” Cops and Medics: The intersect of medicine and law enforcement priorities”

1. ”Cops and Medics: The intersect of medicine and law enforcement priorities” JAY LANCE KOVAR, MD, FACEP JERRY LYNN KOVAR, MSCJ, CCE, CJM

2. Objectives • Define the areas of intersect between Medical care and Law Enforcement priorities • Gain a working knowledge of the rules and obligations of each organization • Facilitate a collaborative approach to the needs of the public we serve

3. Focus on the common interactions and misconceptions that occur when law enforcement and medicine intersect. Highlight errors and define the information that each entity must possess to improve public safety

4. Case in point #1 42 year old male arrested for public intoxication and presenting a danger to himself and others Initially taken to the jail booking facility but revealed a potentially critical ingestion of multiple substances of abuse and became combative. It was advised by jail authorities that he be transported for medical evaluation.

5. Case in point #1 He was restrained in hand cuffs and take by two officers Hospital Emergency Department. The nursing triage notes indicate an elevated heart rate, respirations, and temprature with a history of recent ingestion of multiple drugs, cocaine, and PCP. The nurse also notes the patient to be in mild distress. initial medical work up while the patient was in police custody revealed an abnormal electrocardiogram and potential cardiac injury related to the drug use. ER doctor initiated a transfer request to Heart Specialty Hospital

6. Case in point #1 Patient attempts to get out of the stretcher bed but stopped when realized he remained handcuffed to the stretcher rails. Displays aggression towards Nurse while restrained which required police intervention. They document emotional lability and anger. Attempts at obtaining ambulance transport were stalled by the request for 2 police officers to accompany the patient due to concerns over EMS personnel safety. When police and fire officials were unable to reach an acceptable transport situation (including sedation), Officer instructed by supervisor to release the patient to his own recognizance.

7. Case in point #1 At 02:30 Patient became agitated, left the stretcher and removed his IV line. When the Nurse approached the bedside, she was brutally assaulted. EMS personnel present were able to physically subdue the patient, but Patient suffered a strike to his head and massive bleeding in the action. Police were called back and the patient again placed in handcuffs to the stretcher. Physician states she did not feel it was safe for EMS to transport the patient and changed the disposition of his care to remain at hospital, in continued police custody.

8. Disengage At what point or criteria may law enforcement disengage from an individual? At what point or criteria may medical providers disengage from care?

9. Duties of Law Enforcement TX Penal Code 20.02 Unlawful Restraint- It is no offense to detain or move another under this section when it is for the purpose of effecting a lawful arrest or detaining an individual lawfully arrested. Commission on Accreditation for Law Enforcement Agencies Standard 71.2.1 - A written directive describes restraining devices and methods to be used during prisoner transports w/exceptions noted: It is necessary for officers to know when and how prisoners are to be restrained and when, where and how particular restraining devices are to be employed, including special and prohibited methods. Mentally disabled prisoners may pose a significant threat to themselves and/or transporting officers. The selected device should restrain the prisoner securely without causing injury. These devices should be required whenever practical, but should not preclude the use of handcuffs in emergency situations.

10. Duties of Law Enforcement Standard 71.3.2 - A written directive establishes procedures for the security and control of prisoners transported to medical care facilities or hospitals for treatment, examination or admission: Prisoners who are taken for immediate treatment should be closely monitored. Opportunities for escape, suicide and assault on hospital personnel or the transporting officer should be guarded against and will be more prevalent if the prisoner is unrestrained and/or out of sight. If restraints should be removed for treatment, caution should be exercised while the prisoner is unfettered. Only under unusual circumstances will the prisoner be allowed out of the transporting officer’s sight. If the prisoner is admitted to the hospital, the agency may need to provide additional security. Some measure to consider are the type and period of treatment, degree of risk, continued use of restraints and visitor contact.

11. HEALTH & SAFETY CODE – Ch 462 EMERGENCY DETENTION Sec. 462.041. APPREHENSION BY PEACE OFFICER WITHOUT WARRANT. (a) A peace officer, without a warrant, may take a person into custody if the officer: (1) has reason to believe and does believe that: (A) the person is chemically dependent; and (B) because of that chemical dependency there is a substantial risk of harm to the person or to others unless the person is immediately restrained; and (2) believes there is not sufficient time to obtain a warrant before taking the person into custody. (b) A substantial risk of serious harm to the person or others under Subsection (a)(1)(B) may be demonstrated by: (1) the person's behavior; or (2) evidence of severe emotional distress and deterioration in the person's mental or physical condition to the extent that the person cannot remain at liberty.

12. HEALTH & SAFETY CODE – Ch 462 EMERGENCY DETENTION (c) The peace officer may form the belief that the person meets the criteria for apprehension: (1) from a representation of a credible person; or (2) on the basis of the conduct of the apprehended person or the circumstances under which the apprehended person is found. (d) A peace officer who takes a person into custody under Subsection (a) shall immediately transport the apprehended person to: (1) the nearest appropriate inpatient treatment facility; or (2) if an appropriate inpatient treatment facility is not available, a facility considered suitable by the county's health authority. (e) A person may not be detained in a jail or similar detention facility except in an extreme emergency. A person detained in a jail or a nonmedical facility shall be kept separate from any person who is charged with or convicted of a crime. (f) A peace officer shall immediately file an application for detention after transporting a person to a facility under this section.

13. HEALTH & SAFETY CODE – Ch 462 EMERGENCY DETENTION (g) The person shall be released on completion of a preliminary examination conducted under Section 462.044 unless the examining physician determines that emergency detention is necessary and provides the statement prescribed by Section 462.044(b). If a person is not admitted to a facility, is not arrested, and does not object, arrangements shall be made to immediately return the person to: (1) the location of the person's apprehension; (2) the person's residence in this state; or (3) another suitable location. (h) The county in which the person was apprehended shall pay the costs of the person's return. (i) A treatment facility may provide to a person medical assistance regardless of whether the facility admits the person or refers the person to another facility.

14. Duties of Medical Personnel Primum non nocere "given an existing problem, it may be better not to do something, or even to do nothing, than to risk causing more harm than good." Non-maleficence Ethos "character" the guiding beliefs or ideals that characterize a community, nation, or ideology.

15. 3 Fundamental Ethics of Medicine • The principle of justice • implies that the system be fair and equitable. • The principle of beneficence • requires that actions and intentions are in the best interest of the patient. • Respect for patient autonomy • dictates that the requests of the patient are honored and nothing is done which is contrary to the wishes of the patient

16. The Relationship Between Ethics and Law • Medicine must look to the law for guidance when dealing with patient directives or to implement policy regarding involuntary care. • There are many situations that have not been addressed by statute or case law. • The law also does not address the breadth of ethical imperatives. • Law may not reflect ethical behavior. • case law has stated that a person who knows how to swim has no legal obligation to rescue a drowning child.

17. The Ethical Provision of Services • When medical services holds itself out to the community as an emergency response network it is assuming an important ethical obligation. • It has the duty to respond regardless of the patient's income or social position. • Care must not be limited unfairly to any specific group or class of people. • Financial concerns do dictate the resources available, and often set the community level of care. • These allocation decisions must not be arbitrary, and must not penalize any group unfairly.

18. Duty to Provide Care Must the prehospital providers enter a situation where they feel threatened? • Medical providers have no duty to place themselves at risk in order to care for a patient. How should they interact with a dangerous patient? • There is no responsibility to risk one's own health or safety for the benefit of another.

19. Duty to Provide Care There is a duty to provide a medically acceptable standard of care and ensure continuing education and quality assurance. The system has a duty to meet the commitments which it undertakes. There is no duty to accept risks of harm

20. Coin Toss Combative Self destructive Homicidal/suicidal Altered mental states Jail ER

21. Choices “The relationship between Law enforcement officers and hospital staff was not good; “The officers thought this was not their role, and the staff in the ER didn’t see these patients as an emergency compared to car accident victims, shootings, stabbings. They are very disruptive to the ER, especially when you are sitting there for hours.” • Bexar County Jail Diversion Program • Houston Police Department 1,250 crisis-trained officers ER!

23. Case in Point #2 EMS arrives on scene, patient lying in the back seat of the patrol car acting asleep or passed out. After getting the patient to respond she was taken out of the patrol unit and moved to the ambulance to be checked. While walking to the ambulance patient appeared to pass out and go to the ground. Patient was picked up and taken to the ambulance. As EMS attempted to get her inside the ambulance she tried to break free from them and run away from the ambulance. Patient was then caught by Deputy and put inside the ambulance.

24. Case in Point #2 Deputy told patient that he would handcuff her to the stretcher if he had to and make sure that she would not attempt to get out of the ambulance again. EMT had patient calmed down to where she told them that she would not attempt to run again and would not need to be restrained in the ambulance. After initiating transport about three miles the patient unsnapped the safety restraints on the stretcher and said that she was getting out of the ambulance.

25. Case in Point #2 EMT called for assistance from SO to help with the combative subject but called back in less than a minute and told SO Dispatch to disregard and the patient was under control again. EMT then locked the rear doors of the ambulance just in case patient did try and get out of the ambulance. About five minutes later. Medic states that patient jumped up from the stretcher and got to the rear doors of the ambulance, unlocked the doors, opened them and was attempting to jump out of the ambulance.

26. Case in Point #2 Medic tried to grab hold of patient's blue jean shorts to keep her inside of the ambulance but it was too late. Patient hit the roadway with her foot first and then flipped and landed on her head causing massive head trauma. Medic states that there were two eighteen wheel trucks running behind the ambulance at the time patient jumped from the ambulance and one of those trucks had to avoid running over her in the roadway. Patient pronounced dead on scene

27. Joint Custody Battles

28. HEALTH & SAFETY CODE – Ch 573 EMERGENCY DETENTION Sec. 573.001. APPREHENSION BY PEACE OFFICER WITHOUT WARRANT. (a) A peace officer, without a warrant, may take a person into custody if the officer: (1) has reason to believe and does believe that: (A) the person is mentally ill; and (B) because of that mental illness there is a substantial risk of serious harm to the person or to others unless the person is immediately restrained; and (2) believes that there is not sufficient time to obtain a warrant before taking the person into custody. (b) A substantial risk of serious harm to the person or others under Subsection (a)(1)(B) may be demonstrated by: (1) the person's behavior; or (2) evidence of severe emotional distress and deterioration in the person's mental condition to the extent that the person cannot remain at liberty.

29. HEALTH & SAFETY CODE – Ch 573 EMERGENCY DETENTION ( (c) The peace officer may form the belief that the person meets the criteria for apprehension: (1) from a representation of a credible person; or (2) on the basis of the conduct of the apprehended person or the circumstances under which the apprehended person is found. (d) A peace officer who takes a person into custody under Subsection (a) shall immediately transport the apprehended person to: (1) the nearest appropriate inpatient mental health facility; or (2) a mental health facility deemed suitable by the local mental health authority, if an appropriate inpatient mental health facility is not available. (e) A jail or similar detention facility may not be deemed suitable except in an extreme emergency. (f) A person detained in a jail or a nonmedical facility shall be kept separate from any person who is charged with or convicted of a crime.

30. Medical Clearance • Determine Capacity for decision making • Determine if the patient’s symptoms are caused or exacerbated by a medical illness? • Assess and treat any medical situation that needs acute intervention, and • Determine if the patient is intoxicated, thereby preventing an accurate psychiatric evaluation. There is no standard process for providing this ‘‘medical clearance.’’

31. Disposition Observation/Admission Psychiatric evaluation Psychiatric facility Home Jail Who can leave AMA? Who can we stop? Who can we restrain?

32. Jurisdiction Who’s in charge here? Who’s liable here?

33. Legal Consult If the patient has illegal substances, is using substances illegally, or is under the influence of these substances, are we required to report that to the police? No Are we violating patient rights (HIPAA) if we report it? No, commission of a crime invalidates HIPAA in Texas

34. Required Reporting Reportable Illnesses, Injuries, and Events for Texas Physicians I. Communicable Diseases II. Trauma Events III. Gunshot Wounds and Controlled Substance Overdoses IV. Immunization Reporting V. Child Abuse VI. Adult/Elderly Abuse VII. Domestic Abuse VII. Sexual Exploitation*

35. Texas Penal Code Under Section 21.11 A professional may not delegate to or rely on another person to make the report.

36. What's The Law? FC§261.109 Failure to Report; Penalty. • A person commits an offense if the person has cause to believe that a child's physical or mental health or welfare has been or may be adversely affected by abuse or neglect and knowingly fails to report as provided in this chapter. • An offense under this section is a Class B misdemeanor.

37. Class B Misdemeanor Failure to report suspected child abuse or neglect is punishable by imprisonment of up to 180 days and/or a fine of up to $1,000. Penal Code 3.12.22

39. Questions? jlkovar@aol.com jlkovar@icloud.com