Safety is always the central focus of police training—and that includes protecting suspects from harm. You should be aware that improper restraints during an arrest or transport to jail can cause severe injuries and even death. Medical experts warn about two particular threats to suspects in custody.

Positional asphyxia

This term refers to possible strangulation caused by a body position that interferes with breathing. Positional asphyxia sometimes causes problems for babies in car seats or cribs. In criminal justice settings, positional asphyxia can occur when suspects have been restrained behind their backs and are lying stomach down.

The risk increases if a suspect is obese, has been using alcohol or drugs, or as been involved in a violent struggle. If you restrain a suspect behind their back, you should monitor them constantly for breathing problems until the restraints are removed and call EMTs at the first sign of problems. No suspect should lie face down longer than necessary: move them to a seated position as soon as you can.

Excited delirium (ExDS)

Excited delirium is a potentially deadly psychiatric disorder that can cause asphyxiation or cardiac arrest. It can be triggered by cocaine and other substances, but it may also occur in patients who do not use drugs. Public nudity, aggression, and bizarre behaviors may occur. ExDS is particularly challenging to deal with because some suspects become aggressive, don’t feel pain, and may exhibit extreme physical strength. A suspect who’s experiencing ExDS may not respond to a TASER.

If you find yourself dealing with an out-of-control suspect who does not respond to commands, you should suspect ExDS and call for medical help. Trained medical personnel will know how to administer sedatives or antipsychotic medication.

Because asphyxiation or cardiac arrest is always a possibility, be sure you’re familiar with your agency’s policies and procedures for restraining and transporting suspects.

Be aware that a number of police departments have been subjected to litigation because an officer assumed that a suspect was faking a breathing problem or a cardiac episode that turned out to be real. Your commitment to public safety covers everyone, including suspects. The wisest and safest course is to treat all medical symptoms as if they were serious.