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Management of the Deceased

Notification


  • Medical Examiner/Coroner (ME/C) must either notify or be notified of any mass chemical or biological exposure event
    • The ME/C must be able to identify the Incident Commander (IC) and the level of involvement of other agencies, so that the magnitude of the incident can be ascertained;
    • Gather as much information as possible about the incident and its overall management;
    • See the management hierarchy below. This will help to know who to notify and at what level.

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Evaluation and Incident-Specific Planning


  • Establish an evaluation team, which may work in conjunction with other agencies if the incident is a crime or an accident, or if the incident extends beyond one jurisdiction.
    • Establish Multidisciplinary Team to Evaluate the Specific Incident:
      • Include death investigator personnel, law enforcement, hazardous materials (HazMat), and any other relevant agencies
      • Check required level of personal protective equipment (PPE)
      • Determine complicating factors (e.g., fragmentation, difficult excavation)
      • Take initial pictures of site
      • Determine approximate number of remains and their location
      • Identify locations of atypical cases
  • Members of the evaluation team should be selected based on their overall mission to collect evidence and to determine the cause and manner of the victims´ death.
  • It is the primary role of the ME/C to determine the best approach for managing remains

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Remains Recovery


  • The recovery of remains involves tracking and relocating bodies to the incident or holding morgue.
  • It also includes 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 only requiring an external examination.
  • Additionally, the recovery of remains entails keeping them from public view.

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Managing Chemically Contaminated Remains


  • All interacting with remains need to be in personal protective equipment (PPE) depending on the nature of the agent.
  • All remains should undergo a detailed decontamination before any extensive morgue procedures are conducted.
  • Decontamination involves scrubbing and cleansing all body orifices completely.
  • Depending on the type of chemical and the level of contamination, and if remains are fragmented or have open body orifices, remains may need to be decontaminated a few times before contamination is mitigated.
  • In some cases, it may not be possible to decontaminate the body completely.

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Holding Morgue Operations


  • When remains are recovered, personnel usually perform an initial physical evaluation at the scene and then transfer remains to the morgue, where personnel perform a more extensive evaluation or autopsy.
  • In some circumstances, personnel may need to gather evidence, and remove and track personal effects before remains are transferred for autopsy or identification.
  • The type of disaster will determine the extent of the holding/incident morgue operation.

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Establishing a Personal Effects Depot


  • In a mass fatality incident, death is usually sudden, unexpected, and violent. Due to the tragedy and unexpected timing of a disaster, personal items become more significant to the families (Jensen, 2000).
  • More often than not, remains are not viewable, and in some cases, very few fragments are recovered and, therefore, very few personal effects (PE) can be returned to the families.
  • Establish a team to manage PE from the incident. This team will search and recover PE, establish a PE warehouse, attempt to associate PE with persons eligible to receive it, and, in some instances, decontaminate PE.
  • For further information:
    • "Mass Fatality and Casualty Incidents: A Field Guide," by Robert Jensen, 2000, provides further information about establishing a PE Depot.

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Establishing a Family Assistance Center


  • Establishing a Family Assistance Center (FAC) at the outset of an incident demonstrates to the public that there is some semblance of order, despite the disaster circumstances.
  • The FAC provides family members a place to register their loved ones as missing, to wait and prepare themselves to receive difficult news, and to provide data for identification purposes.
  • It can also act as a support center for those involved in identification/removal/processing of remains.

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Level 1: Transportation and Temporary Storage to Morgue


  • To expand capabilities, incorporate the use of refrigerated trucks as an alternative resource to accommodate cases that exceed their normal transportation and storage capacity.
  • Another option is to cool an area to 37°F with an industrial air conditioning unit.
  • During the transporting and storing process, remains should not be stacked unless shelving units are used. If shelving units are used, personnel should not stack remains higher than waist level to prevent injury to those handling remains.
  • The transportation and storage plan should minimize the number of times remains are moved.
  • Moreover, contaminated remains might need to be packaged in a particular manner to safely transport them from one location to another.

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Morgue Operations


  • Location: The ME/C must determine if remains should be processed at the headquarters (HQ) building or at an off-site location or alternative location.
    • Alternative locations should have:
      • Large open floor space
      • Electrical power (although large generators can supplement this need)
      • Water supply and waste water containment
      • Ventilation, air conditioning, and heating
      • Drainage and medical waste holding tank
      • Provisions for staff (e.g., restrooms, recovery area)
  • Morgue Stations: The ME/C must determine what stations should be established as part of the morgue operation during a disaster.
    • General, these stations include:
      • Triage
      • Anthropology
      • Odontology
      • Fingerprinting
      • Photography
      • Radiology (may have to arrange with local imaging facilities (hospital or other))
      • Pathology/Toxicology (including space and resources for autopsy, specimen preparation/interpretation)
      • DNA Analysis
      • Evidence
      • Personal Effects
      • Intake/Admitting
      • Holding/Record Audit
      • Release/Final Records Audit
  • Establishing Morgue Operations: The following publications provide further information about establishing morgue operations:
    • "Mass Fatality Incidents: A Planning Guide for Human Forensic Identification", the National Center for Forensic Science, under the National Institute of Justice, Office of Justice Programs
    • "Disaster Mortuary Operational Response Team Field Operations Guide", the National Disaster Medical System, Disaster Medical Operational Response Team (DMORT), under the Department of Health and Human Services (HHS)

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Level 2: Transportation and Temporary Storage from Morgue


  • Level 2 Transportation and Temporary Storage involves release of remains.
  • When remains are going to be returned to family members, personnel may only need to establish a holding area for funeral home directors to retrieve remains. In some cases, it may be possible to hold remains at funeral homes until they are released, thereby enhancing the storage capacity.
  • In instances when final disposition requires State sponsored burial, personnel must arrange for transportation and additional handling of remains.
  • Consider using the same transportation assets that were previously used or establishing a holding area within the morgue until final disposition has been determined.
  • Despite the conditions under which remains are released, there may still be a need to enhance the morgue´s storage capacity. Law enforcement and investigative agencies may request that some or all remains be held for purposes of gathering additional evidence, or that personnel store unidentifiable portions of remains until a ceremony is arranged.

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Final Disposition


  • Final disposition options include individual burial, State-sponsored individual burial, entombment, mass burial, voluntary cremation, and involuntary cremation.
  • In general, human remains cannot be disposed of as the State chooses; State laws require that remains be given to family members upon request. The exception is if a public health hazard exists, in which case the Governor can issue an emergency declaration negating current law, which may affect how final disposition is managed.

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References

  1. Robert Andrew Jensen. 2000. Mass Fatality and Casualty Incidents: A Field Guide. Boca Raton, FL: CRC Press.
  2. Mass Fatality Management for Incidents Involving Weapons of Mass Destruction (PDF - 1.61 MB) (DOD, 2005)
  3. Disaster Mortuary Operational Response Teams (DMORTs, HHS/ASPR)
  4. Management of Dead Bodies after Disasters: a Field Manual for First Responders (About mass casualty situations) (PDF - 989 KB) (PAHO, WHO, ICRC, IFRCRCS, 2006)
  5. Mortuary Affairs in Joint Operations, Joint Publication 4-06 (PDF - 2.47 MB) (DOD, 2006)
  6. Hanzlick R, Nolte K, deJong J; National Association of Medical Examiners Bioterrorism and Infectious Disease Committee. Medical Examiner/Coroner´s Guide for Contaminated Deceased Body Management Am J Forensic Med Pathol. 2009 Dec;30(4):327-38. [PubMed Citation]
  7. National Association of Medical Examiners Standard Operating Procedures for Mass Fatality Management (PDF - 884 KB) (National Association of Medical Examiners, 2010)

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