the officer and his or her agency to civil liability.

If the escorting law enforcement officer is the arresting officer, a determination of the health status of the prisoner can rapidly be made based on the circumstances of the arrest and the physical appearance of the prisoner. If an application of force was necessary during the arrest, there may be a higher likelihood that the prisoner may have sustained injuries.

If tactical safety and security considerations permit, a trained prehospital medical provider, such as an emergency medical technician (EMT) or paramedic should be summoned to the scene of the arrest to determine the extent of the injuries or illness and whether medical treatment is required. If this is not possible, medical assistance should be accessed as soon as possible, meeting emergency medical service (EMS) personnel at a prearranged, secure location nearby. The presence of trained medical personnel, either as part of the tactical team or staged nearby, allows for rapid evaluation of in-custody individuals prior to transportation from the crisis site. The inclusion of a medical component in the operational plan reduces delay in access to EMS care and enhances the stability of the site during the critical period following tactical activity. The latter can significantly reduce the risk of additional injury to operators, subjects and bystanders following the arrest.

Law enforcement officers responsible for the transportation or escort of prisoners should be aware of the potential for exposure to body fluids or respiratory-communicable diseases through contact with the prisoner. The use of personal protective equipment (PPE) including disposable nonlatex examination gloves and surgical masks in addition to standard tactical eye protection can greatly reduce infectious disease risk exposure of law enforcement officers. Expeditious transfer of sick or injured prisoners to trained medical personnel prior to transport will also reduce the risk to officers of body fluid contamination during transport.

In the event that the prisoner is received from another agency, a determination should be made as to the health status of the prisoner prior to accepting custody. If a pre-existing medical condition exists and circumstances of the arrest permit, documentation should be obtained in advance regarding the diagnosis, the prisoner’s condition, treatment received, medications required, and special considerations for transportation. In the case of a prisoner with a complicated medical condition or any condition that may require treatment during transport, a trained medical provider should be part of the prisoner escort team. When the prisoner is known or suspected significant medical history, a face-to-face report from the sending facility medical staff should be received prior to the transfer of custody. Where special security risks or considerations exist for the prisoner, it is beneficial to have a sworn officer as the medical provider. This allows the officer/medical provider to perform law enforcement functions while intervening medically when necessary. This also helps to ensure a high level of operational security during transit and minimizes the size of the escort team.

Tactical law enforcement teams at a destination jurisdiction may receive prisoners extradited from other jurisdictions, transporting them to the site of initial processing or confinement. The involvement of tactical teams in these transfers is sometimes required because of the high-risk nature of the subject involved or the need for enhanced security to ensure the safety of the prisoner. A medical annex to the operational plan for such missions is required, as in any tactical mission. As these subjects may be received following prolonged transport by ground or aircraft, pre-existing medical conditions may become problematic while en route. This eventuality should be reflected in the medical plan.

If the prisoner is received from a governmental agency of a country other than the United States, an independent medical practitioner should accompany the prisoner escort team receiving the subject. This medical provider should perform a thorough physical examination of the prisoner prior to custody being accepted. The physical diagnosis requirements of this examination usually require skills beyond conventional EMS training. A certified physician assistant (PA-C), registered nurse practitioner (RN-P) or physician with experience in prehospital or primary care medicine is appropriate for this task. This examination should be recorded in detail and should accompany the prisoner to the point of processing for confinement. Again, if a serious or complicated medical condition exists, a face-to-face report should be given by the escort team medical provider to the receiving facility medical staff.

The method and amount of restraint required for the prisoner may have a significant impact upon transport plans, including the number of escort personnel required,
chosen mode of transportation and level of medical support needed.

From both medical and legal standpoints, the techniques used for prisoner restraint should be the minimum required to ensure the safety of the escort personnel as well as the compliance of the prisoner.

For the short distance movement of a prisoner, a common law enforcement transport technique is to place the handcuffed prisoner in a transport van or car. Handcuffs are usually applied with the prisoner’s hands behind his or her back when used by police as the sole means of physical restraint to prevent the combined use of the joined arms and the handcuff device as a weapon. Single-use disposable plastic wrist restraints, commonly referred to as “flex-cuffs,” frequently used in situations involving the arrest of multiple subjects, are used in a similar fashion.

If a car is used for transport, the prisoner is often placed in the back seat. If the vehicle is without a cage, an escorting officer is likely to be seated behind the driver. If the prisoner has a predetermined medical condition or an injury, a sworn officer who is also a medical provider may be used as one of the transporting officers.

This makes a medically trained officer available to immediately recognize and address medical issues that may arise, even in the course of a relatively short duration transport. Prisoner transport vans are used in the initial arrest phase in some jurisdictions, particularly when arrests of large numbers of subjects are anticipated. Because officers often do not accompany the subjects or have controlled access to the rear of the van during transport, these vehicles are often unsuitable for transport of subjects with confirmed or suspected medical concerns.

Subjects received from extraditions involving long distance transport may be received from the transporting officers in prisoner transport belts. Transport belts allow for the prisoner’s hands to be located in the front, yet still remain secured close to the body. This method increases prisoner comfort and reduces wrist trauma due to friction, reduced circulation, and nerve impingement. This arrangement facilitates monitoring of distal neurovascular status of the hands and also facilitates prisoner selftoileting.

Prisoners classified as ambulatory in conventional medical operations without suspected injury of the limbs may often be transported safely by car using the standard restraint methods described. Any subject with injuries deemed by the treating EMS personnel to be at risk for exacerbation en route should be monitored by a medically trained officer regardless of the mode of transport. Due to the risk of a prisoner becoming noncompliant or assaultive, officer and health care provider safety is always paramount. The use of vehicle or aircraft safety belts, in addition to handcuffs or a transport belt, provides an added layer of restraint to protect the escorting officers and protection of the prisoner from injury in the event of a vehicular accident.

If a prisoner’s condition requires ambulance transportation, he or she must be restricted to the stretcher gurney. Soft restraints should be used on all extremities whenever a prisoner is transported by ambulance. Although this is unusual in general EMS practice, it should be remembered that the patient is in a custodial status and that both restraint and officer escort are required to prevent escape or self-injury. Close medical observation is required due to the potential for unexpected medical deterioration, choking hazards and attempted self-injury. Some officers and jurisdictions require a law enforcement suitable restraint, such as handcuffs, to supplement the soft restraints usually associated with stretchers. Care must be taken in this situation to ensure the ability to deliver care to the subject in the event of a medical emergency during transport and to monitor the distal neurovascular status of any extremity handcuffed to a stretcher.

A prearranged procedure for transfer of a stretcherborne subject in custody should be in place with medical facilities listed in the medical operational plan.

A restrained prisoner may attempt to spit at or bite the escorting officers. The application of a surgical face mask to the prisoner will provide an additional layer of protection to the officers. The mask should be loose fitting, permitting the escorting medic to monitor respiratory effort. Escorting officers should conscientiously address the threat of exposure to communicable diseases from the prisoner’s body fluids. All transporting officers should have medical examination gloves and eye and face protection immediately available on their person. In many cases, this personal protective equipment is best worn as a precaution any time that attendants and escorts occupy the close quarters of a vehicle with a prisoner.

With proper application and careful monitoring, appropriate physical restraints are usually sufficient to achieve safe transport of subjects from the arrest site to the initial arrest processing or medical treatment facility. Modification of restraint to the mutual satisfaction of both security precautions and medical care requirements is routinely achievable when transporting a nonambulatory person in custody.

A special note should be made regarding restrictive fourlimb restraints used in some law enforcement settings. A recurring scenario in some reports of deaths of persons in custody describes the prisoner’s hands being restrained behind the back, the prisoner then placed in a face down position, often in a restrictive posture, either on the floor of the passenger compartment of a car or through further restraint of the legs flexed dorsally behind the back in a “hog tie” fashion, also referred to as “hobble-restraint.” Fatalities associated with this procedure have been postulated to result from so-called “positional asphyxia” due to interference with thoracic and abdominal excursion. While the physiologic basis for positional asphyxia as the terminal
event in these cases has been questioned in some studies (2), this preterminal scenario nevertheless continues to be described frequently in the forensic medicine literature (3, 4 and 5). In addition, the authors can individually attest to anecdotal experience involving restrained subjects, often with clinically obese habitus, exhibiting marked respiratory distress following restrictive supine restraint, relieved by positional change to a lateral decubitus position.

Factors implicated in sudden death following physical restraint include substance intoxication (5,6

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