ROLE OF AN AUTOPSY SURGEON IN MASS DISASTER

Dr. Vivek Kumar

WHO has defined disaster as an occurrence that : A. causes damage,B. ecological disruption, C. loss of human life or D. deterioration of health and health services

on a scale sufficient to warrant an extraordinary response from outside the affected community or area.

MASS DISASTERMass disaster is commonly defined as the death of more

than 12 victims in a single event.

It is the number of deaths that exceeds the capacity of the local death investigation system to handle it.

In certain parts of the World, nature is frequently responsible for mass disaster with flood, hurri canes, volcanoes or earthquakes killing thousands of people.

In these enormous disasters, when whole communities are wiped out, there can be very little detailed investi gations.

MASS DISASTER

Classified into…….

Natural:

disease epidemic

mass poisoning (food/liquor).

ACCIDENTAL

• Industrial

• Civil disturbances

• Warfare

Man made:

EXAMINATION OF THE BODIES OF THE VICTIMS BY FORENSIC EXPERT IS NECESSARY

FOR 3 MAIN REASONS:

(i) To identify each dead body and to establish the cause of death for legal purposes so that a death certificate can be issued

(ii) To discover evidence relating to the investigations of the disaster itself like obtaining sample for toxicological analysis where appropriate

(iii) To find out the cause of the disaster itself e.g. bomb or detonator fragments that may be embed ded in the bodies of the victims.

In many disasters, the extent of damage to bodies and their clothing by traumatic forces or by fire is such that specialized examination of the bodily remains is necessary to establish the identity.

It is therefore considered highly desirable that from the onset very close contact could be established between the police and the pathologist, to carry out postmortem examination.

MANAGEMENT OF MASS DISASTER :1. Coordination2. Infectious disease risk3. Body recovery4. Storage of dead bodies5. Identification of dead bodies6. Information management7. Long term storage and disposal of

dead bodies8. Communication and the media9. Support to families and relatives.

FIRST PHASE (AT THE ACCIDENT SITE)

Isolation, Demarcation and Protection of the site. Visitors should not be allowed to visit.

Survivors to be rescued.

TRIAGE ?????

All possible means should be used to save life without unduly endangering rescuers from the various continuing dangers that may exist e.g., fire.

When no further lives can be saved, situation should be taken under your control

Evidence should be preserved which may contribute both to their identification and to the investigation of the accident itself

The first task should be to

(I) LOCATE BODIES

(ii) Label them with a number

(III) PHOTOGRAPHING THEM IN SITU

(IV) PREPARING A PLAN OF THE DISASTERS showing the main

pieces of wreckage

number of the bodies and their location

(v) Exact location of body at a disaster site may prove to be very important, whatever the disaster

(vi) Work of identification of the bodies should be undertaken

(vii) For accident reconstruction from evidence, bodies are labeled, photographed and a record made of their precise position

(viii) Record each body and place it in a suitable container for transfer to the mortuary.

Make sure that things belonging to one body are not assigned to another.

Polythene sheeting can be used for covering it.

It should be semitransparent to see the numbered label attached to a body without need for further labeling to facilitate carrying

(x) Counselling room: The counsellors to be there for counselling of relatives of the victims and if not possible at the site then near the mortuary counselling should be carried out.

(ix) Media room: A temporary room may be constructed and news regarding the victims may be provided to the press as well as relatives periodically

SECOND PHASE (IN THE MORTUARY)

In the mortuary, accommodation and in particular refrigeration are likely to be problems following any major disaster.

Bodies should be dispersed to numerous small mortuaries but preferably a building of suitable size to be designated a temporary mortuary, for a coordinated investigation, where there is sufficient space and light can be used.

"field mortuaries"

In certain types of mass disaster, where identification is not so difficult, only external examination may be required for identification.

But in case of aircraft accidents, a full autopsy is required from the point of view of accident investigation itself, then better facilities such as a properly equipped autopsy room becomes essential.

It is ideal to have in close proximity an autopsy room, refrigerated mortuary accommodation, an area for embalming and a separate room for interviewing relatives and viewing bodies.

If necessary a suitable room for use as a communication headquarters.

The procedures in the mortuary should be a team work involving at least –

a pathologist and a police officer, usually a forensic odontologist and occasionally other specialists such as a radiologist,

when appropriate to the particular circumstances and conditions of the bodies.

It is always important to count the number of bodies recovered.

This is easy enough when there has been little or no mutilation and fragmentation.

But when the traumatic forces of the accident is

severe, then the human remains recovered may far exceed the number of persons killed

(I) PRIMARY IDENTIFICATION:

Primary identification is mainly done by : a.Visual identification b. By photographs

(a) Visual identification: Is the standard method used by police to establish the identity of a dead

body.

Visual identification of facial features can be reliable when a body is intact or little damaged externally

The effect of burns in a disaster reduces its value considerably

(b) Photographs: of distinctive clothing, personal possessions or physical characteristics may

be recognized if facial features are damaged.

Initial and subsequent photography is essential to make a photographic record to relate body, site and cadaver numbers.

After initial photography clothing and jewellery must be removed from the body, examined and catalogued.

(II) EXAMINATION OF CLOTHING: Evidence of vomit, blood or stains upon clothing may

prove useful.

Any marks on clothing like manufacturer's label or laundry marks also prove valuable.

Examination of clothing is necessary to find out any damage to clothing due to the accident sequence or bomb explosion

(iii) External examination: To deter mine: (a) sex (b) height (c) weight (d) hair colour (e) location and abundance of hair (f) colour of eyes and skin (g) any anatomical, surgical and traumatic scars (h) tattoos or birth marks (i) abnormalities such as congenital or acquired

(iv) Injury sustained during the accident related to cause of death

(v) In case of blast injuries, trace evidences may be preserved

(vi) Radiographic examination:

(a) Ideally, complete set of skeletal X- rays should be taken for each victim

(b) In case of suspicion of damage, full skeletal radiography is required

(c) Radiographs are helpful in identification in case of extremely burnt body and they are also helpful in revealing the presence of articles embedded deeply in charred muscle that may be overlooked

(d) A permanent record of bone injuries are obtained that reduces the time spent in assessing and recording these during autopsy

(vii) Full internal autopsy:

Evidence relevant to identification will be collected such as:

(a) surgical absence of internal organs (b) presence of postsurgical states like gastroenterostomy (c) evidence of preexisting disease (d) any internal injury (e) precise cause of death

(viii) Histological examination:certain organs and tissue will be collected for routine

histological examination

Tissue specimens containing metal fragments for chemical analysis should be deep frozen

Histological examination may reveal a disease relevant to consideration of impaired function if the body is that of operating crew, then medico legal problems for compensation arise

(ix) Fingerprints: They should be taken after the autopsy when all

possible evidence has been collected from examination of the body.

Fingerprints are of limited value in identification of victims of aircraft accidents due to nationality of most of passengers being in question

After powdering, the fingerprints were then transposed onto paper

Finger skin was removed by “degloving”

(X) DENTAL EXAMINATION: At the end of the autopsy,

dentist should make an examination of the jaws and teeth

value of dental evidence in identification has become widely recognized

If an ante mortem radiograph of the relevant part of the dentition is available,

it may prove to be of greatest possible value for comparison with the postmortem radiograph of the fragments recovered.

TSUNAMI VICTIM IDENTIFICATION IN THAILAND

(XI) DNA TECHNIQUESBecause of the rapid decomposition and subsequently

muscular alterations, a sampling of the femoral shaft (recommended for DNA analysis) was carried out by the anthropologist.

Another possibility for DNA sampling was the extraction of two sound teeth, preferably two premolars or canines, because of the presence of a lot of pulp material inside these teeth.

(xii) Other means of identification such as:(a) Multivariate analysis of race in cranium and

cephalic index (b) Identification of scars of parturition and other pubic symphyseal changes in skeletal remains of female(c) Neutron activation analysis of hair are also used.

Last task to be performed in the mortuary is the examination of any fragments of bodies and, matching of those fragments with the bodies from which they originated.

THIRD PHASE(COMPARISON OF RECORDS AND IDENTIFICATION)

Identification of bodies depends upon accurate information about those who are believed to be involved.

When the persons killed are of the country in which the disaster occurs, it is probable that normal police communication system is the best for collection of required information.

During recent years, the need for practical record forms in the context of a mass disaster has come to be appreciated, Australian Police, Interpol has produced a disaster victim identification form.

The forms, which have evolved from 15 years of practical experience consists of four different coloured forms and a white one.

Two of the coloured forms are for the males, other two for the females; white form is for missing persons.

One of the coloured forms is for external feature of the body and the other is for autopsy findings.

They are kept in transparent envelop upon complete and since they are coloured, on single sheets paper, the subsequent exercise of matching records and 'proving', the identification of body is much more simplified.

In India no such form are available and all the information related to identification should be recorded in a postmortem report.

In some disaster the pathological examination of bodies of victims, can achieve beyond proving evidence leading to identification and confirmation of an obvious cause of death.

Comprehensive pathological investigation can help a great deal to reconstruct the accident, sometimes to the extent of revealing the cause

Routine toxicological tests on the tissues of human bodies also reveal a cause of death (like CO poisoning in disaster).

Injuries in passengers and their correlation with damage to seat structures and other solid struc tures is also helpful in knowing the relative safety of different parts of aircrafts/other vehicles and how to improve them to prevent such disasters.

CONCLUSION

Adequate victim identification management goes through strict methodology and protocols.

This requires adopting and applying standard operating protocols.

Such a huge operation requires a multidisciplinary team

The expertise in relation to disaster victim identification is enhanced when team members working together in an interdisciplinary way, share mutual respect are professionally trained and skilled, and have multi functional capacities.

National Centre for Disaster Management was established in 1995 in the Indian Institute of Public Administration (IIPA) by the Ministry of Agriculture.

The Centre was upgraded as the National Institute of Disaster management (NIDM) on 16th October 2003 following the transfer of the subject of disaster management to the Ministry of Home Affairs.

The Institute was inaugurated by Shri Shivraj Patil Union Home Minister on 11th August, 2004.

THE NATIONAL DISASTER MANAGEMENT AUTHORITY (NDMA),

IMPROVING THE EFFECTIVENESS OF DISASTER MANAGEMENT IN INDIA

headed by the Prime Minister of India, is the Apex Body for Disaster Management in India.

The setting up of the NDMA and the creation of an enabling environment for institutional mechanisms at the State and District levels is mandated by the Disaster Management Act, 2005.

THANK YOU