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Preventing in-custody deaths

EMS and law enforcement collaborative training helps prepare responders to treat and monitor patients experiencing a constellation of symptoms


“The constellation of symptoms training is absolutely necessary from a law enforcement perspective, because we are continually seeing this problem in the field and, unfortunately, it is almost always requiring the use of force by police.”

Photo/Sean Hulsman

By Sean Hulsman

As I enter the community college classroom, I am startled by a sudden vocalization from the front of the room.

“Uh-ten-HUH!” barks a recruit. All students in the room immediately snap to their feet, uniforms pressed and clean, eyes cemented forward as I make my way to the podium. As an EMS educator, I’ve never sought or experienced that type of respect when I enter a classroom, yet I understand the philosophy. As professionally as I can, I thank the recruit and, without knowledge of the appropriate jargon, I smile politely and say “please be seated.”

That experience with the 78th Niagara County Law Enforcement Academy (NCLEA) recruit class in New York instantly reinforced for me that police training is a very different animal than EMS education. I was there with my teaching partner at the request of Lieutenant Julie Kratz, co-director of the NCLEA. With a recent uptick in high-profile cases involving in-custody deaths, Lt. Kratz and I had shared correspondence on how EMS could better interface with law enforcement at scenes where subjects presented as agitated. Specifically, she wanted to focus on cases then referred to as “excited delirium” (ED).

Our plan was to give the future officers a rudimentary training in ED (now referred to in New York as “constellations of symptoms,”) including the potential for respiratory compromise resulting from the restraint process, and the increased chance of sudden cardiac arrest among individuals suffering from this medical condition. Our discussions started with basic anatomy/physiology, but ended, probably most importantly, with ideas for how law enforcement can integrate EMS response to everyone’s advantage.

The final product is a solid didactic presentation that is useful for both EMS and LE trainees, including a video simulation of an initial police take-down, followed by EMS intervention and subsequent care. The goal: to engage all possible resources and skills to prevent people from dying in police custody.

Lt. Kratz says of the program, “the constellation of symptoms training is absolutely necessary from a law enforcement perspective, because we are continually seeing this problem in the field and, unfortunately, it is almost always requiring the use of force by police. Often, these cases are involving synthetic stimulants/other drugs (which increase blood pressure and heart rate), in combination with physical exertion during an altercation with law enforcement (which also increases the blood pressure and heart rate). That leads to an extreme increased risk of a sudden cardiac event for the suspect. This is a situation that no officer wants to be in.”

LE officers are often expected to restrain subjects who will not follow commands, exhibiting extreme pain tolerance, who may also be naked, bleeding and aggressive. To be sure, it is a difficult ask for our LE officers to summon the appropriate force and survival mentality to gain control of these persons, potentially sustaining injuries from punches, kicks and bites in the process, and then instantaneously change their mentality toward compassionate patient care.

The vast majority of police can make that change, but it may take a few moments, and often, those moments are critical. To help with the transition, EMS can fill the gap. As noted earlier, police training and EMS training are very different. While LE is focused on safely getting a violent individual in custody while safeguarding themselves, the community and the individual, EMS is spared the burden of the adrenalin dump. We can step in once officers have expertly executed their take-down and begin the process of patient care – which is ultimately what these individuals generally need. Our training approach evolved into a four-step process represented by an acronym “COMA.”

“C” is for Custody

First is the actual take-down. NCLEA and other academies around the state and country are implementing best-practice defensive tactics to ensure that a suspect is taken control of without utilization of holds or body pressure that would compromise the airway or respirations. The “C” is absolutely in the wheelhouse of law enforcement, and it’s important for both LE and EMS to understand that medics and EMTs should not be involved. EMS has neither the authority nor the training to safely take a person into custody. It should be noted that EMS should really never engage in any restraint situation without the presence of law enforcement.

“O” is for Observe

Before and during the arrival of EMS, LE officers should roll handcuffed suspects into a lateral recumbent position to allow for the suspect to breathe as normally as possible. For the remainder of the encounter, the person in custody should be kept recumbent or supine, and this includes during any subsequent transport. Officers should also be regularly observing for responsiveness and breathing. This is non-invasive and very simple. If at any point, the individual stops responding, it is imperative that pulses and breathing are immediately assessed, and CPR and defibrillation are administered as needed.

“M” is for Medical

Ideally, EMS should be summoned as soon as LE realizes they are encountering someone with a potential constellation of symptoms. The sooner EMS is on scene, the sooner police can re-focus on their primary responsibilities. Once EMS takes on a patient care role, police investigatory and clerical duties, as well as psychological decompression can occur, and officers can be treated for any injuries they might have sustained in the encounter. We emphasize advanced life support requests, as paramedics will be the only EMS providers who can administer sedative medications, like versed or ketamine, if the situation calls for it. Ketamine has come under scrutiny in the last few years, but it should be noted that the majority of ketamine problems have resulted from providers overdosing patients and/or failing to monitor the patients adequately after administering the medication.

Kratz reinforces the importance of understanding ALS vs. BLS. “We provide this training to recruits, supervisors and as a part of in-service training to seasoned officers. Without this training, police officers may not have known about the resources that EMS can provide in these types of cases – including the injection of medications like ketamine or versed, right on scene. Prioritizing getting an ALS unit on standby as soon as it is recognized that there may be a constellation of symptoms case arising, as well as laying the subject on their side or upright position as soon as possible can help to prevent any sudden cardiac event.”

“A” is for Assess

Assess continuously. This is the primary realm of the EMS crew, but LE can and will sometimes be helping with it. Assessment ensures that a person in custody is continually monitored for ABCs. It’s a continuation of the observe step, except with higher-level medical personnel there to do it. It should be common sense, however, we have seen recent examples of EMS providers failing to adequately monitor persons in custody both on-scene and during transport only to discover that these people have been in cardiac arrest for some undetermined amount of time. Again, it’s as simple as checking for verbal responsiveness and, if there is no response, immediately moving into a cardiac arrest algorithm.

Overall, the training is being well-received by both EMS and law enforcement. Lt. Kratz states, “I highly recommend providing this training to as many police officers as possible. The NCLEA has received positive feedback from students about the training and how they can more confidently approach these very hard situations and help protect the patient from medical complications.”

In our EMS agency, all current and incoming providers complete the very same training and anecdotally report feeling more comfortable interacting with constellation of symptoms patients and with the law enforcement officers on scene with them.

Our goal would be to offer these training concepts to as many EMS and law enforcement agencies as we can. At the end of the day, EMS and law enforcement have very different backgrounds and very different roles in first response, but they should, and can be, on exactly the same page when working to prevent in-custody deaths.

About the author

Sean Hulsman, MEd, EMT-P, is director of education at Twin City Ambulance Corporation in Western New York. A highly motivated professional educator, he combines extensive experience in teaching and curriculum development with 25 years of prehospital emergency care experience. He is a New York State certified science teacher, paramedic; and CIC and AHA instructor. Sean can be reached at