As Every Detail Counts

The process of identifying victims of mass or major disasters are indeed difficult by visual recognition. Even harder when there a disaster resulting in the deaths of nationals from many different countries as what happen during the air plane crash..

Dead victim of severe burn trauma (>90%) which can be seen in air plane crash like the photo here is definitely impossible to be recognized only through naked eyes. But the fact that the dental structure, skull, and bones are still preserved are of which how forensic anthropology plays their role for the identification procedure.

(Photo courtesy of grantmasonfx)

PRINCIPLE OF FORENSIC ANTHROPOLOGICAL IDENTIFICATION

There are 4 important characteristics to be determined for the identification of the dead person: race, sex, age, stature. I'll go through this one by one:)

RACE

Morphologically, race differences are most pronounced and observable in the skull, with the facial skeleton being the most diagnostic portion.
Just click this picture to enlarged. You can study Paris Hilton, Siti Nurhaliza, and Naomi Campbell faces to make comparison of these 3 major group of races^^

 

The most distinctive Mongoloid feature is the cheekbones. Mongoloid (which includes me, hehe) exhibit high malar projection, both anteriorly and laterally, as well as a malar tubercle at the inferior aspect of the zygomaxillary suture. Should I say, more often than not, we the Mongoloids don't have to use blusher to "show" our cheek^^

According to Prof. drg. Etti Indriati, one of the best racial indicators is alveolar prognathism. In Negroids, the tooth bearing portions of the jaws protrude noticeably in contrast to the straight or orthognathic face of Caucasians and Mongoloids.

Table below lists some craniofacial features that have been linked to race in the three major groups.

Remember: A mixed- blood person such as a daughter of a Mongoloid's mother and a Caucasian's father will have mixtures of both features:)

SEX

Morphological differences of male and female are significant at the skull and the pelvis and most sources say that pelvis is the best sex-related skeletal indicator because of the distinct features adapted for childbearing:)

Skull differences:

Remember: Humans vary both temporally and spatially. To this one may add variation arising from growth factors, environmental stress and pathology or trauma.

Pelvis differences:

There are 3 most pronounced differences can be put into comparisons:

1. Pelvic outlet

2. Sciatic notch

3. Supra pubic angle (subpubic)

The female pelvis is designed to accommodate childbirth as an addition to the same requirements for males which are as a support and locomotion. Wider suprapubic angle and outlet are very much beneficial for the purpose.

A uniquely male trait is the rough everted area of the medial border of the ischiopubic ramus for the attachment of the crus (corpus cavernosum) of the penis. This ramus is more gracile in females and narrows as it approaches the symphysis. Just click the picture to enlarge so what I explain can be seen thoroughly:)

AGE

The estimation of age at death is the most challenging once adulthood had been reached. How humans look as they age is orchestrated by the complicated interplay of genetic, environmental, and cultural factors. However, there are some basic biological processes that all humans undergo from the prenatal months --> infancy --> childhood --> adulthood which I'll explain here: dental and skeletal biological processes.

Dental biological process:

The estimation of age for children is quite easy as the developmental pattern of the child reflected in the eruptions period of the deciduous and permanent teeth. Image below may give a very clear and good guidelines for identification.

Eruption of deciduous teeth

Eruption of permanent teeth

Tooth wear is likely to have the best relationship to broad or general age categories and there's a comprehensive approach to dental aging based on this concept. It's designed to assess a number of characteristics of a cross-section of a tooth including attrition, periodontosis, secondary dentine, cementum apposition and root resorption.

Picture below shows the age phases of dental wear in the maxilla and mandible:

 

Remember: The findings may be differ from what the theory stated. Factors may include the significant racial dimorphism, widely varied diet, socioeconomic status, and even access to health and dental care- anything which is possible to be taken into account to.

Skeletal biological process:

Picture below shows the key features distinguishing the pubic symphysis phases in males. The pubic symphysis of both females and males go through similar phases, but the exact nature of these changes can be altered in several ways :)

This identification thingy is somewhat lots harder than how the theory goes. To be honest, for me, it's quite hard to really distinguish the line, the lipping, borders and etc even if there are already photos and details provided. Years of experiences are very much needed to cope with this matter..  Insya Allah, I'll reach that level.

Back to INDEX

References:

• "Forensic Antropological Roles in Disaster Victim Identification", lecture by Prof. drg. Etty Indriati, Ph. D
• "Forensic Anthropological Identification of Disaster Victims", Practical Session guidelines in BLOCK 4.2 Lab. Manual Book: Health System & Disaster, UGM. (Session guided by Prof. drg. Etty Indriati, Ph D)
• CRANKSHAFT: Morphological Age Estimation
• CRANKSHAFT: Sex Determination

A.M vs P.M

Neither these two refer to 5am in the morning nor 5pm in the evening. But AM for Ante Mortem and PM for Post Mortem:)

We were given lectures about disaster victim management and disaster victim identification and our understandings are strengthened by the practical session on "Forensic and Medicolegal DVI in Mass Disaster" where we were taught how the documentation procedures really goes in practical. It was pretty much an enjoyable practical session as our instructor guided us in a game- like class method. To dr. Yudha Nurhantari, thank you so much for the wonderful teachings:)

 

AM vs PM

Indonesia follows INTERPOL's procedural system of DVI and there are 4 main procedures:

Phase 1: Scene

Taking place at the location of the event.. Searching for bodies (or body parts), taking photos, do collection and bagging of any documents or significant things, labeling, and yes, mapping of disaster.

Phase 2: Mortuary

This is when post mortem (PM) examinations are done, usually in the hospital's morgue. All the details are recorded in the PM pink form.

Phase 3: Detective

There's no specific term for this phase actually, I made it up as this phase is when the procedures go on as much as what can happen under detective's job: digging details as deep as possible:) This is very important to fill in the ante mortem (AM) data compilation, gathered from family, friends, doctors,dentist, etc.

Phase 4: Reconciliation

Comparing AM to PM. This is when a hot debate may occur especially when there are miss- matching. Primary identification method are dental (under Forensic Odontology), fingerprint, and DNA. Secondary's would includes from the victim's property, photos, and any other documents related. 

Example of AM and PM details: DENTAL FINDING

These two details match to one another.

Phase 5: Release and Debrief

Human remains are released to the families, together with the letter of release. DVI team will compile everything, and report the final document to be filled in; this closes the case.

5 phases and wink~ done. Sounds simple..? But indeed- NO.. Disaster actually brings a truly messy, hectic, and chaotic conditions. It's not just because the identifications are troublesome (severely damaged body, too much body separations that scattering nowhere, etc) but also because of the excessive grieving of families who always want things to be fast and even urge to do things on their own make things even more difficult.. Imagine what more to happen in mass disaster..

Credits: All the photos of AM and PM forms are the courtesy of INTERPOL. 

Back To INDEX

References:

• "Forensic and Medicolegal DVI in Mass Disaster", Practical Session guidelines in BLOCK 4.2 Lab. Manual Book: Health System & Disaster, UGM (Session guided by dr. Yudha Nurhantari, Sp. F, PhD)
• "Forensic Antropological Roles in Disaster Victim Identification", lecture by Prof. drg. Etty Indriati, Ph. D
• INTERPOL official website

ER: Disaster

I’ve discussed about the principle of disaster management based on the administration aspect previously, so now would be about the clinical or medical emergency response during disaster as much as how it’s related to our responsibility and ability in the border of proper ethics. I'll use picture below as the guidance to discuss this topic efficiently:)

PREHOSPITAL MEDICAL RESPONSE

The mnemonics of METHANE:)

M = major incident standby / declared

E = exact location

T = type of injury

H = hazard, present and potential

A = access

N = number of casualties

E  = emergency services, present and required

An important procedure under the above actions is the Triage.

Triage is the priority arrangements process to manage a large number of victims of which the principals include:

1. Degrees of life threatening conditions as consequences of injuries (ABCDE of Trauma Victims Management): For instance, patient with threatened airway and breathing are more prioritized than patients with circulation or neurological disturbances.

2. Severity of injuries: Eg. Single fracture may get low priority, but if its single fracture + massive bleeding- high priority.

3. Survival probability: Save the patient with higher chance of survival first.

4. Resources and equipments: Patients requiring unavailable equipments will get low priority till resources are feasible.

5. Time, distance, and circumstances: Treat injuries which take the shortest time of management first.

Let's try arranging these examples of cases from highest priority to the least.

• Case 1: A little 2 year- old girl with heavy diarrhea.
• Case 2: A 75 year- old man with dyspnea and history of COPD since 7 years ago.
• Case 3: A woman with a bleeding wound on her elbow as she just got injured after falling down.

CASE	TRIAGE CARD
1	YELLOW This means “delayed”. The management for toddler can be delayed first, but it is still indeed necessary as heavy diarrhea can cause dehydration which leads to shock if no management is taken.
2	RED “Immediate”! Obviously, he’s the patient with ABC problems with history of respiratory tract disease, plus another co morbid factor: he’s old.
3	GREEN “Minor”. Treatment is to be given, but after the RED’s and YELLOW’s are done. The bleeding needs to be stop and managed properly anyway to avoid infection.

So the TRIAGE goes as:

The old man --> The little girl --> The woman 

One very important thing to remember is that the person who's in charge in this Triage Card labeling should be one with the most competency, not necessarily be a physician.

Resuscitation, Stabilization, and Transportation are also the important procedural actions to be highlighted in pre- hospital medical response as they are the significant continuation processes after Triage.

On the other hand, emergency response for neurological disturbances are also important as mental health is one of the most common impact experienced by the victims of disaster, be it quite as simple as minor depression or as complicated as PTSD.

Psychological first aids

• nActive listening
• nEmpathy: Being sympathetic will only cause the victims to lament more on their plights)
• nAccess the basic needs: Their need may differ from one to another, we can't assume one refugee can list down all the necessities on behalf of others')
• nDon’t push to speak: This is indeed an emergency situation, but we must not rush.Allow them to take their time to calm down a little and express their emotions or thoughts.
• nAvoid from secondary stressors
• nNo medications: Avoid prescribing drugs unless there's an indeed true indication for such.

Authorities playing role in this chain include the community of the disaster itself, NGOs or any other organizations, health center of the specific area or even region, and any voluntary individuals or teams.

HOSPITAL MEDICAL RESPONSE

Hospitals have their own Disaster plan which generally has these important procedures:

Management Support	Medical Support
Command Safety Communication Assessment	Triage Treatment Transport

Psychological (mental health) intervention:

• Manage emergency psychiatric symptoms (major depression, agitation etc)
• nEnsure the availability of psychopharmacy (Eg. haloperidol, benzodiazepines, )
• nContinue the administration of psychopharmacy for chronic mentally ill people who have taken medication previously. Hence, a thoroughly anamnesis is required.

 

The plans by points are:

• Coordinating Team
• Medical team
• Surveillance
• Management back up
• Logistic (resources)

Further posts I'll make later will explain about these deeper. Keep checking me here:)

Back to INDEX

References:

• "Medical Emergency Response", lecture by dr. Hendro Wartatmo, Sp. B- KBD
• "Disaster Management in Mental Health", lecture by dr. bambang HAstha Yoga, Sp. KJ
•  "TRIAGE", SKILLS TRAINING MATERIAL BOOK LIFE SUPPORT SKILLS YEAR IV (BLOCK 4.2)
• TRIAGE CARD

When Nature Takes Its Toll On Us

DISASTER

Based on Medical, Public Health, Wikipedia; Disaster refers to any mishap or misfortune that is ruinous, distressing, or calamitous causing significant physical damage or destruction, loss of life, or drastic change to the natural environment of which requiring urgent management. It can be either natural or man- made hazard.

According to dr.Yudha Nurhantari, it's called mass disaster on the other hand, when involving the death of more than 12 victims in a single event exactly as what we can see from the tsunami and Merapi eruption events, or even plane crash.

Talk about disaster in Indonesia.. Indonesia is like a "supermarket" of disaster: Tsunami, flood, volcanic eruptions, earthquake- you name it. As the world's largest archipelago which spread across 17,500 islands, Indonesia are sandwiched by the world's most active seismic region, the notorious Pacific Ring of Fire and the world's second most active region, the Alpide belt.

Photos courtesy of Wikipedia

Being precariously located above the grinding and mashing of several tectonic plates, and ringed by a chain of fire- breathing volcanoes explain how Indonesia experiences some of the strongest earthquakes and most powerful volcanic eruptions known on earth:( This situations definitely should be taken as a big responsibility on top of the shoulder.

THE PRINCIPLES OF DISASTER MANAGEMENT

The mind- map shown is the simplified Conceptual frame work of disaster and disaster Management by dr. Hendro Wartatmo. I would like to take Merapi 2010 eruption event as an example of disaster to elaborate this chart.

As you can see under the Resilience, there are absorbing capacity and buffering capacity.








The analogy of these are like what happen when I am downloading a song to play.

Let's put the song I want to listen as capacity.When I download the song from a website, it's absorbing capacity. Buffering capacity means to bringing in an extra amount of data till it's reach 100% to be played. One of the factors influencing is my internet connection.

Just like in a case of disaster. The capacity are provided through preparations and mitigation. When disaster happens, the capacity are absorb, so they can be used. But the network from where or who the capacity are located at or being with won't reach the victims or area of disaster in a blink of eyes. How fast it can be provided or distributed, or is there enough human resources as a response, influence the effectiveness of buffering the capacity.

 Click picture to enlarge

All these anyway are based on my personal understandings. Please let me know if there's any mistake.. Thank you very much.

There are 3 main points as to list the important aspects in Disaster Management:

1.Chain of command

The senior official or Investigator in charge as the head to control things. Effective control and co-ordination of the various activities will need at least 3 assistants, each responsible for a major aspect of the overall operations:

• a Director of Communications
• a Director of Rescue Operations
• a Director of Victim Identifications 

2. Communications

Communications center is extremely important. Whenever possible, an independent switchboard and additional communications channels such as radio, telex, facsimile and computer links should be provided.

3. Rescue operations

Rescue operations will be started immediately, often by survivors and members of the public in the vicinity of the incident. The community itself do play role in the rescue efforts.

Back to INDEX

 

References:

• "Disaster Victim Management", lecture by dr. Yudha Nurhantari, Sp. F, Ph. D
• "Conceptual Framework of Disaster and Disaster Management", lecture by dr. Hendro Wartatmo, Sp, B- KB
• "Air Plane Crash", GROUP 8 TUTORIAL SESSIONS (Week 5)
• INTERPOL: Disaster Handling Procedures