EXPERIENCES OF MOBILE EMERGENCY CARE SERVICE PROFESSIONALS IN FORENSIC SITUATIONSABSTRACT
Objective: To learn about the experiences of the Mobile Emergency Care Service team in crime situations.
Method: Descriptive study, with a qualitative approach, carried out from January to February 2022 with 30 professionals who worked in the Mobile Emergency Care Service. Data obtained from the interviews were processed by the software Interface de R Pour les Analyses Multidimensionnelles de Textes et de Questionnaires, version 0.7 alpha2, and analyzed through Descending Hierarchical Classification.
Results: Five categories emerged from the professionals' experiences: the types of forensic incidents that the mobile emergency service experiences, mostly Gunshot Wounds and Stab Wounds, physical assaults, and domestic violence; the importance of police support at the scene to isolate the area and guide healthcare professionals to act in order to preserve evidence; suspected aggressors in the position of injured, attended to by professionals, and in a position of threat and risk to the professionals; recognitions and attitudes of the SAMU team regarding the preservation of forensic evidence; and the alteration of the body, mainly due to changes in position made by family members and other people present at the scene.
Conclusion: The professionals' experience was shown to be permeated by gaps in knowledge regarding the preservation of forensic evidence at crime scenes, by the inadequate handling of the body in emergency situations, and by contamination of the scene during medical care. The professionals pointed to the need for training and qualification in the area.
DESCRIPTORS:
Emergency Medical Services; Expert Evidence; Crime; Violence; Nursing
RESUMO
Objetivo: conhecer a vivência da equipe do Serviço de Atendimento Móvel de Urgência em situações de crime.
Método: estudo descritivo, com abordagem qualitativa, realizado no período de janeiro a fevereiro de 2022 com 30 profissionais que atuavam no Serviço de Atendimento Móvel de Urgência. Os dados obtidos a partir das entrevistas foram processados pelo Software Interface de R Pourles Analyses Multidimensionnelles de Textes et de Questionnaires versão 0.7 alpha2 e analisados pela Classificação Hierárquica Descendente.
Resultados: obteve-se cinco classes a partir da vivência dos profissionais: os tipos de ocorrência de cunho forense que o serviço móvel de urgência vivencia, em sua maioria, por Ferimentos por Arma de Fogo e Ferimentos por Arma Branca, agressões físicas e violência doméstica; importância do apoio policial na cena, para isolar a área e orientar os profissionais de saúde para agirem em prol da preservação de vestígios; suspeito de ser agressor na posição de ferido, atendido pelos profissionais e na posição de ameaça e risco para os profissionais; reconhecimentos e atitudes da equipe do SAMU acerca da preservação de vestígios forenses; e a descaracterização do corpo, ocorrida principalmente pela mudança de posição realizada pela família e demais pessoas presentes no local.
Conclusão: a vivência dos profissionais se mostrou permeada por lacunas de conhecimento acerca da preservação dos vestígios forenses em cenas de crime, pelo manuseio inadequado do corpo em situações de urgência e contaminação do local durante os atendimentos. Os profissionais apontaram para a necessidade de treinamentos e capacitações na área.
DESCRITORES:
Serviços Médicos de Emergência; Prova Pericial; Crime; Violência; Enfermagem
RESUMEN
Objetivo: Conocer las experiencias del equipo del Servicio de Atención Móvil de Urgencias en situaciones de crimen.
Método: Estudio descriptivo, con enfoque cualitativo, realizado de enero a febrero 2022 con 30 profesionales que trabajaron en el Servicio de Atención Móvil de Urgencias. Los datos obtenidos de las entrevistas fueron procesados por el software Interface de R Pourles Analyses Multidimensionnelles de Textes et de Questionnaires versión 0.7 alpha2 y analizados mediante Clasificación Jerárquica Descendente.
Resultados: De las vivencias de los profesionales surgieron cinco categorías: los tipos de incidentes forenses que vive el servicio móvil de urgencias, mayoritariamente heridas por arma de fuego y arma blanca, agresiones físicas y violencia doméstica; la importancia del apoyo policial en el lugar de los hechos para aislar la zona y orientar a los profesionales sanitarios en la actuación para preservar la evidencia; los presuntos agresores en posición de heridos, atendidos por los profesionales, y en posición de amenaza y riesgo para los profesionales; los reconocimientos y actitudes del equipo SAMU respecto a la preservación de la evidencia forense; y la alteración del cuerpo, principalmente por cambios de posición realizados por familiares y otras personas presentes en el lugar de los hechos.
Conclusión: La experiencia de los profesionales se mostró permeada por lagunas en el conocimiento sobre la preservación de la evidencia forense en las escenas del crimen, por el manejo inadecuado del cuerpo en situaciones de emergencia y por la contaminación de la escena durante la atención médica. Los profesionales destacaron la necesidad de capacitación y fortalecimiento de capacidades en esta área.
DESCRIPTORES:
Servicios médicos de urgencia; Testimonio de experto; Crimen; Violencia; Enfermería
INTRODUCTION
The significant increase in violence rates has also led to an increase in healthcare demands. Aiming at minimizing mortality rates, long-term complications, and length of hospital stay, and promoting immediate care, the Mobile Emergency Care Service (SAMU) is called in situations requiring assistance outside of a hospital setting1. When the victim is alive, SAMU provides initial care at the scene and transfers them to the nearest hospital. In cases of death, the police isolate the area until the arrival of the forensic team2.
The crime scene consists of the entire area where the criminal act occurred and is the environment where evidence related to the case can be found. The evidence contains vital information that contributes to the crime investigation and solution. Therefore, it is important that the professionals who make the first contact at the scene collaborate in preserving the evidence until the arrival of the experts, because, according to the basic principles of Edmond Locard, a pioneer in Forensic Science, every contact leaves a mark3.
It is understood that SAMU is one of the entry points for victims of violence and has the first contact with the patient. In this context, it is important to highlight that the nurse is a significant member of the multidisciplinary team working in the SAMU and their role is essential in recognizing, intervening in, and evaluating cases of violence, as well as being relevant for preserving and documenting evidence. Conversely, emergency service professionals have knowledge gaps regarding the management of patients in forensic situations, lack correct and satisfactory practices, and, during the provision of care, significantly alter the evidence4.
Given this scenario, understanding the experiences of the professionals who make up the SAMU team is important, as they frequently witness crime situations. Although SAMU plays an essential role in pre-hospital care, there is still a scarcity of systematic studies on the procedures adopted by professionals regarding the preservation of evidence, which highlights a scientific gap and limits the development of evidence-based guidelines. Therefore, this research is justified by the need to fill this gap, producing knowledge that supports future investigations and assists in the development of specific training programs. Thus, the study has the potential to qualify healthcare practices and contribute to the enhancement of actions related to the preservation of evidence in the context of pre-hospital care.
Given the above, the guiding question of the research was: what is the experience of the Mobile Emergency Care Service team in preserving forensic evidence when acting in crime situations? Consequently, the objective of the study was to get to know the experience of the Mobile Emergency Care Service team in forensic situations.
METHOD
This is a descriptive study with a qualitative approach, conducted between January and February 2022. The research was conducted in accordance with the guidelines of the Consolidated Criteria for Reporting Qualitative Research (COREQ)5. The participants in the research were professionals who worked in the SAMU and who were selected from the network of contacts of the professors of the Nursing Interdisciplinary Research Group (GInterPE) of the Instituto Federal de Educação, Ciência e Tecnologia de Pernambuco. The inclusion criteria chosen were: not only performing administrative or managerial activities, but also providing support during incidents, and having at least one year of experience on the team. Professionals who were on medical leave or vacation during the data collection phase were excluded.
The study's sampling was characterized as non-probabilistic through the snowball technique, where the contacted Pre-hospital Care faculty provided indications of other professionals who fit the sample profile6. One hundred invitations were sent out, and 30 professionals responded and participated in the study.
Data collection was mediated by the principal investigator and took place via telephone interview using the multiplatform communication application WhatsApp and the electronic form of Google Forms. Participants who met the eligibility criteria were invited via WhatsApp. Before data collection began, the study's objective and procedures were explained. After accepting the invitation, the interview was scheduled for the day and time suggested by the participants. On the scheduled day, the access link to Google Forms was sent via WhatsApp, containing the Free and Informed Consent Form (FICF), in which the participant checked the option "I agree to participate in the research" for formal registration.
Sociodemographic data were collected via a form with 13 questions covering: age, sex, city, state of residence, professional category and qualification, length of experience working in the Basic Support Unit (USB) or Advanced Support Unit (USA), the unit they were working in at the time of data collection, the length of experience in SAMU, and the length of professional experience, participation in and teaching of courses on the preservation of forensic evidence.
After answering the questionnaire, the telephone interview would begin. Each participant was asked to position themselves in a private and quiet location. After signaling that they were settled, the audio recording of the interview was announced, and subsequently, the guiding question was asked: "Talk about situations you experienced where you responded to an emergency call to SAMU and it turned out to be a crime scene." The interviews lasted approximately 40 minutes and, after completion, were transcribed in full and compiled into the study text corpus.
To protect the identity and guarantee the anonymity of the participants, the letter "P" for professional was used in the transcripts of the speeches, with the addition of a cardinal number that corresponded to the chronological order in which the interviews were carried out (P1, P2...).
Data obtained from the interviews were processed by the software Interface de R Pour les Analyses Multidimensionnelles de Textes et de Questionnaires (IraMuTeQ), version 0.7 alpha2, and analyzed through Descending Hierarchical Classification. IraMuTeq allows you to obtain text segments that are distributed into similar lexical classes according to the vocabulary used, as well as verify the degree of similarity between the linguistic forms of the corpus and lexical classes. From then on, it allows the creation of the dendrogram, which graphically represents the different sets of classes and their similar words that share a common concept7.
The study was conducted in accordance with the guidelines of Resolution No. 466/2012 of the National Health Council and was approved by the Ethics Committee of the Educational Authority of Belo Jardim-PE.
RESULTS
Thirty professionals participated in the study, 15 male and 15 female, ranging in age from 25 to 40 years, with a mean age of 32.5 years. The interviewees included a variety of professional categories: nurses (10), nursing technicians (9), drivers (8) and doctors (3). The participants worked in the states of Pernambuco (22), Ceará (6), Piauí (1) and São Paulo (1). It was observed that, among the 30 participants in the study, 16 had more than six years of professional experience and had been working in the SAMU for more than four years. Regarding participation in any course on the preservation of forensic evidence in crime situations focused on pre-hospital care, only nine participated, and at the same time, none of them taught a course on the subject.
The Descending Hierarchical Classification highlighted the grouping of corpus into five classes, detailed in Figure 1. It should be noted that the text corpus became compatible and feasible to be analyzed by IraMuTeQ, as it contained 3,922 words, in 36,881 occurrences and 1,014 textual segments, with a utilization rate of 73.46% of all processed content, meaning that 745 segments were used in the analysis.
Dendrogram about the experiences of SAMU professionals in crime situations. Pesqueira, PE, Brazil, 2022.
Class 1. Types of forensic incidents experienced by the SAMU team
Class 1 contained 183 of the 745 text segments, which corresponded to 24.56% of the content that was successfully analyzed. The class showed a statistical significance of less than 0.0001 for the first 22 words and a value of 0.0007 for the last word. With the words "incident (ocorrência)", "bladed weapon (arma branca)" and "firearm (arma de fogo)" being highlighted in the class, the professionals' accounts reveal the types of incidents that the SAMU team commonly experiences, which consist of crimes of physical assault, homicide, and suicide. It was mentioned that the most commonly used instruments to commit the crimes were firearms and bladed weapons, which, in some situations, were still present at the scene and ended up being handled by the SAMU team or the police.
I've already dealt with many cases of physical assault, such as stabbings, beatings, gunshot wounds, bladed weapons wounds, attempted murder, and attempted suicide. (P07)
We are frequently called upon to assist victims of firearm-related injuries. Recently, we responded to a call where the criminal was still at the scene, stabbed, and kept begging us not to let him die. (P01)
I also went to a scene where there had been an exchange of fire; I believe the police officer had two firearms, and they were lying on the ground. As soon as we arrived at the scene, a member of our team started collecting the weapons. (P05)
He had a gunshot wound to the head, and it went unnoticed by her; it ceased to be a physical assault and became murder." (P14)
The professionals' statements revealed an increase in demand for care for psychiatric patients who are victims of abuse and neglect. In these situations, the victims were found debilitated and in precarious living conditions.
Other types of cases where we have a high demand for services are domestic violence and psychiatric patients; these patients are usually very debilitated because of the abuse. (P04)
We've received many reports of crimes involving psychiatric patients; the city is breaking records. In these situations, we see the contempt that these people experience. We had instances of finding the person rotten. (P25)
Class 2: Police support at the scene to preserve forensic evidence.
Class 2 contained 152 of the 745 text segments, which corresponded to 20.4% of the content that was successfully analyzed. The class showed a statistical significance of less than 0.0001 for the first 22 words and a value of 0.0007 for the last word. With the words "scene (cena)", "crime (crime)", "preserve (preserver)", and "isolate (isolar)" being highlighted in the class, the importance of police officers in isolating the area was observed, which culminates in preserving the crime scene.
When we go to the location, we arrive at the scene and it is usually cordoned off by the police themselves. (P03)
We arrive there, the police are present, the area is cordoned off, and if the patient is alive, we carry out all the necessary procedures. (P11)
Professionals stated that, in addition to isolation, police support is important to help preserve the scene during the service provided by SAMU, because, in the attempt to provide care to the victim, alterations are made to the environment and the evidence present is modified. In this regard, the police indicate to the team the locations where they should be touched and/or stepped on, in order to guarantee quality service without altering the crime scene.
My team and I were careful with the evidence at the scene, as the police instructed us not to step there or touch here. (P30)
If there are projectiles on the ground, the police will cordon off the area and mark what is there so that we are careful not to step on or kick them. (P07)
The pre-hospital care courses I took never taught how to preserve evidence; it's always the police who provide information and go along with the call.” (P09)
Class 3: Suspected aggressor: victim treated and threats made against staff.
Class 3 contained 112 of the 745 text segments, which corresponded to 15.03% of the content that was successfully analyzed. The class showed a chi-square statistical significance of less than 0.0001 for the first 25 words and a value of 0.0017 for the last word. Using the key words "assistance (atendimento)," "bandit (bandido)," "police car (viatura)," "provide (prestar)," and "rescue (socorrer)," the group points out that, within the broad profile of victims assisted, those involving suspects at the crime scene stood out. They also emphasized that first aid is administered equally and that the goal of saving the victim's life is independent of any suspicion of criminal activity.
When we arrived at the scene, we believed he was the bandit, but we didn't make any distinction, we treated him and took him to the hospital". (P05)
We are left with that sadness and fear, not knowing if we will be able to help or arrive in time to provide assistance and fulfill my role alongside the team to save that life, regardless of whether he is a criminal, rich, or poor. (P08)
The procedures during the service are provided in the same way, regardless of the victim's history, whether they have a criminal record, whether they are a criminal or not; we don't make any distinction at the time. (P19)
The word "bandit" was present in the aforementioned context of attending to the suspect, as he was injured and subsequently treated by SAMU. However, the same word also appeared in statements that described the suspect's presence as a threat and occupational risk to SAMU professionals. The professionals' experience is permeated by risky situations during the care of crime victims, in which they have often been forced to stop procedures to witness criminals execute the victim. Another problem highlighted by the professionals was their fear that the criminals might still be at the crime scene and possibly increase the risk of aggression during incidents.
There have been situations where criminals stopped an ambulance and finished executing the victim inside. (P29)
We need to be sure that the assailant is not on the scene and that, during the intervention, he does not attempt to complete the crime and may assault the team. (P04)
Class 4: (Re)cognitions and attitudes of the SAMU team regarding the preservation of forensic evidence
Class 4 contained 142 of the 745 text segments, which corresponded to 19.06% of the content that was successfully analyzed. The class showed a chi-square statistical significance of less than 0.0001 for the first 29 words and a value of 0.0003 for the last word. In this class, it was observed during the professionals' discourse that there is recognition of certain procedures related to the preservation of evidence found at the scene, and that the professionals acknowledge awareness of the fact that evidence can be damaged during their work.
I saw team members performing procedures that, in a way, destroyed the evidence that was there, such as: handling objects, changing the victim's position, and stepping on already isolated footprints. (P06)
Unfortunately, the victim was still alive and in agony, but we performed the necessary procedures. In this type of scene, whether we like it or not, we break the crime scene because there will be our footprints, traces that someone touched the patient; I know we've destroyed many scenes. (P10)
It was also revealed that, at the moment they are working at the scene, professionals are potentially immersed in the possibility of saving lives and, therefore, neglect actions that could preserve evidence.
When the victim is still alive, we don't remember to secure the scene; we've already put the patient on a stretcher, placed them inside the ambulance, and started performing the necessary procedures. The forensic team will then reconstruct the crime, questioning the public and asking us about it. What matters there is the patient's life. (P23)
We left the base with the intention of preventing the patient from dying. (P18)
But when the patient is still alive, we don't pay much attention to observing details; the focus is only on the patient. We have no idea what is present as evidence and goes unnoticed because we don't have that perspective. (P21)
Conversely, the professionals' account indicated that, upon confirming the death, they become more careful about preserving evidence, paying attention to where they step and not altering the position of the corpse; however, some cover the body with a sheet.
When we arrive and the patient is deceased, we take great care not to alter the scene, because afterwards the forensic team comes to look at the smell, the victim's movements, if there are bullets on the ground, we take great care not to step on or kick them. We cover the body with a sheet and try to observe as much as possible the injuries present on it, but we do not change the body's position, we do not manipulate the body in any way. (P23)
Because we know you can't move anything, for example: if you find the body in a certain position, don't move it. I've already responded to a call about a hanging; this time we went with the fire department. When we arrived at the scene, we noticed that the patient, in addition to having hanged himself, had cut his wrists. The firefighters freed him from the ropes and had already called the coroner's office. (P24)
When death is confirmed, for example, do not touch the victim's body at the scene, do not remove anything from the location, do not change the body's position, because these are important things in forensic work, that is, they are empirical information passed on by the police themselves in some cases; I did not have any professional training in relation to this. (P08)
Class 5: Disfigurement of the body by the family and other people present at the scene.
Class 5 contained 156 of the 745 text segments, which corresponded to 20.94% of the content that was successfully analyzed. The class showed a chi-square statistical significance of less than 0.0001 in all the words. The statements from this group indicate that, in addition to professionals altering the body of the deceased victim, family members and bystanders present at the scene also commit this error. Often, due to the emotional vulnerability of the moment, they want to help, or they intentionally alter the scene.
I once went to a really rough neighborhood, the boy had been shot in the head with a 12-gauge shotgun, he was about 16 years old, and when we got there, his mother was hugging him in the middle of the street, which completely changed the context of the scene. (P24)
I was the first to arrive at the scene and describe the condition of the body, because the boy's mother suspected that her daughter-in-law had killed her son and that it hadn't been due to much drug use; that the daughter-in-law had put something in the water, thus making the death intentional. (P23)
To give you an idea, we went to an incident where the family had washed the floor to remove the blood, we arrived and the patient was all wet (P16)
DISCUSSION
In the experience of the professionals on the SAMU team, occurrences of physical assault with victims of gunshot wounds (GSW) and stab wounds (SW) were evident. This finding is relevant because the precautions for preserving evidence in cases of injuries from such weapons culminate in necessary care in handling the weapons and in procedures that can be performed to contribute to a greater chance of viability of forensic evidence, such as not inserting intravenous access into the hand of the potential perpetrator and wrapping the hands of the potential perpetrator with a paper bag to facilitate the collection of forensic material8. In this context, evidence suggests that participants recognize limitations in their technical skills to properly collect and preserve evidence when assisting victims of violence9. In this context, it is clear that professionals need continuing education in their field to ensure that the team is trained to prioritize care that is consistent with the preservation of evidence when assisting victims of assault9.
The findings of this study indicate that the experience of SAMU professionals is marked by the importance of the police, who act in isolating the area and guiding health professionals on how to proceed so as not to compromise forensic evidence at the scene. This fact aligns with the content of the Advanced Life Support Protocol from the Ministry of Health, which advocates the need for joint action with the Military Police in situations that may involve crimes10. Considering the circumstances presented, the relevance of intersectoral training and action between health and public safety is highlighted, so that it is possible to integrate and jointly train health professionals working in pre-hospital care and police officers.
SAMU professionals stated that, during incidents involving crime, it was common for them to attend to people suspected of being aggressors and, given the possible presence of the aggressor at the scene, they were afraid that they too would be attacked. In light of the above, it is essential to report incidents to ensure that professionals receive adequate protection while providing care in life-threatening contexts. The fear associated with working in contexts related to criminal occurrences generates insecurity and produces professional burnout, compromising work organization and, consequently, these workers’ health. Continuous exposure to violent situations highlights the need to incorporate nurses with specialized training in forensic nursing into these work contexts11.
Forensic nursing is emerging as a specialty that integrates scientific knowledge into the investigative process, especially in the context of practices related to crime. For the proper performance of their duties, it is essential that the professional has a solid technical and scientific background, to ensure the quality and effectiveness of the actions carried out12. Forensic Nursing, regulated by COFEN Resolution No. 556/2017, establishes the professional's competencies in situations of violence, trauma, sexual abuse, substance use, and psychiatric disorders, encompassing work in expert assessments, consultations, mass disasters, and hospital settings13. Despite the recognition conferred by COFEN, forensic nursing still lacks more robust investments in the educational and institutional spheres. The limited knowledge of nurses regarding forensic demands highlights the need to establish specific guidelines for this area11.
Regarding the experience of SAMU professionals, one can observe the existing recognition of the need to preserve forensic evidence. The professionals also stressed that the team's objective is to prioritize the victims’ lives, not the preservation of the crime scene. This finding diverges from the study that emphasizes that the collection of forensic evidence, along with its proper documentation, is a fundamental step for effective criminal prosecution and for safeguarding the victims’ rights9. From this perspective, the study conducted in Amazonas addresses the fact that a nurse's failure to recognize forensic situations can ultimately compromise the investigation of the case and the evidence found4. In this context, it becomes necessary to train professionals working in the SAMU, to reduce the chances of evidence contamination and to ensure its proper preservation.
The results of this study indicate the victim's body disfigurement by family members and bystanders present at the crime scene. Therefore, it is crucial to emphasize, to SAMU professionals, the need to document any perceived changes caused by third parties. Such documentation can support professionals and provide evidence to experts investigating the case.
The limitations of this study include the fact that data was collected virtually. However, this strategy proved to be advantageous, allowing the participation of professionals from different states in the sample, and these factors did not interfere with the ethical and scientific quality of the study.
This study presents results that may be of interest to professionals in the health and public safety fields who seek to understand the experiences of the SAMU team in crime situations. Moreover, they can contribute to future studies on the conduct adopted by the team in crime situations, since this is a topic that has been little researched in Brazil. In addition, their findings can support continuing education initiatives in accordance with the practices experienced by SAMU professionals.
CONCLUSION
The experience of SAMU professionals when working in crime situations was marked by incidents involving victims of physical violence, in which police support at the scene was relevant for isolating the area and obtaining guidance aimed at preserving the scene. Furthermore, in such instances of violence, the perpetrator was sometimes both the injured person being treated and a threat to the safety of the SAMU professionals while they were assisting the victim of the assault. Recognition regarding the preservation of forensic evidence was identified, which occurs when death is confirmed, since, in case of life presence, the priority is to prevent death, so the preservation of evidence is not considered. The professionals' experience was further marked by alterations made to the scene, as well as the disfigurement of the body, carried out by family members of the victim and other people present at the scene.
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NOTES
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TRANSLATED BY
Denise Costa Rodrigues
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APPROVAL OF ETHICS COMMITTEE IN RESEARCH
Approved by the Research Ethics Committee of the Educational Authority of Belo Jardim-PE, opinion no. 4,572,383/2021, Certificate of Presentation for Ethical Review 40412420.8.0000.5189.
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DATA AVAILABILITY
All the data supporting the results of this study were published in the article itself
Edited by
All the data supporting the results of this study were published in the article itself
