3rd quarter meeting - hca-nys

March 24, 2016

Capital District Sub-regionHealth Emergency Preparedness Coalition

3rd Quarter MeetingMarch 22nd, 2016

March 24, 2016

CDR HEPC

PHEP Updates – BP4 3rd Quarter

March 24, 2016 3

HERDS Surveys – By March 31st, 2016• L-1 Annual Preparedness Survey

• Recommend quarterly looking at M-1 (plans), M-2 (response), M-6, M-7 (trainings) and M-11 (exercises)

• Remember annual requirements such as M-12 (AAR) and M-14 (community engagement)

• L-3 POD Security Survey• Reflect planning changes from L-5 POD Drill• Updates with Partners

• L-7 Medical Countermeasure Drills• Completed with HERDS surveys• Includes new MERITS Pick List HERDS Survey

March 24, 2016 4

EVD Grant

• EVD 6 - Environmental Health Webinar

• May 17th 1-2 pm

March 24, 2016 5

PHEP Funding

• Shift from PHEP to Zika Response

• ~$44 million

• 1-10% cut (federal formula)

March 24, 2016

CDR HEPC

HPP Updates – BP4 3rd Quarter

March 24, 2016 7

HERDs Surveys

• End of Year National Incident Management System Tracking Tool due May 2, 2016

• Revised Critical Asset Survey will be available on HERDs by May 9, 2016

March 24, 2016 8

Hospital to Nursing Home Decompression Project

D14 Hospital- Nursing Home Decompression Project Webinar April 20th 10-11a OR Aprilth 22 2-3p

D15 Hospital- Nursing Home Decompression Project Workshop May 10th at Saratoga

March 24, 2016 9

Additional Preapproved Training

Registration to begin soon for

In person trainings: • May 9-10: Pediatric Care After Resuscitation (PCAR)• June 7, 8-9: Basic and Advanced Disaster Life Support

(BDLS and ADLS)• Regional Training Calendar

https://www.urmc.rochester.edu/emergency-preparedness/calendar/nys-hepc-master-calendar.aspx

https://www.urmc.rochester.edu/emergency-preparedness/calendar/nys-hepc-master-calendar.aspx

March 24, 2016 10

Change to the 2015-2016 HPP Contractual Agreement

The Burn Disaster Plan Exercise has been postponed until Spring 2017

• HPP Deliverable 11• PHEP Deliverable L-12/L-13

• Hospitals may use funds previously allocated to the 2016 Burn Disaster Tabletop Exercise (1-4 participants) to complete other Priority or Additional Deliverables.

• Contract Plan Revisions are not required.

March 24, 2016 11

HSEEP Documents

Now on HCSFor Hospitals:

Documents by Group Hospitals Preparedness Exercises

For LHDs:

Documents by Group LHD Preparedness Exercises

March 24, 2016 12

Next Meeting for Capital District HEPC Sub Regional Planning Group is

May 16, 2016 10am -12:30 pm

March 24, 2016

Capital District Sub-regionHealth Emergency Preparedness Coalition

Mass Fatality Planningin the Capital District

March 24, 2016 14

Mass Fatality Events in Albany Sub-region

Mohawk Airline Flight 405Colonie, NY – March 3rd, 1972• 8:48 pm at night, no fire• 17 Died

(16 on flight, 1 in home)• 36 injured

March 24, 2016 15

Recent Mass Fatality Events in CDR

Ethan Allen Boating AccidentLake George, NY – October 2nd, 2005• 3 pm in the afternoon, sunny, wind-less day• 21 died• 29 rescued

March 24, 2016 16

Recent Mass Fatality Events in NYS

Flight 3407 – Buffalo, NY – February 12th, 2009• At night, Fire an fuel complexities• 50 died (49 on flight, 1 in home)• 2 injured (in home)

March 24, 2016 17

Local Health Department Annual Preparedness Survey

Based on self-reported information of “Fatality Management” (form accessed 3/21/2016)

• System for Unattended Deaths• 3 Medical Examiner based, 14 Coroner based

• Number indicated in system• 3 Medical examiners, 37 Coroners

• Mass Fatality Response Plan• 11 of 17 have a plan

• MFR Plan updated within 2 years• 6 of 11 updated within 2 years

March 24, 2016 18

Resources

NYS Mass Fatality Annex http://www.dhses.ny.gov/planning/state/

UAlbany CPHP – Mass Fatality Events: Learning from the Flight 3407 Tragedyhttp://www.ualbanycphp.org/broadcasts.cfm

http://www.dhses.ny.gov/planning/state/

http://www.ualbanycphp.org/broadcasts.cfm

State-Level Mass Fatality Planning

Presented by the NYS Office of

Emergency Management

March 22, 2016

2

Objectives

• Provide background on State planning efforts.

• Concepts that were chosen.

• Lists of capabilities that were explored.

• Current status and next steps.

3

Background

• TWA Flight 800 (1996)

• The need was recognized for a state-level plan

• Air Disaster Plan

• Things changed…we had a new need and needed more

application

• Pandemic influenza

• State-level task force co-chaired by OEM and DOH

4

NYS Mass Fatality Workgroup

• NYSDOH: Health Emergency Preparedness; Bureau of Funeral • Directing; Bureau of Vital Statistics • New York State Association of County Health Officials (NYSACHO) • Healthcare Association of New York State (HANYS) • New York State Office of Emergency Management • NYS Office of Interoperable and Emergency Communications • NYS Office of Fire Prevention and Control • NYC Office of Chief Medical Examiner • New York State Division of State Police • New York State Emergency Managers Association • NYS Division of Military and Naval Affairs • NYS Office of General Services • NYS Department of Environmental Conservation • NYS Department of Corrections and Community Supervision • NYS Office of Parks, Recreation and Historic Preservation • NYS Department of State: Division of Cemeteries • New York State Funeral Directors Association • New York State Association of County Coroners & Medical Examiners • NYS Human Services Branch: OTDA, OCFS, SED, OMH and ARC

5

Project Objectives

• Bring together a planning team that can assist in developing a State-level, all-hazards mass fatality plan

• Catalyst was the potential mortality rate of a pandemic

• Identify preparedness activities, response capabilities and recovery efforts of partner agencies

• Provide for a structure that can be used in conjunction with, and in support of, local government in managing mass fatalities

6

Planning Basis and Lessons Learned

9

The Goal

• Identify as many operational capabilities that may be available in time of need

• Apply them across all hazards

• For all jurisdictions

• Maintain local-level primacy

10

State Assistance

• Local coroner/medical examiner

• County OEMs

• State assistance is supplemental, with few exceptions

10 Local/Municipal

Federal

County

State

11

Concept of Operations

• Anticipated sequence of events

• Bottom-up: Locally developed scenario that warrants a State response

• Top-down: For legislated events that generate an immediate Federal response

12

Planning Basis

• Scoping of the Mass Fatality Annex – Functional

– All-hazards

– Statewide

– Exceed Federal guidelines – Recognize limitations

– We may still have to respond to the event that resulted in mass fatalities

– Wrap-around services

13

Capability Assessment

• How to categorize various areas of resource support

• Based on real events, we looked into four categories

or response areas:

– Incident scene response operations

– Remains processing and logistics

– Decedent identification and process

– Family assistance center

• Redundancies or similarities in capabilities were

intentional

14

Fill in the blanks…

• Identify what may be available

• Worksheet supported by text

• Real-time usage

• Identifying assets not typically sought in other planning efforts

15

Incident

Scene

Response

16

Process

Remains

and

Logistics

17

Decedent Identification and

Processing

18

Family Assistance Center

19

Detailed Efforts

Instrument/

Detector Combination

Parameter Values for Detecting Spot or Widespread Contamination on Individuals

Calculated Time

Needed to Monitor an

Adult (minutes)

Probe Speed

(inches/sec)

Height of Probe

(inches) Path Width

(inches) CD V-700 with side window detector

4 0.25 to 0.5 0.6 19

CD V-718 with end window detector

3 0.5 to 1 1 12

All tested instruments with pancake detectors, except the Victoreen 190

6 1 to 3 2 3.9

Victoreen 190 with pancake detector

6 1 to 4 3 2.6

20

Integration

• Local and State

• Federal resource support

• Regional planning efforts

• EMAC

21

Agency Participation in Functional

Branches

22

Next Steps….

• Conduct annual reviews every year

• Meeting with DOH on updated list of

capabilities

• Future efforts to consolidate State

response plans into several platforms

• State agency reviews

23

More information

• http://www.dhses.ny.gov/planning/cemp/volume

-2.cfm

• Local planning guidance

• Call us

http://www.dhses.ny.gov/planning/cemp/volume-2.cfm




24

Questions? Thank you!!

David DeMatteo

Planning Section Chief

NYS Office of Emergency Management

[email protected]

(518) 292-2366

mailto:david.dematteo@

NYSDOH MERC

Equipment

Ralph Iler

NYSDOH Logistic ChiefMarch 22nd, 2016

MERC Mass Fatality Response Equipment

Available Upon Approved Request

2 - 48’ Delivery Trailers with Refrigeration

Mortuary racking system for refrigerated storage of human remains

Utility Trailer with heat, A/C, & power generator (build-out for mobile office)

Mobile Shelter (with generator)

Human Remains Pouches (Body Bags)

EVD Remains Disposition Packaging Equipment and Supplies

PPE

Refrigerated Trailers (2)

48’ with lift gate and diesel powered

refrigeration unit

48’ with lift gate and hybrid refrigeration unit

that can be powered by diesel or 220 volt

electrical service

Multiple Uses

Cold chain management (vaccine)

Temporary storage of human remains

(mass fatality event)

Mortuary Storage Racking

Portable Operations Shelter


Military grade 25’W x 26’L x 14’H

Optional hard floor surface

Generator

Optional heating unit for cold weather

application

Lighting

Additional 9’W x 15’L attachable office

Custom modification for direct

attachment to a refrigerated trailer


Use

The shelter is a MERC asset. Requests for its use should follow established asset request procedures.

Portable POD with cold chain management provided by an attached refrigerated trailer

Portable human remains processing center with refrigerated storage provided by an attached refrigerated trailer

Portable on-site command center

Ebola Virus Disease (EVD) Mortuary Response/Planning

Three (3) layer system“Inner bag” – 8 mil (36” x 90”) with curved zipper, heated seals

“Middle bag” – electronically sealed film foil pouch (CADPAK)

40” x 95” x 150 yards

Includes heat sealers (crimpers)

“Outer bag” – Heavy duty, 20 mil, 48” x 98” with 12 built-in

padded handles

All pouches are chlorine free (PEVA) for cremation purposes

Lockable zippers that include evidence tags

MERC also contains biohazard labels, scissors for cutting foil

pouch, disinfectant solutions as well as other supplies

Enough supplies (kits) for fifty (50) decedents as a result of EVD

or the result of another highly-infectious disease

MERC EVD

Mortuary

Kits

(Example)

*OHEP opted to

purchase the

“outer bag” in

bariatric size (48”

x 98”) to allow for

ease of handling

larger remains as

well as additional

packaging from 2

other pouches

“A Thanksgiving to Remember”

BNICER MASS

FATALITY TTX

EXERCISE

Tabletop Objectives

Demonstrate the viability of the

Delaware County Mass Fatality Plan

.

Determine if the County Mass

Fatality Plan meshes with Hospital

plans.

Identify areas of improvement and

planning gaps.

Tabletop Processes

A scenario and update statements will be used to generate discussion of probable response actions.

Participants will provide situational responses based on established procedures and plans. The Mass Fatality Plan is available for reference.

The exercise will conclude with development of action steps needed to support future mitigation and preparedness efforts.

Ground Rules

This is not a test of current capabilities and plans. It is a discussion of probable responses to a hypothetical emergency and consequent cascading events.

The exercise will be an open dialogue. All ideas and input are welcome.

Finger pointing is not acceptable. There will be no GOTCHA.

One person speaks at a time.

The scenario will be accepted as is. However, the facilitator may make modifications at his/her discretion.

No hypothetical resources are available.

There should be no expectation of issue resolution.

“A Thanksgiving to

remember”

Scenario #1

8pm November 22nd:

Weather: A snow squall has just come

through the area with 6 inches of snow and

one tenth inch of ice in the span of 2 hours

with near whiteout conditions.

A tour bus coming back from New York City

has just passed through Margaretville on 28

and has just entered the Town of Andes.

A second bus traveling from Delhi carrying

college students returning home to New York

City has arrived at the same location.

Exercise Scenario – 1

Thanksgiving Break

What are the priority concerns of your

organization at this time?

What should you be considering NOW to

prepare your organization?

What public safety issues should be

anticipated and what preventive and

response actions should be taken?

Discussion Questions--1


Remember”

Scenario #2

Both buses each have 30 people on them.

As both buses approach each other the a fuel tanker doing late deliveries is backing out of a driveway on the Delhi side of Andes.

The fuel truck driver cannot see the lines on the road and backs into the ditch on the opposite side.

The fuel truck driver is stuck and cannot get out. While placing flares outside of the vehicle the driver hears approaching traffic and decides to climb up on the bank with a flare to get the attention of the other drivers.


At that moment the driver see’s that both

buses are headed directly for each other

and can do nothing.

Both bus drivers see each other at the

last second and swerve to miss. The bus

headed to NYC with the college student

plows directly into the fuel compartment

of the fuel truck causing the fuel to leak.

Fuel reaches the lighted flare and within

seconds both the fuel truck and the bus

carrying students are on fire.

Exercise Scenario – 2 cont.

Exercise Scenario-2 cont.

While attempting to miss the other bus the

tour bus goes into a slide on the ice and

careens over the opposite bank, into the

trees below.

An explosion occurs from the fuel truck

causing the bus full of college students to

flip onto its side.

A nearby neighbor calls 911 with the

information.

Exercise Scenario-2 cont.

First responders on scene are triaging on

scene are reporting multiple dead (20 is

the initial report), 15 black tagged, 25

red, 12 yellow and 5 green.

911 dispatch has begun calling in

additional EMS crews and fire

departments for patient transport and

scene support.

County car 1/Delhi Fire 2 has setup

Incident Command on scene.

Hospitals have all been notified.

Discussion Questions--2

What plans will be enacted at your location?

Will Incident command be activated?

If so what roles will be assigned?

What types of communication will be established?

How will the community effected and what activities might occur for the community?

Discussion Questions - 2

What resources will you use? Resource

needs?

Will your mass fatality plan be enacted?


Remember

News Item 3

8:30pmThe Christmas Holiday Parade in

Walton is just ending.

A tow truck driver in Walton who has

been drinking at a local tavern gets a call

to go the scene of the accident on 28 near

Andes.

As the driver of the tow truck is coming is

coming down Delaware Street he is

stopped by the parade. Warm inside his

truck he falls asleep letting his foot off the

brake.


As the truck rolls into the parade route it

runs into a float carrying 12 children and

5 parents.

The float tips over as people watching the

parade start to panic and go in front of

the slowly rolling truck in an attempt to

stop it.

Walton Fire department establishes on

site command.

Initial estimates are 4 dead, 3 black tag, 6

red, 3 yellow and 2 green.


Discussion Questions-3 cont.

What resources are in place for the collection, identification, transportation and storage of the dead?

Is there a role identified at your facility for processing death certificates and managing records?

Discussion Questions – 3

cont.

Given the events that have transpired,

What public safety, legal, environmental,

health, and economic issues face your

organization?


How will the religious and cultural expectations concerning the treatment of death be handled?

How do we address the physical and mental well being of responders, persons providing essential services, and their families?

What should we be doing to help the general public?

What processes are in place to quickly remove remains from a hospital?


How would remains be managed when

funeral capacity is exceeded?

… when cemetery/crematory capacity is

exceeded?

Does your organization’s Mass Fatality

need to be modified?

Hot Wash

What are the top 3 items for

improvement?

What are the top 3 strengths in your

planning?

Did this exercise aid in further

development of your plans?

Next Steps?

Development of Improvement Plan

Strengths

Each organization had a thorough knowledge

of their mass fatality plan.

A variety of organizations were represented

including Medical Examiner, Public Health,

Hospice, Hospitals, Law, EMS and Emergency

Management

A prior review of the County plan in the

proved beneficial in identifying each role.

Organizations realized that additional

clarification was needed to coordinate

resources until an Emergency Operations

Center (EOC) is opened.

Future Discussion and

Planning Temporary morgue capability was not fully

addressed due to further role clarification

needed.

Crime scene vs. Need to recover and identify

human remains

The need for additional resources in a multi-

agency response

Family Recovery Center logistics were not

discussed in as much detail as anticipated

during the exercise

Future Discussion and

Planning More discussion needed to identify at what point

would notification of partners not in the

immediate emergency, be notified to allow them

to provide assistance (PIO, hospitals, health,

social services, College, etc.)

Challenges with expanding the exercise from

addressing the immediate emergency on scene

to the additional response measures as the

exercise continued

Gershon et al. BMC Public Health 2014, 14:1275http://www.biomedcentral.com/1471-2458/14/1275

RESEARCH ARTICLE Open Access

Mass fatality preparedness among medicalexaminers/coroners in the United States:a cross-sectional studyRobyn RM Gershon1*, Mark G Orr2, Qi Zhi1, Jacqueline A Merrill3, Daniel Y Chen3, Halley EM Riley4

and Martin F Sherman5

Abstract

Background: In the United States (US), Medical Examiners and Coroners (ME/Cs) have the legal authority for themanagement of mass fatality incidents (MFI). Yet, preparedness and operational capabilities in this sector remainlargely unknown. The purpose of this study was twofold; first, to identify appropriate measures of preparedness,and second, to assess preparedness levels and factors significantly associated with preparedness.

Methods: Three separate checklists were developed to measure different aspects of preparedness: MFI PlanElements, Operational Capabilities, and Pre-existing Resource Networks. Using a cross-sectional study design, dataon these and other variables of interest were collected in 2014 from a national convenience sample of ME/C usingan internet-based, anonymous survey. Preparedness levels were determined and compared across Federal Regionsand in relation to the number of Presidential Disaster Declarations, also by Federal Region. Bivariate logistic andmultivariable models estimated the associations between organizational characteristics and relative preparedness.

Results: A large proportion (42%) of respondents reported that less than 25 additional fatalities over a 48-hourperiod would exceed their response capacities. The preparedness constructs measured three related, yet distinct,aspects of preparedness, with scores highly variable and generally suboptimal. Median scores for the threepreparedness measures also varied across Federal Regions and as compared to the number of Presidential DeclaredDisasters, also by Federal Region. Capacity was especially limited for activating missing persons call centers, launchingpublic communications, especially via social media, and identifying temporary interment sites. The provision of stafftraining was the only factor studied that was significantly (positively) associated (p < .05) with all three preparednessmeasures. Although ME/Cs ranked local partners, such as Offices of Emergency Management, first responders, andfuneral homes, as the most important sources of assistance, a sizeable proportion (72%) expected federal assistance.

Conclusions: The three measures of MFI preparedness allowed for a broad and comprehensive assessment ofpreparedness. In the future, these measures can serve as useful benchmarks or criteria for assessing ME/Cspreparedness. The study findings suggest multiple opportunities for improvement, including the development andimplementation of national strategies to ensure uniform standards for MFI management across all jurisdictions.

Keywords: Disasters, Mass fatality incident, Preparedness, Medical examiners, Coroners, Death care, CBRNE, Abilityand willingness

* Correspondence: [email protected] of Epidemiology and Biostatistics and Institute for Health PolicyStudies, School of Medicine, University of California, San Francisco, SanFrancisco, CA 94118, USAFull list of author information is available at the end of the article

© 2014 Gershon et al.; licensee BioMed Central. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly credited. The Creative Commons Public DomainDedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,unless otherwise stated.

mailto:[email protected]

http://creativecommons.org/licenses/by/4.0

http://creativecommons.org/publicdomain/zero/1.0/

Gershon et al. BMC Public Health 2014, 14:1275 Page 2 of 15http://www.biomedcentral.com/1471-2458/14/1275

BackgroundHistory is replete with examples of disasters resulting incatastrophic numbers of fatalities. Just in the last decade,a wide range of natural and anthropogenic global eventsresulted in extremely high mortality rates in the affectedcommunities. Examples include the 2001 World TradeCenter attacks (~3,000 deaths), the 2003 Western Europeheat wave (~35,000 deaths), the 2004 South Asian tsunami(~220,000-230,000 deaths), the 2005 Kashmir earthquake(~75,000 deaths), 2008 Sichuan, China earthquake(~87,000), the 2009-10 H1N1 pandemic (~20,000 deaths),the 2010 Haiti earthquake (~200,000 deaths), the 2011Japan mega-disaster (~22,000 deaths), and the recent 2014West Africa Ebola virus disease epidemic (~6,400 deaths)[1-3]. In some cases, these massive fatality incidents com-pletely overwhelmed local and even national capacity torespond appropriately, resulting in both acute and long-term adverse impacts on survivors and communities [4-6].Although they are difficult to prepare for, the well-documented association between ineffective mass fatalitymanagement and adverse impacts on survivors and com-munities is leading to an increased focus on managementof mass fatality incidents; the United States (US), in par-ticular, has recognized this as a high priority of disasterplanning [7].Both large-scale fatality disasters, as well as smaller

scale incidents with multiple fatalities are referred to as“mass fatality incidents” (MFI). Generally, we use theterm MFI to describe situations in which the resultantnumber of deaths exceeds the local jurisdiction’s abilityto respond effectively. More recently, another term, re-ferred to as “Complex Fatality Management” (CFM), isbeing used in recognition of the fact that local capacitycan be overwhelmed by even a single fatality if the inci-dent involves hazardous chemical, biological, radio-logical, nuclear or explosive (CBRNE) agents. (Personalcommunication, Cynthia Galvin, 2014).In the US, the medico-legal authority for decedents is

typically under the purview of Medical Examiners or Coro-ners (ME/Cs). In most jurisdictions (usually county-level),ME/Cs are responsible for the investigation and manage-ment of deaths resulting from homicide, suicide, and acci-dents as well as deaths resulting from incidents that maypresent a threat to public health [8]. Offices of ME/C,spread across over 1000 jurisdictions in the US, can rangefrom very small offices, essentially manned by one-person,to much larger and robust offices, with more than one hun-dred employees [9]. Guidance on MFI management is gen-erally provided in a state’s mass fatality response plan,which many states have, usually as an annex to the state’sdisaster plan [10]. The local ME/C may also have office-specific MFI plans. Although having a written plan is animportant first step, ME/Cs must also have adequate oper-ational capabilities to execute the plan. Pre-existing

relationships with response partners, including governmen-tal agencies, local businesses, and voluntary organizations,can be vital to ensuring ME/Cs offices’ response capacity.These partners may supply additional staff, space, supplies,or other forms of support.In response to MFI, the ME/C must execute or over-

see an array of operational tasks. Some of these include:securing and preserving human remains at a disastersite; recovering human remains; developing and imple-menting public communication messages; credentialingand managing volunteer staff; mobilizing missing per-sons call centers; performing all morgue operations, includ-ing ante-mortem and postmortem data collection forvictim identification (Victim Identification Program); trans-porting, storing and securing temporary interment of re-mains; and releasing human remains for final disposition[11-15]. Furthermore, if CBRNE agents have contaminatedthe scene and/or human remains, then the ME/C must alsotake special precautions to ensure the safety of their staffand community. ME/Cs must also consider the impact oftheir investigative actions with respect to religious rituals orfaith traditions. ME/Cs should also be cognizant of andmake preparations for reducing adverse mental health im-pacts of the MFI response on staff and volunteers.In the US, a mechanism exists for local jurisdictions to

request disaster assistance, described in the National Re-sponse Framework (NRF), the nation’s guide for respond-ing to all-hazards disasters [7]. Under this framework, theDepartment of Health and Human Services (DHHS) is re-sponsible for coordinating MFI needs [16], and upon re-quest, one of the important assets that DHHS can deployare the services of Disaster Mortuary Operational Re-sponse Teams (DMORT). These highly qualified andskilled teams can bring supplies and expertise to MFI tohelp augment local capacity. However, even whenDMORT teams are deployed, ME/Cs are responsible forthe initial MFI management and for requesting this aid[17]. Because of the complexity of mass fatality manage-ment operations, there is a growing concern among ME/Cs regarding preparedness for MFI and their ability tomanage MFI competently, especially for an incident thatinvolves CBRNE [14].These types of concerns were formally raised nearly a

decade ago when a panel of national experts was con-vened by the US Northern Command, which providescommand and control of the Department of Defensehomeland defense efforts. The panel, referred to as theJoint Task Force Civil Support Mass Fatality WorkingGroup (“Working Group”), was charged with examiningthe available data to determine the response capabilitiesand preparedness of the US mass fatality infrastructurefor managing high fatality events, such as pandemics[12]. The Working Group identified several key elementsof preparedness for the management of mass deaths and


acknowledged significant knowledge gaps regarding theextent to which these elements had been adopted. TheWorking Group concluded that knowledge regarding thenation’s ability to manage a mass fatality event was lim-ited. Since that time, many different initiatives have beenundertaken to help ensure the nation’s readiness to man-age MFI, and most currently, in 2014, a high level MassFatality Management Executive Steering Committee wasformed to help provide effective guidance on MFI pre-paredness and management (Personal communication,Cynthia Galvin, 2014).Since ME/Cs arguably have the most critical role to

play in the US mass fatality infrastructure, and becausepreparedness and response capabilities for this grouphave not, to our knowledge, been previously assessedacross the nation, the purpose of this study was as follows:first, to develop criteria for measuring preparedness in thissector; second, to assess subjective and objective prepared-ness and operational capabilities; and third, to identifyorganizational characteristics and other correlates ofpreparedness. This information is valuable in develop-ing mass fatality management benchmarks as well asserving as an indicator for assessing actual prepared-ness. The ultimate goal of this study was to improvenation-wide MFI capabilities.

MethodsStudy design and participantsThis cross-sectional study was conducted over a six-weekperiod in 2014. A self-administered, anonymous survey wasmade available on a SSL-secured site using a web-based tool[18]. Participants were adult professionals in the MedicalExaminer/Coroner field and were recruited through news-letters, websites, and mass emails with the assistance andsupport of professional ME/Cs organizations. All study pro-cedures involving human participants had prior review andapproval of the University of California, San Francisco(UCSF) Human Research Protection Program, Committeeon Human Research (CHR) (approval number 12-09425)and Columbia University Human Research Protection OfficeInstitutional Review Boards (approval number AAAL0206),and informed electronically signed consent was obtainedfrom each participant enrolled in this study.

Questionnaire development and designThe preparedness measures were developed through anexhaustive four-part process involving the assessment ofexisting materials and review by experts in mass fatalitymanagement and emergency preparedness and response.As a starting point for the measures, national docu-ments, such as the 2014 National Response Framework[7] and the National Response Plan (NRP) [19], and inparticular, the NRF Emergency Support Function #8, thePublic Health and Medical Services Annex [16], were

carefully reviewed. A core functional area under ESF #8,is “mass fatality management, victim identification, anddecontamination of remains,” for which the Departmentof Health and Human Services has primary and coordin-ating responsibility. The delineation of the supplementalrole of the federal government was necessary for com-parison and clarity of the ME/C responsibilities all juris-dictional level [5]. The second step in developing themeasures was to conduct an environmental scan ofexisting state annexes or mass fatality plans as well asother available documents on mass fatality planning andresponse from the National Association of Medical Ex-aminers (NAME) and the International Association ofCoroners and Medical Examiners, the two leading pro-fessional associations for ME/C [15,20-26]. Additionally,at this stage, we also reviewed toolkits and checklists de-veloped by several state mass fatality planners, and wealso reviewed the British Columbia Coroners Service(BCCS) Mass Fatality Response Plan [27-29]. These keydocuments provided the reference point for developingthe preparedness measures, which were conceptualizedas consisting of three domains: (1) Mass Fatality PlanElements; (2) Mass Fatality Response Operational Cap-abilities, and (3) Pre-existing Resource Networks. In thethird step, draft items for each of the measures of pre-paredness were then prepared and submitted for reviewand assessment to more than a dozen nationally recog-nized subject experts and key informants. These in-cluded the lead authors of highly developed state andregional plans, members of the national mass fatalityplanning steering committee, leadership of national pro-fessional ME/C organizations, and emergency manage-ment and mass fatality planning leaders. Our goal was toobtain consensus on the content validity of these newmeasures. In the fourth and final step, 11 representativesof the target population (ME/Cs) were asked to pre-testthe computerized version of these measures and other ele-ments of the questionnaire so that we could assess facevalidity of the measures as well as readability and length oftime for completion. A copy of the ME/C questionnaireand codebook are appended in an Additional files 1 and 2,and all other documents related to the development of themeasures may be obtained by contacting the correspond-ing author. The study questionnaire was written in Englishand prepared at a 13.5 grade reading level for ease of com-pletion (length of time to complete ranged from 12-20 mi-nutes) [30]. Most items used “yes”, “no”, “don’t know”response categories or discreet categorical responses. Thethree preparedness measures used a simple checklist boxto indicate a positive (“yes”) response. The questionnaireincluded items that addressed organizational characteris-tics, MFI preparedness measures, and staff ability and will-ingness to report to duty, which is conceptualized as animportant outcome related to preparedness [31-34].


MeasuresOrganizational characteristicsSeven items were used to characterize the respondent’sorganization, including office type (Medical Examiner vsCoroner or other), location (zip code), population size ofjurisdiction served, whether urban or rural setting, num-ber of employees, number of additional fatalities in ex-cess of normal case load within a 48-hour period thatwould exceed capacity, and MFI experience in the past5 years.

Mass Fatality Incident (MFI) preparednessMFI Preparedness was assessed by three new categorical(nominal) measures: (a) Mass Fatality Plan Elements, op-erationalized as a 19-item checklist derived primarilyfrom sample state mass fatality plans and the NationalAssociation of Medical Examiners (NAME) MFI manage-ment procedures [35]; (b) Mass Fatality Response Oper-ational Capabilities, measured with a 21-item checklistdeveloped with input from field experts and sample state,and national guides [14,15,20,27,28]; and (c) Pre-existingResource Networks, measured with a new 12-item check-list of jurisdictional and community resource partners.

Additional MFI planningSeven items helped to further characterize MFI plan-ning, including: (a) an office-specific MFI plan and fre-quency of updating the plan; (b) the plan’s compliancewith the National Incident Management System (NIMS)and with the Federal Emergency Management Agency(FEMA) Comprehensive Preparedness Guide (CPG)[36,37]; (c) the jurisdictional role for ME/C during MFI;(d) interoperability and mutual aide agreements; (e) writ-ten policies on public communication during MFI; (f) useof social media during MFI; and (g) provision of mentalhealth/spiritual counseling to staff and/or volunteers dur-ing and after MFI.

Staff willingness and ability to report to duty, with andwithout contamination with CBRNE agentsThis was assessed using a two-part item based on someof our earlier studies on ability (i.e., availability) and will-ingness of staff to report to duty [31-34]. For theseitems, respondents were asked to indicate the proportionof staff that they thought would be willing and/or able toreport to duty during MFI, with or without CBRNE asfollows: (a) proportion of staff who they thought wouldbe willing to report in their roles during a mass fatalityincident; (b) proportion of staff who they thought wouldbe willing to report in their roles during a mass fatalityincident that involved CBRNE contaminants; (c) propor-tion of staff who they thought would be able to report intheir roles during a mass fatality incident; (d) proportionof staff who they thought would be able to report in

their roles during a mass fatality incident that involvedCBRNE contaminants. Additional items were includedon the preparation of a staff roster and staff pre-eventplanning in order to determine the availability of staffduring MFI.

Training of staff and participation in drillsThree items addressed training, including training ofstaff on the office’s mass fatality plan, training of staff onMFI involving CBRNE agents, and training of the officethrough participation in jurisdictional drills.

Self-reported workplace and jurisdictional preparednessMeasured by two items on respondents’ perceptions ofthe preparedness levels of (a) their office, and (b) theirlocal jurisdiction.

Resource needsOne final item asked respondents to indicate from a list ofseven resources (plus an additional open ended “other” re-sponse category) the resources they thought they neededto help improve their office’s MFI preparedness and re-sponse. The list included such items as “more training”,“more planning activities”, “more funding for preparationactivities”, “more interagency agreements”, etc.As noted, a copy of the study questionnaire and code-

book are appended.

Data analysisAfter checks for internal reliability and validity of responsesand other data editing procedures were completed, anarray of descriptive statistics and graphical techniques (e.g.,frequencies, histograms, measures of central tendency anddispersion) were performed to characterize the distributionof variables and to determine if there were any outliers.This strategy provided familiarity with the data and allowedus to determine if the data met assumptions required bythe intended statistical testing procedures. All analyseswere conducted using R (version 3.1.0, Auckland, NewZealand) [38].The main outcome (criterion) variables were the three

measures of MFI preparedness. To determine the rela-tionship between the three measures, Pearson's product-moment correlation coefficient, r, was used to measurethe degree of linear association between each of the vari-ables, with results ranging from r = .49 - .64, indicatinggenerally moderate to strong correlations. After carefulexamination of the frequency distribution of the threeoutcome variables, each outcome measure was dichoto-mized into two categories (scores below the median = 0;equal or above the median = 1). This was appropriategiven that the data were bimodally distributed (to in-clude zeros) and because these were categorical and notcontinuous variables. The dichotomization also allowed


for visual depictions of the preparedness measures aver-aged across Federal Regions. This also facilitated visualcomparison with the number of Presidential DisasterDeclarations, 2001-2014, also averaged across FederalRegion [39]. The maps as depicted were created usingArcGIS 10.2.2 for Desktop (Redlands, CA) [40].To explore the organizational factors associated with

preparedness, we first performed chi - squared statisticsand estimated odds ratios and their confidence intervalsusing bivariate logistic regression analysis between eachpredictor and outcome measure in order to provideinsight into the non-adjusted relations between predic-tors and outcomes. The next stage in our analysis in-volved logistic multivariable analysis to determine theunique relationship between the outcome variables (pre-paredness measures) and each predictor variable whenconsidering all variables simultaneously. Linear regres-sion was not used as the preparedness variables were, asnoted, categorical and not continuous variables. For allregression analyses, the level of significance was set at5%. Results are presented as estimated odds ratio (OR)and their 95% confidence interval (95% CI).

ResultsOrganizational characteristicsA total of 122 completed questionnaires were collected.The actual response rate cannot be calculated, as thiswas a convenience sample. However, the number of ME/C in the US is approximately 900-1,000 [9], based on themost recent (2004) available data. The mapped distribu-tion of responses by US states and territories is shown inFigure 1. The sample represented each of the 10 FederalRegions and 37 of the 56 states and territories [41]. Most

Figure 1 Distribution of ME/C respondents in US. Federal Regions wereusing black lines. State and zip code data were used from the questionnair

of the respondents were either Medical Examiners (48%)or Coroners (44%), with the remainder indicating an-other role, including Forensic Pathologist (2%), Sheriff(2%), Justice of the Peace (1%), and “other” (3%). Themajority of respondents (49%) indicated that their officeserved large jurisdictions (≥500 K people), followed by25% serving 100 K-499.9 K, 14% serving 50 K-99.9 K, 8%serving 25 K-49.9 K, and 4% serving small jurisdictionswith populations below 25 K. On average, most agencies(52%) employed ≤10 full time employees, with only 9%indicating ≥ 100 employees.

MFI preparedness and additional MFI planningMFI plan elementsFrequencies for the MFI Plan checklist items are shownin Table 1. A large majority of respondents (95%) re-ported that their office had a written mass fatality plan,but only 9% of the sample reported having all 19 itemson the MFI Plan Elements Checklist included in theirplan; on average, respondents reported having 68% ofthe plan elements in their own plans (checklist mean =12 [SD = 6.2], median = 13, min = 0, max = 19). The mostcommon plan items reportedly in place were: morgueservices; human remains recovery; and command andcontrol. The least frequently noted plan items included:job action sheets for the various positions in the plan;funding reimbursement policies; and availability of staffrespite areas.Respondents reported that their local ME/C office’s

plan was updated annually (32%), every two years (22%),or every five years (13%), with only 3% reporting that itwas never updated; a sizeable proportion (30%) were un-sure or unaware of how often the plan was updated. A

colored differently and the states within each region were separatede to determine the location of each ME/C respondent (red dots).

Table 1 Mass fatality plan frequencies (N = 114)

n (%)a

Morgue services 101 (88.6)

Human remains recovery 96 (84.2)

Command and control 94 (82.5)

Security and preservation of the remains 92 (80.7)

Incident notification and plan activation 85 (74.6)

Authorities 81 (71.1)

Family assistance 81 (71.1)

Concept of operations 80 (70.2)

Security and preservation of the disaster site 79 (69.3)

Application and scope 75 (65.8)

Continuity of operations plan 73 (64.0)

Religious/cultural considerations(e.g., disaster emotional and spiritual care)

67 (58.8)

Mass fatality information systems 65 (57.0)

Vital records system 62 (54.4)

Credentialing, managing anddocumenting disaster personnel,including volunteers

57 (50.0)

Assumptions 55 (48.3)

Job action sheets for the variouspositions in the plan

49 (43.0)

Staff respite area 37 (32.5)

Funding reimbursement 33 (29.0)aData shown represent individuals who endorsed each item on the checklist.

Table 2 Operational capabilities frequencies (N = 117)

n (%)a

Refrigerated storage of remains 94 (80.3)

Decedent recovery 89 (76.1)

Postmortem examination/morgue operations 89 (76.1)

Transport of remains 89 (76.1)

Decedent release/final disposition 82 (70.1)

Command and control for fatality management 81 (69.2)

Security and preservation of human remains 80 (68.4)

Ante-mortem data collection 74 (63.3)

Tracking system (i.e., victim identificationProgram) for recovered remains

69 (59.0)

Joint agency death investigation 67 (57.3)

Decedent manifest 59 (50.4)

Information technology/tracking 52 (44.4)

Morgue operations for contaminated(hazard material) human remains

50 (42.7)

Public messaging 46 (39.3)

Incident characterizations 42 (35.9)

Security and preservation of disaster site 42 (35.9)

Caring for or interring human remainsin accordance to the religious ritual orrequirements of most faith traditions

37 (31.6)

Missing persons call centers 28 (23.9)

Communication via social media 26 (22.2)

Temporary interment 21 (18.0)

Long term family management/memorial 10 (8.6)aData shown represent individuals who endorsed each item on the checklist.


large proportion (70%) indicated that their plan wascompliant with NIMS [36]. However, only 40% reportedthat their plan was compliant with the FEMA CPG [37].Engagement at the local level was adequate; a large per-centage (77%) reported that their office had a seat attheir local jurisdiction’s Emergency Operations Centerduring MFI, and an even greater proportion (88%) had adefined position during MFI. Most respondents (78%)had interoperability and mutual aide agreements inplace. A large percentage (75%) of respondents reportedhaving written policies that addressed public communi-cations/public announcements during MFI, but only29% had written policies related to the use of socialmedia during MFI. Less than half (48%) of the respon-dents had plans in place that addressed the provision ofmental health care or spiritual counseling for their staffand/or volunteers during or after MFI.

Operational capabilitiesOnly 9% of respondents reported all 21 OperationalCapability Checklist items (mean = 10 [SD = 5.9], median =11, min = 0, max = 21); on average, respondents reportedhaving 52% of the operational capabilities in place. Themost frequently reported operational capabilities for

managing MFI included: refrigerated storage of remains,postmortem examination/morgue operations and trans-port of remains. The least frequently cited capabilitiesincluded: long term family management (i.e., memorialservices), availability of temporary interment facilities,and communication system in place using social media.See Table 2 for a complete list of the frequencies forthis checklist.

Pre-existing resource networksThe frequencies for the items on the Pre-existing Re-source Networks checklist are shown in Table 3. Only8% of respondents reported having relationships with all12 potential sources of resources needed to respond toMFI. The median checklist score for this measure was8.5 (mean = 8 [SD = 3.3], min = 0, max = 12); on average,the sample had more than 70% of the potential pre-existing relationships in place. The most frequently re-ported pre-existing partnerships in place were with localorganizations and agencies, such as local office of emer-gency management, local members of the death caresector (organizations affiliated with the funeral industry),

Table 3 Pre-existing resource networks frequencies(N = 118)

n (%)a

Local Office of Emergency Management/Civil Defense 99 (83.9)

Local funeral homes, cemeteries, crematories 97 (82.2)

Local first response organizations 95 (80.5)

Local/State Department of Health 92 (78.0)

State Office of Emergency Management/Civil Defense 88 (74.6)

Federal assets 85 (72.0)

Voluntary organizations 79 (67.0)

Local health care organizations 78 (66.1)

Other nearby Coroner/Sheriff’s office/Justice of the Peace 74 (62.7)

Other nearby office of medical examiner 65 (55.1)

Faith-based organizations 51 (43.2)

Disaster management vendors/contractors 47 (39.8)

Other 4 (3.4)aData shown represent individuals who endorsed each item on the checklist.


and the local department of health. A substantial pro-portion (72%) also reported that they planned to rely onfederal assets. Most respondents (75%) reported thattheir jurisdictional partners had their own mass fatalityplan, but less than 30% had signed off on those plans.Typically, the response partners that the ME/Cs ex-pected to assist them in MFI were the same ones thatthey, in turn, would plan to help.

Graphic comparison of the three preparedness measuresA graphic comparison of the three measures and totalFederal Regional Presidential Disaster Declarations from2001-2014, by Federal Region, is provided in Figure 2(A,B,C,D). As noted, we have stratified the preparedness scoresfor each of the three measures into two categories (belowthe median and equal or above the median) across each ofthe Federal Regions [41]. As can be seen, scores varyacross the three measures, as shown in 2(A-C). For ex-ample, only Region 4, which includes Alabama, Florida,Georgia, Kentucky, Mississippi, North Carolina, SouthCarolina, and Tennessee; Region 9, which includesArizona, California, Hawaii, Nevada, and the PacificIslands; and Region 10, which includes Arkansas, Idaho,Oregon and Washington, had uniformly higher scores onall three preparedness measures.Other findings of interest relate to visual comparisons

with the map depicting the Presidential Disaster Declara-tions (2001-2014), by Federal Region. Between 2001 and2014, there were 1,740 declarations made in the US [39].The total number of Disaster Declarations by FederalRegion has been categorized into two groups: < the me-dian and ≥ the median number of reported declarations,per Federal Region) over the time period of 2001-2014. As

can be seen in Figure 2(D), the levels of preparednesswithin each Federal Region are at the same level orhigher than the median number of declared disastersin all regions except for Region 6 (Texas, New Mexico,Oklahoma, Arkansas, and Louisiana), and Region 8(Utah, Colorado, Wyoming, Montana, South Dakotaand North Dakota) [41].

Prior mass fatality incident experience and the number ofadditional fatalities within a 48-hour period that wouldexceed capacityA majority (82%) of respondents reported that their jur-isdiction had not experienced MFI in the past 5 years. Asizeable proportion (42%) of the respondents reportedthat their capacity would be exceeded by the addition of24 or less fatalities (over and beyond their normal caseload) over a 48-hour time period. Additional fatalitiesthat would exceed capacity responses were as follows:25-50 additional fatalities (28%), 51-75 additional fatal-ities (10%); 76-100 additional fatalities (4%), and 13%of respondents reported that they had the capacity tomanage an additional 100 fatalities or more in a 48-hour period.

Staff willingness, ability to report to duty, with andwithout contamination with CBRNE agentsA large majority (83% and 72%) of respondents indicatedthat 80% or more of their staff would be willing andable, respectively, to report to duty during a mass fatalityincident. However, substantially lower proportions (46%and 52%) reported that 80% or more of their staff wouldbe willing and able, respectively, if MFI involved CBRNEagents. Nearly one quarter of the respondents reportedthat they expected less than 20% of their staff to reportif CBRNE agents were involved in MFI. Furthermore,whereas staff rosters had generally been prepared to in-dicate staff availability, less than half of the respondentsthought that staff had made pre-event plans (e.g., plansto address childcare and elder care responsibilities) thatwould ensure their availability to work during MFI. Re-sults of chi-squared analyses indicated significant posi-tive relations between training of staff and staffavailability (p < .01) and between staff participation indrills and willingness to report to duty (p < .01), suggest-ing that training may help support adequate staffing.

Training of staff and participation in drillsMore than 70% of respondents indicated that their officeprovided training to staff on the mass fatality plan, andstaff participation in drills with local partners was com-mon (79%). However, CBRNE–related MFI training wasmuch more limited; only 27% of the respondents re-ported that their office had ever provided this type ofspecialized training.

Figure 2 Comparisons between preparedness measures scores and with respect to the Presidential Disaster Declarations. (A) MFI Planmeasure by Federal Region; (B) Operational Capabilities measure by Federal Region; (C) Pre-existing Resource Networks measure by FederalRegion; and (D) Presidential Disaster Declarations (2001-2014) by Federal Region. Data for the disaster declarations map were available at theFEMA website [27] and median number of regional disaster declarations (N = 138) was used to categorize all 10 regions in map D. Maps A-C werecreated using questionnaire data. Scores for the preparedness measures and number of disaster declarations were categorized into two groups(below median and equal to or above median). The lighter blue represents regions with scores/number of disaster declarations below the medianand the darker blue indicates regions with scores/number of disaster declarations equal to or above the median.

Table 4 Resources needed to improve MFI preparednessand response (N = 120)

n (%)a

Additional training of staff 89 (74.2)

Greater surge capacity (identificationof additional staff, supplies, space)

78 (65.0)

Additional funding for mass fatality planning 77 (64.2)


Perceptions of office and jurisdictional preparednessLess than half (43%) of the sample thought that their officewas well prepared to manage MFI, 16% thought that theywere not at all or slightly prepared, and the reminder(41%) thought they were moderately prepared. Similarly,more than half (55%) of the respondents thought their jur-isdiction was well prepared, 10% thought that their juris-diction was not at all or slightly prepared, and the rest(35%) thought they were moderately prepared.

Additional mass fatality planning activities 71 (59.2)

Additional drills with other response partners 70 (58.3)

Signed interagency agreements 51 (42.5)

Other (e.g., better communications,CBRNE trainings, better coordination, etc.)

19 (15.8)

A written mass fatality plan 15 (12.5)

ME/C office does not need any additionalresources to be better prepared

5 (4.2)

aData shown represent individuals who endorsed each item on the checklist.

Resources needed to help improve MFI preparednessand responseOnly 5 (4%) respondents indicated that their office didnot need any additional resources to improve their pre-paredness. The resources most frequently needed includedmore training for staff, greater surge capacity, and morefunding for mass fatality planning. Detailed results may befound in Table 4.


Relations between preparedness measures andpredictor variablesAs noted in Table 5, several factors were significantly as-sociated with each of the measures of preparedness, butonly one variable, training of staff on the office’s MFIplan, was significantly associated with all three. Trainingof staff was also the single most strongly associated vari-able with respect to the MFI Plan measure (OR = 5.44,95% CI [2.10, 14.11]); i.e., ME/Cs who provided stafftraining on the mass fatality plan had a 5.44 greater oddsof a higher score compared to those ME/C reporting nostaff training. Similarly, staff training was also positivelyassociated with the Operational Capabilities and Pre-existing Resource Networks measures (OR = 3.86, 95%CI [1.58, 9.46] and OR = 2.86, 95% CI [1.19, 6.84]), re-spectively. For the Operational Capabilities measure, thestrongest association was noted for maximum fatalitiesthat could be handled within 48 hours (OR = 5.65, 95%CI [2.52, 12.66]); ME/C reporting that they could handle25 or more fatalities within 48 hours had a 5.65 greaterodds of having a higher score on the Operational Cap-abilities measure than those who could handle 24 or lesswithin 48 hours.Prior experience managing MFI was significantly asso-

ciated with higher scores on the Operational Capabilitieschecklist (OR = 3.54, 95% CI [1.20,10.41]). Self-reportedperceptions of organizational preparedness were strongly(positively) associated with both the MFI Plan and theOperational Capabilities measures, as noted in Table 5,indicating that respondents had perceptions thatreflected at least their own actual level of readiness asmeasured by these two preparedness measures, althoughwe have no information on the actual readiness at thejurisdictional level.Findings of interest include the general lack of a sig-

nificant relation between preparedness measures and thesize of jurisdiction served, although the OperationalCapabilities measure was significantly (positively) associ-ated with a larger workforce (>6 full time employees).

Relations between preparedness measures andwillingness and ability of staff to report to dutyConceptually, willingness and ability of staff is seen asresulting from preparedness of the worksite. That is, themore prepared the workplace, the more willing and ablethe work force will be to report to duty during disasterevents, including MFI. However, since these data arecross-sectional, directionality for any of these study vari-ables cannot be ascertained. To assess the relationshipbetween the willingness and ability variables and thethree preparedness measures we included them, asshown in Table 5, in the bivariate analyses. The pre-paredness measures, for the most part, were not signifi-cantly associated with staff willingness and ability to

report to duty during MFI, with or without contamin-ation with CBRNE. One exception here was the moder-ate positive association between staff willingness toreport to non-contaminated MFI and (higher) MFI Planmeasure score (OR = 2.94, 95% CI [1.04, 8.32]).

Results of the multivariate analysisMost variables significant at the bivariate level were nolonger significant at the multivariate level. Exceptions in-cluded the MFI Plan measure and Operational Capabil-ities measure, which remained significantly correlated toeach other (OR = 3.44, 95% CI [1.27,9.32], p < .05); ME/Cs reporting highly developed plans were more thanthree times more likely to report a high level oforganizational capabilities. Another significant result atboth the bivariate and multivariate levels was that Coro-ners (as compared to Medical Examiners) were morelikely to report a higher score on the Pre-Existing Re-source Network measures (OR = 3.5, 95% CI {1.46,8.40,p < .01]. A borderline significant score was also notedbetween the MFI Plan measure and training on the MFIPlan.

DiscussionBased on our results, the three new preparedness mea-sures presented in this paper provide for a broad and in-clusive perspective on mass fatality managementpreparedness. The MFI Plan measure serves as a roadmap for planning, the Operational Capabilities allows foran in-depth assessment of organizational resources andPre-existing Resource Networks indicates the externalsupports available to the ME/Cs. These three measures,when combined, reflect a more accurate level of localME/C preparedness to manage MFI. A fourth compo-nent, ability and willingness of staff can also be consid-ered an important indicator of preparedness, but weconceptualize this as an outcome of preparedness (i.e.,staff who perceive a more prepared workplace will bemore willing to show up for work during times of disas-ter), rather than a predictor of preparedness. The natureof the willingness and preparedness relationship hasbeen clearly demonstrated in real time during the Ebolavirus outbreak, where well prepared biocontainmenthospitals have reported a large increase in job applicantswilling to work in these high containment facilities incontrast with hospitals treating cases or suspected caseswithout this degree of preparedness reporting job ac-tions and strikes [42,43].The results of the bivariate analysis indicate the im-

portant relationship between high quality planning andtraining; since these data are cross sectional, the exactnature of the relationship for instance, between mea-sures of preparedness and training, cannot be deter-mined. However, it does seem likely that ME/Cs with

Table 5 Bivariate regression analysis of preparedness measures and organizational

MFI plan elementsN= 114

Operational capabilitiesN = 117

Pre-existing resourcenetworks N = 118

Odds ratio95% CI

p-value Odds ratio95% CI

p-value Odds ratio95% CI

p-value

Workplace category (coroner isthe reference category)

1.03 .934 1.03 9.34 0.34 .006**

[0.42-2.17] [0.49-2.17] [0.16-0.74]

Number of full time employees(6 or less is the reference category)

1.77 .129 2.52 0.16* 0.78 .500

[0.85-3.72] [1.19-5.34] [0.37-1.62]

Maximum fatalities that can behandled within 48 hrs (24 or lessis the reference category)

2.25 .025* 5.65 <.001***

1.01 .970

[1.06-4.78] [2.52-12.66] [0.48-2.12]

Having experience of mass fatalityincidents in the past 5 years(no is the reference category)

2.23 .135 3.54 .022* 1.12 .810

[0.79-5.71] [1.20-10.41] [0.44-2.88]

Training on mass fatality plan(no or not have a plan isthe reference category)

5.44 <.001***

3.86 .003** 2.86 .018

[2.10-14.11] [1.58-9.46] [1.19-6.84]

Training on CBRNE (no is thereference category)

1.86 .155 2.17 .075 1.32 .510

[0.79-4.38] [0.92-5.12] [0.58-3.02]

Drills participation (no is thereference category)

4.68 .005** 3.83 .003** 1.75 .250

[1.59-13.73] [1.58-9.46] [0.68-4.48]

Having staff roster (no is thereference category)

1.83 .184 5.48 .001** 2.38 .061

[0.75-4.47] [1.99-15.14] [0.96-5.87]

Proportion of staff that arewilling to report to dutyduring a regular mass fatalityincident (70% or less staff willingis the reference category)

2.94 .042* 2.55 .068 2.25 .110

[1.04-8.32] [0.93-6.98] [0.82-6.13]

Proportion of staff that are willingto report to duty during a CBRNEinvolved mass fatality incident(70% or less staff willing is thereference category)

1.88 .177 1.87 1.27 1.10 .820

[0.85-4.13] [0.84-4.17] [0.50-2.39]

Proportion of staff that are able toreport to duty during a mass fatalityincident (70% or less staff able isthe reference category)

1.53 .313 2.24 .058 1.28 .550

[0.67-3.49] [0.97-5.15] [0.56-2.91]

Proportion of staff that are able to reportto duty during a CBRNE involved massfatality incident (70% or less staff able isthe reference category)

1.27 .552 1.15 .730 0.92 .830

[0.58-2.76] [0.52-2.52] [0.42-2.00]

Proportion of staff that have pre-eventplan (70% or less staff able is thereference category)

1.15 .762 1.77 .224 2.34 .072

[0.47-2.80] [0.70-4.46] [0.93-5.89]

Self-reported workplace preparedness(Less prepared is the reference category)

3.40 .002** 5.27 <.001***

1.56 .250

[1.55-7.45] [2.31-12.00] [0.74-3.28]

Self-reported jurisdiction preparedness(Less prepared is the reference category)

2.35 .025* 2.69 .010* 1.35 .420

[1.12-4.95] [1.27-5.70] [0.65-2.81]

Serving urban area (less than50,000 is the reference category)

2.14 .199 1.65 .386 0.55 .300

[0.67-6.81] [0.53-5.07] [0.17-1.74]

MFI plan elements (below medianis the reference category)

- - 6.71 <.001***

2.93 .004**

[3.04-14.82] [1.40-6.11]


Table 5 Bivariate regression analysis of preparedness measures and organizational (Continued)

Operational capabilities(below median is thereference category)

- - 2.22 0.31*

[1.01-4.59]

Pre-existing resource networks(below median is thereference category)

- -

Note. All organizational characteristics and preparedness measures were coded into binary variables.*p < 0.05. **p < 0.01. ***p < 0.001.


high quality planning also are more likely to implementtraining programs based on their planning. For the mostpart, factors that were significant in the bivariate ana-lyses were no longer significant in the multivariable ana-lysis, probably due to collinearity. More complex studydesigns and the inclusion of other variables not studiedhere, such as the funding available for MFI planning atthe jurisdictional level and MFI training and knowledgeof the ME/C, are needed in order to better characterizethe factors related to preparedness.Our three-tiered approach to measuring preparedness

contrasts with other models for systems-level prepared-ness, which have been suggested, such as the Ready,Willing, and Able framework developed by McCabe andcolleagues [44]. Our approach incorporates many oftheir constructs, especially “Ability”, which is reflected inour operational capabilities measure. In our efforts tocharacterize preparedness, we examined other metricsconsidered by field experts to be essential components,such as resources available to the ME/C through pre-existing relationships and agreements- as these are vitalto effective MFI management. Additionally, in line withsystems-level preparedness models, our approach alsoacknowledges “willingness” as noted above as an import-ant component of preparedness. Compared to other sec-tors we have studied with respect to willingness, theME/C are reportedly very willing to report to duty [31,32].Still, and in consideration of the fact that ME/Cs and staffare under a legal mandate to report to duty, a large pro-portion of staff may fail to report-especially if CBRNEagents are involved. Importantly, even if staff are willing,their availability may be severely limited during an infec-tious disease outbreak causing staff illness; meeting surgecapacity needs for staffing could then be highly problem-atic, as replacement staff most likely would not have theunique skill set required of ME/C and staff.Our findings indicate variable levels of preparedness

using three separate, yet related measures of prepared-ness. While improvements are indicated in all aspects ofpreparedness, special attention is needed to address op-erational capabilities since, on average, respondents hadonly about half of the items on the Operational Capabil-ities Checklist in place. Without these core capabilities,response will be limited.

With respect to the map of Presidential Disaster Dec-larations comparing the median scores of the three pre-paredness measures, while there are some differences, itis important to acknowledge that not all disasters resultin high fatalities; a good example of this was SuperStorm Sandy, which, while causing an estimated $50B indamages, resulted in relatively few direct deaths (N =147) given the magnitude of the disaster [45].Some notable findings in our study include the fact that

preparedness levels did not differ based on type of office(i.e., Medical Examiner vs Coroner), jurisdictional charac-teristics (size of population and rural vs urban), or thenumber of staff. These findings indicate that preparednessmay not be simply a function of organizational character-istics, but potentially influenced by some other factor(s). Itwas also notable and reassuring to find that there was ahigh degree of inter-organizational planning in place, asthis strengthens individual ME/C capabilities. As noted,our results also point towards the need for special atten-tion for certain aspects of preparedness, such as the use ofsocial media to help communicate with the public, andmobilizing missing person’s hotlines. Social media is in-creasingly being used by the public during and in the im-mediate aftermath of disasters to help them connect tofamily, friends, resources and timely information [46,47].There was a gap noted in terms of providing mental

health assistance to staff and volunteers and the provisionof long-term family assistance, which may be particularlyimportant in the wake of MFI [48]. There are a number ofexcellent information resources on the provision of mentalhealth and spiritual care, such as the Interfaith Network oftrained religious and lay leaders who are available for bothplanning and response purposes [49]. We noted that manyrespondents intended to call upon their local death caresector colleagues for instrumental support and they mayalso be able to play a role in terms of family assistance andstaff respite centers.Results from this study indicate that, in some jurisdic-

tions, local ME/Cs are well equipped, staffed and pre-pared to respond to MFI, while in other jurisdictions,they might be overwhelmed by any additional fatalitiesbeyond their typical case load. Complex situations in-volving CBRNE would challenge almost all ME/Cs. Therecent outbreaks of infectious diseases such as Middle


East Respiratory Syndrome (MERS), Ebola virus diseaseand recent influenza pandemics, as well as a number ofindustrial and transportation incidents involving hazard-ous chemicals underscore the need for preparedness forthese types of incidents [3,50]. ME/Cs must look to theirlocal office of emergency management and their localhealth departments for advice on what types of trainingand preparedness activities are feasible and meaningful.At the very least, local ME/Cs should know the agencyor persons to contact for expert advice if there they everhave to respond to a CBRNE incident.The findings here are in agreement with both the first

(2012) and the second (2013) National Preparedness Re-ports; these serve as the nation’s report card for docu-menting progress in building, sustaining, and deliveringthe 31 core capabilities as outlined in the National Pre-paredness Goal [13,51,52]. The 2012, 2013 and the mostrecent 2014 reports highlighted the need for improve-ments in mass fatality preparedness [13,51,53]. Planningfor MFI has been historically subpar; FEMA reportedthat between 2006 and 2011, only 24 out of 56 statesand territories invested Department of Homeland Secur-ity grant funds for fatality management activities, and fa-tality management services were rated as the weakest ofall 31 core response mission capabilities [13]. Since wemerged our findings and presented them by FederalRegion, state level differences are not easily observed.However, at the regional level we can ascertain wide dif-ferences across the nation. These geographical differ-ences may reflect the variable levels of investment inmass fatality planning across states. In the 2013 nationalreview of state’s fatality management plans, it was notedthat while most states had established fatality managementplans, upon review some were inadequate or not action-able [13]. This observation is consistent with our findingsat the local ME/C level, which showed that while individ-ual ME/Cs reported the existence of plans, there was alack of completeness, as assessed by our new measures.Furthermore, more than half of the states do not expect tobe able to build additional capacity and therefore intendto rely on federal assets to close existing gaps [13]. Notableexceptions to this include outstanding progress made incertain jurisdictions including New York City, HarrisCounty Texas, Florida, Alabama, Ohio and several others[13], which may serve as models for states struggling todevelop adequate capacity. Increased efforts to improveMFI preparedness have also been made through the out-reach provided to dozens of jurisdictions by the NationalTransportation Safety Board (NTSB), the formation ofRegional Catastrophic Planning Teams, such as the NewYork, New Jersey, Connecticut and Pennsylvania team; theFBI establishment of the Scientific Working Group inDisaster Victim Identification and the availability of an in-tegrated web-based Unified Victim Identification System,

developed by the NYC Office of the Chief Medical Exam-iner, and training programs developed and hosted by theNational Mass Fatalities Institute [13,54-56].

RecommendationsAlthough these data have important limitations, namelythat they were obtained using convenience sampling anda cross-sectional design, these findings nevertheless rep-resent the largest sample of ME/C to comprehensivelyreport on MFI preparedness and response capabilities.Based on these results, a number of preliminary recom-mendations are made.

1. MFI Plan templates, tailored to local jurisdictionalcapabilities, should be made widely available throughappropriate channels, including the nationalorganizations representing the ME/C.

2. The Operational Capabilities Checklist that we havedeveloped may also be a useful tool that could bemade widely available. Dissemination of tools likethis checklist may help local ME/Cs develop highquality planning. MFI plans, operational capabilitiesand resource sharing agreements should be reviewedby ME/Cs annually and updated as needed. Thedevelopment and upkeep of plans should be atransparent process, and information should bedistributed effectively throughout the organization.The fact that many respondents did not know howoften their plans were updated indicates that this isnot currently the reality for most ME/Cs. Contactinformation, including chain of command (local andstate level) contacts should always be kept up-to-date.

3. Because training was associated with preparedness,it would be helpful to have web-based training madewidely available to all ME/Cs to ensure that they aretrained effectively using up-to-date curricula, andexcellent resources for this, including programsaddressing CBRNE, are available [21,57-59]. Drillswere also important. The local jurisdiction office ofemergency management should take the lead inorganizing MFI drills so that all responding actorscan participate, including local death care industrybusinesses, local first responders, representatives offaith-based organizations, and others.

4. ME/C leadership should identify one or moreexperienced “advisors” within each Federal Regionwho can coach local ME/Cs through the mostimportant first steps in the immediate aftermath ofMFI and to help the local ME/C in forming theappropriate questions to ask of response agencies.Additionally, every ME/C must have ready access toexperts knowledgeable on the management offatalities that involve CBRNE agents, as very fewME/C have the necessary resources to safety and


effectively manage incidents involving thesehazardous agents.

5. Since it is clear that many local ME/Cs expect to beprovided with resources at the federal level, a dialogbetween local, state and federal level respondersmust develop and be ongoing.

6. Funding is needed at national, regional, and locallevels for MFI preparedness and for thedevelopment and implementation of mass fatalitymanagement best practices guidance.

7. Finally, study data should be reviewed by keyinformants in order to triangulate the findings andto ensure adequacy of these preliminaryrecommendations.

Strengths and limitationsA major strength of this study is that this is, to ourknowledge, the first study to develop MFI preparednesscriteria to assess subjective preparedness, and the first toassess national levels and correlates of preparedness.The criteria were developed with the input of manyrespected ME/Cs in the field, which strengthens themeasures and indicates a high level of professional inter-est in improving MFI response capabilities.The three measures (a combined total of 52 items) could

be made widely available for ME/Cs to rapidly conductself-assessments, taking no more than 10 minutes tocomplete. The results might guide tailored quality im-provement activities, such as inter-agency agreementswith local response partners. The measures could also beused at local and regional drills to assess MFI prepared-ness at the state and Federal Region level. Other countriescould adapt these measures to meet their own national re-quirements. The measures could also be used as a post-assessment of MFI response; in the aftermath of MFI, localME/C could conduct a self-evaluation of their response.Data from these measures also provide support for on-going national efforts to improve the quality and effective-ness of MFI management capabilities.There are also several potential study limitations. First,

with a cross-sectional design we cannot infer causality.For example, we cannot determine if staff training leads tohigher levels of preparedness or if agencies with higherlevels of preparedness are more likely to have staff train-ing. Nevertheless, these data do provide a good snapshotof current preparedness among US ME/Cs, filling a gap inthe literature. Second, self-reported (and therefore subject-ive) responses could lead to under- or overestimation ofactual preparedness. However, if self-reporting bias doesexist in the sample, our results are much more likely torepresent an exaggerated degree of preparedness thanmight actually be the case, as ME/Cs with little or no pre-paredness might have been discouraged from completingthe survey. Thus, we believe the preparedness gaps reported

here represent the minimum of those found in the field, andthat actual gaps may be even more dramatic.Finally, because only a relatively small sample of the na-

tion’s ME/Cs participated in this questionnaire, we there-fore have the potential risk of response bias and lack ofrepresentativeness. Our sample therefore may not reflectthe actual state of preparedness of the entire population ofME/Cs in the US. Our small sample and potential re-sponse bias of respondents may therefore lead to a lack ofgeneralizability. However, our findings are similar to thevery limited data presented in the 2012 and 2013 NationalPreparedness Reports and are also consistent with the per-spectives offered by national leaders with broad knowledgeof response capabilities in this sector [13,51]. Our studyalso benefited from representation of every Federal Re-gion. In the future, it would be helpful to conduct annualsurveys on preparedness of this key sector. A morecomplete assessment of preparedness in this sector willlikely be achieved through more robust recruitment andfollow-up measures, larger samples, and prospective studydesigns using multivariable approaches in order to ac-count for potential confounding variables. Actual experi-mental studies should also be conducted (preparednesstraining vs. wait list control) to identify evidence basedtraining programs.

ConclusionsCurrent climatological, meteorological, social and politicaltrends point toward increased risk of disaster-relatedevents and the possibility of MFI. We can mitigate the riskto some extent, but it is likely that MFI will continue.Therefore, it is imperative that we take the necessary stepsto prepare for these as feasibly as possible. Even small pre-paredness steps can increase the effectiveness of mass fa-tality management, and this in turn can help supportrecovery of affected communities. Effective mass fatalitymanagement, which includes respectful, culturally sensi-tive handling of human remains, expeditious identificationof the decedents, and rapid release of the remains to fam-ily members for final disposition, can help support the re-covery and resiliency of survivors and the rehabilitation ofcommunities. Effective MFI management shows both re-spect for the dead as well as compassion for the bereavedand is appropriately one of our nation’s priority goals forpreparedness.

Additional files

Additional file 1: NSF Mass Fatality Management Survey for MEC.

Additional file 2: MEC Code Book.

AbbreviationsUS: United States; ME/C: Medical Examiner or Coroner; MFI: Mass FatalityIncident; CFM: Complex Fatality Management; CBRNE: Chemical, biological,

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http://www.biomedcentral.com/content/supplementary/1471-2458-14-1275-S2.docx


radiological, nuclear or explosive; NRF: National Response Framework;DHHS: Department of Health and Human Services; DMORT: Disaster MortuaryOperational Response Team; UCSF: University of California, San Francisco;CHR: Committee on Human Research; NIMS: National Incident ManagementSystem; NRP: National Response Plan; EMS: Emergency Support Function;FEMA: Federal Emergency Management Agency; CPG: ComprehensivePreparedness Guide; OR: Odds ratio; CI: Confidence interval; NTSB: NationalTransportation Safety Board; IAC & ME: International Association of Coroners& Medical Examiners; NAME: National Association of Medical Examiners.

Competing interestsThe authors declare that they have no competing interests. *Note: Co-authorHalley E.M. Riley, MPH is a participant in the ASPPH/CDC Public HealthFellowship (Class of 2013). The work conducted for this publication wascompleted prior to the fellowship and has no relationship to the fellowshipwhatsoever and was not funded by ASPPH or CDC.

Authors’ contributionsRG, JM, and MO conceptualized the study. RG, Principal Investigator of thestudy, designed the questionnaire, managed the study, and wrote themanuscript. MO conducted and led data analysis and helped write themanuscript. QZ helped to design the questionnaire, collected and managedstudy data, created ArcGIS maps, and assisted on the preparation of themanuscript. JM helped design the questionnaire, conducted network analysisand helped write the manuscript. DC assisted in data analysis and createdtables. HR helped to design the questionnaire and helped revise themanuscript. MS consulted on the data analysis, and helped to write themanuscript. All authors’ read and approved the final manuscript.

AcknowledgmentsThis study was funded by a grant (CMMI-1233673) provided by the NationalScience Foundation. The authors are grateful to the following individualswho graciously shared their expert advice: Ms. Cynthia Gavin, Mr. JohnNesler, Ms. Allison Woody, Dr. Jason Wiersema, Ms. Emily Carroll, Dr. FrankDePaolo, Dr. Suzanne Utley, Dr. Lisa LaPoint, Dr. John Fudenberg, Dr. ElinGursky, Mr. Edward Kilbane and Mr. Kevin Sheehan. We also thank Ms. TaraMcAlexander and Ms. Denise McNally for their input in questionnairedevelopment. We are also deeply appreciative of The InternationalAssociation of Coroners & Medical Examiners (IAC & ME) and the NationalAssociation of Medical Examiners (NAME) for their assistance in questionnairedevelopment, distribution and participant recruitment. A special note ofthanks to the study participants for their enthusiastic participation in thevarious aspects of this study.

Author details1Department of Epidemiology and Biostatistics and Institute for Health PolicyStudies, School of Medicine, University of California, San Francisco, SanFrancisco, CA 94118, USA. 2Virginia Bioinformatics Institute, Virginia Tech, 900N Glebe Rd, Arlington, VA 22203, USA. 3School of Nursing and Departmentof Biomedical Informatics, Columbia University, 617 W. 168th Street,Georgian, 226, New York, NY 10034, USA. 4Association of Schools andPrograms of Public Health (ASPPH), Atlanta, GA 30333, USA. 5Department ofPsychology, Loyola University Maryland, Baltimore, MD 21210, USA.

Received: 3 September 2014 Accepted: 8 December 2014Published: 15 December 2014

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1. Capability a. Objective (s)

2. Capability a. Objective(s)

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The medical response to multisite terrorist attacks in ParisMartin Hirsch, Pierre Carli, Rémy Nizard, Bruno Riou, Barouyr Baroudjian, Thierry Baubet, Vibol Chhor, Charlotte Chollet-Xemard, Nicolas Dantchev, Nadia Fleury, Jean-Paul Fontaine, Youri Yordanov, Maurice Raphael, Catherine Paugam Burtz, Antoine Lafont, on behalf of the health professionals of Assistance Publique-Hôpitaux de Paris (APHP)

IntroductionFriday, Nov 13, 2015. It’s 2130 h when the Assistance Publique-Hôpitaux de Paris (APHP) is alerted to the explosions that have just occurred at the Stade de France, a stadium in Saint-Denis just outside Paris. Within 20 min, there are shootings at four sites and three bloody explosions in the capital. At 2140 h, a massacre takes place and hundreds of people are held hostage for 3 h in Bataclan concert hall (figure).

The emergency medical services (service d’aide médicale d’urgence, SAMU) are immediately mobilised and the crisis cell at the APHP is opened. The APHP crisis unit is able to coordinate 40 hospitals, the biggest entity in Europe with a total of 100 000 health professionals, a capacity of 22 000 beds, and 200 operating rooms. It is very quickly confirmed that the attacks are multiple and that the situation is highly scalable and progressing dangerously. These facts led to a first decision: the activation of the “White Plan” (by the APHP Director General) at 2234 h—mobilising all hospitals, recalling staff, and releasing beds to cope with a large influx of wounded people. The concept of the White Plan was developed 20 years ago, but this is the first time that the plan has been activated. It is a big decision, and timing is key: it would lose its effectiveness if taken too late. On the night of Friday Nov 13 to Saturday Nov 14, the activation of the White Plan had a critical effect. At no time during the emergency was there a shortage of personnel. During these hours, as the number of victims increased, with a sharp increase after the assault was launched inside the Bataclan, we were able to reassure the public and government that our abilities matched the demand. And when we felt that it might be necessary to deal with an influx of severely injured people, two further “reservoir” capacities were prepared: other hospitals in the area were put on alert, together with some university hospitals, more distant from Paris, but with the ability to mobilise ten helicopters to organise the transport of the wounded. These other two reservoirs have not been used, and we believe that despite this unprecedented number of wounded, the available services were far from being saturated. While hospitals were receiving and directing patients to specific institutions based on capacity and specialty, a psychological support centre was set up. 35 psychiatrists, together with psychologists, nurses, and volunteers were gathered in a central Paris hospital, Hôtel Dieu. Most of them had played a similar role during the attacks against Charlie Hebdo. Most of the emergency workers and health professionals working on the evening of Nov 13 had already been involved in serious crises, were used to working together, and had

participated, especially in recent months, in exercises or in updating emergency plans.

In this report, we present the prehospital and hospital management of this unprecedented multisite attack in Paris from the viewpoint of the emergency physician, the trauma surgeon, and the anaesthesiologist. This is a testimony on behalf of the health professionals involved in the night of Nov 13.

The emergency physician’s perspective Triage and prehospital care were the duty of SAMU. In the minutes that followed the suicide bombing at the Stade de France, the Paris SAMU unit regulatory crisis team began to send out medical workers to the emergency sites from all eight units of SAMU in the Paris region and from the Paris fire brigade (Brigade de sapeurs-pompiers de Paris), alongside rescue workers and police. The regulatory crisis team was composed of 15 individuals to answer the calls, and five physicians. Their mission was to organise triage and dispatch mobile units (composed of a physician, a nurse, and a driver) to the wounded and to the most appropriate hospitals. As part of the White Plan and ORSAN (organisation de la réponse du système de santé en situations sanitaires exceptionnelles), 45 medical teams from SAMU and the fire brigade were divided between the sites (figure) and 15 were kept in reserve, since we did not know how and when this nightmare would end. This approach avoided early saturation of services—often, in emergency situations, all the resources are focused on the first crisis site, leaving a shortage for

Published Online November 24, 2015 http://dx.doi.org/10.1016/S0140-6736(15)01063-6

Assistance Publique-Hôpitaux de Paris, Paris, France (M Hirsch MsC); SAMU de Paris, Hôpital Necker-Enfants Malades, University Paris-Descartes Paris, France (Prof P Carli MD); Hôpital Lariboisière, University Paris-Diderot, Paris, France (Prof R Nizard MD); Hôpital de la Pitié Salpétrière, University Pierre & Marie Curie, Paris, France (Prof B Riou MD); Hôpital Saint-Louis, Paris, France (B Baroudjian MD, J-P Fontaine MD); Hôpital Avicenne, University Paris 13, Paris, France (Prof T Baubet MD); Hôpital Européen Georges Pompidou, Paris, France (V Chhor MD); Hôpital Henri Mondor, Créteil, France (C Chollet-Xemard); Hôtel Dieu, Paris, France (N Dantchev MD); Hôpital de la Pitié Salpétrière, Paris, France (N Fleury MsC); Hôpital Saint-Antoine, Paris, France (Y Yordanov MD), Hôpital Bicêtre, Paris, France (M Raphael MD); Hôpital Beaujon, University Paris-Diderot, Paris, France

Figure: Map of Paris attacks and prehospital emergency response

Bataclan medical teams

Stade de France (Saint-Denis)

medical teams

La Comptoir Voltaire

medical teams

Casa Nostra medical teams

3

4

8

9

15

6

Le Petit Cambodge, Le Carillon

medical teams

La Belle Equipe

medical teams

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(Prof C Paugam Burtz MD); Hôpital Européen Georges

Pompidou, University Paris-Descartes, Paris, France

(Prof A Lafont MD)

Correspondence to: Prof Antoine Lafont, Cardiology Department, Hôpital Europeen

Georges Pompidou, Paris, France [email protected]

For more on the APHP see http://www.aphp.fr/

For more on the White Plan see http://www.sante.gouv.fr/plan-

blanc-et-gestion-de-crise.html

For more on the ORSAN plan see http://www.sante.gouv.fr/

le-dispositif-orsan

following crisis sites. 256 wounded people were safely transferred to and treated in hospitals and the remaining patients arrived at hospitals by their own means. Three acute myocardial infarctions were treated. By the middle of the night, more than 35 surgical teams had operated on the most serious injuries (table).

Since the wounds were principally bullet related, the strategy applied was prehospital damage control to allow the fastest possible haemostatic surgery.1–4 This is the civil application of war medicine. Indeed, four out of five people shot in the head or the thorax will die. Among those without lethal wounds, damage control consists of maintaining the blood pressure at the lowest level ensuring consciousness (mean arterial pressure 60 mm Hg) using tourniquets, vasoconstrictors, antifibrinolytic agents (tranexamic acid), and prevention of temperature lowering instead of fluid filling (the demand for tourniquets was so high that the mobile teams came back without their belts).

After initial treatment the wounded were transferred by the Mobile Intensive Care Unit (MICU) teams to trauma centres or nearest hospitals when appropriate. Saint Louis Hospital is a few metres from two of the shooting sites (Le Petit Cambodge and Le Carillon restaurants, figure) and its physicians were able to take care of the patients immediately. Some wounded people were able to walk to the nearby Saint Antoine Hospital. To avoid overwhelming the hospital emergency

department as ambulances arrived, triage also took place at the hospital entrances.

Despite their brutality and appalling human toll (129 dead on sites, and more than 300 injured) the attacks were not a surprise. Since January, 2015, all state departments had known that a multisite shooting could happen, and although the police and intelligence services had prevented several attacks, that possibility remained. For 2 years, the prehospital teams of SAMU and the fire brigade had been developing treatment protocols for victims of gunfire wounds, and three field exercises have mobilised doctors to practise prehospital damage control. SAMU is characterised by the presence of physicians who are able not only to stratify risk according to gathered information and send the patient to the appropriate place, but also to act during the prehospital period. In a cruel irony, on the morning of the day of the attacks, SAMU and the fire brigade participated in an exercise simulating the organisation of emergency teams in the event of a multiple shooting in Paris. In the evening, when the same doctors were confronted with this situation in reality, some of them believed it was another simulation exercise. At the attack sites and in the hospital, the training received by the emergency and medical workers was a key factor in the success of treatment. Analysis of the experience of bombings in many other countries—Israel, Spain, England, and more recently in Boston, USA—as well as lessons learned from Paris, during the Charlie Hebdo attacks in January, were essential to improving the management and application of damage control. It is important to point out that the scientific publications that issued from these horrible events have had a huge effect on the improvement of medical strategies.5–7 But no simulation had ever anticipated such a boost in the scale of violence. During long periods of shooting, the streets surrounding the attacks remained difficult and dangerous for emergency intervention teams. Seriously injured hostages in the hands of terrorists or obstructed by fire could not be evacuated. Although emergency physicians have been receiving training in disaster medicine for more than 30 years, never before had such a number of victims been reached and so many wounded been operated on urgently. A new threshold has been crossed.

The approach of the anaesthesiologistPitié-Salpêtrière Hospital is one of the five civilian level-one trauma centres in the APHP group involved in the treatment of patients after terrorist attack. It is located in the centre of Paris. The shock trauma room is included inside a post-anaesthesia care unit of 19 beds. The routine capacity of the emergency operating theatre is two operating rooms, which can be extended to three for multiple organ harvesting. After activation of the White Plan, which includes a process to call back all staff, but also because many physicians and nurses spontaneously arrived rapidly in the hospital, we were able to open ten operating rooms and treat injured

Absolute emergencies

Relative emergencies

Total

Ambroise Paré 1 6 7

Antoine Béclère 0 1 1

Avicenne 0 8 8

Beaujon 5 0 5

Bicêtre 1 6 7

Bichat 2 17 19

Cochin 0 7 7

HEGP 11 30 41

Henri Mondor 10 15 25

Hotel Dieu 0 31 31

Jean Verdier 0 2 2

Lariboisière 8 21 29

Pitié-Salpêtrière 28 25 53

Saint Antoine 6 39 45

Saint Louis 11 15 26

Tenon 0 10 10

Total 76 226 302

Absolute emergencies require immediate surgery or embolisation; relative emergencies may need surgery and/or embolisation, but not immediately. Numbers do not include psychological trauma and delayed admissions. Because some patients were secondarily transferred from one hospital to another, numbers do not add up. Data are from Assistance Publique-Hôpitaux de Paris (APHP), Nov 20, 2015. HEPG=Hôpital Européen Georges Pompidou.

Table: Numbers of admissions of absolute emergencies and relative emergencies in the APHP hospitals within the first 24 h

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patients (mostly with penetrating trauma), absolute emergencies (mostly admitted in the shock trauma unit), and relative emergencies (all admitted in the emergency department).

The number of admitted patients was far beyond what we could imagine we would treat at the same time. The resources available were never less than required, despite the unprecedented number of patients admitted during a very short period. Several factors may have contributed to these favorable outcomes. First, the injured patients arrived very quickly (in small groups of four or five) because we had worked for several months with the medical service of the French national police counter-terrorism department (RAID), prehospital emergency teams, and in-hospital trauma teams to be able to provide a fast-track service for penetrating trauma, particularly during a terrorist attack.8 Although penetrating traumas usually represent only 16% of our severe trauma cases,9 injuries from firearms, including war arms, are no longer rare events, and our anaesthesiologists and surgeons have been trained to appropriately treat these cases. Before the arrival of the first patients, the postoperative care unit was rapidly emptied and the surgical and medical care unit made several beds available. This was important since, after emergency surgery, patients could be directly admitted into the units, enabling the shock trauma room to be free for new patients, in accordance with the so-called one-way progression concept (no return to the emergency or shock trauma room). A rapid triage was organised at the entrance of the emergency department, directing absolute emergencies to the shock trauma unit and relative emergencies to the emergency department, and this second rapid triage was able to confirm the initial triage done a few minutes previously by the prehospital team. Each absolute emergency patient was cared for by a dedicated trauma team (anaesthesiologist, surgeon, fellow, and nurse), who decided whether or not to perform CT scans, radiology, and to send the patient to a prepared operating room where an operating team was available (with appropriate senior and fellow surgeons, anaes thesiologist and nurse anaesthetist, and operating room nurse). Other post-anaesthesia care units were reopened to receive patients once surgery was done.

A key element was the excellent cooperation of all care-givers under the supervision of two trauma leaders in the shock trauma unit and an operating room allocation leader, who were not directly involved in the care of the patients and who continuously communicated between each other and regularly collated information concerning the entire cohort of injured patients. Furthermore, hospital management could immediately provide logistic support. Another key element was related to the dramatic characteristic of the event—each participant wanted to do more than his or her best for the victims. And they did it! Only 9 h after the event, we were able to decrease the number of operating rooms to

six and send back home some of the more exhausted staff. Within 24 h, all emergency surgeries (absolute and relative emergencies) had been done and no victims were still in the emergency department or the shock trauma unit. The hospital was nearly ready to cope with another attack that we all feared could occur.

The point of view of the trauma surgeonIf I had to summarise the “winning formula” in the recent tragic hours that we lived, in an orthopaedic centre of APHP, I would say that spontaneity and profession alism were the key ingredients. When I arrived in Lariboisière Hospital 2 h after the beginning of the events, I was surprised to discover that at least six or seven of my colleagues of different specialties were already there in addition to the doctors on duty that night. The on-call anaesthetists and intensive care doctors were helped by three colleagues who joined them spontaneously. Extra nursing staff also came to help. All these extra personnel allowed us to open two operating rooms for orthopaedic surgery, one for neurosurgery, one for ear, nose, and throat surgery, and two for abdominal surgery. The first seriously injured patients were operated on within half an hour of admission. The triage of the later patients was done in two locations: in the postoperative care unit next to the operating rooms for the most seriously wounded patients, who were brought directly by the mobile medical units, and in the emergency department for the less critically wounded patients. Triage was done by the most experienced physician in each specialty. During the first night, we operated continuously. On Saturday Nov 14, the orthopaedic surgery team was helped spontaneously by two other teams. The sequence of operations was determined after the last patients were admitted, including five patients who came from hospitals in which orthopaedic surgery was not available. With the anaesthetists and the nursing staff we operated continuously all day long. On Sunday Nov 15, the usual services resumed.

On Monday Nov 16, when all the medical staff reviewed what had been done during the weekend, the common observation was that all but one of the patients were less than 40 years old. All the patients we received had had a high-energy ballistic trauma. All upper limb fractures had been treated with external fixation because of the open nature of the fractures and extensive bone loss.10 The two lower limb ballistic traumas were treated with plates. Nerve damage was frequent, including two patients with median nerve section, one with radial nerve section, one with cubital nerve section, and one with peroneal nerve section. Only one nerve was repaired; for the others, gaps of several centimetres were observed and secondary reconstruction will be needed.11 Vascular damage was not observed in our patients because patients with suspected problems of this sort were directed from the mobile medical unit to a hospital where vascular surgery was available. Psychiatrists were involved in treatment and had contact with all patients

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during this early period to assess for acute stress disorder and begin the follow-up of potential post-traumatic stress disorder.

Professionalism was present at each level. While the operating room is often described as a difficult place—where the human factor is crucial—during this “stress test” difficulties vanished, working together appeared fluid and somehow harmonious. Trust and com-munication between different specialties and jobs were apparent. The common goal was so clear that no stakeholder tried to impose an individual view. Solidarity was observable inside the hospital but also between the different APHP hospitals: when a specialist was not available in one hospital the patient was transferred easily to another hospital where the expertise was available. The APHP network demonstrated its efficiency.

All operations were performed without any delay. The sterile supply chain was augmented to allow a fluid workflow, and administrative staff supported the medical work, finding logistic solutions when necessary (eg, patient registration, finding free beds, etc).

Timing might also have played a part in the success of the response. This disaster occurred at the beginning of a weekend and during the night. Some of the aspects might have been more difficult if it had happened during a working day, when the sterile stock is partly unavailable and when doctors and staff are already busy. Unfortunately, the current situation requires us to be prepared to face even more difficult situations in the future.

ConclusionThis is the legacy of history that led to the creation of the APHP hospital network as a single entity. Its huge size is regularly questioned, both internally and externally, as an obstacle to adaptation in a rapidly changing technological, medical, and social context. The decision circuits are complex, internal rivalries may develop, and changes are slow to spread. We sensed, however, that the size of the organisation could be an advantage in times of disaster. This advantage has now been demonstrated. No lack of coordination has been identified. No leakage or delay has occurred. No limit was reached. Furthermore, we believe that such a structure is not only an advantage in times of crisis, but also on a normal day. A large hospital complex is also able to produce powerful research, to process a considerable amount of data, and to play a major part in public health. What happened strengthens our belief that size can be combined with speed and excellence.

In the aftermath of this terrible experience, it is too early to report the details of the medical expense incurred

and the lessons that can be learned from this event. But we already know that as terrorism becomes more lethal and violent, nothing will prevent the medical community from understanding, learning, and sharing knowledge to become more effective in saving lives. However, we must remain humble and expect deaths to occur among the severely wounded patients in the upcoming days, despite the fact that we observed only four deaths (1%) among the 302 injuried patients, including two deaths on arrival at hospital.ContributorsAll authors contributed equally to this report.

Declaration of interestsWe declare no competing interests. We are all members of the Assistance Publique-Hôpitaux de Paris (APHP), MH is Director General of APHP.

AcknowledgmentsWe thank our colleagues, more than a thousand health-care professionals—including nurses, logistical and administrative staff, medical doctors, and pharmacists—who were committed during this major event to saving lives and supporting victims and their families, and in some cases were personally endangered. We acknowledge the teams of rescuers belonging to the fire brigade of Paris, the police forces, and volunteers.

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