One of the first activities after a natural disaster is to expend great efforts and resources collecting corpses. While rapid retrieval helps when trying to identify the dead, this effort should never take priority over or use resources that are needed to care for survivors.
Place recovered bodies and body parts (e.g., limbs) in body bags along with non-perishable personal belongings, such as jewelry. If body bags are unavailable, use plastic sheets, shrouds, bed sheets, or other locally available material. Place personal documents in a plastic bag, which should be kept with the body.
Generally, bodies need to be taken to either a short-term holding area or to a site for long-term storage or final disposition. Normally, specialized mortuary vehicles are used to transport dead bodies. However, in major disasters, these may be in short supply or unavailable, so you may need to improvise. (Always check local regulations to determine if the use of certain vehicles for this purpose is prohibited.)
While open flatbed trucks can be used, it is preferable to use closed trucks or vans and to cover the floors with plastic. If possible, use refrigerated trucks normally used to transport perishable items. Try to cover any lettering or symbols, including license plates, that identify the companies or individuals who own the vehicles. This avoids any negative repercussions for the vehicles' owners when the public sees them being used in this way. Once they are no longer needed, any vehicles used to transport bodies must be thoroughly cleaned. Any commercial vehicles should then be inspected and approved by government officials as being safe to transport their normal cargo.7
Never use ambulances to transport the dead; they are valuable resources designed to help the living. While this is commonly, and inappropriately, done during minor incidents, using ambulances in this way when there are mass fatalities is dangerous and potentially harms survivors. Even in mass casualty situations with few survivors (e.g., airplane crash), use alternative vehicles such as trucks, pickups, hearses, and vans to transport the remains of the dead.
Bodies initially need to be taken to a short-term holding area (temporary morgue). Ideally, this site will have controlled access, sufficient space, good ventilation, and be air-conditioned—or at least be out of the sun—to avoid rapid decomposition. It should also have facilities for the staff and areas in which to counsel relatives and, if necessary, to do limited autopsies and embalming. Planning the layout as soon as the site is selected is a key element in organizing body identification.
Sophisticated computer programs are often used to help sort and identify remains. Good on-site organization is essential. Sort bodies by category so that specific bodies can easily be found when the family arrives or identifying information is found. Place the remains in groups by gender and age (e.g., elderly men) and then further divide them into subgroups, such as by skin color, and then by hair color. For example, there may be six initial parts of the holding area for groups of men and women, each divided into elderly, adult, and child/teenager. With a sizable number of casualties, each of these areas can be subdivided for bodies of a different skin color (e.g., black, white, other) and hair color (e.g., black, brown, blond, other). If the number of bodies is substantial, these groups can be further subcategorized by height and hair length. Then, even with hundreds or thousands of bodies, the small subset with the six characteristics can be easily located.
Several methods may be available to store bodies. Use any or all of these as the situation requires. Before storing bodies, put each body or body part in a body bag or wrap it in a sheet. Since these will often be unidentified bodies, give each a unique identification number matched to a master list of bodies. Put any identifying information with the body or part, and put their identification number on waterproof labels (e.g., paper in sealed plastic). Do not write the identification numbers directly on the body or body bag/sheet, since they get rubbed off during storage.
Cold storage is optimal, especially in hot climates where decomposition advances so rapidly that facial recognition is not possible after 12 to 24 hours. The optimal temperature for storage is between 2°C and 4°C. If available, the refrigerated transport containers used by commercial shipping companies can each store up to 50 bodies. Since sufficient refrigeration is rarely available immediately at a disaster site, try to obtain commercial refrigerator trucks. They can be moved close to the site to be used for temporary storage and later to transport remaining corpses.
Burial can be used either as temporary storage or as a permanent disposition.
Temporary burial provides a good option for immediate storage, sometimes at the disaster site itself, when no other method is available or when longer-term temporary storage is needed. This can also be used for individual deaths in remote areas when the body cannot safely be removed at that time. One benefit is that temperatures are lower underground than at the surface; this helps to preserve the body. Temporary burials should be designed so that it is possible later to locate and recover the bodies. To ensure retrieval, use individual burials for a smaller number of bodies and trench burial for a larger number. All bodies should have waterproof identification tags on them and in the body bags or sheets.
Mass common graves, however, should not be used. Rushing to dispose of bodies without proper identification traumatizes families and communities, cannot be justified as a public health measure, violates important social norms, wastes scarce resources, and may make it difficult or impossible to recover and identify remains later.3,8 Likewise, mass cremations are not only technically and logistically difficult, but also waste tremendous amounts of scarce resources (mainly fuel, and usually wood). They also destroy evidence for any future identification. Complete incineration is difficult, usually resulting in partially incinerated remains that must be buried.9
If possible, human remains should be buried in clearly marked, individual graves, although after very large disasters, communal graves may be unavoidable. When digging the graves, consider what the prevailing religious practices say about the bodies' orientation, such as the head must be facing east or toward Mecca and so forth. Each body must be buried with its unique reference number on a waterproof label. This number must be clearly marked at ground level and mapped for future reference.
The following are the general guidelines for constructing graves, although the distances may have to be increased depending on soil conditions. Graves should be ≥1.5 meters (5 feet) deep. Communal trench graves should consist of a single row of bodies placed parallel, ≥0.4 meter (1.5 feet) apart. Bury them in one layer, and never stack the bodies on top of each other. Graves with fewer than 5 bodies should allow for ≥1.2 meters (4 feet) between the bottom of the grave and the water table or any level to which groundwater rises; allow ≥1.5 meters (4.5 feet) if the burials are in sand. Communal graves should have ≥2 meters (6 feet) between the bottom of the grave and the water table or any level to which groundwater rises.10
When choosing any burial site, consider (a) the number of bodies needing burial—allow some leeway; (b) soil conditions; (c) the highest water-table level; (d) the location's acceptability to nearby communities; and (e) the distance from nearby water sources. Clearly mark burial sites and surround them with a buffer zone ≥10 meters (30 feet) wide to allow the community to plant deep-rooted vegetation and to separate it from inhabited areas.
For public health reasons, burial sites must be at least 200 meters (600 feet) from any water source, such as wells, streams, lakes, springs, waterfalls, beaches, and the shoreline. The distance, in part, will vary with the number of bodies being buried, soil porosity, and the water-table level. The more porous the soil and the higher the water table, the farther the grave should be from the water source.10 The suggested distances between burial sites and drinking-water sources are listed in Table 37-1.
Table 37-1 Distance of Grave from Water Sources |Favorite Table|Download (.pdf)
Table 37-1 Distance of Grave from Water Sources
|Number of Bodies||Distance From Drinking Water Source|
|≤4||200 meters (600 feet)|
|5-60||250 meters (750 feet)|
|≥60||350 meters (383 yards)|
|≥120 bodies per 100 m2||350 meters (383 yards)|
Ice is not the optimal method for preserving bodies in warm climates. It melts quickly and large quantities are needed. When it melts, ice produces large amounts of dirty wastewater that must be disposed of so that it doesn't seep into the water supply system. In cold regions, using the ambient cold temperatures or existing ice and snow may be an option.
Dry ice, solid carbon dioxide (CO2) frozen at −78.5°C (−109.3°F), may be suitable for short-term storage. To use it most effectively, build a low wall of dry ice (i.e., 0.5 meters high [1.5 feet]) around groups of about 20 bodies and cover them with a plastic sheet, tarpaulin, or tent. Do not place dry ice on top of bodies, even when wrapped—it damages them. You will need about 10 kg of dry ice per body per day, depending on ambient temperature. Use dry ice preservation only in well-ventilated areas (e.g., outdoors), since it produces carbon dioxide gas when it melts. Use gloves to handle dry ice to avoid "cold burns."12
Generally, the simplest body disposition is to release all identified bodies to relatives or their communities for disposal according to local custom and practice. Long-term storage is required for the remaining unidentified bodies.
Embalming requires skills acquired through special training. However, when necessary, rudimentary embalming using the steps13 outlined here can be accomplished by any clinician with basic surgical skills. The goal is to inject approximately the person's blood volume (~70 mL/kg) of embalming fluid. Of course, some of the blood will normally have to be drained out and disposed of (safely) first.
Place the body supine and extend the extremities. Incise the inside of the upper left arm and expose the brachial artery. Pass two ligatures, 5 cm apart, under the artery. Then make a transverse incision just large enough to insert a trocar, feeding tube, or very large needle pointing distally. Tighten the proximal ligature and inject embalming fluid. Loosen the ligature and redirect the trocar proximally, tie the distal ligature, and tighten the proximal ligature around the trocar. Inject most of the embalming fluid in this direction. Then remove the trocar, tie off the vessel, and close the incision. This procedure can also be done through the carotid or femoral arteries.
A less-effective but simple alternative or supplement to this procedure is to insert a trocar into the abdomen (Fig. 37-1) and then into the chest at multiple points, and aspirate any gas or liquids. Then, inject at least 16 oz (~500 mL) of embalming fluid into each cavity. This can also be done in a male's genitals. Sew the trocar holes closed. To embalm the cranial cavity, inject embalming solution through the carotid arteries or insert a trocar through the cribriform plate via the nose.14
Cavity embalming using a trocar. (Reproduced with permission from Iserson.15)
Embalming solution can be made from 40% formaldehyde (formol) and carbolic acid. The more commonly used solution is 10% formaldehyde plus alcohol and glycerin: for each liter of formaldehyde, use 0.5 L alcohol. If formaldehyde is not available, use 20% zinc chloride in alcohol or glycerin. One formula, recommended by the Pan-American Health Organization, uses the following ingredients16:
- 30% formaldehyde, 300 mL
- 80-proof ethanol, 700 mL
- Glacial acetic acid, 5 mL
- Phenol, 20 g
To embalm body fragments, first attempt to suture them together, and to the body, if available. Then inject them with preservative. Alternatively, preserve the fragments using powdered forms of calcium hydroxide (lime), zeolite, or formalin that will adhere to the surface. Then place the fragments in plastic bags wrapped tightly with adhesive tape. This generally prevents fluid leaks and reduces odors during handling.
Embalm a fetus by instilling preservative fluid though the umbilical vein. Use gravity to instill ~1 L fluid. For a newborn, either use this method or inject 1 to 2 L of preservative through the brachial, axillary, or femoral artery and fill the abdominal and thoracic cavities with preservative-soaked material.
In cases of rapid putrefaction and bloating, the affected areas can be punctured to release the gasses. This is most common in the perineum, scrotum, and the female mammary folds. Facial swelling can be lessened by incising the mucosa on the interior cheeks and compressing them with gauze.
Bodies may have radiological, biological, or chemical contamination. Individuals handling these bodies should wear the appropriate personal protective equipment. These bodies should generally not be embalmed, and those performing autopsies should take special precautions. In these cases, cremation is the preferred method of disposition, although burial in sealed containers may be permitted by local health officials.
If part of local custom, viewing can generally be permitted for most bodies with death due to a disease that requires a vector (e.g., tularemia, Rocky Mountain spotted fever) or due to radiological contamination (they are generally not "contaminated," but rather affected by radiation). Viewing should not be permitted when death was due to a chemical warfare agent or an infectious disease with person-to-person transmission (e.g., anthrax, hemorrhagic fever, smallpox).17
Three factors determine whether animal bodies can harm humans: (a) if the animal carcasses have specific infectious agents, particularly Cryptosporidia, Campylobacter, and Listeria; (b) if the pathological microbe can survive the animal's death; and (c) if the corpse is leaking contaminating material into drinking water.18 Unless all three of these elements are present, the dead animal presents no threat to humans. Note that the microorganisms mentioned survive only briefly if the animal's carcass is on dry land.
Three methods for disposing of animal remains exist: bagging, burying, and burning. Usually, the easiest is to bag the body. The University of Virginia's protocols for disposing of animal remains after natural death or disasters recommends putting animal bodies in sealed, thick plastic bags until they can be taken to an area designated for final disposal.19
Burying animal remains is more labor intensive, especially when there are large numbers of dead animals. The danger is that other animals may unearth these burials. Place a layer of a thorny plant (such as cactus or brambles) over the animal and burial site. This discourages dogs, foxes, and other canines from digging up the site. In the case of herbivores that have a large amount of grass in their four stomachs, putrefaction often swells the body, causing the soil over the animal to rise. Puncture the stomach to allow gas to escape before interring the animal. To be effective, bury animal carcasses at least 3 feet deep. Initially, they can be sprayed with oil and then covered with soil to protect them from predators until they can be destroyed or buried.20
Cremating animals in austere circumstances is generally a bad idea. Not only does it waste valuable resources, but it also often fails to incinerate the body fully, which makes it more difficult to inter the body at a later time.20