Custody or Care; What is the Role of Emergency Medicine?

Custody or Care; What is the Role of  Emergency Medicine?

(Cooperative, inter-agency communication and training can solve a lot of these issues)


Kip Teitsort, EMT-P
Founder, DT4EMS

Have you ever been a witness to, been a part of, or heard peers discuss witnessing or being a part of any of the following:

A doctor “snowing” then intubating an uncooperative drunk in the ED because they were tired of listening to them yell and curse?

A group of EMS and Fire wrestling a drunk or drugged individual to force them onto a stretcher in order to place them into an ambulance?

An ED nurse wrestling with an intoxicated or drunk individual (who is cursing and swinging) to force them to stay in an ED room or on the bed?

If you have answered yes to any of the questions above, ask yourself, “Was I providing care or taking custody of someone”?

Then ask yourself, if those actions were captured on video, placed on the internet or local news, would those very actions be viewed as “a recognized form of medical treatment”? A definition of  reasonable adj., adv. in law, just, rational, appropriate, ordinary or usual in the circumstances (1)

If you believed your actions were “reasonable” because you used those actions to place a person into medical restraints… what documentation can you provide for the training of using those techniques.Custody_care

Across the country, most in emergency medicine be it EMS/Fire or ED staff state they have received less than 4 hours of training in the application of medical restraints. When I ask them about that training the overwhelming majority admit the training was on the “application” of the actual soft-restraint and their training had little or nothing to do with the physical skills nor the dynamics involved with how to “control” a person and place them into the soft restraints.


Let’s go back to the original question of custody versus care, which are we supposed to provide? Care means we operate under some form of consent. Custody is usually obtained by the use of, or the threatened use of force, usually accompanied by some form of pain compliance if force is used. So, who would “consent” to pain?

Is a dog pile a form of recognized medical treatment? Watch the  video below. I am sure the firefighters were doing what they thought was “right” mainly because they felt “compelled” to do something. But are they taking custody or providing care?

Problem 1 :

The emergency medical community has a misconception regarding the term combative patient.

Solution 1 : Educate staff on what is and what is not a patient requiring immediate medical attention. For instance, Drunk is not sick. Sick is sick. Furthermore by removing the words “combative patient” from medical lingo because such person, purely by definition cannot exist as further described here.

Problem 2: Too often inappropriate levels of force are applied in the ED or pre-hospital setting be it too much or too little. Many times this is due to “Unofficial Training“.

Solution 2: Train staff in the “reasonable” use of force. Simply learning a few techniques that work on a compliant partner in a classroom or a class on verbal skills does not give the staff member the much needed critical thinking skills when faced with a violent encounter. Use a system designed for the actual situations a staff member faces without employing police style (custody/control) or martial arts (win a fight) that have no place in medicine (care).

Problem 3: Administrative Support or perceived lack thereof.

Solution 3: Inform staff they have administrative support for not only fleeing a violent encounter, but for support in filing criminal complaints if they were criminally assaulted. In nearly every class I have taught across the country, at least one participant will describe an incident where a criminal assault had taken place and there was little to no support from administration. I can assure you, a person does not have to be killed to be changed forever due to criminal assault.

Ignoring the problems exist will not stop incidents like staff being assaulted (Assault on Staff Log is where we keep a record of news events involving staff criminally assaulted) nor will it keep staff from acting inappropriately like assaulting patients and getting arrested. (2), (2a), (2b)

Quote me… When faced with a violent encounter, staff will respond. How they respond will be based upon their training…or lack of it.

 Now… you might find it interesting that many cases of injury to staff from attackers and patients due to staff actions have come from RESTRAINT situations.


(1) Accessed 12-02-2013