Abstract
Field hospitals may be deployed within the borders of the jurisdiction of the care provider or, upon official request, within a different, often remote, jurisdiction such as during humanitarian missions. The field hospital is incomplete without capabilities in the areas of forensic medicine (FM) and victim identification (VI). The specifics of what constitutes appropriate indications and circumstances warranting deployment of FM and VI services in the field hospital setting, and the necessary functions and capabilities required, is the subject of this chapter.
Introduction
In addition to the essential medical and technical specialties, the field hospital is incomplete without capabilities in the fields of forensic medicine (FM) and victim identification (VI). The specifics of what constitutes appropriate or necessary circumstances and what are the indications and required capabilities for deployment of FM and VI services in the field-hospital setting is the subject of this chapter.
For operational purposes, field hospitals can be divided into two major types: (1) those deployed within the borders of the parent jurisdiction of the care provider, and (2) those deployed, per official request, within another jurisdiction such as within the context of remote humanitarian missions. In the former, deployment of FM and victim identification services, with all the associated complexities, is both impractical and counterproductive when these activities remain fully operational and easily accessible in facilities not compromised by the effects of the disaster. An exception to this would be circumstances, natural or hostile, that resulted in neutralization of the local, permanent facilities. In such cases, field deployment of these essential services may be necessary.
Field hospitals are usually erected in areas where the available functional resources are insufficient to meet basic medical needs from the standpoint of personnel and equipment. It has been argued by some that, under such emergency circumstances, FM should not be a priority. However, proper mortality management cannot be avoided. Absence of definitive identification prevents closure for the bereaved family and is a well-recognized source of unrest and friction between the affected population and the authorities. Pressure from public officials to identify the decedents can be tremendous. For these reasons, identification of human remains has been recognized by WHO as one of the major required tasks of medical agencies[1]. FM is also needed to assist in reconstructing factors leading up to the disaster, establishing the cause and mechanism of death, and presenting detailed explanations to the bereaved relatives. Other essential functions of FM include documentation of medical treatment and discussing this with the providers, evaluation of the effectiveness of protective gear, documentation of distribution of wounds, and, in the case of hostilities, correlation of mechanisms of injury with weapons specifications.
Mortality Management in the Field-Hospital Setting
FM and VI require a multidisciplinary team of different professions from different agencies, as will be explained later in this chapter. The responsibility for identification of human remains usually rests with the local governmental jurisdiction.
A major challenge, worldwide, for those responsible for VI is preparedness for circumstances when the number of casualties exceeds the capabilities of the responsible jurisdiction to perform the task within an acceptable period of time.
The success of the identification and the investigation process depends on the efficiency of organization, level of experience, and the accuracy of interpretation of findings. Communication between staff members from different agencies and different fields of expertise can be difficult. Because of the complex nature of the tasks related to management of the dead and VI, application of international protocols for disaster victim identification (DVI) operations such as Interpol, WHO, and the International Committee of the Red Cross (ICRC) provides important standardization[2,3]. Intactness of the functional integrity of the responsible local jurisdiction and its operational divisions is of major importance for the success of such efforts.
Major Steps in Victim Identification
Regardless of whether the task is performed within a permanent facility or in a field hospital setting, VI involves many, if not all, of the steps listed below. Each of these steps requires adequate professional staffing. Moreover, VI procedures must be closely coordinated with, and usually follow, an examination by a forensic pathologist or FM specialist (see “Postmortem Procedures in the Field Hospital” later in the chapter) so as not to disturb critical physical evidence.
1. Preparation of site for arrival of victims and remains: close coordination with remains retrieval units
2. Ordinance screening: close coordination with explosive ordinance disposal (EOD) units
3. Assigning a unique identifier for all victims and detached remains
4. Description and labeling of personal effects without disturbing forensic evidence
5. Antemortem data collection or access to previously collected antemortem records
6. Postmortem CT scan, if available
7. External forensic survey (general, wounds, treatments, and photography)
8. Fingerprints
9. Dental evaluation and crossmatching
10. DNA specimen collection and management
11. DNA laboratory processing and analysis
12. Transfer of body to the medical examiner for advanced postmortem identification if needed
13. Data evaluation by senior forensic committee
14. Temporary or final burial
Teams at the Scene
An advanced team from the FM department of the field hospital should visit the disaster site as early as possible before items and bodies are removed. This is necessary to evaluate the terrain, the extent of the damage, the number and state of the deceased (e.g., degree of dismemberment and fragmentation or advanced decomposition), suspicion of contamination of remains, the need for any special equipment for recovery, and the optimal method for transporting the bodies.
According to the information gathered by the advanced team, a second search/recovery and evidence-collection team (not necessarily from the intrinsic forensic team of the field hospital) should be sent to the scene. This team should have at least one forensic pathologist whose job it is to provide the necessary medical experience regarding management of the bodies and to ensure preservation of means of identification and other medical evidence important for the investigation. A forensic anthropologist, operating under the authority of a medical examiner, can fill this role if he or she has adequate recovery experience.
It is the job of the advanced team to provide technical advice for the search and recovery team. The specific location of each body (or body part) should be recorded. Other pieces of evidence (documents, belongings, and so on) should also be recorded and collected by the accompanying nonmedical personnel. The objects found on the scene could be crucial for identification and subsequent investigation of the event; hence, the location of each item should be registered individually and accurately recorded in relation to the body. This emphasizes the need for meticulous documentation of the recovery site (description, photographs, or sketch of the position of the body and location on a grid or map). Nevertheless, the extent of advance detail collected may need to be modified by the officer in charge in circumstances requiring hasty recovery.
It should be emphasized that determining the original association of detached body parts should be done only at the FM department of the field hospital itself and not at the scene. Only authorized forensic medical experts can do this; not recovery personnel. Many times, the matching can be performed only by genetic methods (DNA) and not anatomically. This is the reason why each detached body part should be labeled by a separate distinct number and be treated as a separate body.
The state of preservation of the bodies is a major component of successful identification and investigation. Since the condition of bodies can deteriorate very quickly depending in large part on exposure to environmental conditions, effort should be made to move the body to a proper storage facility as soon as possible. In cases of significant delay, it may be advisable to collect a DNA sample from the human remains (from blood or muscle tissue) before commencement of the recovery operation provided trackable identification (body and sample) is assured.
It is essential that the field-hospital management staff make sure that communication routes are established to ensure flow of information from the scene of disaster and with all relevant authorities and relevant agencies.
Postmortem Procedures in the Field Hospital
Identification of human remains can be divided into three types:
1. Visual recognition
2. Definitive, positive, scientific identification
3. Circumstantial identification
In a multicasualty event, it is highly recommended to refrain from visual identification. Disfigurement of bodies, changes due to decomposition, and the general psychological atmosphere of stress and urgency can lead to mistakes in identification. It is always most advisable to use scientific methods of identification. Most of the scientific identification methods are based on comparison of postmortem data (from the body) with antemortem data from the same person while he or she was alive. The comparison is based on stable and unique characteristics: stable, that do not change during life, and will be comparable regardless of when they were taken and when death occurred; unique, that have sufficient power of differentiation and resolution between individuals.
The antemortem data regarding the individual are usually still unavailable when the body arrives at the field hospital. Thus, all relevant biometric parameters (fingerprints, dental examination, X-ray and/or CT scan, and genetic markers such as DNA) should be collected on arrival.
The external forensic examination is an essential tool for the investigation of the event (see below). Complete autopsy is an excellent and recommended tool for investigation of the cause of death and collection of other forensic data. However, it is seldom necessary for the purposes of identification. Considering that autopsy is a time- and effort-consuming procedure, and taking into account the heavy workload in the setup of a field hospital, the chapter authors recommend, in contrast to most existing comprehensive protocols, to save the resources and perform autopsy for the purpose of identification only when all other means of identification have failed.
Regarding work flow, in the case of multiple decedents arriving at the field hospital, one efficiently run line has been determined to be preferable, resulting in fewer mistakes and less chance of “bottlenecks.” However, in mass-casualty events with a large number of fatalities, it may be necessary to work in multiple separate lines as depicted in Figure 29.1. This will reduce hold-ups on the line such as those caused by complicated cases. It should be stressed that all findings should be photographed and documented, and the process as a whole should be supervised and quality controlled.
The postmortem team at the field hospital should include forensic pathologists, mortuary technicians, forensic odontologists, forensic anthropologists, photographers, trace-evidence officers (for fingerprinting and data collection), and secretarial workers to document all retrieved data. A team manager should be appointed to direct and identify problems in the work flow.
Fingerprints should be taken by forensic officers (e.g., law-enforcement officers, death investigators, or forensic pathologists). In the setup of a field hospital, fingerprints will usually be taken as ink prints. In a jurisdictional framework where there is a reservoir of fingerprint data, a scan can be used such as in the case of an automatic fingerprint identification system (AFIS)[4]. Fingerprinting is one of the first steps in the data collection process because of its efficiency and promptness of results.
All personal items and clothing that accompany the body must be described, photographed, and kept for further investigation since they can provide valuable information of relevance to the identity of the individual and circumstances of his or her death. These include identification cards, jewelry, watches, credit and bank cards, notes, wallets, and so on. Clothing should be described for size, color, brand, and so on. Clothing is important not only for support of identification but also for signs of penetration or impact, since many times it can preserve the evidence of the impacting object better than the skin. Clothing is also important for detection of gunpowder residue, explosive material, cuts and tears, thermal effects, and so on.
Collection of medical data by external examination is very important for the investigation and assessment of injuries, and is not less important for the process of identification. The external examination can point to scars of surgical procedures or healed injuries. It can reveal tattoos, birth marks, anatomical variations, and even simple differentiating data (e.g., color of the eyes, color of the hair, hair length, age, ethnic group, weight). All findings of the external examination should be described and photographed with inclusion of a ruler in each frame.
Photography is used not only for body marks but also for documenting jewelry, clothes, general features of the body, and documentation of wounds, injuries, scars, and so on. Photography is important not only for maintenance of the chain of evidence but also for relatives who would like to see the body as it was when it arrived at the field hospital.
Samples for DNA can be obtained from blood, muscle, mucosa, and sometimes from bones where soft tissues are missing or decomposed. In case of fragmentation of bodies, samples must be taken from each body part. However, in cases where the fragmentation is severe (explosions, airplane crashes, and so on), the number of tissue fragments can be very high, exceeding the practical processing capacity of the DNA lab. In such circumstances, a managerial decision must be taken to determine the minimal size of tissue fragment to be sampled. It is impractical to sample every piece of tissue the size of few cubic centimeters. However, meticulous sampling can be necessary for determining the number of casualties in cases of severe fragmentation of bodies. Establishment of the number of deceased is accomplished not by counting anatomic structures (this can be grossly inaccurate) but by counting genetic profiles. In many multicasualty events there are individuals represented only by one, or a few, body parts.
No field hospital is equipped with a forensic molecular biology laboratory. This means that the tissue samples must be preserved in accordance with the requirements of the laboratory that will process the samples. Constant communication must be maintained between the FM department of the field hospital and the DNA processing laboratory regarding quality of tissue, need for resampling, and feedback regarding profile analysis.
Dental examination should be performed on all bodies where possible. In some cases, it can be difficult due to rigor mortis or decomposition. One might ask why perform this time-consuming examination when usually just a small percentage of the bodies are identified by dental means. One may argue that only bodies that are not identifiable by other means should undergo dental examination. However, dental examination (including dental X-ray) can provide important unique morphological information of relevance to identification even when antemortem dental records are unavailable. It can also reveal valuable morphological and pathological data that can provide clues of direct relevance to the death investigation.
Comparison of postmortem radiographs to antemortem radiographs taken at the same view can be a very important tool for identification. X-rays can reveal prostheses, evidence of previous surgical procedures including their locations, positioning of indwelling catheters or other devices, anatomical variations, presence of jewelry in case of burned bodies, and location and characteristics of penetrating projectiles such as bullets, and so on. When there is no hint or indication regarding identity, X-ray can assist in estimating the age, sex, and sometimes even race of an individual.
If there is a possibility to obtain a CT scan it is highly recommended. Mobile CT units are available and can be deployed to the field-hospital area when possible and practical. Although most mobile CT units, if deployed to the field-hospital setting, will be used for the injured, total-body CT is a matter of few minutes, and the relevant information can be available in a few more minutes. This can provide valuable forensic data and save extremely time-consuming and invasive postmortem surgical procedures. On the other hand, total body X-ray takes approximately 45 minutes and much more effort is involved. A postmortem CT scan can create a three-dimensional reconstruction of the body with its skeleton and also produce dental panoramic radiographs at the same session, thereby also eliminating the need for dental X-rays.
Related posts:
Chapter 6 – Training and Accreditation
Chapter 3 – Definitions, Needs, Scenarios, Functional Concept, and Modes of Deployment
Chapter 11 – Auxiliary Medical Services in a Field Hospital
Chapter 7 – Personnel
Chapter 17 – Wound Management in a Field Hospital Environment
Chapter 24 – Intensive Care Unit Buildup Within a Field Hospital Setting
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