When a disaster occurs, a joint preliminary damage and needs assessment is done. The local emergency operations center (EOC) is activated, and a command center is set up in a secure location. The local area immediately puts into motion mitigation for the prioritized and identified hazards. The state emergency management agency (EMA) is contacted to respond and also calls in assistance from other states as predetermined through mutual aid agreements. State assets may well be overwhelmed thus requiring a call for assistance from the governor to the president (McGlown, 2004). A presidential declaration of a federal emergency or major disaster provides assistance to the event as specified in the Federal Response Plan (FRP). Before the actual authorization of federal assistance, FEMA can “authorize critical supplies and equipment such as food, water, generators, or emergency medical teams” (p. 161) (McGlown, 2004) in situations of imminent damage.

In the early 1980s, the U.S. government recognized the need to improve emergency preparedness by establishing the Emergency Mobilization Preparedness Board. The eleven working groups within the board provided the precursors for our present system of emergency support functions (ESFs) allocating functional responsibilities to specific cabinet departments and the American Presidency Project (The American Presidency Project).

Its response to the presidential mandate for health program development resulted in the creation of a single system charged with the responsibility to care for large numbers of casualties from either a domestic, natural, or man-made disaster or a conventional overseas war. Services are expanded to include health and medical assessment, surveillance, surge capabilities, evacuation, definitive care, food, drug and device safety, veterinary services, medical personnel, worker health and safety, weapons of mass effect (WME), mental health, public information, vector control, potable water and solid waste disposal, and mortuary services.

The National Response Framework (NRF) is the basis on which state and local plans are constructed. It is built on scalable, flexible, and adaptable coordinating structures to align key roles and responsibilities across the nation, linking all levels of government, nongovernmental organizations, and the private sector. It is intended to capture specific activities and best practices for managing incidents that range from serious but purely local, to large-scale terrorist attacks, to catastrophic natural disasters (Fig. 15-1). This is the basis of the “all hazards” strategy.

Preparedness planning is lead by the Office of Preparedness Planning (OPP) in order to fulfill Health and Human Services (HHS) responsibilities under ESF8 of the NRF and Homeland Security Presidential Directive (HSPD) 10. The Office of Preparedness and Emergency Operations OPEO leads the HHS and interagency planning and response activities required to fulfill HHS responsibilities under ESF 8 of the NRF and HSPD 10 OPP works to integrate mass casualty preparedness activities, through its surge capacity efforts, across local, state, and federal levels consistent with the National Incident Management System (NIMS). NIMS provides a consistent nationwide template to enable all government, private- sector, and nongovernmental organizations to work together during domestic incidents. It goes beyond the incident command structure by providing a common and universal framework for maximum response regardless of the size of the event.

The National Disaster Medical System (NDMS) is a cooperative asset-sharing partnership of four federal departments and agencies including the Department of HHS, Department of Defense (DoD), Department of Veterans Affairs (VA), and FEMA (Twomey & Goll-McGee, 1999).

One essential element of any disaster response plan is implementing the Emergency Management Assistance Compact (EMAC). This compact provides form and structure to interstate mutual aid crucial to states when local and state services become overwhelmed from a disaster. EMAC is administered by the National Emergency Management Agency (NEMA) and administers liability and reimbursement issues when finances are already strained. Equally important is the inclusion of memorandums of agreement among regional agencies that may have not been affected by the impact of the event and can respond immediately to assist with the response and return to normalcy. Advanced arrangements are not only smart but bring in coordinated interagency support to a damaged infrastructure.

Healthcare disaster response expertise is found globally. In the United States, specialty teams have been formed regionally under the auspices of the Department of Homeland Security (DHS). The Disaster Medical Assistance Team (DMAT) is a group of “volunteers and support personnel with the ability to quickly move into a disaster area and provide emergency medical care or augment the efforts of overloaded local care organizations” (p. 47) (Langan & James, 2005). Deployment conditions may be hazardous and harsh with medical care rendered in field hospitals, tents, or abandoned buildings. These teams are fully equipped and self-sufficient, enabling their immediate response to an austere environment or to augment the response of previously deployed teams and to support overwhelmed local and state resources as necessary. The dynamic response is dictated by need with specific pediatric, burn, trauma, critical care, and international specialty teams augmenting the efforts of a responding DMAT.

“Care and identification of the dead in a Mass Casualty Incident (MCI) can overwhelm a medical examiner/coroner system. Disaster Mortuary Operational Response Teams (DMORTs) were originally formed to support a national level response, enhancing the original unit conceived by the National Funeral Directors Association (NFDA). DMORT also is charged with victim identification and mortuary services in the event of a mass disaster” (p. 32) (Williams, personal communication). These teams have been integrated into the federal system and now fall under NDMS.

DMORT serves to provide the “establishment of mobile morgue operations, forensic examination, DNA acquisition, remains identification, and search and recovery. In addition, DMORT can provide scene documentation, records data entry, embalming and casketing, antemortem data collection, and postmortem data collection, and establish family assistance centers” (p. 48) (Ibid, p. 4) or care teams. Teams may be predeployed for consequence management of planned events (Olympics) or high-profile events.

It is paramount for the forensic nurse to be involved in the disaster management system before a critical incident occurs. This affiliation will provide essential indoctrination to mass casualty responses and establish opportunities for leadership. Preparedness is what unlocks opportunities to respond with other medical relief organizations. Connecting among and within one’s community ideally positions the forensic nurse to contribute effectively to the team of stakeholders.

Roles of the forensic nurse include identifying the dead, recognizing medicolegal issues, supplying information and education, providing direct patient care, and conducting disaster research. There is definite opportunity for specialized role negotiation and role development with the evolving threat of domestic and foreign disasters. The forensic nursing specialty is not limited within or restricted to any practice areas. The role of the clinician is elastic for a forensic nurse specialist responding to disasters. The dimensions of the clinical forensic nurse specialist embrace research, the experience of peers, and consults with those in other disciplines. Forensic nurse leaders manage clinical staff and advise in protocols and response, adhering to the scope and standards of forensic nursing at each practice effort. The scope and standards of forensic nursing practice state that “the victim can be the client, the family, the perpetrator and the public in general” (IAFN, ANA, 2007). Disaster response satisfies advocacy to all these areas serving “the client and the family” affected by the catastrophic event, and the “public in general” with a security focus for reasons to which the forensic nurse specialist must be knowledgeable.

In light of the medicolegal aspects and potential of man-made and natural disasters, forensic nurses bring to these teams the ideal cross training, versatility, and expertise on which the team’s success, specificity, and efficiency rely. The legal aspects of various man-made disasters call for the recognition, collection, and preservation of evidence at the scene, when possible, concurrently with treatment to the individual. The medicolegal aspect of any disaster extends itself from the inception of the event through the recovery phase for cause and manner to support and adjudicate the findings as presented throughout the legal process. The timely and efficient identification of disaster victims satisfies the natural inclination and emotional strain of loved ones to give remains a proper burial. The scientific identification of a victim provides the basis for the issuance of the death certificate. This legal document is required for the settlement of estates and wills, payment of life insurance benefits, and other legal actions such as the remarriage of survivors.

Those affected by natural catastrophes may be aggravated by the human error or carelessness underlying the medicolegal aspects from substandard construction codes. Other areas of concern are nuclear reactors built without sufficient infrastructure to guard against radiation hazards, improper engineering and construction of dams and levees, and design flaws in transportation systems. The forensic nurse aware of the link between the primary and secondary impact does not understate this type of secondary victimization.

Another focus that the forensic nurse specialist involved in disaster response ponders, predicts, and addresses involves current and future public needs for information, education, and guidance about health and environmental threats or concerns as a direct result from the disaster. The forensic nurse clinician improves clinical skills through an extensive knowledge base augmented with experience expanding the professional capabilities into advanced practice nursing capacities. These include, but are not limited to, clinical response, family assistance, and forensic processing.