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Feature
This Side of the Sea of Tranquility
Emergency response experts tackle post 9-11 expectations for dentists
Ann L. Norrlander, D.D.S.
John M. Williams, D.D.S.
Frederick W. Nolting, D.D.S.
Introduction
Northwest Dentistry convened the following roundtable discussion on the emerging issue of dentists' role in post 9-11 emergency preparedness. Participants were Dr. Ann Norrlander, general dentist (Minneapolis), Board certified forensic dentist, and originator, Dental Disaster Identification Team and assistant head of that team to date, member, DMORT; Dr. John Williams, general dentist (Minneapolis), member, Minnesota Dental Disaster Team, and member, Disaster Mortuary Operational Response Team (DMORT) for Region 5; and Dr. Frederick W. Nolting, general dentist (Byron), and Chair, Minnesota Dental Association Wellness, Environment, and Safety Committee's Bioterrorism Subcommittee. The roundtable was held March 7, 2003.
NWD: Please orient the dentists of Minnesota to their new public health role since "9-11” particularly as it relates to bioterrorism threats.
Dr. Nolting: Back in November when we met with Robert Einwick of the Minnesota Department of Health, we weren't even on the radar screen as being part of anything. In all their discussions, the DOH had never even considered the dentists of Minnesota as players. Thus,we are simply trying to get up and running so we can make a contribution in case of an attack. As health care providers who are "nonessential”, we are part of the second tier. . . the third tier being the public.
Dr. Williams: I think now the basic role that dentists will play regardless of "tier” will be making the diagnosis or being part of the surveillance for irregular pathology, for any kind of oral symptomatology, some of the things that may be caused by biohazard material or disease pathogens. The key to containing the effects of any WMD agent is early, accurate, pathogen-specific diagnosis. The reality is that no one has to die from biological WMD agents.
Dr. Norrlander: In addition to that, because of our ability and our position as professionals within this community, we will also be of great assistance to the general public in helping to allay fears, communicating educational ideas to them, and working as an interface between the medical profession, which will be overly taxed at any point, and the public.
Dr.Williams: In 1918 there was a flu epidemic that killed approximately 600,000 persons ã I believe 1,200 in the city of Boston alone ã and in a situation like that, dentists, nurses, and other trained health care providers were asked to come in and participate with medical personnel to fill the gap. Those are the things I think we can be helpful with in terms of what we do on an ongoing basis: going "back to [dental] school”, revisiting some old concepts about patient care and close attention to the overall health of an individual, doing basic diagnosis. That early surveillance is going to be critical. Even if we're not first tier players, if we're doing our job and we know how to report our findings, I think we can be very helpful.
NWD: Then being a volunteer is part of a professional responsibility every dentist automatically understands?
Dr. Nolting: I would say so. As for roles we can play as volunteers, we're likely looking at a two-tiered structure. First would be educating our members and all Minnesota dentists to be able to recognize a bioterror attack, and diagnose and report findings to the appropriate authorities. The second level would be triage and treatment in a temporary clinic setting, wherever that might be. I think dentists will already feel comfortable being identified as the health care professionals standing beside the physicians and nurses should they become ill.
Dr.Williams: I think it's very important that volunteers be affiliated with a recognized emergency organization such as the Minnesota Dental Disaster Identification Team, DMORT, Public Health, the Medical Examiner's Office, or emergency services in the various communities. It has been proved that individual efforts are far less effective than those of a team.
Dr. Nolting: In our area of the state we will follow the Minnesota Incident Management System (MIMS), so when an incident occurs and is declared, there will be a command structure in place. It would be our role to know where we fit in that structure and what we're supposed to be doing. Then there will be a lot of work being done with no wasted motion because we will know the relationships among law enforcement, hospitals, first responders, and all the other components of the response. That's why it is incumbent on everyone, no matter where you are from, to get in contact with your DOH district and find out what the command structure is going to be in your community.
NWD:How close are we to having those things available? Is this just starting?
Dr. Nolting: The effort in my part of the state has been going for more than a year. They have had a tabletop simulation exercise and are now involved in the small pox vaccination program and evaluating that. As of our last meeting, small pox vaccination Phase Two has a working title of "What We Know ã and What We Don't”, which means that a timetable is not yet in place for Phases 2 and 3 of the small pox vaccination.
NWD: Did local emergency response to bioterror attack have to be invented following 9-11, or is there a continuum from what was in place?
Dr. Williams: If something happens either here or outstate, we have to be prepared to deal with it ourselves. What would happen is the feds and DMORT would come in to assist. If they found a situation we couldn't handle, they would take it over. They are quite well trained in all areas of the disease arena. That is what happened in New York.
Dr. Norrlander: However, politically, typically the local people would like to keep things locally controlled. If there are deceased, the Medical Examiner is in charge. Ramsey and Hennepin Counties have indicated they will prefer not pulling DMORT in. However, in a situation with a large number of fatalities where we are just beyond our means, DMORT would be an option. What it takes is that phone call, from whoever is in charge, to the feds to call for the assistance. That is true of the FBI as well. At this point, any federal assistance has to be requested. However, a terrorism situation may throw it into the federal category immediately.
NWD:What is the training needed to be part of the bioterror response team, and where can
dentists receive it? Where does a dentist's skill set fit?
Dr. Nolting: I'd place MIMS first. If that is the command structure that's going to be in place and as a professional you do not know your role, you are going to be in big trouble. If you are integrated into the system, you will know who is in charge of what, where to report your findings, what your role will be once local clinics are set up, where you will be, how patients will arrive, how clinics will be structured, who does triage, how it's organized to set up very quickly, because we won't have much response time. Things get moving sooner. Having that framework is very important. MDA districts coincide with Minnesota Department of Health districts very closely. That helps, too.
Dr. Williams: Two priority roles for dentists will be (1) the surveillance of the various types of pathogens, and (2) if there are large numbers of deceased, there would be the identification process. Dentists would have to be ready to tie that into MIMS.
Dr. Nolting: The MDA is working to develop a two-level training course: first, recognition, diagnosis, and reporting; second, triage and treatment. The goal is to educate everyone on the first level and recruit volunteers for the second.
Dr. Norrlander: The HIPAA seminar model was such an effective way to reach a lot of people quickly. That would be a wonderful way to educate. Bring physicians from the University in a clinical setting to show people what the specifics look like and how they should approach a situation, diagnose and discuss disease entities, then finish with a clinical training session. . .
Dr. Nolting: Use videotape,CD-ROM, follow-up/back-up materials such as reference or field guides to work in support of that kind of training.
Dr. Norrlander: It has to be the educational information first, and it has to be of that magnitude.
Dr. Williams: An essential part of the educational process in terms of keeping the system functional is that everyone has to be on the same page in terms of documentation. It has to be done the same way by everyone, thus everyone has to be trained in the procedure.
Dr. Norrlander: Access to this educational information is critical. It would be very helpful to have some of this "paperwork” on the MDA's website: reporting, forms, and so on, even development of courses that could be taken on the web.
Dr. Williams: DMORT's website has an online learning feature, but it's not complete yet.
Dr. Nolting: The Minnesota Department of Health is developing a curriculum for medical students, they're hoping by June. However, what the Medical School does will be in their system. And, of course, the ADA is developing a curriculum. The people who are about as far along as anyone are at NYU. Dean Alfano had watched the towers go down, and he became personally committed to developing curriculum. Their task became developing curriculum for both continuing and community education for dentists and in school.
Dr. Norrlander: I would love to see NWD carry directions to this educational material in a prominent place, plus an article on a specific current public health topic in each issue.
Dr. Williams: People with a more serious interest could join the Minnesota Dental Disaster Identification Team for educational opportunities that are very helpful.
Dr. Norrlander: Although that team's focus is on the deceased. In these situations we are currently discussing, the focus is on the living. . .
NWD: Is the consideration now that dentists need to let public safety/public health sources know what we need from them?
Dr. Nolting: That is something they have to be made aware of.
Dr. Williams: I think what the MDA subcommittee is doing is probably most critical to that. Hopefully out of this process will evolve what the role of the dentist should be, because right now most dentists don't know what they should be doing.
NWD: How do we let them know the dental community wants to be educated, wants to be a part of this, and wants to be a part of making educated decisions?
Dr.Norrlander: MIMS is the first step in deciding how we are going to be involved. Then within each district we are going to need to have people make contact with other organizations so that on a local level we are familiar with names and faces. It is going to take some legwork on each of our parts to make those initial contacts with people in our "neighborhoods”.
Dr. Nolting:We're going to have to be the ones to initiate contact, to say, "Here we are, our MDA district is ready to help out, where do we fit in your structure?” Each DOH district may have a somewhat different structure ã metro vs. outstate especially. Every community will have a different set of problems. Whatever the framework, we as dentists need to know (1) where we fit in, and (2) what we can do to help, and then train for that role. Our subcommittee is working to organize "a dentist from each district”. So far we are about half done.
Dr. Norrlander: And those people could potentially recruit a few more. . .
Dr. Nolting: They'll have to.
Dr. Williams: I want to re-state that surveillance is going to be the most important part in the role dentists will play, because our offices are designed for specific functions. Physicians are thinking in terms of treating in a medical facility; they may call us into the hospitals to assist. What we will be used for almost immediately is surveillance. [pause] But ã [laughter] The door is open, and anything is possible.
Dr. Norrlander: In any disaster situation, until you are confronted with it, you don't know what you are going to be dealing with, so all we can do is consider the possibilities and be prepared to be flexible.
Dr. Nolting: It may be cliche, but the first step is to start the discussion. The biggest thing from the MDA standpoint is that we are getting people like this together, talking and trying to put that district- and MDA-level structure together. We had never even thought of having a bioterrorism committee before. Our immediate goal is to try to prevent chaos. We need to identify knowledgeable people in our community, then work to get out the information. We have been working on the access issue for 30 years. We don't have that kind of time on this.
Dr. Williams: It's very important to understand that you always want to have experienced people working with non-experienced people ã "match •em up with someone who has done it before”. It is a lot different from reading a book.
NWD: There are two basic scenarios: in-office and off-site. Let's consider questions that might occur to people just trying to orient themselves to this whole idea, such as ã
Dr. Nolting: As turning our offices into temporary hospitals. Perhaps outstate; probably not in the metro area. OSHA guidelines? No À their jurisdiction doesn't apply to a terrorist situation.
Dr. Williams: There will be some guidelines from other sources, but what will be applicable is what we normally do.
Dr. Nolting: Our procedures (sterilization et al) would be the same.
NWD: What about responsibilities for treatment, distributing medication, decontamination, sample collection. . .
Dr. Williams: Sample collection is part of surveillance and as such is a first priority. I believe there are some mobile units for distributing medications and so on. For contamination there are about four teams in the country for live decontamination and one for the deceased. I believe the National Laboratory Network already has something set up, and every hospital has a system to move those samples through quickly.
Dr. Norrlander: It will take some education to let dentists know how this operates: how to collect, where to send, just letting the dentist know this is something he or she may be asked to do.
NWD: So someone is going to have to develop curriculum.
Dr. Norrlander: That's right.
NWD: So we really are at square one.
Dr. Norrlander: We are.
NWD:At the most personal level for the dentists, what are the risks, for instance, from second tier vaccinations?
Dr. Nolting: Let's start by saying there are risks and side effects. Small pox, for instance ã with the vaccination there is a chance of 54 persons in a million having a side effect; .001 in one million if you have already been vaccinated. That's pretty small, but it has been emphasized because up until now every program has been voluntary. If we had a bioterror attack involving small pox, 54 in a million is nothing in comparison to the devastation the disease would bring. These are the scenarios. Preparedness versus attack is just another set.
Dr.Williams: I think the jury is still out on the small pox issue. Some of our local hospitals are refusing to vaccinate staff simply because it can be contagious. There are a lot of issues around it.
Dr. Nolting: You won't get small pox from it ã the vaccine is actually the vaccinea virus. But you may get something. The health care vaccination is still voluntary in Phase One.
NWD: Is there law in place that makes it mandatory in event of attack?
Dr. Nolting: [laughs] No. You can choose to get vaccinated, or you can choose to die.
NWD: What are the legal liabilities for volunteers?
Dr. Nolting: Conference Committee Bill HF 3031 was going to introduce this in our state legislature, but language was removed addressing a "Good Samaritan law” in case of a bioterror attack that is declared, so we're at square one here, too.
Dr.Williams: You do have liability coverage when you're with an organization or agency.
NWD: How about economic impact on a dentist?
[laughter]
Dr. Norrlander: Without a doubt there is an economic impact. [to Dr. Williams] Who paid your staff when you were in New York?
Dr. Williams: There isn't good news here. Just reimbursed on a per diem, and that did not cover my expenses.
Dr. Nolting: If the attack is here at home, you are not going to be doing a lot of dentistry, so there is the economic impact, too.
Dr. Norrlander: You revert to your role as a citizen, and you will do what you need to do to the best of your ability to get you and your neighbors through that time of trouble.
Dr. Williams: That said, I think some of the primary players would have to have some contractual agreements. If you don't have that ahead of time, it is volunteer.
NWD: But this is the proverbial special case. Dentists may/will be asked to do an enormous amount. They are the trained professionals we will need. That is the difference, and that is why we want to make sure this issue is in the mix.
Dr. Williams: I think a very serious issue is how many people will be willing to participate.
Dr. Nolting: For the first level, recognition and reporting, I think most of our profession will volunteer, but for the treatment level, that is where you are going to see a smaller number.The kicker is, the more of those people we have, the better off we are going to be.
NWD:If you are going to the public health authorities wanting to be an active and proactive part of this, you will be taking along the things you will need to stay healthy and functioning, among them psychological support.
Dr.Williams: Most organizations have some type of psychological debriefing, although I know I never received it, and I don't think any of the First Call Team did. But there are local groups ã fire and police departments especially ã who have established ties with mental health agencies because they are going through this type of trauma all the time.
Dr. Nolting: We are reviewing just that [reads a preliminary list of agencies] as part of the benefit provided by the Association. We are identifying things already in place and how to access them.
Dr. Williams: If the MDA sponsors people to go out to take care of this type of problem, they are going to have some liability. If someone has a nervous breakdown, there is a suicide, whoever deployed him or her would have that liability.
Dr. Nolting: I don't believe we would say the MDA is deploying these people. They are volunteers on their own. I think there is a movement through public health and physicians to keep this discussion alive. In January there was a Good Samaritan law put in place at the federal level.
Dr. Norrlander: At some point should we be surveying the dentists to find out to what extent they would be willing to help out?
Dr. Nolting: Once we get the subcommittee in place, we will start doing that.
NWD: How many people on your subcommittee?
Dr. Nolting: Nine ã one from each district, plus two members-at-large.
NWD: Let's include a basic element of the dentist's skill set that can be overlooked ã the educator.
Dr. Norrlander: It's important for us to be well educated in terms of what we are looking for in the disease arena, but also just to calm some of the fears that are out there. We are in a great position to talk with our patients and to put them to at least some degree of ease, hopefully squelch some rumors that are obviously going to get really out of hand in some cases. We can be a good source of information for our patients and their families. That is a role dentists would be comfortable taking, and a very good place to start involvement in this and draw on what the subcommittee will be generating.
Dr. Williams: With dentists' community involvement, another way to get the word out is to present adult education classes.
NWD: Who is coordinating all this?
Dr. Nolting: The statewide effort is through Public Health; Robert Einwick is the state's Director for Emergency Preparedness. Then it goes down through the districts, law enforcement, first responders, hysicians, and hospitals.
Dr. Norrlander: Your committee function, then, is to set up
a sub-structure to interface.
Dr. Nolting: to prepare dentists to fit in wherever they will have to fit in. But it is going to be a different role for everyone.
NWD:And if a dentist chooses not to participate in training and bioterrorism response?
Dr. Williams: I strongly believe individual dentists need to
be involved with an appropriate organization. Dentists need
not only to educate themselves but get training, training, and
training; be prepared to help with the surveillance and help
where needed.
Dr. Norrlander: There are so many ways dentists can be involved in this effort. Everyone will find his or her way to fit in - education, triage, distributing needs. . .We have a lot of work ahead of us.
Dr. Nolting: I agree with both my colleagues. [pause] But if they choose not to do any of this, then they will have to stand in line like everybody else and take their chances.
Copyright 2003. Minnesota Dental Association
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