mass fatality planning in bexar county - strac

RANDY FROST, M.D.

CHIEF MEDICAL EXAMINER

BEXAR COUNTY

MEDICAL EXAMINER ’S OFFICE

MASS FATALITY PLANNING

IN BEXAR COUNTY

ONCE UPON A TIME…..

� >15 YEARS AGO

� THE MEDICAL EXAMINER RARELY RECEIVED ANY

INVITATION TO ATTEND MASS CASUALTY

PLANNING MEETINGS

� WHEN WE DID ATTEND, LITTLE OR NO ATTENTION

WAS PAID TO FATALITIES

� PRE-9/11, AND FOLKS NOT VERY ATTUNED TO

MASS CASUALTY SITUATIONS

� FOUND OUT ABOUT AN UPCOMING EXERCISE AND

ASKED IF WE COULD “PLAY”…….

10,000 FATALITIES??

� TABLETOP EXERCISE

� INFLUENZA PANDEMIC

� THOUSANDS OF FATALITIES PREDICTED OVER

SHORT PERIOD OF TIME

� AT THE END OF THE PROGRAM, SOMEONE

ASKED ABOUT WHAT HAPPENED TO ALL THE

DECEDENTS

� ANSWER?

10,000 FATALITIES??

�NO PROBLEM….

�WE’LL JUST CALL THE CORONER!

M.E. RESPONSE?

� (SOFTLY, FROM THE BACK OF THE ROOM)

“SORRY, BUT THOSE CASES DON’T FALL

UNDER OUR JURISDICTION…..WE WON’T

BE TAKING THEM….”

� SHOCKED LOOKS…..

� NOW WHAT??

A LITTLE BACKGROUND

� NO SUCH THING AS A CORONER IN THE STATE

OF TEXAS…OFFICE DOES NOT EXIST

� MEDICAL EXAMINERS (IN URBAN COUNTIES)

AND JUSTICES OF THE PEACE (IN RURAL

COUNTIES) ARE RESPONSIBLE FOR DEATH

INVESTIGATION

� BUT ONLY CERTAIN TYPES OF CASES FALL

UNDER THEIR JURISDICTION

� VAST MAJORITY OF DEATHS ARE NOT UNDER

OUR JURISDICTION…INCLUDING SOME MASS

FATALITY DEATHS

SOME OTHER FACTS TO KEEP IN MIND

� WE ARE PRIMARILY INVOLVED IN TRAUMATIC OR INTOXICATION DEATHS

� ALSO LOOK INTO DEATHS DUE TO UNKNOWN CAUSES

� PRINCIPAL GOAL IS TO DETERMINE CAUSE AND MANNER OF DEATH IN THOSE CASES

� IN THE CASE OF A NATURAL DEATH (INFLUENZA?) WHEN THE CAUSE OF DEATH IS KNOWN, WE ARE NOT INVOLVED

� IDENTIFICATION OF BODIES IS OFTEN THE PRIMARY GOAL OF THE M.E.IN MASS FATALITY INCIDENTS

NON-M.E. CASES

� IF THERE IS A DIAGNOSIS OF NATURAL DISEASE AND THE PATIENT IS UNDER MEDICAL CARE, IT WILL NOT FALL UNDER THE M.E.’s JURISDICTION

� THERE IS NO “COUNTY MORGUE” FOR STORAGE

� DISPOSITION IS AT THE DISCRETION OF THE FAMILY AND FUNERAL DIRECTOR� UNLESS WE ARE DEALING WITH A PESTILENTIAL EPIDEMIC….HEALTH OFFICIALS ARE IN CHARGE IN THOSE CASES

FAST-FORWARD TO 2014:

THINGS ARE MUCH BETTER NOW

� WE ATTEND MOST MASS CASUALTY

MEETINGS AND DRILLS

� CONSULTED ON MANY CASUALTY PLANS

FROM OTHER AGENCIES

� B.C.M.E.O. FAIRLY WELL PREPARED FOR A

TYPICAL MASS FATALITY SCENARIO

� INVOLVING 25-35 FATALITIES; LESS IF

FRAGMENTED

� BUT NO ONE IS PREPARED FOR ANOTHER

9/11-LEVEL EVENT

THE SITUATION IN BEXAR

� ADEQUATE STAFF FOR A TYPICAL EVENT� THOUGH ADMINSTRATIVE SUPPLEMENTATION FROM OTHER COUNTY RESOURCES WOULD PROBABLY BE REQUIRED

� TRAINED TECHNICAL STAFF ESSENTIALLY NON-EXISTENT OUTSIDE THE M.E. SETTING

� FACILITY BECOMING TOO SMALL

� INADEQUATE STORAGE; WOULD REQUIRE REFRIGERATED TRAILERS

� EXCELLENT MEDICAL, RADIOGRAPHIC, DENTAL AND ANTHROPOLOGIC SUPPORT

WHAT ABOUT THE

NON-METROPOLITAN COUNTIES?

� OBVIOUSLY NO MEDICAL EXAMINER OF

THEIR OWN

� J.P. IS IN CHARGE OF DEATH INVESTIGATION

� J.P.’s GENERALLY SEND BODIES INTO A

LARGE M.E. OFFICE IF AN AUTOPSY

EXAMINATION IS DESIRED (FOR A FEE)

� SOME FACILITIES HAVE CONTRACTS WITH

SMALLER COUNTIES….BEXAR DOES NOT

� IDENTIFICATION, INVESTIGATION, ETC.

STILL RESTS WITH THE COUNTY J.P.

NOW ABOUT THOSE OTHER COUNTIES

� RECENTLY, MANY J.P.’s IN OUR REGION WERE SURVEYED

� MANY WERE SOMEWHAT SURPRISED TO LEARN THAT THE B.C.M.E.O. WOULD NOT TAKE OVER IN THE EVENT OF A MASS FATALITY EVENT

� UNDER THE LAW, THE LOCAL COUNTY J.P.’s RETAIN FULL AUTHORITY AND RESPONSIBILITY FOR ANY DEATH WITHIN THAT COUNTY, EVEN IF DUE TO A MASS FATALITY INCIDENT

NOW ABOUT THOSE OTHER COUNTIES

� ALL OUR OFFICE CAN DO IS ASSIST IF ASKED TO DO SO BY THE OUTSIDE COUNTY

� WE ARE AVAILABLE ONLY ON AN “AS AVAILABLE” BASIS

� OUR OWN COUNTY CASELOAD MUST STILL BE ADDRESSED DURING THE INCIDENT

� THE COST IS SIGNIFICANT, AND MANY SMALLER COUNTY BUDGETS WILL BE OVERWHELMED BY A TRUE MASS FATALITY SITUATION

STUMBLING BLOCKS

� $$$$

� ALMOST ALL M.E. OFFICES ARE STAFFED AND EQUIPPED ONLY TO BARELYMEET DAY TO DAY CASELOAD

� LITTLE, IF ANY, EXPANSION CAPABILITY

� M.E. OFFICE “CATCHMENT” AREAS ARE NOT CONGRUENTWITH H.S.R. REGIONS

� POTPOURI OF FORENSIC PATHOLOGY EXAMINATION CENTERS

� DEATH INVESTIGATION CENTERED AT THE COUNTY LEVEL…., BUT MOST SMALL COUNTIES DON’T HAVE THE RESOURCES TO HANDLE A MASS CASUALTY EVENT

BUT PROGRESS IS OCCURING

� DSHS REGIONAL PLANNING MEETINGS HAVE

TAKEN PLACE

� HSR-8 CONOPS (CONCEPT OF OPERATIONS)

HAS BEEN DEVELOPED IN OUR REGION

� BUT THERE IS STILL A SIGNIFICANT BURDEN

OF RESPONSIBILITY ON THE RURAL

COUNTIES, AND THEIR RESOURCES ARE

OFTEN VERY LIMITED

� RECENT EFFORTS HAVE BEEN FOCUSED ON

DEVELOPING A STATEWIDE RESPONSE PLAN

(TMORT…STAY TUNED)

OUR VIEW….

HOPE FOR THE BEST

PLAN FOR THE WORST

Mass Fatality Management Operations:

What are we planning for?

Jason Wiersema PhD, DABFA, DABMDIForensic AnthropologistDirector of Forensic Emergency ManagementHarris County Institute of Forensic Sciences

� Mass fatality is not synonymous with disaster

� Catastrophic focus (pandemic, 9/11, etc.)

• Number of fatalities

• Human remains storage

Catastrophic Mindset

� Mass Fatality Incident defined:

� Any incident producing fatality management circumstances that overwhelm local resources

Average Deaths per MFI

*data courtesy of New York City Office of the Chief Medical Examiner

84

U.S

. M

FIs

20

00

-20

12

52*not including 9/11

Terrorist attacks


U.S

. M

FIs

20

00

-20

12



33*not including 9/11 Terrorist attacks or Hurricane Katrina


U.S

. M

FIs

20

00

-20

12

� July 2013

San Francisco, CA Asianaplane crash: 3

Quebec, CA train incident: 47

Alaska plane crash: 10

� August 2013

Birmingham, AL UPS cargo plane crash: 2

� February 2014

Bellevue, TN plane crash: 4

� March 2014

Manhattan, NY building explosion: 8

Oso, WA mudslide: 36

Very Recent History

� December 2012Newtown, Ct: 28

� April 2013Boston Marathon: 3

West, TX: 14

� May 2013Granbury, TX tornado: 6

El Reno, OK tornado: 8

Moore, OK tornado: 23

Houston, TX firefighters: 4

� June 2013 Yarnell, AZ firefighters: 19

Philadelphia, PA building collapse: 6

13

� Number of Victims

� Condition of HR

� HR Recovery

� Victim Identification

How important is the fatality count?

� Responders

� Geography

� Community Impact

� Interest to Others

I-35W Bridge collapse, Minneapolis, MN, Aug 1, 2007American Commuter Flt #5966 crash, Kirksville, MO, Oct 19, 2004

� Scene investigation

� Decedent transport

� Postmortem examination

• Cause and manner certification

• Decedent identification

� Notification of NOK

� Release to funeral agency

Medicolegal authority responsibilities

� Site Operations

� Morgue Operations

� Identification

� Family Assistance Center

� Victim Accounting• Call Center

• Missing Persons Investigation

• Victim Information Center

� Data Management

Mass Fatality Preparedness Components

antemorteminformation

postmorteminformation

comparison(unique biological characteristics)

identification

What is an identification?

� Circumstantial• Personal effects

• ID cards

• Tattoos

� Scientific• Fingerprint comparison

• DNA

• Dental radiograph comparison

• Radiographic comparison▪ Radiographic comparison of fragmentary remains

Means of Scientific Identification

Same methods available in both daily and mass fatality contexts…different emphasis

� Scale (number of fatalities)

� Condition of remains (taphonomy)

� Nature of incident (criminal vs. accident vs. natural)

� Decedent population (open or closed)

� Antemortem data: types, availability, accuracy

� Identification focus: victims or remains

� Role of DNA: ID and/or re-association

� Concerns/expectations of society and NOK

MFI Variables

• Reported missing vs. actual missing

• Increased reliance on DNA ID

• Lesser role for conventional ID

• ID all pieces vs. ID all victims

• Re-association required

World Trade Center

• Reported missing vs. actual missing

• Conventional ID

• Minimal DNA required/corroborative

role

• Re-association not required

Earthquake, cemetery flood

• Decedent list known

• More rapid acquisition of antemortem

data

• Increased reliance on DNA IDs

• Lesser role for conventional ID

• Re-association required

United 93, Egyptair 990

• Decedent list known

• More rapid acquisition of antemortem

data

• Conventional IDs

• Minimal DNA required/corroborative

role

• Re-association not required

Mass transit MVA (e.g. motorcoach)

Fragmentary remainsC

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Op

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� The FAC is a secure facility established to serve as a centralized location for the provision of information and assistance about missing or unaccounted for persons and decedents to family members, and for the collection of information in support of the identification process from family members.

Family Assistance Center: what is it?

Medical examiner

Social services

Law enforcement

familiesSocial/emotional support

ST

EP

6:

FR

C/F

AC

Opera

tions

� Victim Information Center

• Family interviews

• DNA reference sample collection

• Data management

• Notification

• HR Release

• Family briefings

� Support Services

• Childcare

• Credentialing

• Behavioral health services

• Family briefings

• First aid

• Food/refreshments

Family Assistance Center Components

Family Assistance Center

� The role of the medicolegal authority at the FAC is limited:

• Antemortem data collection

▪ Family interviews

• Decedent recovery and identification briefings

▪ Establish realistic expectations

▪ Dispel misconceptions (whole body, autopsy etc)

• Notification of identifications

• Not management

Medicolegal Role at the FAC

� Missing Persons reporting

• 10-100 calls per fatality

• Call center

� Patient tracking

• Data access/protection

• Medical Operations Center

� Sheltering

• Data access/protection

� Evacuation

Victim Accounting

Victim Accounting

?victims

Call

Cen

ter

Ho

sp

ital

Sh

elt

er

Evacu

ati

on

S

afe

& W

ell

Man

ifest

� MFI operations are not emergency operations

� DMORT is not the whole plan

� TFDA is not the whole plan

� A medicolegal authority maintains their responsibility during a MFI response

� Some of the functions that are required for mass fatality response are similar to daily operations, just on a larger scale

� Identification is the primary goal of MFI response

� Family assistance/communication is critical• Family assistance will be the most unfamiliar to local responders

• Families must get information prior to public

• It is not the medicolegal authority’s responsibility to manage the FAC

Fundamental assumptions

Recent Advances in Texas

� Lead by Texas Disaster Medical System

• Mass Fatality Management Workgroup

� Supported by Department of State Health Services (DSHS) and Texas Division of Emergency Management (TDEM)

� Great traction in this environment for education, training, and potentially some grant funding for further initiatives

� Involves subject matter experts from numerous regions and disciplines around the state

Texas MFM Planning Initiative

� TDMS Steering Committee identified Fatality Management as a priority and formed the workgroup in early 2013

� Workgroup Chairs

• Jason Wiersema, PhD

• Allison Woody, MS

• Dee Grimm, RN, JD

� First Project: validate assumptions of preparedness levels

TDMS MFM Workgroup

� Survey sent out to all local Texas jurisdiction in March 2013• Local offices of emergency management

• Local public health offices

� Asked ~35 questions re: fatality management• Demographics

• Planning

• Training

• Exercises

• Equipment

� 78 total respondents (city/county)� Presented at the 2013 Texas Emergency

Management Conference

Survey Responses

� Validates many MFM preparedness assumptions

� Did not anticipate significant change in results with a larger survey population

� Essential information for TDEM, DSHS, and TDMS in order to prioritize steps forward

� May be able to look at the return on investment for previous mass fatality-centric initiatives (what worked and what didn’t)

� Determined what assets and teams are available in the state

Results Summary

� Texas Funeral Directors Association (TFDA) Disaster Team

� Texas Military Forces (TMF) Fatality Search & Recovery Team (FSRT)

� Texas A&M Engineering Extension Service (TEEX) – Texas Task Force 1 (TxTF1)

Current Texas MFM Response Teams

� Incident Assessment

� Recovery

� Transport

� Temporary Storage

� Disinterment

� Family Interviews

Response Capabilities

� PPE

� Body Bags

� Embalming Fluid

� Refrigerated Trailers (3)

Equipment Cache

Texas Funeral Directors Association

does not have the same capabilities as a DMORT team

� Search & recovery in chemical environments

� Newly developed team – still in training

� Caveats:

• Team is not always available – part of the National

Guard, so unit may be deployed anywhere in the world

• Only the governor may activate this resource

Texas Military Forces FSRT

� Texas Task Force 1 (USAR)

• Assist with human remains recovery in complex

environments

▪ Collapsed structures

▪ Water environments

TEEX – TxTF1

� Storage

• Mortuary Enhanced Remains Cooling Systems

(MERCS)

• Refrigerated Trailers/Trucks/Conex boxes

� Body bags

� Disaster Portable Morgue Unit (DPMU-2)

� Regional Postmortem Response Trailer

(RPR-1)

Grant-Funded MFM Assets

MERC System

� Fully-equipped mobile morgue

• Body bags

• PPE

• HVAC

• Command tent

• Water stations

• Forensic equipment

� Located in Houston

• SETRAC

• HCIFS

Disaster Portable Morgue Unit

� Hard, weather-tight, roofed structure (preferred)

� 10,000-12,000 sq ft� Non-porous floors� Water� Electrical

� Loading dock

� Fuel service

� Sanitation

� Waste services (biomedical)

� Communication services

Disaster Portable Morgue Unit

� Located in Health Service Region (HSR) 8

� 42-ft self contained trailer

� Full autopsy suite

� Refrigerated storage for 2 decedents

� Designed as an infectious disease autopsy suite

� Specs:

• Full bath, dressing, decon areas

• Generator powered (on board)

• 150-gal water supply

• Gray / Black / Contaminated water tanks

• Dual air filtration system

Regional Postmortem Response Trailer

� Temporary morgue facilities

� Victim identification

� Forensic dental pathology

� Forensic anthropology methods

� Processing

� Preparation

� Disposition of remains

� Family Assistance

Response Capabilities

� (3) DPMUs stationed across the U.S.

• Texas

• California

• East Coast

Equipment

Disaster Mortuary Operational Response Team

Federal Asset: one for each FEMA Region

� Medical Examiner Offices

� Private Pathology Services

� Justices of the Peace

Stakeholder Engagement

� ~240 Justice of the Peace counties in Texas

� Need for outreach, education, training

� Presented at several JP & Constable conferences

� Taught course at JP Training Center

� Continuing to develop training plans and refining rural planning guidance

Justice of the Peace Engagement

� Texas Mortuary Operations Response Team

• MFI assessment

• Human remains search & recovery

• Morgue operations

• Victim information

• Victim identification

• Family Assistance Center

What’s in development?

Trying to prevent this…

National News Channel

streaming local central Texas news

Phone callsTwitterEmail

� Identified need for more comprehensive information in the early hours after the incident

� Who do we train?

• Emergency Managers in fatality management?

• Medicolegal personnel in emergency management?

� Developed Rapid Assessment Guide

Rapid Assessment Capability

� Situational assessment

� Site operations

� HR transport & storage

� Morgue operations

� Call center & public info

� FRC & FAC

� Close out

TMORT MFI Assessment

Rapid Assessment Teams (RAT)

Evaluation Page Notes Page

TMORT RAT Assessment Guide

� Texas Mortuary Operations Response Team

• MFI assessment

• Human remains search & recovery

• Morgue operations

• Victim information

• Victim identification

• Family Assistance Center

Future Texas MFM Response System

mass fatality planning in bexar county - strac

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