Oral Health Professionals Within State-Sponsored Medical Response Teams: The IMERT Perspective

In 1999, the State of Illinois recognized the need for a trained and credentialed medical response that can respond to any disaster within the state and will bring health professionals, logistical support, supplies, and equipment to assist local providers when their resources are overwhelmed. The following article reflects on the historical background of the Illinois medical emergency response team, its team development, partnerships, activations, and future directions with the integration of oral health care professionals as a vital resource for emergency response.

There has always been a need for comprehensive, well-trained medical response teams in disaster events, including environmental catastrophes (eg, hurricanes, tornadoes, floods) and extreme heat and cold. Natural and man-made disasters, such as pandemic flu and industrial spills, respectively, can challenge our communities. They also include acts of terrorism, including chemical, biologic, radiologic, and nuclear warfare and explosives (CBRNE). Medical support during these times of domestic crises plays a significant role in the overall preparedness, response, and mitigation of such events. Federal teams have been well established in the form of disaster medical assistance teams (DMATs) . A broad array of health care professionals has participated in DMATs, including dentists. Federal and local responses historically have formed a medical response in a disaster event. What has been lacking is an integrated state-based response team. In 1999, the State of Illinois recognized the need for a trained and credentialed medical response that can respond to any disaster within the state and bring health professionals, logistical support, supplies, and equipment to assist local providers when their resources are overwhelmed. With public health leadership, collaboration with nongovernmental agencies, and state public health allocation of federal funds, a volunteer team was created called the Illinois Medical Emergency Response Team (IMERT). This team included a broad array of individuals, including oral health care professionals, such as oral surgeons, dentists, and dental health hygienists. The following article reflects on the historical background of IMERT, its team development, partnerships, activations, and future directions with the integration of oral health care professionals as a vital resource for emergency response.

Historical background

Early in 1999, in response to the increased focus on terrorist threats and concern about deployment of weapons of mass destruction (WMD), a small group of emergency physicians, toxicologists, and emergency nurses began meeting with the Division of Emergency Medical Services of the Illinois Department of Public health (IDPH). Their initial intent was to assess the level of awareness and preparedness of emergency department personnel in Illinois to respond to a large-scale WMD incident. Such incidents would likely overwhelm public health agencies . During this period, planning was underway to enhance emergency preparedness for a major incident in many large cities (eg, metropolitan medical strike teams) . The Illinois group realized that the state needed a network of coordinated mutual support and a more systematic approach in the response to a large-scale catastrophe. The group realized that it was important to develop organized protocols, formalize communication systems, and recognize a core of specially prepared responders to assist in a case of mass casualty or WMD event. These responders also must be educated, trained, and cognizant of command systems.

In the summer of 1999, IDPH applied for and received a grant from the Centers for Disease Control and Prevention, which provided seed funding for IMERT. The funds were earmarked for the development of educational programs on emergency preparedness and the creation of infrastructure and equipment needed for medical response teams. Subsequent funding streams have been the Health Resources Services Administration, administered by IDPH, and Department of Homeland Security grants, administered by the Illinois Terrorism Task Force. The IMERT executive council was created to serve as oversight for IMERT. IMERT executive council members, who are emergency physicians, dentists, emergency nurses, and paramedics with extensive experience in emergency medical services (EMS) and disaster planning, are volunteers. They maintain leadership positions in their areas of employment. There are also selected individuals with military and technical expertise. The IMERT executive council has liaisons with advisors from IDPH, the Federal Bureau of Investigation, the US Public Health Services, and the Army Civil Support Team.

The mission of IMERT is to respond to and assist with emergency medical treatment at mass casualty incidents, including—but not limited to—environmental, chemical, biologic, and radiologic incidents, when activated by the director of IDPH or designee. IMERT is an integral part of the state medical disaster plan as depicted in the organizational chart ( Fig. 1 ).

Fig. 1
Illinois medical disaster plan organizational chart.

Team development

The initial teams proposed consisted of a physician, nurse, an advanced life support specialist (EMT paramedic or intermediate), and a basic life support specialist (EMT-B). Their requirements were based on those advocated by federal DMATs but tailored toward the needs of the state. The requirements include online training composed of the National Incident Management System (NIMS), Federal Emergency Management Agency (FEMA) Incident Command System (ICS-100, -200), and a government-approved WMD course. Additional online training for administrators and training staff include the National Response Plan (NRP) IS-800 . The team member applicant is also required to have current and unrestricted Illinois state licensure appropriate for his or her health care position. There is also a “boot camp” training session ( Fig. 2 ). The first session was launched in June 2002. Boot camp is comprised of didactics on command structure, Illinois disaster medical response plan, equipment training, and various clinical skills workshops. Boot camp provides for team building and allows active members to participate in training sessions. In addition to online training and boot camp, the applicant also signs a “code of conduct” adapted from similar documents from federal teams and reviewed by a medical ethicist (coauthor Dr. B. Heilicser). Once members have completed requirements designated for their positions, they maintain their membership status by being on call for 2 weeks every 6 months and participation at least twice a year in drills or education activities or both. These extensive requirements ensure membership commitment and permit the various health care and non–health care volunteers to have the same baseline level of knowledge. For example, a dental health care professional has experience with intraosseous insertions or learns to provide mass medical triage, items not typically presented in their daily practice. In addition to the inherent benefits of volunteer service to one’s community, IMERT provides continuing education certificates for members based on their level of activity. These certificates can contribute to meeting a health care professional’s state licensure requirements, including dentists.

Fig. 2
IMERT boot camp activity (setting up medical care tents).

The initial medical team has expanded significantly as more diverse individuals have expressed interest and IMERT has evolved and learned from each event, drill, or deployment. There are three types of teams: the general team, the state WMD team, and the urban search and rescue team. Overseeing these teams are command teams based on NIMS command structure with specific titles and duties. Knowledge of and compliance with NIMS allows IMERT to have parity with other agencies in terms of nomenclature and responsibilities. The command staff provides tactical and strategic support for the medical teams. Their main mission is to allow the medical teams to perform their duties in an efficient and productive fashion. The general teams have expanded their roster to include dentists and dental hygienists. Mental health professionals and pharmacists have been included. It also became evident that administrative support is critical in allowing practitioners to function properly. This acknowledgment led to the addition of safety, communication, logistical, and information technology specialists. There are two general teams on call at all times in each of the four regions in Illinois. The four regions are divided according to the Illinois Emergency Management Agency (IEMA) divisions ( Fig. 3 ). IMERT responds within 4 hours of activation. IMERT may be tasked upon to mitigate an event or as an interim measure until the arrival of federal resources in a declared state of emergency. Federal support is extensive and massive, but it would take an average of 72 hours to mobilize . IMERT members are given specific recommendations to be self-sufficient for at least 72 hours.

Fig. 3
IMERT regions.

The IMERT state WMD team is the medical component of the Illinois state WMD. The Illinois state WMD team is a multiagency for the investigation and mitigation of a WMD incident. It consists of State of Illinois employees from the Illinois State Police, Illinois Environmental Protection Agency, IDPH, IEMA, and the Office of the State Fire Marshall . The IMERT Urban Search and Rescue Team supplies the medical component to the Illinois Task Force 1 Urban Search and Rescue . IMERT provides two medical teams on call at all times with these groups. Another group that germinated from IMERT is the Illinois Nurse Volunteer Emergency Needs Team (INVENT). They are activated to enhance an IMERT response and provide initial recovery phase health care.

This formalized approach to a medical response team provides collaborative opportunities for dentists and other oral health care professionals. In 2006, there were more than 9500 licensed dentists, and 80% were general dentists in Illinois . Dentists have extensive knowledge of basic sciences and clinical skills and can be a valuable resource for emergency medical surge demands. A New York University Dental and Medical School 2002 survey of health professional leaders, including dental/medical school deans and dental/medical society presidents, showed a general agreement that dental professionals have an ethical obligation to assist during catastrophic events, but they also noted that they need disaster training and curriculum . Dentists in the military have been shown to be capable of mass casualty triage . Several publications have noted the potential role of dental professionals in emergency response . A 2006 survey of dentists in Hawaii showed that only 2.3% of respondents reported having received prior bioterrorism preparedness training, and 14.5% felt that they were able to identify and recognize a bioterrorism event. A total of 73.8% indicated a willingness to provide assistance to the state in the event of a bioterrorism attack . These findings lend support to the need for educational and training programs in order for dental health professionals to be properly prepared to assist a state. The dental community has much to offer in a disaster; they could assist in triage, medical evaluation and treatment, delivery of inoculations, providing analgesia, and health care administrative skills.

As the team composition evolved and grew, it became apparent that administrative and logistical supports are critical to optimal function of the medical teams. Their responsibilities include, but are not limited to, ensuring the safety of team members and the response site, maintaining adequate supplies, maintaining reliable lines of communications, providing information technology support, and ensuring reliability and safe transport of equipment. The primary goal of these team members is to guarantee the ability of the medical teams to deliver their services to the state of Illinois. Individual medical team members who have met the requirements for these roles have taken on logistical and administrative assignments, which provide another avenue of participation for oral health care professionals with additional nonclinical expertise.

The growth of the team in complexity and numbers requires a vast array of educational and training offerings. One advantage of a dental professional volunteering in IMERT is that the course requirements are also applicable to their daily work environment. For example, the NIMS curriculum from FEMA has been developed for responders. This common knowledge base allows responders from different jurisdictions and disciplines to work together in response to natural disasters and emergencies, including acts of terrorism. Some of the highlights include a unified approach to incident management, standard command and management structures, and emphasis on preparedness, mutual aid, and resource management . The entities required to be NIMS compliant are governments and organizations that receive federal grants. The implications for NIMS compliance are broad and affect governments, corporations, and nongovernmental organizations. IMERT members are all NIMS compliant and have insight into the importance of an incident command structure to any response situation. In addition to the required course work, IMERT members are provided with numerous educational and training programs, many in collaboration with other agencies. Some examples of these programs are cadaver workshops that demonstrate anatomic aspects of certain IMERT clinical skills, IMERT-sponsored and -developed domestic preparedness courses, the annual IMERT conference, advanced hazmat life support, equipment training sessions, incident command training courses, explosives and bomb response programs, simulation mannequin workshops, and basic trauma life support through the International Trauma Life Support Organization, Advance Cardiac Life Support, and National Disaster Life Support programs.

The National Disaster Life Support program is worthy of further discussion. National Disaster Life Support program is a collaborative effort among the American Medical Association, the Medical College of Georgia, the University of Georgia, and the University of Texas, with federal appropriations managed by the Centers for Disease Control and Prevention. In 2004, the National Disaster Life Support educational consortium offered a train-the-trainer program for providers in Illinois. IMERT was in the unique position to extend this offer to their member leadership. As a result of that effort, two IMERT leaders, one of them an oral surgeon, became course directors and have been able to provide the coursework for members and other professionals in Illinois. The program provides varying levels of knowledge and skills in all hazards topics and response for the health care and non–health care community (core disaster life support) to the basic and advanced medical professional. The advance disaster life support course offers an advanced practicum using medical simulation mannequins and technology that are at the forefront of medical training . The simulations include scenarios with CBRNE-related events. The Disaster Emergency Medicine Readiness Training Center in Chicago, Illinois is one of the training sites. The Center has instructors and program directors who are also IMERT members. The Disaster Emergency Medicine Readiness Training Center has particular relevance to the dental community. It is housed in the University of Illinois, College of Dentistry. The Disaster Emergency Medicine Readiness Training Center prepares health care professionals within the Sate of Illinois, FEMA Region V, and the nation. It also focuses on the role of the oral health care professional in bioterrorism and disaster response . It began with initial Health Resources Services Administration funds allocated by IDPH and funds from the Centers for Disease Control and Prevention, which gives validation toward the important leadership role that oral health care professionals can contribute to emergency response.

Credentialing and indemnification are two important factors in the provision of reliable emergency response in a mass casualty event. These issues were particularly evident on September 11, 2001, when medical providers responded to the World Trade Center attack without readily available credentials, insight to their level of training in disasters, lack of knowledge of command structure, and lack of oversight . This led Congress to authorize federal authorities to assist states and territories in developing emergency systems for the advance registration of volunteer health professionals (ESAR-VHP). Through advance registration, it is proposed that volunteers will be vetted, trained, and mobilized more effectively during emergencies . The end result is a reliable and identifiable health care professional capable of integrating into the overall response to an event with oversight by the sponsoring organization. IMERT’s inherent structure has set forth the components necessary for meeting a program such as ESAR-VHP.

Although ESAR-VHP addresses the professional integrity of a health care volunteer, it does not address the liability issues. The legal environment of volunteer health care professionals is complex and ambiguous at best. Some recommendations proposed include minimum legal standards, balanced liability protections, and compensations for harms to volunteers . The Illinois legislature has enacted several laws called Public Acts that address some of the challenges in meeting the legal protection of such volunteers. IMERT is covered under Public Act 92-597 or the IEMA Act last amended in June 2002. The state, under the IEMA Act, extends workman’s compensation and liability coverage and reimbursement for the response if there is a gubernatorial disaster declaration . This has offered a certain level of comfort for IMERT volunteers, their employers, and their families. Another legislative support for emergency responders is Public Act 94-409 signed into law in August 2005, which includes the definition of a dental emergency responder, which modifies the scope of practice of dentists in Illinois who respond to emergencies from local to state. The dental emergency responder is a dentist or dental hygienist “acting within the bounds of his or her license when providing care during a declared local, state or national emergency” . This law allows for legal recognition of a dental professional as a valuable health care resource in a disaster.

Team development

The initial teams proposed consisted of a physician, nurse, an advanced life support specialist (EMT paramedic or intermediate), and a basic life support specialist (EMT-B). Their requirements were based on those advocated by federal DMATs but tailored toward the needs of the state. The requirements include online training composed of the National Incident Management System (NIMS), Federal Emergency Management Agency (FEMA) Incident Command System (ICS-100, -200), and a government-approved WMD course. Additional online training for administrators and training staff include the National Response Plan (NRP) IS-800 . The team member applicant is also required to have current and unrestricted Illinois state licensure appropriate for his or her health care position. There is also a “boot camp” training session ( Fig. 2 ). The first session was launched in June 2002. Boot camp is comprised of didactics on command structure, Illinois disaster medical response plan, equipment training, and various clinical skills workshops. Boot camp provides for team building and allows active members to participate in training sessions. In addition to online training and boot camp, the applicant also signs a “code of conduct” adapted from similar documents from federal teams and reviewed by a medical ethicist (coauthor Dr. B. Heilicser). Once members have completed requirements designated for their positions, they maintain their membership status by being on call for 2 weeks every 6 months and participation at least twice a year in drills or education activities or both. These extensive requirements ensure membership commitment and permit the various health care and non–health care volunteers to have the same baseline level of knowledge. For example, a dental health care professional has experience with intraosseous insertions or learns to provide mass medical triage, items not typically presented in their daily practice. In addition to the inherent benefits of volunteer service to one’s community, IMERT provides continuing education certificates for members based on their level of activity. These certificates can contribute to meeting a health care professional’s state licensure requirements, including dentists.

Jun 15, 2016 | Posted by in General Dentistry | Comments Off on Oral Health Professionals Within State-Sponsored Medical Response Teams: The IMERT Perspective
Premium Wordpress Themes by UFO Themes