Aportaciones y avances de la genética forense en los sucesos con víctimas múltiples / Contributions and advances of forensic genetics in mass fatality incidents

La identificación de los afectados por un suceso con víctimas múltiples es una prioridad por razones humanitarias y legales. La genética forense juega un importante papel en estas situaciones que, por su complejidad, a menudo se convierten en un reto para los distintos profesionales implicados. El establecimiento de guías y recomendaciones facilita el seguimiento de protocolos estandarizados que permiten garantizar la fiabilidad del resultado final de la identificación. Así mismo, los avances en la genética forense contribuyen a agilizar la respuesta, aportando nuevas estrategias de análisis y herramientas de tipo bioinformático. Con este artículo, se pretende ofrecer una visión general de cómo la genética forense y sus avances pueden contribuir en estas situaciones, así como algunas claves para entender la labor de los laboratorios de genética forense en la identificación de cadáveres en sucesos con víctimas múltiples. (AU)

Disaster victim identification is crucial for humanitarian and legal reasons. Forensic genetics plays an important role in these situations which often become a challenge for the different professionals involved due to their complexity. The establishment of guidelines and recommendations makes it easier to follow standardized protocols that make it possible to guarantee the reliability of the identification final result. Likewise, advances in forensic genetics contribute to speeding up the response, providing new analysis strategies and bioinformatic tools. This article aims to provide an overview of how forensic genetics and its advances can contribute in these situations, as well as some keys to understanding the work of forensic genetics laboratories in the identification of corpses in events with multiple victims. (AU)

Changes to the Korean Disaster Medical Assistance System After Numerous Multi-casualty Incidents in 2014 and 2015.

OBJECTIVE: A number of multiple-casualty incidents during 2014 and 2015 brought changes to Korea's disaster medical assistance system. We report these changes here. METHODS: Reports about these incidents, revisions to laws, and the government's revised medical disaster response guidelines were reviewed. RESULTS: The number of DMAT (Disaster Medical Assistance Team) staff members was reduced to 4 from 8, and the mobilization method changed. An emergency response manual was created that contains the main content of the DMAT, and there is now a DMAT training program to educate staff. The government created and launched a national 24-hour Disaster Emergency Medical Service Situation Room, and instead of the traditional wireless communications, mobile instant smart phone messaging has been added as a new means of communication. The number of disaster base hospitals has also been doubled. CONCLUSION: Although there are still limitations that need to be remedied, the changes to the current emergency medical assistance system are expected to improve the system's response capacity. (Disaster Med Public Health Preparedness. 2017;11:526-530).

Propuesta de tarjeta triaje en incidentes NBQ con múltiples heridos / Proposal of Triage Tag in NBQ Multi-Casualty Incidents

INTRODUCCIÓN: La amenaza por un incidente nuclear, químico o biológico (NBQ) es una preocupación que aumenta progresivamente en nuestra sociedad actual. El porcentaje de heridos en este tipo de sucesos puede ser potencialmente muy elevada. El triaje de éstos debe estar bien estructurado y adaptado a las distintas áreas de zonificación. OBJETIVO: El principal objetivo es presentar dos nuevas herramientas de diseño propio que sirvan para realizar el triaje de los heridos en escenarios NBQ con múltiples heridos. La primera de ellas es la «tarjeta triaje NBQZC» y está diseñada para su utilización en la zona contaminada. La segunda es la «tarjeta triaje NBQZNC», la cual se emplea en la zona no contaminada. Ambas están creadas para su utilización en zona de operaciones, siendo fáciles de interpretar y de cumplimentar. CONCLUSIONES: Se exponen dos tarjetas de triaje de heridos NBQ de aplicación en el ámbito militar

INTRODUCTION: Nuclear, Chemical or Biological incident's threat is a concerning issue progressively increasing in our society. In these events injures' percentage potentially might be very high. Casualties' Triage has to be well structured and adapted to the different zoning areas. OBJECTIVE: The main goal is to introduce two new own design tools assisting in the performance of CBRN triage in a Major Incident. The first one is «Triage Tag NBCZC» and it is accomplished in the contaminate zone. The second one is «Triage Tag NBCNZC» and it is filled in the not contaminate area. Both of them are created to be executed in an Area of Operations and their interpretation and completion can be made easily. CONCLUSION: Two news Triage Tag CBRN casualties are showing available to a military scene

Managing mass casualties and decontamination.

Careful planning and regular exercising of capabilities is the key to implementing an effective response following the release of hazardous materials, although ad hoc changes may be inevitable. Critical actions which require immediate implementation at an incident are evacuation, followed by disrobing (removal of clothes) and decontamination. The latter can be achieved through bespoke response facilities or various interim methods which may utilise water or readily available (dry, absorbent) materials. Following transfer to a safe holding area, each casualty's personal details should be recorded to facilitate a health surveillance programme, should it become apparent that the original contaminant has chronic health effects.

RELIGION AND DISASTER VICTIM IDENTIFICATION.

Disaster Victim Identification (DVI) is a triangle, the components of which are secular law, religious law and custom and professional methods. In cases of single non-criminal deaths, identification often rests with a hospital or a medical authority. When dealing with criminal or mass death incidents, the law, in many jurisdictions, assigns identification to the coroner/medical examiner, who typically uses professional methods and only answers the religious requirements of the deceased's next-of-kin according to his personal judgment. This article discusses religious considerations regarding scientific methods and their limitations, as well as the ethical issues involved in the government coroner/medical examiner's becoming involved in clarifying and answering the next-of-kin's religious requirements.

[Fatal incidents by crowd crush during mass events. (Un)preventable phenomenon?]. / Tödliche zwischenfälle durch menschengedränge bei grossveranstaltungen. (Un-)vermeidbares phänomen?

BACKGROUND: Crowd crushes with dozens or even hundreds of casualties have occurred several times at the Hajj in Saudi Arabia and also in soccer stadiums in Western Europe. As fatal accidents after human stampedes during mass events occur very rarely and are usually accompanied by many years of criminal court proceedings in order to identify underlying responsible mechanisms and culprits, it is very difficult to draw conclusions and formulate precautions from an emergency medical point of view. METHODS: This study analyzed a fatal crowd crush which occurred on 4 December 1999 following the "Air & Style" snowboard contest with approximately 22,000 people attending in the Bergisel stadium in Innsbruck, Austria. Firstly, focused interviews were conducted with professional rescuers, police and physicians and secondly publicly available court records dealing with this incident in the district court of Innsbruck, Austria were analyzed. RESULTS: During the snowboard contest 87 emergency medical technicians, 6 emergency physicians, 1 leading emergency physician, 21 policemen and 140 security personnel were present. Following the accident additionally some 100 emergency medical technicians, 36 emergency medical service vehicles and 4 physician-staffed emergency medical service vehicles responded to the scene. The deadly crowd crush resulting in 6 fatalities, 4 patients still in a vegetative state and 38 injured, was due to a severe crowd accumulation at one stadium exit, which was not recognized and dispersed in time. Construction of the exit in line with darkness, steep slope and slippery surface contributed adversely to this dangerous situation, although panic did not occur at any time. CONCLUSIONS: Unfortunately, there is no patent remedy to completely prevent fatal accidents by a crowd crush at mass events. If planning is initiated early, sufficient material and personnel reserves are kept in reserve and despite conflicting interests of the organizers, the host community, security, police and emergency medical services, a joint concept is designed and followed, the risk of a severe incident can be kept to a minimum. Each involved party including the spectators have to be aware of their responsibility in order to contribute to the success and safety of the mass event. A comprehensive and critical review of all facts and implementation of conclusions implies a time and financial burden but has a positive impact on the success and safety of mass events.

First responder and physician liability during an emergency.

First responders, especially emergency medical technicians and paramedics, along with physicians, will be expected to render care during a mass casualty event. It is highly likely that these medical first responders and physicians will be rendering care in suboptimal conditions due to the mass casualty event. Furthermore, these individuals are expected to shift their focus from individually based care to community- or population-based care when assisting disaster response. As a result, patients may feel they have not received adequate care and may seek to hold the medical first responder or physician liable, even if they did everything they could given the emergency circumstances. Therefore, it is important to protect medical first responders and physicians rendering care during a mass casualty event so that their efforts are not unnecessarily impeded by concerns about civil liability. In this article, the author looks at the standard of care for medical first responders and physicians and describes the current framework of laws limiting liability for these persons during an emergency. The author concludes that the standard of care and current laws fail to offer adequate liability protection for medical first responders and physicians, especially those in the private sector, and recommends that states adopt clear laws offering liability protection for all medical first responders and physicians who render assistance during a mass casualty event.

[Bioethics in catastrophe situations such as earthquakes]. / Después de un terremoto: bioética en situaciones de catástrofe.

A catastrophe of the magnitude of the earthquake and tsunami that hit Chile not long ago, forces us to raise some questions that we will try to answer from a philosophical, ethical and responsibility viewpoints. An analysis of the basic principles of bioethics is also justified. A natural catastrophe is not, by itself, moral or immoral, fair or unfair. However, its consequences could certainly be regarded as such, depending on whether they could have been prevented or mitigated. We will identify those individuals, who have the ethical responsibility to attend the victims and the ethical principles that must guide the tasks of healthcare and psychological support teams. The minimal indispensable actions to obtain an adequate social and legal protection of vulnerable people, must be defined according to international guidelines. These reflections are intended to improve the responsibility of the State and all the community, to efficiently prevent and repair the material and psychological consequences of such a catastrophe.

When disaster hits, where does the standard of care go?

On July 22, 2011, it was reported in the news that a $25 million-dollar settlement was reached in a class-action lawsuit alleging that Memorial Medical Center in Louisiana failed to adequately prepare for the devastating catastrophe known as Hurricane Katrina. This magnitude of a claim raises serious questions regarding the viability of lawsuits and the lack of immunity available to hospital facilities, physicians, nurses and other healthcare providers for the provision of emergency aid during national disasters. This article is intended to address one aspect of the legal issues facing healthcare providers and to analyze the standard of care by which facilities and individual providers may be judged, measured and assessed following national disasters.

The strategies to DVI challenges in Typhoon Morakot.

Small village populations in which there is a high amount of kinship can cause complications in cases of disaster victim identification. This problem was highlighted by the loss of life after Typhoon Morakot struck Taiwan where over 500 people from small isolated communities lost their lives. Most of the victims were buried by landslides in the remote mountainous areas of southern Taiwan. Only 146 pieces of human remains were recovered after searching for 4 months. Most of the human remains were received for examination as severely damaged fragments prevented possible identification by morphological features. DNA testing using the traditional duo parent/child or sibling screening by STR data opens the possibility of including not only the actual victim but also false positives. Variable likelihood ratios were obtained when comparing DNA types from human remains to those from potential relatives; however, with the DNA typing of numerous members of the same living family, multiple matches to potential families were avoided. Of the 146 samples obtained and collapsed to 130 victims, they were linked to 124 individuals resulting in their identification when compared to a pool of 588 potential relatives. Six of the human remains could not be linked to any living relative and remain unknown.

[Medicolegal identification of victims in mass disasters using the example of aircraft accidents]. / Rechtsmedizinische Identifizierungsaufgaben bei Katastrophen am Beispiel von Flugunfällen.

In mass disasters, the main task of the medicolegal expert is to support the victims' identification. As such events are rare, the knowledge obtained during previous operations should be evaluated and published to improve the quality and effectiveness of the identification work in future disasters. This report describes the experience gained at the Institute of Forensic Medicine of the Humboldt University in Berlin during the identification of the victims of three aircraft accidents (1972, 1986, 1989). The advantages and disadvantages of the identification methods used are discussed. Medicolegal experts should make themselves familiar with available experiences to be adequately prepared for the responsible task of identifying the victims in an emergency.

[Triage: (medico-) legal implications]. / Triage--(medizin-) rechtliche Implikationen.

Incidents with a large number of diseased and injured people (i.e., mass casualty incidents) require special medical logistics. Due to the disproportion between the unknown number of patients and the limited number of medical personnel and equipment, there is an urgent need to use available resources to their full extent so that the largest possible number of patients can receive the emergency care they need. This, however, requires a medical categorisation of patients based on the indication and urgency of their medical treatment. This process of prioritising is the primary task of the senior emergency physician. The result of this so-called triage is being documented on triage tags.