Mass fatality incidents present many challenges. To effectively plan for such events, certain key factors must be taken into consideration: common causes and challenges, as well as resources available. By communicating with the local medical examiner/coroner, being familiar with mass fatality plans, and learning about any pertinent capabilities and limitations, emergency planners can make informed decisions and close existing gaps.
A mass fatality incident (MFI) is essentially a surge issue. Just as a mass casualty incident is a surge on the emergency medical transportation and trauma care systems, an MFI is a surge of the medical-legal system in the authority having jurisdiction (AHJ). The medical-legal system is the system within the AHJ that is responsible for determination of the cause and manner of death and the identification of unknown decedents and the issuance of a death certificate document.
For planning purposes, some first responder organizations define an MFI by the number of victims – for example, three times the normal caseload for the AHJ within 24 hours of the event. The problem with setting a minimum number is that it does not take into consideration the level of available response capabilities or the condition of the remains. Twenty fatalities caused by a single incident could be overwhelming for a small community, but a larger medical-legal system would find those numbers well within their capabilities. A more practical approach to consider is to ask:
- What is the maximum number of the deceased that the local system can handle, taking into consideration that fragmented or contaminated remains may complicate the problem?
- Then, what plans and exercises should be developed to reflect the reality of local resources, and how would they need to be augmented?
Common Causes of & Challenges Related to an MFI
The most common causes of an MFI are: transportation (air, rail, motor coach, marine vessels) accidents, structure fires or collapses, floods, hazardous materials releases, and mass homicides. These events are often the results of earthquakes, tsunamis, hurricanes, tornadoes, and criminal (terrorism included) acts. Pandemic illness can factor into this, though pandemics generally are not acute situations and are often regional events and may develop over time. Pandemics can impose a sustained “surge” on the AHJ that lowers the threshold for becoming overwhelmed. In some jurisdictions, the opioid epidemic is having this effect.
First responders face six challenges when dealing with an MFI. The first challenge is the “It won’t happen here” or “It’s not my job” challenge. In some planning models or threat analysis programs, an MFI is a low- to medium-probability event, and then only if there is a target hazard such as an airport in the jurisdiction. That being the case, the “It will not happen here mindset” kicks in and there is little to no attention paid to MFI planning or budgeting or inclusion of the medical examiner/coroner in drills and exercises. It would be wise to take a closer look at MFI probability factors. If major highways or rail lines are within the community, the risk of an incident that causes many fatalities is real. If tornadoes or earthquakes threaten the area, the potential for an MFI may be significant, and any town can experience mass fatalities from a shooter with automatic weapons and a desire to kill.
Second, the resolution of MFIs will last for days, weeks, or more. Prepare for a multi-operational period event. If the event includes an extended recovery of the remains – like the Oklahoma City bombing in 1995 or the World Trade Center in 2001 – the process will take several days or weeks. If the remains are less than intact, as often is the case with aircraft accidents or explosions, the collection and processing of the fragments will take a lot of time. The remains could be contaminated with a hydrocarbon, toxic industrial chemical, or chemical-warfare agent. Clearly, there will be a need for a significant command post and resources to support a logistically intense operation. If the event is a crime scene, like the Pulse Nightclub (Orlando, Florida), expect a major law enforcement presence and that bodies will not be moved until law enforcement is finished with the investigation. That process could take days.
Any major incident that involves a large number of government agencies, medical facilities, and other community resources requires a management system that can address: the multi-agency, multi-jurisdictional operations; the planning, logistical, and administrational issues; and the tracking costs. A system is needed that can expand and sustain itself for weeks and address public information, safety, and liaison needs. The obvious solution is Incident Command System, and the fire service is often the only local agency that can think of sustaining operations for days or weeks. The fire department’s role may evolve as the incident moves from response to recovery to identification. The role of the fire department may be to provide the functions of an “overhead team.” Similar to the U.S. Forest Service, the fire department’s role would be to assist in the development and publication of the Incident Action Plan.
Media coverage is the third challenge. There must be a plan to manage media response – a designated area for the media, with controls on unwanted or illegal intrusions that are enforced by the police, especially at and around the scene and near the families of the victims. A joint-information center/process/plan is a must.
Fourth, the expectations of the deceased loved ones or Next of Kin (NoK) can be challenging:
- What will the families or the NoK be told about the process of identifying and releasing the remains?
- Where do the families go to receive timely accurate information regarding their loved ones?
- Once the deceased is legally identified, what is the process and structure for notifying the NoK? The medical examiner and often law enforcement handle this step, but it is important that all first responders are aware of who is responsible for this task.
Few people outside the forensic community understand what is involved in the accurate, positive identification of the deceased, why it needs to be done a certain way, and that the process takes time. Distraught family members may agonize through the hours between the incident and the final confirmation of the loved one’s death. There are expectations that the accurate, positive identification of the deceased can occur within an hour. This misconception is reinforced by the entertainment industry with forensic-based television programs and movies. In these programs and films, family members are routinely shown the bodies to visually verify their identities. These expectations are neither realistic nor are they considered to be scientifically appropriate methods for positive, legal identification. Identifications need to be properly done and done only once. That will take time. If DNA collection of ante mortem evidence is needed, then the process of collecting and analyzing the evidence can be time consuming and requires communications with NoK.
It is essential to develop and test a plan for standing up a family assistance or victim assistance center. A single, centralized location for the release of official information and privacy for the NoK can be accomplished on the terms that they are compassionate, respectful of privacy, and timely. The example in Oklahoma City in 1995 after the Murrah Building bombing is considered a model for this type of center. A large church in the downtown area was used as a center because it was an easily located landmark. Ample parking was available and a commercial-grade kitchen was on-site. There were private rooms for notification and grief counseling out of sight of the public. One element not present was overnight lodging accommodations, as this was primarily a local event. In an event where families may be traveling some distance, considerations for lodging have to be included. There is much more information available at the U.S. Department of Justice’s Office for Victims of Crime website. The National Transportation Safety Board (NTSB) also has resources available through the Aviation Disaster Family Assistance Act of 1996.
The fifth challenge is determining which specialists might be needed to augment local capabilities and to mobilize those resources. Conversely, first responders need to have a plan to deal with the likelihood of unneeded, or self-dispatched responders driven by curiosity or a desire to be at “the big one.” MFIs related to disasters and other high-visibility events have often brought out many unrequested, self-dispatched responders who can cause significant problems for the jurisdiction already strained by the event. These responders can be in a variety of disciplines, such as forensic canine (K-9) handlers, mental health providers, and off-duty first responders from other jurisdictions. There should also be a policy on unrequested responders in disaster plans.
A final challenge is the “We got this” syndrome, which is when authorities resist reaching for assistance. This challenge is not limited to public safety; the medical examiner/coroner is not immune to this syndrome. An exercise that focuses on an MFI with complicating circumstances is one of the best ways to demonstrate when/where a community can be overwhelmed. If mutual aid is needed, then make sure these resources are included in a mutual aid plan and that the plan is up to date and has been exercised. If assistance is requested, ascertain the logistical and support needs of the resources and the estimated time of arrival as well as the length of time the resource can provide assistance.
Several items have been mentioned in this article, specifically, the need for an overall MFI response and recovery plan as well as a media/communications plan, a family assistance plan and a mutual/aid assistance plan. Many communities today are training and exercising for an “active shooter” event. However, in the design of the exercises and training, do not stop when the last Basic Life Support unit leaves the scene. Instead, start the second phase or next exercise with the scenario that all of the living have been transported or treated: law enforcement has completed their investigation and is now providing perimeter security. Then consider what is next.
Available Mortuary Resources
There are various types of assistance available to local agencies, private sector groups, and state and federal level response teams. Funeral directors associations have response capabilities that can assist the AHJ with management and release of remains. These teams can respond in less than 24 hours and provide assistance with handling bodies and communications with the NoK. Funeral directors associations may not be able to provide assistance in the forensic part of the process, as they do not have the expertise or equipment to do so.
Florida and Michigan, for example, have state-level teams that can assist with victim identification. These teams are sometimes partnerships between the state and universities that have forensic science programs. Like funeral directors associations teams, state teams can respond quickly, generally in less than 24 hours. Some of these teams have equipment that can support or supplement the AHJ with morgue operations. A limitation of the state teams as well as the funeral directors associations is the length of time they are available to assist in the identification process. Many of the providers on these teams have limits on how long they can be away from their primary place of employment. However, for smaller numbers of decedents, a state-level team may be the appropriate resource.
Federal assistance is available through the Department of Health and Human Services, National Disaster Medical System (NDMS). NDMS has a Disaster Mortuary Operational Response Teams (DMORT) in each FEMA region and two national teams. These teams are staffed with specialists that become temporary federal employees for the duration of their deployments. These teams can provide two-week rotations that can continue for several months as needed. This was the case in New York after 9/11 and in Louisiana after Hurricane Katrina.
DMORT has three deployable morgue units that are strategically located throughout the country. These units can be delivered by trucks and generally set up in less than 72 hours in the continental United States. One of the national teams (Victim Assistance) can be brought in to assist with the family/victim assistance functions, while the other national team (DMORT-WMD/All-Hazards) can decontaminate the remains. To request these teams, local government asks the state for assistance, which, in turn, requests federal help under Emergency Support Function #8 (ESF-8).
In preparation for an event with mass fatalities, become familiar with the local or state medical examiner/coroner. Become familiar with their plans or plans of the agency (often state or local emergency management) that address fatality incidents. Learn the capabilities and limitations of their staff, their facilities, and their equipment. By doing so, informed decisions can be made regarding the gaps between the “surge” from the incident and capabilities of the medical-legal system.
Note: Since this article was first drafted, the National Disaster Medical System, as part of a larger reorganization and re-alignment of resources, has “terminated” the mission of the DMORT-WMD All/Hazards team. Emergency planners should review their MFI plans to determine if this change has an effect on their plans and expectations of federal assistance via ESF-8.
Daryl D. Sensenig
Daryl Sensenig is a retired battalion chief from the Anne Arundel County (Maryland) Fire Department (AACO FD). Since 1998, he has been a member of the National Disaster Medical System’s Disaster Mortuary Operational Response Team (DMORT), and a former member of the Weapons of Mass Destruction/All-Hazards unit, within the U.S. Department of Health and Human Services, Assistant Secretary of Preparedness and Response. He has an in-depth knowledge of fatality response from several leadership positions for mass fatality disaster response and recovery efforts, including United Flight 93 on 9/11 and Hurricane Katrina. He has served as a hazardous materials team member and commander, the operations officer for the Emergency Management Bureau, of the AACO FD. During the Deepwater Horizon Oil Spill in 2010, he accepted deployment to serve on the Incident Management Team in Louisiana as a deputy operations section chief. Currently, he is a faculty member at the University of Maryland’s, Maryland Fire and Rescue Institute (MFRI), Special Programs Section.