“Our dead are never dead to us, until we have forgotten them” – George Elliot

“The dead cannot cry out for justice. It is a duty of the living to do so for them”- Lois McMaster Bujold

A mass fatality incident or event is any circumstance resulting in mass deaths which exceed local death investigation resources. The challenges posed by fatality management and death/medicolegal investigations in the context of CBRNE terrorism are multifaceted and resource intensive.

The commonalities present in mass fatality management of CBRNE events, include:

  1. The event presents as a crime scene with inherent forensic considerations, and involves a complex investigative response. EVERY mass fatality event should be treated as a crime scene until proven otherwise by competent investigative and forensic authorities.
  2. The event may generate a large casualty load with various mechanisms of harm leading to mass fatalities requiring identification of human remains.
  3. As in all cases of natural and unnatural death, the cause of death is of paramount importance.
  4. CBRNE events create the need for special precautions and decontamination of fatalities.
  5. Community, survivor, first responder and first receiver crisis intervention and disaster mental health services will be required.
  6. Mass fatality management resources must be integrated into community emergency preparedness and operational response plans.
  7. Faith-based assets must be included in all aspects of mass fatality management and be readily available to provide pastoral counseling and critical event chaplaincy services.
  8. Cultural and ethnic differences in handling and disposition of human remains must be respected, as much as possible.

The overall response to a mass fatality even is comprised of the following three phases:

  1. Arrival of responders, implementation of Incident Command System (ICS) structure, scene size-up and assessment, critical incident/event plan activated, and coordination of multiagency assets.
  2. After activation of the Emergency Response Plan (ERP), the second phase of response begins. The ICS becomes operational, assuming more of a joint Unified Command (UC), involving multiple agencies and a undertaking of lead public safety roles.

Law enforcement and fire-rescue service personnel create secure inner and outer perimeters, provide hazard assessments and control, and conduct initial rescue operations. EMS providers perform triage, provide stabilizing medical care and decontamination, and transport survivors to designated health care facilities (HCFs). Additional resources are requested, as needed.

  1. The final phase is the resolution phase, which involves on-going crime scene and criminal investigation, removal and transport of human remains, coordination of morgue services, next of kin notifications, forensic identification process, and community-wide support services.

The last phase of medicolegal death investigation, identification and mortuary operations utilizes the Medical Examiner or coroner, as the Incident Commander (IC) to coordinate these activities.

After the overall IC/UC, deems that the incident site is safe and secure, the initial evaluation team, usually comprised of an operations officer, crime scene investigators and a lead forensic medicolegal investigator/death investigator will proceed to the location to initiate the preliminary phase of death scene/crime scene processing and documentation. All personnel conducting mass fatality operations in a CBRNE environment must don and wear adequate personal protective equipment (PPE) and maintain situational awareness at all times.

TerrorismeThe ME’s or coroner’s office must interface with the site Incident Commander as needed for periodic updates regarding scene conditions, safety/hazard assessment issues, including ascertaining the appropriate level of PPE that is required for any hot-zone/incident site operations, as well as receiving a brief on the particulars/circumstances which generated the mass fatality event.

The ME or coroner must also reciprocate and advise the Incident Commander on current capabilities and  what information and resources are required to conduct and optimize the fatality management mission, e.g. mobile refrigeration  units, additional personnel, cadaver dogs, etc.

The three major operational areas of mass fatality management are: search and recovery, morgue operations, and family assistance. Scene operations involve search and recovery operations and initial evidence collection/recovery, morgue operations include identification and processing of human remains, including the determination of cause of death, e.g. exsanguination, multiple trauma, toxic chemical inhalation/pulmonary edema, anoxia, etc.

The family assistance center of the medical examiner’s or coroner’s office provides antemortem information, identification notification, and the care of families, including grief counseling and assistance with disposition of any processed remains .

Thus, local funeral directors and their services become of supreme importance in mass fatality events, and during the continuum of the postmortem period. Provisions for the full participation of funeral and mortuary services in community-wide emergency preparedness efforts must be made by each locality, and close liaisons be formed between funeral and mortuary services and other stakeholders in crisis and emergency management.

Information that is relayed to the ME or coroner during notification of a mass fatality event includes:

  • Type of incident i.e.(explosion, structural collapse, toxic chemical or biohazardous material, radioactivity, fire)
  • Location
  • Estimated number of fatalities
  • Condition of bodies (i.e., burned, fragmented)
  • Demographics of deceased, and including any hazardous conditions (i.e., entrapment, chemical or radiological contamination, exposure to infectious etiologic agents)
  • Ongoing response activities
  • Response agencies currently engaged in operational response

In search and recovery operations, locating and removing the decedents, anatomical parts, and personal effects, and maintaining accountability and chain of custody are mission -critical.

Human remains must be treated with the utmost respect and dignity. The remains should be covered or shielded from public view, and any fatality collection point or temporary morgue, should be set up away from any triage, treatment and medical transport areas, as well as protected from media inquiry.

In general, decedents are not to be moved from the incident site/death scene until cleared by the ME or coroner’s office. The decedents’ body position and location, coupled with any distinguishing features should be noted and documented by emergency response personnel, and the remains should not be moved until crime scene and on-scene medicolegal investigators have completed their duties, cleared and released the scene.

Morgue operations involve several different divisional functions designed to record and provide information about the decedent for comparative analysis with the ante mortem data, e.g. dental records. The use of sophisticated DNA assays will yield valuable information regarding the identity of decedents. For example, in providing mass fatality management services in the aftermath of the September 11, 2001 terrorist attacks on the World Trade Center, most human remains were crushed, severely burned/charred, fragmented or commingled.

Bombs car inspectionInnovative DNA methods for DNA analysis were implemented using novel software to facilitate the identification process. The morgue holds an in-processing area and  specialty areas and laboratories for forensic anthropology, forensic odontology, fingerprint cataloguing and analysis, forensic photography and radiology stations, personal effects stations, anatomic /gross and microscopic/histology capabilities, DNA analysis; including mitochondrial DNA, serology, forensic toxicology and chemistry and a mortuary science section where remains may be embalmed and otherwise prepared for appropriate dispositions, including repatriation.

There will be a need for grief counseling and interface with relatives for final dispositions, as the bodies are released to families or other responsible parties.

There are two pressing concerns here: identification and establishing cause of death. Death investigations and forensic examination, generally establish a physiological reason for death, e.g. asphyxiation/anoxia, and correlate it with the surrounding circumstances to establish causality, e.g. carbon monoxide poisoning or strangulation, and will rule on the legal status of the death: natural, accidental, intentional or indeterminate.

In CBRNE events, most assuredly, mass fatalities would equate mass homicide as a very workable, and evidence -rich ruling. To some, especially the perpetrators of political violence and terrorism, and their defense attorneys, would go so far as to argue that some fatalities, may indeed have been caused by “natural ” or “accidental” causes, i.e. an elderly man with pre-existing heart disease succumbs to the squamae of a myocardial infarction in the aftermath of a terrorist attack, or first responders who sustain injuries while en route to an incident site or stumble and fall onto a jagged debris pile, or suffer from environmentally-induced respiratory disease due to toxic dust inhalation and succumb to mesothelioma or pulmonary fibrosis.

Are these not equivalent to casualties of asymmetric warfare, whether the deaths were related to direct or indirect impacts, whether psychological or physiological, whether acute, delayed or chronic illnesses or injuries acquired later in life, yet attributable to terrorist action? Does it not all become “intentional”?

The family assistance center (FAC) becomes the central hub in mass fatality operations for families of terrorism victims. The FAC provides various support services, crisis intervention and mental health, religious/spiritual needs, volunteer resources such as Red Cross , Salvation Army and other NGOs.

In large events that prove to be resource constrained, state and Federal resources, such as specialized mortuary teams, e.g. Disaster Mortuary Operational Response Teams (DMORTs) which are US National Disaster Medical System assets specializing in mass fatality operations, may be deployed to augment local and state resources, and lend specialized capabilities such as decontamination of mass fatalities and expanded, mobile forensic and mortuary services in the US or abroad, when requested. Similarly, the US Armed Forces Office of the Medical Examiner (OAFME) and the FBI may be involved in cooperative mass fatality management operations.

Chemical and radiological contamination and exposures are unique characteristics which are relevant to mass technological disasters, e.g. Chernobyl, Fukushima or chemical manufacturing/petrochemical and environmental disasters, i.e. Deep Horizon oil spill, and events utilizing CBRN /weaponized agents. Decedents that have been internally and /or externally contaminated with radionuclides, for example, present a threat to emergency responders and other personnel, including those involved in mass fatality operations. Adequate levels of PPE must be worn by all responders dealing with all phases of emergency incident response by consultation with health and safety officers and the Incident Commander, and selecting the appropriate level of PPE.

For radiological-nuclear events a radiation safety officer/health physicist must be available as a Technical Specialist /Advisor to the IC. He or she must be consulted regarding personal protective countermeasures, dosimetry and “stay times”, for example.

Decontamination may be achieved by removing contaminated clothing and apparatus, use of warm water and soap solution and for decedents washing bodies with soap or sodium hypochlorite solution (bleach) prior to performing autopsies or embalming.

Decontamination run-off must be controlled and decontamination operations must be performed away from embalming procedures due to the possibility of some decontaminating solutions and solvents, such as bleach, may generate toxic reactants when mixed with embalming fluid. The process is closely monitored utilizing survey and sampling equipment, such as chemical agent monitors (CAMs) and / or radiac survey meters.

In summary, mass fatality events involving CBRNE agents are highly complex and multifaceted, requiring an astute multidisciplinary and coordinated effort. With every passing day, CBRNE attacks and other high acuity events involving hazardous materials become more prevalent, and endangering not just localities, but regions and diverse, unprotected populations.

The recent experiences in the war torn nations of Iraq  and Syria, have shown the heinous devastation and carnage generated by the use of high order Improvised Explosive Devices (IEDS) and chemical warfare agents (CWAs) such as chlorine and sarin nerve agent on combatants and non-combatants, including children.

What do we say to the dead? How do we garner justice for the deceased and their grieving loved ones? How will we speak for them? While we bury and mourn our dead, here and abroad, due to barbaric acts of political, religious ultraviolence and asymmetric warfare, we offer solace, dignity, reverence for the countless souls lost in war, conflict and terror, and we will continue to seek justice against the sub- species known as “terrorists”.

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Frank G. Rando possesses over 30 years of real world experience as a public safety professional,clinician, educator ,emergency and crisis manager ,author and consultant in the areas of tactical ,disaster and operational medicine, weapons and tactics, law enforcement /criminal investigations ,counterterrorism, hazardous materials management and emergency response ,toxicology, environmental safety and health,and health care and public health emergency management .