In November 2003, the New York University School of Medicine and the New York University College of Dentistry, New York City, were jointly awarded a U.S. Department of Justice grant entitled "Enhancing Medical and Public Health Capabilities During Times of Crisis." (The grant subsequently was transferred administratively to the U.S. Department of Homeland Security [DHS].) Both schools are using this grant to develop training programs and training content for dentists that heighten their knowledge of weapons of mass destruction (WMD) and other all-hazards catastrophic events, as well as for their potential inclusion in programs that respond to such events.

	DENTAL CARE PROFESSIONALS

TOP ABSTRACT DISASTER RESPONSE DENTAL CARE PROFESSIONALS METHODS RESULTS CONCLUSION REFERENCES

 
In a number of cases, members of the dental profession have exhibited a strong interest in responding to a bioterrorist event. A 2004 survey of dentists in Hawaii³ indicated that 74 percent of respondents in that state were willing to participate in the response to a bioterrorist attack, but only about 9 percent felt prepared to do so effectively. In Illinois, the state’s Department of Public Health’s Division of Oral Health has successfully integrated oral health care professionals into the emergency medical response system.⁴ Though our report is based on dental professionals’ involvement in disaster response activities, the principles and opportunities discussed for potential disaster volunteers are applicable to a wider range of health care and public health professionals. Clearly, these volunteer health care personnel generally require some familiarity with health care principles and public health principles and practice; they also must be from elective health services, as the typical day-to-day demands on the surviving medical and public health services will continue during any type of widespread event.

Response. The dental profession has responded in a variety of ways to define its roles and responsibilities regarding participation in a response to disasters, whether natural, accidental or terrorist-initiated.^2,5–11 Several authors have proposed competencies and formal education for dental students and dental residents.^8,12,13 A recent report based on the findings of a survey of dental and medical school deans and state dental and medical society presidents concluded that dental professionals not only have the capability to serve as responders to mass casualty events but also have an ethical responsibility to be involved in a response to a disaster.²

Tasks. Some of the tasks envisioned for dental personnel, on the basis of their education and training, include infection control and decontamination, record keeping and data management, limited wound surgery and suturing, managing infections, prescribing medications, distributing medical supplies, administering immunizations, managing victim triage and patient management.^14–17

As proposed above, other health care professionals also should consider their participatory and ethical responsibilities regarding disaster response and training, and the medical and public health systems should consider these workforce sources for integration into disaster response efforts.

Several key nationally organized emergency response programs are in operation, and dental health care professionals should be aware of them. Coule and Horner¹⁸ described one such training program, the NDLS program. We discuss here the national-level emergency response programs that may be of interest to dental and other health care providers.

	METHODS

TOP ABSTRACT DISASTER RESPONSE DENTAL CARE PROFESSIONALS METHODS RESULTS CONCLUSION REFERENCES

 
The foundation for the information presented here is the collective work of a multidisciplinary team of 10 physicians, dentists, informatics specialists and epidemiologists performed during a recent five-year period. These 10 professionals were the core members of a New York University School of Medicine and New York University College of Dentistry project entitled "Enhancing Medical and Public Health Capabilities During Times of Crisis." Members of the project’s core group (with research support from interested dentists, hygienists and research assistants), both independently and as subgroups, were involved intensively during the project’s duration in identifying existing specialty-area training programs, training materials and practical national-level response programs that structurally can incorporate these nontraditional medical personnel. The process also identified enabling regulations (that legally allow a broader range of clinical practice for various health care personnel) and national medical profession– based training/education programs bridging health care disciplines.

Literature and Web sites. The project team conducted literature reviews that generally resulted in the discovery of one or two reports whose citations led to further reports. More importantly, we conducted a similar process of identifying Web sites via the use of Web search engines. We gained direct experience by receiving specialized training (for example, the U.S. Department of the Army’s Chemical, Biological, Radiological and Nuclear Casualty Care Course). In addition, we held discussions with many content and systems experts from a range of organizations and disciplines, which enabled us to benefit from their direct experience in areas such as triage and decontamination and also resulted in program leads. These experts included, but were not limited to, nuclear, biological and chemical specialists from various military commands (U.S. Department of Defense), public health and emergency response specialists from the national to local levels, legislators and members of professional organizations (such as the American Dental Association) with disaster response experience in their portfolios. Again, one lead to a program often triggered identification of further programs. In addition, discussions within the team often led to new directions for program searches or evaluations.

In this report, we describe key national programs of general interest rather than more specialized programs, such as that offered by the DHS Noble Training Center, or long-existing programs such as that offered by the American Red Cross. This report reflects the multidisciplinary, multisource dedicated research and planning conducted across several years to meet the need for a surge response utilizing nontraditional professionals. Clearly, while targeted initially to the dental profession, this information is applicable across many health care fields.

	RESULTS

TOP ABSTRACT DISASTER RESPONSE DENTAL CARE PROFESSIONALS METHODS RESULTS CONCLUSION REFERENCES

 
Key national emergency response programs. Five major volunteer disaster response programs at the national level are of particular interest to health care professionals; however, administration of these programs generally is delegated to state and local authorities. The Federal Emergency Management Agency administers the Community Emergency Response Team (CERT) program,¹⁹ and the Office of the U.S. Surgeon General sponsors the Medical Reserve Corps (MRC).²⁰ The U.S. Department of Health and Human Services (DHHS) oversees the National Disaster Medical Systems (NDMS)²¹ and its several subprograms. DHHS, Office of the Assistant Secretary for Preparedness and Response, implements the Advance Registration of Volunteer Health Professionals program.²² Finally, the American Medical Association (AMA) developed and sponsors NDLS training courses.²³ Table 1 presents these programs and contact information.^1,19–28

MRC. The MRC was developed in 2002 as a system of medical and other health care professionals who serve as volunteers in natural disasters and other emergencies.²⁰ The MRC program, like CERT, is a component of the Citizens Corps. However, the MRC relies on trained and credentialed health and public health personnel to respond in emergencies, with some non– health care professionals serving in administrative capacities.

The MRC works at local, regional and national levels, responding to each community’s defined needs, as well as building an effective communication system at these levels of responsibility.²⁰ The MRC can provide specialized training for front-line volunteers in emergency and public health procedures. Training may include basic life support, CERT training, the handling of hazardous materials, and basic first aid skills for common medical emergencies such as burns, shocks, poisoning and wounds.²⁰ In another role, the New York City MRC is designed to staff points of distribution should mass vaccinations or citywide distribution of medication be necessary.²⁹ All health care professionals in the MRC are volunteers who serve in a broad, well-structured system for local and regional disaster response that can be integrated into a national response if necessary.

NDMS. A more highly structured program for health care professionals is the NDMS.²¹ The NDMS is a federally coordinated system that augments the nation’s medical response capability. The system assists with the national medical response in the event of natural disasters, technological disasters, major transportation accidents and terrorist acts including those involving WMD. Participation in NDMS requires a greater time commitment from health care professionals than that for many other volunteer emergency response programs. Various specialized response teams are organized within the NDMS, including Disaster Medical Assistance Teams (DMATs), Disaster Mortuary Operational Response Teams (DMORTs), Veterinary Medical Assistance Teams (VMATs) and National Nursing Response Teams. Dental health care professionals are most likely to participate in DMATs, although dentists also are key members of DMORTs. Veterinarians are attached to VMATs. Though these are community resources that support local, regional and state needs, these programs also can be deployed for out-of-state operations.

DMATs. DMATs are composed of professional and paraprofessional medical personnel who provide emergency medical care during a disaster. In mass-casualty events, the responsibilities of DMATs include triaging patients, providing austere medical care and preparing for the evacuation of patients. In addition, DMATs also provide primary health care and serve to augment overloaded local health care facilities.²⁴ Moreover, additional training is conducted to prepare members for immediate field deployment, aeromedical operations, equipment use and maintenance, casualty collection, regional evacuation point operations, command and control, and NDMS organizational, structural and administrative requirements.²⁴

DMORTs. DMORTs were developed to provide victim identification and mortuary services in mass-fatality events. Members of DMORTs are activated in disasters, and the multidisciplinary personnel include medical examiners, forensic specialists, dentists, dental and medical assistants, and their administrative staffs. The dental professionals function as forensic odontologists. During an emergency response, DMORTs work under the guidance of local authorities by providing technical assistance and personnel to recover, identify and process victims.²⁵ Specific assistance in the event of a disaster can involve forensic pathology, identification of victims, medical and psychological support, and data administration.²⁵ Currently, 10 regional teams are active, and training is available at an NDMS annual conference and via DMORT online training.²⁵

VMATs. VMATs support the local community in a disaster by providing support for affected animals, including rescue dogs that may become victims, and they have the ability to set up field hospitals.²⁶ VMATs are capable of responding to natural disasters and terrorist events, and they can provide support to the U.S. Department of Agriculture during animal epidemics. VMATs are composed of veterinarians, veterinary technicians, scientists, epidemiologists, toxicologists and other medical and lay support personnel.²⁶

Advance Registration of Volunteer Health Professionals. A legislative approach also exists that promotes an organized system for volunteer health personnel in emergencies via the Emergency System for Advance Registration of Volunteer Health Professionals.²² This program was developed at the federal level by DHHS, which has the responsibility of carrying out the legislation and assisting each state (and territory) in establishing a standardized, volunteer health professional registration system. The intended result is to give each state and territory a database that will allow for the time-sensitive identification and appropriate use of jurisdictional volunteer health professionals in emergencies and disasters by providing verifiable, up-to-date data regarding identity and credentials. In addition, this program should allow for the rapid exchange of health care professionals between states if necessary to respond adequately to a catastrophic event.

The ongoing process of establishing databases for the Advance Registration of Volunteer Health Professionals program requires extensive collaboration among states, professional associations, accrediting organizations and federal partners. The Health Resources and Services Administration has developed interim guidelines entitled "Interim Technical and Policy Guidelines, Standards, and Definitions."³⁰ Pilot testing of the guidelines for physicians, registered nurses and behavioral health professionals began in 2005 with the involvement of 10 states.³⁰

NDLS courses. During the past several years, national-scale disasters, such as September 11th and the postal system– disseminated anthrax event, and natural disasters, particularly Hurricane Katrina, have highlighted the critical need for training for all-hazards threats, and health care professionals recognize this need. The AMA has developed NDLS courses,²³ a preparatory training program for health care professionals and emergency responders in the event of a disaster. The AMA developed NDLS to standardize emergency response training nationwide and strengthen the country’s public health system.^1,23 NDLS consists of a hierarchical series of training courses: Core Disaster Life Support (CDLS),³¹ Basic Disaster Life Support (BDLS),²⁷ Advanced Disaster Life Support (ADLS),²⁸ Decon Disaster Life Support (NDLS-D)³² and the ADLS-Instructor Course³³ (Table 2). Health care professionals can obtain different levels of training in disaster response to meet their interests and needs.

BDLS. BDLS, an eight-hour multidisciplinary course, uses the all-hazards approach to disaster response to educate personnel in the health care professions.²⁷ The BDLS course is conducted in a didactic format in one day or in multiple sessions, and training includes the disaster paradigm, the nature of disasters (including explosive, chemical, biological and nuclear emergencies), as well as psychological aspects of disaster events.²⁷ Health care professionals receive standardized training in all-hazards emergencies and become better prepared to participate as emergency responders. Multidisciplinary training enhances the capability to integrate medical and other professionals in a disaster response.

ADLS. ADLS is an advanced training program available to people who have completed the BDLS curriculum. The ADLS training includes detailed mass-triage operations, use of personal protective equipment, community and hospital disaster planning, media relations and communications during disasters, and mass-fatality management.²⁸ The intensive ADLS course is a two-day program: day 1 consists of a didactic program and day 2 consists of hands-on training in the previous day’s curriculum (for example, practicing triage of patients during a chaotic event).²⁸ The ADLS training enables participants to become better prepared to serve as responders in large-scale emergencies when their efforts are integrated with local response systems.

NDLS-D. NDLS-D was developed to meet the need for trained personnel to provide decontamination in emergencies.³² Participation in the NDLS-D course is open to those who have completed the CDLS course. The eight-hour NDLS-D course provides intensive training in proper decontamination skills for nonmedical providers, particularly hospital personnel.³² Health care professionals with NDLS-D training will be effective surge responders for decontamination in emergencies, an extremely labor-intensive operation.

ADLS Instructor Course. The ADLS-Instructor Course offers health care professionals with ADLS training an opportunity to serve as NDLS instructors. This four-hour course trains health care professionals to conduct NDLS courses.³³ Many types of health care professionals are eligible to serve as instructors to teach NDLS courses to health care personnel.

	CONCLUSION

TOP ABSTRACT DISASTER RESPONSE DENTAL CARE PROFESSIONALS METHODS RESULTS CONCLUSION REFERENCES

 
Formal, integrated multidisciplinary systems that allow health care professionals to participate as surge responders to disasters are in place and under continuing development. Health care professionals other than those from the medical and nursing professions have reported favorable results regarding all-hazards training.³⁴ We have described five primary national-level voluntary programs for disaster response, including disasters pertaining to terrorist-initiated events.

Because of their training and background, dental health care professionals and other health care personnel possess diverse skills that would be a valuable addition to these programs. Dentists and staff members may wish to seek specific training, such as that described above, to enhance their contributions to their communities. Professional societies and educational programs should be encouraged to educate their members in the basics of disaster medicine. They also should provide information to their members about the opportunities that are available to serve as volunteers who contribute to a regulated and integrated surge response.