H
Fatalities Management Strategies

The following is a white paper prepared for the June 10–11, 2009, workshop on medical surge capacity, hosted by the Institute of Medicine Forum on Medical and Public Health Preparedness for Catastrophic Events. All opinions expressed in this paper are those of the author and not necessarily of the Institute of Medicine.


By Lisa R. LaDue, M.S.W., L.I.S.W.

Deputy Director

National Mass Fatalities Institute


and


Jack Herrmann, M.S.Ed., N.C.C., L.M.H.C.

Senior Advisor

Public Health Preparedness

National Association of County and City Health Officials

STATE-OF-THE-ART SUCCESSES IN MASS FATALITIES MANAGEMENT

There have been many defining moments in U.S. history where the challenges of responding to mass fatality incidents have been clearly realized. The bombing of the Edward P. Murrah Federal Building in Oklahoma City, the terrorist attacks in New York City and on the Pentagon on September 11, 2001, and Hurricanes Katrina and Rita along the southwest Gulf Coast were such moments that painted a bleak landscape of the



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H Fatalities Management Strategies The following is a white paper prepared for the June 10–11, 2009, work- shop on medical surge capacity, hosted by the Institute of Medicine Fo- rum on Medical and Public Health Preparedness for Catastrophic Events. All opinions expressed in this paper are those of the author and not necessarily of the Institute of Medicine. By Lisa R. LaDue, M.S.W., L.I.S.W. Deputy Director National Mass Fatalities Institute and Jack Herrmann, M.S.Ed., N.C.C., L.M.H.C. Senior Advisor Public Health Preparedness National Association of County and City Health Officials STATE-OF-THE-ART SUCCESSES IN MASS FATALITIES MANAGEMENT There have been many defining moments in U.S. history where the challenges of responding to mass fatality incidents have been clearly re- alized. The bombing of the Edward P. Murrah Federal Building in Okla- homa City, the terrorist attacks in New York City and on the Pentagon on September 11, 2001, and Hurricanes Katrina and Rita along the south- west Gulf Coast were such moments that painted a bleak landscape of the 143

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144 MEDICAL SURGE CAPACITY impact that mass fatality disasters bring on U.S. cities large and small. The recent H1N1 outbreak, with its 1918 predecessor, the Great Pan- demic Influenza, created a 21st century reminder of the potential catas- trophic impact an influenza pandemic could have on the nation and across the world. These pivotal events, and the anticipation of what may come, require emergency managers, public health preparedness planners, and elected officials to assess what has been accomplished in our na- tional efforts to plan for and respond to mass fatality incidents and to prioritize the development of a comprehensive and coordinated approach to address such incidents in the future. This country’s modern-day efforts to address and respond to the po- tential impact of mass fatality incidents began in the 1980s, when a committee was formed within the National Funeral Director’s Associa- tion to address disaster situations and, more specifically, incidents in- volving simultaneous multiple deaths. A multifaceted nonprofit organization was eventually formed by this committee to support the concept of a national-level response protocol for all related professions. Led by Tom Shepherdson, the Disaster Mortuary Operational Response Team (DMORT) gained federal recognition in 1992 and became incor- porated into the federal disaster response system within the National Dis- aster Medical System. This initiative resulted in the formation of 10 DMORTs representing each federal region of the country. Two specialty teams—the Weapons of Mass Destruction Team and the Family Assis- tance Core Team—were added later. While the early years of mass fatalities planning and response fo- cused essentially on the identification and release of decedents, this focus has greatly broadened in light of our country’s experience with such events. The Department of Homeland Security’s Target Capabilities List (2007) defines fatalities management as “…the capacity to effectively perform scene documentation, the complete collection and recovery of the dead, victim’s personal effects and items of evidence; decontamina- tion of remains and personal effects (if required); transportation, storage, documentation, and recovery of forensic and physical evidence; determi- nation of the nature and extent of injury; identification of the fatalities using scientific means; certification of the cause and manner of death; processing and returning of human remains and personal effects of the victims to the legally authorized person(s) (if possible); and interaction with and provision of legal, customary, compassionate, and culturally competent required services to the families of the deceased within the context of the family assistance center.” 1 This expanded way of thinking

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145 APPENDIX H about mass fatality response sets the stage to consider the complexities of planning for these categorical areas of response. Many public and private initiatives have been put forth over the past decade or more to improve the ability for state and local communities to respond to mass fatality incidents. Four years after the formation of the DMORTs and following the devastating mid-air explosion of TWA Flight 800 off the coast of Long Island, New York, assistance to families of the deceased took a national spotlight. The National Transportation and Safety Board (NTSB) was tasked in 1996 by the Aviation Disaster Family Assistance Act to coordinate assistance to families of victims involved in major aviation accidents. That Act also required the NTSB to identify a human service organization to assist them in the coordination of the provision of mental health and spiritual care services for families of the victims. The American Red Cross (ARC) was designated as that agency and since that time, both the NTSB and the ARC have worked collaboratively to address the needs of families affected by all types of transportation disasters resulting in mass fatalities. One particular chal- lenge is that operationally, these services should be available in the im- mediate aftermath of a disaster; yet many local ARC chapters and local emergency managers are unfamiliar with the provisions of this Act. In 2000, a congressional appropriation, administered by the Centers for Disease Control and Prevention (CDC), created a mechanism to form the National Mass Fatalities Institute (NMFI) located at Kirkwood Community College (KCC) in Cedar Rapids, Iowa. The NMFI’s mission focuses primarily on planning and workforce development by providing technical guidance and training at the local and state levels. KCC’s Haz- ardous Materials Training and Research Institute also developed an online library, which lists a variety of documents and other resources pertaining to the field of mass fatalities management.2 Since the ending of its federal funding period in 2007, the Institute has struggled to main- tain its mission and ensure that all communities across the country have mass fatalities plans and a robust and highly trained workforce to re- spond to mass fatality events. Even so, the Institute continues to identify alternate mechanisms of funding so that it may continue its contribution to the field of mass fatalities planning and response. A number of workgroups and sentinel documents have also been credited with furthering the field of mass fatalities management. Provid- ing Relief to Families After a Mass Fatality: Roles of the Medical Exam- iner’s Office and the Family Assistance Center3 offers guidance on establishing a Family Assistance Center, providing emotional and spiri-

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146 MEDICAL SURGE CAPACITY tual support to families of the victims, and tackles the challenges of ante- mortem data collection. This document has been an instrumental re- source in training local ARC volunteers and other potential responders at the community level. In June 2005, the National Institute of Justice convened a technical working group to develop Mass Fatality Incidents: A Guide for Human Forensic Identification.4 This guide was one of the first documents to address issues facing medical examiners, coroners, and other forensic professionals involved in the identification of human remains resulting from a mass fatality incident. It notes some of the critical differences be- tween “normal fatality management” operations (i.e., responding to a motor vehicle accident with five fatalities) and those involving incidents with mass fatalities (i.e., terrorist attacks involving hundreds or thou- sands of deaths). The release of The Capstone Document: Mass Fatality Management for Incidents Involving Weapons of Mass Destruction,5 also in 2005, provided an important resource to the field in the response to domestic and international acts of terrorism. This document provides a compre- hensive review of forensic issues for managing contaminated human re- mains of known toxic agents. Similar resources were developed by the National Association of Medical Examiners and include The Medical Examiner/Coroner’s Guide for Contaminated Deceased Body Manage- ment,6 and a document entitled the Mass Fatality Plan,7 which provides technical information and recommendations for Medical Examiners and Coroners on the management of contaminated human remains. There is also a body of knowledge that has emerged from the inter- national theater. The Pan American Health Organization (PAHO) pro- duced Management of Dead Bodies After Disasters: A Field Manual for First Responders8 in the aftermath of the 2006 Indian Ocean Tsunami. This guide for non-specialists provides guidance on managing the essen- tial aspects of mass fatality incidents, focusing primarily on “manage- ment of the dead.” It also provides suggestions on how to support families of the victims and communicate with the media and the public. The PAHO also developed a mass fatalities checklist that serves as a template for developing a mass fatalities annex to an overall mass fatality plan.9 From a planning and response perspective, public health depart- ments, both state and local, and healthcare facilities share facing consid- erable challenges in the aftermath of mass fatality incidents. Many are significantly underresourced to address and respond to the complexities

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147 APPENDIX H of such events. Two key resources have been developed in the past year to address these critical gap areas. The first is the Los Angeles County (CA) Mass Fatality Incident Management: Guidance for Hospitals and Other Healthcare Entities.10 This guide applies mass fatality manage- ment concepts and operations to hospital settings, with particular empha- sis on responding to a catastrophic disease outbreak. The second is the Managing Mass Fatalities Toolkit,11 developed by the Santa Clara County (CA) public health department, a National Association of County and City Health Officials–designated public health preparedness Ad- vanced Practice Center. Toolkit materials were developed based on les- sons learned from actual events, including the Oklahoma City bombing, 9/11, and Hurricane Katrina, and provide scalable, operational guidance and resources to assist local public health jurisdictions in creating a local mass fatalities plan. The CDC has also produced numerous public health bulletins avail- able on the Emergency Preparedness and Response section of its website (www.cdc.gov). Information for both the public and clinical audiences include topics such as traumatic stress and coping after disasters and other mass fatality incidents and technical guidance for medical examin- ers and coroners in biologic terrorism and response. Additional attempts have been made to bring together subject matter experts in mass fatalities management to brainstorm and address critical, unanswered questions. A notable example is a 2006 2-day workgroup conference sponsored by the U.S. Northern Command in cooperation with the Department of Health and Human Services (HHS) at the Joint Task Force Civil Support headquarters in Fort Monroe, Virginia. Civil- ians, government, and military met to address the myriad issues in mass fatality planning and response to an influenza pandemic. A series of White Papers were generated to lay the foundation for a national strategy for pandemic influenza fatality management. HHS also conducted a se- ries of teleconferences with subject matter experts to develop a Concept of Operations (CONOPS) for Fatality Management. Completed in 2007, the purpose of this CONOPS is to identify federal fatality management resources and outline procedures for their engagement during a mass fa- tality event that overwhelms regional, state, local, territorial, and tribal capacities. In short, there have been many initiatives undertaken and key re- sources developed to address the challenges of mass fatalities manage- ment. But can these initiatives and resources be defined as “state of the art?” Are we any further along in developing a comprehensive and uni-

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148 MEDICAL SURGE CAPACITY fied approach to fatalities management at the local, state, and federal lev- els? At best, what has been accomplished to date only scratches the sur- face when considering what it would take to fully and comprehensively address the complex planning challenges and response needs of a large- scale, catastrophic mass fatality incident. Elected officials, emergency planners, public health professionals, and a variety of other disciplines needed to carry out the multitude of tasks and activities following such an event must give priority to developing both short- and long-term ap- proaches to creating a mass fatalities management strategy that can be adopted and implemented at all jurisdictional levels. SHORT-TERM OPPORTUNITIES Creating a National Mass Fatalities Strategy The first short-term goal would be to call for the creation of a Na- tional Mass Fatalities Strategy. The call to establish this national priority would be directed to both the Department of Homeland Security (DHS) and HHS and require both organizations to identify agency representa- tives who would take the lead in coordinating the creation and develop- ment of this critical national strategy. Currently, HHS is the lead federal agency for Emergency Support Function 8 (ESF-8), the area within the National Response Framework (NRF) that is currently responsible for mass fatalities management. ESF-8 also includes public health, medical, and mental health services, three very large and complex areas that re- quire robust financial and human resources in order to adequately pre- pare the nation for its federal obligations and roles in response to disaster. DHS, which is responsible for the National Integration Center and is the “keeper” of the National Incident Management System (NIMS) and NRF documents, would support the creation of a national mass fatalities strategy by clarifying and describing the U.S. govern- ment’s roles, responsibilities, and authorities in mass fatalities manage- ment as described in the NIMS and the NRF. Recently, a Fatality Management Interagency Steering Committee, convened and facilitated by the HHS Office of the Assistant Secretary for Preparedness and Response, revised the CONOPS for Fatality Man- agement in an effort to create some much-needed structure for the federal government’s response to mass fatality events. Although the fate of this most recent document is currently under review, it is imperative that such

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149 APPENDIX H a resource be shared with DHS and brought forth to create a framework for future response to mass fatality incidents. Once endorsed, this docu- ment can be used as a matrix by the two federal agencies to conduct a comprehensive gap analysis to identify areas for future research, training, and technical assistance and the development of key resources in fatali- ties management. Enhancing Workforce Development One of the glaring gaps identified by many subject matter experts is the lack of a fully functional workforce that is able to respond to a range of mass fatality incidents, especially in rural areas of the country. The Pandemic and All-Hazards Preparedness Act and the Homeland Security Presidential Directive 21, which addresses public health and medical preparedness, calls for the creation of the Federal Education and Training Interagency Group (FETIG). It is still largely unknown how this group— which is proposed to be a coordinating mechanism for public health and medical disaster preparedness and response core curriculums, training, and education across federal agencies, departments, and other stake- holders—will function, but efforts must be made to ensure that one of its roles is to address the workforce and training needs of responders to mass fatality incidents. Currently, federal and state assets (i.e., the Department of Defense, DMORT, and the National Guard) can and will play important roles in large-scale, mass fatality disaster response and recovery, but local and state planners are largely unfamiliar with these roles and how they will be engaged. Once these roles are clarified, and the gaps in the available workforce identified, developing a nationally recognized training strat- egy to create a workforce at the state and local levels with the capacity to respond to incidents involving multiple fatalities is imperative. To date, training curriculums lack evidence base and are primarily developed from the anecdotal experiences of planners and responders. In the short term, efforts should be made to generate a comprehensive list of cur- rently available and “reputable” training curriculums, with the goal of creating an “interim training plan or guidance document” for local and state planners to use as a resource to train first responders and others in mass fatalities response. Longer term initiatives to establish training core competencies should be addressed by the FETIG and other invested stakeholders. Enhancing the knowledge and skill levels of a mass fatali-

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150 MEDICAL SURGE CAPACITY ties response workforce could also be accomplished through the creation of related drills and exercises that test and reinforce such knowledge and skills. Local, state, and national planners must build on their current ex- ercise scenarios in an effort to continually stretch and examine their re- sponse capabilities and capacities and integrate “lessons learned” into future training and exercise opportunities. Finally, opportunity exists to require healthcare facilities funded by the HHS Hospital Preparedness Program (HPP) to have robust training plans for hospital workers who may be called on to respond to such events. Handling Human Remains How are we going to handle the dignified recovery, storage, identifi- cation, and processing of human remains following mass fatality inci- dents? How much do we know about how to develop flexible and scalable ways of handling these remains when fatality numbers grow beyond “the hundreds” and surge toward the “tens or hundreds of thou- sands”? Who has the legal authority and responsibility for handling these remains? A short-term goal could include HHS convening a group of subject matter experts, both domestically and internationally known, to create a plan for the development of modeling and resource management algorithms that can inform future planning to prepare for such catastro- phic disasters. Current legal authorities, mostly at the state and local lev- els, though not entirely, present significant challenges in the recovery, release, and interring of human remains. A comprehensive review of lo- cal, state, and federal laws and statutes must be conducted so that revi- sions and changes in such areas may be considered and proposed. Enhancing Family Assistance Services The Aviation Disaster Family Assistance Act of 1996 was a key piece of legislation to address the needs of families in the aftermath of a mass fatalities incident. The Act required the provision of a range of supportive services, including psychological and spiritual, much of which are provided in Family Assistance Centers in the localities where these transportation incidents occur. Often local chapters of the Ameri- can Red Cross, in collaboration with local public health departments and emergency managers, are responsible for planning and “standing up”

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151 APPENDIX H these “mass resource” centers. Because of competing priorities and a lack of understanding of the myriad services required within a Family Assistance Center, many local communities have not fully developed their “family assistance” plans and end up doing so haphazardly when disaster strikes. Greater recognition for the need for pre-planning for family assistance must be given and reinforced through the requirements for federal funding to agencies carrying such responsibility. Guidance needs to be provided to state and local agencies to establish family assis- tance services for mass fatality incidents that are not related to transpor- tation disasters and are therefore without the mandated assistance of the NTSB and related support agencies. Another gap area that needs to be addressed in the short run is how to provide support to victims’ families during the time it takes to set up a community-based Family Assistance Center. Many communities, par- ticularly hospitals and other healthcare facilities, are exploring ways to fill this gap. Family Reception Centers are typically located in close proximity to a mass fatality scene or in a location, such as a hospital, where the families of victims are likely to congregate. Chaplains, social workers, and other hospital support staff provide the interim information and support until a more comprehensive Family Assistance Center can be opened. However, not all hospitals are prepared to provide such services. One opportunity to create such infrastructure is through the national Hospital Preparedness Program. Administered by HHS, the HPP pro- vides funding to acute care facilities to aid in disaster planning and re- sponse. Such funding should require planning and exercising for how to resource and staff a mass fatalities family reception center. Such a plan should also include the comprehensive training of hospital personnel and community volunteer resources, such as a local medical reserve corps, and address the ways in which a hospital-based center would be inte- grated into the larger community plan for family assistance services. All transportation hubs (airports, train stations, bus depots, cruise ship ports) across the country should also be involved in the development of these plans and exercises because it is likely that such reception centers can be opened in these facilities to support waiting family members in the event of transportation disasters.

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152 MEDICAL SURGE CAPACITY LONG-TERM OPPORTUNITIES Developing National Policy Many of the challenges in establishing a comprehensive national mass fatality plan or strategy are a result of the workings and structure of the American government. Lines of federal authority, limited funding opportunities, and outdated policies may present obstacles to putting in place an ambitious and time-efficient plan for advancing the field of mass fatalities management and response. Even so, we have a moral, ethical, and practical obligation to identify and address ways to resolve such governmental barriers. Subject matter experts and other invested stakeholders, convened by public and private entities, must come to- gether with policy makers and elected officials to address key policy ar- eas that can bring due attention and resources to the development of a national mass fatalities management strategy. Policy implications for research, training, workforce development, and establishing performance standards and metrics should be reviewed and recommended. Securing Adequate Funding When looking at the broad-based challenges identified in this paper and the potential short- and long-term opportunities to address these challenges, the issue of securing adequate and sustainable funding to carry out these initiatives seems unlikely in this country’s current finan- cial climate. This is why it is even more imperative that a group of key stakeholders, to include public health economists, be convened to ex- plore the cost of building a sustainable national mass fatalities strategy that will have quantifiable and efficacious outcomes at the local and state levels. In the interim, current funding opportunities such as those through the HHS Hospital Preparedness Program, the CDC’s Public Health Emergency Preparedness grant program and Cities Readiness Initiative program, and the Department of Homeland Security Grant Program should be reviewed to identify ways to include mass fatality planning and exercise initiatives and requirements. These funding streams should also be flexible to allow funding of organizations outside their traditional target audiences. For example, local and state medical examiner agencies are typically exempt from applying for such federal funding because they

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153 APPENDIX H are not considered “first responders,” but are at the center of any plan for mass fatality management. Creating a National Research Agenda Establishing an evidence base for mass fatalities management must be a national priority that is funded and resourced at levels commensu- rate with other such federal priorities. To date, research priorities for the field are lacking and it is not certain who is accountable for identifying such initiatives. One suggestion would be to task the Fatality Manage- ment Interagency Steering Committee and the FETIG with making short- and long-term research recommendations toward the creation of a na- tional research agenda in mass fatalities management. Identifying Training Core Competencies As mentioned earlier in this paper, most training curriculums avail- able to date draw on the anecdotal experience of trainers. Lacking is a consensus on what foundational knowledge, skills, and attitudes must be in place for those responding to mass fatality disasters. Developing train- ing core competencies that can inform the education of mass fatality dis- aster responders is an important first step to strengthening capacity and resiliency at the local, state, and national levels. Again, this may be a role for the newly developed FETIG in collaboration with other public and private stakeholders. NEXT STEPS Prioritizing the creation of a national mass fatality management strategy is critical in preparing the country to respond to large-scale natu- ral and human-caused disasters involving multiple, simultaneous deaths. This strategy must include and focus on addressing the complex infra- structure needed to respond to the challenges posed by human remains recovery, the morgue and forensic operations in place to support these recovery efforts, the systems to properly track missing person informa- tion and obtain ante-mortem data for decedent identification and release, and the mental health and spiritual assistance services necessary to sup-

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154 MEDICAL SURGE CAPACITY port grieving family members. Although this discussion paper identifies some key agencies and organizations, public and private, that might take the lead in initiating some of these recommendations, further efforts must be taken to identify the appropriate lead source to fill the gaps identified in this critically important area. REFERENCES 1. U.S. Department of Homeland Security. 2007. Target Capabilities List: A Companion to the National Preparedness Guidelines. Avail- able at: http://www.dtic.mil/cgi-bin/GetTRDoc?AD=ADA506879& Location=U2&doc=GetTRDoc.pdf (accessed March 8, 2010). 2. Hazardous Materials Training and Research Institute (HMTRI) Online Resource Center. Available at: http://www.hmtri.org/library/ mass_fatalities.htm (accessed June 1, 2009). 3. Blakeney, R. L. 2002. Providing Relief to Families After a Mass Fa- tality: Roles of the Medical Examiner’s Office and the Family Assis- tance Center. Office for Victims of Crime Bulletin, November 2002. Availabile at: http://www.ojp.usdoj.gov/ovc/publications/bulletins/ prfmf_11_2001/188912.pdf (accessed March 8, 2010). 4. Technical Working Group for Mass Fatality Forensic Identification. 2005. Mass Fatality Incidents: A Guide for Human Forensic Identi- fication. Prepared for the U.S. Department of Justice, Office of Jus- tice Programs, National Institute of Justice. Available at: http:// www.ncjrs.gov/pdffiles1/nij/199758.pdf (accessed March 8, 2010). 5. U.S. Army Research Development and Engineering Command, Mili- tary Improved Response Program and the Department of Justice, Of- fice of Justice Programs, Office of Domestic Preparedness. 2005. The Capstone Document: Mass Fatality Management for Incidents Involving Weapons of Mass Destruction. Available at: https://www. edgeword.army.mil/hld/dl/MFM_Capstone_August_2005.pdf (ac- cessed March 8, 2010). 6. Hanzlick R., Nolte K., deJong J., and the National Association of Medical Examiners Biological and Chemical Terrorism Committee and the Bioterrorism and Infectious Disease Committee. 2006. The Medical Examiner/Coroner’s Guide for Contaminated Deceased Body Management. Available at: http://thename.org/index.php? option=com_docman&task=cat_view&gid=38&Itemid=26 (accessed March 8, 2010).

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155 APPENDIX H 7. National Association of Medical Examiners. 2007. Mass Fatality Plan. Available at: http://www.dmort.org/FilesforDownload/ NAMEMFIplan.pdf (accessed March 8, 2010). 8. Morgan, O., Tidball-Binz, M., van Alphen, D., eds. 2006. Manage- ment of Dead Bodies After Disasters: A Field Manual for First Re- sponders. Washington, DC: Pan American Health Organization. Available at: http://www.paho.org/english/dd/ped/DeadBodies FieldManual.pdf (accessed March 8, 2010). 9. Pan American Health Organization. 2006. Mass Fatalities Plan Checklist for Ministries of Health and National Disaster Offices. Available at: http://www.paho.org/English/DD/PED/deadbodies5 checklist.htm (accessed March 8, 2010). 10. Los Angeles Department of Coroner; Los Angeles Department of Health Services, Emergency Medical Services Agency; and Los Angeles Department of Public Health, Office of Health Assessment & Epidemiology, Data Collection & Analysis Unit. 2008. Los Ange- les County (CA) Mass Fatality Incident Management: Guidance for Hospitals and Other Healthcare Entities. Available at: http://ems. http://ems.dhs.la-county.gov/ManualsProtocols/MFIM/MFIGuidance ForHospitals808.pdf (accessed March 8, 2010). 11. Santa Clara County Public Health Department Advanced Practice Center. 2008. Managing Mass Fatalities: A Toolkit for Planning. Available at: http://sccphd.org/portal/site/phd/agencychp?path=% 2Fv7%2FPublic%20Health%20Department%20(DEP)%2FAdvanced %Practice%20Center%20(APC)%2FManaging%20Mass%20Fatalities (accessed March 8, 2010).

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