1. Mass Disaster: Past and Present Current Trends: 5 th Annual Conference December 1, 2004 Nizam Peerwani, M.D. Chief Medical Examiner Tarrant-Denton-Parker Counties, Texas Wednesday, December 1, 2004 peerwani@aol.com Anthrax Bacilli Gram Stain Terrorism is the unlawful use of force or violence against persons or property to intimidate or coerce a government, the civilian population, or any segment thereof, in furtherance of political or social objectives -Federal Bureau of Investigation

2. December 1, 2004Mass Casualty Disposition2 Objectives Mass Fatality & Legal Authority at Local Level Role of Medical Examiner in Mass Fatality Event Types of Events resulting in Mass Fatalities and Human Identification “Bioterrorism” – a different model necessitating different approach

3. December 1, 2004Mass Casualty Disposition3 Definition Mass trauma is the term used to describe the injuries, death, disability, and emotional stress caused by a catastrophic event, such as a large- scale natural disaster or a terrorist attack Mass Fatalities: Any situation in which there are more human bodies to be recovered and examined that can be handled by the resources of the existing facility. Mass Fatalities in Tarrant-Denton-Parker: Is defined as any event where there are more than 10 casualties resulting from a single event

4. December 1, 2004Mass Casualty Disposition4 Legal Authority In Texas, the medical examiner is empowered by Statute 49.25 of the Code of Criminal Procedures which requires a duly appointed medical examiner to conduct “inquest” or inquiry into certain types of death including: Deaths due to unnatural causes Unattended deaths Deaths that occur within 24 hours of admission

5. December 1, 2004Mass Casualty Disposition5 Medical Examiners in Texas 2003 For more information: david.zane@tdh.state.tx.us Facts Texas has no State Medical Examiner (ME) Texas has a mixed ME and Coroner system 13 MEs in Texas MEs are located in 15 counties Population served by ME counties is ~ 13 million (58% of state) In Texas - Medical Examiners are: Appointed Physicians licensed by the State Board of Medical Examiners Trained and experienced in pathology, toxicology, histology, and other medicolegal sciences Appointed by the County Commissioners Court Source: Bureau of Epidemiology and Bureau of Vital Statistics

6. December 1, 2004Mass Casualty Disposition6 Tarrant County Medical Examiner’s District - Serves Tarrant, Parker and Denton Counties Jurisdiction 3,000 SM Population: 2.1 million Cities served: 60 Law Enforcement Agencies: 63 Inquests: 8,000/year (40% of all deaths)

7. December 1, 2004Mass Casualty Disposition7 Chief Medical Examiner Deputy Medical Examiners Histology Lab Technical and Administrative Director Forensic Death Investigation Forensic Toxicology Lab and Crime Labs Morgue and Evidence Forensic Dentist (Human ID Lab) Commissioners’ Court Table of Organization

8. December 1, 2004Mass Casualty Disposition8 Four Forensic Pathologists Forensic Anthropologist Forensic Dentist Forensic Toxicologists Criminalists Latent Print Examiner Forensic Death Investigators Full-service Toxicology Lab Reference Crime Lab (52 full-time employees)

9. December 1, 2004Mass Casualty Disposition9 1 st Major Terrorist Attack in the United States: April 19, 1995 Murray Federal Building: 5000 lbs of Ammonium Nitrate fertilizer in a Truck

10. December 1, 2004Mass Casualty Disposition10 National Defense Policy Against Terrorism: Counterterrorism The policy (June 21, 1995) evolved in the aftermath of Oklahoma Bombing on the 2 nd anniversary of the Waco Disaster on April 19,1995 President Homeland Defense FBI FEMA Crisis Management Consequence Management State/Local Agencies County Medical Examiners Role?

11. December 1, 2004Mass Casualty Disposition11 Role of Medical Examiner in Mass Fatality Event Assessment of the Event Death Scene Investigation Body Recovery Examinations Identification of Human remains Establishment of Cause and Manner of Death Protect Personal Property and Evidence Disposition of Remains to Loved Ones

12. December 1, 2004Mass Casualty Disposition12 Mass Casualty Involvement by Tarrant County Staff Delta Airline Crash at DFW Airport,1985 Delta Airline Crash at DFW Airport, 1986 Waco Disaster, 1993 International: Rwanda Genocide Investigation, 1996 Bosnia & Kosovo, 1996-1997 Guatemala, 1997 – 2002 Afghanistan & Iraq Mass Graves, 2002- 2004

13. December 1, 2004Mass Casualty Disposition13 Types of Mass Fatality Events Natural Man-Made Weather: Tornado, Flood Fire: Forest fire Earthquake Fire: Hotel, School, Church Transportation: Aircraft, Bus etc Industrial: Chemical Terrorism: Domestic or Foreign

14. December 1, 2004Mass Casualty Disposition14 Notification Emergency Operations Center (EOC) Police – Law Enforcement News Media

15. December 1, 2004Mass Casualty Disposition15 Koresh Compound on Thursday, April 22, 1993

16. December 1, 2004Mass Casualty Disposition16 “Bunker” Water Tower Kitchen/Dining Area

17. December 1, 2004Mass Casualty Disposition17

18. December 1, 2004Mass Casualty Disposition18

19. December 1, 2004Mass Casualty Disposition19 Modes of Identification Visual: Body Intact Fingerprints Dental Body X-Rays DNA

20. December 1, 2004Mass Casualty Disposition20 Fingerprint Comparison: AFIS

21. December 1, 2004Mass Casualty Disposition21 Dental

22. December 1, 2004Mass Casualty Disposition22 X-Ray Comparison

23. December 1, 2004Mass Casualty Disposition23 DNA A Definitive …For Identification: Genomic (STR) or Mitochondrial

24. December 1, 2004Mass Casualty Disposition24 911 Taught Us That We Remain Unprepared

25. December 1, 2004Mass Casualty Disposition25 Dense Smoke & Debris Several Days After The attack (September 15, 2001) Destruction May Be Widespread Recovery Efforts Can Be Extremely Hazardous

26. December 1, 2004Mass Casualty Disposition26 Shifting Paradigm

27. December 1, 2004Mass Casualty Disposition27 In a Bioterrorist Attack…. In most cases, the cause of death will be clearly established by Hospital or Public Health Department There will be involvement of FBI (as the lead law enforcement agency) All deaths will be classified as “homicides” Number of casualties will continue to arrive in reverse order The major responsibility of the medical examiner will be to: Take custody of the remains to establish the identity To issue Death Certificate Dispose remains to designated location or for burial

28. December 1, 2004Mass Casualty Disposition28 Category A/Diseases & Agents Anthrax (Bacillus anthracis) Botulism (Clostridium botulinum toxin) Plague (Yersinia pestis) Smallpox (variola major) Tularemia (Francisella tularensis) Viral hemorrhagic fevers (filoviruses [e.g., Ebola, Marburg] and arenaviruses [e.g., Lassa, Machupo]) Highest Priority Agents: Can be easily disseminated or transmitted from person to person May cause high mortality, and have the potential for major public health impact Might cause public panic and social disruption Require special action for public health preparedness

29. December 1, 2004Mass Casualty Disposition29 Category B Diseases & Agents Multstuberculosis Nipah virus Tick-borne encephalitis]) Melioidosis (Burkholderia pseudomallei) Psittacosis (Chlamydia psittaci) Q fever (Coxiella burnetii) Ricin toxin from Ricinus communis (castor beans) Staphylococcal enterotoxin B Typhus fever (Rickettsia prowazekii) Viral encephalitis (alphaviruses [e.g., venezuelan equine encephalitis, eastern equine encephalitis, western equine encephalitis]) Water safety threats (e.g., Vibrio cholerae, Cryptosporidium parvum) Second Highest Priority Agents include those that: are moderately easy to disseminate cause moderate morbidity and low mortality require specific enhancements of CDC's diagnostic capacity and enhanced disease surveillance

30. December 1, 2004Mass Casualty Disposition30 Category C Diseases & Agents Hantaviruses Multidrug-resistant tuberculosis Nipah virus Tick-borne encephalitis viruses Tick-borne hemorrhagic fever viruses Yellow fever Third Highest Priority Agents include emerging pathogens that could be engineered for mass dissemination in the future because of: availability ease of production and dissemination potential for high morbidity and mortality and major health impact.

31. December 1, 2004Mass Casualty Disposition31 Inexperience: Most medical examiners have no field experience Smallpox: Pustules & Early Scarring Anthrax: Vascular Thrombosis Anthrax Bacilli

32. December 1, 2004Mass Casualty Disposition32 Large-scale Act of Bioterrorism… Federal and/or State Emergency Local jurisdiction may be suspended and the medical examiner in a local area may play a supporting role only