Body Count

You are the director of Tri-County EMS, a third-service EMS agency, and are heading into the office one morning when you hear the call come over the radio: "Dispatch to units EMS 1, EMS 7, Medic 2, Medic 3 and Rescue 311. We have reports of a school bus into a tractor trailer on Interstate 47 northbound. Numerous callers are reporting multiple injuries and fatalities." You think, Thank goodness we hammered out that mass fatality plan, then get on the air and advise dispatch that you are responding as well.

EMS agencies have the potential to respond to high-impact incidents of all varieties, including transportation incidents, industrial accidents, severe weather or natural disasters, fires or acts of violence and/or terrorism that result in mass fatalities. There is a definitive need for EMS to be an active element of the planning process as well as the response component for these incidents. Just the term “mass fatalities” conjures up images of chaotic scenes with multiple agencies having distinct responsibilities that may or may not be related to their day-to-day operations. When thinking about the various elements involved in mass-fatality management, it is important to keep in mind recent examples of incidents that produced mass fatalities, such as the earthquake/tsunami combination that hit Japan and the tornadoes that recently devastated several areas in the United States.

Prior to discussing the planning elements that must go into incidents involving mass fatalities, a definition is in order. One of the more expansive definitions comes from California Health and Safety Code Section 103451, titled “Mass Fatalities Incident: Definition,” which states:

“(a) For purposes of this plan, 'mass fatalities incident' means a situation in which any of the following conditions exist:

1. There are more dead bodies than can be handled by local resources

2. Numerous persons are known to have died, but no bodies were recovered from the site of the incident

3. Numerous persons are known to have died, but the recovery and identification of the bodies of those persons is impractical or impossible.

(b) The county coroner or medical examiner may make the determination that a condition described in subdivision (a) exists.”

For the purposes of this article, a mass-fatality incident can simply be defined as: "An incident where more deaths occur than can be handled by local resources." This defining point is an important distinction, as some jurisdictions could easily handle 10 or more fatalities at the same incident scene, while others would be quickly overwhelmed.

Although various jurisdictions have different lead agencies in regard to mass-fatality planning, EMS needs to ensure it has a seat at the table. This means being involved with the various planning and response elements—emergency management, fire, law enforcement/public safety and hospitals—on a day-to-day basis. This strong pre-existing relationship will ensure you are invited to the table and your concerns will be heard and addressed.

Planning

The first step in the planning process should be a hazard vulnerability assessment, which will, at a minimum, establish specific hazards that have impacted your jurisdiction (this can be local, county, regional or state) in the past and have the potential to impact it in the present and/or future. Understand that this is not something an EMS agency conducts on its own, and EMS plays a valuable role in this regard. Questions surrounding your HVA could typically include:

• What types of natural disasters/severe weather, such as flooding, hurricanes, tornadoes, major snowstorms, have impacted your community in the past?
• Do you have an airport, seaport or other transportation hub?
• Are there major highways running through your jurisdiction?
• Is there major industry, and what is it?
• What are the typical large-scale planned events?
• What past events have occurred in your community? Have these included acts of terrorism?

This planning process is exceptionally important, and the need for partnerships is paramount; thus, having all of the key players involved in the plan is critical. It is also important to have a representative from the coroner's or medical examiner's office at the meeting, as well as someone from the state or local funeral home association. Typically, these entities in the death-care industry are better informed about operational realities in dealing with mass-fatality management (such as handling large numbers of bodies).

During the planning process, it's important for EMS agencies to make the others at the table aware of their resources and operational realities, including number of vehicles per shift (both ALS and BLS), typical crew makeup, specific protocols regarding mass-fatality incidents (if applicable), mutual aid agreements, memoranda of understanding, and additional considerations.

Your plan, at a minimum, should include relevant definitions, the scope of the plan, authorities involved, overarching incident priorities, and the various responsibilities of all entities responding to or receiving patients from the incident.

A solid example of the template approach mentioned above comes from the Thomas Jefferson Emergency Medical Services Council based in Charlottesville, VA (available at https://www.tjems.org/TJEMSMCIPlan2009.pdf). This plan includes all of the elements mentioned above and others, including a list of potential high-risk entities in the region, a comprehensive list of initial actions to be taken at the scene of a mass-fatality incident, a list of the distinct roles of both EMS entities and medical care facilities, as well as standard precautions all EMS providers should take at such an incident and a deactivation component for the plan.

Another example of collaborative planning was promulgated by the Los Angeles Department of the Coroner; Los Angeles Department of Health Services, Emergency Medical Services Agency; and the Los Angeles County Department of Public Health (https://ems.dhs.lacounty.gov/ManualsProtocols/MFIM/MFIGuidanceForHospitals808.pdf). This plan, too, is comprehensive and is specifically directed at the healthcare aspects of mass-fatality management. The plan includes lists of key contacts with phone numbers and e-mail addresses, as well as after-hours contact information, various planning checklists, infection control procedures for staff handling human remains, job action sheets (JAS) for personnel with specific responsibilities in mass-fatality response, and an equipment and supplies checklist.

Response Reality

The response phase of a mass-fatality incident must be grounded in a sound mass-casualty incident response plan. Emergency medical services agencies must obviously first address the needs of those patients who are alive and/or most likely to survive. The discussion about mass-fatality management only reasonably occurs after mass-casualty response planning has already occurred. Using the National Incident Management System (NIMS) model, incident priorities are established as:

• Life safety
• Incident stabilization
• Property conservation
• Environmental protection.

One question that arises regarding response is, where in the ICS continuum does fatality management fall? Is it an EMS, public health or law enforcement function?

It is essential that these questions are addressed prior to the event, during the planning phase. Fatality management should rightfully fall after life safety, but prior to property conservation.

Consider Your Current Capability

In the United States, someone dies approximately every 11 seconds (www.census.gov). Every community is forced to adapt its fatality plan to local conditions. The agencies and resources involved with a single fatality will all have roles in addressing the requirements for mass-fatality management. For this reason, planning for a “mass-fatality” incident—"an incident where more deaths occur than can be handled by local resources”—must have an established foundation in the jurisdiction’s “single-fatality” plan. There is no doubt that every community across the country has had to respond to a fatality. The logical question must be asked: What number will overwhelm your community resources? Has the exact number even been considered?

To understand your single-fatality plan, one of the most appropriate ways to proceed is to ask some simple yet thought-provoking questions of all the relevant agencies and non-governmental organizations involved. These would include:

How is a single fatality addressed?

Engage those agencies and non-governmental organizations that would normally address a single-fatality incident. The normal procedures associated with these operations need to be understood to “scale up” to a mass-fatality incident. For example, as previously mentioned, law enforcement, coroner/medical examiner, EMS, funeral directors and public health officials may all have a role and should be included in the “how” step.

Why do we do it?

What are the public's expectations of how you handle human remains and deceased persons? What cultural and religious beliefs need to be considered? How likely are these to impact your community?

Included in this step is research and identification of any laws or regulations that are relevant to addressing deceased persons. What laws or regulations govern the handling and transportation of human remains and deceased persons? For example, the Code of Maryland Regulations Article 10.03.01.05 indicates that, “Human remains may not be transported within the state or moved from the state without a burial-transit permit.” Under what circumstances can this permit requirement be suspended? Who has that authority? Can EMS units be used to address this need? Should they be used to address this need?

Who will be responding to a mass-fatality incident?

This question includes which governmental as well as non-governmental organizations (NGOs) will be involved. What triggers will cause them to become involved (e.g., will public health be the lead for an infectious disease incident?)? What resources do they bring?

When do agencies respond to deceased persons?

What are the triggers that engage other organizations?

What is the process by which a single fatality is addressed by these agencies?

What resources are brought to bear in this process? What are the likely shortfalls? These can include staffing, training, equipment and transportation, as well as other potential issues. What bottlenecks will interrupt or derail the process?

Once you have established how this operation functions for one fatality, consider two, three, and so on. Understanding this process is critical, because you must identify those resources that are necessary, how those resources are exhausted and when. You must know when the local system will have the potential to fail or need support so you can plan to request additional resources.

Target Capabilities

The Department of Homeland Security Target Capabilities List (TCL) “provides a guide to addressing the priorities and achieving the National Preparedness Guidelines. Capabilities provide the means to accomplish a mission and achieve desired outcomes by performing critical tasks, under specified conditions, to target levels of performance.”

One such response capability is defined as fatality management (https://www.fema.gov/pdf/government/training/tcl.pdf). Compare your current “single-fatality plan” to the activities described in the fatality management capability, which includes 10 specific activities:

1. Develop and maintain plans, procedures, programs and systems
2. Develop and maintain training and exercise programs
3. Direct fatality management tactical operations
4. Activate fatality management operations
5. Conduct on-scene fatality management operations
6. Conduct morgue operations
7. Manage ante-mortem data
8. Conduct victim identification
9. Conduct final disposition
10. Demobilize fatality management operations.

The capabilities in the TCL are considered national standards. Many of these activities are not specific to the traditional EMS role; however, depending on the jurisdiction, EMS resources may be necessary to accomplish these activities in cooperation with other agencies.

Hazard and Vulnerability Assessment

Once the number of fatalities exhausts your resources, you must determine if your capability is appropriate for the risks that face your jurisdiction. This is the role of the HVA. What is a reasonable number of fatalities your system may encounter? How many fatalities have you encountered in the past from a single incident? Planning to the concept “more than can be handled” may leave you questioning your capability to respond. Exercising that concept is also difficult, as measuring performance against a vague concept is nearly impossible. A more concrete expectation needs to be developed to establish both your agency and jurisdictional expectations for performance.

Planning to Improve Capability

In this article, we have discussed:

• Current capability—how many fatalities exhaust local resources?
• Target capabilities—what should you be able to do?
• Hazard and vulnerability—how many fatalities can you reasonably expect?

Now that you know all that, how do you use it? Here is an example:

• Current capability: Your planning process reveals there are only four medical examiners legally authorized to process human remains in your locality. Each one can process two fatalities from a single scene, so your current capability is halted at 8 fatalities.
• Target capability: The medical examiner is a key resource throughout the fatality management TCL, and you have validated your current local process is consistent with the federal TCL.
• Hazard and vulnerability: You are a large jurisdiction, with more than 1 million population, and several major interstates and passenger rail lines. You have had experience in dealing with several incidents with more than 10 fatalities in the past several years. Your HVA target for fatality management is reasonably established at 20.

You have clearly identified a gap in your capability—specifically, an inadequate number of medical examiners. How can you address that? Is it a planning, personnel, training, facility or equipment problem? For this example, consider it a personnel problem. The medical examiner's office is woefully underfunded and cannot afford to hire additional personnel. How do you get medical examiners from neighboring jurisdictions? How can you increase each medical examiner's capability? How do you get from a current capability of 8 to a reasonable planning figure of 20, and is the dearth of medical examiners the only shortfall that keeps you from that planning figure?

That is the strength of defining and understanding the process in your planning effort. The ability to see all the interactions and resources necessary gives you the ability to consider alternatives to address your shortfalls, which must be addressed by either accessing those resources elsewhere or by changing standards of practice or procedures. If the medical examiners were planning by themselves, they may not understand that other gaps exist. In other words, the fix may not have fixed anything.

Conclusion

Emergency incidents involving mass fatalities have the potential to be some of the most hectic and dynamic scenes EMS agencies will encounter. Recent events in Japan showed that traditional response entities and authorities have seen expanded roles when large-scale incidents arise. The logistics behind responding to exceptionally large-scale mass-fatality incidents are way outside the scope of most mass-fatality plans but need to be in the forefront of EMS agencies' minds.

Understand that knowing your partners in advance and utilizing those relationships to assist in developing well-researched response plans can result in an efficiently run response to what has the potential to be a very difficult emergency scene.

Raphael M. Barishansky, MPH, is chief of public health emergency preparedness for Prince George's County (MD) Health Department. A frequent contributor to and editorial advisory board member of EMS World Magazine, he can be reached at rbarishansky@gmail.com.

Dennis C. Wood, MS, NREMT-P, is the major of Emergency Medical Services for the Prince George’s County Fire/EMS Department in Maryland.  He has been in the fire and emergency medical services for more than 20 years.  He can be reached at dcwood@princegeorgescountymd.gov.