The medical response to a mass casualty further complicates the hectic environment that follows a terrorist event. In addition to providing treatment, medical professionals may discover items or persons of interest to the pending investigation and should be aware of how to handle these situations appropriately. Examples of case law are provided to illustrate how practitioners’ actions could help or hinder prosecution. The traditional forensic role of dental professionals is identifying victims through dental records. In this article, the dental professional is considered a member of a disaster response team, and the differences in responsibilities are highlighted.
The medical response to a mass casualty incident will always be complicated. Providing quality care while understaffed, undersupplied, and possibly operating in an unfamiliar or inhospitable environment is not an easy task. The situation is further complicated when the mass casualty incident is the result of a terrorist act, which forces medical response to occur in conjunction with a federal criminal investigation . Although medical professionals and students commonly receive training on the recognition of terrorist events and appropriate interventions, legal aspects and evidence collection are rarely addressed in depth.
The purpose of the first portion of this article is to provide an overview of legal precedents and forensic techniques that could be applied to a terrorist investigation, with a discussion of specific current and emerging technologies that could be used in the investigation of a chemical, biologic, nuclear/radiologic, or explosive event. The authors hope that this information will assist medical responders to recognize potential physical evidence and persons of interest to become confident that intervention does not necessarily conflict with an investigation . The second portion of this article describes forensic techniques and advances that apply to investigations of the deceased to provide a contrast in the goals and responsibilities of a dental emergency responder and a forensic odontologist, summarized in Tables 1 and 2 .
| Goals | Dental emergency responder | Forensic odontologist |
|---|---|---|
| Personal safety | × | × |
| Recognize possible evidence in a CBRNE event | × | × |
| Establish victim identity through personal belongings | × | × |
| Document chain of custody for all potential evidence | × | × |
| Provide total body care to victims | × | |
| Ensure patient well-being above all other priorities | × | |
| Establish identity through maxillofacial structures | × | |
| Ensure long term evidence fidelity | × |
| Observations of interest | Dental emergency responder | Forensic odontologist |
|---|---|---|
| Suspected dispersion device on patient body | × | |
| Blue prints or architectural drawings on patient | × | |
| Potential explosive device on body of patient | × | |
| Stage of illness relative to population | × | |
| Emotional state of patient | × | |
| Medical records | × | |
| Labeled dentures/tagged molars | × | |
| Database | × | |
| Pathologies | × |
Dental emergency responder
In light of a nation-wide discussion regarding the role of the oral health community in disaster response , modifications to the Dental Practice Act were proposed, ratified, and took effect January 1, 2006 . This amendment defined the dental emergency responder as a position within the scope of practice of dentistry in Illinois. Although debate on the specific roles and recommended training continues, in the framework of Illinois, the dental emergency responder is most commonly used to provide total body patient care in one of four roles: (1) care for the worried well (those who are not part of an event but are seeking advice from a medical professional to ensure the safety of themselves and their family); (2) care for the walking wounded (those in need of minimal medical intervention after an event); (3) triage care (after receiving additional training as part of formalized response team membership); and (4) participants in mass dispensation and mass inoculation response . None of these roles are exclusively filled by dental emergency responders; instead, the dental emergency responder becomes part of a multidisciplinary team dedicated to ensuring the well-being of the community during a terrorist event or public health emergency. Although the examples provided herein are offered with the dental emergency responder (or an equivalent role in another state) in mind, the scenarios could also apply to any medical responder fulfilling the roles defined above.
Pertinent precedents
In any investigation, the bulk of physical evidence is collected by law enforcement professionals or specially trained military units (eg, a National Guard Civilian Support Team). Detailed analysis is performed in a laboratory setting that is determined by the nature of the incident. Nevertheless, there is a chance that medical responders may discover evidence that will be pertinent to an investigation. Specific items that may be of interest to investigators are covered in detail under each scenario. This section provides an overview of case law in Illinois directly related to the act of search and seizure.
Private seizures
The standard for law enforcement officers to perform a search is probable cause; officers receive training specifically related to proper search and seizure protocols and are aware that illegally seized evidence will be excluded from the prosecutor’s case in chief . This standard does not apply to medical professionals as private citizens. It is common practice to perform a search of a patient’s personal belongings if he or she is unconscious or exhibiting an altered mental status to establish identity, medication usage, or the presence of allergies. Should a search of this nature yield evidence, the items may be turned over to law enforcement officials and used by the state for its case in chief, despite the lack of probable cause .
Status as a private citizen and medical professional does not allow an individual to perform a search of a patient at the behest of a law enforcement officer if this search would not have been performed otherwise . For example, medical personnel providing care to “worried well” victims that have not been exposed to an agent and are not exhibiting signs of critical injury that would warrant removal of clothing or a search of personal possessions cannot perform a search of a patient at the request of the police. Any evidence obtained through such a scenario in which a law officer encourages a private citizen to perform a search when probable cause is not present will likely be disallowed at trial.
Chain of custody
Once an item of evidence has been seized or is located on a patient, care must be taken to record the whereabouts and access to the item in writing; the more susceptible the item is to contamination or tampering, the more closely it should be monitored . For example, an article of clothing with a distinctive logo would be more readily recognizable than a small piece of shrapnel removed from a wound. Medical records can serve as a chain of custody between providers throughout care to establish the time, location, and status for objects of interest that are not removed from the patient on scene but hours or days later . Items that are discovered and collected in the field should be labeled (name of patient, name of practitioner, date, time) and preferably stored in an area with limited public access until they are collected and signed for by a law enforcement officer; inconsistencies in delivery and receipt conditions could lead to the suppression of evidence .
Health Information Protection and Accountability Act
The Health Information Protection and Accountability Act (HIPAA) was enacted originally in 1996 , with modifications in 2000 and 2002 to ensure the confidentiality of patient information among covered entities, such as health care providers, insurance companies, and health care clearinghouses . During a disaster, the standards of HIPAA still apply; providers should continue to be mindful of protected health information, especially in light of the limited privacy inherent in field response and possible media presence. All medical responders would be considered covered entities, including volunteers, but there are several notable exceptions to accountability and disclosure pertinent to a terrorist attack. Disclosures to law enforcement officials involved in the investigation, to public health authorities involved in surveillance or efforts to avert a serious threat to health and safety, or to protect national security do not require written authorization from an individual patient .
Pertinent precedents
In any investigation, the bulk of physical evidence is collected by law enforcement professionals or specially trained military units (eg, a National Guard Civilian Support Team). Detailed analysis is performed in a laboratory setting that is determined by the nature of the incident. Nevertheless, there is a chance that medical responders may discover evidence that will be pertinent to an investigation. Specific items that may be of interest to investigators are covered in detail under each scenario. This section provides an overview of case law in Illinois directly related to the act of search and seizure.
Private seizures
The standard for law enforcement officers to perform a search is probable cause; officers receive training specifically related to proper search and seizure protocols and are aware that illegally seized evidence will be excluded from the prosecutor’s case in chief . This standard does not apply to medical professionals as private citizens. It is common practice to perform a search of a patient’s personal belongings if he or she is unconscious or exhibiting an altered mental status to establish identity, medication usage, or the presence of allergies. Should a search of this nature yield evidence, the items may be turned over to law enforcement officials and used by the state for its case in chief, despite the lack of probable cause .
Status as a private citizen and medical professional does not allow an individual to perform a search of a patient at the behest of a law enforcement officer if this search would not have been performed otherwise . For example, medical personnel providing care to “worried well” victims that have not been exposed to an agent and are not exhibiting signs of critical injury that would warrant removal of clothing or a search of personal possessions cannot perform a search of a patient at the request of the police. Any evidence obtained through such a scenario in which a law officer encourages a private citizen to perform a search when probable cause is not present will likely be disallowed at trial.
Chain of custody
Once an item of evidence has been seized or is located on a patient, care must be taken to record the whereabouts and access to the item in writing; the more susceptible the item is to contamination or tampering, the more closely it should be monitored . For example, an article of clothing with a distinctive logo would be more readily recognizable than a small piece of shrapnel removed from a wound. Medical records can serve as a chain of custody between providers throughout care to establish the time, location, and status for objects of interest that are not removed from the patient on scene but hours or days later . Items that are discovered and collected in the field should be labeled (name of patient, name of practitioner, date, time) and preferably stored in an area with limited public access until they are collected and signed for by a law enforcement officer; inconsistencies in delivery and receipt conditions could lead to the suppression of evidence .
Health Information Protection and Accountability Act
The Health Information Protection and Accountability Act (HIPAA) was enacted originally in 1996 , with modifications in 2000 and 2002 to ensure the confidentiality of patient information among covered entities, such as health care providers, insurance companies, and health care clearinghouses . During a disaster, the standards of HIPAA still apply; providers should continue to be mindful of protected health information, especially in light of the limited privacy inherent in field response and possible media presence. All medical responders would be considered covered entities, including volunteers, but there are several notable exceptions to accountability and disclosure pertinent to a terrorist attack. Disclosures to law enforcement officials involved in the investigation, to public health authorities involved in surveillance or efforts to avert a serious threat to health and safety, or to protect national security do not require written authorization from an individual patient .
Evidence collection and preservation
Overall, medical professionals should attempt to the best of their ability to store evidence in a manner that will facilitate future analysis. First, one should avoid cutting through holes in patient clothing that were created before their arrival for care. Maintaining holes intact will help forensic specialists recreate the scene, corroborate the size and force of an object that penetrated the victim, and give guidance for tests to determine the presence or absence of trace evidence. Cutting through the hole causes permanent distortion to the fabric (especially in the case of knitted fabrics) and can contaminate the surface of the fabric with metal or other debris from the scissors that might not be distinguishable from pertinent evidence. Second, one should avoid sealing items while they are still damp. Wet items may grow mold or mildew that will contaminate the evidence and make further analysis more difficult. If the possibility exists, the item should be allowed to dry before sealing the container. Third, one should avoid the use of plastic bags when possible. Plastic can cause the degradation of biologic and chemical evidence and can lead to a moist environment inside the bag . All evidence, regardless of nature or origin, should be handled with gloved hands to protect it from trace damage (such as fingerprints) and to protect medical professionals from exposure to toxic chemicals or other agents . Although these measures may sound tedious, they have been practiced by sexual assault nurse examiners in hospital settings for over 20 years .
Evidence collection summary
Evidence collection does not supersede the responsibility of a medical responder to provide medical care. A medical responder should never hold evidence collection over preservation of life and limb; however, proper collection and storage of evidence discovered on the scene of a mass casualty incident will assist police operations in terms of the viability of detailed analysis and admissibility. By maintaining records of possible evidence, storing evidence in a manner least likely to result in contamination, and submitting evidence to law enforcement officers as expeditiously as possible, medical professionals can do a great service to the investigation of and the victims of a terrorist event.
Forensic techniques and evidence sources in specific scenarios
Intentional man-made events are generally broken down into five major categories: chemical, biologic, nuclear/radiologic, and explosive (CBRNE). Each of these categories can be divided further into specific agents or patient characteristics. To best serve medical responders, for each major category the authors provide a description of standard analysis, an overview of emerging detection and forensic techniques, possible scenarios in which medical professionals may discover evidence, and measures to protect the integrity of the evidence while ensuring personal safety.
Chemical scenario
The specific forensic techniques use in the investigation of a chemical event will vary based on the nature of the agent; however, certain facts will require resolution for the state to build a sufficient case for the prosecution of suspects. The verified agent identity, proof of victim exposure to agents, and the ability of suspects to synthesize and disseminate the agent will be of particular interest to those involved in prosecution.
Preliminary agent identification will likely come as victims present with symptoms associated with toxic exposure (eg, dyspnea, rhinorhea, ocular pain, dizziness, vomiting) . Intelligence related to possible terrorist threats in the area might also support the preliminary agent identification. The support of hazardous material (HAZMAT) teams will provide more information; handheld detectors and manual testing will confirm the presence of an agent class (eg, nerve agent versus sulfur mustard). Improvements in the reliability and range of detectable agents are being explored with the use of different forms of spectrometry (such as Fourier transform infrared spectroscopy), photometry, and chip-based sensors based on carbon nanotubes .
As part of the detailed analysis, scientists will also note the impurities and precursors found in the sample. Few chemical reactions provide 100% yield in every step; in the Tokyo subway attack, the liquid sampled on the train was only 30% sarin. The other 70% of the substance provided clues as to the synthetic protocol used, allowing law enforcement officials to narrow the search to facilities/business entities that had purchased these chemicals recently . The sophistication of the synthetic model and the purity of the product will also indicate the type of facility and personnel that would likely be associated with the agent production. Examinations of organic and aqueous extractions of samples using instrumentation routinely used in forensic investigations, such as gas chromatography/mass spectrometry and liquid chromatography/mass spectrometry, have proven sufficient to identify most agents, especially when coupled with pre-concentration techniques and tandem mass spectrometry .
Depending on the agent, identification may be enough to support charges for violating the chemical warfare ban but will not be sufficient to support homicide and battery charges. Most chemical agents are either nonpersistent (vapor) or require wet decontamination. Because life and limb supersede a forensic investigation, samples will not be taken before decontamination or medical intervention, even if personnel were able to take samples on scene. As an alternative to immediate or superficial collection, biophysical changes specific to agent exposure can be determined through blood analysis . Raman spectroscopy also shows promise as a noninvasive means to determine exposure to chemical and biologic agents .
At the time of an attack, it is highly likely that intelligence gathering will have narrowed the field of suspects. Through interrogation and investigative work, it is also possible that a facility or dissemination device will be located. The analytical techniques and instrumentation discussed previously can be applied to confirm the presence of chemical agents on equipment. Precursors, solvents, and equipment consistent with the suspected synthetic model will likely be present in the facility where the agent was manufactured .
Chemical events are particularly dangerous to medical responders, especially for those operating in the “cold zone.” Many chemical agents can be absorbed through the skin (or latex gloves), leaving responders vulnerable to secondary contamination. By the time a dental responder is on scene, the nature of the agent will be at least preliminarily confirmed, and the manner of decontamination will have been decided. With this in mind, observing a patient’s attempt to avoid decontamination (which will require removal of clothing) should be considered highly suspicious, and law enforcement officials should be notified of this behavior. If when monitoring patients triaged as minimally injured, several patients exhibit a sudden onset of more severe symptoms simultaneously, the medical responder should notify medical team leaders and law enforcement. The sudden onset may be caused by a secondary device or by proximity to the dissemination device. In both instances, the authorities should be notified, and all personnel should prepare to undergo decontamination measures. If the agent is persistent, the medical responder should report any objects found in the patient’s possession or in the treatment area that appear oily or greasy but should not attempt to handle the item, even with gloved hands.
Biologic agents
The investigation of a biologic agent is the most challenging CBRNE event. Although an outbreak of an unusual nature (such as smallpox) would trigger an immediate response and investigation, most biologic agents act slowly within a population, and patients present with nondescript ailments in many locations over an extended period of time (days or weeks as opposed to minutes or hours in a chemical attack). The core questions of agent identity, patient exposure, and agent production require investigation.
In the best case scenario, agents will be detected before an infection occurs. The persistence of biologic agents and the necessity of relatively high concentrations of biologic agents for infection to occur are used to the advantage of law enforcement and public health officials. Various federal efforts to create sentinel detectors, such as the Biological Aerosol Sentry and Information System (BASIS), BioWatch, and Automated Biological Agent Testing System (ABATS) aim to provide identification of agents as they are released into the environment through continuous sampling at a static location; however, these technologies rely on the airborne presence of the agent, which may not occur in cases of food-borne dissemination .
Currently, sentinels are not ubiquitous; therefore, a real possibility remains that the first warning of an attack will occur when citizens become infected. Agent identity will initially be established through common histologic procedures performed at hospitals, public health laboratories, or specialized facilities . Analytical techniques are being refined to offer faster and more accurate agent characterization that can be used for any type of agent and to more readily recognize hoaxes . Microchip-based technologies allow for simultaneous detection of multiple agents in the field and clinical settings .
The prevalence of genetic engineering may also contribute to a delayed recognition of a biologic attack . Techniques widely used in academic and commercial settings allow scientists to control the genetic properties and abilities of bacterial and viral agents, meaning that an agent could “look” like salmonella during screening but actually contain the genetic ability to produce a more virulent toxin. Projects to map bacterial and viral genomes are underway to provide baseline information about genetic differences between and among strains that are currently found in the environment so that the future release of a laboratory cultured agent will be more readily apparent .
Unlike chemical agents, the production of biologic agents does not require regulated chemical precursors. The equipment and chemicals necessary to replicate or modify a bacteria or virus have many benign uses and are ubiquitous in biologic and genetic laboratories, enhancing the possibility of “dual use” facilities . Several businesses are devoted solely to the creation of DNA sequences to order and do not always screen these sequences against the DNA sequences of known biologic agents; therefore, the possibility exists that a major part of production did not even occur within a facility . Nevertheless, intelligence suggesting that this method was used to orchestrate a biologic attack would allow law enforcement to trace involved parties through billing records of a sequencing company. Rather than focusing on the specific location or ability to produce the parent agent, a link to the equipment used in the replication of the agent might be established. DNA analysis of samples found in a suspected facility could be compared with the DNA analysis of samples taken from the scene and from victims, and statistical models derived from genome mapping projects could allow probabilities of association to be extrapolated, much in the same manner that DNA analysis of bodily fluids can yield a probability of association with an individual .
A medical provider may contribute to an investigation in two likely ways: (1) by recognizing and reporting a person of interest or (2) by recognizing a device that was part of the dissemination of the agent. During any sort of epidemic (natural or intentional), populations are affected at different times and at different rates; a patient presenting with a more developed infection than anyone else in the area is a person of interest. This individual may have come into contact with the agent before anyone else in the community (perhaps as a result of travel) or may have had involvement in the synthesis or dissemination of the agent. In both cases, this person will assist public health and law enforcement authorities in pinpointing the origins of the outbreak and will provide useful information in the case of an outbreak. The second possibility is the discovery of a dissemination device in the possession of a patient. Items such as vials, medicine droppers, test tubes, and other containers would be of interest to law enforcement officials, particularly if these containers were concealed but provided easy access, such as being taped to the wrist. Another item of interest would be architectural plans, especially if they include details of a heating, ventilating, and air conditioning system . Handling items potentially contaminated with biologic agents should be performed while using the recommended personal protective equipment associated with the particular agent.
Nuclear/radiologic event
A radiologic event will require immediate evacuation (much like a chemical event) and the intervention of specially trained teams, such as the National Guard Weapons of Mass Destruction Civilian Support Team, the Department of Energy Nuclear Emergency Support Teams, and the Environmental Protection Agency , in detection, characterization, and recovery efforts. If recently suggested guidelines are adopted, an area of 500 m (approximately 0.31 miles) will be evacuated and considered the “hot” zone where radiation levels are considered too high to operate without appropriate protection and medical oversight . Information discovered by these teams could be used at the launch of a police investigation. For example, the specific isotope discovered on scene will indicate whether the material was likely to have been derived from industrial or medical instrumentation and will lead to the cross-check of those facilities for reports of stolen or damaged equipment . Detector technology based on neutron generation and gamma ray spectra interpretation offers the ability to characterize unexploded ordnance .
As the threat of radiologic exposure diminishes, information about the device can be sought similar to the investigation of an explosion, especially in the case of a radiologic dispersion device or “dirty bomb.” Emerging technologies are capable of detecting and classifying explosives from a distance, making it possible for information to be gathered while minimizing the chance of injury. Again, forensic scientists will focus on the explosives and the contaminants to link the device with a facility and a perpetrator.
The most probable circumstance for medical volunteer involvement would be in response to a radiologic dispersion device. If a patient presents with symptoms associated with high levels of radiation exposure but shows no sign of trauma or gross external contamination or if he or she presents with only burns to the hands or forearms, the patient would be a person of interest to law enforcement because they may have been involved in the preparation or transport of the device. Patients close to the explosion site may receive penetrating injuries from shrapnel. Facilities on scene and operating procedures may not allow for the removal of the foreign body, but a note on the nature of the shrapnel, patient information, and destination hospital (if known) would be useful to the investigation. If the foreign body is removed (if it is blocking the airway), provider information, the time, date, and patient information should be noted on the bag and the item placed away from traffic flow until law enforcement officials are able to retrieve it. In the radiologic dispersion device scenario, the amount of particulate matter on a single piece of shrapnel is not likely to cause a health risk.
Explosive events
Bombings are the most common form of terrorist action to date. Hundreds of events have occurred internationally causing countless fatalities and casualties . As a result, law enforcement agencies are relatively prepared for the necessary analyses following an explosive event; most forensic laboratories have sections devoted to arson and explosive investigations . Some police forces cross-train officers in urban search and rescue to allow forensic investigators early access to the crime scene in the safest manner possible. As is true in the other scenarios, the goal of the forensic investigation is to characterize the agent (through recreation of the device and the chemical composition of the explosives), link the agent to an individual or group, and prove that an individual or group planted the device in a specific location.
To prove the existence of an explosive device (as opposed to an accidental explosion), investigators seek evidence of the four required components of an improvised explosive device: a power source, initiators, explosives, and switches. A fifth component, which is not necessary but can provide useful information, is fragmentation and shrapnel such as ball bearings, nuts, and screws included as part of the device to inflict greater damage and increase the likelihood of secondary blast injuries. Bringing these components together can give officers an idea of the level of sophistication of the device and the level of training of the offenders and can provide a possible connection between crimes. For example, the use of home-manufactured rather than commercially machined screws was a trademark of explosives in the Unabomber cases, and the use of a Big Ben alarm clock was consistent among all of the devices planted by Eric Rudolph (the Olympic Park bomber). Also, if several devices were used in the same attack, evidence of these necessary components would confirm the number of devices used and whether specific design characteristics were shared among the devices.
Characterization of the actual explosive will begin with an examination of the physical characteristics of the device fragments. Low explosives deflagrate, that is, they propagate energy through thermal conductivity; therefore, the discovery of fragments that are warped or charred would be indicative of a low explosive. High explosives detonate, which is the propagation of energy through a pressure wave at supersonic speeds; fragments that have sharp edges and limited signs of heat exposure would indicate the possible use of a high explosive . If physical components are not immediately recovered, surrounding structures and damaged objects can be swabbed and tested for the presence of explosive residue. Currently, colormetric tests are employed to determine whether to sample an area or object for more specific analysis. Such tests rely on a chemical reaction between the explosive and an introduced agent that results in a color change . Studies of the use of photoluminscent techniques that use laser excitation to improve visualization in the field have been developed and are undergoing validation and testing . In specialized laboratory settings, explosive identification may also be achieved through re-crystallization and observation under polarized light .
Some of the handheld monitors used for chemical detection can also detect the presence of explosives ; however, more sensitive and accurate instrumentation based on Raman spectrometry is emerging that is capable of detecting explosive mixtures at a distance . Neutron interrogation devices have demonstrated the ability to characterize explosives (and other substances) by reading the gamma ray signatures released by an object following excitation by neutrons released by the detector . This testing is especially useful in the determination of the fill of unexploded or buried devices .
Further confirmation can be achieved with laboratory-based analysis, which is made necessary by the fact that most improvised explosives are derived from commonly used, commercially available products with benign uses. For example, a nitrate-based fertilizer mixed with diesel fuel creates an explosive material (ammonium nitrate fuel oil). The presence of nitrates or the presence of diesel fuel is insufficient to definitively characterize the nature of the explosive; both substances could be detected by chance in a given area. Analytical techniques that reveal more information about the specific structure or molecule complex are more useful in characterizing explosives . Sensitivity is further improved with concentration techniques such a solid phase extraction before analysis, as well as the use of artificial neuronal networks, a form of enhanced software to modulate the separation conditions according to the specific needs of the sample . Recently, success has been reported in extracting DNA from skin cells left on the surface of exploded pipe bombs; therefore, genetic analysis could also prove that an individual handled a specific device .
The aim of the primary investigation of a suspect is to connect the individual or a group with the explosives used in an event. Police officers will likely use preliminary techniques on scene, such as colormetric tests, to determine the presence of explosives and will use the results as probable cause to detain a suspect pending further investigation. Explosive residues are readily collected from nonporous surfaces, skin, and fabric. Studies have shown that hair has the ability to concentrate vapors from some military explosives and that concentrations can be linked to exposure time and still be traced after washing or environmental exposure . In the laboratory setting, characteristics of trace elements associated with the explosive, such as sulfur, can be analyzed to associate the explosive material with a suspect or may be found in the suspect’s possession (even in trace form) with explosive material recovered from the scene .
The nature of an explosive event provides the greatest opportunity for a medical responder to recover evidence or identify persons of interest. The most dangerous situation would be the discovery of an undetonated device on the body of a patient. This situation might occur in a suicide bombing in which multiple bombers planned to attack a site, one or more perpetrators carried devices that did not detonate, and the suspects sustained injury as a result of the proximate blast, or if the device was intended to detonate upon removal from the patient by medical personnel. In the event of such a discovery, one should notify law enforcement immediately. Do not attempt to remove the device or move the patient any more than absolutely necessary. Evacuate the surrounding area rather than attempting to move the device (or the patient it is attached to). Other persons of interest may be less severely wounded patients who act nervous rather than panicked, particularly if the individual seems focused on police activities. Law enforcement officials may not be readily available for interrogation, but a detailed description of the individual including identifying characteristics and contact information should be provided to investigators, along with any transport information.
Penetrative injuries of varying severity are common in bombings ; recorded injuries range from hardware to bone fragments from a suicide bomber. Because fragmentation evidence can be useful in device reconstruction or trace analysis, police knowledge of the removal of such fragments from patients is useful. Fragments associated directly with the device are important; objects that resemble batteries, springs, electronics (eg, wires, transistors, microchips, cellular phone components), or plastic tubing should be noted. If the items are removed in the field, one should package and store shrapnel following the guidelines presented previously, making sure to wear gloves and a mask to prevent DNA contamination. In the more likely circumstance that the patient is transported with the shrapnel still embedded, the medical responder should make note of the patient’s name, identifying characteristics, the nature of the shrapnel, and the transport hospital (if known) and should provide this information to law enforcement officials.
In an explosive event that creates extreme structural damage, clothing removed from patients evacuated from the scene could be of use. Evidence collection will always run secondary to engineering concerns such as structure stability. The ability to start the investigation by conducting an initial analysis on articles of clothing will save a great deal of time, because safety concerns may disallow evidence collection from the explosion site for hours or days. One should store items of clothing as described earlier.
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