When a patient presents an imminent threat of harm to self or others, law enforcement and EMS providers have their respective responsibilities: the police to secure the scene and EMS to safeguard the well-being of the patient. However, complications sometimes arise when the police and EMS providers respond to emergent situations that require the services of both disciplines. The respective responsibilities of these agencies may at times present as competing interests in a chaotic emergency setting. In particular, law enforcement’s emphasis on taking a suspect into custody and securing the scene can interfere with EMS’s responsibility to take control of the patient for purposes of assessment, treatment, and/or chemical restraint for safe transport.
To minimize these complications, the panel recommends that, at minimum, paramedics who administer ketamine should be trained to know and understand the scope of their role and responsibilities in an emergency setting with law enforcement presence.
The panel also encourages local law enforcement and EMS agencies to develop guidelines regarding the interaction between police and EMS providers, where possible. The panel concurs with the June 27, 2018 Statement on Sedation of Prehospital Patients in which the “Eagles Coalition,” a national collective of urban EMS medical directors and chief medical officers that promotes EMS protocols, best practices, and training requirements, makes this assessment:
- Coordination with law enforcement is critical to the safe management of violent patients. This partnership between EMS and law enforcement is intentional and is the result of a national effort to decrease the risk of in-custody death. Appropriate uses of physical containment and restraints as well as sedation with calming agents are critical tools for the safety of both the patients and the responders who are called to care for them. Law enforcement officers are typically the most highly trained individuals to safely physically subdue violent people and are most qualified for initial management. The use of medications is, however, solely the decision and responsibility of EMS.
The panel also agrees with the position taken by the National Association of EMS Physicians (NAEMSP) and other national EMS organizations in 10 17 20 Clinical Care and Restraint of Agitated or Combative Patients by Emergency Medical Services Practitioners. In this position statement, these organizations recognize that “law enforcement protocols may be different than EMS-based restraint protocols and so both agencies should recognize their roles and work cooperatively when the use of restraints is appropriate.” In the panel’s view, collaborative training between EMS agencies and law enforcement concerning their respective roles and responsibilities would be ideal.
The panel discussed some of the concerns that can arise when law enforcement and EMS provide a coordinated response. One such problem occurs when there is a delay in patient hand-offs. (The term “patient hand-off'' here refers to law enforcement giving EMS access to the patient in order to assess, treat and transport.) Panel members report that EMS providers should ideally medically evaluate patients in a side-lying or supine position without handcuffs, but it can be difficult to get police to remove handcuffs or reposition a patient who has presented a significant risk for violence to providers. Delayed patient hand-offs may result in increased morbidity and mortality, especially when law enforcement has applied physical or mechanical restraints/positions that may compromise the patient’s airway.
The panel noted that EMS providers receive insufficient training on how to perform such hand-offs. There is no mention of the transfer of care process in the national paramedic curriculum, National Education Standards, accreditation standards, textbooks, or in-class discussions. Based on its deliberations, the panel recommends that EMS agencies conduct training, jointly with law enforcement where possible, to equip EMS providers with the skills to initiate and implement patient hand-offs with law enforcement. The training should reinforce how important it is for EMS providers to access the patient immediately for evaluation, assessment, and monitoring. It should also clearly describe the transfer of care process from law enforcement to EMS providers, recognizing that physical control of the patient may require both EMS and police participation after the “hand-off” until the patient can be safely de-escalated or restrained.
Another significant concern that arises when EMS and the police respond to an emergent scene is the issue of who is in charge of the patient. Dr. Whitney Barrett, a former EMS medical director at the Denver Health Paramedic Division, advised the panel that although police do not routinely attempt to direct medical care, law enforcement requests for EMS to use chemical restraints on patients do occur.
A perceptible power differential between law enforcement and EMS providers may exist in the field, but the panel reaffirms that EMS providers are solely responsible for the patient’s medical care in the prehospital setting. HB 21-1251, the bill that Governor Polis signed into law on July 6, 2021, specifically acknowledges this power differential in the prehospital ketamine context. The law expressly prohibits police from interfering with EMS providers’ medical and ketamine decisions, and it criminalizes law enforcement conduct that seeks to use, direct, or unduly influence EMS providers’ use of ketamine. The panel agrees that law enforcement must neither expressly request the administration of chemical restraints nor indirectly pressure paramedics to do so. While law enforcement and others who were at the scene prior to EMS arrival can and should serve as a source of information about the patient’s behavior, the use of medications is solely the decision and responsibility of the EMS provider.
The panel therefore recommends that EMS providers should operate under clear guidelines concerning their role in the prehospital setting, including the appropriate and inappropriate use of restraints. To that end, EMS agencies should conduct training sessions in the following areas, including joint sessions with law enforcement where possible, that:
- Delineate the respective roles and responsibilities of law enforcement and EMS agencies at an emergency scene in the prehospital setting.
- Delineate the distinction between restraint practices. Law enforcement restraint practices may be different from EMS chemical restraint protocols. Both agencies should understand the differences.
- Emphasize that paramedics, and not law enforcement, are in charge of medical care.
- Demonstrate the ways that paramedics can establish appropriate boundaries where patient care is concerned, which can be especially important in chaotic situations where power dynamics come into play and the separation of roles becomes blurred.
- Enable skills practice with both police and EMS personnel in which patients are moved from a prone to supine position, transferred from the ground to the ambulance stretcher, all while maintaining adequate control of the restraints (physical or chemical) necessary to maintain patient and provider safety.