A chemical spill, nuclear attack, biological agent, pandemic, hurricane, and numerous other threats and hazards have the potential to kill enough people to overwhelm any particular jurisdiction. Whether that number is 10 or 10,000 or more, the “unthinkable” can happen anywhere. On 16 June 2017, DomPrep hosted a panel discussion on this topic at the International Hazardous Materials Response Teams Conference in Baltimore, Maryland. The key takeaways from that session are summarized here.
When a disaster strikes, communities must be prepared in advance to manage whatever consequences occur. In a worst-case scenario, this may include mass fatalities. To adequately prepare, communities need to be equipped with the right combination of incident management, personnel, training, and supplies. Valuable assets, which may be available locally or through mutual aid, include, but are not limited to disaster response/recovery teams, crisis and grief counselors, search and cadaver dogs, forensic and storage facilities, and body bags. If the complex mass fatality management process (i.e., recovering, handling, identifying, and reuniting human remains) is introduced during a crisis, then additional public health, mental health, and public relations problems are certain to arise. By understanding such critical information, first responders will be equipped to play a greater role in mitigating the potential cascading life, health, and safety effects to themselves and the public when they are faced with this worst-case scenario.
Meet the Experts
Mass fatality incidents are often in news reports around the world. However, data on such incidents are not clearly defined because the number of fatalities that would overwhelm local resources varies between jurisdictions. A participatory session at the International Hazardous Materials Response Teams Conference hosted by the International Association of Fire Chiefs (IAFC) in Baltimore, Maryland, on 16 June 2017, featured a panel of subject matter experts who presented information and answered questions about the mass fatality response process. Each of the following panelists has been involved in one or more mass fatality incidents:
- The moderator of the discussion, Ron Vidal, is a partner at Blackrock 3 Partners and has served on 12 federal, state, and local task forces. He is a member of the Oakland (California) Fire Safety Task Force, formed by an executive order of Mayor Libby Schaaf, in the wake of the “Ghost Ship” warehouse fire, where 36 people died.
- Daryl Sensenig, MPA, is a faculty member at the University of Maryland’s, Maryland Fire and Rescue Institute (MFRI), Special Programs Section and was a member of the recently deactivated National Disaster Medical System’s (NDMS) Disaster Mortuary Operational Response Team (DMORT), Weapons of Mass Destruction/All-Hazards unit, within the U.S. Department of Health and Human Services, Assistant Secretary of Preparedness and Response (Note: Effective 31 July 2107, the DMORT-WMD/All Hazards team mission was canceled by the NDMS). He held leadership positions for mass fatality disaster response and recovery efforts during various incidents, including: United Flight 93 crash in Shanksville, Pennsylvania, on 9/11 (40 fatalities); and Hurricane Katrina in 2005 (more than 1,000 fatalities).
- Elias J. Kontanis, Ph.D., is a registered medicolegal death investigator and currently serves as chief of the Transportation Disaster Assistance Division of the National Transportation Safety Board (NTSB). He has participated in victim recovery and identification operations, as well as family assistance operations at more than 40 mass casualty incidents. Three of these incidents were the 2004 Boxing Day Tsunami in Thailand (~230,000 fatalities), the 1999 crash of Egypt Air flight 990 in Rhode Island (217 fatalities), and the 9/11 World Trade Center attacks in New York (2,753 fatalities).
- Paul I. Carden Jr. is the regional disaster officer for The American Red Cross – National Capital Region and director of a Red Cross Divisional Response Management Team. During his 35 years at the Red Cross in volunteer and career positions, he has been involved in or directed the Red Cross Disaster Relief Operations to multiple mass casualty incidents, including: the 1981 Hyatt Regency Skywalk collapse in Kansas City, Missouri (114 fatalities); the Washington Navy Yard shooting in 2013 (12 fatalities); Hudson River mid-air collision in 2009 (9 fatalities); and 9/11 attacks.
- Anthony S. Mangeri, MPA, CPM, CEM, is currently the director of fire and emergency management initiatives and is on the faculty of the American Public University System. He has prepared numerous mass fatality guidance documents and response strategies. He has lectured on the topic of mass casualty and mass fatality operations. He completed a Fellowship in Public Health Emergency Preparedness & Response. He served as operations chief at the New Jersey Emergency Operations Center during the terrorist attacks of 9/11, where he coordinated that state’s response to the passenger-aircraft crashes into the World Trade Center in New York City.
- James “Jim” Bruzdzinski is a third generation funeral director and currently serves as the commander of Maryland’s only mass fatality team. In this role, he helped write Maryland’s Mass Fatality Plan and has responded to incidents such as: a 1987 Amtrak Disaster in Chase, Maryland (16 fatalities); 2005 Hurricane Katrina in Gulf Port, Mississippi (at least 80 fatalities); and a 2004 tanker explosion in Ocean City, Maryland (3 fatalities). Even when the mass fatality team is not needed, it is still called to the scene and ready to deploy whenever multiple fatalities occur.
Multiple people in the audience also had experience in mass fatality incidents, including: the human remains manager for 1,100 decedents of Hurricane Katrina; responder to an aircraft crash resulting in 50 fatalities; and a U.S. Marine battalion commander in Iraq, where an improvised explosive device (IED) killed 39 Iraqi police officers and 49 Marines. With over 200 years of combined experience in the room, it quickly sank in that a mass fatality incident can occur by land, air, or sea and in any city, state, or country around the world.
Define a Mass Fatality Incident
No specific number defines a mass fatality event. It varies between jurisdictions and agencies/organizations depending on the resources and capabilities available when an incident occurs. For example, Sensenig noted that, in addition to the daily workload, a medical examiner can quickly become overwhelmed, especially considering the surge such events would cause on the medicolegal system (e.g., death certificates are required before other services can be provided). Mangeri warned about declaring set limits for mass fatalities, but rather planners should determine risk tolerance through impact analysis such as Threat and Hazard Identification and Risk Assessment (THIRA). Regardless the standards set at the local, state, and federal levels, a community’s capabilities vary based on factors such as location and preparedness efforts.
Kontanis offered an alternative approach, stating that “book definitions” that sound good on paper do not necessarily help people think operationally, “I read book definitions and they sounded awesome, up until I was woken up at night and asked, ‘Are you going?’ Then the book definitions were not very useful. You need operational triggers that are clearly articulated and understood by everyone in your response community.” More important than a textbook definition is establishing operational triggers to determine when to implement the mass fatality plan. Instead of a set number of fatalities, the triggers for the plan are: the potential for 10 or more fatalities; a complex protracted recovery operation; a chemical, biological, radiological, nuclear, or high-yield explosive (CBRNE) event; or federal agency involvement. The time to implement the plan is shortly after the incident occurs, not when a final victim count is established (e.g., when a building collapses, not after bodies are retrieved).
From a social service perspective, Carden pointed out another factor that is more important than the number: the impact of the decedents on the community. The more connected the decedents were will dictate the level of community disruption, the impact on the community, and the time needed for recovery. Sensenig noted, “You could have a single fatality, but that person is so ingrained in the community that it is a huge loss.”
For example, Sensenig mentioned that the threshold number for the state of Virginia is now about 40-50 decedents, yet the Virginia Tech shooting in 2007 resulted in 33 fatalities. The State Office of the Chief Medical Examiner (OCME) mobilized its mass fatality plan, took staff from the regional offices, and went to Roanoke. In about three days, the OCME was able to follow its plan, move resources where needed, address public expectations, and manage the incident without shutting down its other regional offices, thus maintaining continuity of operations throughout the response effort. In contrast to that response, he has witnessed cases where, “When the bell rings, they ignore the plan and try to wing it.”
Understand How Fatality Management Has Changed
Once a decedent is retrieved, other concerns are raised about management of the human remains. Knowing how to respectfully handle, identify, process, and reunify the remains with their next of kin are complex actions with serious consequences when not done properly. In some cases, resources that once were available may no longer exist. For example, Mangeri pointed out that hospitals often no longer have morgues because “hospitals cannot charge for decedent management. It’s now an operations issue that can be costly to the hospital.” Therefore, using hospitals when the medical examiners are overwhelmed may not be an option. This is the type of situation requiring careful planning and asking the right questions in advance.
One positive change in mass fatalities that Kontanis has noticed over the years is “a shift in concept from numbers and ‘mass’ [mass fatality] to thinking about ‘complexity’ [complex incident fatality management].” Contaminated remains – for example, one dead person infected with Ebola – present a complex fatality. With the federal government and media converging on the location, such incidents present additional complexities related to families, first responders, transportation, and so on. In addition to those killed during the incident, cemeteries containing hundreds or thousands of previously deceased remains can also pose recovery management concerns as caskets become displaced.
Another complexity for mass fatality incidents involves fragmented remains. Sensenig shared the example of a 30-person commuter jet crash. Thirty people may be within the jurisdiction’s threshold, but the complexity of the fragmented remains (e.g., retrieving and identifying bone samples) may affect the mission. Forensic science such as DNA testing can facilitate the process, but can add further complexities as well. In Shanksville, Pennsylvania, on 9/11, he noted, DNA analysis was conducted, whereas DNA testing was not performed following Hurricane Katrina. The disparity was caused by fiscal accountability and arguments over who would pay for the testing.
Families of the decedents present another complexity. Sensenig noted concerns that victim assistance teams encounter when talking to the families about remains, “We’ve identified your loved one (and it’s an amount that fits in a shoebox).” Complicating an already sensitive situation includes determining what to do if more remains are identified later in the process.
Manage Surge During Complex Events
With all the complexities involved in a mass fatality incident, managing the surge requires extensive planning. Bruzdzinski described how Maryland’s surge capacity has grown and expanded over time by building dual-use facilities, “It has really changed, and for the good.” For example, a new morgue for the state of Maryland has “a phenomenal autopsy suite” that is used every day and another that is used for surge. The parking garage is designed to convert into a disaster morgue within about an hour with a capacity for about 100 decedents. The garage is equipped with hot and cold water lines, drains in the floor, electrical outlets, and a garage with body boards.
To effectively plan for mass fatality incidents, it is important to remember that mass fatalities coincide with mass casualties, which means that family services, emergency medical services, law enforcement, and other response agencies may not be available. “Know that, during these watershed events, contingency systems may be overwhelmed as well – medicolegal systems for fatality management, and care and management systems for both the injured and their families,” said Mangeri.
Many steps occur before fatality management begins. For example, at the triage level, transport resources cannot be applied to decedent management until all living transports have been made. This means being able to identify not only when the event begins, but also when the event ends, and what the jurisdiction’s ability is to respond to other incidents that happen during that period.
Even on a day-to-day basis, highly infectious diseases result in a percentage of decedents, which should be a public health wakeup call. On an emergency response call – hazardous material, law enforcement, and emergency medical – fatality events may unfold throughout the response. Complex incidents require a better understanding of how to surge for an event and continue to operate for the next event for unknown durations. As complexity increases, political and budgetary realities also set in.
At the NTSB, a federal agency with approximately 420 employees across the United States, Kontanis emphasized the whole community response concept following a mass casualty incident, “What works really well is the concept of collaboration in a complex fatality management event. Fostering collaboration and setting aside egos is what NTSB embraces.” Enhancing, rather than impeding, each others’ abilities to do their work was demonstrated in the NTSB’s response to flight 3407 – an aircraft that crashed in Buffalo, New York, on 12 February 2009, resulting in 50 passenger, crew, and ground fatalities.
The NTSB is responsible for facilitating victim recovery and identification following air carrier accidents that occur in the United States resulting in a major loss of life. The agency accomplishes this objective by conducting a gap analysis with the medical examiner or coroner early in the response and activating pre-established memoranda of agreement with various federal agencies to support the victim recovery and identification process. Following the Buffalo accident, the NTSB at the request of the Erie County Medical Examiner’s Office activated the Armed Forces Medical Examiner System, Department of Health and Human Services – DMORT, and FBI Evidence Response Team and Disaster Squad to support the medicolegal process. In addition to these federal forensic assets, a total of 68 federal, state, and local agencies, and nongovernmental organizations responded to this accident.
Enhance Personnel & Process Resilience
It is important to note that the state must engage DMORT (under ESF-8) early because it may take 36 hours for the team to get to the scene and become fully operational in a deployable morgue. In the meantime, other response teams could suffer from burnout and need to be managed effectively to minimize the physical and psychological effects that may compound as the hours pass. Because mutual aid is often required in mass fatality incidents, the use of standard triage tags that are regionally recognized can facilitate operations.
Media and cameras are common during complex incidents, so media management is a big part of large-scale incidents. In addition to media, mass care operations are also a standard part of each mass fatality situation. Mangeri pointed out that there is typically 5-10 family members, friends, colleagues, etc. that show up for each decedent. As such, they must be planned for as well. Transportation events and areas with large transient populations increase the chance that loved ones will be coming from other areas and may require additional sheltering and care resources. This highlights the need to know the population being served (e.g., languages spoken) and the services being provided:
- Hospitals and emergency medical services care for the injured, ill, and infirmed;
- Mortuary, funeral, and medical examiner/coroner services care for decedents;
The Incident Management System provides consistency across all hazards, but jurisdiction over the incident is situational to where the event occurs and who has authority to make decisions (e.g., state or county government, commonwealth). This can be complicated more by the timing of the event. As such, agencies and organizations must determine the rules during “peacetime,” so they are more prepared for “wartime” – when seconds count. By mapping relationships and conducting drills and exercises with key stakeholders – including the medical examiner/coroner – during peacetime, responders save critical time during the incident.
Bruzdzinski warned that the medical examiner/coroner car often does not have a radio to communicate with incident command like the law enforcement, emergency management, and emergency medical services do. As such, they may not know what is going on and may not even have access to the triage tent to begin necessary operations with regard to those killed during the incident. Plans should include a liaison to ensure that the medical examiner/coroner have the access they need to fulfill their roles and responsibilities. Drills can help identify these and other gaps as well as overlaps, which can lead to delays as agencies determine who is responsible for various tasks.
Carden recommended bringing a lawyer in either during or following the exercises because of the complexities involved in mass fatality incidents. Some things an agency may normally do, may not be permitted or acceptable when managing fatalities – for example, a death certificate may be needed before moving any bodies – and some regulations may need to be established in advance. In addition, some decisions cannot be made until jurisdiction is established.
Jurisdiction includes determining which doctor signs the death certificate. Mangeri noted that a past TOPOFF (a national level exercise with top officials) revealed this question is not always easy to answer. For example, if a person dies in the field and is brought to the hospital emergency room, the doctors may not like to sign the death certificates if they were not present when they passed. The more fatalities involved, the more complicated the situation becomes and the more critical it is to have an established flow path.
This goes beyond the legality of the situation to a legally recordable event. Firefighters, for example, are familiar with the process of respond, deploy, and back in service, but that does not work in a mass fatality scenario. If not planned, there will be an adverse effect on service continuity because of the need to dedicate services for the duration of the event. A planning matrix should include: local conditions, contact lists, relationships, as well as gaps and overlaps in resources and agency roles. With so much time being devoted to taking care of decedents, the next concern to tackle is what to do about the people who are still alive and still on scene, “How do we get our people back?”
Address Psychological Well-Being of Responders
Carden described the American Red Cross’s desire to prequalify people before sending them into the field – for example, knowing the level of knowledge, skills, and abilities of each person. This includes whether they have witnessed a death before. Although not fully implemented yet for knowing all deployable resource capabilities, the Red Cross is working toward that goal. Other response agencies may also prequalify personnel before deploying them to high-stress incidents. Self-selection and looking out for each other play large roles as well – for example, opportunities for social interaction at the end of each day to determine how teams are coping with the response and improve camaraderie. Engagement makes a difference for psychological wellbeing.
The psychological status of responders is an area that is receiving an increasing amount of attention, which panelists agreed is a “good thing.” Although Kontanis is “not a fan of mandatory debriefing sessions after an event,” he said that, “What does work is cohesiveness, which is built on open communication.” He clarified that this communication needs to be with somebody on the team who that person can confide in and trust, as well as a support network outside of work – both built on open lines of communication. As a leader, he encourages his team members to feel comfortable voicing their limits without fear of punitive repercussions. He stresses to his team that, if they do not take care of themselves, then they cannot take care of others, and, “If we can’t take care of others, then we won’t meet our mission objectives.” Mangeri agreed, “You are a long-term asset at the scene. Know when to put yourself out of service.”
Unlike the fire and other large-scale response services, the funeral industry is more isolated, without the same level of camaraderie. Bruzdzinski, recalled his response to Hurricane Katrina, where his 12-person team “infiltrated” funeral homes – that is, took over operations when locals were not able to fully manage the adverse conditions. Similar to the fire service, the culture of funeral directors is not conducive to asking, “How do you feel?” However, he noted the significant benefit of his team gathering around a campfire at the end of each day to just ask, “What did you do today?”
Key Takeaways & Recommendations
Everyone is part of a “tribe” – hazmat, funeral directors, firefighters, emergency medical, public health, emergency management – but all must work across jurisdictions and agencies when a mass fatality incident occurs. Perhaps the biggest challenge for mass fatalities is managing expectations:
- Time expectations: When people expect that forensic science takes only 20 minutes (i.e., “CSI” effect). Accuracy is more important than speed, especially in situations where the wrong decedents’ remains could be given to families.
- Recovery expectations: When people expect recovery to occur rapidly. However, entire buildings may need to be rebuilt as bodies continue to be identified. In New York City, remains recovered from the scene are still being identified more than 15 years after 9/11.
- Process expectations: When people expect fewer steps in the process. A large building fire, for example, beyond putting out the fire and recovering bodies involves post-event fire investigations, changes in building codes, etc.
The panelists closed the discussion by describing what keeps them up at night when considering mass fatality incidents. Self-care was the prevailing response:
- Acknowledge what needs to be done, but understand that sleep is needed.
- Ensure the safety and well being of all team members.
- Form an operational perspective to address expectations of society and align these expectations with the reality of the situation.
- Do not make promises that cannot be kept (“We are not going to stop until we find your loved ones,” may not be feasible).
- Protect the scene and do not take pictures of anything that could compromise the response or recovery efforts.
- Build capacity and resilience to ensure that people are equipped with the right strategy and resources to implement the system.
- Counter statements such as, “It will never happen here,” “It’s not my job,” and “I got this,” with realistic expectations, education, and trainings.
Complex fatality management requires a multidisciplinary, multijurisdictional response. However, perhaps the biggest difference between fatality management and other disaster management efforts is that not all the key stakeholders and processes are known in advance and integrated into the response. By building relationships with medical examiners, coroners, and other fatality management personnel, other response agencies will better understand and facilitate the process of managing decedents – from moment of impact to reunification of remains with their loved ones.