Incident Morgue Operations

Several standard operating guidelines for disaster victim identification and morgue operations are available from the websites of organizations such as Interpol, DMORT, the National Association of Medical Examiners, the UK Home Office, the U.S. National Institutes of Justice, and PAHO. These guidelines reflect the importance of a standardized process for documentation, analysis, quality assurance, and respect for the dead. The particulars of the disaster may require modification of parts of the morgue process, but the procedures remain largely the same.

Figure 23.4 is a morgue operational plan that demonstrates the typical movement of remains through the incident morgue. Controlling the flow of the deceased into the morgue allows for efficient processing and avoids overwhelming the morgue team with remains for analysis. Once brought into the morgue, remains are radiographed in their container (e.g., body bag, pouch, or transfer case). Radiographs allow for evaluation of the container’s contents prior to opening. For complete bodies, radiographs can reveal explosive devices or other hazards, personal effects, forensic evidence, the extent of trauma, and potential commingling with other remains in the same container. For fragmented remains, radiographs reveal potentially identifiable body portions, evidence, personal effects, non-biological material, and the extent of commingling. Radiographs are essential for the next step, known as triage. Triage is the process of sorting human remains, first to remove any material not related to determining identity, and then to assess their potential for identification.^44,45 In the first step, four categories of materials are typically separated: 1) personal effects; 2) wreckage or other types of evidence; 3) remains with a potential for identification; and 4) remains with no or little potential for identification.

Figure 23.4.

Morgue Operational Plan.

During the second step, each body or body part is assessed using a probative index that classifies remains according to their identification potential or investigative value. The probative index is incident-specific because factors such as availability and accuracy of antemortem information impact identification potential. Triage of whole bodies allows for sorting by the potential for identification, such as the presence of dental work or evidence of surgery. For fragmentary remains, triage personnel assess each body part for positive and presumptive identifying features that may lead to dental, fingerprint, medical, or DNA identification. Remains usually suitable for identification include dental specimens, large body portions, hands, feet, prosthetic devices, and bone showing healed trauma. Accordingly, remains with the greatest potential for identification are analyzed first. Small pieces of skin, fatty tissue, muscle, and similar specimens lacking characteristics usable in the identification process do not initially enter the morgue processing stream, but can be examined if the initial identification process does not account for all victims.

Following triage, remains are moved to the admitting area where a case file containing postmortem analytical paperwork and other administrative data is created. Remains are assigned a number corresponding to the case file. A simple numbering system reduces confusion and decreases administrative errors. Remains should be assigned unique simple consecutive numbers. Letters, dashes, and similar characters should be avoided (e.g., 34/A-2, 96–0005A34). During the course of the morgue analysis, if additional remains are found commingled with a specimen, then the new body part can be brought to the admitting station and assigned the next consecutive number. Morgue personnel can preserve associated numbering systems assigned at the disaster scene if a similar logic has been applied. Data from the scene associated with the remains can be placed in the pertinent case file. After identification and reassociation of fragmented remains, the coroner or medical examiner assigns a unique victim number or case number to the remains comprising that individual.

Various technologies reduce errors in the management of large numbers of remains. For example, computer-readable barcodes and radiofrequency identification chips were used to manage remains in disaster morgue operations following the World Trade Center disaster, the 2004 Indian Ocean tsunami, and Hurricane Katrina.⁴⁶

Once numbered, the individual remains are photographed, radiographed, and then moved through the postmortem examination stations. Forensic scientists with mass fatality experience staff these stations, which are usually referred to by the discipline conducting the work – dental, pathology, anthropology, fingerprint, and DNA. Requirements of the investigation dictate whether remains are examined at each station or just at stations that are relevant to a particular body part. At each station, information is collected according to a protocol created for the specific disaster response.

Forensic odontologists (dentists) staff the dental station, where they examine the maxilla, mandible, and any fragments thereof to document dental structures, fillings, and other unique features.⁴⁷ Fingerprint experts take prints from fingers, hands, and feet (if necessary) for comparison to existing print records. Forensic anthropologists document anatomical structures to determine sex, age, stature, and other pertinent biological attributes useful in identification, such as bone trauma or unique skeletal characteristics. Forensic pathologists examine remains for evidence of unique features, assess information relative to cause of death, and conduct autopsies if necessary. In some cases where equipment is available and the remains are complete, MRI scans can assist pathologists in this determination, thus avoiding the need for an invasive autopsy. DNA technicians take samples from soft tissue and bone, which are later analyzed in the DNA laboratory. Interaction across discipline boundaries is essential for successfully completing the process of postmortem documentation. Once finalized, postmortem data are entered into a data management system for later retrieval during the identification process.

These same forensic specialists are also involved in comparison of the postmortem data with the antemortem records – the process of positive identification. Regularly scheduled meetings between the medicolegal authority and the forensic experts allow for review of current findings and discussion of identifications. Details of each identification are documented, and the information is presented to the medicolegal authority for validation and authorization. This process usually takes place at the disaster morgue for those identifications accomplished by conventional methods. If DNA analysis is used, the identifications may take months to complete and a separate DNA identification team is established to document and validate identifications. Once a victim is identified, the next of kin is notified via the medicolegal authority’s usual process for death notification. Remains may then be released to the next of kin for final disposition, or remains are maintained at the morgue awaiting reassociation based on the next of kin’s decision.

Policy and Ethical Questions in Mass Fatality Management

The decisions and processes involved in managing and identifying disaster victims create unique policy and ethical questions arising from the interplay of three different domains: the remains of the victims, the expectations of family members and society, and the tools and technical limitations of victim identification science. These questions often concern how remains are identified, the extent of resources allocated to conduct identifications, and expectations about what is returned to the family for final disposition. Such questions include:

Answers to these questions are influenced by available resources, the characteristics of the disaster, the desires of the family members (individually and as a disaster-specific group), cultural and religious beliefs about death and final disposition of remains, societal expectations about what science can provide, and the availability of appropriate forensic identification tools and techniques.^3,35 These questions are not unique to disaster work, as forensic scientists involved in human rights investigations have raised similar concerns.⁵³ Additionally, the increased use of DNA testing for disaster victim identification has raised ethical questions about the use of samples for such events.⁵⁴

DVI science has limitations that must be explained to family members and society because their expectations can be at odds with scientific capabilities. When families believe that identifications will happen quickly, scientists must convey realistic expectations to the families about the timeframe and associated complexities. This difficult but necessary readjustment helps families understand the reasons behind the answers to the aforementioned questions.^9,55

Resolving these questions is rarely done through public dialogue, presumably because of the sensitivities of discussing the details of the event. Informed public discussion is essential, however, to answer these questions appropriately.^56,57 Family members want and deserve factual, compassionate discourse. Although the discussions may be difficult, they help families navigate the complex grief process associated with a disaster while concurrently assuring a community that their loved ones receive appropriate consideration and care.

Caring for Mass Fatality Workers

Despite their routine exposures to death, the psychological impact of disaster work on forensic responders should not be underestimated. Disaster forensic work is physically and psychologically stressful.^58–60 Even with the familiarity of working with human remains, certain tasks increase stress for most forensic responders.⁶¹ These include the handling of personal effects, examining the remains of children, the condition of remains (particularly aspects of visual grotesqueness, odor, and tactile features), and exposure to a large number of victims. Identifying or personalizing with the victims increases emotional attachment to the remains, may reduce objectivity, and may increase vulnerability to psychological distress. Such stressors can result in normal emotional reactions, such as sadness, disgust, anger, pity, fear, and numbness. Physical reactions can include headache, sleep difficulties, intestinal problems, appetite changes, and fatigue.⁶²

The most effective coping strategies involve talking with trusted coworkers, appropriate use of humor, reflecting on the larger purpose of the work, avoiding media coverage of the event (particularly information about the victims), and taking regular time off from the disaster work. Camaraderie and talking with colleagues both during and after the event has been shown to be an important source of positive feelings about a disaster response. Peer-support models, as found in fire/rescue and police agencies, are preferable for forensic responders, because outside mental health professionals typically do not understand the particular stressors of forensic work.⁶⁰ Despite the stress, forensic responders report that disaster work is a valuable experience, provides a sense of accomplishment, and increases their appreciation of life.⁵⁸

Assistance to Victims and Their Families of Victims

Because one of the main goals of mass fatality management is to comfort the living, it is important that appropriate support is provided to survivors and to victims’ families. Issues to address include the type of help needed when a mass fatality occurs and identifying the needs of the victims and their families after the immediate emergency passes. Survivors of mass fatality events and family members of those killed often experience an “existential crisis” marked by a profound sense of emptiness and despair.⁶³ Family members, survivors, and others impacted in the community are likely to exist in a state of psychological shock, uncertain about the whereabouts of loved ones and about the future.⁶⁴

Responding to the needs of those affected is complex from a logistical perspective, yet simple in determining a successful outcome. The complexities arise from the myriad of state, local, and federal agencies, private groups, and local community nonprofit organizations each attempting to provide assistance. The measure of success for those assisting family members is simple: it is determined by how effectively the needs of victims and their families are met and by the compassion demonstrated during the response.

Managing a mass fatality event requires coordination among all participants from each area of the disaster response. Prompt and precise communication about the needs of those impacted is crucial. In the chaos of the moment, however, responders can lose sight of the victims’ real needs. There is a tendency to respond based on a broad generalization of what the disaster response should entail. Clearly, there are guiding general principles that influence responders when assisting victims; however, it is equally as important to stay focused on the individual impacted by the disaster. It is often best to reflect on who the victims are and what their needs may be in order to maintain the proper focus and deliver appropriate services.

Listening to victims and their families describe their needs and expectations can also help guide future responses. The U.S. Task Force on Aviation Disaster Family Assistance, formed by the passage of the Aviation Disaster Family Assistance Act of 1996, articulated a series of recommendations.⁶⁵ Family members, representatives from the commercial aviation community, government agencies, and nonprofit organizations attempted to create a more effective approach to meeting the needs of victims and their families following an aviation disaster. In the United Kingdom, the charity Disaster Action is composed of survivors and family members who provide an independent advocacy and advisory service representing the perspectives of individuals directly affected by disaster. The Fédération Nationale des Victimes d’Accidents Collectifs (FENVAC) in France comprises victims’ families from various mass fatality disasters and terrorism events. In addition to supporting family members, FENVAC also serves to defend the rights of victims and to promote accountability and accident prevention.

Family members impacted by a mass fatality event describe an overwhelming sense of loss of control over their world. The loss they experience is often in the context of a larger public tragedy.⁶⁶ When individuals suffer a loss under such circumstances, they experience grief.⁶⁷ Grief is expressed in numerous ways, including physical, psychological, behavioral, and social and spiritual responses and reactions.⁶⁸ The nature of this larger public tragedy makes the grief process more difficult for victims and their families. An effective mass fatality response and recovery must carefully consider these aspects and integrate proper remedies.

The grief experienced in response to a mass fatality event is further complicated by the traumatic nature of the incident. Trauma refers to situations out of the normal range of experience and includes things such as suddenness and lack of anticipation; violence, mutilation, and destruction; preventability or randomness of the event; and the mourners’ personal encounters with death. The individual experiences either a significant threat to personal survival or a shocking confrontation with the death or mutilation of others.⁶⁹ Traumatic events challenge the many assumptions people have about the world and cause them to feel they no longer control the basic facets of daily existence. An effective and responsible effort to assist victims and their family members must consider the loss experienced and the grief response in the greater context of a traumatic event.

Corr and Doka observed two main elements in ongoing responses to public tragedy: coping with loss, grief, and trauma and finding ways to adapt to a changed world.⁷⁰ Janoff-Bulman states, “In the end, it is rebuilding of this trust – the reconstruction of a viable non-threatening assumptive world – that constitutes the core coping task of victims.”⁷¹

The path from victimization to regaining a sense of control and trust requires the individual to cope with the traumatic event and the grief resulting from the loss of a loved one. Those responding to a mass fatality must be sensitive to this emotional state and have an understanding of what is needed. A systematic approach to address the physical, psychological, social, and spiritual needs of victims and their families is vital. These approaches, which take many forms depending on the disaster, help victims and their family members begin to reestablish a sense of control. When handled properly, such interventions will also help them rebuild the shattered trust caused by the mass fatality event.

Corr describes several strategies that responders can use to aid people coping with public tragedies.⁶⁷

The lives of victims and their family members impacted by a mass fatality will be forever changed. The goal of any response should be to mitigate further trauma and help the victims reestablish a sense of control. Most individuals, with a little assistance, can use their coping skills to adapt to even the most horrific of circumstances.