State law regulates the delineation of authority in regard to the declaration of death. Most states allow first responders to declare death when conclusive signs are present. Furthermore, advanced prehospital care providers, such as paramedics, may often declare death when faced with an advanced directive or inability to regain a perfusing rhythm after a set number of interventions. The patient is then classified as dead on arrival (DOA). Often, when first responders reach the scene, they have had advanced information that indicates they should not expect to find a viable patient. The initial 911 call information, scene dynamics, and direct statements from bystanders will provide these clues. In these cases, prehospital teams should approach the body with minimal equipment and supplies and then do a rapid immediate assessment to confirm death while disturbing the scene as little as possible. Personnel and bystanders should enter and leave the death scene by the same route to minimize risks of altering environmental elements at the scene. The first responder team must document all information surrounding the encounter for law enforcement officials and the medical examiner. This documentation should include the times from dispatch, the time the pronouncement of death was made, scene entrance and exit routes, and any disturbances made to the scene by personnel involved in intervention. Physical assessment procedures or other medical care should be noted, including information about any areas of the body that were touched in the process. Disposable equipment used on the patient (e.g., defibrillator pads) should be left in place for the medical examiner. Gloves or other expendable items used by the care team should be placed in a paper bag, labeled, and left at the scene as well.

Sudden infant death syndrome (SIDS) is the leading cause of death among infants age 1 to 12 months and is the third leading cause of infant mortality in the United States averaging more than 4500 deaths a year. Ninety percent of the SIDS deaths occur in infants younger than six months, with a majority dying between two and four months of age (CDC, 2008).

According to Guntheroth and Spiers (2002), SIDS is most likely caused by a combination of three factors. This “triple-risk” model incorporates: (1) biological vulnerabilities, (2) environmental stressors, and (3) a critical development period. Research has shown SIDS to occur more frequently when the baby is male, African American, or Native American. Certain heart and brain abnormalities, as well as certain genetic predispositions have been identified that put some infants at greater risk for SIDS. Additionally, a mother who smokes cigarettes or uses drugs during pregnancy or a baby exposed to secondhand smoke has also been linked to an increased risk of SIDS. Although some of the risks for SIDS can be minimized (for example, by avoiding cigarette smoke and having the baby sleep on his or her back), there is no guarantee that doing so can prevent a SIDS death.

Because EMS personnel are usually the first responders on the scene of a SIDS death, Bledsoe (2008) reported that rescue personnel take on three major roles: (1) providing medical care if needed; (2) offering support and consolation for the family; and (3) observing, assessing, and documenting the scene.

As the first link in the evidence chain, it is extremely important to accurately note the death scene and thoroughly document your findings. First responders need to ask questions about the event and the baby. If possible, the first responder should try to question the parents separately to reduce the likelihood of receiving rehearsed stories. Also, open-ended questions generally provide better information and are recommended.

According to Bledsoe (2008), questions should include the following:

Some families may insist that resuscitation be attempted, whereas others understand that such measures are hopeless. Some parents may simply want to hold the baby. Rescue personnel need to walk a fine line between meeting the family’s requests, following medical protocols, and protecting the scene for law enforcement. It is important for first responders to remember that SIDS is often a tragic, innocent, event. But they must always consider the possibility that something criminal may have transpired.

Because most current research shows that SIDS patients have a 0% chance of survival, many scholars suggest that lights and siren responses should not be used and resuscitation (if it has been initiated) be terminated at the scene (Smith, Kaji, Young, Gausche-Hill, 2005). The death of a child is one of the most devastating events that can happen to a family. It is also among the most stressful events that emergency medical services (EMS) personnel encounter. After a SIDS death has been determined, the child’s parents and family essentially become the patients. It may be necessary to provide psychological first aid. It is also important to remember that people react to the shock of death in different ways. Rescue personnel must recognize this to remain calm, objective, and professional.

Pronouncement of death outside a domestic dwelling produces a different set of challenges for the first responder. Many of these deaths are on major roadways where there may be an increased number of people interacting with the scene of the crime or death. Additionally, wildlife can invade the scene and remove elements that may potentially be considered evidentiary. Because the area is open to the public, the first priority is to isolate the scene. The principles of patient care and scene management are identical to those for “at home” deaths. As soon as death has been confirmed, the immediate area should be sealed with crime scene barrier tape while first responders await law enforcement officers and crime laboratory personnel who will further document and search the scene for evidence. For detailed directions pertaining to large crime scene preservation, see Chapter 5.

Injuries caused by firearms have altered dramatically since the 1990s, not only in the number of incidents of gun-related violence but also in the increasingly variable population of those using guns and falling victim to gunfire (Perkins, 2003). Without the education of all personnel involved, from first responders through surgeons, evidence needed to properly evaluate and prosecute cases will be lost (Evans & Stagner, 2003).

For example, when the first responder comes into contact with a shooting victim, the responder will normally expose the affected area identified by the loss of continuity of the clothing surface or by the obvious location of hemorrhage. It may seem natural to take trauma shears and cut up to and through the hole in the clothing, or even to use the bullet hole as a starting point in the exposure process. This must not be done, however, because cutting through bullet holes creates the first breach in preserving vital forensic evidence.

When a bullet is fired from a weapon, heated gases emerge, as well as burning and unburned gunpowder. This gunpowder comes to rest on the first surface with which it comes into contact, frequently the victim’s clothing. Investigators can use this clothing in several ways. First, the gunpowder itself can be examined and may give an indication about the type of ammunition used. Second, the investigators can take the suspected weapon, along with the suspected ammunition, and test fire it to determine the distance (range of fire) between the perpetrator and the victim when the gun was discharged. Last, the test fire is matched to the victim’s shirt. These procedures make it imperative not to cut through the hole caused by the bullet or gases.

Clothing collection is also vital to forensic investigation. Garments should be placed in paper bags, not thrown onto the floor, tossed into a stairwell, left in the ambulance, or crammed into a biohazard bag. If time does not permit proper packaging, clothing should be preserved by hanging it (or placing it) over paper (or on a clean white sheet) to facilitate air-drying. Any clothing that is still wet should be noted as such, packaged, and immediately turned over to law enforcement personnel so that the technical investigative services can complete the drying process. New (nonrecycled) paper bags should be readily available on the ambulance and in the emergency department. Do not place clothing into a plastic biohazard bag. When enclosed in plastic, biological specimens will undergo chemical changes, degrading their value as forensic specimens. Biological evidence must be preserved in a receptacle that permits airflow in and out of the container. However, if clothing is sufficiently saturated with blood or bodily fluids that it cannot be contained in double- or triple-layered paper bags, the entire paper-packaged and sealed garment should be placed in a plastic biohazard bag and left open to air.

Next, in cases involving firearm shootings, first responders should observe and document the characteristics of wounds. Rather than classifying the wound as an entrance or exit wound, first responders should describe in detail the characteristics that would support such a classification. Most important, documentation should consist of location (including measurement from obvious landmarks), the presence or absence of an abrasion ring, the direction of the weighted border of the abrasion ring, and the presence of stippling or soot (Fig. 11-1). Unless absolutely necessary, the first responder should not clean the wound or disturb the patient’s or victim’s hands. Sophisticated tests may be required to determine whether or not gunshot residue (GSR) is present on the victim’s or patient’s hands. Paper bags should be placed over the hands and taped at the wrist to prevent any loss of the substance.

Arguments have been made that the hands may be needed for vascular access. However, current standards in trauma care call for large-bore peripheral intravenous lines (IVs) to be placed in the antecubital fossa. If, in the rare case vascular access can only be obtained in the hand or wrist, cleansing beyond the immediate venipuncture site should be avoided.

After the victim arrives at the emergency department, hospital staff should remove bandages covering any wounds and preserve them so that they can be examined for the presence of gunshot residue. Any bullets or bullet fragments should be preserved by picking them up with either a gloved hand or rubber-tipped (shod) forceps and placing them in a small envelope or padded specimen container for transfer to the proper law enforcement authorities (Evans & Stagner, 2003).

First responders encounter several different types of sharp force trauma from which two distinctive categories emerge: incised wounds, including cuts and slashes, or punctures such as stab wounds.

All sharp force trauma produces smooth edges without bridging of tissue. Abraded or contused margins are also usually absent, except when the instrument used is particularly dull or serrated. Incised wounds are classified as such because their length exceeds their depth. Conversely, stab or puncture wounds have a depth that exceeds their surface length. Incised wounds usually give little information about the offending object itself. However, the observation of tailing, which is created when the angle at which the sharp object loses contact with the tissue becomes increasingly shallow, demonstrates the direction of the offending forces (Fig. 11-2). The main objective in preserving evidence of sharp force trauma is accurate documentation of the characteristics of the wounds, as well as their locations on the victim’s body.

There are four primary types of blunt force trauma: abrasions, lacerations, contusions, and fractures. Frequently, a determination can be made from these injuries as to the circumstances that surrounded and caused the injury.