Guidelines For Mass Fatality Management During Terrorist Incidents Involving Chemical Agents
Guidelines For Mass Fatality Management During Terrorist Incidents Involving Chemical Agents
Guidelines For Mass Fatality Management During Terrorist Incidents Involving Chemical Agents
Key Points
Agents
• With proper handling and decontamination the
majority of chemically contaminated fatalities can
be safely returned to families for disposition.
• The mass fatality management process is U.S. Army Soldier and Biological Chemical
enhanced if Medical Examiners and Coroners are
trained and equipped to operate in a hazardous
environment. Command (SBCCOM)
November, 2001
SBCCOM
The findings in this report are not to be construed as an official Department of the Army
position unless so designated by other authorizing documents.
The use of trade names or manufacturers' names in this report does not constitute an
official endorsement of any commercial product. This report may not be cited for
purposes of advertisement.
Guidelines for Mass Fatality Management During Terrorist Incidents Involving Chemical Agents
Preface
The FY97 Defense Authorization Bill (P.L. 104-201, Sept 23, 1996), commonly called
the Nunn-Lugar-Domenici legislation, funded the U.S. Domestic Preparedness initiative.
Under this initiative, the Department of Defense was charged with enhancing the
capability of federal, state, and local emergency responders in responding to incidents
involving nuclear, biological, and chemical terrorism. The U.S. Army Soldier and
Biological Chemical Command (SBCCOM), in Aberdeen Proving Ground, Maryland,
established an Improved Response Program (IRP) whose mission is to identify problems
and develop solutions to the difficult challenges associated with response to and recovery
from acts of terrorism using unconventional weapons. SBCCOM established two
separate analysis groups to address these challenges, one for biological and one for
chemical events.
This report assists emergency managers, medical examiners, and coroners to better
prepare for and determine the best course of action for responding to a mass fatality
situation following a chemical weapon of mass destruction (WMD) incident. The
findings and recommendations in this report are neither mandated nor required for state
or local jurisdictions. Rather, they are presented to provide technical and operational
guidance for communities and departments that are planning to respond to such events.
We encourage you to review the information, understand the implications, and
consciously decide what response procedures you would perform. Once you have made
the decision that is best for your community, you should train and equip your jurisdiction
accordingly.
The mass fatality management working group included a cross-section of operational and
technical experts from local, state, and federal agencies. Responders from Baltimore,
MD and Washington, D.C., along with experts from across the nation were included to
ensure solutions were broad-based and usable by most jurisdictions. The working group
included public health representatives, medical examiners, hazardous material handling
specialists, law enforcement officers, emergency managers, disaster consultants, and
private and Department of Defense chemists and toxicologists.
This document has been approved for public release. It may be freely reviewed,
abstracted, reproduced and translated, in part or in whole, but not for sale nor for use in
conjunction with commercial purposes. The report can be obtained from the following
Web site http://www2.sbccom.army.mil/hld/
The use of either trade or manufacturers’ names in this report does not constitute an
official endorsement of any commercial product. This report may not be cited for
purposes of advertisement.
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Guidelines for Mass Fatality Management During Terrorist Incidents Involving Chemical Agents
Acknowledgements
The authors gratefully acknowledge the contributions of each of the members of the Mass
Fatality Management Working Group who contributed their time and expertise to this
project. Special thanks are extended to the Maryland and Washington, D.C. Medical
Examiners, and the Region III Disaster Mortuary Operational Response Team.
Disclaimer
***Special Note
The use of the term medical examiner throughout this document is meant to
imply medical examiners and coroners.
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Guidelines for Mass Fatality Management During Terrorist Incidents Involving Chemical Agents
Table of Contents
Preface .............................................................................................................................................ii
Acknowledgements .......................................................................................................................iii
Disclaimer.......................................................................................................................................iii
Table of Contents...........................................................................................................................iv
1. Introduction...............................................................................................................................1
1.1 General ...............................................................................................................................1
1.2 Objective .............................................................................................................................2
1.3 Working Group Process ......................................................................................................2
3. Processing Remains................................................................................................................12
3.1 General...............................................................................................................................12
3.2 Remain Recovery: General ................................................................................................13
3.3 Holding Morgue: General....................................................................................................14
3.4 Transportation & Temporary Storage: General...................................................................18
3.5 Processing Remains at an Off-Site Morgue: General. ........................................................19
3.6 Transportation & Temporary Storage .................................................................................24
3.7 Final Disposition: General...................................................................................................24
4. Conclusion................................................................................................................................29
Appendix A Generic Response Incident Planning Guide for Medical Examiners ......................... A-1
Appendix B Disaster Mortuary Operational Response Team WMD Unit...................................... B-1
Appendix C Environmental Protection Agency: Contaminated Water Run-off .............................C-1
Appendix D References ...............................................................................................................D-1
List of Figures
Figure 1 Processing Flow of Contaminated Fatalities ....................................................................12
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Guidelines for Mass Fatality Management During Terrorist
Incidents Involving Chemical Agents
1.0 Introduction
1.1 General
Natural disasters, terrorists’ attacks, and accidents such as plane crashes have the
potential to produce catastrophic numbers of fatalities. The United States has
suffered such incidents, for example the bombing of the Alfred P. Murrah Federal
Building in Oklahoma City, Oklahoma in 1995 resulted in 168 fatalities and the
crash of TWA flight 800 in 1996
in Long Island, New York claimed
the lives of 230 people. Outside
the United States, an earthquake in
India produced over 30,000
fatalities in 2001, while an
earthquake in El Salvador the
same year produced close to 1,000
fatalities. In Bhopal, India (1984),
an industrial chemical accident
resulted in over 6,000 fatalities.
Attacks using weapons of mass destruction (WMD) have the potential to create
extraordinary numbers of fatalities similar to the numbers seen in large accidents
and natural disasters. Presently the United States is unprepared to manage
catastrophic numbers of fatalities at the local and regional level. At the federal
level, the Disaster Mortuary Operational Response Team (DMORT) is the only
response organization prepared to handle large numbers of fatalities. The Improved
Response Program (IRP) established a Mass Fatality Working Group, comprised of
experts, to address fatality management in the event of a chemical terrorist incident
on US soil.
A well-executed chemical terrorist incident will likely result in the same large
number of fatalities mentioned above; however, the agent contamination poses new
concerns for the medical examiner and directly influences how a jurisdiction
manages the processing of remains. Jurisdictions experience a gap in their response
capability as hazardous materials (HazMat) teams have experience operating in
contaminated environments, but are unfamiliar with medical examiner procedures
for processing remains and vice versa. Very few state and local medical examiners
have the necessary equipment, training, and resources for operating in a
contaminated environment.
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Guidelines for Mass Fatality Management During Terrorist Incidents Involving Chemical Agents
1.2 Objective
The Mass Fatality Management Working Group was convened under the auspices
of the IRP in January 2000. The working group held meetings over the next year, at
which time the attendees cross-trained fellow members on their agency’s
procedures and policies to various chemical scenarios. Several members, having
experience in mass casualty and mass fatality situations, cited best practices for the
group to consider as a whole. This was particularly true for the experiences and
lessons learned from the Oklahoma City bombing.
Early in the process the group realized that certain constraints had to be put in place
as operating parameters. These parameters were meant to help the group come up
with solutions that were practical and acceptable to a range of response
communities and jurisdictions. Some of the operating parameters included:
Issues that could not be immediately answered by the group were referred to
scientific experts with the resulting information being fed back into the group
process. After all related information was presented, the working group focused on
the methods that had a broad applicability to most jurisdictions in developing these
guidelines.
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Guidelines for Mass Fatality Management During Terrorist Incidents Involving Chemical Agents
2.2 Personnel
The medical examiner will need personnel who can be part of an initial
evaluation team whose objective is to enter the hot zone and formulate the
best approach for processing the scene and processing remains. The team
approach requires a minimum of four members, each having distinct
objectives for reviewing the scene. The IRP recommends that the team
consist of the medical examiner investigator, a Federal Bureau of
Investigation (FBI) HazMat Technician, a law enforcement evidence
collection technician, and a forensic odontologist. Members should be
selected based on the overall mission to collect evidence and to determine the
cause of death. Upon conducting the evaluation, each agency involved will be
better able to formulate an incident specific mass fatality management plan.
The initial evaluation team should specifically identify the total number of
remains, their location and any complicating factors, i.e. fragmentation or
difficult excavation. The second priority includes identifying which remains
require a full autopsy (see Section 3.5.4 for further information on
autopsies). Knowing the total number of remains and the specific number of
those that require an autopsy will help the medical examiner plan the morgue
operation.
Though it is primarily the role of the medical examiner to determine the best
approach for managing remains, input from all team members may be helpful.
Each agency works within certain operational and resource constraints that
may influence how the incident site is processed, e.g. the need to gather
enough evidence to prosecute the criminal case. Thus, the information
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Guidelines for Mass Fatality Management During Terrorist Incidents Involving Chemical Agents
gathered via this initial evaluation team, will serve as the basis from which all
agencies can collectively agree on an organized approach to process the
incident site, e.g. who will be performing which tasks, when each agency will
perform their tasks, and what assets must be mobilized to support the task.
Due to the criminal nature of the incident and the fact that remains are
evidence, jurisdictions should not grant non-medical examiner personnel
unrestricted access to the remains. Those handling remains should be
arranged in teams with an FBI and medical examiner representative who
oversee all movement.
Many tasks that the medical examiner normally performs in the morgue will need to
be performed before remains are decontaminated. Medical examiners must gather
evidence, remove and tag personal effects, perform a thorough external evaluation,
and perform a preliminary identification check. Once these tasks are complete,
personnel can decontaminate remains and then move remains to a traditional
morgue for final processing.
Shifting the location of gathering evidence from the medical examiner’s office to
the incident site requires the medical examiner to wear PPE. Most medical
examiners however do not have the budget to train personnel to use PPE nor do
they have a budget that can maintain this equipment for a “possible” event.
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Guidelines for Mass Fatality Management During Terrorist Incidents Involving Chemical Agents
Despite a lack of resources, local medical examiners can begin training personnel to
use PPE through mutual agreements with local fire departments, HazMat teams,
local private industrial Hazmat teams, or their local/state environmental protection
agency equivalent. A specialized team of at least four individuals should be trained
to the HazMat Technician Level, so that they are prepared to enter a Hot Zone in
Level A or B PPE. This provides the medical examiner two teams of two
individuals, so that each team has a backup that can relieve the other when an
evaluation takes longer than the thirty-minute air supply. The rest of the staff
should be trained to use Level C PPE.
The medical examiner may need to approach other departments that normally use
PPE and request if they can make a portion of their stock available to the medical
examiner. It is unlikely that the medical examiner will have the ability to purchase
and maintain a tremendous amount of PPE and it unlikely that those who have the
PPE, but are not medical examiner investigators, would be inclined to handle
human remains. Purchasing enough PPE for all personnel for an incident that might
happen is not the best utilization of limited resources; thus, the IRP recommends
that medical examiners coordinate their needs to use these items with other
departments when it becomes necessary to process a chemical mass fatality incident
scene.
It is possible that personnel will be able to use a lower level of PPE than the initial
responders used at the onset of the incident. Most chemical agents will have been
identified in the first 48 hours, which will confirm the level of PPE required. The
medical examiner should consult with the Incident Commander to determine what
level of PPE is necessary, before personnel begin processing remains at the scene.
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Guidelines for Mass Fatality Management During Terrorist Incidents Involving Chemical Agents
Establishing an off-site morgue for a chemical incident differs than establishing one
in other disaster situations, as the medical examiner may need to set up a few
additional stations. In addition to an autopsy area and identification station, the off-
site morgue should have adequate room for a detailed decontamination station, an
embalming station, and a final rinse station.
When planning the stations at this off-site
morgue, the medical examiner should
remember that personnel will have performed
many tasks at the incident site morgue, such as
an external body evaluation, removal of
personal effects, and a preliminary
identification check. Consequently, the off-
site morgue will not need a separate evaluation
area and this space can be used to establish the
aforementioned stations.
Plans should include identifying several locations that would serve as off-site
morgue sites. If there is a lack of appropriate fixed locations, then tents can be used
if they are located near or outfitted with a source of electrical power and water.
Off-site morgues that are established in or near buildings may already allow access
to resources like large parking lots or fire hydrants. Fixed sites may be more
suitable as those locations will limit on-lookers from viewing remains.
2.6 Communication
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Guidelines for Mass Fatality Management During Terrorist Incidents Involving Chemical Agents
Establishing a family assistance center (FAC) for a chemical disaster is not any
different than in other disasters, e.g. plane crashes or building collapses. The
medical examiner should be prepared, however, to mobilize the appropriate
resources to establish a FAC at the same time that he/she mobilizes resources to
manage the incident specifically.
Establishing a FAC early on provides many benefits. One benefit is that the public
acknowledges that there is some order despite the chaotic circumstances. Secondly,
family members have a place where they can register their loved ones missing.
This list assists medical examiners with positively identifying remains and
coordinating final disposition. Moreover, establishing a FAC allows family
members a place to wait and prepare themselves to receive difficult news.
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Guidelines for Mass Fatality Management During Terrorist Incidents Involving Chemical Agents
locations with designated staffs may provide more order and continuity for
managing a mass fatality situation overall.
Other issues the medical examiner should consider when planning a response to a
chemically contaminated incident site are the inclusion of DMORT as a resource
enhancement, addressing the issue of organ transplant requests during a disaster,
and handling contaminated animal remains.
DMORT does not establish command and control over the fatality
management operation. The local medical examiner maintains responsibility
to recover remains as well as sign death certificates. Each jurisdiction should
have their own system in place that is flexible enough to effectively and
expeditiously incorporate DMORT’s resources, but should not rely on
DMORT to be their disaster plan.
Presently DMORT has one WMD team, for the nation, that is capable of
decontaminating chemically contaminated remains and monitoring them to
ensure they are free of chemical agents. Appendix B presents information
regarding DMORT’s WMD capabilities. For additional information regarding
DMORT and DMORT WMD, go to their Web Site www.dmort.org.
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Guidelines for Mass Fatality Management During Terrorist Incidents Involving Chemical Agents
The local medical examiner should consider consulting with their DMORT
Regional Commander, to understand how DMORT can best fit into their
jurisdiction’s response plan. It is possible for the local medical examiner to
incorporate the use of the traditional DMORT regional team in chemical
WMD incidents if remains are already recovered, decontaminated and
monitored for residual contamination before they are sent through the
autopsy/identification process. The DMORT Regional Commander is
familiar with how their resources can be used and how their efforts can be
funded. To contact the appropriate DMORT Regional Commander go to their
Web Site www.dmort.org and click on the “contact us” button to locate the
appropriate Commander for each of the ten federal regions.
The medical examiner may receive questions regarding organ donation and
transplant when patients die from complications following chemical agent
exposure. Some patients that were transported from the incident site may die
in the hospital and family members may request or be asked to consider organ
donation. The Maryland Transplant Resource Center was consulted regarding
this possible situation and stated that donor candidacy is based on brain death
and specific organ viability, which is based on laboratory values. If organs
were severely injured from the chemical agent exposure, then tests results
would indicate abnormal values and the organs would not be considered
viable.
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Guidelines for Mass Fatality Management During Terrorist Incidents Involving Chemical Agents
should gather and dispose of animal remains since they could be considered
part of the crime scene. It is possible that contaminated animal remains may
not only be located within the incident site but may also be located throughout
the jurisdiction.
The medical examiner may also encounter questions from private animal
burial agencies. Morticians report that people have a tendency to treat pets
like family members and may desire burial services. Thus, the medical
examiner may need to advise these agencies as to how these animals should
be properly handled and disposed. The medical examiner, local health
commissioner, and the Incident Commander will need to determine whether
animal remains can be released to an animal crematorium or if it is safe for
remains to be released for public disposition. Time, effort, and resources may
dictate a blanket policy to mass incinerate all animal remains resulting from a
chemical WMD incident.
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Guidelines for Mass Fatality Management During Terrorist Incidents Involving Chemical Agents
In this section, the IRP will present those variables that medical examiners may
encounter when trying to process chemically contaminated remains. Though the
processing flow to manage contaminated remains will not differ for each incident,
many variables within each phase of the process may need to be altered due to the
specific incident. The size of the event, the geographic location, the type of
chemical agent, the availability of assets, if remains are fragmented, and the
required time to safely process remains without jeopardizing those handling
remains are just some variables that may influence each phase of the process as well
as the final disposition. Figure 1 conceptually depicts the process flow for
managing contaminated remains.
Any one of the aforementioned variables can strongly influence how to effectively
conduct each phase of the operation. The medical examiner in conjunction with the
those who participated in the Initial Evaluation Team should specifically address
who is performing which task, what order the tasks may be performed, where the
task will be performed, and why the details must be carried out in a specific manner
for each phase of the operation. After the Initial Evaluation Team collectively
determines the operation plan, the medical examiner will begin processing remains.
Off-Site
Morgue:
Autopsy
Off-Site
Morgue:
Identification
& Embalming
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Guidelines for Mass Fatality Management During Terrorist Incidents Involving Chemical Agents
The medical examiner may need additional personnel trained to use PPE
to support the recovery of remains. If the local, state, and regional area do
not have enough medical examiner personnel to perform recovery, the
medical examiner should request the aid of personnel who are accustomed
to wearing PPE, e.g. hazmat, firefighters, personnel from the department
of the environment, or the National Guard. If non-medical examiner
personnel are needed, then the medical examiner should coordinate remain
recovery and direct the efforts of non-medical examiner personnel.
Due to the criminal nature of the incident and the fact that remains are
evidence, jurisdictions should not grant non-medical examiner personnel
unrestricted access to the remains. Those recovering remains should be
arranged in teams with an FBI and medical examiner representative who
oversee all movement.
3.2.2 Tracking
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Guidelines for Mass Fatality Management During Terrorist Incidents Involving Chemical Agents
off bar coded stickers. The medical examiner may consider using these
types of tags if they do not presently have a waterproof tagging system of
their own.
Under normal circumstances, law enforcement gathers evidence at the crime scene
while the medical examiner only gathers a preliminary assessment of remains at the
scene and performs the actual evaluation at the morgue. An incident that involves
chemical WMD changes this norm. To avoid cross contaminating other areas and
personnel and to create a safer circumstance for others to handle remains, the
medical examiners must gather evidence, remove and track personal effects, and
decontaminate remains before they are transferred to the morgue area for autopsy
and/or embalming.
Once remains are recovered they must be brought to a central location, the
Incident Morgue, for processing.
The IRP highly recommends that the medical examiner make plans to
cover remains from public view at the Holding Morgue. For example
tents can be set up so that when remains are recovered they are lined up in
one of two tented areas- remains for autopsy, remains not requiring an
autopsy. Under this cover, medical examiners can collect evidence,
perform the initial identification check, remove personal effects, and
perform an external evaluation. Once these tasks are performed and
decontamination personnel are ready to manage another case, handlers can
move remains to a covered decontamination area.
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Guidelines for Mass Fatality Management During Terrorist Incidents Involving Chemical Agents
Providing cover from the public’s view provides a sense of honor and
respect for the dead, as well as protects the public from viewing remains
via news camera media pictures.
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Guidelines for Mass Fatality Management During Terrorist Incidents Involving Chemical Agents
Due to the length of time required to process the case, the FBI and medical
examiner should provide the Joint Operations Center’s Public Information
Officer information regarding the processing of personal effects. This
information should address if personal effects will be returned, and when
family members will receive the effects. It should also include an
explanation as to what family members may expect to receive, how long it
will take, and why it will take so long (e.g. they must be decontaminated
before they can be returned, or the investigation process is lengthy.)
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Guidelines for Mass Fatality Management During Terrorist Incidents Involving Chemical Agents
processing remains, the Hot Zone is the location where the incident
occurred and the medical examiner personnel removed personal effects
and performed external evaluations. Remains enter the Warm Zone when
they are brought to the decontamination area. Once remains have
undergone a gross decontamination, they are brought to the Cold Zone
where they are put into refrigerated storage units. When personnel
perform gross decontamination, they should perform it in a manner that
respects the deceased, i.e. remains should not be deliberately exposed to
the view of on-lookers.
Additives increase the level of safety for those handling remains but they
can also create tissue decay. The U.S. Army Mortuary Affairs Center
conducted studies that indicate the use of low concentrations of household
bleach, two to three percent solution with a five-minute contact, produces
no negative effects on remains and successfully removes chemical agents.
There are concerns that although higher concentrations of bleach solution
(five percent or greater) remove chemical agents, they may have negative
effects on human tissue and cause tissue decay (U.S. Mortuary Affairs,
1992). Therefore, medical examiner personnel should use the appropriate
solution when decontaminating remains.
After gross decontamination, the medical examiner should not assume that
remains are free of contamination. This can only be determined with low-
level detectors (i.e. mass spectrometers) that are not likely to be available
on the scene. Remains should be wrapped in two body bags. Personnel
should seal the initial body bag with duct tape, rinse the bag, and then
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Guidelines for Mass Fatality Management During Terrorist Incidents Involving Chemical Agents
place the remains in a second body bag before remains are put into a
refrigerated unit. Personnel should wear PPE until all remains are
monitored with a chemical detector device and are deemed free of
contamination.
A number of issues arise when the medical examiner must transfer and hold a large
number of contaminated remains. For example, the number of fatalities may
influence the type of transportation needed to move remains from the incident site
to the morgue or embalming site as typical vans can only hold a few remains.
Additionally, the medical examiner generally stores those from the same incident in
the same location to promote order, however most morgues are not able to hold
more than 20 cases.
In this section, the IRP will discuss transportation and storage assets.
The medical examiner’s disaster plan may need to include the use of
refrigerated trucks and railroad cars as alternative transportation units for
caseloads that exceed their normal transportation capacity. The use of
refrigerated trucks or railroad cars is especially helpful since remains can
be transported and stored in the same unit.
The use of railroad cars does require the medical examiner to do some
additional planning. Medical examiners will need to coordinate efforts to
bring remains to the railroad cars, since railroad cars can not just pull up to
the incident site. In addition, the medical examiner may need to establish
a off-site morgue site that is close to the railroad tracks so that processing
remains is not further complicated. Normally, a railroad car can
accommodate 32-40 bodies (Military Planning for Health Services
Support, 1994).
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Guidelines for Mass Fatality Management During Terrorist Incidents Involving Chemical Agents
help the medical examiner achieve the ability to return remains to family
members.
The plan should also identify other locations that can be used for storage.
Possible locations include an anatomy board, small buildings or rooms
that can cool to 37 degrees Fahrenheit. Other options include securing a
large air conditioning unit that can cool a room to 37 degrees Fahrenheit.
Decisions regarding processing remains are not based on singular variables but
rather a cadre of events and the status of resources available. Once remains have
been transferred to the morgue, issues facing the medical examiner will include
detailed decontamination, identification procedures, autopsies, and embalming
procedures. Though it may be difficult to plan the specific order of events to
process remains, the medical examiner should take into consideration how each part
of the operation may affect the overall ability to return remains to family members.
Depending on the magnitude of the incident the medical examiner may not
be able to process all of the remains at the morgue. The morgue’s current
available space and capacity may dictate the use of off-site morgues.
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Guidelines for Mass Fatality Management During Terrorist Incidents Involving Chemical Agents
If the number of fatalities exceeds the capacity of the morgue and the
planned alternative locations, the medical examiner may need to establish
multiple temporary morgues. Additional locations can include empty
warehouses, airplane hangers and tents.
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Guidelines for Mass Fatality Management During Terrorist Incidents Involving Chemical Agents
3.5.3 Identification
3.5.4 Autopsies
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Guidelines for Mass Fatality Management During Terrorist Incidents Involving Chemical Agents
The medical examiner may need to add a few additional procedures to the
autopsy process, i.e., testing for chemical contaminants or residual
metabolites. With the inclusion of additional procedures, it may take longer
than three hours to process a single case. Medical examiners should not
seek to alter the exact order of the autopsy or reduce the amount of time
needed to perform them.
3.5.5 Embalming
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Guidelines for Mass Fatality Management During Terrorist Incidents Involving Chemical Agents
Next, the medical examiner may request that personnel scan remains for
internal devices before they are embalmed. To scan for and remove internal
devices does not take very long and personnel will already be wearing PPE.
If the decision is made, to voluntarily or involuntarily cremate remains later,
then the medical examiner will have avoided the laborious step of donning
PPE and processing remains before final disposition. (See Section 3.7.3
for more information regarding cremation.)
Next, personnel can proceed with their normal procedures for embalming.
Body fluids and solutions should be contained and handled according to pre-
established procedures. No additional risk is associated with handling
contaminated body fluids mixed with embalming solutions, as handling
instructions for embalming fluid provide personnel adequate safety.
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Guidelines for Mass Fatality Management During Terrorist Incidents Involving Chemical Agents
After remains are embalmed, the medical examiner should obtain the FBI’s and US
Attorney’s inputs before remains are prepared for final disposition. It is possible
that authorities will request the medical examiner to hold some or all of the remains
for purposes of gathering additional evidence to prosecute the case. The medical
examiner may need to perform additional autopsies on embalmed remains to gather
this evidence.
Logistically, the medical examiner will have all the necessary assets in place to
accommodate holding remains. The most prominent concerns will be informing
family members of the delay, and dealing with the public’s response to the medical
examiner stagnating the final disposition process.
If the medical examiner plans to use the same transportation and storage units that
were used previously, then he/she should direct personnel to decontaminate the
units before using them to hold decontaminated remains.
Each state has laws pertaining to the final disposition of remains. In general, laws
require that remains must be given to family members upon request and cannot be
disposed of as the state chooses. If the medical examiner, the local jurisdiction’s
health department, and the state’s Secretary of Health determine that a public health
hazard exists, then the governor can issue an emergency declaration negating
current law. If the decision is made for the purposes of protecting the public, then
there is no limitation established by legal statute pertaining to final disposition. It
is possible that the governor and the aforementioned persons will have to make
controversial decisions during critical moments following a chemical incident.
Medical examiners should review and understand their states laws regarding acts of
terrorism, chemical agent exposure, and characteristics of a public health hazard.
They should also determine if they have the assets to prevent a public health hazard
(i.e. refrigeration assets to prevent decay), as well as the ability to verify that
remains are free of contamination (i.e. chemical agent monitoring). It is possible
that a public health hazard will exist independent of the chemical contamination, as
specific aspects of fatality management are time critical (e.g. recovery) and
dependant on certain assets to support the operation (e.g. enough personnel who can
wear PPE to process remains).
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Guidelines for Mass Fatality Management During Terrorist Incidents Involving Chemical Agents
Final disposition may carry a great deal of public scrutiny from the public and
possibly from local morticians and funeral home directors. Medical examiners and
emergency managers should seek to incorporate the support of religious leaders
upon announcing an unfavorable final disposition decision. In addition, the medical
examiner should consider providing local morticians and funeral home directors
with specific handling instructions if they assist in the final disposition phase, to
minimize their confusion and promote safe handling.
Final disposition options include: burial, sealed casket burial, state sponsored mass
burial, and cremation- voluntary and involuntary.
To ensure that remains are free from contamination the medical examiner
should monitor remains before releasing them to the community for final
disposition. Chemical agent monitoring, is difficult, time consuming, and
expensive. Most jurisdictions will require assistance in performing this
type of monitoring from specialized military units, specialized HazMat
teams (i.e. the FBI Hazardous Materials Response Unit (HMRU)), or from
DMORT WMD.
Two main types of chemical agent monitors exist. The Chemical Agent
Monitor (CAM) provides hi-level monitoring capability, which
technicians use to monitor gross levels of agent. The second type of
monitoring, which SBCCOM and the FBI HMRU use, is mass
spectrometer monitoring. This type of monitor is used for low-level
monitoring.
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Guidelines for Mass Fatality Management During Terrorist Incidents Involving Chemical Agents
The IRP recommends that local medical examiners choose to monitor the
airspace of the storage units using low-level monitoring devices. This
process is not as time consuming as monitoring each body bag. Standard
protocols exist so that technicians can collect a sample, obtain a reading
and determine the level of contamination.
3.7.2 Burial
When authorities determine that remains are not safe to handle or safe for
family viewing, the medical examiner may choose to mandate the use of
sealed caskets. The IRP discussed this option and determined that most
local morticians do not understand what sealed casket procedures are and
morticians may still open the caskets. In addition, sealed caskets are not
100% sealed. Caskets are designed with air holes to promote airflow
exchange for the express purpose of equalizing pressure. Despite these
concerns, jurisdictions may determine that sealed casket procedures are
better than other alternatives.
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Guidelines for Mass Fatality Management During Terrorist Incidents Involving Chemical Agents
The public may be more inclined to accept state sponsored mass burial if
remains are placed in individual caskets, are located in an area that is
protected, and the site is commemorated.
Remains that are cremated will not pose an environmental hazard. The
Department of Army Regulations (AR 385-61) state that all chemical
warfare agents are nullified when exposed to temperatures of 1000 degrees
Fahrenheit for fifteen minutes. US crematoriums set their crematoriums
higher than 1000 degrees Fahrenheit thus cremation will nullify all
chemical agents.
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Guidelines for Mass Fatality Management During Terrorist Incidents Involving Chemical Agents
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Guidelines for Mass Fatality Management During Terrorist Incidents Involving Chemical Agents
4.0 Conclusion
In a chemical WMD incident the medical examiner must perform many additional tasks,
and be prepared to enter a contaminated environment. Managing chemically
contaminated remains is difficult and the task may become daunting if there are multiple
remains to process. Appendix A is a generic response planning guide that summarizes
the tasks the medical examiner must coordinate in order to process chemically
contaminated remains.
The chief task of the local medical examiner is not to independently process all remains
from such a disaster, but rather to create an infrastructure so that when assets arrive those
assets can backfill and support the operation. Thus, the medical examiner must know
what assets he/she has on hand, where to obtain other necessary assets, and how to
effectively use those assets.
To successfully achieve the end goal to keep handlers safe, honor the dead, and return
remains to their family members, the medical examiner must plan how to process remains
by phases. By breaking down the operation by phases and addressing the critical
variables that influence the operation, the local medical examiner will be prepared to
manage not only a chemically contaminated incident but other disasters as well.
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Guidelines for Mass Fatality Management During Terrorist Incidents Involving Chemical Agents
30
Guidelines for Mass Fatality Management During Terrorist Incidents Involving Chemical Agents
APPENDIX A
A-1
Guidelines for Mass Fatality Management During Terrorist Incidents Involving Chemical Agents
i. Recovery Phase
• Who is performing remain recovery.
• Do teams need to be established with FBI and ME as team
leaders.
• Determine which agency is responsible for what and in what
order do personnel enter the scene to perform their tasks.
• Determine if personnel should take pictures of remains in
location they were found.
• Use waterproof tracking/triage tag.
• Determine location for holding morgue so that personnel know
where to deliver remains.
A-2
Guidelines for Mass Fatality Management During Terrorist Incidents Involving Chemical Agents
A-3
Guidelines for Mass Fatality Management During Terrorist Incidents Involving Chemical Agents
6. Other Coordination
• Determine method of communication between the Incident Morgue,
the Morgue, the family assistance center, and the headquarters
building.
• Establish support for medical examiner staff, i.e. Critical Incident
Stress Debriefing.
• Water/re-hydration stations.
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Guidelines for Mass Fatality Management During Terrorist Incidents Involving Chemical Agents
APPENDIX B
The federal Disaster Mortuary Operational Response Team (DMORT) has established a
contingent that is ready to respond to incidents involving weapons of mass destruction
(WMD). Unlike a typical disaster, WMD incidents will present different variables that
will affect DMORT’s response plan. In particular, the type of chemical weapon deployed
will affect decontamination and autopsy procedures thus this team is prepared to
decontaminate remains and monitor them before remains are autopsied and returned to
family members for final disposition.
Presently DMORT has one WMD team. Their equipment is located in York, SC and can
be airlifted or driven anywhere in the US upon request, as it is less than 15 minutes from
the Charlotte, NC airport. Those on the DMORT WMD team are not necessarily located
in the same area as the equipment, so that those members that are closest to the incident
will arrive before the entire team is mobilized, to help the jurisdiction with coordinating
the response. DMORT plans to add a second WMD team to cover incidents that occur on
the west coast as well as a third WMD team to cover the central states. It is unknown
when these additional teams will be operational. Additional information and contact
information can be obtained from the following Web sites.
http://mediccom.org/public/tadmat/ndms/ndms.html
http://www.dmort.org/
The DMORT WMD team is comprised of a minimum of 35 workers, all of whom are
volunteers and have received extensive training in decontamination. They are capable of
performing their function in level A, B, or C Personal Protective Equipment (PPE). All
disciplines within the DMORT community are represented on the team. Members are
trained for their particular duties within the team, but some are cross-trained for two or
more tasks. DMORT WMD can function as a stand-alone team, or they can operate with
other agencies familiar with their protocols to include the National Medical Response
Team (NMRT) and the Chemical Biological Incident Response Force (CBIRF).
Prior to any entry into a contaminated area, each WMD team member is given a health
evaluation by the team physicians and nurses to insure good health, as well as upon
exiting the decontamination area, during recovery time. The team is broken down into
three subgroups: one team is operational, another team is recovering, while the third is
B-1
Guidelines for Mass Fatality Management During Terrorist Incidents Involving Chemical Agents
suited and prepared to “rescue” and remove a worker from the area due to a torn suit,
illness or other unforeseen incident.
Unlike the ten regional DMORT teams, DMORT WMD will initiate identification
procedures prior to decontaminating remains, to include a full body examination,
fingerprint gathering, DNA sample extraction, photography, and, if necessary, autopsy.
DMORT WMD takes into account the criminal aspect of a terrorist incident, and realizes
that decontamination efforts will not likely begin until 24-48 hours post incident. Prior to
decontamination, DMORT WMD requests and works with an FBI agent at the beginning
of the "Reception Area" in the Hot Zone, who determines what is needed as evidence.
All other items not noted as evidence are marked as “personal effects”, removed, tagged
with a body number, stored in a container, and placed in a secure area. DMORT WMD
strategically assigns members with law enforcement experience at the beginning of the
mass fatality management process. These members are trained in and capable of
determining what is evidence. DMORT WMD is also able to secure, for a long or short
period, weapons that are found on victims or on the scene.
After decontamination, all remains, whether full body or body part, are placed into a
clean storage unit and scanned for any traces of chemical agent before they are further
processed. DMORT WMD can hand off remains to the Regional DMORT unit, should
the jurisdiction requires their assistance, who can continue processing remains within
their normal scope of practice.
DMORT WMD also removes wastewater and does not allow it to run into the ground
water system.
DMORT WMD requests that jurisdictions provide the following items when they request
DMORT’s service.
• Ice.
• Refrigerated trucks or trailers.
• Water supply, either via water line or fire apparatus.
• A 60’x60’ hard surface (minimum), i.e., parking lot. Preferably outside as
opposed to inside, unless bad weather dictates otherwise. The ideal surface will
have a gradual slope.
• Security for the entire perimeter by either law enforcement or National Guard.
• Transportation in some cases to and from the airport. This may also include
transportation for equipment.
• LIGHT, NUTRITIONAL meals, drinks, and lodging.
Simply put, DMORT WMD operates much like a high level HazMat Team, with the
exception that they do a lot of forensic and post mortem work during the decontamination
process. The DMORT WMD team, operating a duel system, is able to decontaminate
eight bodies per hour under normal conditions. Inclement and hot weather conditions
may slow the process down, as members will need longer recovery time.
B-2
United States Office of Solid Waste EPA 550-F-00-009
Environmental Protection and Emergency Response July 2000
Agency (5104) www.epa.gov/ceppo/
FIRST RESPONDERS’
ENVIRONMENTAL
LIABILITY DUE TO MASS
DECONTAMINATION
RUNOFF
The Environmental Protection Agency (EPA) is issuing this alert as part of its ongoing effort to
provide information on environmental issues related to biological, chemical, and nuclear terrorist
incidents. EPA publishes Alerts to increase awareness of possible hazards and environmental
concerns. It is important that SERCs, LEPCs, emergency responders and others review this
information and take appropriate steps to minimize risk.
The question is: Can emergency initial entry for more than one hour,
responders undertake necessary awaiting the arrival and set-up of pools to
emergency actions in order to save- collect the deconwater. While the actor-
lives in dire situations without fear of survivors were dying a slow, painful,
environmental liability even when convulsive death, state and federal officials
such emergency actions have were debating and insisting that
unavoidable adverse environmental deconwater had to be collected for proper
impacts? This concern is not limited disposal. By the time the rescuers set up
to WMD terrorist incidents, it has the holding pools and entered the site,
broad implications for our National Response System (NRS) nearly 90 minutes later, the “survivors”
First Responders’ Environmental Liability due to Mass Decontamination Runoff July 2000
had expired. The contaminated water was During a hazardous materials incident (including
collected but the “victims” died. a chemical/biological agent terrorist event), first
responders should undertake any necessary
GOOD SAMARITAN emergency actions to save lives and protect the
PROVISIONS public and themselves. Once any imminent
threats to human health and live are
The Comprehensive Environmental Response, addressed, first responders should
Compensation, and Liability Act (CERCLA), immediately take all reasonable efforts to
Section § 107 (d) Rendering Care or Advice, contain the contamination and avoid or
addresses this issue. Section 107 (d) (1), mitigate environmental consequences. EPA
often known as the “good Samaritan” will not pursue enforcement actions against state
provision states: “No person shall be liable and local responders for the environmental
under this sub chapter for costs or damages as consequences of necessary and appropriate
a result of actions taken or omitted in the emergency response actions. First responders
course of rendering care, assistance, or advice would not be protected under CERCLA from
in accordance with the National Contingency intentional contamination such as washing
Plan (NCP) or at the direction of an on-scene hazardous materials down the storm-sewer
coordinator appointed under such plan, with during a response action as an alternative to
respect to an incident creating a danger to costly and problematic disposal or in order to
public health or welfare or the environment as avoid extra-effort.
a result of any releases of a hazardous
substance or the threat thereof.” This OTHER LIABILITY ISSUES AND
provision does not preclude liability for costs STATE TORT LAWS
or damages as a result of negligence.
Releases of chemical and biological warfare EPA cannot prevent a private person from filing
agents due to a terrorist incident are suit under CERCLA. However, first responders
considered hazardous materials incidents and can use CERCLA’s Good Samaritan provision
therefore CERCLA §107 (d) (1) could apply, as defenses to such an action. First responders
to the extent that there is a release or could also be subject to actions under other
threatened release of a hazardous substance. laws, including state tort laws. A state’s tort law
allows individuals and businesses to seek
In addition, §107(d)(2) provides that state and compensation for losses or harm caused by
local governments are not liable under another. The extent of tort liability of a state or
CERCLA “as a result of actions taken in local governmental jurisdiction, as well as
response to an emergency created by the individual employees or representatives of that
release or threatened release of a hazardous jurisdiction, is established by the tort law of each
substance generated by or from a facility state. The liability of governmental jurisdictions
owned by another person.” Section 107(d)(2) and their employees may be shaped by factors
would insulate state and local governments such as negligence, statutory and discretionary
from potential CERCLA liability arising from immunity, etc. First responders should
first responder actions. However, the consult legal counsel in their state to
provision does not apply to costs or discuss authority, status as an agent of the
damages caused by “gross negligence or state, immunities, and indemnification.
intentional misconduct by the state or
local government.”
APPENDIX D
References
Blewett, WK, Arca, VJ, Rowan, WA, Jones, DW, Aleman, R, Gladden,
D., US Army Chemical Research, Development and Engineering Center (1992).
Evaluation Of A Mortuary Affairs Collection Point-Decontamination. RDTE Project No.
1-M-465710-DO49.
D1-