Ch52 Crime Scene Awareness.docx

Chapter 52 Crime Scene Awareness Unit Summary As an educated and effective health care provider, you need to know how to avoid violence when possible and how to protect yourself when violence erupts. Sound survival skills training will help you identify and avoid potentially dangerous situations. Once you recognize a violent situation, your goal is to retreat to a safe location and await the assistance of law enforcement personnel. National EMS Education Standard Competencies EMS Operations Knowledge of operational roles and responsibilities to ensure patient, public, and personnel safety. Knowledge Objectives Understand the significance of potential violence that can occur on an EMS call, including specific settings in which violence is more likely to occur. (pp 2345-2347) Discuss practical measures that can be taken to reduce the likelihood of a paramedic becoming a victim on the scene, including uniform style and body armor. (p 2346) Describe factors to assess during scene size-up that can help determine whether the scene is safe, including specific indicators of violence. (pp 2346-2347) Discuss the role of standard operating procedures at a potentially violent incident. (p 2347) Describe how to park and position your emergency vehicle when responding to a call involving another motor vehicle. (pp 2347-2348) Describe the safest way to approach a passenger-style motor vehicle. (pp 2348-2349) Describe the safest way to approach a van. (pp 2348-2349) Describe how to retreat from danger. (pp 2349-2350) Describe how to approach a residence safely. (p 2350) Discuss types of exits, including primary exit and secondary exit. (p 2350) List items that can potentially be used as a weapon. (p 2350) Discuss techniques to use when responding to a call involving potential domestic violence. (p 2351) Discuss concerns related to clandestine drug laboratories. (p 2351) Discuss concerns related to gang territories and measures that the paramedic can take to work safely in these areas. (pp 2351-2353) Discuss procedures the paramedic should follow at mass shootings and at scenes involving active shooters or snipers. (pp 2353-2355) Define cover and concealment, and provide examples of each. (pp 2353-2355) Describe measures the paramedic can take to increase his or her safety in a hostage situation. (pp 2355-2356) Discuss the role self-defense can play in the practice of paramedicine. (pp 2358-2359) Discuss measures the paramedic can take to preserve evidence at a crime scene, while still providing optimal patient care. (pp 2359-2361) Skills Objectives There are no skills objectives for this chapter. Readings and Preparation Review all instructional materials including Chapter 52 of Nancy Caroline’s Emergency Care in the Streets, Seventh Edition, and all related presentation support materials. Support Materials • Lecture PowerPoint presentation • Case Study PowerPoint presentation Enhancements • Direct students to visit the companion website to Nancy Caroline’s Emergency Care in the Streets, Seventh Edition, at http://www.paramedic.emszone.com for online activities. • Local law enforcement can add a lot to this discussion. Use them for demonstrations as well as providing enhancements for lecture. Cultural considerations: Use caution when discussing criminal activity; ensure that no single ethnic group is singled out as always being criminal. Teaching Tips Use local law enforcement to provide discussion and demonstration to emphasize the importance of scene safety. Unit Activities Writing activities: Have students research the number of incidents where EMS providers were dispatched to unsecured scenes within your local area. Students should discuss the types of calls and whether or not the provider agency has a scene entry policy. Student presentations: Students may present the results of their group assignment to the class. Group activities: Divide the class into groups. Assign each group an area on your campus to assess for concealment and cover if they were put in a position of danger with little to no warning. Visual thinking: To demonstrate situational awareness, have someone walk in unannounced into your classroom. The person needs to hand you a piece of colored paper or a small object that can be easily identified. Then the person can exit the room. Have students describe the person and the object and/or color of the paper. Have the person enter the room after the discussion to determine the student’s accuracy. Medical terminology: If your local law enforcement agencies use 10-code or signals instead of plain text when on the radio make sure to cover these with your students. Pre-Lecture You are the Medic “You are the Medic” is a progressive case study that encourages critical-thinking skills. Instructor Directions Direct students to read the “You are the Medic” scenario found throughout Chapter 52. • You may wish to assign students to a partner or a group. Direct them to review the discussion questions at the end of the scenario and prepare a response to each question. Facilitate a class dialogue centered on the discussion questions and the Patient Care Report. • You may also use this as an individual activity and ask students to turn in their comments on a separate piece of paper. Lecture I. Introduction A. Thousands of times each year, paramedics face potentially violent situations. 1. You may encounter different types of calls. a. A place where violent or attack animals are being raised b. A methamphetamine lab or other drug-producing process housed at the location B. Paramedics have been severely injured or killed while attempting to reach and treat sick and injured people. 1. In 2009 the Bureau of Labor Statistics estimated that 200 EMS workers were reported to have sustained injuries from assaults alone. a. Most studies suggest EMS work is on par with other hazardous occupations including fire fighting and law enforcement. b. A 2008 Bureau of Labor Statistics report listed EMS workers as having the third highest rate of injuries. C. You need to know how to avoid violence and how to protect yourself when violence erupts. 1. Actively seek out self-protection courses geared toward EMS providers. 2. Once you recognize a violent situation, your goal is to retreat to a safe location and await the assistance of law enforcement. a. You cannot help anyone if you become a victim. b. You become a burden to other responders if you become a victim. II. Awareness A. Attacks against emergency responders are serious and widespread. 1. In many rural areas, paramedics may arrive at the scene before law enforcement personnel. 2. Perform a scene size-up with an eye towards safety before you begin patient care. a. Look for indicators of potential violence and escape routes. b. If you feel the scene is not safe: i. Contact law enforcement personnel. ii. Retreat to your ambulance. iii. Wait for them to secure the scene. B. Paramedics mistaken for law enforcement personnel 1. Many patients and bystanders mistake paramedics for police officers. a. EMS personnel wear similar color uniforms, utility belts, and badges in many jurisdictions. b. Aggressive behavior intended for the police may be directed at you. c. Many agencies have adopted a more casual uniform to counteract this. C. Body armor 1. Most police officers wear soft body armor; some EMS agencies offer this protective garment as well. a. Body armor is not bulletproof. b. There are six levels of protection. i. Body armor does not shield your neck or head. ii. You will still be vulnerable to injury. 2. Consult with your department and local law enforcement officials to decide if you need protection. D. Indicators of violence 1. If you are dispatched to the scene of a shooting, stabbing, or attempted suicide, potential violence can be obvious. 2. Always expect aggressive behavior when you arrive at a scene of an injured person. a. Patient may be upset for having been a victim of violence. b. Family members may be agitated that it took you too long to reach the scene. c. Be aware of the potential for someone to burst through the door in rage. 3. Quickly identify potentially dangerous situations and act to remove yourself, your team, and the patient to a safe place. 4. Continuously evaluate scenes for the potential for secondary violence. a. Do not develop tunnel vision. i. Becoming completely involved with patient care that you fail to see the possibility of physical harm E. Standard operating procedures 1. Some agencies or regions have developed standard operating procedures (SOPs) for dealing with potentially violent incidents. a. In many parts of the country, paramedics have advanced protocols that allow them to sedate patients who are or pose a threat to themselves and others. 2. Review the contents of your agency’s SOP manual. a. SOPs cannot cover all the circumstances that you may find yourself in. i. Use them as the basis for your approach. ii. Be prepared to abandon them if they interfere with the preservation of your or your partner’s life. III. Highway and Rural Road Incidents A. Highway incidents account for the bulk of serious injuries to EMS personnel. 1. Be aware of: a. Violent patients b. Moving vehicles c. Drivers gawking at the incident 2. A motor vehicle crash could be the culmination of a number of events. a. Armed robbery b. Drug use c. Stolen vehicles d. Perpetrators fleeing the scene of a violent crime B. Approach and vehicle positioning 1. At an incident with a single vehicle where danger is high and you are the first responder: a. Stop a minimum of 21 feet behind the stopped vehicle. b. Stop at a 10° angle to the driver’s side facing the shoulder. c. Your front wheels should be turned all the way to the left. i. Wheels and the motor block will provide limited protection in the event of gunfire. 2. If you are not the first vehicle to arrive at the scene: a. Ask the incident commander (IC) where to park your vehicle, or b. Try to park downstream of the incident. 3. Your agency may have specific policies regarding the use of light after dark. a. You may use your vehicle’s high beams and spotlights to illuminate the patient’s vehicle. i. Bright light will also conceal you as you approach the vehicle. b. Some agencies prohibit the use of high beams so as not to blind passing traffic. c. Do not walk between the spotlight and the vehicle. i. Alert any responsive occupants to your position 4. Do not approach a vehicle if you have an uneasy feeling about it. a. Before leaving your vehicle consider notifying the dispatcher of: i. The situation ii. Your location iii. The license number and state of the motor vehicle b. Follow your department’s policy. C. Approaching the motor vehicle 1. A systematic approach is not usually needed for cases of: a. Personal injury collisions at a busy intersection b. Vehicle found torn wide open c. Situations with bystanders already around the motor vehicle 2. Procedures to follow when there are two or more paramedics in the unit: a. The person riding in the right front seat makes the approach. i. All other members of the response team remain with the ambulance or medical unit. b. Proceed to the rear passenger-side trunk area and place the response bag or jump kit out of the path of travel. c. Look out for people hiding in the trunk of the vehicle. d. Check the trunk lid to ensure that it is properly closed. i. If the trunk is open, retreat to your vehicle. e. Proceed to the C post on the passenger side of the vehicle. f. Stop at the left C post and look in the rear and side windows. i. Notice the number of people in the vehicle. (a) Pay particular attention to the location of their hands. i. Try to see if there are items lying on the seat or on the floor. ii. Look for weapons. (a) If you see a deadly weapon, retreat to a safe location and call for law enforcement. (b) Never attempt to unload a weapon. g. If the back seat is occupied, do not pass C post. h. Move forward to the B post if there are no passengers in the back seat. i. Examine the front seat area. i. Where are the occupants’ hands? ii. What are the occupants doing? iii. Are any weapons visible? j. When letting the driver know that you are there, do so without moving past the B post into the driver’s door area. i. Law enforcement personnel refer to this area as the kill zone. k. Tap lightly on the window of the vehicle and announce yourself: “Paramedic. Do you need help?” l. After the IC declares that the incident scene is safe, follow the SOPs for your department. m. Keep your flashlight off until you need it. i. Hold the light at arms-length away from your body before you turn it on. ii. Illuminate the scene for only a few seconds during each use. 3. Take special precautions when approaching vans. a. Vans can carry many types of cargo and a large number of people that you cannot see. b. Safe approach: i. Move 10 to 15 ft away from the passenger side of the van. ii. Remain clear of the side door throughout the approach. iii. Walk parallel to the van until you are approximately 45° forward of the A post. (a) Gives the greatest visibility inside of the van from this distance (b) Keeps you at a safe distance D. Retreating from danger 1. The safest means of retreat is to back away and call for law enforcement assistance. 2. If your partner is injured while approaching the motor vehicle, back away and call for assistance. 3. Provide the dispatcher with the following: a. The number of aggressors involved b. The number and type of injuries c. The number and type of weapons involved d. The make, color, body style, and license number of the vehicle involved e. The direction of travel if the vehicle leaves the scene before the law enforcement personnel arrive 4. Make sure to document in detail why you had to leave the scene. IV. Residential Incidents A. Warning signs 1. Calls that require an obvious level of caution include: a. Assault b. Domestic dispute c. Shooting d. Stabbing 2. Routine calls also have the potential for violent outcomes. 3. Standard procedure for any call involving violence: a. Allow law enforcement personnel to arrive and secure the scene before your entry. b. Ensure that the scene is safe before going in to provide patient care. c. Continually reevaluate the situation while providing patient care. B. Approaching a residence 1. When you arrive at the residence: a. Listen for loud, threatening voices. b. Glance through available windows for signs of struggle. c. Look for visible weapons. 2. Any time you perceive danger, back away to your vehicle. a. Call for law enforcement assistance. b. Wait for the officers to arrive. C. Entering a residence 1. Use an alternative path while approaching rather than using the path to the front door. 2. Once at the front door, stand on the doorknob side of the door when you are preparing to knock. a. If you stand on the hinged side, any person in the room can observe you by opening the door only slightly. 3. Knock on the door and announce “Paramedics,” “Fire department,” or “Rescue squad.” a. This will make sure you are not mistaken for a law enforcement officer. 4. Ask whoever answers the door to lead you to the patient. a. The person who leads you acts as a shield for you. i. Gives you a few extra moments to react if the situation deteriorates. 5. When entering any type of structure: a. Pick a primary exit. i. Usually the door that was used to enter the building. b. Pick a secondary exit. i. Might be a rear door or a window. c. Try to keep at least one means of escape accessible at all times. 6. As you arrive at the patient’s location, scan the room for weapons. a. Back your way out of the residence if there is a gun or knife. b. Call for law enforcement assistance. c. Many people keep loaded firearms in the house for personal protection. i. Nightstands ii. Dresser drawer iii. A table next to a comfortable chair d. Be aware of objects that can be used as weapons. i. Ashtrays ii. Scissors iii. Bottles iv. Fireplace pokers v. Knitting needles e. Move any potential weapon out of the patients reach. D. Domestic violence 1. If a violent or physical dispute is in progress when you arrive at a residence, wait for law enforcement. 2. Tempers may flare while you are treating a patient. a. Use good communication skills in conjunction with eye contact and appropriate body language to defuse the situation. i. Know what words to use or not use in the situation. ii. Be aware of the tone, pacing, pitch, and rhythm of your voice. iii. Talk to people with the same respect that you expect from them. 3. You may also use a technique known as contact and cover. a. One paramedic makes contact with the patient to provide care. b. The second paramedic obtains patient information and gauges the level of tension. i. Warns his or her partner at the first sign of trouble 4. Conduct yourself as a professional no matter how unpleasant or difficult the situation. 5. Crisis intervention is not part of your job and should be left to the professionals. a. You may be required by law to report certain conditions to local authorities. i. Domestic violence ii. Child abuse V. Violence on the Streets A. Clandestine drug laboratories 1. The most popular substance manufactured in clandestine labs is methamphetamine, also known as meth, speed, and crank. 2. Everything associated with a clandestine lab is hazardous. a. Highly flammable properties and toxic nature of chemicals 3. Some methamphetamine “cooking” operations may look like a chemistry laboratory but others are harder to recognize with only a few signs. a. Large quantities of over-the-counter cold remedies i. Containing ephedrine or pseudoephedrine b. Gallon containers of camping fuel c. Sulfuric acid in the form of lye 4. Some cookers use booby traps to safeguard their operations a. Fragmentation and incendiary devices b. Animal traps c. Impaling stakes 5. Once a clandestine laboratory is identified: a. Remain clear of the area until the scene is secured by trained law enforcement personnel and hazardous materials specialists. b. Take any patients with you if you can do so without exposing yourself and your team to additional danger. c. Patients should be decontaminated by specially trained hazardous materials personnel before you approach them. B. Gangs 1. There are approximately 20,000 violent gangs, with more than 1 million members operating in the United States, according to a 2009 FBI report. 2. Gang activity has migrated to suburban and rural places in order to: a. Evade law enforcement and other gangs. b. Extend their influence. c. Recruit new members. d. Promote drug trafficking into virgin territories. 3. Gangs predominately survive through the drug trade but also earn money through: a. Robbery b. Extortion c. Human smuggling and human trafficking d. Gun running e. Prostitution rings f. Insurance and bank fraud g. Identity theft 4. There are three different types of gangs a. Street gangs b. Prison gangs c. Motorcycle gangs 5. In states like California, Illinois, and New Mexico, the FBI estimates that gang members outnumber law enforcement personnel by a ratio of six to one 6. Most gang communication is far more sophisticated than the familiar “gang signs.” a. Multiple prepaid cell phones that are easily discarded b. Text messaging, email, and satellite communications c. Internet social networks such as Myspace and Facebook d. Voiceover phone (VoIP; Internet phone) and Skype 7. Contact your local law enforcement to ask about known gang territories. a. When entering these areas, be mindful of: i. Threat of gang violence ii. Types of activities the local gangs are involved in b. Encourage your service or agency to work with local law enforcement to share information on: i. New gangs that may be entering ii. “Turf wars” that are ongoing or may start iii. Illegal activities that are on the rise 8. The last thing a rival gang wants to see is the paramedics coming to rescue the person they just shot or stabbed. a. Situational awareness is best and often the only defense in potentially violent situations. b. You should know: i. Your surroundings ii. The players iii. The climate of violence or strife C. Mass shootings, active shooters, and snipers 1. The paramedic is an integral part of emergency operations at mass shootings. a. Paramedics must prepare, plan, and train for these complex and difficult violent incidents. 2. You may find yourself on the scene with an active shooter (a gunman who has begun to fire on people). a. Persons who appear to be released hostages could in fact be the perpetrator or accomplices. b. Paramedics must take direction from law enforcement personnel. i. Whom to treat ii. When to treat iii. Never how to treat c. Carefully document any requests or demands to deviate from your local protocols. i. Instructions to withhold treatment ii. Being prevented from treating a patient who clearly requires emergency medical care d. Refer any serious matters to your on-scene dispatcher only if time permits. i. If it is a crime scene you MUST follow the directives of law enforcement personnel until the scene is secured. 3. Paramedics should remain in the staging area until the scene is secured. a. May need to be one half to 1 mile away from the actual scene b. Line-of-sight and line-of-fire from windows must be avoided. 4. Paramedics who unknowingly respond to a mass or active shooting scene need to know how to use cover and concealment. a. Cover objects are usually impenetrable to bullets. i. Trees ii. Utility poles iii. Mail collection boxes iv. Dumpsters v. Curbs vi. Vehicles vii. Depressions in the ground b. Use concealment when cover is not readily available. i. Tall grass ii. Shrubbery iii. Dark shadows 5. Paramedics should consider having a training session with local police to: a. Learn how to assess the police officer that has been shot. b. Address specific topics like removal of full-body armor and officer’s duty belt. c. Establish the protocol for who removes the officer’s weapons and how. 6. Tactical paramedics are used where there is actual violence or the potential for violence. a. In most jurisdictions their primary function is to care for law enforcement teams that are making tactical entry into violent situations. b. Also provide care for: i. Barricaded patients ii. Patients being held hostage iii. Other special operations D. Hostage situations 1. Hostage situations are under the jurisdiction of law enforcement until the scene is secure. a. You should take additional training on handling armed people in the field. 2. Hostages are usually held as a collateral to ensure compliance with a promise. a. If you are taken hostage, you can increase your chances of survival if you can anticipate the feelings and actions of the hostage taker and negotiators. 3. Psychological results of being held hostage are of greater concern than physical problems. a. A person can develop post-traumatic stress disorder (PTSD). b. It is wise to seek counseling after your release even if you think you don’t need it. 4. If you are taken hostage, manage yourself and your personal environment. a. Do not do anything that will attract unwanted attention. b. Do no stare at your captors. c. If the hostage takers believe you are in their way or you irritate them they may kill you. i. Your only chance of survival is to maintain your role as a bargaining chip. d. Other hostages may look to you for guidance and strength because of your uniform. i. Your captors may consider this as a threat to their authority. ii. Remove the badge, collar pins, and patches from your uniform or turn your shirt inside out. e. Ask to help the wounded, if possible, even for minor injuries. i. This will serve to help you gauge the intentions of your captors. ii. It will make you seem less threatening. iii. Your mind will stay sharp by performing tasks that you are used to doing. iv. This will hopefully offer other captives comfort. f. You may also consider offering treatment to any of the captors. VI. Contact and Cover A. You must never assume that you will not be harmed because you are identified as a paramedic during a violent situation. 1. If you see law enforcement personnel seeking cover, you must not remain in the immediate vicinity. 2. Remember the objects that provide cover and those that offer concealment only. a. You should make your body conform to the shape of the object as much as possible. 3. People shooting from a higher position than you can usually see the upper part of your torso or head over the cover. a. Use the engine block and wheel area of a motor vehicle as cover. 4. Select a fire hydrant as a cover only if you cannot immediately find large objects. a. Your central body mass vital organs will be protected. 5. Items inside a structure can provide cover or concealment. a. You can use furniture and appliances for cover. i. A solid oak desk or refrigerator can stop a bullet. b. A sofa or stuffed chair can be used for concealment. B. Using walls as cover 1. You cannot assume that a wall will provide safe cover. a. Many only provide concealment. 2. You must determine if the type of wall you have chosen gives you cover or concealment. a. Brick and concrete are much safer than cinder block walls. i. Cinder blocks will not absorb the bullet’s energy. b. Most interior walls are constructed of wood or aluminum studs and covered with dry wall or siding. i. They are not impenetrable. ii. If your only protection is behind a frame wall, stand near the door or window frames. (a) Usually constructed with extra framing materials and contain more wood. C. Evasive tactics 1. Change locations only if the new location is: a. Better cover b. Farther from the hostile atmosphere c. Can be reached without revealing yourself to the attacker 2. Before changing locations, look out from your cover several times. a. Look from a different height and angle each time. b. Always return to cover as quickly as possible. 3. If you decide that you would be safer in another location: a. Run in a zigzag pattern. i. You have less chance of being hit if your movement takes you across the assailant’s field of view. D. Concealment techniques 1. Tall grass, shrubbery, and dark shadows are considered areas of concealment. 2. When cover is not readily available use concealment to provide some protection while you assess your position and seek cover. 3. Areas of concealment are more common after dark than in daylight hours. a. If you are involved in a violent situation at night, move into the darkness or shadows and stand still. 4. In rural areas, tall grass or a cornfield can conceal you whether it is day or night. a. Remain motionless so the foliage does not move. VII. Self-Defense A. Recognizing the potential for violence when you arrive on the scene gives you time to request support and protection from law enforcement officers. 1. You must also consider what to do if the violence is ongoing or breaks out while you are providing care. 2. Consider taking a self-defense course. 3. Identify yourself if someone prevents you from reaching your patient. a. Instruct the person to move away. b. Inform the person that the patient may die if you are not allowed to provide assistance. c. You should still radio your dispatcher and request law enforcement personnel assistance if the person moves out of your way. d. If the person does not move: i. Take a side step and repeat the verbal challenge. ii. Inform the person that if they do not move the police will be summoned. 4. You can control an unexpected attack. a. Always make sure that your exit path is not blocked and you can easily retreat the way you came. b. Use household objects to obstruct the assailant’s path toward you as you retreat. i. Stretchers and equipment are also excellent obstructions. B. Self-defense in armed encounters 1. Distraction techniques are useful in breaking the chain of events in a shooting incident and in preventing attacks with sharp objects. a. Increase your chances of survival by giving you time to escape b. It does not have to be elaborate. 2. When something is coming at you, your initial instinct is to blink or flinch. a. This is the same type of reaction you want to provoke. b. Throw whatever you have handy at the person. i. Gives you long enough to get out of the line of fire and run to safety. c. If the patient takes aggressive action during your initial interview, one technique is to throw a light object directly at the aggressor’s nose. i. Use only a lightweight object that will not cause undue harm. ii. Once the object leaves your hand: (a) Turn toward you vehicle. (b) Get out of the potential line of fire. (c) Run to safety. 3. Put as much distance as possible between you and the aggressor. 4. Use physical force as a defensive technique, not an aggressive motion. a. The amount of defensive force needed to protect yourself varies with each incident. b. If you believe your life is in imminent danger, any action that gets you out of the situation is a reasonable level of force. VIII. Crime Scenes A. By assisting law enforcement personnel to maintain the integrity of the crime scene, you increase the probability that a suspect will be captured and convicted. B. Preserving evidence 1. Generally there are two types of evidence: a. Testimonial evidence i. The oral documentation by a witness of the facts b. Real or physical evidence i. Ties a suspect or a victim to a crime and includes body materials, objects, and impressions 2. Do not disturb, damage, or alter physical evidence at a scene. a. Small blood stains can yield critical forensic information. b. Unnecessary cutting or removal of clothes can destroy or dislodge fibers, hair, or other evidence. 3. Law enforcement personnel should collect evidence. a. If you must remove a piece of evidence in order to treat the patient: i. Place each piece of evidence into a brown paper bag. ii. If the item is saturated, place the paper bag into a plastic bag for biohazard control. 4. Follow law enforcement direction when you are asked to park in a specific area or to avoid a certain location. 5. Only the necessary amount of EMS personnel should enter the scene. 6. Crime scene investigators usually wear full-body Tyvek suits. a. Every time they enter a crime scene they deposit evidence. b. Evidence can collect on their clothes and damage it or make it less useful. c. Every interaction with a space or surface entails the deposition of your DNA on to the area. i. Limit your time and interaction of what you touch with the crime scene. ii. ALWAYS wear gloves when entering. 7. First responders are typically the first to enter a crime scene. a. Regardless of how careful you are, that scene is automatically altered. b. Paramedics are often called to speak with investigators and prosecutors, who will want to know exactly: i. What you saw ii. What you touched iii. What you smelled iv. What you heard (radio, TV, fan, alarm clock) v. What you did while you were there c. Do not: i. Clean up the scene. ii. Alter items. iii. Move bodies, unless doing so is essential to establish the need for resuscitation. d. Be mindful of: i. Bullet casings ii. Weapons iii. Blood spatter iv. Puddles e. When you remove clothes to expose a wound: i. Do not cut through bullet holes, knife cuts, or tears. ii. Once clothes are removed, do not shake them; valuable evidence may fall to the floor. 8. It is imperative that the incident be properly documented. a. Much time can elapse between the call and when you are asked to provide information or testimony about it. b. Your documents may be read by dozens of people and potentially the jury. c. The better your documentation is the more likely that you will recall what you witnessed years later. d. Elements of proper documentation i. What you saw ii. What you heard iii. What you were told iv. What you smell (if there were any odors) v. What you moved, altered, or disturbed vi. The chain of custody that items were presented to you or that you found on the patient or decedent vii. A description of the scene (a) How many patients or decedents? (b) Was the victim supine or prone? (c) Where was the weapon? (d) Were any characteristics of the scene noteworthy? e. Do not draw conclusions or overstate facts. f. Any statements made by the patient during transfer to a medical facility should be documented. IX. Summary A. EMS can be a dangerous profession and your mission, beyond providing optimal patient care, is to return safely at the end of each shift. If you are injured you cannot care for patients. B. No community, socioeconomic group, race, or religion is immune to violence. Sound survival skills will reduce the potential for you to fall victim to an act of violence while on an emergency call. C. Perform a scene size-up for indicators of potential violence, and escape before performing patient care. If you feel a scene is not safe, retreat to your ambulance and wait for law enforcement personnel to secure the scene. D. Obvious indicators of violence include calls for shootings, stabbings, or attempted suicides; body language; and use of profane language or yelling. E. Be aware of the possibility that secondary violence can occur during a call even if indicators of violence were not present at the outset. F. Your agency will have standard operating procedures for dealing with potentially violent incidents. Familiarize yourself with them and be sure to follow them. G. 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. Turn front wheels all the way to the left to provide limited protection in the event of gunfire. H. When you are approaching a standard automobile, use your high beams, but don’t walk in front of the light. Approach the vehicle with your abdomen facing the vehicle, checking the trunk and inside of the vehicle before reaching the B post. If the back seat is occupied do not proceed past the C post. I. When you are approaching a van remain clear of the side door of the van throughout your approach. Walk parallel to the van until you are approximately 45° forward of the A post. J. When a dangerous situation develops, retreat from the scene and alert the dispatcher of the situation and include details about the situation. K. When you are approaching a residence, stand to the side of the door. Do not stand on the hinged side; this will provide you a view of you as the person inside opens the door. L. When you are entering a structure, always identify a primary and secondary exit in case the primary exit becomes inaccessible. M. Clandestine drug laboratories are extremely hazardous. Once such a site is identified, remain clear of it until trained law enforcement and hazardous materials specialists have secured it. N. Gang activity can present hazards to EMS crew. Work with local law enforcement so you are aware of areas gangs may be affiliated with. O. In situations that involve an active shooter or sniper, follow law enforcement’s direction, even if it means a patient cannot receive care immediately. P. You may need to use cover and concealment if a scene becomes dangerous. Cover includes objects or areas that are difficult or impossible for bullets to penetrate. Concealment includes objects or areas where it is difficult or impossible for you to be seen but that could still be penetrated by bullets. Q. Consider taking a self-defense course to help increase your ability to survive should dangerous situations develop. R. When you are working at a crime scene, make every attempt not to disturb, damage, or potentially alter the scene or physical evidence. Properly and thoroughly document these scenes and the actions you performed. Post-Lecture This section contains various student-centered end-of-chapter activities designed as enhancements to the instructor’s presentation. As time permits, these activities may be presented in class. They are also designed to be used as homework activities. Assessment in Action This activity is designed to assist the student in gaining a further understanding of issues surrounding the provision of prehospital care. The activity incorporates both critical thinking and application of paramedic knowledge. Instructor Directions 1. Direct students to read the “Assessment in Action” scenario located in the Prep Kit at the end of Chapter 52. 2. Direct students to read and individually answer the quiz questions at the end of the scenario. Allow approximately 10 minutes for this part of the activity. Facilitate a class review and dialogue of the answers, allowing students to correct responses as may be needed. Use the quiz question answers noted below to assist in building this review. Allow approximately 10 minutes for this part of the activity. 3. You may wish to ask students to complete the activity on their own and turn in their answers on a separate piece of paper. Answers to Assessment in Action Questions 1. Answer: B. Tunnel vision Rationale: You must have the ability to quickly identify potentially dangerous situations and act to remove yourself, your crew, and if possible, the patient to a safer location. Having tunnel vision does not allow you to do this. Be aware of your surroundings at all times when there is a potential for harm. 2. Answer: C. C Rationale: When you are approaching a suspect vehicle, do so from the rear of the motor vehicle. The C post is closest to the trunk and directly behind the rear passenger seat. The A post is closest to the motor/hood. The B post is between the driver’s door and the rear passenger door. Using a belly-in movement, proceed to the C post on the passenger side of the motor vehicle. Moving belly-in toward the motor vehicle creates as small an image as possible for the occupants of the motor vehicle to see. 3. Answer: A. Primary exit Rationale: When you are entering any type of structure, you should select a quick escape route. This is usually the door you entered, which is called a primary exit point. Always be aware of where this door is in relation to your current position. 4. Answer: B. The door you entered Rationale: As the name implies, a secondary exit is your second choice of a way out of the building you are in. Secondary exits include windows, other doors, or external fire escapes. The secondary exit may not be the easiest exit to reach, but it will get you to safety in a timely manner. 5. Answer: D. Your voice Rationale: Your voice is the most effective tool you have to keep yourself out of trouble. Knowing what words to use or not use in a situation is only part of your goal. You must also be aware of the tone, pitch, and rhythm of your voice. 6. Answer: A. Contact and cover Rationale: The technique of contact and cover can be used to keep a crew out of harm’s way. One aspect of the technique involves one crew member making contact with the patient to provide care. The second crew member obtains patient information and, more importantly, gauges the level of tension to provide a warning if necessary. 7. Answer: C. Cover Rationale: Objects such as trees, utility poles, dumpsters, vehicles, and depressions in the ground are examples of objects that will provide effective cover. Cover is considered impenetrable to bullets. Tall grass and shadows are considered concealment because they provide no protection other than being hidden from sight. Additional Questions 8. Rationale: Generally, there are two types of evidence: testimonial and real or physical. Testimonial evidence is the oral documentation by a witness of the facts. Real or physical evidence ties a suspect or a victim to a crime and includes body materials, objects, and impressions. Follow law enforcement direction when you are asked to park in a specific area or to avoid a certain location. Officers may be attempting to safeguard tire imprints, bullet casings, or blood. Once you are at your patient’s side, try to alter the scene as little as possible. Be mindful of bullet casings, weapons, blood spatter, and puddles. Whenever possible, walk around such evidence. Do not pick up expended cartridge casings to determine the caliber. Do not use telephones, flush toilets, or turn on water in a sink. In each case, valuable evidence can be lost. When you remove clothes to expose a wound, do not cut through bullet holes, knife cuts, or tears. Once the clothes are removed, do not shake them because valuables, including valuable trace evidence, may fall from the pockets to the floor. Assignments A. Review all materials from this lesson and be prepared for a lesson quiz to be administered (date to be determined by instructor). Unit Assessment Keyed for Instructors 1. What are some of the indications that violence may occur on a scene? Answer: Violence can often be predicted, as most experienced EMS providers already know. If you are dispatched to the scene of a shooting, stabbing, or attempted suicide, the potential for violence can be obvious. You should always expect aggressive behavior when you arrive at the scene of an injured person. The patient may be upset for having been a victim of violence. Family members can also be agitated, pacing the room with fists clenched and using profane language because they perceive that it took you too long to reach the scene, or because they feel you are moving too slowly in your treatment of their loved one. (p 2346) 2. What are precautions you should take when parking at a single vehicle incident ? Answer: For your maximum safety when you are arriving at incidents with a single vehicle in which the potential for danger is high, and you are the first vehicle to respond, your vehicle should be positioned a minimum of 21 ft behind the stopped vehicle at a 10° angle to the driver’s side facing the shoulder. The front wheels should be turned all the way to the left. In this position, the wheels and the motor block will provide limited protection in the event of gunfire. (p 2347) 3. What is the recommended approach for walking up to a single motor vehicle with people inside (not in a collision)? Answer: Proceed to the rear passenger-side trunk area, and place the response bag or jump kit at the rear of the motor vehicle out of the path of travel . Look out for people hiding in the trunk of a motor vehicle, and check the trunk lid to ensure that it is properly closed. Use only a light touch on the trunk seam to detect motion or an unsecured trunk lid. If the trunk is open, retreat to your vehicle. Using a belly-in movement, proceed to the C post on the passenger side of the motor vehicle. Moving belly-in toward the motor vehicle creates as small an image as possible for the occupants of the motor vehicle to see. (p 2348) 4. How should you approach the same vehicle in question 3 if there are passengers in the front and rear of the vehicle? Answer: If the back seat is occupied, do not pass the C post. If you pass the C post, the back-seat passengers will be behind you. You will have to divide your attention between the front and rear seats. If there are no passengers in the back seat, move forward to the B post with the same belly-in movement. (p 2348) 5. Why do law enforcement officers consider the entry door to a residence to be extremely dangerous? Answer: Law enforcement officers consider entry doors to residences extremely dangerous. Many law enforcement officers have been shot and killed while standing in front of a door after knocking to gain entry. Most bullets pass easily through all but the heaviest doors. (p 2350) 6. When entering a residence, what are the recommended number of escape paths you should find? Answer: When you are entering any type of structure, you should pick a primary exit and a secondary exit. Your primary exit is usually the door that was used to enter the building. A secondary exit might be a rear door or, in an emergency, a window. Whenever you are in a building, try to keep at least one means of escape accessible at all times. (p 2350) 7. What is the most effective tool you have for keeping yourself safe when on scene of a dispute? Answer: Your voice is the most effective tool you can use to keep out of trouble in a dispute. Knowing what words to use or not to use in a situation is only part of your goal. You must also be aware of the tone, pacing, pitch, and rhythm of your voice. Talk to people with the same respect that you expect from them, regardless of your personal opinion of them. A good paramedic is always respectful because it puts patients at ease and can suppress the anger of a violent person who is not the patient. That person may turn on you, and the situation can quickly deteriorate to a dangerous level if you do not use respectful language, body posture, and tone. (p 2351) 8. What actions should you take if you come across a clandestine drug lab in a residence? Answer: Once a clandestine laboratory is identified, it is your job to remain clear of the area until the scene is secured by trained law enforcement personnel and hazardous materials specialists. If possible, take any patients with you if you can do so without exposing yourself and your team to additional danger. Remember that patients should always be decontaminated by specially trained hazardous materials personnel before you approach them and before they enter the ambulance. (p 2351) 9. What is situation awareness? Answer: In all potentially violent situations, the paramedic’s best and often only defense is situational awareness. That means knowing your surroundings, the players, the climate of violence or strife, and synthesizing that information quickly so you can make rapid, effective decisions even while under stress. (p 2353) 10. How can you use cover and concealment to keep yourself safe? Answer: Paramedics who unknowingly respond to a mass or active shooting scene need to know how to use cover and concealment. You need to know the difference between objects that provide cover and those that offer concealment only. Cover objects, such as trees, utility poles, mail collection boxes, dumpsters, curbs, vehicles, and depressions in the ground are usually impenetrable to bullets. Tall grass, shrubbery, and dark shadows are areas of concealment. When cover is not readily available, use concealment to provide some protection while you assess your position. (p 2355) Unit Assessment 1. What are some of the indications that violence may occur on a scene? 2. What are precations you should take when parking at a single vehicle incident ? 3. What is the recommended approach for walking up to a single motor vehicle with people inside (not in a collision)? 4. How should you approach the same vehicle in question 3 if there are passengers in the front and rear of the vehicle? 5. Why do law enforcement officers consider the entry door to a residence to be extremely dangerous? 6. When entering a residence, what are the recommended number of escape paths you should find? 7. What is the most effective tool you have for keeping yourself safe when on scene of a dispute? 8. What actions should you take if you come across a clandestine drug lab in a residence? 9. What is situation awareness? 10. How can you use cover and concealment to keep yourself safe?