MASS FATALITY PLANNING IN BEXAR COUNTY - STRAC
Transcript of 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
*data courtesy of New York City Office of the Chief Medical Examiner
U.S
. M
FIs
20
00
-20
12
Average Deaths per MFI
Average Deaths per MFI
33*not including 9/11 Terrorist attacks or Hurricane Katrina
*data courtesy of New York City Office of the Chief Medical Examiner
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
� 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
los
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po
pu
latio
nComplete remains
Op
en
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n
� 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?
� 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