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Proposed Educational Objectives for Hospital-Based Dentists During Catastrophic Events and Disaster Response

Key words: bioterrorism, dental education, hospital dentistry, disaster, catastrophe preparedness, dental residencies, emergency management, surge response

Submitted for publication 01/16/06; accepted 04/10/06

	Abstract

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The purpose of this project was to define education and training requirements for hospital-based dentists to efficiently and meaningfully participate in a hospital disaster response. Eight dental faculty with hospital-based training and/or military command and CBRNE (chemical, biological, radiological, nuclear, and explosive) expertise were recruited as an expert panel. A consensus set of recommended educational objectives for hospital-based dentists was established using the following process: 1) identify assumptions supported by all expert panelists, 2) determine current advanced dental educational training requirements, and 3) conduct additional training and literature review by various panelists and discussions with other content and systems experts. Using this three-step process, educational objectives that the development group believed necessary for hospital-based dentists to be effective in treatment or management roles in times of a catastrophic event were established. These educational objectives are categorized into five thematic areas: 1) disaster systems, 2) triage/medical assessment, 3) blast and burn injuries, 4) chemical agents, and 5) biological agents. Creation of training programs to help dentists acquire these educational objectives would benefit hospital-based dental training programs and strengthen hospital surge manpower needs. The proposed educational objectives are designed to stimulate discussion and debate among dental, medical, and public health professionals about the roles of dentists in meeting hospital surge manpower needs.

Multiple scenarios have been developed that describe situations of large numbers of physical and true psychological casualties^3–5 and the encompassing demands on responders by those who are not at risk but are concerned for their health, i.e., "the worried well."⁶ These scenarios have often focused on local hospitals that have diminished staff due to casualties and/or infrastructure damage and the effect of overwhelming patient demand that stretches the capacity of medical institutions to respond adequately. The need for a local surge manpower capacity in catastrophic events was evident during the fall 2005 hurricane season, particularly with the Katrina response. As is clearly evident to any observer, the NIMS failed in that immediate critical period. Regional and national resources were limited in their immediate supporting response due to mobilization and transportation requirements, as well as due to a geographically wide natural disaster area. These resource limitations may reoccur with future natural or terrorist events. This Katrina response failure demonstrates that planning for and executing those plans in the field are different entities and that better preparation and field operations simulations are necessary. Further, the initial Katrina response inadequacies demonstrated the absolute necessity of local institutions to be independently self-sufficient for several days in their ability to respond to high volume emergency/disaster needs of their catchment population. This provides the rationale for considering their dental staff as one partial source for a surge manpower pool for hospitals.

In the dental profession, oral and maxillofacial surgery (OMFS), general practice residency (GPR), and many pediatric dentistry (PD) training programs are hospital-based or contain a major hospital training component.⁷ All of these programs have various levels of additional training and education in medicine and surgery above that presented in a standard dental school curriculum. Further, graduates of these hospital-based programs often continue to have hospital practices or affiliations. These personnel are present and should accept their ethical obligation to participate in the management of mass casualties. Therefore, minimal additional training consistent with the goals of the advanced and specialty dental training programs may be all that is necessary to enable these dentists to be integrated into the hospital response in certain catastrophic events. Logic dictates that hospitals planning to respond to a catastrophic event must include optimization of scarce human resources.^3,4 The training and education of hospital-based dentists coupled with the elective nature of much of their routine clinical activities suggest that these personnel may be able to augment emergency staffs in surge manpower situations, that is, those conditions in which extra health practitioners are needed to respond to large numbers of casualties who may quickly overwhelm hospital manpower resources in catastrophic events.⁸ The demand for services during a catastrophic event could create situations in which the OMFS, GPR, and PD residents and hospital staff dentists assume roles that may include the triage and initial treatment of individuals who have experienced head and neck injuries. These activities can be vitally important and may be conducted in environments with potential secondary chemical, biological, or radiological contamination. Casualties in these contaminated situations may have extensive morbidity and include other concomitant injuries. Additionally, training dentists to start IVs, provide respiratory support, conduct injury triage, and provide decontamination may support skilled emergency room manpower during periods of surge requirements.^7,9 Special needs patients (the infirmed and elderly and children) are often not attended properly or may be overlooked in disaster situations. An additional skill that PDs can offer is their understanding of children’s response to a crisis and their ability to manage fear in that particular population.

The purpose of this project was to identify the additional education and training requirements for hospital-based dentists that would allow their efficient and meaningful participation in hospital disaster responses to catastrophic events. These educational objectives were developed by means of an expert opinion consensus process. The project was supported by the U.S. Departments of Justice and Homeland Security.

As a foundation for developing education and training to prepare dentists to contribute meaningfully to a hospital’s surge manpower response to a catastrophic event, five dental faculty conducted a literature review, held discussions with New York City Office of Emergency Management and Health Department planners and the U.S. Army’s Nuclear, Chemical, and Biological Health Sciences Department, and participated in NYC Department of Health and Mental Hygiene point of distribution (POD) exercises and the American Medical Association’s National Disaster Life Support training programs. Based on information gained through these activities, this group of faculty developed the following working assumptions:

1. Minor intraoral and extraoral traumatic injuries will likely be the responsibility of dentists.
   
2. All patients of dental personnel will require a physical examination due to the nature of initial triage.¹⁰
   
3. Some catastrophic events scenarios may require dental personnel to stabilize and manage extensive facial injuries.^10,11
   
4. Some catastrophic events scenarios may require dental personnel to stabilize and manage systemic traumatic injuries.^10,12
   
5. Some catastrophic events scenarios may require dental personnel to assist in the immediate post-stabilization and emergency treatment of systemic traumatic injuries.^10,12
   
6. Blast and burn injuries may be contaminated by radiological or chemical agents that dental personnel must know how to manage.^10,12–14
   
7. Dental personnel may be utilized in other roles in hospital disaster plans such as:
   1. part of the decontamination team,¹²
      
   2. part of the vaccination/medication delivery team in biological events,^15,16
      
   3. triage officers,^7,17,18 and
      
   4. to direct or facilitate communication, particularly with the worried well.
      
   
   
8. Biological attacks employing toxins such as botulism may require a surge capacity of personnel capable of respiratory management, which could include dental personnel.^4,10,12
   

It should be noted that many of these assumptions may suggest additional training in medical and nursing education.^19,20 Moreover, the developed model is not limited to dental professionals, but it can be applied to other nonphysician and nurse health care groups such as dental hygienists, pharmacists, podiatrists, and mental health workers. By identifying particular areas of surge manpower needs and the underlying training needed by health care professionals including dentists, surge roles can be addressed and the necessary skill sets can be incorporated into these professionals’ education.

	Methods

Top Abstract Methods Proposed educational objectives Discussion References

 
Eight dental faculty with hospital-based training—two oral and maxillofacial surgeons (OMFS), two pediatric dentists (PD), one oral medicine specialist (OM), one general practitioner (GP), and two additional faculty with military command and CBRNE expertise—were recruited as an expert panel. A consensus set of recommended educational objectives for hospital-based dentists was developed using this process: 1) identify assumptions supported by all expert panelists, 2) determine current advanced dental education training requirements, and 3) conduct an additional training and literature review and discussions with other content and systems experts.

The process of establishing the consensus recommendations was as follows. First, two panel members drew up a list of assumptions based on literature reviews, their previous theoretical work on meeting surge manpower requirements, and individual discussions with the panel members. This list was circulated to three additional panel members for comment. These revised assumptions were then circulated until final agreement was reached. Second, the accreditation requirements and the specific hospital-based training programs’ curricula with which specialist panel members were involved were reviewed and summarized to provide the panel with a contextual base to integrate proposed learning objectives. Third, the same process as described for establishing the assumptions on which the proposed training was to be based was repeated for the proposed learning objectives: the initial proposal was circulated and comments were used to establish a revised set that was then recirculated until five panel members agreed.

The final step of the educational objectives development process was a review by medical experts in emergency medicine and/or catastrophe response. Their suggestions were then incorporated into the final recommendations following a last review and agreement by all eight panel members.

Several notable background activities were concomitantly conducted by various members of the panel to assist in the decision process for competency determination. Among these activities were:

1. Five of the expert panelists attended a comprehensive five-day training course at Fort Sam Houston in San Antonio, Texas. This course was designed by the U.S. Army’s Nuclear, Biological, and Chemical Sciences Division of the Army’s Health Sciences School. The purpose of this training was to enhance the panel’s knowledge base regarding bioterrorism and weapons of mass destruction including chemical, biological, radiological, nuclear, and explosive (CBRNE) devices. The course also outlined the role of military dentists as triage officers on the battle-field. The first four days consisted of lectures on the types of weapons that have been used and the weapons with the greatest potential for use. The role of government agencies in the chain of command in times of crisis was included. Part of the fourth day was spent on case scenarios to help panel members become familiar with effects of the types of weapons that could be used in an attack. The fifth day was devoted to a field exercise designed to enable the participants to experience and test themselves in setting up a decontamination station and effectively treating casualties in a simulated terrorist attack.
   
2. Two members of the expert panel participated in a series of courses conducted by the American Medical Association on disaster life support from core through basic and advanced levels (CDLS, BDLS, and ADLS). These courses are designed to better prepare health care professionals and emergency response personnel for all-hazards mass casualty events. The overarching goal of these courses is to standardize emergency response training nationwide and strengthen the nation’s public health system. The courses stress a comprehensive all-hazards approach to help physicians and other health professionals deal with catastrophic emergencies from manmade acts as well as from explosions, fires, natural disasters (such as hurricanes and floods), and the outbreak of infectious diseases.
   
3. Under the direction of the New York City Department of Health, two point of distribution exercises were conducted at the New York University College of Dentistry. In the case of a bioterrorist attack, mass prophylaxis may be required. To dispense antibiotics or vaccine to the public, point of distribution (POD) systems would be set up, requiring thousands of health professionals as staff. In these PODs, clinic roles are assigned to each health professional based on his or her skills and licensure. Specific POD functions include medical evaluation, triage, vaccination or distribution of medication, and customer service/line management. Four members of the expert panel participated, with one member also directing one of the POD exercises.
   
4. Two members of the expert panel participated in six disaster response seminars developed by NYU Medical School’s emergency medicine faculty and also participated in a mini-internship in the Emergency Medicine Department at Bellevue Hospital where, under the direction of ER physicians, they were exposed to the skills of rapid patient evaluation and the search for underlying systemic disease.
   
5. Six of the expert panel’s members were trained by the New York City Department of Health and Mental Hygiene in telephone triage for an avian flu outbreak. Four of these participants are now part of New York City’s Medical Reserve Corps specifically assigned to the health department for telephone triage duties.
   

	Proposed Educational Objectives

Top Abstract Methods Proposed educational objectives Discussion References

 
After participating in the training experiences and reviewing their own experiences, the expert panel developed educational objectives in five thematic areas for hospital-based dentists during catastrophic events and other disaster response situations. The educational objectives define skills that the panel believes necessary for hospital-based dentists to be effective in treatment or management roles in times of a catastrophe.

The proposed learning objectives are presented in Tables 1–5. Each table contains the learning objectives of one of the five thematic areas: 1) disaster systems, 2) triage/medical assessment, 3) blast and burn injuries, 4) chemical agents, and 5) biological agents. Each table contains a column with the specific learning objectives and sources where information on the learning objective can be found. The right column on each table provides the specific detailed citation reference chapters/pages for sources referenced under multiple learning objectives.

1. Disaster Systems
   The first set of educational objectives is related to gaining an understanding of hospital and national response systems (Table 1). Attainment of this knowledge base will enable dentists to communicate effectively and professionally with staff and the public regarding a response to a catastrophic event. These educational objectives also may promote dental professional involvement at all levels in disaster planning and response.
   
2. Triage/Medical Assessment
   The triage/medical educational objectives address emergency medical assessment in addition to triage systems (Table 2). Dental professionals who acquire these skills will understand the operation of triage systems and how casualty classification is performed in response to a catastrophic event. Furthermore, dental professionals will be able to perform critical medical assessment and immediate treatment with the training proposed for emergency medical procedures.
   
3. Blast and Burn Injuries
   These educational objectives include validating the knowledge of pathophysiology and general treatment of blast and burn injuries (Table 3). Dental professionals who acquire the knowledge and skills addressed in these objectives will be able to recognize specific symptoms and differentiate types of blast and burn injuries. The didactic and clinical skills described will prepare the dentist to carry out an assessment and emergency treatment to casualties with blast and burn injuries.
   
4. Chemical Agents
   Table 4 lists educational objectives regarding chemical agents and the decontamination process. Meeting these objectives will provide dentists with a working knowledge of different types of chemical agents and treatments for them. Dental professionals who acquire these skills may be able to function as a responder in the event of chemical attack. In addition, dental professionals will be able to properly use personal protective equipments as well as perform mass decontamination in the chemical environment.
   
5. Biological Agents
   The final set of educational objectives is related to the understanding of biological agents and mass medication/vaccination delivery systems (Table 5). Dental professionals who accomplish these objectives will be able to understand the specific symptoms and signs of various Class A biological agents. Moreover, meeting these educational objectives will enable dental professionals to participate in a point of distribution (POD) system and perform medication delivery and vaccinations. The biological agent objectives will encourage dentists to play a role in the response to a biological attack or outbreak.
   

	Discussion

Top Abstract Methods Proposed educational objectives Discussion References

 
Natural or manmade catastrophic events place great manpower demands on communities and their health care and public health systems. This surge manpower requirement may need to be addressed in innovative ways that utilize the skill of clinically experienced personnel who are not physicians or nurses and fall outside the traditional model for delivering care in a hospital and/or emergency room. Accomplishing this will require a paradigm shift in thinking about who should be recruited, how they should be trained and credentialed, where they should function and in what capacity, and what is the mechanism to integrate them seamlessly into the health delivery system. To accomplish this concept shift, the designers of emergency management programs should think broadly about any health care professional group or allied health group whose training provides a basic skill set that could be used to meet the manpower needs during an emergency response.

Dentists, particularly those trained and/or associated with hospitals, have advanced clinical training and a familiarity with the operation of such medical systems. This knowledge makes hospital-based dentists a considerable resource in mass casualty situations. However, additional training and the combined efforts of the dental and medical professions are needed to encourage and demonstrate practical integration of dentists into hospital disaster response plans. Additionally, dentists receiving specialized training modules related to catastrophic events will be able to provide leadership in their communities’ planning, even in the absence of a direct surge manpower responsibility, and assist in formulating public health response planning.

Although the proposed competencies described here may seem extensive and difficult to incorporate into the typical postgraduate dental training program, much of the material is already available or already exists in dental residency training components such as anesthesia rotations or modules on physical diagnosis. Given that many of the competencies we propose are mutually reinforcing to the medical training that hospital dentists normally receive, one would expect an enhanced learning experience to result, allowing development of additional skills that will be valuable during a response to a mass casualty emergency requiring deployment of surge manpower.

Many of the proposed components have also been suggested for inclusion in the dental school curriculum²¹ and are, in fact, integrated at some dental schools.¹ Such actions at the dental undergraduate level would both decrease the time/resources commitment needed at the postdoctoral level and present an intellectual argument within hospital environments for the practicality of dentists’ having a broader role in disaster response planning.

We conclude that there are specific educational objectives that would benefit hospital-based dental training programs and strengthen hospital surge manpower needs in catastrophic events. Further, the knowledge base and the skills we described here may be considered for the dental school curriculum and non-hospital-based advanced training programs to provide communities with trained leadership from the dental profession for a significant contribution to local catastrophic response planning. The proposed training should be a catalyst for dentists, physicians, public health specialists, dental educators, and faculty in accredited dental residency programs to discuss and debate the roles of dentists in meeting surge medical and public health needs.

We invite our readers’ feedback and encourage formal discussions as to whether these proposals truly improve community capacity to deal with disasters. Is the initiative to give hospital-trained dentists a role on the emergency medicine team valid? Have the proper and realistic priorities been addressed, and are the proposed competencies adequate to achieve their training goals? Readers are directed to "Dental Profession Comments Forum" at chip.med.nyu. edu/course/view.php?id=36.

	Acknowledgments

 
We would like to thank the following New York University faculty and students for their assistance on this project: Drs. Robert Glickman, Rajiv Karloopia, and Vasiliki Karlis and Mr. Seokhwan Oh. We would also like to express our appreciation to the U.S. Army’s Nuclear, Biological, and Chemical Sciences Division of the Army’s Health Sciences School faculty and staff, the New York City Department of Health and Mental Hygiene, and the faculty and staff of Bellevue Hospital Emergency Department, New York City.

	Footnotes

 
Dr. Psoter is Assistant Professor, Department of Epidemiology and Health Promotion, New York University College of Dentistry, and Associate Professor, School of Dentistry, University of Puerto Rico; Dr. Herman is Clinical Professor, New York University College of Dentistry; Dr. More is Professor, Department of Epidemiology and Health Promotion, Department of Pediatric Dentistry, New York University College of Dentistry; Ms. Park is Assistant Research Scientist, New York University College of Dentistry; Dr. Robbins is Clinical Associate Professor, Department of Oral Medicine, New York University College of Dentistry; Dr. Rekow is Professor and Director for Translational Research, Department of Basic Science and Craniofacial Biology, Department of Orthodontics, New York University College of Dentistry; Mr. Ryan is a dental student, New York University College of Dentistry; Dr. Triola is Assistant Professor, Medical Informatics, Division of General Internal Medicine, Department of Medicine, New York University School of Medicine; and Dr. Glotzer is Clinical Professor, Department of Cardiology and Operative Dentistry, New York University College of Dentistry. Direct correspondence and requests for reprints to Dr. Walter J. Psoter, New York University College of Dentistry, Department of Epidemiology and Health Promotion, 345 East 24th Street, New York, NY 10010; 212-998-9217 phone; 212-995-4087 fax; wp9{at}nyu.edu.

This project was supported by a grant from the U.S. Department of Justice, Office of Justice Programs, 202-DT-CX-K002.

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Top Abstract Methods Proposed educational objectives Discussion References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Psoter, W. J. Articles by Glotzer, D. Search for Related Content PubMed PubMed Citation Articles by Psoter, W. J. Articles by Glotzer, D.