What are the main duties of a medical examiner during mass disasters?
In regions of Kiev, such as Bucha, and Mariupol in particular, the recent discovery of mass graves has caused horror. Ukrainian authorities have announced the massacre of hundreds of civilians by the Russian army, which the Kremlin denies.
Laurent Martrille, University of Montpellier
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More than 7,000 investigations have been opened in the last two months by Ukraine's Prosecutor General Iryna Venediktova, and many countries (including France) have sent teams of experts to assist.
In general, what are the roles of forensic scientists in situations involving mass fatalities? And how does international collaboration work? An overview of the procedures usually implemented by Laurent Martrille, forensic scientist, lecturer at the University of Montpellier, member of the French Society of Legal Medicine and Medical Expertise (SFMLEM) and the Montpellier Criminal Law and Forensic Science Team (EDPFM). He is also a reserve doctor at the National Gendarmerie Criminal Research Institute (IRCGN) and has previously been assigned to the International Criminal Court.
The Conversation-France: What are the main roles of a medical examiner at a mass casualty scene?
Laurent Martrille: The medical examiner has two functions: identifying victims and investigating the causes and circumstances of death.
However, in this context, identifying victims is the main task in which the medical examiner is involved. Each country has specialized teams for this purpose.
In France, the UNIVC (National Unit for the Identification of Disaster Victims) is in charge; it itself comprises two sub-units,the UGIVC (gendarmerie) and the UPIVC (police). Each unit is composed of police officers or gendarmes (including specialists in DNA, fingerprints, etc.), forensic doctors, and forensic dentists.
The UGIVC is part of the National Gendarmerie Criminal Research Institute (IRCGN) and is able to intervene anywhere in France and can also be deployed internationally (a team was dispatched to the Lviv region, editor's note]). It has the necessary equipment to operate remotely, including radio, DNA analysis, autopsy, etc.
The second role, investigating the causes and circumstances of death, is not systematic: the authorities concerned may or may not assign this task. After the tsunami in Thailand on December 26, 2004, for example, the task was solely identification. Things may be different when a third party is possibly involved, whether in an accident, an attack, or a war.
TCF: When there are many deceased persons to identify and the specialized teams on site come from different countries, how do they work together?
L.M.: There is no improvisation (even though every disaster is different and requires adjustments). All procedures were reinforced and standardized after the 2004 tsunami, when more than 5,000 bodies had to be identified. This enormous modern disaster made it possible to establish international standards.
Work is now carried out according to standardized procedures established by Interpol and accessible to all: the procedures known as "Disaster Victim Identification" (DVI). This allows teams responding to large-scale disasters to share protocols and results.
With regard to identification, these international standards are based on three so-called primary identifiers, which must be strictly adhered to. A body can only be identified if one of these has been used: fingerprints, DNA, or dentistry.
To enable identification, two types of data must be collected for subsequent comparison:
- Post-mortem data, collected in the field and on the body by forensic scientists, dentists, sometimes anthropologists, and fingerprint specialists.
- Ante-mortem data, obtained from families or, where applicable, from the authorities of another country.
Interpol provides extremely detailed post-mortem and ante-mortem forms to fill out, with very rigorous coding to facilitate data comparison. Cross-checking is done using software, but ultimately it is an identification commission comprising judicial and local authorities from the countries concerned, forensic scientists, dentists, investigators, etc. that verifies everything before making a decision.
In such circumstances, there are two main principles to follow: protocol and nothing but protocol... and adapting to the situation at hand, because each mission has its own particularities, which often vary greatly from one situation to another. When you are sent on a mission following a tsunami or a plane crash, the circumstances are very different.
TCF: When does the medical examiner get involved?
L.M.: In theory, the medical examiner can be involved at every stage of the process. However, except in special cases, they do not usually participate in what we call the collection of bodies or, depending on the situation, their exhumation—there are specialized teams for this, although a medical examiner may accompany them. It may be beneficial for us to be present when there are very few bodies.
When there are a large number of deaths, the added value of our intervention on site is limited. Moreover, even if identification teams can be mobilized quickly, out of respect for the deceased, it is not possible to leave bodies on site, in the streets for example, before the arrival of forensic scientists. There is therefore an initial "collection," which is carried out by the local authorities without Interpol coding.
This had been the case with the tsunami: the bodies had initially been numbered according to Thai standards, then renumbered to facilitate international collaboration.
The specialized teams in charge of this stage follow Interpol procedures: with very precise numbering and specific coding. Each body or body part is placed in a separate bag, identified... Everything is planned and organized, then the bodies are transferred to the morgues where we work.
Another point: in some cases, it may be necessary to secure the area with bomb disposal experts or specialists trained in CBRN (chemical, biological, radiological, and nuclear) risks. They ensure that there is no risk, or that the risk has been eliminated, and decontaminate the scene if necessary. The bodies themselves may have been contaminated (chemically, biologically) or even booby-trapped.
There is therefore a whole process of verification beforehand to prevent doctors and investigators from being exposed to additional threats. It is quite rare, but it is a very important requirement.
TCF: All these upstream interventions will delay the moment when forensic teams can intervene. Is there a risk of information being lost?
L.M.: Obviously, it is not possible to leave bodies exposed to the open air for long periods of time. That is why, depending on the circumstances, initial exhumations are carried out to allow for (very) relative preservation. The ideal solution, of course, is to place the bodies in refrigerated storage units.
When remains are scattered over a fairly large area, they cannot be left in place for days while arrangements are made and a coroner comes to remove the bodies in situ... this is common sense and shows basic respect for the deceased.
The collection of bodies, even if done very carefully, will inevitably interfere with the subsequent investigation. However, following international protocols allows us to begin working with the evidence collected at the scene.
The most important thing is to implement solutions for storing bodies at low temperatures. The usual storage temperature is 4°C. In Thailand, there were dozens and dozens of refrigerated containers.
TCF: How is the process of identifying bodies that arrive at the morgue carried out?
L.M.: Depending on the circumstances (number of bodies, condition, etc.) and the human resources available, when a body arrives, we usually perform X-rays and now CT scans (when possible). This allows us to keep accurate digital records once the body is returned to the family.
Next, investigators establish two chains of identification:
- The "X presumed to be so-and-so" approach: when a body, for example, is carrying identification papers. This allows the investigation to proceed a little faster, as there are clues that can guide the search. But be careful, there is no certainty: you could be carrying someone else's papers...
- The "X" category: when there is no information to suggest the identity.
The first step in this process is usually fingerprinting. Next, we begin by examining and describing the clothing before undressing the body; samples may be taken at this stage if necessary (e.g., hydrocarbons, etc.), at our suggestion, by specialized technicians.
Everything recovered from a body, like what was collected at the scene, is sealed under conditions that will allow for possible analysis at a later date. Each sample is sealed and packaged in a specific way.
Once undressed, the body undergoes an external examination to note anything that may contribute to its identification or help establish connections: measurements, tattoos, clothing, injuries, and scars, etc.
There may be situations where bodies are severely degraded, or even reduced to bones: in such cases, forensic anthropologists are called in. Obviously, a lot of data is lost, such as fingerprints, but bones retain information about age, sex, height, biogeographical origins and, where applicable, signs of trauma.
At the end of this stage, a DNA sample is taken. This may be from the wound if the body is fragmented, or by making an incision in a muscle. Dentists are the last to intervene.
It is also possible to conduct contact DNA testing on items such as links and clothing. However, if bodies have been piled up in mass graves, for example, or handled carelessly during recovery, there is a high risk of contamination from another body, which compromises the usefulness of contact DNA testing to identify individuals who touched or harmed the victim during their lifetime. As a result, the relevance of such surface samples becomes limited.
At the end of this process, a quality control check is carried out to ensure that nothing has been overlooked. Good coordination allows for speed: in France, the 86 victims of the Nice attack on July 14, 2016, were identified in four and a half days.
The identifying features are therefore provided jointly by the dentist, the medical examiner, and even the anthropologist. Please note that the medical examiner does not identify the body himself: like the anthropologist, he provides clues to aid identification, but also takes DNA samples for later analysis. The dentist, meanwhile, provides the information that enables the identification commission to make a direct identification. However, the only person who can determine the cause of death, if requested, is the medical examiner.
TCF: What happens if the medical examiner is assigned to investigate the cause of death?
L.M.: Autopsies to determine the cause of death are only performed at the request of the authorities, as this is not part of UNIVC's usual remit.
As previously indicated, any external items taken from the body are handed over to investigators: clothing, but also any possible ties and personal effects, etc. Samples may be taken from these items for further analysis.
In addition, we look for any signs of injury or violence on the skin, but also by performing an autopsy on the body. If we imagine that the person has been subjected to acts of torture or violence, the description of any injuries will be essential to understanding the circumstances of the death or events leading up to it.
When death is recent and the body has been preserved in optimal conditions, the marks are still perfectly visible and fairly accurate information can be provided.
The more time passes, the more complicated it becomes. Decomposition will interfere with external examinations, yet analysis of the skin is essential as it provides vital information about the types of injuries (ballistic, blunt force trauma, marks from restraints, etc.).
However, even when the bodies are so badly decomposed that only bones remain, it is still possible to find clues. Any marks on the bones are "frozen" in time: bones retain the memory of trauma and how it occurred. However, determining the cause of death becomes much more complicated, and is often impossible... For example, we may observe a significant head injury, which is fatal in itself, but if the cause of death is secondary to a bullet that passed through the body without leaving any marks on the bones, we will see nothing (as the head injury observed may have been inflicted after death).
It is also important to remember that we do not work alone: all experts from forensic science laboratories (in ballistics, toxicology, DNA, entomology—dating the time of death based on necrophagous insects—analysis of fire traces, soil, etc.) can be called upon to assist.
All stages of the procedure are documented by taking photographs and, in some cases, filming. This extreme rigor is essential to enable discussions between experts and limit any possibility of subsequent disputes.
Once identification and/or autopsy procedures have been completed, the bodies are prepared (as far as possible) so that they can be presented to the families, who have the right, in all circumstances, to see them before burial. Families are supported during this very difficult time. The aim is to return the deceased to their loved ones as quickly as possible once identification has been confirmed.
Laurent Martrille, Associate Professor at the University of Montpellier, Hospital Practitioner at Montpellier University Hospital, EDPFM, University of Montpellier
This article is republished from The Conversation under a Creative Commons license. Readthe original article.