Monday, May 5, 2014
Thomas C. Grubbs, RN, BSN, EMT-P
During a local celebration of Marines and sailors returning from a long overseas deployment, the docks are crowded with family, friends, media correspondents and curious onlookers. The huge ship is packed with elated soldiers, each straining to find a familiar face in the crowd. When the ship finally docks, the soldiers rush off to begin the celebration and festivities. While the jubilant atmosphere is at its height, no one considers the large out-of-state news van parked nearby.
Within a couple of minutes, the van suddenly erupts into an enormous fireball. The explosion is devastating and destroys all supporting vehicles on the dock and much of the docking complex. Casualties are extreme.
As initial calls come in, rumors abound to what happened and what’s occurring now. EMS and emergency flight crew members receive initial staging area and landing zone (LZ) information, but these locations change at least twice before they arrive. Confusion proliferates as chaos flourishes at the scene. When incident command finalizes the LZ location and EMS point of entry, responders start to locate patients who are still alive. But, even with incident command’s direction, the responders ponder where to go first—with so many to triage and treat, the situation is overwhelming.
As EMS and emergency nursing personnel enter the scene, it becomes clear that this large-scale mass casualty incident (MCI) is also being secured by civil and military command. This has become an international crime scene.
A Constant Problem
D.H. Garrison, Jr., of the forensic unit of the Grand Rapids, Mich., Police Department, reported in an FBI law enforcement bulletin that one of the predominant difficulties for crime scene technicians is contamination of the crime scene.1 He notes that, regardless how unintentional, any widespread trampling at a crime scene can damage the efforts of the investigator, causing a loss of opportunity to gain the evidence needed to convict criminals. Contamination is a problem when valuable evidence is lost by careless and hasty practices by first responders. Personnel at the scene inadvertently deposit material from clothing and equipment, and this contamination is compounded as the number of rescuers, police and investigators increase. Experts observe that the majority of contamination at a crime scene is directly related to on scene personnel.2
To prevent the loss of crime scene integrity, crime scene consultant Dick Warrington says the first-arriving responder, be it police or medical provider, can play an essential role in the investigation of any crime: “That officer can make or break your case, depending on the actions he takes—or fails to take—when he arrives at the scene.”3
Although preserving evidence never takes precedence over patient care, it’s the responsibility of EMS and emergency nursing responders to do everything reasonable not to complicate the investigation. Regardless how difficult the job seems, caution must be taken not to contaminate or transfer evidence. Physical and biological evidence at MCIs are powerful guides in determining the circumstances of the crime and the nature concerning the perpetrators.4 Making an effort to assist investigators by preserving and not contaminating an MCI crime scene may be the best way to prevent the anguish of a second event.
Crime Scene Guidelines
The following guidelines are adapted from a number of crime scene consultants, training instructors, and well-established, acknowledged and appreciated programs. (Agencies consulted are listed on p. 43.) These guidelines are intended to facilitate the quality of patient care while maintaining the integrity of the crime scene. The goal is to encourage and stimulate thought into the ways EMS, emergency nursing, and flight crew members can approach, enter, render care in and exit large MCI scenes without destroying valuable evidence.
During any crime scene investigation, personnel safety and the preservation of life carries the highest priority and is paramount in respects to initial crime scene management.5 These guidelines may not encompass the magnitude of many large-scale events and aren’t intended to be comprehensive.6 Many times first responders must lean on
experience-based judgments when policy doesn’t provide specific direction. Emergency care is to be given with consideration to the needs of the investigator. Responders should anticipate following direction, but not if it impedes quality of care.7
It’s unlikely medical responders will arrive before police at a large-scale MCI event. If this does occur, police should be requested before exiting the unit or aircraft.7 Upon arrival, responders should anticipate being directed where to park ambulances and other rescue vehicles. These locations should be in an area that allows prompt access to the general patient population but are generally determined by crime scene management personnel. Aircraft LZ areas can be significant distances away—farther away from what many are accustomed to because of the extreme nature of the call—and could require EMS transport to the scene. In situations where units are directed to the immediate crime scene area, caution should be made to prevent driving over footprints, tire tracks, broken glass and items such as shell casings when firearms are used.5
Entering and exiting: Movement shouldn’t prevent responders from being cognizant of surroundings. Remain vigilant concerning unknown material, spills, damaged containers and leaks.8 Direction change from the entry point may be mandatory, requiring movements to be limited and to refocus toward the patient location. In doing so, safety precautions are enhanced and will help responders stay mindful of the responsibility to remain aware important evidence can be destroyed with simple entry into the scene.5
When entering chaotic scenes, responders should enter and exit by the same path and leave the scene in its original condition. Entry should also be conducted with the minimal number of rescuers necessary to care for and retrieve the patient,5 and the path should be as direct as possible to minimize contamination and alteration. A designated path will limit the responders’ movements and prevent unnecessary contact with the environment outside the immediate treatment area.6 Police may have already designated an entry path if they arrived first.9 Medical responders need to keep in mind that police are ultimately in charge. It’s better to yield to direction when unaware of what path to take—especially when tension is high.7 Historically, tension and anxiety increase rapidly during these high-profile situations.
Personal protection equipment will protect caregivers from body fluid contamination, but will also protect the scene by preventing responders from leaving their DNA in areas where investigators may have to perform timely elimination printing.8 It’s also imperative that responders not step directly into pools of blood or other fluids.2
Death: Bodies and other large objects shouldn’t be moved unless they impede patient care. If it becomes imperative to move an object, report its original position to investigators.5 Many of the referenced guidelines also recommend that responders not approach patients who are obviously deceased or presumed dead by police. For those deemed “obviously dead,” ECG confirmation of asystole or any other manipulation of the body shouldn’t be performed. If a judgment call is thought necessary to confirm death, then ECG confirmation should be done with minimal movement of the body.5
Many agencies use similar conditions in their protocols to define what is considered “obvious death,” including:
Incineration of 90% or more of the total body surface area;
Decomposition or putrefaction;
Transection of the torso;
Patient’s total incineration of torso or head;
Dependent lividity with rigor;
Total separation of vital organs from body or total destruction of these organs accompanied by no detectable pulse or respirations; and
Any other injury not compatible with life in a pulseless apneic patient.
One important consideration is that in most states, law enforcement personnel have authority to presume/declare death, and when this occurs confirmation procedures by EMS are unnecessary.5 It’s appropriate by law for the emergency responders to move to the next patient situation. If the medical team disagrees with police and the responders feel patient harm is likely, a request can be made for immediate on-scene supervision or direct medical oversight. If there’s disagreement between the medical and law enforcement teams, it’s important to obtain names and badge numbers of the involved professionals. This information will be helpful in the event of a retrospective discussion of the case.
Clothing and patient belongings: When at the patient’s side, make every attempt to avoid cutting through any holes in the clothing thought to be related to the event. Do so as one would when avoiding bullet holes and stab wounds.8 This protects from possible loss of evidence from smudges or powder residue and other chemistry around the openings. Responders should handle and remove clothing as little as possible.8 This too will minimize loss of valuable evidence.
When removing clothing becomes medically necessary, responders should make every effort to retain the articles in paper bags. Bloody clothes should never be rolled up and placed in plastic bags. Plastic bags promote moisture, which degrades evidence and enhances decomposition.10 It’s critical these bags be identified with patient name or other patient tracking tag. Personal articles and clothing should remain with investigators. Any item removed from the scene, such as an impaling object, should be promptly reported to police. Pertinent items that could be considered evidence but need to stay with the patient, such as health aids, should also be promptly reported to police.10 Most personal items won’t be transported with the patient, especially when from an explosion site: These are now evidence.
Recommendations advise to never move or unload firearms unless they pose an immediate threat. When this is unavoidable, the weapon should be secured away from patients and bystanders. Many EMS agencies use on-board lock boxes to secure critical items, but if no protocol is in place, law enforcement should handle this evidence collection. When firearms are present, the patient’s hands should not be cleaned but bagged in paper bags.6 In the midst of an MCI, it may not be apparent whether the patient is a victim or one of the perpetrators.
Treating at the scene: Initiate an IV above the hand when possible.11 Consider using the mid-forearm, median cubital or antebrachial fossa veins. If injury placement allows, the external jugular vein or an intraosseous insertion to the greater tubercle or anteromedial tibia are excellent alternatives.
Alteration of the scene can include items left behind.5 Responders may find it difficult to manage trash created during pressing and urgent procedures. A good rule of thumb is to not remove medical waste except for sharps. Investigators prefer most medical waste remain to determine where patients were treated and what treatment was performed. Caregivers need to be aware that it’s possible to inadvertently remove trace evidence that may adhere to the supply packaging used during medical procedures, and caution should be taken.9
Many law enforcement agencies use videotaping at crime scenes as a routine documentation procedure, and some responders feel they may be able to assist them with video and photos since many ambulances are equipped with interior and exterior cameras.12 However, police officers generally feel first responders need to remain mindful that non-law enforcement personnel should never use videography or still photography at a crime scene. When cameras of any type are used—even to document preservation—it becomes the property of the district attorney until the investigation is complete. Video documentation could prove invaluable during large scale MCIs but should only be done by police.
Medical documentation within crime scenes is considered an important step in properly processing the scene.12 Mike Byrd of the Miami-Dade Police Department Crime Scene Investigation team describes scene documentation as an organized step-by-step approach similar to how nursing approaches the physical examination.13 Minimally, during the rescue, the responder should document any conversation made and report it to law enforcement. Documentation should include to whom and under what circumstances any comments are made from victims, possible suspects or witnesses. This includes any conversation during transport.9
Many times patients who are fearful of their outcome may voice concerns involving the incident. These statements need to be documented because they can be what law enforcement considers a “dying declaration,”9 statements made by individuals when they believe they’re dying versus simple spontaneous utterances made in the heat of the moment.
Documenting dying declarations may require agencies to review their local jurisdictional laws. When legally allowed as evidence, these statements may provide critical information. The patient could be one of the perpetrators, victims or a credible witness. Always remember to document the statements of the key players and use direct quotations as often as possible.14
As discussed earlier, it’s acceptable to move some items when arriving at the patient’s side. However, the responder should make clear notation of what was done to alter the area of the scene.14 The purpose of documentation by first responders in these situations is to create a visual record to assist criminal investigators in recreating an accurate picture of what occurred at the scene.15 This record will help preserve the location and relationship of physical evidence and condition at the scene.12
When working a scene where death is involved, documentation is key because investigators will look at documenting case information first.16 When assisting investigators in MCIs, responders should accept a responsibility to document events as accurately as the investigator.
In short, responders are encouraged to document in great detail and chart objectively.14 Only document what’s experienced at the scene. Notes should be constructed in chronological order using only the facts of the incident.13 Clearly describe overall observations, actions, and descriptions of the scene, and document your section of the scene in detail with all the actions you’ve taken.12
First responders can anticipate being contacted by investigators afterward.16 Police may request information like unit or aircraft ID, phone numbers and agency name for ongoing investigative reasons. During the pre-transport phase when tension and stress may be at its highest due to the critical need to depart, an investigator’s request for information may be satisfied by exchanging business cards.
As the threat of terrorism and conflict continues to increase, first responders must become better educated to the complexity of crime scene integration. Review of the literature clearly documents that law enforcement officials are primarily concerned with patient well-being and safety. Law enforcement and medical responders are a team during any crime scene intervention but never more so than in a large-scale incident where evidence preservation and contamination is crucial. EMS must bear in mind the necessity to respect the needs of law enforcement in managing the crime scene and preserving evidence while effectively retrieving and treating the injured.7 jems
1. Garrison, Jr. D. (1994.) Protecting the crime scene. Oracle ThinkQuest. Retrieved Sept. 19, 2011, from http://library.thinkquest.org/TQ0312020/protecting_the_crime_scene.htm.
2. Baldwin HB, May CP: Crime scene investigation and examination/contamination. In J Siegel, P Saukko, G Knupfer (Eds.), Encyclopedia of forensic sciences (first edition). Academic Press: Maryland Heights, Mo., pp 444–457, 2000.
3. Warrington D. (Aug. 5, 2011.) Crime scene basics. Forensic Magazine. Retrieved July 18, 2012, from www.forensicmag.com/article/crime-scene-basics.
4. Physical evidence-eNotes. (2006.) E-Notes. Retrieved June 17, 2012, from www.enotes.com/physical-evidence-reference/physical-evidence.
5. NHSHP crime scene guidelines. (2007.) Yale New Haven Sponsor Hospital Program. Retrieved Sept. 22, 2012, from www.sponsorhospital.org.
6. Manitowoc County EMS Association prehospital care manual. (January 2009.) Manitowoc County EMS Association. Retrieved Nov. 2, 2012, from www.manitowoccountyems.com/index.htm.
7. Crime scene management/evidence preservation. (March 1, 2004.) Northern California EMS. Retrieved June 17, 2012, from www.norcalems.org/pnp-manual/masterbinder/05_Miscellaneous_Policies_Module/0300_Patient_Care_Policies/316_Crime_Scene_Management_Evidence_Preservation.pdf.
8. Lenox Ambulance Service crime scene and scene safety guidelines. (September 2006.) Lenox Ambulance. Retrieved Feb. 8, 2012, from www.lenoxambulance.org/Local%20Guidelines.htm.
9. National Institute of Justice. (June 2000.) Fire and arson scene evidence: A guide for public safety personnel. National Institute of Justice Reference Service. Retrieved June 22, 2012, from www.ojp.usdoj.gov/nij/pubs-sum/181584.htm.
10. Knight KA. (2007.) Forensic nursing—real life CSI. Nurse.com. Retrieved Sept. 9, 2012, from http://news.nurse.com/apps/pbcs.dll/article?AID=200770101019.
11. Crime scene management/evidence preservation. (Nov. 24, 2010.) Alameda County Public Health Department Emergency Medical Services. Retrieved June 17, 2012, from www.acphd.org/ems-ofm/ofm_pdf/OPERATIONS/CRIME_SCENE_MANAGEMENT_EVIDENCE_PRESERVATION_web.pdf.
12. Lee HC, Palmbach TM, Miller MT: Crime scene documentation. In Henry Lee’s crime scene handbook. Academic Press: San Diego, pp. 23–112, 2001.
13. Byrd M. (2012) Written documentation at a crime scene. Crime Scene Investigator Network. Retrieved Feb. 8, 2012, from www.crime-scene-investigator.net/document.html.
14. Smith BD. (2009.) Crime scenes: Documenting assessment & management of crime victims. JEMS. Retrieved Nov. 2, 2011, from www.jems.com/article/operations-protcols/crime-scenes.
15. Layton J. (2012.) At the crime scene: Scene documentation. How Stuff Works. Retrieved Oct. 1, 2012, from http://science.howstuffworks.com/csi2.htm.
16. Warrington D. (Jan. 6, 2005) It’s all in the report! Forensic Magazine. Retrieved June 6, 2012, from www.forensicmag.com/article/its-all-report?page=0,0.
17. Summary of the HIPAA privacy rule. (May 5, 2003.) US Department of Health and Human Services. Retrieved Oct. 1, 2012, from www.hhs.gov/ocr/privacy/hipaa/understanding/summary/privacysummary.pdf.
Crime scene investigation: A reference for law enforcement. (June 2004.) Crime Scene Investigator Network. Retrieved Oct. 1, 2012, from www.crime-scene-investigator.net/CrimeScene InvestigationLE-2013.pdf.
Dick T. Crime scene: How to support the cops and serving the public. EMS World. 2011;40(2):22.
Warrington D. (2008) Crime scene observation. Forensic Magazine. Retrieved Oct. 1, 2012, from www.forensicmag.com/article/crime-scene-observation.
There are six circumstances where patient information is allowed to be reported to state and federal law enforcement:
1. As required by law (including court orders, court ordered warrants, subpoenas) and administrative request.
2. To identify or locate a suspect, fugitive, material witness, or missing person.
3. In response to a law enforcement official’s request for information about a victim or suspect victim of a crime.
4. To alert law enforcement of a person’s death, if the covered entity suspect that criminal activity cause the death;
5. When a covered entity believes that protected health information is evidence of a crime that occurred on its premises; and
6. By a covered health care provider in a medical emergency not occurring on its premises, when necessary to inform law enforcement about the commission and nature of a crime, the location of the crime or crime victims, and the perpetrator of the crime.17
Similarly, disclosure is appropriate when information is believed necessary “to prevent or lessen a serious and imminent threat to a person or the public, when such disclosure is made to someone they believe can prevent or lessen the threat (including the target of the threat).” Disclosure may also be allowed if needed by law enforcement to “identify or apprehend an escapee or violent criminal.”17
Consulted Agency Guidelines
Alameda County Public Health Department (ACPHD), Oakland, Calif.: Crime Scene Management/Evidence Preservation (#8001), Policy & Procedure Manual, www.acphd.org, Nov. 24, 2010.
Lenox Ambulance Service, Lenox, Iowa, Operations Manual, Appendixes: Crime Scene and Scene Safety Guidelines: Crime Scene Preservation Guidelines, www.lenoxambulance.org/Local%20Guidelines.htm, September 2006.
Manitowoc County EMS Association (MCEMS), Mishicot, Iowa, Prehospital Care Manual: Aberrant Situations, www.manitowoccountyems.com, January 2009.
New Haven Sponsor Hospital Program (NHSHP), New Haven, Conn., Protocols: NHSHP Crime Scene Guidelines, www.sponsorhospital.org, February 2007.
Northern California EMS, Inc. (Nor-Cal EMS), Redding, Calif., Nor-Cal EMS, Crime Scene Management/Evidence Preservation #316, www.norcalems.org, March 1, 2004.
U.S. Department of Justice, National Institute of Justice (NIJ), Washington, D.C., Crime Scene Investigation: A Reference for Law Enforcement Training, Emergency Care, www.crime-scene-investigator.net/CSItrainingNIJ.pdf, June, 2004.