Medical Examiners - Transcript

Frank DePaolo: Hello. My name is Frank DePaolo. I am the Director of the Special Operations Unit, with the New York City Office of Chief Medical Examiner. For the past three years we have worked closely with the Centers of Disease Control and Prevention to develop guidelines for health physicists, medical examiners, and coroners who may be required to recover and examine decedents contaminated by radioactive material. In this video we will instruct health physicists on the basic concepts of fatality management at the scene of the incident and in the morgue. We will also provide medical examiners and coroners with guidance for operating safely in the presence of radioactive material. We have developed a hypothetical scenario to illustrate these concepts. The scenario is a natural gas explosion in a nuclear medicine pharmacy. This scenario was chosen because it presents unique issues such as having to work with multiple radioactive isotopes. The pharmacy contains no hazardous drugs, chemicals, or biological agents. The Medical Examiner personnel that appear in the film are certified Hazardous Materials Technicians and are active members of the New York City Medical Examiners Special Operations Response Team or MESORT unit. The training certification meets the EPA's requirements for hazardous materials technicians. In this video we show only the precautions necessary for working in radiation areas.

Police Officer: Morning. Dave Kao NYPD counter-terrorism,, How are you?

Medical Examiner: Good, Dennis Cavalli from the ME's office.

Officer: I just want to take a couple Seconds to bring you up to date on what's been going on. About 90 minutes ago there was an explosion inside the nuclear medicine pharmacy room in the hospital. There was a lot of people injured. Those injuries have been removed by the fire department personnel. The NYPD swat team has done a search of the premise in and about the area there are no secondary tertiary devices found. Also the building engineer has come in and evaluated structural integrity of the room. There is no load bearing walls involved with the explosion that was damaged, so you have a sound room to walk into.

Examiner: Do we know how many fatalities are on the scene?

Officer: It apparently looks like there are 4 DOA's on the ground.

Examiner: OK, Just to let you know initially when your ESU team went to do a walk through our video team did an entry with them also and set up our video system, so we actually have a live feed here so that we can see the scene. What I need you guys to do is go in, do a walk through, do some mapping, take some readings. I'm going to assign one of our OCME personnel to do the joint agency fatality evaluation. You guys can go over to medical get your vital signs don your PPE and go head and do the walk through and then come back and give us a briefing on what you find inside.

Narrator: Before people can work safely in an area where radiation is present, the radiation dose rates must be measured and mapped. This may be done by emergency responders before turning the area over to the medical examiner, or coroner or it may be done by the medical examiner's team. Let's now look at the preparations for working in an area were radioactive material is present. Law enforcement has already cordoned off the area with caution tape. A remote controlled camera has been set up to reduce the number of people required to enter the scene. At the entry point a person called a control point watch, has been stationed to control entry and exit from the area. This person is equipped with step off pads, a plastic bag for contaminated waste, a meter with a pancake probe, rubber gloves, and a table. The table has designated sides for clean and contaminated equipment. The duties of the control point watch include, controlling entry and egress, inspecting for proper PPE, checking instruments to make sure they are correct, calibrated and on, and recording dosimeter readings both in and out for all persons entering the contaminated area. All personnel working in a hazardous material scene must have their vital signs read and recorded before donning protective clothing
and starting work, and again after they leave the area. The first step is to establish a survey team, consisting of a surveyor and a scribe who will prepare an area map. Those entering the area should wear two dosimeters. An optically stimulated luminescent dosimeter should be placed inside the protective clothing. This dosimeter will provide the legal record of their exposure. A second self-reading dosimeter is placed outside the protective clothing so it can be checked periodically during the operation. Since standard protective clothing does not have a belt or a pocket for carrying an external dosimeter it is necessary to add a belt. This belt is also useful for carrying a radio. CDC recommends wrapping the external dosimeter in clear plastic to prevent its contamination.

Examiner: What is your name?

Officer: Kao NYPD.

Control Point: Kao NYPD.

Narrator: As each person enters the area the control point watch records the name, time in, dosimeter serial number, and dosimeter reading.

Control Point: Time in, ten- forty-five, dosage zero.

Narrator: The control point watch ensures that all personnel and equipment leaving the area are surveyed for radioactive contamination and records the time of their leaving and dosimeter reading. Radiation can be detected anywhere. Dose rate readings, especially low ones are meaningless without first obtaining a measurement of background radiation. Note that the workers always measure and record background radiation before entering an area or starting work.

Officer: Background reading twenty microR per hour

Narrator: It is not safe to enter a radiologically controlled area then turn on a meter. You need to know the dose rate before exposing yourself to potentially high levels of radiation. In addition some instruments saturate and read zero in high dose rate areas.

Officer: OK let's go in.

Narrator: The surveyor in this group carefully reads his instrument as he approaches the room starting at the control point. He has already checked the calibration date
on his instrument and used a radioactive source to verify its operation. He then wrapped it in a plastic bag to prevent its contamination while taking readings in the room. The surveyor surveys the door then opens the door and checks before entering the room. The scribe remains in the low dose rate area in a position where he can observe the surveyor while the surveyor moves around the room announcing the dose rates for him to record.

Officer: First Deceased five-zero milliR per hour.

Narrator: Now we will show the procedures to be followed when persons exit the contaminated area. First all equipment such as radios and instruments are surveyed. Clean equipment goes to the clean side of the table and contaminated to the contaminated side. Note that the pancake probe has been wrapped in a plastic sheet to prevent its contamination. This is appropriate because the radiation safety officer determined from the hospital that no alpha or beta emitting isotopes are present. When using a pancake probe the surveyor needs to consider 3 parameters: Distance of the probe from the surface to be measured, speed of the probe and distance between successive sweeps. CDC recommends headsets or a speaker on the meter to facilitate the detection of radiation.

Control Point: Clean.

Narrator: Techniques for removing protective clothing may vary depending on whether it is anti- contamination clothing in a nuclear power plant, firemen's bunker gear or a Tyvek suit. Once the protective clothing is removed the control point watch or his assistant checks the bottom of the foot of the person leaving the contaminated area.

Control Point: Clear.

Narrator: Then the person leaving steps on the clean pad, this should be repeated with the other foot. Conduct a complete survey of the person in his street clothes after he is outside of the area. In incidents involving radiation it is advisable to appoint a radiation safety officer to advise the safety officer. The duties of the radiation safety officer are to ensure proper dosimetry, establish administrative limits on doses, calculate estimated stay times based on this limit and enforce the ALARA principle: As Low As Reasonably Achievable.

Radiation Safety Officer: I'm going to recommend that you establish a stay time of one hour.

Narrator: Here the radiation safety officer has determined that all of the isotopes involved are gamma emitters with very short half lives. We've explained that the timely processing of human remains must be weighed against the need to minimize radiation exposures where possible. The incident commander and radiation safety officer must determine whether to proceed now or defer operations. Variables that should be considered include the dose rates, half life of the isotopes present and temperature at the site.

Examiner: What we're going to do is we're going to have a three person team that's gonna go in, we're going to have one person function as a scribe, a photographer and then one person that's actually gonna do the exam.

Radiation Supervisor: Ok then I recommend you establish a limit of 100 millirem per person.

Narrator: The medico-legal investigative team consists of a photographer, a scribe, and a investigator. The Radiation Safety Officer conducts a briefing for the team, using the map to plan their work and to minimize the team's exposure to radiation. Stay time is determined by dose rate, maximum allowed dose, and work that needs to be done. The radiation Safety Officer will determine the appropriate level of personal protective clothing based on a hazard analysis and full characterization of the incident. This is a scene from a different exercise, one involving detonation of a radiation dispersal device on a city bus. In this scenario the radiation safety officer determined that the filter masks provided a sufficient level of respiratory protection. The team will use the "one-person-at-a-time rule" - only one person at a time will be in the high dose rate area.

Examiner: I'm going to shoot a photo from the low dose area angle of the overall scenes of all the victims.

Narrator: Everyone in the work area remains in the low dose rate area unless they actually need to do something in the high dose rate area. First the photographer, following standard forensic protocol, takes photos. He then places a remains recovery tag on the body and steps back.

Examiner: Ok I'm going to do a quick exam. I have a white male.

Narrator: The medico-legal investigator conducts an external examination describing his findings to the scribe. He removes any identification on the deceased, records the information and places the identification back where it was found. All personal effects associated with the victim must remain with the body during transport to the morgue. To preserve the integrity of the victim's identification, clothing and personal effects will be removed in the morgue. When the medicolegal investigation is complete at the scene, the investigator places the remains recovery tag on the victim if the photographer has not already done so. Do not survey the body for contamination at the scene.

Examine: One-Two-Three

Narrator: The remains recovery team receives a safety briefing and begins work. This team consists of at least three to four people. The victim is placed into the body bag with all clothing and personal effects intact. A tag, which has the same number as the tag attached to the victim, is placed on the outside of the body bag. At this point the inside and outside of the body bag are assumed to be contaminated.

Examiner: OK let's prepare for removal and transport.

Narrator: A remains tub is placed outside the room but inside the control area. The body bag is placed into the remains tub, which is then covered to prevent the spread of contamination. All items inside the remains tub are assumed to be contaminated. The outside should be uncontaminated, but this must be verified at the control point. The surveyor at the control point checks the team members and the wheels of the cart. He cannot survey the remains tub itself, however, because it is impossible to tell the difference between readings from the exterior of the container and readings from the victim. He uses swipes to check the outside of the container for contamination, and then, holding the probe away from the container, reads the swipe. If he gets a positive reading, he should put the swipe down and read it again to ensure he is not reading contamination on his own fingers. If the tub is contaminated, decontaminate the tub and test it again.

Outside the controlled area, medical examiner or coroner team members have set up a Collection Point and a field morgue. At the Collection Point, the surveyor surveys all of the victims removed from the scene. Bodies reading greater than 100 millirem per hour at any point will be sent to a refrigerated truck for temporary storage. Victims reading less than 2 x background or less than 300 counts per minute above background will be transported to the medical examiner's or coroner's office for normal processing. Contaminated bodies reading less than 100 millirem per hour will be processed in the field morgue. He takes a background reading before starting to survey the first victim.

Examiner 1: Background is .58-.60 counts per second.

Examiner 2: Background .58-.60 counts per second, copy.

Narrator: The uncontaminated victim requires the most time because it is the only one that requires a complete survey. Before sending a body to the medical examiners office the body must be surveyed front and back. The inside and outside of the body bag and the interior of the remains container must also be completely surveyed. The uncontaminated victim is loaded into a van for transport to the medical examiner's office. The surveyor receives a reading above100 millirem from the second victim.

Surveyor: We're getting one-hundred and thirty millirem hour. What's the time?

Examiner: OK it's fourteen-forty five and that's one-thirty millirem per hour.

Narrator: He moves the victim to the reefer truck. There are three reasons for doing this: Prevent overexposure of the morgue staff Allow dose rates to decrease Devise a special procedure with a health physicist and a pathologist for dealing with this victim later. This is a portable body storage unit. It may be used at a mass fatalities scene instead of a refrigerated truck. We shift now to the field morgue. There are three phases in the field morgue operation. It is recommended that the operation be conducted one phase at a time, not simultaneously, to ensure effective management and allocation of resources.

A remote controlled camera is installed to permit law enforcement and medical examiner staff to view the proceedings remotely and document personal effects and other evidence removed from the victim. A portable x-ray machine may be installed if needed. Entry and exit from the field morgue is controlled the same way as at the incident scene. A forensic anthropologist conducts the initial examination in the field morgue. The medico-legal investigator reads the recovery tag number aloud and assigns a specimen number to every article of clothing or fragmented part from the remains. The forensic pathologist directs this process and conducts the external examination. All articles of clothing and other personal effects are bar code labeled and documented. To minimize exposure to radiation, the "one person at the table at a time" rule is generally followed. The examiner steps back when the photographer is working.

At the evidence table all identification information, such as credit cards or drivers' licenses, are placed on the table and photographed with the bar code label visible. Besides documenting the information for legal purposes, this enables law enforcement and medical personnel outside the morgue area to begin their work. The medicallegal investigator has completed his initial assessment and begins clothing removal. There are two people at the table at this point because the pathologist has decided she wants to closely observe this operation, so she did not step back. Normally, personal effects are returned to family members unless they are needed as evidence. The CDC recommends returning only those items that have emotional or financial value and are easily decontaminated, like watches and rings. Items that will not be returned to the family will be bagged separately. Clothing removal is complete.

The abdominal wound reads 60 millirem per hour at 1", indicating the presence of shrapnel. The pathologist and investigator decide to complete photography and examination of the decedent before shrapnel removal. It is essential to remove shrapnel using forceps to avoid touching shrapnel even if gloves are worn. This could cause tissue necrosis in the fingers. According to the inverse square law, increasing distance from the radiation source will greatly reduce exposure. These are photos of tissue damage caused by contact with a radioactive source. The pathologist places a specimen jar in a bucket prior to removing the shrapnel, so she will not have to handle the jar with the radioactive source inside. The congealed blood from the wound causes the shrapnel to stick to the forceps. She places the forceps and shrapnel in the specimen jar rather than using her fingers to detach the shrapnel. The decontamination station is in a separate and adjacent area. The staff takes a background reading in the decontamination area before the arrival of the first victim.

Surveyor: OK stop.

Narrator: The surveyor finds elevated counts on the hand.

Surveyor: When you lift up the hand don't touch the hand, just touch below the hand. There might be some contamination on there.

Narrator: He raises the hand and measures again to make sure the contamination is on the hand and not on the victim's side.

Surveyor: Ok its not the top, let me check the hand. Ok I'm getting three counts per second. Try and do a vacuuming on it.

Narrator: Use of a vacuum cleaner with an OSHA-approved HEPA filter avoids creating contaminated liquid runoff. Because of the heat of the motor, a vacuum should not be used if the suspected contaminant is volatile. There are some vacuums designed to handle volatile contaminants.

Surveyor: I'm still getting two counts per second I think we're going to have to spot wet decon. Let me just finish surveying other parts of the body, you can put it down.

Narrator: It is good practice to remove as much contamination as possible, regardless of what the "approved" level is. The decontamination team attempts a second decontamination using a spray and wipe, again minimizing runoff.

Surveyor: Let's do a glove change for you.

Narrator: The team changes gloves whenever they begin decontamination of a different area. The tighter surgical gloves are on the outside to provide greater manual dexterity. An autopsy should not be performed on a body with internal contamination unless absolutely necessary. An autopsy may cause excessive radiation exposure to the hands, and it increases the risk of contamination of the morgue. The final stop is the DNA and fingerprint station. The medical examiner's staff will use several methods for determining the decedent's identity - photographs, personal fingerprints, dental x- rays, and DNA.

DNA Technician: Some of the major things we try to do is first to get a blood sample if it is accessible and safe. And if we can't get blood then we'll go for a small piece of deep muscle tissue maybe about 3mm by 3mm. In addition to blood and muscle we also try and get a piece of long bone and we look for about three-quarter inches wide by four quarter inches long. We would use an autopsy saw or a Dremmel for those purposes.

Narrator: The DNA will be saved but not processed unless it is needed. The swab of the mouth does not pose radiological risk. If the DNA technician decides to do biopsy, she should be told how to avoid any fixed or internal contamination location. (If the body has already been through two attempts at decontamination, CDC does not recommend any restrictions on the taking of fingerprints even if the contamination level of the hands reads above the background contamination level. There are no radiological restrictions on releasing the victim to the funeral home, when it is clear that:

  1. There is no external contamination
  2. There is no shrapnel
  3. The body is tagged to indicate dose rate and the distance at which dose rate was measured.

Let's quickly review the three phases of the recovery process: Forensic Examination and Evidence Control, Decontamination, and Identification During Forensic Examination and Evidence Control the recovery team examines and documents evidence and the nature of the victim's injuries. During the Decontamination Phase, the team takes steps to ensure that the victim is fully decontaminated, by scanning, decontaminating, and rescanning until it is clear that all possible contamination has been removed. During the Identification Phase, the victim's fingerprints, dental features and DNA evidence are collected to ensure proper identification.

Frank DePaolo: After watching this video, health physicists should now better understand medical examiner and coroner field and morgue operations so they can play an effective role during incidents. Medical examiners and coroners should better understand the health effects of radiation, types of contamination, operations planning based on the ALARA principles, and release criteria for contaminated human remains.