You don’t have to be a public information officer or a sheriff facing reelection to know that headlines like these are not the kind your department wants or needs.
Law enforcement officers can’t be expected to make medical diagnoses, especially during incidents that are “tense, uncertain and rapidly evolving,” as the Supreme Court called them. However, headlines like these may indicate departments need to do a better job of making officers aware of various medical conditions that may present with signs similar to drug or alcohol intoxication. Officers must be taught to consider and recognize these conditions as soon as a chaotic situation has been brought under control or during non-violent encounters, such as the typical DUI arrest.
Dealing with a combative drunk or drugged subject may be physically similar to dealing with a combative patient experiencing a medical or traumatic emergency, but it’s morally different. An intoxicated person made their own decision to ingest a substance to excess and consequently break the law. Although some medical problems may result from a lack of personal responsibility, the subject, or patient, is not breaking the law. Even if officers have to fight to gain control of a combative patient, a criminal charge may not be the appropriate resolution.
The missing critical element in many charges is the subject’s criminal intent. It is not law enforcement’s responsibility to make a person take their medication properly. It is our responsibility to enforce the law and protect the general public.
The Legal View
Ironically, two of the most influential U.S. Supreme Court cases affecting law enforcement training involved medical situations. In Canton v. Harris (489 U.S. 378 ), a female claimed to have suffered “emotional ailments” as a result of officers’ refusal to provide emergency medical care for her after she was arrested, found to be incoherent and fell down several times. She was released several hours later, at which point her family called an ambulance to transport her to a hospital.
The plaintiff alleged that the department supervisor was responsible for determining whether or not a prisoner needed medical attention and that the supervisor was not adequately trained to make this determination. This case established the concept of an agency’s liability for a deliberate or conscious “failure to train” with regard to tasks officers are expected to perform. For a suit based on failure to train to be successful, the training program must be inadequate to the tasks performed and responsible for the injury.
In Graham v. Conner (490 U.S. 386 ), Graham, a diabetic, was reportedly suffering from low blood sugar and asked a friend to drive him to a convenience store so he could purchase some orange juice to raise his sugar level. After officers observed suspicious behavior they felt was consistent with a possible robbery attempt, they stopped Graham and his friend and detained them while investigating what had occurred at the store. During their detainment, Graham was handcuffed, and he claimed officers used excessive force against him. The officers reportedly applied the handcuffs tightly, shoved his face against the hood of a car and threw him headfirst into the back seat of a patrol car. Graham sustained a broken foot, cuts on his wrists, a bruised forehead, an injured shoulder and a persistent ringing noise in his right ear that continued long after the incident.
Graham reportedly pleaded with the officers to check his back pocket for his
diabetic alert card, to no avail. Officers also refused to allow Graham’s friend to give him some orange juice. Once officers determined Graham had done nothing wrong, they drove him home and released him.
The Court ruled that any use of force must be consistent with a level a reasonable officer would have done in like circumstances that the Court acknowledged to be tense, uncertain and rapidly evolving. The Court also determined that use-of-force decisions were to be judged on the information officers possess at the time force is applied and not with the benefit of 20/20 hindsight.
Although the Court ruled the officers’ actions were reasonable given the information they possessed, a similar incident today would likely be reported in the media and create a firestorm of bad publicity. A slightly different response by responding officers could mitigate the storm.
The officers involved in these two cases may or may not have been able to do anything differently. However, the circumstances and importance of these two cases indicate an urgent need to train officers to deal with people who are possibly experiencing medical problems that may mimic intoxication.
Medical & Traumatic Conditions
A number of medical conditions have at least some symptoms that can mimic those of intoxication or drug use. These conditions may make otherwise good and reasonable people do unreasonable things they would never otherwise do, such as attack a law enforcement officer. Following are a few of the most common conditions officers will encounter.
Hypoglycemia , or low blood sugar, is most commonly associated with diabetics, but can affect non-diabetics as well under extreme circumstances. Hypoglycemia is probably the most common medical emergency mistaken for intoxication. Record numbers of people are being diagnosed with diabetes due in part to poor eating habits and record obesity rates. Thus, it’s becoming more likely that you’ll encounter a diabetic suffering from hypoglycemia. Diabetics sometimes suffer from hypoglycemia when they take too much insulin, don’t eat, overexert themselves or vomit a meal.
Observable signs and symptoms of hypoglycemia include slurred speech, staggering and unsteadiness, unconsciousness, cold and clammy skin, anxiety, seizures, confusion and combativeness. Acquaintances of the subject who are present may have no prior knowledge of the subject’s diabetes and describe the subject’s behavior as uncharacteristic with a sudden onset. Additional indicators may include more obvious signs, such as Medic Alert pendants, bracelets or wallet cards or possession of a container of sugar tablets, lancets, needles, syringes or a blood glucose meter. One relatively new technological item an officer may see is a pager-size insulin pump connected to the user’s thigh or abdomen by tubing and a catheter.
Hypoxia is a lack of oxygen to the body. It may be caused by a variety of situations that slow breathing to inadequate levels, displace oxygen-carrying cells in the body or limit the body’s ability to absorb oxygen. These conditions include stroke, shock, emphysema, drug overdoses, heart attacks and smoke or other hazardous material inhalation. Signs and symptoms may include restlessness, confusion, an altered mental status and cyanosis (or blue-gray skin color).
A stroke occurs when brain tissue dies or is damaged. It may be related to ruptured blood vessels or arterial blockages in the brain. The subject may demonstrate facial drooping or weakness on one side of the body. Communication may be difficult due to a partial or complete inability of the subject to speak or because they use incorrect words. Confusion, dizziness, loss of bladder and bowel control, impaired vision, snoring, nausea or vomiting, seizures, unequal pupils and unconsciousness may be other signs of a possible stroke.
Traumatic head injuries can cause a person to become combative and may also be mistaken for intoxication. Head injuries may result from such events as motor vehicle collisions, falls and assaults that include blunt trauma to the head or face. Serious vehicle damage or a high fall are not required to cause serious head injury. For example, in August 2008, a Tennessee police officer was running when he was tackled in a field during a training exercise. He struck his head on a telephone pole lying hidden in tall grass. After lying unconscious for about 15 minutes, he awoke, didn’t recognize his fellow officers and became combative with them. Open head injuries are obvious and may include visible bleeding or lacerations. Closed head injuries may not be as apparent. They may include concussions, skull fractures, and bruising or bleeding in the brain.
Some similarities between signs of alcohol or drug intoxication and head injuries include unequal pupils, mood changes, altered mental status and poor balance. Be alert for additional signs of possible head injury, including forceful vomiting, impaired hearing and vision, irregular breathing patterns, bleeding or clear fluid from the ears and/or nose, the appearance of a sunken eye, discoloration of the tissue under both eyes (also called “raccoon eyes”), depressions or deformities of the skull, swelling and bruising behind the ears (also known as Battle’s sign).
Variances in the body’s core temperature may lead to such conditions as hypothermia (low body temperature) or hyperthermia (high body temperature). Both conditions may cause an altered mental status, and both have a greater effect on the elderly and those already under the influence of drugs or alcohol. Hypothermia may develop despite air temperatures well above freezing and may present signs similar to intoxication, including drowsiness, staggering, confusion and a “glassy stare.” In addition, a hypothermia victim may demonstrate a stiff or rigid posture, removal of clothing, rapid breathing and pulse, and muscular rigidity. Shivering may be present early on, but lessens as the severity of the hypothermia increases.
In addition to an altered mental status, victims of excessive heat exposure (hyperthermia) may exhibit such signs as dizziness, rapid and shallow breathing, loss of consciousness and dilated pupils.
Seizure disorders are most commonly identified by periods of uncontrolled and dramatic muscle spasms called “convulsions.” Seizures may be related to a variety of conditions, including hypoglycemia, epilepsy, stroke, hypoxia, heatstroke, brain tumors, swelling or inflammation of the brain, irregularities in metabolism and head injuries. Subjects who experience a generalized or grand mal seizure may become unconscious, may lose bowel and bladder control, and may stop breathing for a while. When they regain consciousness, they may appear drowsy and confused and, due to this, in rare cases can become combative.
Assessment & Response
When you arrive on scene and find a subject acting violently or creating a dangerous situation, you may have to respond immediately based on limited information and observation. You may have to use force to restore safety and order and allow medical personnel to provide treatment. Any use of force could be portrayed by the media and public as excessive. Ensure your force is reasonable and never punitive. Don’t take the subject’s uncooperative or assaultive behavior personally. If the subject is the unfortunate victim of a medical emergency instead of illegal activity (drug/alcohol intoxication, etc.), they may not be responsible for their actions. Any unreasonable force or unnecessarily rough or unprofessional behavior by responding officers will make an unfortunate situation look even worse, possibly causing community unrest and branding responding officers as badge-heavy bullies.
Avoid focusing solely on the apparent criminal conduct, and be alert for clues of a medical emergency. If time and circumstances permit and the subject has cooperative friends or family present or accessible, ask them about the subject’s history of drug and alcohol use, medical history and the speed of onset of the subject’s current condition. Maintain a position of advantage that will provide you with time to respond to a sudden threat. Don’t get lulled into a false sense of security just because you suspect a medical or traumatic emergency. Do what you have to do to protect yourself and others. Request EMS as soon as you identify a possible medical emergency and be prepared to include EMS personnel in your control of the subject.
Remember, once the subject is under control, focus on making sure the subject receives necessary medical attention. Talk to the patient and the patient’s family as soon as possible after the incident, demonstrate your concern for their welfare, and be prepared to explain your actions in a calm professional manner. Provide the patient with your business card, offer to provide additional assistance, and provide your supervisor’s name and contact information in case the patient has any questions later.
A simple demonstration of compassion and a helpful attitude can go a long way if the story reaches the media or a civil suit develops. Make sure your response is one you would be proud to see displayed on the evening newscast. Thoroughly document the information and observations you had and the actions you had to take.
Law enforcement officers respond to a multitude of situations involving those suspected of being under the influence of alcohol or drugs. A small percentage of those people may actually be in dire need of medical attention instead of a trip to jail. Every community, regardless of size, has individuals who suffer from various medical and traumatic conditions that can mimic the appearance of intoxication and may even make them combative. Don’t get so focused on a suspected DUI arrest that you can’t recognize that.
In the event the subject is combative or acting violently, protect yourself, your fellow officers, the public and the subject as much as possible. You may need to act quickly and use force to gain control based on limited information, but be alert for the possibility of other causes for the situation. If you suspect or discover the subject is suffering from a medical condition and you have the situation stabilized, get appropriate help quickly and understand the patient may not have acted with the criminal intent that may be required for certain criminal offenses. As with any use of force, fully document the subject’s behavior, your actions and the subject’s response to each of your actions. After the incident, either the involved officers or a supervisor should communicate with the patient and be prepared to explain why certain actions had to be taken. Conclude by documenting how you checked for signs of a medical emergency and ensured that the subject received any necessary medical care.
Ensure your actions or those of your fellow officers are not punitive or based on “contempt of cop.” An improper arrest or use of force reflects poorly enough on law enforcement without media headlines announcing that improper actions were taken against an innocent person suffering from a medical condition. Do what you need to in order to control the situation. Be alert for clues that the subject you’re dealing with may be suffering from a medical condition. Pay attention to requests from the suspect for medical attention or suspect statements regarding their medical history and get EMS on scene as soon as possible.
1. DeLeon A: A Summary of U.S. Supreme Court Decisions For The Criminal Justice Community . Looseleaf Law Publications Inc.: Flushing, New York, 2007.
2. Limmer D, O’Keefe MF, Grant HD, et al: Emergency Care , 9th edition. Brady/Prentice Hall Health: Upper Saddle River, N.J., 2001.