Last Responders: Arkansas Funeral Homes And Coroners Prepare For Rising Death Toll
Funerals aren’t what people want to think about during a pandemic. In a moment when every ounce of health care workers’ energy is poured into preserving life, when the entire globe is engaged in a concerted effort to stave it off, dwelling on the death count feels borderline treasonous. Then again, death isn’t something people want to think about under normal circumstances, either.
“This is a job that everybody tends to forget about, because we deal with death,” Pulaski County Coroner Gerone Hobbs said. "It’s that thankless job, until it’s your family member. … I hope that people realize that we play a very important role, that we’re what we call the ‘last responders.’ You’ve got the first responders, and they’re gonna try to stabilize, and if they cannot, we’re the last responders. That’s the coroner’s office.”
“The hardest deaths that we deal with in the industry are the unexpected ones,” Justin Wittenberg, CEO at Ruebel Funeral Home in Little Rock, said. “The ones where someone dies in a car wreck, or you were with them that morning, and then they’re gone that afternoon.
“We have such a culture of hospices and nursing homes where people tend to slowly decline,” Wittenberg said, “and family and friends get to go and see them, to visit with them and come to terms with passing away.” But COVID-19 can kill within days, and the sick are typically quarantined away from their loved ones. “We’re gonna slowly start encountering clients who have passed away from COVID-19 and were otherwise healthy people, and we know that that’s gonna be very difficult for these families.”
Funeral home staff, like medical examiners and coroners, are considered “essential workers” during the pandemic. That is, while the rest of us are trying to navigate Zoom and AMI school packets, those in the funeral industry are navigating potentially risky cremation and burial procedures. “We’re out here, just like we were during the HIV/AIDS crisis,” Hobbs said. “Just like hospitals and the police departments, our office doesn’t close.”
The Pulaski County coroner’s office certifies about 5,500 deaths a year — “a lot of cases for a nine-member team,” Hobbs said. As of April 6, Arkansas has had 16 confirmed COVID-19-related deaths, and the virus had spread to at least 64 of Arkansas’s 75 counties. Without widespread testing in the state, though, it’s difficult to know how many cases of the virus Arkansans are incubating, particularly since the disease can present itself without symptoms, as in the case of state Rep. Reginald Murdock (D-Marianna). Death tolls are soaring in hotspots like New York City and Los Angeles, and more southerly states like Florida and Louisiana are following in their footsteps. Hobbs’ workload — and the workload of cases around the state — can reasonably be expected to rise sharply in coming weeks, even if many COVID-19 deaths are certified by an attending physician, and therefore don't require a visit from the coroner. PULASKI COUNTY CORONER: Gerone Hobbs.
Wittenberg’s job can be demanding even in normal times. “We really work 24/7 … because people pass away at all times of night. Everybody that I know in the funeral industry knows that, and they get a sense of joy and pleasure out of their job by helping people out of the norm, not in this square box of 9 to 5.” Ruebel, like most funeral homes in the state, supplements its full-time staff with a roster of part-time staff it can deploy should business exceed what the staff can handle.
Kevin Cleghorn, the Saline County coroner and the president of the Arkansas Coroner’s Association, anticipates that resources will be strained in upcoming weeks. “If we have those projected numbers and they come pretty rapidly, that’s going to overwhelm our hospitals," he said "It’s gonna overload our coroner’s offices. It’s gonna overload the funeral homes.”
“And keep in mind,” Hobbs told us, “We still have homicide. We still have car accidents. We still have suicide on top of this COVID-19.”
Those who deal with the dead may also expose themselves to infection. Unlike the Ebola virus, the primary means of coronavirus transmission is through the respiratory system, and human remains of those who died from the coronavirus don’t pose the same threat as those transmitted through the blood or other bodily fluids. The World Health Organization notes in a set of guidelines issued March 24 that to date, there is no evidence of a living person being infected with coronavirus from exposure to a dead body. Nevertheless, those guidelines recommend a rigorous hygiene and PPE protocol for those coming into contact with a dead body and recommend that funeral homes instruct any visiting family members not to touch or kiss the deceased.
Typically, Centers for Disease Control says in a set of guidelines issued in March 2020, “spread from a living person happens with close contact (i.e., within about 6 feet) via respiratory droplets produced when an infected person coughs or sneezes, similar to how influenza and other respiratory pathogens spread,” but adds that “this route of transmission is not a concern when handling human remains or performing postmortem procedures.” Still unknown, though, is exactly how long the virus may stay active in the respiratory system after death, and whether viral matter that remains on the deceased’s skin can transmit infection to a person who handles the remains. “It may be possible,” those CDC guidelines say, “that a person can get COVID-19 by touching a surface or object that has the virus on it and then touching their own mouth, nose, or possibly their eyes, but this is not thought to be the main way the virus spreads.”
“The health care workers are still on the front lines, and we love them for it … [but] with the funeral home industry and the medical examiners and the coroners, we’re taking a risk as well,” Hobbs said.
Part of that risk, too, is complicated by the same supply chain shortages the health care industry faces. Both the Pulaski County Coroner’s office and Ruebel Funeral Home, for example, keep PPE (Personal Protective Equipment) on hand at all times, and use it year-round. Josh Taylor, the manager, funeral director and embalmer at Ruebel, orders all the embalming supplies and chemicals the mortuary portion of Ruebel's business needs, but says stockpiling any additional resources in anticipation of a rising death count has been tricky.
“Luckily, I’ve been a planner," Taylor said, "so I have a lot put back for year-round use. … But I have run into difficulty trying to get PPE from our regular suppliers. In most instances, they are out of PPE. With gloves and some of the disinfectants that we use, certain companies are putting limitations on them, and I’ve had to look for additional resources elsewhere, which have been very difficult to find.”
“We have coroners all across our state that are having trouble getting PPE,” Cleghorn said. Coroner’s offices around the state vary not only in their size, but in their levels of dependence on other entities, like funeral homes. The Saline County coroner’s office, he said, is “a standalone entity,” and maintains its own supply of PPE. “We keep on hand gloves, we have arm sleeves, footwear, Tyvek suits, N95 masks, face shields. Even in a regular setting, before COVID, if we got into situations where we needed more advanced gear than we had, we have resources we can contact and have them respond. Even now, with COVID-19, Tyvek is very appropriate, and will protect your clothing and protect your arms.”
Asked how he protects himself when he comes home from the job, Hobbs laughed and said, “I’m blessed to have a garage!” With the safety of his wife and kids in mind, he told us, his routine was one established well before COVID-19 arose. “I strip immediately, I have hand sanitizer, and I put my clothes in the washer. I go in and wash my hands and take a shower.”
Will supply levels be enough? “For what we’ve seen in our county,” Cleghorn said, “what we have is adequate at this point in time. However, if the projections come true that are being seen on the national scale, and what the governor has put out in his press release, no. It won’t be adequate in our state, period … we’re talking about PPE for police, firefighters, coroners, paramedics, EMTs and funeral directors. That is a mass amount of people.”
Another big question mark: the availability of a post-mortem testing procedure for COVID-19.
CDC recommends that “medical examiners, coroners, and other healthcare professionals should use their judgment to determine if a decedent had signs and symptoms compatible with COVID-19 during life and whether postmortem testing should be pursued,” weighing both specific medical conditions of the deceased as well as broader epidemiological factors, like whether the death was “a part of a cluster of respiratory illness in a closed setting (e.g., a long-term care facility).”
Neither the Saline County nor the Pulaski County coroner’s offices have access to those tests, though. Cleghorn said it’s “very rare” for an Arkansas coroner to have access to testing at the moment, though a few hospitals have worked closely with their local coroners to assist with testing. “And that has been a huge asset in those areas. But not every county has a hospital. Not every county has those relationships.”
“Right now, we’re trying to get test kits available to us,” Hobbs said. “Those kits are hard to come by. It’s a question I’ve asked the health department, and nobody can give me an answer.”
Arkansas coroners’ offices, Cleghorn said, have received a set of COVID-19-specific screening questions from the CDC, to be asked by a 911 dispatcher, EMT or police officer when a death occurs at an Arkansas home. They include asking what sort of symptoms they may have had prior to dying, and whether the deceased left the country or state recently, although that last question becomes increasingly less relevant as the virus spreads within Arkansas state lines. “This is a whole new screening process … There have always been established questions that you ask for officer safety, or for the safety of our responders,” Cleghorn said, “but since COVID-19 came into play, they’ve had to adjust those questions.” If that screening process indicates COVID-19 may have been a factor in the deceased’s death, Hobbs said, the case is escalated to the health department or to the medical examiner’s office. Without adequate testing, though, some COVID-19 deaths may be undiagnosed as such, and therefore undercounted in reports of statewide death rates. “As soon as we can get some test kits,” Hobbs said, “we’ll start swabbing if they fall under those guidelines, with those symptoms.” As for Ruebel Funeral Home, “every one of our clients that comes in, we are treating them as if they had COVID-19," Wittenberg said. "That’s just the safest way to do it. We're trying to limit the amount of contact that anyone has with the deceased.”
In the past, Ruebel has allowed families who plan to cremate their loved ones to see the unembalmed bodies before the cremation process; now, the bodies must be embalmed beforehand. “Once the body’s embalmed, in theory,” Wittenberg said, “the COVID-19 has all been destroyed. … . So that’s a little bit of a change, and it’s a little more expense for the family. And that's unfortunate, but we’re trying to contain a disease.”
Arkansas families experiencing a death, whether a result of COVID-19 or unrelated, will also begin to see some changes in the way they grieve -- particularly, whether they can grieve together. “At this point, we have to limit all indoor gatherings to 10 or fewer people,” Wittenberg said. As Ruebel’s CEO, it’s Wittenberg’s job to enforce those limitations. “I know my staff well,” he said, “and they will want to say yes to these families.” Ruebel, like many funeral homes, is equipped to conduct memorial service remotely, by video, but families have been reluctant to use those services, choosing instead to delay funerals altogether.
“They’re saying to me, ‘No, we want to be around people, and to celebrate this person’s life with friends and family. When we’re allowed to do that, we’ll do it.’ And I totally understand. That’s what a funeral is for, to get together and show love and support for each other and share their memories and reminisce on this person’s life. That’s how we heal — as a community.”
The new normal could last a long time, Wittenberg said. “I’m thinking that as this progresses and goes on longer and longer, I’ll get more families saying, ‘We originally thought we were gonna have to delay, but how much longer can we delay?' ”
This reporting is courtesy of the Arkansas Nonprofit News Network, an independent, nonpartisan news project dedicated to producing journalism that matters to Arkansans.