Guidelines For Mass Fatality Management During Terrorist Incidents Involving Chemical Agents

Guidelines for Mass Fatality
Management During Terrorist

Incidents Involving Chemical
Key Points
Agents
• With proper handling and decontamination the
majority of chemically contaminated fatalities can
be safely returned to families for disposition.
• Only under extreme circumstances should Prepared by:

involuntary cremation be necessary.
• 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
Approved for Public Release; distribution is unlimited

Disclaimer
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 process used to develop the recommendations in this report involved a

comprehensive review of related literature, multiple workshops focused on various
scenarios, and input from scientific experts experienced in chemical agent characteristics.
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.
ii
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.
iii
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
2. Planning For Incidents Involving Chemical Agents................................................................3

2.1 General.................................................................................................................................3
2.2 Personnel .............................................................................................................................4
2.3 Establishing a Holding Morgue .............................................................................................5
2.4 Personal Protective Equipment.............................................................................................5
2.5 Establishing an Off-Site Morgue ...........................................................................................7
2.6 Communication.....................................................................................................................7
2.7 Family Assistance Center Planning ......................................................................................8
2.8 Maintaining Daily Caseload Management ............................................................................8
2.9 Special Considerations .........................................................................................................9
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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THIS PAGE IS INTENTIONALLY LEFT BLANK
v
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.
1
1.2 Objective
The objective of this report is to identify technical and operational issues

specifically associated with the management of fatalities that result from a chemical
WMD incident and to cite planning considerations that will help jurisdictions
mitigate the consequences of such an attack.
1.3 Working Group Process
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:
• Procedures must be usable and expand on or supplement current operating

plans.
• Procedures must address protection of personnel who handle remains.
• Procedures must address the final disposition of remains with the intent of
returning remains to the family.
• Procedures must be supported by sound science or technical information.
• Procedures must address processing the deceased with honor, dignity, and
with an awareness of family members’ religious belief systems, when
applicable.
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.
2
12) represents a sample flow of processing contaminated remains from the

incident scene through final disposition.
• The medical examiner will need to establish and maintain three operations:
processing remains from the incident, establishing a Family Assistance
Center or bereavement center, and continuing to process the normal
caseload.
2.2 Personnel
The medical examiner must have a sufficient number of personnel capable of

working in the contaminated area. These personnel must have a specific level of
training to wear PPE and operate within a contaminated area. It is possible that the
medical examiner will need more personnel than normal, as working in PPE
fatigues workers more quickly, and handling contaminated remains, in general, will
be more difficult.
2.2.1 Initial Evaluation Team
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.
Due to contamination concerns, much of the initial medical

examiner’s investigation will be performed at the incident site.
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
4
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.
2.2.2 Additional Personnel
Handling remains is the responsibility of the local medical examiner, but in a

mass fatality situation handling a large number of remains will likely exceed
the capability of their staff. The medical examiner will need additional
personnel to assist with physically handling remains. In most cases, there will
be personnel at the incident scene who are equipped to assist with certain
operations inside the contaminated area. The medical examiner may be able
to obtain enough personnel trained to use PPE to support recovery and
handling of remains by requesting help from the FBI, the local law
enforcement agency, the fire department, and/or supporting specialized
military teams.
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.
2.3 Establishing an Incident Morgue
In a chemical incident, the medical examiner should be prepared to establish a

preliminary morgue at the incident site. The primary reasons for establishing an
holding morgue is to gather evidence from remains before they undergo
decontamination and evidence is lost, as well as to mitigate cross contamination so
that remains are safer to handle.
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.
2.4 Personal Protective Equipment (PPE)
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.
5
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.
Level A PPE consists of a self-contained breathing apparatus, with full-facemask

cover, a fully encapsulated chemical resistant suit, and inner chemical/biological
resistant hand covers and resistant safety boots/shoes.
Level B PPE consists of a self-contained breathing apparatus, with full-facemask

cover a chemical resistant suit, and inner and outer chemical/biological resistant
gloves, and chemical resistant boots/shoes.
Level C PPE consists of a full-face air purifying canister-equipped respirator, full

body chemical resistant suit, inner and outer chemical/biological resistant gloves,
and resistant boots/shoes.
Level A Level B Level C
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.
6
2.5 Establishing an Off-Site Morgue
The medical examiner may need to establish a morgue at an off-site location to

process remains from a chemical or other type of disaster involving a large number
of remains. Typically, medical examiner buildings will not be able to accommodate
processing a large number of remains, as a large morgue can hold only twenty
bodies. Therefore, medical examiners should consider establishing an off-site
morgue so that remains from the same case are kept together and so that there is
room to set up additional stations to support managing contaminated remains.
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
Communication between medical examiner personnel may be a challenge,

particularly when the medical examiner must operate from four different locations,
i.e., the incident site, the family assistance center, the off-site morgue, and the
morgue headquarters building. The IRP recommends that the medical examiner
establish a direct communication link between these four locations. This direct
communication link allows medical examiners and personnel to obtain and deliver
information quickly. It also keeps all parties abreast of pertinent information, and it
will not be subject to as many system failures as radios or cell phones.
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2.7 Family Assistance Center (FAC) Planning
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.
For more information regarding establishing a FAC or bereavement center, medical

examiners and coroners can read a report titled, Providing Relief to Families After a
Mass Fatality: Roles of the Medical Examiner’s Office and the Family Assistance
Center by Mr. Ray Blakeney, Chief of Operations for the Oklahoma State Medical
Examiner’s Office and Mr. Brian Fiffick from the National Transportation Safety
Board. It is published by the Department of Justice’s, Office of Justice Programs,
the Office for Victims of Crime. It may be retrieved via their Web site,
http://www.ojp.usdoj.gov/ovc.
2.8 Maintaining Daily Caseload Management
Maintaining the ability to attend to the everyday caseload, in light of managing a

chemical WMD incident, is not any different than managing the daily caseload in
the midst of other types of disasters. It is likely that the local medical examiner will
be overwhelmed with organizing the incident and mobilizing resources, however
he/she needs to plan how their office will continue to address the daily influx of
cases.
Medical examiners will have limited resources to perform autopsies on non-

chemical incident cases. Medical examiners should consider the possibility that
criminal activity involving homicides and murders may actually increase, as
criminals may use disaster circumstances as a cover for their activities. Thus, there
may be an increase in the number of daily cases during a disaster.
The IRP recommends two general principles regarding caseload management.

Medical examiners should consider keeping the two caseloads separate so that
personnel can focus on their assigned tasks. Second, the IRP also recommends that
medical examiners avoid scheduling 24-hour operations, as this will quickly fatigue
all personnel. Instead, they should add a second shift of personnel to address the
chemical incident caseload at a separate location (or temporary morgue). Separate
8
locations with designated staffs may provide more order and continuity for
managing a mass fatality situation overall.
2.9 Special Considerations
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.
2.9.1 Incorporation of Disaster Mortuary Operational Response Team

(DMORT)
When planning a response to a chemically contaminated incident, medical

examiners may consider including the resource and capabilities of DMORT.
DMORT is part of the National Disaster Medical System under the
Department of Health and Human Services. It is an organized team with the
experience and expertise to manage a large number of fatalities. There is one
team for each of the ten federal emergency management agency regions. The
teams are comprised of private citizens with expertise in victim identification
and mortuary procedures. The team is federalized when they respond to a
presidential declared disaster. DMORT works under the authority of the local
jurisdiction. They can:
• Provide a mobile morgue.

• Perform autopsies.
• Perform identification of remains.
• Perform tracking of remains.
• Establish and operate a family assistance center.
• Provide ante-mortem data collection.
• Provide assistance for the recovery of remains in non-contaminated
settings.
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.
9
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.
2.9.2 Organ Donation/Transplant
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.
Although chemical agent exposure does not necessarily preclude organ

donation, the medical examiner may consider attending to these cases a low
priority. In routine organ donor cases, the medical examiner must determine
if an autopsy is warranted to determine the cause of death before personnel
can harvest organs. If a person dies in a hospital and a contributing factor is
the chemical agent exposure, the medical examiner must also decide if an
autopsy is warranted before the death certificate is signed. Under these
circumstances, it is likely that there will be too many other concerns for the
medical examiner to address that may prevent him/her from responding to
donor cases in a time critical manner. Furthermore, it is also probable that no
one will take the risk of transplanting organs from such a donor, even if it is
deemed safe.
2.9.3 Contaminated Animal Remains
Although not specifically their responsibility, medical examiners may be

asked to address the issue of contaminated animal remains following a
chemical terrorist incident. A serious health risk may exist when large
numbers of contaminated animal remains are in public areas. The local
animal control agency may consult with the medical examiner as to how they
10
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.
Medical examiners should provide animal control personnel with the

following answer:
The local animal control department should consult the FBI to
determine if these animals need to be held for evidence or if they can
be disposed.
Animal remains should be collected, tagged, and identified according
to the specific area where they were found, if they are considered
evidence.
Small animal remains can be sealed in 55-gallon hazardous waste
drums, and given to the FBI.
The local animal control department can also consult with the State
Veterinary Services and request cremation for larger animals.
Those handling animal remains must wear Level C PPE unless the
Incident Commander specifically states that a different level of PPE is
acceptable, e.g., plastic gown, foot covers, facemask, and butyl gloves.
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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3.0 Processing Flow of Contaminated Remains

3.1 General
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.
Specifically in chemically contaminated incidents, many functions that are normally

reserved for the morgue may have to be performed at the scene. Remains must be
decontaminated before they are removed from the incident site to avoid cross-
contaminating other areas and people. The medical examiner will need to gather
evidence before remains undergo gross decontamination so as not to loose vital
evidence to the case. Consequently, personnel will need to wear PPE while
performing their tasks, as much of the operation will be conducted within the Hot or
Warm Zones.
Off-Site
Morgue:
Autopsy
Remain Transport & Transport & Final

Recovery Holding Morgue Temporary Transport (?) Temporary Disposition
Storage Storage
Off-Site
Morgue:
Identification
& Embalming
FIGURE 1 – Processing Flow of Contaminated Remains
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3.2 Remain Recovery: General
The first step in processing remains involves recovering remains. Recovering

remains will entail tracking remains and moving remains to the Incident Morgue.
Recovery of remains may also entail taking pictures of remains in the location they
were found, determining if additional bodies require an autopsy, and separating
remains identified for autopsy from those not requiring an autopsy as they are
brought to the holding morgue area.
3.2.1 Additional Personnel
In some circumstances, the medical examiner and Federal Bureau of

Investigation (FBI) may determine that the FBI should manage the task of
search and recovery (S&R) of remains. Typically, the FBI Evidence
Response Team handles S&R operations in non-contaminated incidents,
i.e. aircraft remain recovery, but in contaminated incidents, the FBI’s
evidence team, the Hazardous Materials Response Unit (HMRU), may not
be able to manage remain recovery. It is likely that the medical examiner
will not be able to task the FBI with the entire S&R operation. The
medical examiner and FBI should jointly coordinate and oversee these
efforts, requesting the aid of other supporting agencies when they do not
collectively have enough personnel to perform recovery operations.
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
The tracking of remains using waterproof tags needs to begin at the

recovery phase of the operation. Decontamination makes it difficult for
the medical examiner to track remains by ordinary methods. Most tags
used by the medical examiner are not waterproof and will not withstand
the decontamination process. In some jurisdictions, Emergency Medical
Services may already use waterproof triage tags that have multiple peel-
13
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.
Bar code scanners can also simplify the recording/tracking process.

Personnel can use portable scanners on-site, which may expedite the
tracking process.
DMORT already uses a comprehensive tracking system that consists of

scanners and a specific computer software program. A jurisdiction may
want to request that their regional DMORT team share their experiences
with regards to tracking remains and demonstrate the scanner and software
system they use.
Due to the need to decontaminate remains at the incident site, the

medical examiner must use a durable waterproof tracking tool.
3.3 Holding Morgue: General
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.
3.3.1 Covering Remains
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.
14
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.
3.3.2 Collecting Evidence
In a chemically contaminated situation, the medical examiner needs to

perform initial evidence collection at the incident site before remains are
transferred. Remains must be decontaminated before they are removed
from the incident site to minimize cross-contamination and make the
remains safer to process. Evidence critical to the investigation may be lost
through this process. It is likely that remains may have already been
partially washed as part of the overall incident decontamination effort;
however, they will still undergo a gross decontamination before being
removed from the scene. The medical examiner should attempt to gather
as much evidence as possible prior to gross decontamination.
All remains must undergo a thorough

external evaluation. Medical examiner
personnel should collect body-surface
swab samples for chemical agents, and
obtain samples of tissue, blood, and
fabric. Part of this evaluation should
inlcude a preliminary identification check.
Some personal effects may be considered evidence. The IRP recommends

that medical personnel remove personal effects with FBI personnel
present. Personal effects identified as evidence should be removed, tagged
and directly handed over to the FBI. Medical examiner personnel should
place evidence in glass containers as many plastics allow certain chemical
agents to seep through the material. Since glass containers are breakable,
glass containers should be placed in a second container, e.g. a clean paint
can, so that the evidence is protected. Items that are not considered
evidence are considered personal effects. (See Section 3.3.3 for handling
personal effects.)
3.3.3 Handling Personal Effects
At the Incident Morgue, the medical examiner should remove personal

effects from remains, tag them, and segregate them into durable and non-
durable piles. Non-durable items, such as clothing, will most likely be
destroyed rather than decontaminated and returned. Durable items such as
keys, wallets, and cell phones may be eventually returned to family
members, providing the medical examiner coordinates efforts to
decontaminate and monitor the items so that they are free of
contamination. Investigators and prosecutors must determine if any
15
personal belongings are considered evidence before the medical examiner

can begin returning personal effects.
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.)
3.3.4 Gross Decontamination
Though not normally performed by the medical examiner,

decontaminating remains becomes the medical examiner’s responsibility
in a chemical WMD incident.
The medical examiner should begin by obtaining the necessary equipment

to perform gross decontamination. The IRP recommends that medical
examiners establish a rapport with an agency that is capable of setting up a
decontamination line, supplying extra PPE, and providing experienced
manpower rather than purchasing all the equipment and establishing all
these capabilities on their own. Examples of agencies, which can provide
such support, include local or regional HazMat teams, the State
Department of Environment, or private industry HazMat teams. Agencies
already on the scene may have decontamination lines established for
patient decontamination and for responders who entered the Hot Zone.
The medical examiner must coordinate with the respective agency if they
desire to use these decontamination lines. For a mass fatality incident, a
decontamination line must include equipment to assist with lifting,
carrying, and moving large numbers of remains (sawhorses, rollers), as the
strenuous activity will rapidly fatigue personnel wearing PPE.
Personnel performing decontamination should

wear an appropriate level of PPE. Personnel may
not need to wear as extensive PPE as those
personnel who responded on the initial day of the
incident. As a minimum, Level C protection is
recommended; however, the medical examiner
should check with the Incident Commander
regarding the appropriate level of PPE.
As part of the incident response, there should already be contamination

control zones (Hot, Warm, and Cold) established. These zones need to
remain in place during the processing of remains. In the case of
16
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.
When performing decontamination, medical examiners will need a system

similar to those that support non-ambulatory casualties. These types of
decontamination systems may have elaborate rollers, showers, and dikes
so that remains do not need to be lifted from decontamination pool to
decontamination pool. Medical examiners can simply incorporate
sawhorses, backboards, pools, and water from a hose line to support
decontaminating remains. In either system, performing decontamination
should incorporate mitigating contaminated water runoff (see Appendix C
regarding the Environmental Protection Agency’s stance on contaminated
water runoff).
The IRP recommends that medical examiners use additives when

performing gross decontamination. Common additives used in
decontamination of chemical warfare agents include:
• Soap, which aids in dissolving oily substances like mustard or

blister agent.
• Bleach (sodium hypochlorite), which removes, hydrolyzes, and
neutralizes most chemical agents.
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
17
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.
For other recommendations regarding gross decontamination, medical

examiners may want to incorporate the best practices outlined in the IRP’s
Guidelines for Mass Casualty Decontamination During a Terrorist
Chemical Agent Incident report. (To obtain this report go to the
SBCCOM Web Site www2.sbccom.army.mil/hld). Many of the
procedures in this report have applicability when decontaminating
remains.
3.4 Transportation & Temporary Storage: General
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.
3.4.1 Transportation 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).
Refrigerating remains may alleviate the medical examiner from some of

the burden associated with performing time critical tasks. Refrigerating
remains, depending on the refrigeration temperature, can prevent or
greatly slow down tissue degradation, which ultimately mitigates one type
of public health hazard from occurring. Thus refrigerating remains may
18
help the medical examiner achieve the ability to return remains to family
members.
Medical examiners should devise a plan that minimizes the number of

times remains are transported and moved. Every time remains are moved,
a cadre of logistical support must be in place, to include transportation
vehicles, personnel who must move remains in PPE, and possibly FBI
agents to oversee remain movement since remains are considered
evidence. Thus minimizing the number of times remains are moved
simplifies overall management of remains.
3.4.2 Storage Assets
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.
Regardless of the type of storage the medical examiner uses, remains

should not be stacked unless shelving units are utilized. Even with
shelving units, remains should not be stacked higher than waist level to
prevent injury to those handling the remains.
3.5 Processing Remains at the Off-Site Morgue: General
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.
3.5.1 Processing Locations
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.
When establishing an off-site morgue, medical examiners should consider

using alternative sites identified in their standard evacuation plan. The
medical examiner should already be familiar with these sites and the
equipment and supplies necessary to make them operational. Evacuation
plans should be supplemented with a resource list identifying items needed
to process contaminated remains. Additionally, the medical examiner
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should consider requesting the aid of law enforcement officers to provide

security at each off-site morgue facility.
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.
Alternative locations should have:
• Large open floor space.

• Electrical power (although large generators can supplement this
need).
• Water supply.
• Air conditioning/heat.
• Provisions for staff (restrooms, recovery area).
Ideally, each alternative facility should be capable of performing all four

critical functions required to process remains, i.e. detailed decontamination,
autopsy, identification, and embalming. This would reduce the need to
transfer remains between locations.
When the medical examiner must use a decentralized means of processing

remains and not all four functions can be performed at the same location, all
fatality processing should be well coordinated. The local medical examiner
must provide overall command and control, as he/she will have overall
responsibility for processing the remains and signing death certificates.
If the medical examiner must use a decentralized means of processing

remains then he should consider how the operation could be most effectively
divided. One suggestion is for detailed decontamination and autopsy
procedures to occur in one location and detailed decontamination,
identification, and embalming to occur in a different area. Another
suggestion is to maintain autopsy and identification procedures in one
location so that only one detailed decontamination station is needed and
embalming is in a different location. Thirdly, the medical examiner may
need to set up three separate locations, dividing the entire operation into
detailed decontamination and autopsy; detailed decontamination and
identification; and embalming.
3.5.2 Detailed Decontamination
Although remains underwent gross decontamination at the incident site,

those handling remains should not consider them free of contamination.
Many types of chemical agents are not easily washed away during the gross
decontamination process. All remains must undergo a detailed
20
decontamination, using soap or bleach solution, before an autopsy is

performed or embalming takes place. If the decontamination is performed
in an enclosed area, it must be ventilated.
When remains are to be embalmed, they should be decontaminated in a

separate area or room from the embalming area. Some decontamination
solvents such as bleach create toxic reactants when mixed with embalming
fluid. The medical examiner should take every precaution to avoid creating
further hazards.
3.5.3 Identification
Despite the magnitude of the incident, procedures to identify remains should

not change. Normal identification procedures are lengthy and the FBI fully
supports the amount of time the medical examiner needs. The chemical
agent exposure does not specifically interfere with the normal processes
used for identification.
3.5.4 Autopsies
In the case of a large number of fatalities, it may not be feasible to consider

performing a complete autopsy on all remains. The medical examiner, FBI,
and the US Attorney, should collectively determine which remains require
an autopsy. Each agency has its specific requirements for identifying
autopsies to support the overall investigation. After determining the number
of cases for autopsy, it may exceed the operational capacity of the medical
examiner’s office. In this case, the medical examiner should coordinate
support from adjoining jurisdictions, states, or from federal resources.
In situations when the medical examiner must process a large number of

remains, the IRP recommends that the aforementioned agencies consider
only performing an autopsy on a random sample of bodies found inside the
Hot Zone, as well as on atypical cases instead of on each remain. Those
remains not originally identified for autopsy will still undergo a thorough
external evaluation, identification check, and medical examiner personnel
will still gather from them a certain amount of evidence.
If the agencies still require additional autopsy information at a later point,

the medical examiner can perform an autopsy on embalmed remains.
Though some evidence may be altered from the embalming fluid, it is easier
for medical examiner personnel to perform autopsies on embalmed remains
rather than on decayed remains. (See Section 3.5.5 for more information
regarding embalming and why the local medical examiner may want to be
responsible for this additional task).
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Those performing autopsies may question if they will be exposed to harmful

chemicals as a result of performing autopsies on contaminated remains.
With the exception of ingested cyanide pills, chemists, toxicologists and
medical examiners supporting the working group process indicated that
chemicals are metabolized, hydrolyzed or tightly bound in the body’s
tissues; therefore, there should be little threat of chemical off-gassing when
performing an internal examination. However, personnel may still be
exposed to chemical contamination that persists on the outside of the body.
While the dangers from external contamination are low, especially after
remains have been decontaminated twice, personnel should continue to wear
Level C PPE while performing autopsies.
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.
Medical examiners should follow their standard protocols for gathering,

packaging, and storing evidence found during the autopsy process. If there
is not enough room to properly store evidence due to the number of remains,
then the medical examiner should request law enforcement personnel to take
immediate possession of the evidence. If personnel are concerned that the
evidence is chemically contaminated, then it should be packaged in a
manner that prevents cross-contamination but does not destroy the evidence.
One option is to place evidence inside a glass container and then place that
container inside a clean paint can.
In the case of a large number of fatalities, it may not be feasible to
consider performing a complete autopsy on all remains.
3.5.5 Embalming
Although embalming is not their direct responsibility, medical examiners

should consider supervising these efforts, at the temporary morgue, to
simplify the management of a large caseload. Local morticians may have a
lot of questions regarding safe handling procedures and turn to the medical
examiner for support; thus handing off remains to the local mortician may
result in more work for the medical examiner in the end. It is likely that
when local morticians have questions and seek their input, the medical
examiner will have to re-engage in managing remains.
Another reason the medical examiner should consider overseeing

embalming is that chemically contaminated remains may create a more
22
hazardous situation than the local mortician is prepared to manage.

Embalming may resurface internal contamination on the skin, therefore
monitoring remains for residual chemical contamination before they are
embalmed, may produce inaccurate data regarding their state of
contamination (See Section 3.7.1 regarding chemical agent monitoring).
Ultimately, the medical examiner is responsible to ensure the highest level
of safety for those handling remains, before remains can be are transferred
to local morticians.
Other benefits of embalming include:
• Embalmed remains do not require refrigeration unless they are

held for more than 3 weeks post embalming.
• The number of refrigerated cars/units is reduced.
• Embalmed remains only need to be stored in a cool area.
• A more accurate contamination reading from chemical agent
monitors is possible if data is collected after remains undergo
embalming.
• Embalmed remains are easier to autopsy than decayed remains.
To safely perform embalming the medical examiner should establish a

specific order of tasks. Additionally, all personnel should wear Level C
PPE and all rooms should have adequate ventilation.
Before remains are embalmed, personnel should perform a detailed

decontamination with additives (soap or sodium hypochlorite). This
detailed decontamination should take place in different room from where
embalming takes place, as embalming fluid and sodium hypochlorite
produce a hazardous gas when mixed. (See Section 3.5.2 regarding
detailed decontamination procedures specifically).
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.
23
Once embalming is complete, remains must undergo a thorough rinse. It is

possible for certain contaminants to resurface on the skin after the
embalming process is complete. Upon completion of this final rinse,
personnel can place remains in double body bags.
3.6 Transport and Temporary Storage
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.
3.7 Final Disposition: General
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).
24
In short, a chemical WMD incident should not automatically preclude a jurisdiction

from returning remains. The only variable that directly affects the decision to
withhold remains is the inability to completely decontaminate them, which
consequently results in a public health hazard. The factor that may indirectly affect
the ability to return remains is the length of time it takes to identify, mobilize, and
coordinate the large number of resources needed to process chemically
contaminated remains in a time critical manner. Thus, several factors may
collectively influence final disposition.
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.
3.7.1 Chemical Agent Monitoring
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.
Proper low-level monitoring may be impracticable

when there are a large number of remains to process.
The chemical agent protocols, specified in military
procedures, involve sampling the airspace of each
body bag using a mass spectrometer is time-
consuming and requires trained personnel. It is
impractical to expect a local medical examiner to have
the resources to monitor each body or the assets to
support chemical agent monitoring.
25
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.
If a low level mass spectrometer does detect contamination, the medical

examiner, in conjunction with the local and state health commissioner, the
chief officer for the department of the environment, the state emergency
manager, and the governor, can make a risk based decision regarding the
level of contamination and how it affects final disposition of remains.
Medical examiners should know that that the federal Environmental
Protection Agency does not accept any detectible level of contamination.
If chemical agent contamination is not measurable above pre-existing

background levels of ground/air contamination, with a low-level mass
spectrometer, then the medical examiner may consider the remains safe
for return to family members.
3.7.2 Burial
There are three options associated with the burial of previously

contaminated remains. They are standard burial, burial using sealed
caskets, and state sponsored mass burial.
Standard burials are acceptable when contamination levels are considered

safe for morticians to handle without any associated exposure risks.
Present burial procedures protect the environment from hazards. If
remains are considered safe to return to family members, then they are
considered safe to bury and will not adversely affect the environment.
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.
Another option regarding final disposition is state sponsored mass burial.

Though it has rarely been used in the United States, authorities may accept
mass burial under extreme circumstances. One such circumstance is when
burying remains is safer than cremating remains. This issue presents more
26
often when remains are biologically contaminated rather than chemically

contaminated remains, however, some jurisdictions may not have adequate
access to crematoriums to support individual cremation. Thus to prevent
contamination from spreading, authorities may choose to minimize
handling remains and identify a site that can support mass burial.
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.
3.7.3 Cremation- Voluntary and Involuntary
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.
When contamination cannot be mitigated with decontamination efforts,

involuntary individual cremation may be the only remaining option. A
jurisdiction’s emergency plan should reflect the location and capability of
area crematoriums.
The medical examiner should make every effort to return remains

to family members for final disposition. Remains should only be
held when contamination cannot be brought to a safe level or if
there is a declared public health hazard.
Medical examiners should consider preparing remains for cremation even

if authorities have not determined their final disposition. One reason for
this is that some family members may automatically prefer cremation
instead of burial. A second reason is if authorities decide that remains will
undergo involuntary cremation, after remains have been processed through
the morgue, then remains will already be prepared while personnel were
wearing PPE.
The appropriate time to prepare remains for possible cremation is before

they are embalmed (See Section 3.5.5 for more information regarding
embalming). Personnel should scan and remove all internal devices, e.g.,
automatic defibrillators and internal pacemakers, before embalming since
it does not take very long and personnel will already be wearing PPE.
Preparing for cremation early in the fatality management process will
possibly mitigate re-processing remains at a latter point, thereby
minimizing the number of times personnel must handle remains.
27
3.7.4 Local Morticians
Regardless of the measures medical examiners take to ensure safety,

morticians and funeral directors may still be reluctant to receive
contaminated, or previously contaminated remains. For example, in the
1980s, morticians were reluctant to handle remains when the cause of
death was AIDS. Now, after many years, morticians who are accustomed
to the AIDS procedures practice the standard and perform their work with
confidence that they will not become infected.
It would be prudent to include morticians when jurisdictions develop their

plans and conduct training and exercises on chemical mass fatality
management.
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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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APPENDIX A
Generic Response Incident Planning Guide for

Medical Examiners
I. Manage Incident Site

A. Obtain Information from the Incident Commander.
• Chemical agent.
• Number of approximate remains.
• How the agent was disseminated, (i.e. vapor, liquid).
• Type of incident (i.e. traditional bomb, chemical cloud).
• Location and if there are any geographic complications, e.g. building
destruction.
• Location of the Command Post.
B Send Evaluation Team to Incident.

• Report to the Command Post.
• Prepare to enter the scene with the FBI HazMat Technician and other
relevant agency representatives.
• Check on level of PPE required- Level A/B/C.
• Two teams of two persons (one team is needed as a backup).
• Identify challenging issues e.g. fragmentation, difficult excavation,
contamination.
• Take initial pictures of the scene.
• Determine total number of remains and their location.
• Determine the initial number of cases for autopsy.
C. Establish the Plan

1. Address the General Operation
• Include Incident Commander, FBI, and potentially DMORT Regional
Administrator and or DMORT WMD and any other relevant agency
representatives in the planning process.
• Know identity of the chemical agent as this will determine the
decontamination solvents and safe handling procedures.
• Determine which remains should be autopsied based on the local
medical examiner’s capability and the FBI’s need to gather evidence
and the US Attorney’s need to prosecute the case.
• Determine if chemical monitoring will be used to determine if remains
are free of contamination or if remains will not be monitored
individually but rather collectively via air sampling.
o Determine who will do this and when it will be performed as
this will affect if ME/Coroners must wear PPE during certain
stages of the operation.
• Determine location for the off-site morgue.
A-1
• Create an infrastructure to process remains so additional resources can

backfill the operation. Identify who, what, when, where, and how for
each phase of the operation.
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.
ii. Holding Morgue Phase

• Establish a covered area.
• Establish area to perform evidence removal, external
evaluation, initial identification check, and removal of personal
affects.
o Determine if FBI is needed to help identify additional
evidence.
o Determine if medical examiners are to perform any
additional procedures as part of the external evaluation,
e.g. chemical agent body swab, sample of clothing.
o Obtain 55-gallon drums to store personal effects.
o Obtain glass jars and paint cans to store evidence.
• Establish area to perform initial decontamination.
o Water and bleach or detergents.
o Mitigate contaminated water run-off.
o Double body bag with duct tape.
iii. Transportation and Storage Phase

• Obtain refrigerated vehicles- 18-wheel vehicles or railroad
cars.
o Do not stack remains; use shelving units.
o Do not place remains higher than the waist level of the
handlers.
• Obtain refrigerated storage location if trucks are not available.
• Try to co-locate mortuary affair functions in close proximity to
one another.
A-2
iv. Off-Site Morgue Operations Phase

• Determine if the morgue operation can be centralized in one
location or if it must be decentralized into several smaller
locations.
• Perform detailed decontamination.
• Perform autopsy on those remains previously identified
requiring an autopsy and then send remains for identification
and embalming.
• Perform identification procedures.
• Perform embalming procedures.
• Perform final rinse after embalming.
• Determine location for holding/storage if FBI and US Attorney
do not authorize the release of remains.
v. Final Disposition Phase

• Determine if a public health hazard exists.
• Determine if remains will undergo chemical agent monitoring
with a mass spectrometer.
• Determine if remains can be returned to family members.
• Determine if family member prefer cremation.
• Determine transportation method to final disposition.
2. Assign Personnel- Roles & Responsibilities

• Mobilize local personnel with appropriate PPE and assign tasks.
• Identify specific ME/Coroner personnel to take charge of certain tasks
and supervise others.
• Establish shift/breaks with PPE in mind.
• Determine if additional non-ME/Coroner personnel are needed and
formulate teams with local ME and FBI as part leaders of each team.
3. Mobilize Other Agencies:

• Local agencies- HazMat teams locally (mutual aid agreements).
• State agencies- Department of the Environment, National Guard.
• Regional- Surrounding states that may be able to support your efforts.
• Federal agencies- DMORT.
• Military agencies- Joint Task Force-Civil Support.
• Volunteer agencies- American Red Cross to assist with the Family
Assistance Center.
4. Mobilize Specific Resources [This is not a comprehensive list of additional

resources.]
• Refrigerated trucks.
• Decontamination line/equipment for the holding morgue and the
Temporary Morgue.
A-3
• PPE for personnel.

• Final rinse station after embalming.
• Ventilation fans.
• Additional body bags and duct tape.
• Additional evidence collection containers- glass jars and paint cans.
• Storage containers for PPE, e.g. 55-gallon drums.
• Tents to keep remains from public view.
• Water-proof tracking tag/tool.
5. Identify Financial Issues.

• Contact state emergency management agency to initiate application
process.
• Track all activities and expenses regardless of incident being declared
a presidential disaster.
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.
II. Plan for Family Assistance Center (FAC).

• Establish a hotline/help-line to simplify notification and identification process.
• Establish FAC location in reasonable proximity to the off-site morgue.
• Plan to disseminate information to family members as well as the Joint Operations
Public Information Officer (PIO) on a regular basis.
• Address if and when personal effects may be released.
• Obtain multi-religious leader support.
• Plan a memorial service and plaque for the city.
III. Plan to Maintain Processing the Daily Case Load.

• Add a second shift to handle the incident site remains so that original staff can
focus on the daily caseload.
• Keep caseloads separate.
• Avoid 24-hour operations.
A-4
APPENDIX B
Disaster Mortuary Operational Response Team WMD Unit
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.
DMORT WMD is qualified, ready, and available to respond to a presidential declared

disaster under the auspices of the Federal Response Plan, via the Office of Emergency
Preparedness, Department of Health and Human Services. The team is comprised of
forensic scientists who understand the characteristics of WMD and two emergency
managers who have gleaned ideas, as to the best way to manage chemically and
biologically contaminated incidents, from experts across the country.
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
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.
PROBLEM and frequently is discussed in the

hazardous materials response community.
On April 19, 1999, the Team Leader
of the Chemical Weapons Improved THE NERVE AGENT DRILL
Response Team (CWIRT), U.S.
Army Soldier and Biological The federal government recently
Chemical Command sent a letter to sponsored a multi-agency drill based on a
EPA raising issues concerning first simulated nerve-agent attack. The release
responders’ liability during a of the nerve agent resulted in hundreds of
weapons of mass destruction simulated casualties who survived the
(WMD) terrorist incident. initial terrorist attack. The hazmat team
Specifically, the CWIRT asked had to rescue and decontaminate these
about the first responders’ liability for “survivors” before they could receive
spreading contamination while medical attention. The hazmat team
attempting to save lives. identified the need to collect the water
used to decontaminate the victims
ALERT
Environmental liability resulting from (deconwater) to avoid a release to the

critical lifesaving actions may seem environment. During the drill, these very
unlikely, but could be a serious capable, well-equipped, well-intentioned,
concern for many first responders. professional hazmat teams delayed their
CHEMICAL SAFETY
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.”
Chemical Emergency Preparedness and Prevention Office

First Responders’ Environmental Liability due to Mass Decontamination Runoff July 2000
FEDERAL SUPPORT DURING conducted.

A WMD INCIDENT
PRE-PLANNING IS KEY!
Contaminated runoff should be avoided
whenever possible, but should not impede It may not be technically feasible to contain all
necessary and appropriate actions to protect the runoff resulting from a WMD incident, but
human life and health. Once the victims are emergency responders may be able to reduce its
removed and safe from further harm and impact to the environment by pre-planning.
the site is secured and stable, the first Responders can maximize local resources by
responders should be doing everything using existing response mechanisms as much as
reasonable to prevent further migration of possible. Local Emergency Planning
contamination into the environment. Committees (LEPCs) are a good starting point.
LEPCs are established under the Emergency
First responders should involve state and Planning and Community Right-to-Know Act to
federal officials as soon as possible to reduce develop local governments’ emergency response
potential liability concerns. Under CERCLA, and preparedness capabilities through better
the Federal On-Scene Coordinator (FOSC) coordination and planning, especially within the
can determine which environmental regulations local community. LEPCs include elected
are applicable (or relevant and appropriate) to officials, police, fire, civil defense, public health
any removal response and may further professionals, environmental, hospital and
determine that any such environmental transportation officials, who can work together
regulation is impracticable to achieve creatively using available resources to minimize
depending on the exigencies of the situation. If the environmental impact of WMD incidents.
the FOSC determines that it is impracticable
to comply with any particular environmental
regulation, then the responders (local, state, For More Information..............
Federal or responsible party) do not have to
comply with that particular environmental
regulation. By involving FOSC, first
responders can substantially reduce their Contact the Emergency Planning and
potential liability. Community Right-to-Know Hotline
In addition, FOSCs have an expanse of (800) 424-9346 or (703) 412-9810

resources under the NRS to support state and TDD (800)553-7672
local responders in determining a solution
which best addresses protectiveness of human Monday -Friday, 9 AM to 6 PM, EASTERN
health and the environment. Under the NRC, TIME
the FOSC can provide invaluable assistance in

determining clean-up and decontamination ———
needs, health criteria and appropriate clean-up Visit the CEPPO Home Page on the
protocols as needed. FOSC support is even World Wide Web at:
more critical in the aftermath of a WMD http://www.epa.gov.ceppo/
terrorist attack when critical post-emergency
actions such as agent identification, crime
scene sampling, crime scene preservation, and
long-term risk evaluation are also being
Chemical Emergency Preparedness and Prevention Office

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.
Department of the Army (1997). Toxic Chemical Agent Safety Standards,

Chapter 5: Decontamination and Disposal. AR 385-61.
Department of Health and Human Services. (1991). Managing Hazardous

Material Incidents: Managing Guidelines for Acute Chemical Exposure vol. 3 (ATSDR
Contract No. 205-90-0817). Rockville, MD: Agency for Toxic Substances and Disease
Registry.
Department of Health and Human Services (1999). Disaster Mortuary

Assistance Team: DMORT Emergency Team Handbook. 9350.1-HB.
http://mediccom.org/public/tadmat/ndms/ndms.html, http://www.dmort.org/
Nordberg, M. (1996). Terror At The Olympics. Emergency Medical

Services, 25 (11) 54.
U.S. Army Soldier and Biological Chemical Command, Domestic Preparedness,

Chemical Team (1999). Guidelines for Mass Casualty Decontamination During a
Terrorist Chemical Agent Incident.
U.S. Army Soldier and Biological Chemical Command, Domestic

Preparedness, Chemical Team (1999). Use of Positive Pressure Ventilation Fans To
Reduce the Hazards of Entering Chemically Contaminated Buildings.
U.S. Army Soldier and Biological Chemical Command, Domestic

Preparedness, Chemical Team (2000). Personal Protective Equipment for Use by Law
Enforcement Officers at a Terrorist Incident Involving Chemical Warfare Agents.
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Guidelines for Mass Fatality

Management During Terrorist

• Only under extreme circumstances should Prepared by:

Approved for Public Release; distribution is unlimited

The process used to develop the recommendations in this report involved a

2. Planning For Incidents Involving Chemical Agents................................................................3

The objective of this report is to identify technical and operational issues

1.3 Working Group Process

• Procedures must be usable and expand on or supplement current operating

12) represents a sample flow of processing contaminated remains from the

The medical examiner must have a sufficient number of personnel capable of

2.2.1 Initial Evaluation Team

Due to contamination concerns, much of the initial medical

2.2.2 Additional Personnel

Handling remains is the responsibility of the local medical examiner, but in a

2.3 Establishing an Incident Morgue

In a chemical incident, the medical examiner should be prepared to establish a

2.4 Personal Protective Equipment (PPE)

Level A PPE consists of a self-contained breathing apparatus, with full-facemask

Level B PPE consists of a self-contained breathing apparatus, with full-facemask

Level C PPE consists of a full-face air purifying canister-equipped respirator, full

Level A Level B Level C

2.5 Establishing an Off-Site Morgue

The medical examiner may need to establish a morgue at an off-site location to

Communication between medical examiner personnel may be a challenge,

2.7 Family Assistance Center (FAC) Planning

For more information regarding establishing a FAC or bereavement center, medical

2.8 Maintaining Daily Caseload Management

Maintaining the ability to attend to the everyday caseload, in light of managing a

Medical examiners will have limited resources to perform autopsies on non-

The IRP recommends two general principles regarding caseload management.

2.9 Special Considerations

2.9.1 Incorporation of Disaster Mortuary Operational Response Team

When planning a response to a chemically contaminated incident, medical

• Provide a mobile morgue.

2.9.2 Organ Donation/Transplant

Although chemical agent exposure does not necessarily preclude organ

2.9.3 Contaminated Animal Remains

Although not specifically their responsibility, medical examiners may be

Medical examiners should provide animal control personnel with the

3.0 Processing Flow of Contaminated Remains

Specifically in chemically contaminated incidents, many functions that are normally

Remain Transport & Transport & Final

FIGURE 1 – Processing Flow of Contaminated Remains

3.2 Remain Recovery: General

The first step in processing remains involves recovering remains. Recovering

3.2.1 Additional Personnel

In some circumstances, the medical examiner and Federal Bureau of

The tracking of remains using waterproof tags needs to begin at the

Bar code scanners can also simplify the recording/tracking process.

DMORT already uses a comprehensive tracking system that consists of

Due to the need to decontaminate remains at the incident site, the

3.3 Holding Morgue: General

3.3.1 Covering Remains

3.3.2 Collecting Evidence

In a chemically contaminated situation, the medical examiner needs to

All remains must undergo a thorough

Some personal effects may be considered evidence. The IRP recommends

3.3.3 Handling Personal Effects