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The dental team
C O M M E N TA RY GUEST EDITORIAL
The dental team A ready reserve or an overlooked resource? E. Dianne Rekow, DDS, PhD
catastrophe that can overwhelm resources and devastate the health delivery infrastructure is inevitable. Recent events like U.S. Gulf Coast hurricanes, the Asian tsunami and the bombings in London have made this possibility abundantly clear. As clinicians, we have an extensive set of skills to apply in catastrophe preparedness, response and recovery. We are well-versed in the daily practice of infection control, taking and using information from medical histories to guide our actions, taking and interpreting radiographs, administering injections, suturing wounds, managing infections, prescribing medications and making diagnoses on the basis of clinical signs and symptoms. All of these skills apply directly to catastrophe response. One of our strongest, and perhaps most unappreciated, skills is our ability to manage patients who are concerned and upset. In unanticipated events, people are frightened. The “virus of fear” can overwhelm resources quickly, even when they are not needed. During the anthrax incidents in the fall of 2001, fewer than 25 people were affected nationwide1—but people who had no symptoms and who had not been exposed demanded treatment, resulting in shortages in prophylactic antibiotics and overwhelmed testing laboratories.2,3 For bioterrorist agents, it is anticipated that for each af-
A
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JADA, Vol. 137
fected person, between 10 and 100 unaffected people will demand treatment,4 a situation that surely would overwhelm the health care system if not held in check. Dentists, who are among the most respected members of a community, can play an extremely important role in educating their patients about the real risks of various bioterrorist agents before anything happens. Then, should an event occur, people will be more informed and less alarmed, and responses can be more rational. The Centers for Disease Control and Prevention5 offers a number of fact sheets that you might want to digest and make available to your patients. The vast majority of dentists (see the article in this issue by Katz and colleagues6) and physicians7 are willing to respond to an emergency. But what can— and should—we do? There are many answers to this question, beginning with some actions that are quite simple. Before any event, we all should have a plan in place for how to deal with emergencies, especially immediately after an event before authorities can provide instructions. Decisions made in the first few seconds can have life-threatening consequences. Without planning, you might find yourself keeping your patients and staff members in a building in which they are exposed to noxious gases (for instance, in a fire) or sending them out of a building that could have protected them from expo-
sure (to, for instance, a dirty bomb or a chemical plume). Resources to consider in making the plan for your business and family, including some focusing specifically on children, can be found in many publications and at the U.S. Department of Homeland Security’s (DHS’s) “www.ready.gov” Web site.8 Early detection of an unfolding event could save literally millions of lives. First symptoms from exposure to biological agents with potential for terrorist use are flulike—but they are likely to develop in atypical seasons or in unexpected populations. Each of us has a sense of the natural rhythm of patient cancellations and staff illnesses. If that rhythm changes, we should stop to see if there is a logical explanation (for example, the high school sports team won a championship in overtime and there was much postgame celebrating). If there is no reasonable explanation, call your colleagues and see if they are noticing the same things—and report the change to your local department of health, fast. Your responsiveness could save thousands of lives. Smallpox, for instance, is contagious before obvious pox marks emerge, and it is estimated that each person with smallpox could infect as many as 20 others.9 A warning issued one or two days earlier than might otherwise be possible if we continue to rely on traditional diseasetracking mechanisms could have a tremendous impact in limiting
http://jada.ada.org April 2006 Copyright ©2005 American Dental Association. All rights reserved.
C O M M E N T A R Y GUEST EDITORIAL
the extent of the spread of the disease in your community. The article in this issue by Rinaggio and Glick10 outlines initial signs of a smallpox attack. The part of catastrophe readiness that is the most perplexing and difficult is what we should do when there are mass casualties—that is, when the number of casualties outstrips the capability of the local system to deal with the problem. While it would be nice to assume this would never happen, within recent history, the Gulf Coast hurricanes provided a frightening example of the infrastructure’s becoming insufficient to meet the demand for care. Should the H5N1 (avian flu) virus mutate, making person-to-person transmission possible, projections suggest that millions of people around the world would be affected,11 surely overwhelming the capacity of the existing traditional health care delivery system. Destruction of the public health and medical care infrastructures has the potential to be more devastating to the health of the population than the event itself.12 The DHS has implemented a National Incident Management System (NIMS) to unify and coordinate preparedness and response. Unfortunately, NIMS fails to recognize the special expertise of dentists. The dentists in this country, by virtue of skill and of sheer numbers, offer a capacity to complement traditional health care delivery, providing a surge capacity that could preclude or minimize many of the health-related disasters of largescale events. The challenge to both our profession and other medical and public health specialists is to
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unite to overcome the obstacles that prevent us from being that ready reserve. Illinois has taken some steps in this direction (see the article in this issue by Colvard and colleagues13), integrating the dental emergency responder (a licensed dentist or hygienist who is appropriately certified in emergency medical response) into the response team—but only while the responder is “acting within the bounds of his or her license when providing care during a declared local, state, or national emergency.” In most states, that within-practice-act limitation is remarkable, in some cases severely confining dentists to providing dental care without permitting them to make sutures for facial injuries, for instance, even though the alternative is leaving the injured with no care. We need to work toward modifying the state practice acts to permit an expanded scope in mass-casualty situations. In parallel, we must remember that physicians, who usually lead the response-planning activities and training, often are unaware of the extent of skills that dentists could provide.14 We need to do a far better job at enlightening them about what we can do. Foremost, however, we need to get the attention of our own profession and of the health care community and to begin with them a national discussion—one in which we conceptualize masscasualty situations and create strategies to capitalize on the skills of all health care workers to respond to and recover from large-scale events, be they generated by humankind or by nature. We have the responsibility to
ourselves, our profession and our communities to force policy changes to become a ready reserve. Otherwise, we will remain an untapped and overlooked resource. ■ Dr. Rekow is a professor and the chair, Department of Biological Science, Medicine and Surgery, and the director, Translational Research, New York University College of Dentistry, New York City. 1. Centers for Diesase Control and Prevention. Investigation of bioterrorism related anthrax and adverse events from antimicrobial prophylaxis. MMWR Morb Moral Wkly Rep 2001:50:973-6. 2. Sperry P. Safe from anthrax, sick from cipro? WorldNet Daily Oct. 24, 2001. Available at: “www.worldnetdaily.com/ news/article.asp?ARTICLE_ID=25058”. Accessed March 2, 2006. 3. Hughes J, Gerberding J. Anthrax bioterrorism: lessons learned and future directions. Emerg Infec Dis 2002;8:1013-14. 4. Evans RG, Crutcher JM, Shadel B, Celements B, Bronze MS. Terrorism from a public health perspective. Am J Med Sci 2002; 323(6):291-8. 5. Centers for Disease Control and Prevention. Emergency preparedness and response: General fact sheets on specific bioterrorism agents. Available at: “www.bt.cdc.gov/ bioterrorism/factsheets.asp”. Accessed March 2, 2006. 6. Katz AR, Nekorchuk DM, Holck, PS, Hendrickson LA, Imrie AA, Effler PV. Dentists’ preparedness for responding to bioterrorism: a survey of Hawaii dentists. JADA 2006;137:461-7. 7. Alexander GC, Wynia MW. Ready and willing? Physicians’ sense of preparedness for bioterrorism. Health Aff 2003;22:189-97. 8. U.S. Department of Homeland Security. Ready.gov. Available at: “www.ready.gov”. Accessed March 2, 2006. 9. Henderson DA, Inglesby TV, Bartlett JG, et al. Smallpox as a biological weapon. JAMA 1999;291:2127-37. 10. Rinaggio J, Glick M. The smallpox vaccine: an update for oral health care professionals. JADA 2006;137:452-60. 11. Centers for Disease Control and Prevention. Pandemic influenza: Key facts about pandemic influenza. Available at: “www.cdc.gov/flu/pandemic/keyfacts.htm”. Accessed March 2, 2006. 12. Nieburg P, Waldman RJ, Krumm DM. Hurricane Katrina: evacuated populations— lessons from foreign refugee crises. N Engl J Med 2005;353:1547-9. 13. Colvard MD, Lampiris LN, Cordell GA, et al. The dental emergency responder: expanding the scope of dental practice. JADA 2006;137:468-73. 14. Psoter W, Glotzer D. Report to Department of Justice: Enhancing medical and public health capabilities during times of crisis—a summary report on the expansion of the role of dentists and their enhancement of the medical surge response. Available at: “http://chip.med.nyu.edu/course/ view.php?id=36”. Accessed March 7, 2006.
http://jada.ada.org April 2006 Copyright ©2005 American Dental Association. All rights reserved.
The dental team A ready reserve or an overlooked resource? E. Dianne Rekow, DDS, PhD
catastrophe that can overwhelm resources and devastate the health delivery infrastructure is inevitable. Recent events like U.S. Gulf Coast hurricanes, the Asian tsunami and the bombings in London have made this possibility abundantly clear. As clinicians, we have an extensive set of skills to apply in catastrophe preparedness, response and recovery. We are well-versed in the daily practice of infection control, taking and using information from medical histories to guide our actions, taking and interpreting radiographs, administering injections, suturing wounds, managing infections, prescribing medications and making diagnoses on the basis of clinical signs and symptoms. All of these skills apply directly to catastrophe response. One of our strongest, and perhaps most unappreciated, skills is our ability to manage patients who are concerned and upset. In unanticipated events, people are frightened. The “virus of fear” can overwhelm resources quickly, even when they are not needed. During the anthrax incidents in the fall of 2001, fewer than 25 people were affected nationwide1—but people who had no symptoms and who had not been exposed demanded treatment, resulting in shortages in prophylactic antibiotics and overwhelmed testing laboratories.2,3 For bioterrorist agents, it is anticipated that for each af-
A
432
JADA, Vol. 137
fected person, between 10 and 100 unaffected people will demand treatment,4 a situation that surely would overwhelm the health care system if not held in check. Dentists, who are among the most respected members of a community, can play an extremely important role in educating their patients about the real risks of various bioterrorist agents before anything happens. Then, should an event occur, people will be more informed and less alarmed, and responses can be more rational. The Centers for Disease Control and Prevention5 offers a number of fact sheets that you might want to digest and make available to your patients. The vast majority of dentists (see the article in this issue by Katz and colleagues6) and physicians7 are willing to respond to an emergency. But what can— and should—we do? There are many answers to this question, beginning with some actions that are quite simple. Before any event, we all should have a plan in place for how to deal with emergencies, especially immediately after an event before authorities can provide instructions. Decisions made in the first few seconds can have life-threatening consequences. Without planning, you might find yourself keeping your patients and staff members in a building in which they are exposed to noxious gases (for instance, in a fire) or sending them out of a building that could have protected them from expo-
sure (to, for instance, a dirty bomb or a chemical plume). Resources to consider in making the plan for your business and family, including some focusing specifically on children, can be found in many publications and at the U.S. Department of Homeland Security’s (DHS’s) “www.ready.gov” Web site.8 Early detection of an unfolding event could save literally millions of lives. First symptoms from exposure to biological agents with potential for terrorist use are flulike—but they are likely to develop in atypical seasons or in unexpected populations. Each of us has a sense of the natural rhythm of patient cancellations and staff illnesses. If that rhythm changes, we should stop to see if there is a logical explanation (for example, the high school sports team won a championship in overtime and there was much postgame celebrating). If there is no reasonable explanation, call your colleagues and see if they are noticing the same things—and report the change to your local department of health, fast. Your responsiveness could save thousands of lives. Smallpox, for instance, is contagious before obvious pox marks emerge, and it is estimated that each person with smallpox could infect as many as 20 others.9 A warning issued one or two days earlier than might otherwise be possible if we continue to rely on traditional diseasetracking mechanisms could have a tremendous impact in limiting
http://jada.ada.org April 2006 Copyright ©2005 American Dental Association. All rights reserved.
C O M M E N T A R Y GUEST EDITORIAL
the extent of the spread of the disease in your community. The article in this issue by Rinaggio and Glick10 outlines initial signs of a smallpox attack. The part of catastrophe readiness that is the most perplexing and difficult is what we should do when there are mass casualties—that is, when the number of casualties outstrips the capability of the local system to deal with the problem. While it would be nice to assume this would never happen, within recent history, the Gulf Coast hurricanes provided a frightening example of the infrastructure’s becoming insufficient to meet the demand for care. Should the H5N1 (avian flu) virus mutate, making person-to-person transmission possible, projections suggest that millions of people around the world would be affected,11 surely overwhelming the capacity of the existing traditional health care delivery system. Destruction of the public health and medical care infrastructures has the potential to be more devastating to the health of the population than the event itself.12 The DHS has implemented a National Incident Management System (NIMS) to unify and coordinate preparedness and response. Unfortunately, NIMS fails to recognize the special expertise of dentists. The dentists in this country, by virtue of skill and of sheer numbers, offer a capacity to complement traditional health care delivery, providing a surge capacity that could preclude or minimize many of the health-related disasters of largescale events. The challenge to both our profession and other medical and public health specialists is to
434
JADA, Vol. 137
unite to overcome the obstacles that prevent us from being that ready reserve. Illinois has taken some steps in this direction (see the article in this issue by Colvard and colleagues13), integrating the dental emergency responder (a licensed dentist or hygienist who is appropriately certified in emergency medical response) into the response team—but only while the responder is “acting within the bounds of his or her license when providing care during a declared local, state, or national emergency.” In most states, that within-practice-act limitation is remarkable, in some cases severely confining dentists to providing dental care without permitting them to make sutures for facial injuries, for instance, even though the alternative is leaving the injured with no care. We need to work toward modifying the state practice acts to permit an expanded scope in mass-casualty situations. In parallel, we must remember that physicians, who usually lead the response-planning activities and training, often are unaware of the extent of skills that dentists could provide.14 We need to do a far better job at enlightening them about what we can do. Foremost, however, we need to get the attention of our own profession and of the health care community and to begin with them a national discussion—one in which we conceptualize masscasualty situations and create strategies to capitalize on the skills of all health care workers to respond to and recover from large-scale events, be they generated by humankind or by nature. We have the responsibility to
ourselves, our profession and our communities to force policy changes to become a ready reserve. Otherwise, we will remain an untapped and overlooked resource. ■ Dr. Rekow is a professor and the chair, Department of Biological Science, Medicine and Surgery, and the director, Translational Research, New York University College of Dentistry, New York City. 1. Centers for Diesase Control and Prevention. Investigation of bioterrorism related anthrax and adverse events from antimicrobial prophylaxis. MMWR Morb Moral Wkly Rep 2001:50:973-6. 2. Sperry P. Safe from anthrax, sick from cipro? WorldNet Daily Oct. 24, 2001. Available at: “www.worldnetdaily.com/ news/article.asp?ARTICLE_ID=25058”. Accessed March 2, 2006. 3. Hughes J, Gerberding J. Anthrax bioterrorism: lessons learned and future directions. Emerg Infec Dis 2002;8:1013-14. 4. Evans RG, Crutcher JM, Shadel B, Celements B, Bronze MS. Terrorism from a public health perspective. Am J Med Sci 2002; 323(6):291-8. 5. Centers for Disease Control and Prevention. Emergency preparedness and response: General fact sheets on specific bioterrorism agents. Available at: “www.bt.cdc.gov/ bioterrorism/factsheets.asp”. Accessed March 2, 2006. 6. Katz AR, Nekorchuk DM, Holck, PS, Hendrickson LA, Imrie AA, Effler PV. Dentists’ preparedness for responding to bioterrorism: a survey of Hawaii dentists. JADA 2006;137:461-7. 7. Alexander GC, Wynia MW. Ready and willing? Physicians’ sense of preparedness for bioterrorism. Health Aff 2003;22:189-97. 8. U.S. Department of Homeland Security. Ready.gov. Available at: “www.ready.gov”. Accessed March 2, 2006. 9. Henderson DA, Inglesby TV, Bartlett JG, et al. Smallpox as a biological weapon. JAMA 1999;291:2127-37. 10. Rinaggio J, Glick M. The smallpox vaccine: an update for oral health care professionals. JADA 2006;137:452-60. 11. Centers for Disease Control and Prevention. Pandemic influenza: Key facts about pandemic influenza. Available at: “www.cdc.gov/flu/pandemic/keyfacts.htm”. Accessed March 2, 2006. 12. Nieburg P, Waldman RJ, Krumm DM. Hurricane Katrina: evacuated populations— lessons from foreign refugee crises. N Engl J Med 2005;353:1547-9. 13. Colvard MD, Lampiris LN, Cordell GA, et al. The dental emergency responder: expanding the scope of dental practice. JADA 2006;137:468-73. 14. Psoter W, Glotzer D. Report to Department of Justice: Enhancing medical and public health capabilities during times of crisis—a summary report on the expansion of the role of dentists and their enhancement of the medical surge response. Available at: “http://chip.med.nyu.edu/course/ view.php?id=36”. Accessed March 7, 2006.
http://jada.ada.org April 2006 Copyright ©2005 American Dental Association. All rights reserved.