2.  Clarify the jurisdiction and role of the Office of the Chief Medical Examiner (OCME)  Describe OCME roles and responsibilities in a Mass Fatality Event– terrorist acts, other criminal events, natural disasters, natural disease outbreaks  Describe fatality management plans and the interactions between OCME and local/regional planning districts

3. Mission & Jurisdiction

4.  Model, statewide death investigations system  All citizens have the same access to forensic expertise regardless of where they live  Staff pathologists are board certified, no coroners in Virginia  Local Medical Examiners are all licensed physicians appointed by the Chief, not elected  Four district offices, all accredited by the National Association of Medical Examiners (NAME)

5. 1.Districts are divided by population 2.Each district currently has 3-4 fulltime paid forensic pathologists and 5-7 FT medicolegal death investigators 3.We are co-located with the crime lab (DFS)

6. Source: A survey of more than 60 of the nation's largest medical examiner and coroner offices conducted by ProPublica, FRONTLINE, and NPR.

7.  Approximately 6,000 cases per year › Autopsies  Approximately half of all cases  All homicides, gunshot cases, suspected SIDS, on- the-job › Views/External examinations  Majority performed by LMEs  Motor vehicle collisions, unattended natural deaths  >2500 Turndowns per year  Available 24/7

8.  § 32.1-283 outlines the jurisdiction of the OCME › The OCME is charged with the medicolegal investigation of deaths that are sudden and unexpected, unattended by a physician, unnatural, the result of violence or in custody  § 32.1-285 concerns autopsies › An autopsy shall be performed when in the opinion of the medical examiner investigating the death or of the Chief Medical Examiner it is advisable and in the public interest

9.  Trauma  Violence  Poisoning  Accident  Suicide  Unusual/Suspicious  Cremation/ Burial at sea  Homicide (All Terrorism)  Unnatural manner  Sudden in apparent good health  Unattended by physician  In jail, prison or in custody  State mental health patients  In the interest of public health

10.  A natural event is a happening such as hurricane or earthquake and may cause unnatural accidental deaths due to drowning, blunt force, CO poisoning from generators, cave-in etc. These are medical examiner cases by statute  A natural death is due to a natural disease process arising out of the ordinary course of an individual’s life e.g. diabetes, cancer, ASCVD, COPD, pneumonia, flu › The death certificates are the responsibility of the primary/treating or pronouncing physician in a pan flu event. The human remains in these cases are the responsibility of the families and communities, not the Office of the Chief Medical Examiner

11.  Under ordinary circumstances, if a disease is naturally occurring and results from the normal course of life, the associated deaths are natural deaths and are NOT medical examiner cases  The OCME has no jurisdiction over natural deaths even if the numbers are large  E.g. Flu is naturally occurring and deaths from flu are natural deaths and do not fall under the OCME  E.g. Smallpox is not naturally occurring (only found in research labs) so any resulting smallpox deaths would likely be due to a terrorist act homicides (unless death is due to accidental contamination of a laboratory worker)

13.  When the loss of life overwhelms the state system and requires extraordinary support the mass fatality is likely to trigger disaster declarations from the State level and possibly Federal  There is NO minimum number of deaths for an incident to be considered a mass fatality incident because communities vary in size and resources

14.  Natural Events › Floods › Earthquakes › Hurricanes  Accidents › Transportation › Industrial  Terrorism › Explosives › Chemical Agents › Biological Agents

15.  Mother Nature

16.  Accidents

17.  Mother Nature  Accidents  Terrorism

18.  Mother Nature  Accidents  Terrorism  Mass suicide / genocide

19.  To effectively manage a fatality incident from an event that may cause a large number of fatalities  To ensure the complete collection and examination of the dead, determination of the nature and extent of injury, recovery of forensic evidence, identification of the fatalities using scientific means and certification of the cause and manner of death  All activities will be sufficiently documented for admissibility in criminal and civil courts  Complete the daily non-event demands of the community

20. Managing /documenting the scene including remains, evidence, personal effects Recovery of dead Decontamination of the dead, if necessary Identification of remains › Antemortem record collection › Postmortem forensic examination Collection of forensic evidence for law enforcement Notification of next of kin/collection of ante-mortem data Managing personal effects Return of remains to the next of kin Media/political involvement

21. › It’s not “Who’s in charge.” › It’s “Who’s responsible for what” and “Who needs to talk to whom.”

22.  Each agency performs their usual role…..just on a larger scale

23.  Fire Department › Scene safety › Decontamination

24.  Fire Department  Law Enforcement › Scene Security › Physical evidence

25.  Fire Department  Law Enforcement  Funeral Home Personnel › Recovery of decedents

26.  Fire Department  Law Enforcement  Funeral Home Personnel  Medical Examiner

27.  Coordinate recovery of remains and oversee collection point(s)

28.  Operate temporary and permanent morgues

29.  Coordinate recovery of remains and oversee collection point(s)  Operate temporary and permanent morgues  Examination of remains › Cause & manner of death  Collect evidence › Cataloging of personal effects › Identification › Coordinated release of remains and personal effects

31.  Decontamination › Chemical › Nuclear › Biological  Removal of explosives

33. Intake Photography Pathology Anthropology Fingerprinting X-Ray Odontology DNA

34.  “As is” photography  Verify remains as “safe to process”  Ensure no co- mingling of remains

35.  Tracker is assigned  File is generated › ME case # › DMORT case #

36.  Each stage of disrobing the remains is photographed  Personal effects are cleaned and photographed

37.  Projectiles › Old & new  Prior surgeries › Pacemaker › Surgical clips, screws, & plates › Hardware bearing serial numbers

38.  External examination › Signs of injury › Scars › Tattoos

39.  May or may not be utilized  Anthropological assessment › Age › Sex › Ancestry › Stature › Trauma › Disease processes

40.  Postmortem charting  X-ray

41.  Complicating factors › Mummification › Adipocere  Importance of “gloves”

42.  Standard section › Anterior tibia  May or may not be submitted

45.  OCME Mass Fatality Plan  State Family Assistance Center Plan  Natural Disease Plan  Chemically Contaminated Remains  Biologically Contaminated Remains

46.  Underwent major revision  Shows OCME roles and responsibilities for mass fatalities that fall under our jurisdiction › Job action sheets › Operational Section covers Recovery, Temporary morgue operations, district office morgue operations, identification and family assistance center › Use of volunteers (MRC) › Expectations from other agencies

47.  Temporary morgue sites › Space/Land – bring in a temporary morgue › Facilities – could be used as morgue (ex. unused airport hangar)  Human remains holding facilities › Not the same as a morgue › Space/Land › Facilities – be prepared to never use the facility again  Transportation › MOUs with funeral homes/transport companies

48.  Went into effect July 11, 2011  The core services provided at the FAC will include: › Call Center › Reunification and Identification › Postmortem Data Collection › DNA Collection Samples › Medical Records Collection › Missing Persons Activities › Missing Persons Phone Line › Family Notification › Information › Behavioral Health Care › Registration › Referrals

49.  Are you planning on developing your own plan or rely on state’s plan  Known locations across district/region that would be suitable for FAC  Can you help staff an FAC › MRC volunteers › VDH nurses › Funeral directors

50.  Written in response to H5N1  Reminder: Influenza deaths are natural deaths and therefore do not fall under the jurisdiction of the OCME  Provides guidance for localities to manage a mass fatality event d/t a natural disease

51. Natural deaths should stay close to locality for the convenience of hospitals, families, funeral directors and police Big concern is surge capacity for holding bodies close to home If number of bodies are large, localities need to integrate local resources

52.  Local hospitals, nursing homes, police, funeral directors, vital records, health departments, social services and others need to work together to: › Augment overworked local hospitals, funeral homes and cemeteries with refrigerated holding capacity – room for up to 300 at OCME morgues with 4 statewide › Identify regional locations and/or refrigerated trucks for storing and cooling bodies until next of kin can claim them – MOU with DOF for refrig seedling storage areas and have purchased MERC System through EP&R grant › Number and tag the bodies and track release to kin

53.  OCME has no statutory jurisdiction over routine natural deaths even if the numbers are large. Community is responsible. › OCME cannot store non-ME natural deaths  No legal right to do so  No liability protection  Communities need to develop local plans by partnering with FH and hospitals or buying body storage systems for MFI

54.  Hospitals/community resources are tasked with holding bodies locally until next of kin claims body if deaths are natural  Hospitals should notify police if a body is unidentified so police can identify the person  Police are tasked in cooperation with hospitals to establish identification by usual means – viewing by family or fingerprints › OCME helps with complex scientific ID

55.  If bodies still remain unidentified after a diligent several day documented search by hospital and police, notify OCME and we will coordinate with police investigators for further identification efforts  OCME will authorize transport to an OCME district office or regional morgue for ID purposes only, not for simple body storage

56.  If bodies are identified but unclaimed after diligent documented search for next of kin, notify the Sheriff of the jurisdiction of death for final disposition, code section §32.1-288  The identified but unclaimed are not medical examiner cases

57.  HRs in which decedent ingested, inhaled or internally or externally absorbed a chemical › Could result in secondary harm through off- gassing or direct contact of bodily fluids/tissues

58.  Expectations › Local or regional HAZMAT officers will ensure that HRs are externally decontaminated and the scene deemed safe › Monitoring of HRs during autopsy/view to ensure acceptable levels, if requested  OCME staff or designee will transport

59.  Virginia has the first commissioned BSL-3 autopsy suite in North America (non- military)  Safely examine remains contaminated with BSL-3 agents › Smallpox › Weaponized anthrax  Small facility › In large bioterror attack, OCME would use facility for index cases but would then possible require temporary morgue

60. Anna C. Noller, PhD Anna.Noller@vdh.virginia.gov 804-786-6063 Inquiries about receiving local mass fatality plan templates: Rochelle.Altholz@vdh.virginia.gov 804-786-1015