This article examines the dental professional’s role in emergency management activities, specifically related to design and execution of such federal exercises as the Top Officials (TOPOFF) series. Experiences from the Chicago TOPOFF 2 exercise are used as an example.
The vulnerability of our nation to disasters, both natural and man-made, has become abundantly clear in recent years. It is necessary that we use the composite knowledge, creativity, expertise, and all available human resources if we hope to successfully prepare for, respond to, and recover from these devastating events. Our concept of man-made disasters has been tragically broadened from accidental chemical spills and nuclear reactor radiation leaks to the horror of terrorism in all of its destructive forms. We have become familiar with such terms as asymmetrical warfare, the unthinkable tactics used when another belief system or country fights someone much stronger or of greater military might. We are haunted by the visions of death and disease as we consider and create scenarios for pandemic influenza.
In the past, the dental professional’s role in disasters has been limited to the field of forensic dentistry . In real life, through forensic dentistry and the application of dental and paradental knowledge, the living and the dead can be identified. In some cases, cause of death can be determined, with all of the associated legal and criminal ramifications. In the unreal world of theater and film, however, the dental profession is often portrayed somewhat differently. Films have evoked images of dentists as villains and evil indeed. The former Nazi torturer, Dr. Christian Szell (Lawrence Olivier), used his dental drill to torture Thomas Levy (Dustin Hoffman) in the 1976 film “Marathon Man.” Then there were the insane dentists: Dr. Alan Feinstone (Corbin Bernsen) as the murdering dentist from the 1996 movie “Dentist” and Dr. Orin Scrivello (Steve Martin) in the 1986 cult classic “Little Shop of Horrors.”
Far beyond these images, both real and imagined, lies the much greater perspective of the role and importance of the trained dental professional during times of crisis . The role of the dental professional as a source of information, reassurance, medical care, dispensing of antimicrobial agents or vaccines, and guidance during a disaster must not be minimized. If we are to survive as a nation after disaster, we must use all of the resources, training, and expertise at our disposal. This article examines the dental professional’s role in emergency management activities, specifically related to design and execution of such federal exercises as the Top Officials (TOPOFF) series. Experiences from the Chicago TOPOFF 2 exercise are used as an example.
The effects that a massive disaster can have on society and resulting societal disruption have been seen clearly here and abroad in recent years. Hurricane Katrina was a defining moment for us in preparedness and response to natural disaster, as was the 2004 Indian Ocean tsunami on a global scale and September 11th for homeland security in the United States. The stark realization of our vulnerability and desperate need for preparedness and interaction of sectors became abundantly clear. Historically, dental professionals, including dentists, hygienists, dental assistants, laboratory technicians, and all others considered to be dental auxiliaries, have been poorly used in these national response activities . This lack of involvement has resulted in a plethora of questions as to their importance should an event actually occur.
Potential roles for the dental professional
There are many areas in which dental professionals may provide assistance, depending on the specifics of the disaster and needs of the community . The following list includes a few of those areas, as suggested by Dr. Guay and others:
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Surveillance and notification
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Diagnosis and monitoring
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Referral
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Medications
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Triage
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Medical care augmentation
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Decontamination and infection control
The vital need for persons to assist with medical tasks takes on new meaning when considering that only 50% of health care workers (eg, doctors, nurses, and hospital workers) said they would report to work during a potential outbreak of avian flu . Experts suggest that a specific dental emergency response plan, along with its own command and control structure, be in place . This plan must be fully integrated into the overall area plan and well communicated to the professional dental societies.
Alfano stated that “One group that will be ready, based on the ADA’s leadership, is the nation’s dentists, who will play a far more important role in preparedness and response than anyone ever imagined in the dark days of September 2001” . A central role for public health in disasters involving infectious diseases, and one in which nontraditional professionals could be of great importance, would be at the points of dispensing (PODs) of antibiotics and vaccines. This area is of vital importance to decreasing disease-associated morbidity and mortality. In many cases, the needed tasks are part of the day-to-day routines for individuals in the dental profession.
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As people entered the POD, visual triage would take place to identify and remove persons who are exhibiting symptoms. In the dental office, patients would be viewed in a holistic manner. Skin, eyes, gum tissue, voice, and stature would be appraised while seating the patient.
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Individuals seeking medications at the POD would be required to complete a medication administration record or a mini health history. These documents would be reviewed before movement into the dispensing area. Questions would be asked regarding medications or illnesses that could preclude them from receiving certain medications. Every patient in a dental office is requested to complete a medical history form regularly and update at each visit. The members of the dental team would review these documents and provide services accordingly.
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Regardless of the type of medications dispensed at the PODs, whether injections or pills, dentists and hygienists are trained to provide them. These skills are required when attempting to prevent the spread of a pandemic or other type of disease. States may have certain restrictions, but based on emergency powers acts, these restrictions may be lifted in a major public health event. In dental practices across the country, dentists give injections daily. Some states give this same licensure to hygienists.
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Use of personal protective equipment may be necessary. First responders and individuals called upon to assist must know how to use and remove personal protective equipment. The members of the dental team have long used masks, gloves, smocks, and aprons. Their expertise could be taught to persons who are called upon to assist during an emergency of this type.
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Certain areas of the POD would have to be cleaned to ensure an aseptic field. This is an area of expertise held by workers in the dental field and a skill needed at the PODs.
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Dental professionals are trained in cardiopulmonary resuscitation and first aid, skills that are greatly needed during disasters of any type.
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Dentists have expansive knowledge and great credibility. They are recognized leaders and members of social and philanthropic groups. They are well known for “giving back” to their neighborhoods and could recruit other volunteers to assist in the emergency operations.
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Dental professionals have knowledge of the many community resources. Many have provided services in schools and are aware of how best to care for children.
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Dental professionals are excellent at record keeping, another critical skill needed for the recovery phase.
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Dentists and hygienists could be recruited easily through their professional societies. The requirement for continuing education credit would make the education desirable.
Evolution of the federal Top Officials series of exercises
Before the September 11th attack and in response to such events as the 1995 sarin gas attack in the Tokyo subway, in 1988, Congress mandated that the Department of State and Department of Defense conduct a series of challenging role-playing exercises that involved federal, state, and local levels . They would be national level, multiagency, multi-jurisdictional, real-time, limited notice events in response to terrorism involving weapons of mass destruction. The TOPOFF events are held in various locations in the United States and abroad.
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TOPOFF 1, 2000: Portsmouth, New Hampshire and Denver, Colorado
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TOPOFF 2, 2003: Chicago area, Illinois, Seattle area, Washington, and Canada
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TOPOFF 3, 2005: Union and Middlesex counties in New Jersey, New London, Connecticut, and the United Kingdom
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TOPOFF 4, 2007: Portland, Oregon, Phoenix, Arizona, and Guam (to be held in October 2007)
Evolution of the federal Top Officials series of exercises
Before the September 11th attack and in response to such events as the 1995 sarin gas attack in the Tokyo subway, in 1988, Congress mandated that the Department of State and Department of Defense conduct a series of challenging role-playing exercises that involved federal, state, and local levels . They would be national level, multiagency, multi-jurisdictional, real-time, limited notice events in response to terrorism involving weapons of mass destruction. The TOPOFF events are held in various locations in the United States and abroad.
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TOPOFF 1, 2000: Portsmouth, New Hampshire and Denver, Colorado
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TOPOFF 2, 2003: Chicago area, Illinois, Seattle area, Washington, and Canada
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TOPOFF 3, 2005: Union and Middlesex counties in New Jersey, New London, Connecticut, and the United Kingdom
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TOPOFF 4, 2007: Portland, Oregon, Phoenix, Arizona, and Guam (to be held in October 2007)
Homeland Security exercise and evaluation program
The Homeland Security exercise and evaluation program (HSEEP) was designed to assist state and local governments in developing and implementing a state exercise and evaluation program to assess and enhance domestic preparedness . Homeland Security Directive Number 8 directed that the Department of Homeland Security, in coordination with other appropriate federal departments and agencies, establish a “national program and a multi-year planning system to conduct homeland security preparedness-related exercises that reinforces identified training standards, provides for evaluation of readiness, and supports the National Preparedness Goal.” HSEEP provides the program structure, multiyear planning system, tools, and guidance necessary to build and sustain exercise programs that enhance homeland security capabilities and preparedness . HSEEP is described as a capabilities and performance-based exercise program that provides a standardized policy, methodology, and language for designing, developing, conducting, and evaluating all exercises. All HSEEP exercise design objectives draw from the target capabilities list. Fifteen national scenarios were created as the worst case scenarios for natural and man-made disasters . The target capabilities list was created from a consideration of all the capabilities needed to respond to these disasters. The Department of Homeland Security has released its latest draft of the target capabilities list, in which specific areas of activity for dental professionals can be found .
All HSEEP material can be found on the Department of Homeland Security Web site, including the five instructional volumes of the program .
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Volume 1: HSEEP overview and exercise program management
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Volume 2: Exercise planning and conduct
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Volume 3: Exercise evaluation and improvement planning
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Volume 4: Sample exercise documents, formats, multimedia files, and policy guidance for exercise planning
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Volume 5: Prevention exercises
Volumes 1 to 3 are new editions for 2007, whereas Volume 5 is currently in draft form and undergoing revisions. The site contains a wealth of information for individuals involved in exercise design and execution.
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