Curriculum Update: Crime Scenes Behavioral Emergencies Toxic Exposure Abuse and Assault

1. Curriculum Update:Crime ScenesBehavioral EmergenciesToxic ExposureAbuse and Assault Condell Medical Center EMS System September 2006 Site code #10-7200-E-1206 Revisions by S Hopkins, RN, BSN

2. Objectives • Upon completion of the module, the EMS provider should be able to: • describe approach to a crime scene and steps taken to preserve evidence • describe what a behavioral emergency is and medical legal considerations • list drugs that are abused and field interventions that may be necessary

3. Objectives cont’d • list types of abuse and assault and the legal considerations • actively participate in case scenario discussion • review activation of cardizem syringe • successfully complete the quiz with a score of 80% or greater

4. Crime Scenes

5. Crime Scenes • Crime Scene Definition • A location where any part of a criminal act occurred • A location where evidence relating to a crime may be found

6. Crime Scenes • EMS personnel may be mistaken for police • Uniform colors • Badges • Exiting a vehicle with lights and sirens • Can initiate aggression toward an authority figure

7. Approach to the Scene • Approach is part of scene size-up • Identification of possible hazards is part of scene size-up • Key point – identify and respond to dangers before they threaten • Safety concerns begin with dispatch information • Use available resources before arrival • Do not enter the scene until it is safe and secured

8. Approach to the Scene • A secured scene can become unsafe again - be on guard • Retreat from the scene if the scene cannot be made safe; there is no such thing as a dead hero! • Know local protocols • Begin observation several blocks before the scene

9. Use of Red Lights & Sirens • Urban areas - excess use may draw crowds • Highway scene - lights required for safety • lights can also be hypnotizing and cause drivers to drive into the lights

10. Known Violent Scenes • Stage safe distance from the scene until police advise scene “secure” • Out of sight of the scene • If you can be seen, people will come to you • Entering an unsafe scene adds another potential victim • You may be injured, killed, or taken as hostage • You may become another patient

11. Violent Scenes • Coordinate your approach with police • You do not want to be misidentified • Approach potentially unsafe environments single file • If holding a flashlight, hold from the side • Armed assailants often aim at the light • Stand to the side of doorways when knocking • Standing directly in front of a door makes you a target

12. Approach to the Scene • Remember non-violent dangers such as hazardous materials, power lines, dangerous pets, etc • Scene safety considerations must continue throughout the call • Others could expect you to intervene in violent situations • Remember to include “escape and strategic escape plans” in yourprotocols

13. Crime Scene Preservation • Evidence • Prints • Fingerprints - ridge characteristics are left behind on a surface with oils & moisture from the skin; unique in that no 2 people have identical fingerprints • Footprints • Blood and body fluids • DNA and ABO blood typing possible • Blood splatter pattern is evidence • Particulate evidence • Hairs, carpet & clothing fibers - leave sheets under the patient in the ED (may hold evidence)

14. Crime Scene Observations • Patient (victim) position • Patient injuries versus marks you added (ie: IV attempts) • Conditions at the scene • lights, curtains, signs of forced entry, anything moved or touched by EMS • Statements of persons at the scene • Statements of the patient/ victim • Dying declarations • place in quotation marks “He done it!”

15. Evidence Preservation at Crime Scenes • Patient care is the ultimate priority • You may be restricted to only 1 team member for initial scene entrance • Evidence protection is performed while caring for the patient • Carry in only necessary equipment • Evidence preservation techniques • Be observant • Touch only what is necessary for patient care

16. Use of Gloves At Crime Scenes • Wear latex gloves • Used for infection control • Prevents you from leaving your fingerprints • Prevents smudging of other fingerprints

17. Crime Scene Documentation • Note observations objectively, not subjectively (ie: note color of bruising and not “new” bruise) • Put patient’s or bystander’s words in quotes • Patient care records are legal documents • Avoid opinions not relevant to patient care • Patient care records will be used in court - will your charting stand up?

18. Mandatory Reporting • EMS providers are required to report certain types of crimes • Child abuse - DCFS must be notified • Suspected elder abuse (age 60 or older) and/or neglect • Domestic violence • If a refusal, EMS is mandated by the State to report all cases of domestic violence to the local police • Offer an informational brochure to the patient • Document your actions • Certain violent crimes (i.e. sexual assault, gunshot, etc.) • Confidentiality needs to be maintained

19. Crime Scene Questions?

20. BEHAVIORAL EMERGENCIES

21. “Normal Behavior” No clear definition or ideal model Ideas vary by culture or ethnic group What society accepts at the moment “Abnormal Behavior” Deviates from society’s expectations Interferes with well being and ability to function Harmful to individual or group BEHAVIORAL EMERGENCEIS

22. What Is A BEHAVIORAL EMERGENCY? • General term to describe a broad range of conditions of varying severity including unanticipated or maladaptive behavioral episode • Use of the word “abnormal” is very subjective • Recognized as behavior requiring immediate intervention • Not always a clear cut EMS call

23. Behavioral Calls • Indications of a behavioral or psychological condition include: • interference with core life functions (eating, sleeping, ability to maintain housing, interpersonal or sexual relations • posing a threat to the life or well-being of themselves or others • significant deviation from the expectations or norms of society

24. Responses to Behavioral Emergencies • Most of your assessment skills will depend on your interpersonal & people skills more than use of diagnostic tools • Remember, on all calls your safety is #1 and your partner’s is #2 • Will need to exercise observational skills • patient • family • bystanders

25. BEHAVIORAL EMERGENCIES • Incidence • Estimates vary with as much as 20% of the population experiencing some type of mental problem • Incapacitates more people than all other health problems combined • 1 person out of 7 will require treatment for an emotional disturbance

26. BEHAVIORAL EMERGENCIES • Common misconceptions • Abnormal behavior is always bizarre • All mental patients are unstable and dangerous • Mental disorders are incurable • Having a mental disorder is cause for embarrassment and shame

27. Specific Psychiatric Disorders • Cognitive disorders • Organic causes such as brain injury or disease • Includes delirium (rapid onset disorganized thought) and dementia (gradual development memory & cognitive impairment) • Schizophrenia • loss of contact with reality • hallucinations, delusions, depression • Anxiety & related Disorders • panic attacks • phobias • post-traumatic stress syndrome

28. Mood disorders • depression • bipolar disorder (manic-depressive episodes) • Substance use/abuse • Physical symptoms with no apparent physiological cause • Factitious disorders • intentional production of signs/symptoms • motivation to assume the sick role • external incentives are absent (ie: avoid police)

29. Dissociate disorders • failure to recall (psychogenic amnesia) • physically moving miles away (fugue state) • multiple personality disorder (2 or more compete personalities) • depersonalization (loss of one’s self) • Eating disorders • anorexia - loss of appetite; excessive fasting • bulimia - uncontrollable bingeing & vomiting or diarrhea • these patients are at risk for electrolyte imbalance and dysrhythmia

30. Personality disorders • acting odd or eccentric • dramatic, emotional, fearful, anxious patients • Impulse control disorders • failure to control certain impulses that may be harmful to the patient or others • Suicide/suicidal attempts

31. BEHAVIORAL EMERGENCIES • Management considerations • Treat existing medical problems • Maintain safety • Do not confront or argue with patient • Control violent situations • Remain with patient at all times • Avoid challenging the patient’s personal space • Avoid judgements

32. BEHAVIORAL EMERGENCIES • Medical Legal Considerations • Standard of care must always be followed • Obtaining consent may help avoid charges of assault or battery • assault - a verbal or physical threat • battery - patient force without consent • Limitations of legal authority • if in doubt regarding action, contact medical control • Objective documentation will be your best defense

33. Methods of restraint Verbal de-escalation speaking in a calm manner avoid patient’s “personal space” Physical restraint includes soft (ie: sheets) and hard restraints (ie: handcuffs,leathers) Have enough man-power available prior to beginning restraint procedure, if possible Restraint in a prone (face-down) position can make the patient susceptible to positional asphyxia - watch for airway compromise!!! Use of Restraints

34. Restraints • Once a patient is restrained, never leave them unattended • Once restrained, frequently monitor and document neurovascular assessments of restrained extremities • need to maintain adequate circulation • EMS personnel need to contact medical control as soon as possible when restraints are being considered or have been used

35. Restraints • Never compromise the patient’s airway • Do not further aggravate injuries or illness • EMS to clearly document the behavior that led to use of restraints • Handcuffs are to be applied by police only • If handcuffed, a police officer must accompany the patient in the ambulance while being transported (CMC policy)

36. Taser Use By Law Enforcement • Use of propelled wires to conduct energy that affects the sensory and motor functions of the central nervous system • Overrides the central nervous system to achieve incapacitation • previous weapons worked on pain compliance which can be overcome by drugs, alcohol, or focused & combative patients

37. Taser Use • Static discharge on a doorknob - 35,000 -100,000 volts • Taser system - 50,000 volts • Does not cause electrocution in a wet environment • Electricity will not pass to others in contact with the subject unless contact is made directly between or on the probes • Patient can be touched while Taser is active • do not touch probes or step on wires

38. Taser Use • Do not place yourself in the pathway of the unit being discharged

39. Taser Probes • Probes are embedded in the skin; they do not continue to give off charges

40. Taser Probes • Law enforcement may remove/break wires near probes • CMC EMS have not been authorized to remove laser probes • Removal of probes most commonly performed in the ED • probed grabbed firmly and pulled straight out • skin wiped with alcohol pad • Treat removed probes with precautions similar to contaminated sharps

41. Transportation Against The Patient’s Will • Patient presents as a threat to themselves or others • When ordered by medical control • Implemented by law enforcement authorities • An incompetent patient will not be allowed to make health care decisions • When in doubt, contact medical control and document the contact

42. Transportation of Patients with Psychiatric Issues • All patients must be evaluated in an ED before psych admission can occur • Admission destination often based on many factors including but not limited to: diagnosis, available beds, insurance requests • Just because one facility has a psych unit is no guarantee a patient stays at that facility if in the ED there

43. Petition for Involuntary Admission • Completed by person(s) witnessing the behavior (ie: police, EMS, family, hospital) • If petition not completed in ED and ED staff have not witnessed behavior, patient may be discharged • Petition may be completed by family only if they witness behavior or conversation • Transporting authority acting in good faith and without negligence shall incur no liability, civil or criminal, due to transport

44. Most of form often completed as group effort with EMS and hospital staff for accuracy & legal boundaries

45. This is the section EMS or other witness would be expected to objectively describe behavior observed

46. Signatures important Phone numbers may be work numbers

47. Questions Behavioral Emergencies?

48. Toxic Exposure

49. Biological Nuclear Irritants Chemical Nerve agents Blister agents Blood agents Farm chemicals Cleaning agents Petroleum products and by-products Medicine/drugs Inert gases Explosion hazards Multiple Forms of Toxic Exposure Substances

50. Alcohol • A central nervous system depressant • A common & favorite mood-altering drug • Affect on body influenced by: • age • gender • physical condition • amount of food eaten • other medicines/drugs taken • Is a toxic drug producing pathological changes in liver tissue (cirrhosis) and can cause death