CRIME SCENES Standard Operating Procedures

EMS Operations • Standard operating procedures (SOPs) may be in

Knowledge of operational roles and place for dealing with potentially violent incidents.
responsibilities to ensure patient, public, and − Review the contents, and use them as the
personnel safety basis for your approach.
Introduction Highway and Rural Road Incidents
• Paramedics face potentially violent situations. • Account for bulk of serious injuries to EMS
• Paramedics have been severely injured or killed • Be aware of:
while trying to treat patients − Violent patients
• Know how to avoid violence and how to protect − Moving vehicles
yourself when violence erupts. Approach and Vehicle Positioning
• Once you recognize a violent situation: • At a single vehicle incident:
− Retreat to a safe location. − Stop 21 feet behind the vehicle.
− Await the assistance of law enforcement. − Stop at a 10˚ angle to the driver’s side.
Awareness − Turn front wheels to the left.
• Paramedics may arrive at a scene before law
enforcement.
− If you feel the scene is not safe:
• Contact law enforcement personnel.
• Retreat to your ambulance.
• Wait for them to secure the scene.
Paramedics Mistaken for Law Enforcement
• Paramedics are often mistaken for police officers.
− Aggressive behavior may be unintentionally
directed at you.
• If you are not first vehicle to arrive:
− Many agencies have adopted more casual
− Ask IC where to park vehicle, or
uniforms.
− Park downstream of the incident
Body Armor
• You may use high beams and spotlights to
• Body armor is not bulletproof.
illuminate the patient’s vehicle.
− Does not shield your neck or head
− Some agencies prohibit this.
• Consult with your department and local law
− Do not walk between the light and the
enforcement officials to determine if you need
vehicle.
protection.
• Do not approach a vehicle if you have an uneasy
Indicators of Violence
feeling about it.
• Always expect aggressive behavior. − Identify
Retreating from Danger
potentially dangerous situations and remove
• The safest means of retreat is to back away and
yourself, your team, and the patient to a safe place.
call for law enforcement assistance.
• Continuously evaluate the scene.
• If your partner is injured while approaching the • Be aware of objects that can be used as
motor vehicle, back away and call for assistance. weapons.
• Provide the dispatcher with the following: Domestic Violence
− Number of aggressors • If a violent dispute is in progress, wait for law
− Number and type of injuries enforcement.
− Number and type of weapons • Tempers may flare while you are treating a
− Make, color, body style, and license patient.
number − Use good communication skills, eye
− Direction of travel if vehicle leaves the contact, and appropriate body language.
scene • Contact and cover technique
Residential Incidents − One paramedic makes contact with the
• Procedure for any call involving violence: patient.
− Allow law enforcement personnel to − The second paramedic obtains patient
secure the scene before entry. information and gauges the level of tension.
− Ensure scene is safe before going in. • Warns partner at the first sign of trouble
− Continually reevaluate the situation while • Conduct yourself as a professional.
providing patient care. • Crisis intervention should be left to the
Approaching a Residence professionals.
• When you arrive at residence: • You may be required to report certain conditions
− Listen for loud, threatening voices. to local authorities.
− Glance through windows for signs of Gangs
struggle. • Approximately 20,000 violent gangs
− Look for visible weapons. • Gang activity has migrated to suburban and rural
• Any time you perceive danger, back away to your places.
vehicle. • Gangs predominately survive through the drug
Entering a Residence trade.
• Use an alternative path to approach. • Most gang communication is more sophisticated
• Stand on the doorknob side of the door. than “gang signs.”
• Knock and announce yourself
• Ask whoever answers the door to lead you to the
patient.
• Pick a primary exit.
• Pick a secondary exit.
• As you arrive at the patient’s location, scan the
room for weapons.
− Back out of the residence if there is a
gun/knife.
• Call for law enforcement assistance.
• Contact your local law enforcement to ask about − You can increase your chances of survival
known gang territories. if you can anticipate feelings and actions of
• The last thing a gang wants to see is the hostage taker.
paramedics rescuing the person they just shot or • If you are taken hostage:
stabbed. − Do not attract unwanted attention.
− Situational awareness is often your only − Do no stare at your captors.
defense. − Remove badge, collar pins, and patches.
Mass Shootings, Active Shooters, and Snipers − Ask to help the wounded.
• You may find yourself on the scene with an active Contact and Cover
shooter. • Remember the objects that provide cover and
− Take direction from law enforcement those that offer concealment only.
personnel. − Make your body conform to the shape of
• Whom to treat the object as much as possible.
• When to treat Using Walls as Cover
• Document any requests or demands to deviate • Determine if the type of wall gives you cover or
from your local protocols. concealment.
• Paramedics should remain in the staging area − Brick and concrete are safer than cinder
until the scene is secured block.
• Paramedics need to know how to use cover and − Most interior walls are not impenetrable.
concealment. Evasive Tactics
− Cover objects are impenetrable to bullets. • Change locations only if new location is:
− Use concealment when cover is not − Better cover
available. − Farther from the hostile atmosphere
• Paramedics should consider having a training −Reached without revealing yourself to
session with local police to: attacker
− Learn how to assess a shot police officer. • Before changing locations, look out from your
− Address specific topics. cover several times.
− Establish protocol for who removes − Look from different heights and angles.
weapons and how. Concealment Techniques
• Tactical paramedics • Tall grass, shrubbery, and dark shadows are
− Used where there is actual violence or considered areas of concealment.
potential for violence − More common after dark than in daylight
− Primary function: hours
• Care for law enforcement teams making entry into • In rural areas, tall grass or a cornfield can conceal
violent situations you.
Hostage Situations Self-Defense
• Under the jurisdiction of law enforcement • Consider taking a self-defense course.
• Hostages are usually held as collateral.
• Identify yourself if someone prevents you from − Place each piece into a brown paper bag.
reaching your patient. − If the item is saturated, place the paper
− Instruct the person to move away. bag into a plastic bag.
− Inform the person that the patient may die. • First responders are typically the first to enter a
− Radio your dispatcher and request law crime scene.
enforcement personnel assistance. − Do not:
• If the person in your way does not move: • Clean up.
− Take a side step and repeat the verbal • Alter items.
challenge. • Move bodies.
− Inform the person that police will be • The incident be properly documented.
summoned. − Much time can elapse between the call
• Always make sure your exit path is not blocked and your testimony.
and you can easily retreat. − Documents may be read by dozens of
Self-Defense in Armed Encounters people.
• Distraction techniques are used to break the chain • Elements of proper documentation:
of events. − What you saw
• Throw whatever is handy at the person. − What you heard
− Gives you long enough to run to safety. − What you were told
• If the patient takes aggressive action during your − What you smell
initial interview: − What you moved, altered, or disturbed
− Throw a light object at the nose. − Chain of custody
− Turn toward your vehicle. − Description of the scene
− Get out of the potential line of fire. Summary
− Run to safety. • EMS can be a dangerous profession, and your
Crime Scenes mission is to return safely at the end of each shift.
• Assisting law enforcement personnel to maintain • No community, socioeconomic group, race, or
the integrity of the crime scene increases the religion is immune to violence.
probability that a suspect will be captured and • Perform a scene size-up for indicators of potential
convicted. violence and escape before performing patient
Preserving Evidence care.
• Two types of evidence: • Obvious indicators of violence include calls for
− Testimonial shootings, stabbings, or attempted suicides; body
− Real or physical language; and use of profane language or yelling.
• Do not disturb, damage, or alter physical evidence • Be aware of the possibility that secondary
at a scene. violence can occur during a call.
• If you must remove a piece of evidence in order to • Your agency will have standard operating
treat the patient: procedures for dealing with potentially violent
incidents.
• When you are responding to a vehicle on a road,
park your vehicle a minimum of 21 ft behind the
stopped vehicle, at a 10˚ angle to the driver’s side
facing the shoulder.
• When you are approaching a standard
automobile, use your high beams, but don’t walk in
front of the light. Check the trunk and inside of
vehicle before reaching the B post.
• When you are approaching a van remain clear of
the side door of the van throughout your approach.
• When a dangerous situation develops, retreat
from the scene and alert the dispatcher of the
situation.
• When you are approaching a residence, stand to
the side of the door.
• When you are entering a structure, always identify
a primary and secondary exit.
• Clandestine drug laboratories are extremely
hazardous.
• Gang activity can present hazards to EMS crew.
• In situations that involve an active shooter or
sniper, follow law enforcement’s direction.
• You may need to use cover and concealment if a
scene becomes dangerous.
• Consider taking a self-defense course.
• When you are working at a crime scene, make
every attempt not to disturb, damage, or potentially
alter the scene or physical evidence.
PSYCHIATRIC EMERGENCIES • Behavioral emergency − Some disorder of
Psychiatric mood, thought, or behavior that interferes with
• Recognition of − Behaviors that pose a risk to the ADLs
EMS provider, patient, or others • Psychiatric emergency − Behavior that
• Assessment and management of threatens a person’s health or safety and the health
− Basic principles of the mental health and safety of another person
system Prevalence
− Suicidal/risk • Average number of mentally unhealthy days for
Anatomy, physiology, epidemiology, Americans has increased
pathophysiology, psychosocial impact, − 1993: 2.9 days/month
presentations, prognosis, and management of − Today: 3.5 days/month
− Acute psychosis • 45.1 million US adults with any mental illness in
− Agitated delirium the past year
− Cognitive disorders
− Thought disorders
− Mood disorders
− Neurotic disorders
− Substance-related disorders/addictive
behavior
− Somatoform disorders
− Factitious disorders
− Personality disorders
− Patterns of violence/abuse/neglect
− Organic psychoses
Introduction
• The mind and body are inseparable.
− Illness affects a person’s behavior.
− Changes in mental state affect physical
health
Definition of Behavioral Emergency
• Most experts define behavior as the way people
act or perform.
− Overt behavior is generally understood by
those around the person.
− Covert behavior has hidden meanings or
intentions
 behavior, and responses to the stress of
emergencies.
• Injury and illness
− Illness results in stress on coping mechanisms.
− Acute trauma creates stress.
• Post-traumatic stress disorder (PTSD)
• Substance-related
− Alcohol
− Cigarettes
− Illicit drugs
− Other substances
Psychiatric Signs and Symptoms
• When mental health is challenged, mechanisms
or behaviors work to return homeostasis.
− Present as psychiatric signs and

Medicolegal Considerations
• When behavior, speech, and thoughts are erratic,
it can be difficult to communicate.
− Spend time with the patient.
− Obtain consent when possible.
− Be clear in your explanations
Causes of Abnormal Behavior
• Four broad categories
− Biologic or organic in nature
− Resulting from the environment
− Resulting from acute injury or illness symptoms
− Substance-related
• Biologic or organic
− Organic brain syndrome Patient Assessment
− Conditions alter the functioning of the • Assessment of the patient with a behavioral
brain emergency differs from other methods.
• Environmental − You are the diagnostic instrument.
− Psychosocial and sociocultural influences − The assessment is part of the treatment.
• When consistently exposed to stressful Scene Size-Up
events patients develop abnormal reactions. • Situations with a strong behavioral component
• Sociological factors affect biology, may have a sudden and unexpected turn of events.
 − Determine whether it is dangerous to you − Stay alert to potential danger.
and your partner. • Airway and breathing
• The environment can give clues. − Assess the airway and evaluate breathing.
− Social history − Provide interventions based on your
− Living conditions findings.
− Availability of support • Circulation
− Activity level − Assess the pulse rate, quality, and
− Medications rhythm. − Obtain systolic and diastolic blood
− Overall appearance pressures.
− Attitude/well-being − Evaluate for shock and bleeding.
− Assess the patient’s perfusion level.
• Transport decision
− Disturbed patients should see a physician.
− If a patient withholds consent, they may
be taken against their will at the request of:
• Police
• Community mental health
physician
History Taking
• Mental status examination
− Key part of assessment
− Check each system using COASTMAP.
COASTMAP
• Consciousness
− Level
− Concentration
• Orientation
− Year/month
− Location
• Activity
− Behavior
− Movement
Primary Assessment
• Speech
• Clearly identify yourself.
− Rate, volume, flow, articulation, and
• Form a general impression.
intonation
− Assess appearance, posture, and pupils.
• Thought
− Limit the number of people around the
− Is the patient making sense?
patient.
• Memory
 − Recent Crisis Intervention Skills
− Remote • Be as calm and direct as possible.
− Immediate • Exclude disruptive people.
• Affect and mood • Sit down.
− Do the inner feelings seem appropriate? − Preferably at a 45-degree angle
• Perception • Encourage some motor activity.
− “Do you hear things others can’t?” • Stay with the patient at all times.
Secondary Assessment • Bring all medications to the hospital.
• Obtain vital signs. • Never assume that it is impossible to talk with any
• Examine skin temperature and moisture. patient until you have tried.
• Inspect the head and pupils. Physical Restraint
• Note unusual odors on the breath. • Improvised or commercially made devices
• In examining the extremities, check for: • Be familiar with restraints used by your agency.
− Needle tracks • Make sure you have sufficient personnel.
− Tremors − Minimum of four trained, able-bodied
− Unilateral weakness or loss of sensation people
Reassessment • Discuss the plan of action before you begin.
• Routinely performed during transport − Include law enforcement.
• Your radio report should include: − Use the minimum force necessary.
− Medical and mental health history − Don’t immediately move toward the
− Medications prescribed patient.
− Assessment findings • If the show of force doesn’t calm the patient, move
− Information from the mental status quickly.
examination − Grasp at the elbows, knees, and head.
• Discuss with the hospital the need for restraints or − Apply restraints to all four extremities.
medications. − The best position is supine.
− If the patient is aggressive or violent, • Never:
provide advance notice to the emergency − Tie ankles and wrists together
department. − Hobble tie
Emergency Medical Care − Place a patient facedown in a Reeves
• If the erratic behavior could be caused by a stretcher
medical disorder: • Once in place:
− Treat that before presuming the behavior − Don’t remove restraints.
is due to an emotional or psychiatric cause. − Don’t negotiate or make deals.
Communication Techniques − Place a mask over the face of a spitting
• Begin with an open-ended question. patient.
• Let the patient talk. • Continuously monitor the patient.
• Listen, and show that you are listening • Never place your patient face down.
• Check peripheral circulation every few minutes. • Perception − Auditory hallucinations
• Be careful if a combative patient suddenly
becomes calm. • Management
• Document everything in the patient’s chart. − Reasoning doesn’t always work. –
• You may defend yourself against an attack. Explain what is being done.
Chemical Restraint − Directions should be simple and
• Use of medication to subdue a patient consistent.
− Only use with approval from medical − Keep orienting the patient.
control − Before pharmacologic treatments, try:
− Follow local protocols and guidelines. • Maintaining an emotional distance
• Closely monitor the patient’s: • Explaining each step of the
− Pulse rate assessment
− Blood pressure • Involving people, the patient trusts
− Respiratory rate − When methods fail, it may be appropriate
• Be prepared to support ventilation. to:
Acute Psychosis • Safely restrain the patient.
• Pathophysiology • Administer a medication to help the
− Person is out of touch with reality behavior.
− Occur for many reasons Agitated Delirium
− Episodes can be brief or last a lifetime. • Pathophysiology
• Assessment − Delirium: a state of global cognitive
− Characteristic: profound thought disorder impairment
− A thorough examination is rarely possible. − Dementia: more chronic process
− Transport the patient in an atraumatic − Patients may become agitated and
fashion. violent.
− Use COASTMAP. • Assessment
• Consciousness − Try to reorient patients.
− Awake and alert − Perform a thorough assessment.
− Easily distracted • Management
• Orientation − Disturbances more common in − Identify the stressor or metabolic problem.
organic disorders Suicidal Ideation
• Activity − Most commonly accelerated • Pathophysiology
• Speech − Neologisms
• Thought − Disturbed in progression and content
• Memory − Relatively or entirely intact
• Affect and mood
− Mood is likely to be disturbed.
− Affect may reflect mood or be flat.
 − Suicide: any willful act designed to end
one’s life

• Assessment
− Every depressed patient must be
evaluated for suicide risk.
− Most patients are relieved when the topic
is brought up.
− Broach the subject in a stepwise fashion.
− Higher-risk patients include patients who
have:
• Made previous attempts
• Detailed, concrete plans
• A history of suicide among close
relatives
• Management
− Don’t leave the patient alone.
− Collect implements of self-destruction.
− Acknowledge the patient’s feelings.
− Encourage transport