Your Captain Speaking: EMS and Evidence

“Samantha, you said you ran into our favorite coroner, and he mentioned ‘EMS can turn a crime scene into a hot mess.’”

Like Samantha, my first thought was, How many times did we cause this problem? “Maybe,” I tell her, “we should look at whether EMS really is the problem and what we should be doing.”

There are times we enter scenes knowing they’re crime scenes by the callout description. Other times, not at all. Once we were called to a residence for an unresponsive male. We found him in bed, under the covers, and sure enough unresponsive. When we pulled back the sheets, we noticed the car tire tracks across his body. Tire tracks! (Yes, a real call.)  

We’ve all had calls that turned out much different than what was dispatched. Here’s where some Crew Resource Management works: Maybe you’ll be first, or maybe it’s your partner who will start to get a feeling you’re working not just an EMS call but a crime scene. Communicate with each other quietly and review the basics. Is the scene safe? Do you need additional equipment or resources, such as law enforcement?

Here’s a actual example: We were called out to “My grandfather fell down.” We’ve done lots of them. The family was very agitated upon arrival and desperate for us to hurry. We turned the corner of the hallway and found the grandfather on the kitchen floor with a large knife in his abdomen. A crime scene? He looked over at me and said, “I should have used a gun,” which sorted out a lot in a moment (and made it a crime scene in our district). The family just wanted EMS and worded their call to avoid the police responding.

We paused for a second to review the basics: scene safe; personal protective equipment; initial triage; additional equipment needed? We deemed it safe, had the right PPE on, no one else was hurt, and we called for police to assist. As partners, we communicate—we practice CRM. In an airplane cockpit going 500 knots or an EMS call, anyone who uses the word “CRM” tells me they have a concern—it’s time to listen up and decide on a course of action.

Evidence Preservation

If you know it’s a crime scene from the start, you may not be first on scene, but in any event you cannot be only concerned with the medical aspects. Providing care to the sick or injured is a high priority, but we must also protect evidence and prevent disruption of the scene. What are some things we should do to meet these requirements? Here are some examples:

• Use one site for entrance and exit and take notes on the details of the scene as best you can.
• If you don’t have to touch it, pick it up, or move it around, leave it where it was! If you move furniture to access the patient, record it in your report.
• Watch where you walk! Don’t walk through bodily fluids. There’s a whole science to reading blood spatter, and often we don’t concern ourselves with it, but it can be critical to processing a crime scene. Blood location and especially bloody footprints can be crucial, but not if EMS has tracked bloody footprints everywhere.
• If on the scene of a gunshot victim, you don’t need to pick up a shell casing to see what caliber it is. You can look at it to see if it was a handgun or rifle casing, but you do more harm than good by picking it up. Don’t kick them around, either.

Clothing

We cut clothing a lot. Never cut through bullet holes or knife cuts in clothing. If any part of a victim’s clothing is bloody or contaminated, just zigzag around it. If you remove clothing at the scene, leave it for processing if needed. If in the ambulance, don’t just toss it on the floor because you’re done and plan to clean up later, often after stepping on it or dragging the gurney over it.

So what are we supposed to do with the clothes? Do you have paper bags in your ambulance? If not, you should. Put potential evidentiary clothing into a paper bag. If it is wet, put it into a paper bag, then a clean plastic bag—not a biohazard bag! Biohazard bags tend to get put together with other biohazard bags and hopelessly contaminated from an evidence perspective. Biohazard bags get thrown out, and evidence is totally lost. Do you have clear plastic bags in your ambulance? If you have neither paper nor plastic bags, then take a moment to place the clothing on a clean sheet and save it for law enforcement. Communicate with your partner what needs to be preserved so it is not inadvertently lost or made worthless to an investigation.

Other Cases

Sexual assault is a tough subject. The tiniest bit of DNA evidence can make or break a prosecution. You have a patient on your gurney who asks for some water to wash her face off. No! Neither do you wipe the tears from her eyes or provide hand sanitizer. If you need to clean a spot to start an IV, do so. If you don’t need to remove clothing, leave it in place. Long ago I learned to place an absorbent plastic pad on the gurney before a sexual assault victim sat down for transport. If there was any fluid that leaked out, it would likely be captured, then placed in a paper bag for evidence collection. Remember, women, men, and children all can be victims of sexual assault, and it might not be obvious from the start that’s what you’re dealing with.

Encountering deceased persons isn’t uncommon for EMS, and many we won’t attempt to revive, as we see obvious signs of death. Limit access to the scene and don’t move objects unless the reason is compelling. Here’s the hard part: If possible, don’t let the family back with the deceased before the coroner. Politely keep the family away so as to not disturb the scene and body until the coroner does their own scene size-up. The coroner can make the call when to allow the family to say good-bye.

Some regions require an EKG showing asystole, so perform this with minimal disruption of the scene. As an aside, if taking a 3-lead EKG to document asystole, do not have the family present, as the deceased patient might have a pacemaker, which might make a family member think their loved one has a heartbeat and insist you revive them. Just trust me on this. The less you touch or move around, the better. Emotions are guaranteed to be high, so use a gentle touch where possible.

Evidence Turnover

On scenes there are fewer situations where you need to collect evidence and begin or continue its chain of custody. The back of an ambulance is a whole other story. When you remove a piece of clothing and it is possible evidence, there needs to be an unbroken trail of who was responsible for the evidence to protect it from tampering.

One answer is to call the police agency involved and ask them to meet you at the hospital and collect the evidence. When they arrive the police will ask for the pertinent information as they take custody of it. Another choice is to ask the hospital about its evidence-collection protocol and turn the evidence over there.

There are problems with both approaches, however. There could be a delay in the police responding to the hospital, and like EMS, hospital staff are primarily concerned with taking care of patients. Evidence collection is not their priority, and our experience has been that they are often less than excited to assist. However, it is at the hospital where rape kits, for example, are performed, so staff there do have responsibilities with evidence.

Documentation

It’s not certain that every piece of evidence is critical to a crime investigation, but documentation is extremely important. On many calls we do not go into detail about what the scene looked like when we arrived. We need to record if furniture is moved, what was said in quotes, footprints observed—lots more than what we might normally write on the PCR. We have no idea how many times our PCRs were reviewed by lawyers and found exactly correct or perhaps used to tear apart an investigation. We finish a run, and it’s pretty routine for us, but how many times did the parties involved have our run reports scrutinized? When I’ve been called in and asked questions about a run, I initially worried but later found what I saw and did was thankfully documented.

If there’s a most-important part of this article, it’s about your PCR documentation. Make it complete, accurate, and with no opinion but lots of facts. Include what you saw, what you did, what you collected, and whom you turned it over to.

A good resource on this subject is “EMS, Crime Scene Responsibility” by Timothy G. Price and Rory M. O’Neill. Check it out at www.ncbi.nlm.nih.gov/books/NBK499999/.

Dick Blanchet (ret)., BS, MBA, worked as a paramedic for Abbott EMS in St. Louis, Mo., and Illinois for more than 22 years. He was also a captain with Atlas Air for 22 years and an Air Force pilot for 22 years.

Samantha Greene has been a paramedic, field training officer, and operations supervisor for Abbott EMS of Illinois for the last 10 years and a lieutenant for the Madison, Ill., Fire Department for the last five.