Dealing immediately with the dead and wounded would overwhelm local U.S. authorities in most locales. Depending on the disaster's characteristics -- whether it involves multiple jurisdictions over many miles, or if bodies can't be recognized -- it could take years to identify, catalog and decontaminate the victims.
While there's been progress in preparing for a disaster's aftermath, plans are based on small incidences like building collapses, train wrecks or tornadoes, said Joe Scanlon, journalism professor emeritus at Carleton University in Ottawa, and former director of Carleton's Emergency Communications Research Unit. But a real catastrophe in the United States would heavily strain our emergency response system.
Walking Wounded
Emergency personnel must provide swift medical care while wisely using limited resources during a disaster.
Hospitals fill up fast with severely injured and moderately injured patients -- the least injured are easiest to transport and are driven in people's cars to close-by hospitals, bypassing triage, soaking up resources and leaving less hope for those who are dying. And because the Emergency Medical Treatment and Labor Act of 1986 requires hospitals to treat all incoming emergency patients, U.S. hospitals can quickly get bogged down with newcomers.
For this to happen, Scanlon said, hospitals would have to screen patients at the disaster site -- before they arrive at a hospital where they won't be turned away.
The Institute of Medicine, an independent scientific group based in Washington, D.C., declared in three reports issued in June 2006 that U.S. emergency systems are woefully overburdened, underfunded and unprepared for a large-scale disaster. Though hospitals have closed 425 emergency facilities, patients needing emergency treatment rose 23 percent in the 10 years studied, ending in 2003.
Scanlon, who recently led a 12-month investigation of the Indian Ocean tsunami and is now looking at the last millennium of disasters in Canada, studied a tornado that whipped through Edmonton, Alberta, in 1987, causing the bulk of victims to travel immediately to the closest hospital, overloading the system.
And while many cities assume mutual aid during a disaster, an influenza pandemic could easily strike multiple jurisdictions at once, he said, disabling many hospitals.
Naming the Dead
Americans haven't experienced many mass casualty incidents, Scanlon said, but they've had their share of mass death scenarios such as 9/11, the Oklahoma City bombings and Hurricane Katrina."What makes a mass fatality incident so difficult -- besides the emotional part of having people killed in an event -- is you have to try to identify those who died in any event," said Tom Brondolo, former deputy of the New York City Office of Chief Medical Examiner (OCME), who was extensively involved with identification efforts during 9/11.
Medical examiners and coroners identify bodies, and catalog the cause and manner of death. Their dual role in public health and safety is vital during a deadly disaster.
There's a premium put on identifying the dead to hurry lengthy legal proceedings, accommodate cultural formalities and provide solace to the person's family. Despite widespread belief, there's no medical evidence confirming that corpses spread disease. The main concern is how technicians handle the dead as this affects the survivors' mental well-being. Because people generally have a strong need to recover the bodies of dead loved ones, identification efforts are important, Scanlon said.
In contained incidents, such as airplane crashes, first responders are likely to know whose bodies will emerge from the rubble. But with 9/11, the Indian Ocean tsunami and Hurricane Katrina, there were many unknown bodies, making it difficult to identify victims. In these cases, piles of predeath data -- like dental records, fingerprints or DNA strands -- must be collected and sifted through, Brondolo said, to identify the unnamed dead.
"It may sound callous, but if you've got an air crash at an airport, and you can control it because everybody's dead, it's not very difficult to deal with," Scanlon said. "It's time consuming, but the immediate problems are not there."
And as the disaster increases in size, the number of reported missing persons multiplies, said Brondolo, who founded the emergency management-consulting firm Brondolo Associates in 2005.
Between 20,000 and 30,000 calls flooded call centers to report missing persons in the aftermath of 9/11, he said.
The OCME collected 2,749 dead persons and 20,000 disparate body parts treated as potential individuals -- all at different levels of compressed and burned mutilation. The total death toll for 9/11, including the 246 on four hijacked planes, is about 2,973.
Body identification also depends on the condition of the remains, Brondolo said.
Body parts can be singed, decomposed, fragmented or decayed from hot salt water, like they were during the Indian Ocean tsunami. Also, bodies may have to be unearthed, which slows the jurisdiction's recovery rate. In 2006, Brondolo said, hundreds of bodies were still being uncovered around ground zero in New York City.
He said 9/11 was the first event where DNA technology was heavily relied on for forensic identification. This meant that medical examiners and coroners depended less on the physical characteristics or secondary features to identify remains. However, the use of fingerprinting, dental records and DNA still requires certain predeath data.
And even with many tools at their disposal, and technological improvements, Brondolo said not all bodies can be identified during a disaster, despite high expectations.
Myriad Challenges
Ample resources are required to save the wounded, and much time, effort and resources are needed to tend to the dead. And it doesn't have to be a very large number -- any body count that overwhelms local authorities counts as a mass fatality incident, according to the Disaster Mortuary Operational Response Team (DMORT), a federal-level response team dedicated to helping state and local governments during mass fatality incidents. DMORT now falls under the U.S. Department of Health and Human Services, although it was apart of the Federal Emergency Management Agency (FEMA) during Hurrican Katrina.
"When you have a large number of fatalities," Brondolo said, "you have to spend a lot of time and energy just on the logistics of handling those bodies, setting up the systems, storage and the time required to do an exam of each of those bodies and remains that come in."
Even the accuracy of the death count is important. Take Katrina -- early estimates pegged the death toll at 10,000 people. This led to millions in misspent funds and quickly built massive tents to support the torrent of bodies, Brondolo said. "The inability to quickly put together a national call center to pull together missing persons reports and the recognition of having to do that led to this estimate of 10,000."
DMORT ferried 910 bodies through the St. Gabriel facility and the Identification Center in Carville, La., according to the Louisiana Department of Health and Hospitals. As of August 2006, state records estimated Katrina's death toll at 1,723.
Even during 9/11, there were exaggerations that more than 20,000 dead bodies awaited medical examiners and coroners in the wreckage.
"That fog can lead to spending a lot of resources that are not necessary," Brondolo said, "and it can delay focus on getting the appropriate resources."
It's also difficult when a disaster bleeds outside a city's limits and into neighboring jurisdictions.
Hurricane Katrina is an example of a multijurisdictional disaster. "FEMA reported that benefits were filed from New Orleanians who were displaced from nearly every county and every state in the United States -- that's how tremendous the dispersal was," said Arbie Goings, former director of DMORT's Louisiana Family Assistance Center (LFAC).
Once the hurricane hit, DMORT was called into duty to run the morgue and help operate the call center.
Since family members and friends were flung across the country, searches for missing persons were routed through the call center in Louisiana, which fielded 13,147 calls, a few hundred of which were duplicates. Of the 11,722 total missing persons from Katrina, 135 still remain missing, according to the Louisiana Health Department.
Goings, who helped administer bodies and directed the LFAC where callers notified next of kin of the deceased, said it was especially hard for volunteers to return phone calls when matches were made because traveling family members had initially called from hotel rooms or temporary FEMA phones and could not be traced.
DMORT also deployed Goings to New York during 9/11, and Texas during the Columbia Space Shuttle disaster. He said there are some common elements during all mass death situations, but that the real challenges come with the variables.
"[Katrina] was the biggest thing that anyone's had to face. And there was no book, you know," Goings said. "So a lot of it we had to create as we went along."
The possibility of biological, chemical and radiological elements involved in terrorist attacks would also challenge first responders.
"When you add contamination to a disaster," Scanlon said, "you put the rescuers at risk, and that creates an enormous problem."
The trouble comes when contaminated victims contaminate friends, family and strangers who chauffeur them to hospitals, Scanlon said, because hospitals don't usually record the names of the people who bring the injured in, creating a breeding ground for toxins to spread.
Even if foreign agents are contained, and medical responders use precautions like donning gloves and zippered suits, Brondolo said, it would take heaps of resources, funding and manpower to decontaminate bodies before the identification process even begins.
Brondolo said coroners in the United States, who are elected to run small-town agency operations, administering around 100 deaths a year, would have trouble building a complex organizational structure to manage police and fire, and coordinate private, local, state and federal operations during a mass death incident.
"This event happens, and suddenly you have to become the manager of thousands of people," Brondolo said. "One day you're this sleepy little agency that may have trouble buying paper, and the next day you're managing this response with a national spotlight."
Editor's Note: There was a correction made regarding the status of the Disaster Mortuary Operational Response Team (DMORT). DMORT is a federal-level response team.
