Disaster Victim Identification

How I Heard

As my cell phone rang, I began to realize this was not a dream and reached over to grab it from the night stand. The time was around 4:00 a.m. on June 12, 2016. The caller ID displayed the name of our hospital’s chief operating officer (COO). I was not the administrator on call, so the only reason he would be calling me, I thought, was not going to be good. All of those thoughts rushed through in seconds. Carlos Carrasco, our COO, told me there had been a mass shooting of at least 20 people and asked if I could come in to work. I was stunned. I asked him to repeat himself, although I had heard him clearly. He repeated his question and I replied, yes, I would come in.

I sat at the end of my bed in disbelief. Just then my cell phone received a push-notification from an international news agency that read, “Mass shooting at Pulse nightclub in Orlando. At least 20 confirmed shot.”  Reality struck. This really was happening.

Synopsis

A typical day for me as an administrator will start with two hours of walking rounds in various areas I oversee. Three days a week, these rounds consist of making contact with managers who report directly to me. We have informal conversations related to their specific scope of responsibility. At the time of the Pulse shootings, my areas of responsibility included respiratory care, patient transport and medical equipment distribution, acute care therapy, inpatient rehabilitation, outpatient rehabilitation, clinical nutrition, and food and nutrition.

After rounding, much of my day includes meetings related to operational issues and planning as well as individual meetings with managers for their professional development. I attend task force meetings and strategic planning sessions. My days usually are well structured and on an appointment calendar with the exception of an occasional human resource-related or patient-related concern that I must attend to.

Preparation

The drills I participated in had revolved around mass casualty intake. I was typically part of the incident command team or in a supportive role. We tested our abilities to surge our patient bed capacity and activate a decontamination team. We had drilled on situations related to patients contaminated with unknown agents and active-shooter events. Debriefings included discussions of what went well and what needed to improve.

Response

During my 45-minute drive to the hospital that Sunday morning, I made several calls. I called almost every manager who reported to me or sent them a text message before leaving my house. Each of them asked me if this was a drill and each one reacted with shock. Not one person told me they would not come to the hospital.

I listened to CNN radio during the drive. I heard them mention the sound of an explosion and that the police said it was friendly, meaning this was the police making entry into the club. I called Carlos to let him know the police had made entry and more casualties may be on their way. I told him that, according to the news, the shooter was dead.

As I got closer to the hospital, I could see ahead in the distance, red and blue flashing lights. There were too many to count. I remember asking myself, Why aren’t there any ambulances? I would discover later that day that our law enforcement officers had brought the injured to us and many victims had walked in. As I turned toward the parking garage, I saw individuals walking on the sidewalk near the hospital. They looked young. They looked as if they were lost.

I arrived at the parking garage. It was dark outside. There was a silence when I exited my car that I can only describe as chilling. Knowing what was happening just down the street from me, I could not understand the silence. I entered the hospital through the rear loading dock as I always had. This time, as I scanned my badge to enter, I saw a deputy sheriff in a marked SUV. He stood outside the driver’s side holding his black rifle. While I was glad to see him, my stomach fluttered with anxiety.   

I reported directly to incident command where I asked our incident commander and hospital president, Mark Jones, where he needed me. I was asked to find our COO, Carlos, and assist. Carlos was in the emergency department.  As I approached him standing at the ambulance entrance, I could see several white medical examiner’s vans outside, where I normally would see ambulances on a busy day at the trauma center. The back doors of the vans were open and body bags were empty but ready for use, strapped to stretchers. As I stood there with Carlos, I saw a police officer enter the emergency room and approach another officer. I heard him state in a low, monotone voice, “There are at least 30 more dead in the club.”  I do not recall what I was speaking about with Carlos when I heard those words. But I do remember feeling like a fog had come over me in which I could not hear or think. Carlos said that we needed to return to incident command for an update. I remember feeling hollow, as if I was in a dream and walking in slow motion.

We arrived at incident command to hear an update from our team, EMS and law enforcement representatives. I leaned in toward the table where the main incident command team sat and whispered to our hospital manager of security, Mark Lang, “Mark, I just heard a police officer in the ED say that there are at least 30 more people in the club, but they are dead.”  Mark took in a deep breath and said in a very low and calm voice, “Oh, no.”

I stood back from the table and listened. I recall hearing that we did not expect any more patients from the scene and that the last OR case of a shooting victim was taking place. The team began discussing operational plans moving forward.  At that point, something caught my attention on one of four flat-screen monitors mounted on the wall.  The live video feed showed the five shiny, white, medical examiner’s vans I originally had seen in the emergency department ambulance bay. They were leaving. One at a time, in synchrony, each van backed up and pulled forward, driving to the main street where the hovering news helicopters could see them. Each van carried one or two victims who did not make it to us soon enough. There is something about that visual that haunts me to this day. I still think about them planning to go to a dance club with friends, to laugh and socialize, not knowing that it was their last day on Earth. How can that be happening in Orlando, Florida? It still makes no sense to me. It shouldn’t make sense to anyone.

My colleague, Holly, had been assigned to open a conference room for the victims’ loved ones who were outside the hospital. Families and friends were beginning to arrive at the hospital as the news made its way to the local stations. People began to wake up and turn on their televisions and radios.  Holly stepped into the incident command room and I remember hearing her say with a cracking voice and tears in her eyes, “It’s bad. It’s really bad.” She, along with her managers and the conference services manager, had opened the conference room and began the intake. The emotions were indescribable. I recall being offered one of two options for how I could assist with the overall incident at that time. I do not remember one of the options, I only remember hearing that the family room was in need of assistance and I immediately responded that I needed to be there. I was insistent on being there. I felt I needed to support the families and other loved ones while they waited for answers.

I entered the family room and immediately noticed an acquaintance. When I approached her and asked who she was looking for, she showed me a photo of a young woman on her cell phone with her boyfriend. I asked her to send the photos to my cell phone so I could share them with law enforcement. I did not realize at that moment that this would become my primary role for the next 12 hours.

In collaboration with local law enforcement, it was decided that I would give my hospital email address to the families in order to obtain and print victims’ photos. I printed each email with the photo and took them to the emergency department where two Orlando police officers were in constant contact with the medical examiner. As I handed the stacks of 15-20 emails and photos at a time to the officers, they would tell me if the victim was alive or deceased and whether the family had been notified by the Florida Department of Law Enforcement (FDLE). One young victim, I was told, had died in the parking lot of a restaurant near the club. She was taken there by other individuals in an attempt to save her life during the shooting. FDLE was on their way to her family’s home, and I had just received an email from a friend of hers who was looking for her. I walked back to my office, looked up the email, and replied to her, “Hi. I have given the photo of your friend to law enforcement. Please try contacting her family in case they get any news as well.” I knew her friend had died. I have no words to express my sadness and guilt. Although I knew that this was a crime and this victim did not pass away at my hospital, meaning I was in no position to provide specific information regarding her status, I felt guilty and was overcome with sadness.  

For hours, I continued to print and take the information to officers with the Orlando police department (OPD). During an update meeting with incident command, Mark Jones asked me to step into another room and review the names of those who were being sought out by families. When I entered the room, I saw an FBI agent and many of my co-workers looking over the list. I was supposed to read them and determine if I had identified any via the OPD officers’ information and my photos. I could not read. The letters on the paper all blurred together. There was name after name, and I began to panic. I felt like I needed to leave immediately and keep answering my emails. The emails would not stop coming. I looked at my phone and saw my inbox number increase in increments of 5-6 emails within seconds. I turned to Mark Jones and said, “Look, they won’t stop. Look at these emails. They just keep coming. There are so many.” Mark did not say a word but gave me exactly what I didn’t know I needed to get me through this horrific situation that I had absolutely no control over. With one arm, Mark reached out to me and gave me a hug. I cried hard enough while he held onto me that I was shaking. When I could take a deep breath, I did, and Mark let go, stepping away. He walked out the door and back to incident command. Reality hit me that there were more emails and photos than there were living victims at the hospital.

I replied to each of the emails, letting the senders know that their photo and contact information were with law enforcement. Some would email me several more times over the course of the evening and overnight. Each time, I quickly replied, letting them know that we were looking for their loved one. They needed to know that someone out there was listening, even if there was still no answer.

“Please tell me she’s alive,” one mother asked me with an attached photo of a beautiful young lady, her daughter. I would later learn that her daughter did not survive.

“I think I saw my son being carried out of the club by five people on the news. Here is his photo,” another mother asked. He was not alive.

Loved ones looking for their brothers, sons, daughters, mothers, sisters, husbands, wives, fathers and best friends displayed sheer panic and desperation in their emails.

The next day I watched CNN run the list of names of those who had passed away. I saw the names of those whose families were looking for them all night. I emailed and texted those family members to tell them how sorry I was to learn of their loved ones’ passing. Some had to wait 24 hours after the shooting to learn they had lost someone. In many cases, this was because the victim was not carrying identification or was using a fake ID.  

Lessons Learned

• A disaster victim identification (DVI) unit should be created and written into all disaster response and mass casualty plans.
• A family reunification plan should be written into all disaster response and mass casualty plans.
• Members of each law enforcement agency involved in the investigation (as applicable) should have at least one representative present in the DVI room until all victims have been reconciled.
• The DVI structure should involve public relations, family care unit and information technology experts.
• According to the Disaster Victim Identification Guide from INTERPOL (2014), do not be dependent on photography only. It is imperative to ask for descriptions of scars, tattoos, birthmarks, jewelry, etc.
• Share your DVI plan with local and federal officials so that they are aware of your actions. This may assist in avoiding duplication of information.
• Employees asked to serve on the DVI should have the appropriate skill set. They will be exposed to photos and alarming communications regarding the deceased. These individuals may include those with prior military experience and/or leaders with clinical backgrounds and prior experience with emergency situations and high stress.
• Create an email address that can be shared with the public to gain photos and other information. Have someone dedicated to only this.
• Save every piece of communication and correspondence between the DVI and community. This includes emails, photos and spread sheets with victim information. In our case, I saved everything to a secure, encrypted USB flash drive and made printed copies. I gave everything to our corporate manager of emergency preparedness. He then had custody of this information for our after action report (AAR) and in case law enforcement requested it.
• Prior to sending decedents to the medical examiner, take 3 photos. Our mass fatality incident (MFI) plan states:
  • “Team members in the hospital shall photograph the face and/or unique identifiers, i.e. tattoos, piercings, birthmarks, scars; display Medical Record Number in the photo that is on body bag; place one copy with the body (outside of the body bag) attached to the paperwork referenced in Attachments B through D, retain one for family identification to be posted in the Family Staging Area and one set-aside for the MFI Morgue Unit Leader. Restrict photo usage to three (3) copies”.
• Consider a web-based application that allows for photos and download in real-time. For a hospital, the ability to take a photo with identification and download to a screen in the DVI room, real-time, shaves minutes and hours off of identification time. This enables physicians to know exactly who they are treating and family members to know their loved one’s status. Existing products offer required privacy protection.
  • Some applications allow for public download of photos as well as other important information. The public-facing website only allows them to enter information. We have been working with a product vendor to investigate its potential to serve these needs.
  • Other organizations have used simple photo printing on paper. The concern in this example is the inability to share the web link with law enforcement or other hospitals who have received disaster victims. You will inevitably leave valuable incident participants out of the information sharing. This is how we managed with this tragedy.
  • If web-based applications are not an option, consider using a program such as Microsoft Share Point where multiple people within the same hospital/organization can access uploaded photos. Specify who can access the site.
• Finally, do not underestimate the psychological effects that the DVI unit will endure. Select the team ahead of time and provide them with training that helps them identify stress- and anxiety-control during the disaster as well as the ability to identify signs and symptoms of anxiety stress disorder (ASD) after the incident.

What We Changed

We have added a process by which up to three individuals will be assigned to photograph all unidentified victims. Pertinent information will be recorded in bold, black ink on a 5” X 7” demographics card and held next to the victim’s face and any other identifying marks or tattoos. We have the ability to upload the photos and other information to a protected Microsoft Share Point link where assigned individuals can view them. Photos can be printed and shared with law enforcement and hospital leadership assigned to victim identification and family reunification.

Conclusion

I have hundreds of emails that I could quote from, but the message remains the same -- the long wait for family members and friends to hear of their loved one’s status is beyond agonizing.

In a Facebook post a year after the shootings, the friend of a victim who passed away described how he drove to his friend’s apartment and spent the night looking for his car with the hope that he would be coming home. He did not come home. Since June 12, 2016, however, I have become good friends with the victim’s godmother. She has taught me about resilience.

Key Takeaways

• Do not underestimate the psychological effects that the DVI unit will endure. Select the team ahead of time and provide them with training that helps them identify stress- and anxiety-control mechanisms during the disaster as well as the ability to identify signs and symptoms of anxiety stress disorder after the incident.
• Rapid victim identification is imperative to maintain appropriate care of the individual patient needs.
• Consider early (within 1 week) contact with individuals who have shared similar experiences. Everyone from victims and first-responders to clinical and non-clinical healthcare workers will be affected. Peer-to-peer mentorship is invaluable. https://www.oneworldstrong.org/