August 1, 2010
by Allan Warnick, DDS, DABFO
“It is impossible to predict if, when, and where the next act of terrorism or natural disaster will occur. Every American, including emergency workers and first responders, has the right to expect that if they are a victim of a terrorist attack or natural disaster, every effort would be made for a quick and accurate identification.”1
“It is important to be prepared before a disaster”.2 As with any professional responding to a disaster, dentists too must be prepared before, not after a situation occurs. The focus of this article describes the training of dentists and their response to a situation when assisting in the identification process in Mass Fatality Incidents (MFI).
The world has experienced a plethora of mass disasters in recent years: hurricanes, floods, transportation mishaps, fires, volcanic eruptions, terrorist activity, armed conflict, and earthquakes, most recently in Haiti. And we still remember vividly the attack on September 11, 2001 of the World Trade Centers (WTC) and The Pentagon.
The role that dentists play in such disasters varies throughout the world and the response to a disaster may also differ for various responders.
The Forensic Dental Identification Team however, must be ready to respond when the disaster strikes in their area. Preparation should already be in place before a disaster occurs. In some areas, this may mean that local dentists must take the initiative and help municipalities prepare for identifying victims of a mass fatality incident. This requires the formation of a Forensic Dental Identification Team endorsed by either the local and/or state (provincial) dental associations, and this team should have a good working relationship, not only amongst themselves, but with the local medical examiner/coroner in their jurisdiction.
The Dental ID Team should consist of a “Go Team” and a “Support Team”. The “Go Team” is a small group of dentists with experience in Forensic Odontology and Mass Casualty Management. They can be rapidly deployed to assess the situation and assist local agencies in the initial response to the disaster incident.
The “Go Team” is comprised of a Team Leader; an Assistant Team Leader(s); and Section Leader(s) to deal with post mortem (after death), ante mortem (before death) and computer management analysis (comparing ante & post mortem records). The individual “Go Team” member dentist when deployed is committed to the incident for its entirety or at least 14 days.
The WTC disaster in New York taxed the dental section as the identification process continued for more than nine months, therefore additional Section Leaders were trained to keep the continuity and efficiency of the exercise in place.
It is helpful to have about ten to fifteen “Go Team” members since it is hard to have the entire team respond when called. Factors such as illness, not in town, family commitments, office responsibilities, etc. may preclude the “Go Team” member from committing for the initial 14-day response.
The “Support Team” consists of a group of dentists, hygienists and/or dental assistants who may or may not have had previous experience in mass casualty situations. The Support Team members will be assigned to a specific section (post mortem, ante mortem and/or computers) by the appropriate Team Leader.
It is important to have regular training sessions for the entire team. This allows each team member to be better assessed as to what section they have expertise or an interest in, and then be assigned to that section.
Section Leaders must be trained in all facets of the operation so they can fill in when asked or needed to assist in a different section. Each “Support Team” member will be asked to respond initially for a minimum three-day commitment. This also helps to keep the continuity of each section.
In the United States, the Disaster Mortuary Operational Response Team (D-Mort) is part of the National Disaster Medical Service (NDMS) working under the division of Homeland Security. There are 10 D-Mort regions in the United States allowing deployment of trained personnel to any area of the country in a relatively short period of time.
The D-Mort unit is composed of a multi-disciplinary team that is trained and prepared to respond to any mass fatality incident that overwhelms the local jurisdiction. The unit is made up of forensically trained: pathologists, dentists, anthropologists, medical legal investigators, funeral directors and administrators.
The D-Mort dental teams are made up of forensic dentists, hygienists and dental assistants who are trained in the mass fatality incident identification process. They were part of the many D-Mort units that were sent to assist the Chief Medical Examiner’s Office (CMEO) in New York City and also in Shanksville, Pennsylvania following the 9/11 World Trade Center disaster.
The mission of the D-Mort team is to assist local facilities. For the dental team, they work directly with the Chief Forensic Dentist who is a member of the local Medical Examiner’s (ME) office. Under his/her direction the D-Mort dental unit helps in the identification process.
Normally the dental team members may be deployed to work a minimum of two weeks (as was necessary during the WTC disaster). It was found that in New York City, it was helpful to have a continued presence of the key D-Mort dentists to help in keeping continuity over this long & most difficult situation.
It is imperative that the Dental Team be trained and prepared before a situation occurs. This includes regularly scheduled meetings, mock disaster update training and having the most current protective & proper equipment available.
The Team Leader is on call 24/7/365. If he/she cannot fulfil this commitment, then the Assistant Team Leader will be automatically designated as the lead person for the team. When the situation occurs, the Team Leader will be designated as the Lead for the entire team. He/she will be notified of the problem as has been previously established by protocol with the ME’s office, Emergency Management personnel of the County/State, and/or the local/state law enforcement agencies.
The Team Leader will then set in motion the response protocol for the particular team. It is imperative that team members do not call the Team Leader -THEY will call YOU. The initial stage of a mass fatality incident is extremely busy and member’s calls only complicate and delay the response time.
It may be helpful to have dental team members trained in the body recovery process. Dentists are more aware and may be able to more easily recognize small dental fragments and/or appliances that may be useful in the identification of mass fatality victims.
Team members must be aware that “mass disaster situations are trying times, both physically and emotionally. Previous knowledge and understanding of team members will help to make this most difficult task a smooth running operation”3
However, there are situations when dental personnel should not be in the field, as was the case at Ground Zero in New York where only trained recovery teams were used. Triage centers can be set-up near the disaster site where dental members can assist in the sorting of victims and/or body parts.
The dental section is part of the regular morgue set-up in a mass fatality setting. Other sections consist of: photography, personal effects, pathology, anthropology, fingerprint and radiology. The Dental Section is part of the regular morgue set-up, and consists of three main areas: Post Mortem, Ante Mortem and Computer. Each of these sections also has a Team Leader, Assistant Team leader and Support Team members.
The Post Mortem (PM) section’s task is t
o examine and evaluate the victim’s remains for any dental evidence which may be an intact face with complete natural and/or artificial dentition, or just fragments with single teeth or parts of the maxilla and/or mandible. The PM section will have the proper equipment and supplies necessary to accomplish the identification process.
The section members work in threes (two dentists and either a dentist/hygienist/assistant) to examine and workup the victim. The PM process of three members should have a minimum of two dentists. One examines the remains and describes any dental information to the other two. The second dentist also observes the remains and confirms that what the first dentist sees is, in fact, correct. The third person, who may be a dentist or a hygienist or an assistant, writes the information onto the PM dental chart form.
The team members then switch roles as investigator; observer and scribe. As time permits, this process can be repeated again thus giving all three team members a chance at each specific role in the PM identification process.
Any PM supplies should be purchased and then the process for replenishing them arranged before the situation occurs. This includes the basics of dental equipment that will help in the ID process, such as dental mirrors, explorers, scalers and even toothbrushes.
Instruments to disarticulate the mandible or maxilla may also be required even though the dental team will try to keep them intact if at all possible.
The radiology and photography sub-sections will document body parts for future evaluation and comparison. The use of digital units for both photography and radiology saves a huge amount of time and is extremely useful. They can also be directly integrated into the WinID Computer ID System.4
The digital system also allows the team member to see immediately what has been documented. Digital radiology eliminates the need for a Dental Film Developer and the necessity of water and chemicals.
The post-mortem workup should consist of photographs, clinical examination and charting, radiographs and the formation of the completed post-mortem dental record so it can be entered into the WinID’s Computer System.
It should also be noted that the grid number given to the victim must be placed on all dental information collected and the dental section should not release anything before checking for the proper grid numbers.
The Ante-Mortem (AM) section should be set up in an area away from the post-mortem section. It may even be in another building as it was in the initial weeks following the WTC Disaster. The AM Section consists of a Section Leader and Assistant Section Leader(s) and the support team members.
The AM Team leader will make sure that all dental information is inventoried and then logged into the section by either placing the notations into a log book or into a computer program such as the one developed by Dr. Frank Den during the WTC Disaster.
The log-in system allows for the tracking of the ante-mortem dental records and is helpful when additional information on a victim comes in, sometimes months after the initial workup of the AM dental chart. The system can track the disposition of the victim indicating an identification has been made; date of the ID; and even the exact time.
The AM Section members work in teams of at least two dentists having the task to condense all the victim’s AM dental information into a comprehensive dental chart which can be entered into the WinID Computer System. If a problem or question arises concerning the information supplied by the victim’s dentist, a designated AM team member will contact the dentist to clarify the information before it is put into the computer system.
The members of this section should be familiar with the WinID Computer System. The completed post mortem and ante mortem dental charts are entered into the system utilizing a two-person team of at least one dentist. It is extremely important that all information going into the system be re-checked as an error could hamper the identification process.
This section should have both the software and hardware for the situation already pre-arranged and works in conjunction with the Comparison Unit which will enter a completed ante mortem record to be compared to the post mortem data base. However every incident team must adapt. At the WTC Disaster, the opposite occurred. The post mortem record was compared to the ante mortem data base as the recovery of victims took several months.
When a possible identification is found, the complete packet containing the post mortem dental charts, radiographs and photographs are then compared to the complete ante mortem record base.
The Comparison Team has a Team Leader, who works closely with the Section Leader (ante mortem and post mortem computer) and they will then re-evaluate the findings. If it is a positive identification, the identification form is completed, signed, and taken to the Medical Examiner/Coroner’s representative to make any announcement concerning the identification.
Dental section members will never make any comments on the identification of a victim. In some situations under the direction of the Medical Examiner/Coroner, the Team leader may meet with the press and/or families of the victims to explain the dental identification process.
The Dental Identification process is accurate, efficient and cost effective. It has been used successfully in disaster situations ranging from natural disasters, aircraft mishaps to explosions and building fires. The availability of good accurate ante mortem dental records (those same clinical records we all have of our patients in the office) are most prevalent in the United States, Canada and most Western countries. Many other countries do not have this data base to work from, making dental identification extremely difficult if not impossible.
Following a mass fatality situation, debriefing sessions should be held with the entire team and also with individual team members. A psychologist should be available at the site and during these discussions to help with any problems.
Each team member is an individual and will respond differently to the particular situation. The use of training sessions at the morgue or through presentations of previous disaster situations will help team members cope with this most trying time.
However, no one is completely prepared psychologically for what will be encountered at a mass fatality site. Even though disasters may be similar, each one is unique unto itself, as illustrated in New York City at the WTC Disaster.
The more prepared individuals are before the disaster occurs, the easier it will be for the entire team during the most trying of times.
All dentists have a moral and ethical responsibility to ourselves and to our community when asked to help in a mass disaster situation. It is extremely difficult to put a dollar value on the time spent for such a humanitarian effort.
However, team leaders must be prepared to respond to the question of compensating members of their dental identification team. Responders and other disaster workers such as police, fire personnel, funeral directors, paramedics, and Medical Examiners are paid. Must the dental team volunteer?
Dental experts are needed. As recognized professionals we should not feel that we must volunteer our services. However, we must be realistic in the amount of compensation. Each disaster is different as is each disaster team. Individual situations must be evaluated regarding the value to place on the identification task.
Whatever the means of compensation, remember that everyone on the team has volunteered; therefore, the compensation is minimal compared
to the hours worked and out-of-office time.
Dental team members must be aware that a mass casualty incident is a sensitive situation that presents with trying times for the families of victims. The media can bring additional pressure to team members to disclose what is being done and who has been identified.
It is important that no dental team member speak to representatives of the media. If a situation arises, the Team leader should speak for the dental team only under the direction of the Medical Examiner/Coroner.
We can never fully prepare ourselves for a disaster; however continued re-evaluation and learning from previous disaster situations will prepare the dental community to do an even better job when called upon.
Communities, in concert with dental organizations and/or Universities & Colleges, are starting to prepare for such mass fatality emergencies by having training exercises in concert with local health-care professionals such as dentists, local coroners and the city’s full EMS response teams.
The City of Brantford, Ontario has had such exercises via their Mohawk College at the Brantford Campus. Operation ‘Fireball’ held in 2009 dealt with a scenario of 35 fatalities with 210 injuries. Operation ‘Acrobat’ set for October 2010 has a scenario of 20 fatalities with 120 injuries and will incorporate the entire EMS response team in the City of Brantford, the County of Brant and local dental, & law enforcement professionals & students.
For more information on Operation ‘Acrobat’, contact Mohawk College’s Continuing Education department at: firstname.lastname@example.org or (905) 575 2064.
1. Bowers, C.M.; Bell, G.; Manual of Forensic Odontology, 3rd Revised Edition, Colorado Springs: American Society of Forensic Odontology, 1997.
2. McGivney, J.; WinID Dental Computer System, Available at: www.WinID.com
3. Warnick, A., Mass Disaster Management, Chapter 8, pgs. 236 – 257, Manual of Forensic Odontology, 3rd Revised Edition, Colorado Springs: American Society of Forensic Odontology, 1997. OH
Dr. Warnick is a 1964 graduate of the University of Detroit Mercy School of Dentistry and currently the Chief Forensic Odontologist for the Medical Examiner’s Office of Wayne & Oakland Counties in Michigan. He is the Team Leader of the Michigan Dental Association Forensic Dental Identification Team and headed the response for the Northwest Flight #255 crash in Detroit, Michigan in August, 1987 and was deployed to New York City to work on the World Trade Center disaster.
Oral Health welcomes this original article.
1. The Odontology Victim Identification Skill Assessment System, Zorn, Dashkjow, Aschheim, Dobrin, Glazer, Kirschbaum, Levin & Feldman, JFS, Vol 55, No 3, May 2010, pg 788
2. Mass Disaster Management, Dr. Allan Warnick, Manual of Forensic Odontology, C. Michael Bowers & Gary L. Bell, 3rd Edition, ASFO, pg 236.
3. Ibid, pg. 238.
4. WinID Computer System, Available at: www.WinID.com
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