UTSW/BioTel Policy: Evaluation & Management of a Patient in Custody

Purpose: The purpose of this policy is to assist paramedics in providing the best possible prehospital care for persons who are in the custody of police or other public safety officials.


    1. Custody: A person who has been arrested or detained by a peace officer for a specific reason or offense.
    2. Under Arrest: Action by a peace officer which may be either on view or pursuant to a warrant issued by a judge, whereby an individual is taken into physical restraint with the intent to take to jail or some other area of confinement as authorized by the law.
    3. Emergency Detention (Apprehension by a Peace Officer Without a Warrant (APOWW)): An arrest made by a peace officer in which the peace officer has probable cause to believe that the subject arrested is an immediate threat to him/herself or others and requires mental health services.
    4. Detained: An individual for whom freedom of movement has been restricted by a peace officer for a limited time and under limited circumstances, although the person is not formally under arrest.  This sometimes includes asking a person to wait while a peace officer checks for outstanding warrants, for wanted status or to verify some specific account given by the person.
    5. Court Order: An order issued by a judge whereby a person is ordered by the Court to do or not to do something. In EMS application, the only court of record we deal with is a district court, which is a state judicial office. The judge may have either criminal, civil, or both joint civil and criminal jurisdiction.
    6. Mental Health Hold: A non-legal term sometimes used by physicians or other healthcare professionals to indicate that a person in the hospital has been cleared for medical purposes but nonetheless requires psychiatric evaluation prior to release.

In EMS, “Custody” most frequently involves persons who are either “Under Arrest”, or “Emergency Detention”. For questions regarding other “Custody” issues that are not covered in this policy, contact BioTel for assistance.

  1. Evaluation of Patients Who Are “Under Arrest” or “Emergency Detention”
    1. If a public safety official requests that a UTSW/BioTel paramedic evaluates a person who is under arrest or Emergency Detention, then, by definition, that person is a PATIENT.
    2. The evaluation of patients who are under arrest or Emergency Detention is no different from the evaluation of any other patient, assuming that the patient consents to the evaluation and it is safe to evaluate the patient.  The minimum assessment and documentation requirements for patients may be found in the EVALUATION AND TRANSPORT Policy.
    3. These patients RETAIN the right to self-determination with regard to assessment and treatment. Paramedics shall not initiate treatment against a patient’s will, UNLESS failure to do so would likely result in imminent death or permanent disability.  If there is ANY question regarding whether to assess or treat a patient against their will, contact BioTel immediately.
    4. Persons who are simply detained have the right to refuse BOTH evaluation and transport.
    5. Patients who are under arrest or Emergency Detention DO NOT have the right to refuse ambulance transport. If a police officer requests that one of these patients be transported by ambulance, paramedics SHALL transport the patient to a receiving hospital emergency department. If there is a disagreement regarding the need to transport the patient by ambulance, contact an EMS supervisor or BioTel immediately.
    6. If transporting an incompletely assessed patient because the patient would not allow assessment OR because it was unsafe to assess the individual, notify BioTel as early as possible so that appropriate resources can be ready and available at the receiving hospital.
  1. Transport and Destination Decision-Making
    1. Paramedics shall follow their respective City and EMS Agency policies regarding transport destination decision-making for patients who are “under arrest”.
    2. Emergency Detention patients should be transported to the closest appropriate receiving hospital emergency department for medical clearance.
    3. If there are any questions regarding the appropriate destination for an Emergency Detention patient or a patient who is under arrest or from jail, contact BioTel immediately.
  1. Medical Clearance
    1. ONLY a physician in a hospital emergency department OR jail medical staff can “medically clear” a patient who is in custody.
    2. UTSW/BioTel paramedics CANNOT “medically clear” a patient. They may, after complete assessment, report that a patient’s vital signs appear to be stable and that in the paramedic’s judgment the patient does not warrant ambulance transport to a receiving hospital emergency department.  If the police are comfortable transporting the patient either to jail for medical clearance or to a hospital emergency department for medical clearance, the ePCR shall be completed and the reasons for allowing the police to transport the patient should be clearly documented.
    3. Patients who are in custody who meet ANY of the criteria for “Mandatory Offer of Transport” in the “Prehospital Evaluation & Transport Policy” MUST be transported by ambulance.
    4. If a public safety officer requests that paramedics transport a patient by ambulance, paramedics shall honor this request OR shall immediately contact an EMS Supervisor or BioTel for assistance.
  1. Patient Restraints & Handcuffs
    1. For detailed information, see the “UTSW/BioTel Patient Restraint Policy”.
    2. Patients who are assessed to be a potential harm to themselves or others shall be restrained in the safest, least restrictive manner possible.
    3. At no time shall UTSW/BioTel paramedics utilize handcuffs.
    4. At no time, shall a patient who is handcuffed, be transported in a BioTel agency ambulance without the presence of a law enforcement officer in the back of that ambulance, who has the key to release those handcuffs.  If local city policy dictates, a restraint system may be used that allows immediate release of patient, in lieu of handcuffs. 
    5. When transporting a patient who is in the custody of law enforcement, a law enforcement officer shall accompany the patient in the back of the ambulance.
    6. A patient shall never be transported in a prone position. A patient shall NEVER be “hogtied”.
    7. Restrained patients shall have their cardiorespiratory status CONTINUOUSLY monitored.
  1. Excited Delirium (Refer to the EXCITED DELIRIUM Guidelines)
    1. Persons in custody may exhibit wild or combative behavior and altered mental status. This condition is referred to as “Excited Delirium” and is often associated with drug ingestions, particularly, cocaine, PCP, and/or amphetamines.  These patients are often tachycardic, tachypneic, and hyperthermic.
    2. A number of medical conditions including brain injury or hypoglycemia may mimic drug-induced “Excited Delirium”, and only sophisticated testing in an emergency department can determine the exact cause of this patient presentation. This CANNOT be differentiated in the field.
    3. Paramedics should be aware that this represents a true medical emergency and these patients are at extremely high risk of SUDDEN DEATH.
    4. These patients MUST be transported by ambulance to a hospital emergency department.
    5. If it is unsafe to assess any combative patient, that patient shall be placed in an ambulance along with as many law enforcement officers as necessary to control the patient during transport to an appropriate emergency department.
    6. If safe to do so, paramedics shall obtain vital signs and a blood glucose determination, initiate cardiac monitoring, administer oxygen and perform any other assessment or treatment that is indicated.  Continuous assessment of airway, breathing and circulation is CRITICAL.
    7. BioTel shall be notified as early as possible during transport that an incompletely assessed combative patient is en route.
  1. Mace/Pepper Spray
    1. Refer to the MACE/PEPPER SPRAY section in the EYE INJURY Guidelines.
  1. Taser Barb Removal
    1. Refer to the TASER BARB REMOVAL Policy
  1. Juveniles in Custody
    1. Juveniles in custody shall be managed just as any other in-custody patient would be managed. They maintain the right to refuse assessment and treatment but they do not have the right to refuse transport.  In general, juveniles in custody shall be transported to Parkland Hospital.  If there are any questions regarding the assessment, treatment, transport or destination for a juvenile in custody, contact BioTel.
  2. Transporting Prisoners From Jail
    1. Paramedics may be required to provide transportation for prisoners when requested by medical personnel at a penal facility. Paramedics shall follow their respective City and EMS agency policies regarding transport of prisoners from jail.
    2. An officer must ride in the back of the ambulance with the prisoner.
    3. Contact BioTel and an EMS Supervisor if there are any questions or concerns regarding the evaluation, treatment or transport of a jail patient.
    4. In general, jail patients in cardiac arrest should be transported to the closest appropriate facility, unless they meet the criteria for DETERMINATION OF DEATH IN THE FIELD. BioTel shall ALWAYS be contacted regarding determination of death for jail patients. Patients in cardiac arrest from the Lew Sterrett Justice Center (jail) shall ALWAYS be transported to Parkland Hospital.
  3. Overdose Patients
    1. When assessing a patient who has possibly intentionally overdosed on medications or other drugs, that patient should be considered a potential harm to himself or herself, even if they deny that they have overdosed. 
    2. If a third party reports that a patient ingested drugs or medications in an attempt to harm himself or herself, OR if the third party reports that the patient has expressed suicidal thoughts, the patient MUST be transported by ambulance.
    3. Such patients must be transported to a receiving hospital emergency department for assessment of potentially life-threatening complications of an overdose AND whether they pose a threat to themselves and warrant psychiatric assessment.
    4. Paramedics cannot determine this risk in the field.  If such a patient declines assessment or transport, the local police agency should be called to assess the situation and determine if the patient should be placed under Emergency Detention. If the patient is not under Emergency Detention, paramedics shall contact BioTel for possible activation of the Emergency Legal Assistance Program (ELAP).
  4. Acute Adult Psychiatric Patients
    1. Nearly all patients who have 911 called for evaluation of acute psychiatric illness require “medical clearance” before they can be evaluated by psychiatric emergency services and therefore shall be transported to an appropriate receiving hospital emergency department for “medical clearance”.
    2. Paramedics cannot “medically clear” these patients in the field.
    3. Paramedics shall perform a standard patient evaluation unless the patient refuses consent for such an evaluation or if the patient is combative and it is deemed unsafe to evaluate the patient. In such cases, BioTel shall be contacted immediately.
    4. Paramedics may not transport patients directly to Green Oaks, Timberlawn Hospital or any other primary psychiatric facility.
    5. Patients who are under Emergency Detention or under arrest may be transported to any appropriate hospital emergency department for medical clearance.
    6. Psychiatric patients maintain the right to determine treatment and therefore may refuse evaluation and treatment. They CANNOT refuse transport without BioTel Physician approval.
    7. Patients under Emergency Detention or under arrest can also refuse evaluation and treatment, but they CANNOT refuse transport.
    8. Any patient exhibiting signs and symptoms of “Excited Delirium” MUST be transported by ambulance to a hospital emergency department and early notification through BioTel is mandatory.
  5. Pediatric Psychiatric Patients
    1. Age 0 to 12 years (up to 13th birthday): shall be transported to Children’s Medical Center (CMC). CMC can evaluate patients 13 to 18 years of age who are NOT violent or in custody.
      1. Children’s Legacy criteria are the same as Children’s Dallas
    2. Age 13 or greater who are violent or in custody: should be transported to Parkland Hospital.
  1. Green Oaks
    1. UTSW/BioTel paramedics shall NOT transport patients directly to Green Oaks Psychiatric Hospital.
    2. Dallas Fire-Rescue paramedics shall refer to their Standard Operating Procedure regarding EMS response to Green Oaks.
  1. Timberlawn Hospital
    1. UTSW/BioTel paramedics shall NOT transport patients directly to Timberlawn Hospital.
    2. Dallas Fire-Rescue paramedics shall refer to their Standard Operating Procedure regarding EMS response to Timberlawn Hospital.
  1. Parkland Hospital’s Psychiatric Emergency Service
    1. Parkland Hospital’s Psychiatric Emergency Service no longer accepts patients directly from the field.
    2. When a UTSW/BioTel Agency EMS unit transports a patient for urgent psychiatric evaluation to Parkland Hospital, paramedics will enter the main emergency department EMS triage entrance.
    3. Parkland Hospital EMS triage staff will determine if an EMS patient should be seen in the main emergency department or can be transported by paramedics down the hallway to be evaluated first by the Psychiatric Emergency Department.
  1. The Dallas City Detention Center (CDC)
    1. The Dallas City Detention Center is run by the City Marshal’s Office and can accept persons who are assessed to be simply intoxicated with drugs and alcohol that are transported by police officers or other law enforcement officials but NOT by paramedics.
    2. EMS units may NOT transport directly to the CDC.
    3. If paramedics are asked by police to evaluate a person for possible transport by police to the CDC, follow the instructions in “Section 17”, below.
  1. Persons Detained For Simple Public Intoxication
    1. Patients with conditions including but not limited to epilepsy, diabetes or brain injury may appear to be simply intoxicated.  Thus, paramedics shall perform a complete assessment of any patient with alteration in mental status (AMS) to assess for possible causes other than drug and/or alcohol intoxication.
    2. If paramedics are not reasonably certain that a patient’s AMS is due ONLY to alcohol or drug intoxication, then that patient must be transported by ambulance to an emergency department for further evaluation.
    3. Paramedics MUST transport via ambulance to a receiving hospital emergency department any patient thought to be simply intoxicated and meeting ANY of the following criteria:
      1. Glasgow Coma Score of less than 13;
      2. Pulse rate less than 60 or greater than 120;
      3. Systolic blood pressure less than 90;
      4. Diastolic blood pressure greater than 110;
      5. Respiratory rate less than 12 or greater than 24;
      6. Oxygen saturation less than 95%;
      7. Capillary blood glucose analysis (BGA) level less than 60 or greater than 300;
      8. Active hemorrhage;
      9. Bruising or hematoma above the clavicles indicating the need for spinal immobilization;
      10. Witnessed seizure within the last hour;
      11. ANY signs or symptoms of Excited Delirium;
      12. Inability to ambulate with limited assistance;
      13. A law enforcement officer reports that he/she is NOT comfortable transporting the patient by means other than ambulance.
    4. Persons thought to be intoxicated from alcohol or street drug intoxication who - after complete evaluation - have no obvious, acute medical condition or co-existing medical complaints and who meet NONE of the criteria in Section “c” above may be transported by DPD either to jail or to the City’s Detention Center (CDC).
    5. Ambulances shall NEVER transport patients to the CDC or to jail.
    6. If law enforcement personnel are not comfortable transporting a patient to the CDC, jail or the emergency department, then the patient shall be transported by ambulance to a hospital emergency department.
    7. If a patient with AMS thought to be due to alcohol or drugs refuses transport and cannot be convinced by law enforcement officers to accept ambulance transport to an emergency department, paramedics shall immediately contact BioTel and their EMS supervisor for further assistance and direction.
    8. If a patient is thought to be simply intoxicated with drugs/alcohol, requires ambulance transport and their location is roughly equidistant to more than one hospital, and one of those hospitals is Parkland Hospital, the patient should be transported to Parkland Hospital. (Parkland Hospital will soon have a novel program to assist patients with chronic drug/alcohol problems-see below.)
  2. The Dallas Serial Inebriate Project (“SIP”)
    1. The City and County of Dallas are currently developing a program designed to attempt to break the cycle of alcohol and drug addiction and homelessness. The goal of the Dallas Serial Inebriate Project (SIP) is to develop and implement a series of integrated and coordinated behavioral health crisis services that can be accessed by persons suffering from chronic addiction and homelessness.
    2. These “high utilizers” of emergency services would be offered enrollment into the program at Parkland Hospital and other sites throughout the City and County.
    3. Once fully developed and implemented, UTSW/BioTel paramedics would assist in the identification of potential enrollees to the program.
    4. This will benefit not only these persons but also the UTSW/BioTel EMS System and our individual EMS agencies’ and receiving hospital partners’ operations.
  3. BioTel Emergency Legal Assistance Program (“ELAP”)
    1. Parkland Hospital/BioTel’s Emergency Legal Assistance Program (“ELAP”) provides on-call attorneys who are licensed to practice law in the State of Texas, are board-certified by the Texas Board of Legal Specialization, and have certification in Civil Trial Law and Personal Injury Trial Law.
    2. These attorneys are intimately familiar with the delivery of Emergency Medical Services and applicable laws pertaining to the Texas Medical Practice Act, the Health and Safety Code and other applicable laws. 
    3. The ELAP is available to UTSW/BioTel paramedics 24-hours a day, 7 days a week for emergency legal consultation. The attorneys can obtain a court order to transport a patient when indicated, and can provide advice on any legal subject, such as out-of-hospital DNRs, as well as provide additional legal assistance.
    4. Paramedics shall contact BioTel for possible activation of the ELAP. The attorneys shall NOT be contacted directly by paramedics.