Guidelines for the Development of a
Disaster Dental Identification Team
History
Natural or man made catastrophes often result in multiple casualties under circumstances that make their identification difficult.1 It has long been recognized that under these circumstances, the use of dental records and x-rays by a team of trained forensic odontologists can greatly assist in the expeditious identification of the casualties. This facilitation of the identification and release of the victims to their families, not only provides a humanitarian service relieving the feelings of suffering and helplessness, but also satisfies several medicolegal requirements. It is only a matter of time, when and where a mass disaster will occur.
Based upon the significant role that forensic odontology has played in recent disaster response, it is the goal of the American Board of Forensic Odontology, Inc. to make available, to all who may have need, a simple but complete set of guidelines for the development of a dental identification team. Formal documentation of death demands positive identification. The degree of success in any disaster investigation is directly proportional to the degree of preparation.2
Purpose
These guidelines are designed as a resource for those agencies or jurisdictions who wish to develop an identification team either as a free standing unit or as a section of an overall disaster preparedness plan for a specific region. Realizing no two disasters are identical, nor that the needs of all jurisdictions are the same, modification of any plan may be necessary. Based upon the combined experience of many Diplomates with first hand experience in the identification of multiple casualties, these guidelines are flexible. They provide a complete, but simple outline around which an organization can develop an identification team to suit its purposes.
Team Development
Basic to any disaster identification team plan is the development of a concept of operation. How will your team function? Many states
3 have organized dental identification teams, some under the auspices of their state dental societies. The Council on Dental Practice of the American Dental Association has taken on the task of assisting and coordinating the activity. Will your team be integrated into an overall Emergency Government Plan for an entire state, or will it serve a county or region? Will your team be integrated into an overall Emergency Government Plan for an entire state, or will it serve a county or region? Will your team be a part of a Disaster Mortuary Team (D MORT), under the National Disaster Medical Service? Understandably, all of these objectives may not apply in planning by prospective international teams outside the jurisdiction of the United States and Canada.If trained odontologists are not available to form the core of the team, how will the training be accomplished? Will the team be dependent upon assistance from odontologists from other areas, or will it be free standing with the capability of handling all of its own functions? Once some of these questions are answered, those who are organizing the team can begin to consider the development of a plan, based upon five general areas:
Team personnel
Team organization
Equipment and supplies
Safety and health considerations
Facilities
A bibliography in the addendum lists publications that may be helpful as references, together with a master list of all of the equipment and supplies which may be required in disaster response. Consider that there is overlap between the odontologists, pathologists and funeral directors in the need for some of the equipment and supplies. Some of the equipment may be available from these sources and used jointly.
Mutual aid agreements such as those which exist between the Disaster Dental Identification Teams in Illinois, Indiana, Michigan, Minnesota and Wisconsin may also be advantageous in the event of an extensive disaster.
Outline of a Team Organization
Initial Organizational Planning
Evaluate your need for a dental identification team
Responsibility to the public.
Probability of an incident.
Prior existence of area or state teams.
Evaluate resources
Trained dental personnel.
Equipment and supplies.
Financial assistance.
State and local dental societies.
State and local emergency management agencies.
Organizational implementation.
Team leadership.
Written organizational plan.
Written participation agreement4
Written protocol with job descriptions. Flow chart for division of duties. Written record of participation and training. Sponsorship. State Dental Association. State Emergency Government Administration. State or local Medical Examiner/Coroner.Team personnel
Source
Diplomates of the American Board of Forensic Odontology
Qualified odontologists
A nucleus of highly trained odontologists are necessary to serve in a supervisory and instructional capacity.
The remainder of the team may be composed of dental personnel with skills in dentistry and limited training in forensic dentistry.
Number of Personnel
Consider your potential for a disaster and its size.
Major metropolitan area vs small city or rural area.
International Jetport vs local airport.
Presence of a geologic fault, volcano.
Reality of floods, hurricanes, or tornadoes.
Hazardous and explosive chemical industry.
Sources for personnel recruitment
Forensic organizations.
American Academy of Forensic Sciences.
American Society of Forensic Odontology.
American Board of Forensic Odontology.
Dental societies.
Dental schools.
Additional resources
Armed Forces Institute of Pathology, Department of Oral Pathology.
National Disaster Medical Service, Disaster Mortuary Teams.
Odontologists in Armed Forces Reserve Units.
Federal monetary assistance under Public law 932.88.
Training
Initial Training
Courses are offered by:
Armed Forces Institute of Pathology
Diplomates of the American Board of Forensic Odontology, Inc.
American Academy of Forensic Sciences, Odontology section
American Society of Forensic Odontology
University Dental Schools, Continuing Education Courses
National and state dental society meetings
Other resources
Fire and rescue services training locally
Hazardous Materials Teams (HAZMAT) training courses
Federal Bureau of Investigation, Disaster Squad
Cost of training
Individuals responsibility
Sponsoring organizations responsibility
Emergency government funds
Scheduling of periodic continuing education drills
Quarterly would be very difficult
Semiannually is possible
Yearly is probably the most realistic
Cross training of section members is highly desirable
Objectives of training5
Familiarity with subject Understanding dental identification Antemortem problems and procedures Acquiring flight manifests and names Locating and securing dental records Problems with poor quality records Postmortem problems and procedures Gaining access to dental structures Obtaining postmortem radiographs Fragmentation and commingling Comparison section problems Coping with large numbers of records Computer versus manual searches Identification of fragmented and commingled remains Determination of the number of team members required Based upon magnitude of disaster The condition of the human remains Based upon the estimated time required Special skills required Dentists with forensic training, Oral surgeons, Oral pathologists Auxiliary personnel, Hygienists, Assistants for records compilation Computer assisted identification program specialists Psychologists trained in critical incident stress disorder (CISD) An experienced member to serve as a liaison with other sections of the investigative team Amateur radio service operators for emergency communications Clergy Staging area (may be the responsibility of emergency government). However, the dental identification team should be familiar with this concept. Location Transportation of team personnel to the morgue site Private vehicles Buses, vans or four-wheel drive vehicle Access to the disaster area by dental personnel for the recovery of fragmentary dental evidenceLegal Considerations
Status of the team members as volunteers or employees Responsibility for their health and safety Workers compensation or liability insurance to cover any injury or exposure Compensation of the team members Rate Establishment of the rate according to experience, training and skill Responsibility for the time and record keeping Agency or underwriter responsible for payment
Team members should be informed of their probable compensation prior to participation
Consider a written agreement for team members6
Rules and regulations for participation Authorized photography Authorized press interviews only by official spokesperson Procedure for activation and participation Responsibilities Participation in continuing education Obligation to report changes in telephone number or address Code of ethics Nondisclosure of privileged information Report to staging area only when activated No unauthorized contact with the media Written authorization from Coroner or Medical Examiner to conduct a limited autopsy Methods to gain access to the teeth Viewable vs nonviewable cases Specific authorization on removal of jaws Written authorization for the retention of any tissueJurisdictional Considerations
Conflict of any of the identification team guidelines with an existing emergency government disaster plan. Limitation of the team's area of operation. State or governmental licensure considerations applicable. Mutual aid agreements already in effect for other dental identification teams.Mobilization Procedure (activation)
Method for both drills and actual notification Phone tree FAX One individual solely responsible for placing all calls for activation is recommended. Ability to confirm the team member's availability Ascertain the duration of assignment the team member can accept. Assign a specific time to report or duty to be performed. Periodic update of telephone contact numbers and phone drill Annually should be the minimum to keep records current. More frequently is desirable Determination of which team members are to be activated Decided by the team leader, or designee, in consultation with the Medical Examiner/ Coroner and based upon: Number of fatalities Skills required
Security/Identification of Authorized Team Personnel
Photo identification cards are most foolproof Distinctive color baseball caps with logo identify from a distance Distinctive colored protective equipment, e.g. vests are especially valuable at the disaster site
Team Organization/Structure
Can be divided into sections for specific training and duties Antemortem records section Postmortem, photography and x-ray section Comparison section Size of sections determined by magnitude of catastrophe Team leader, alternate team leader and section supervisors should be on call 24 hours at a time to effectively be able to activate the team Units of the team can be organized regionally
Equipment and Supplies (a complete listing is found in the addendum)
Basic Equipment Dental X-ray machine(s) Auto film processor(s) with daylight loader Autopsy equipment (much may be available from Medical Examiner or Coroner office)
Bard Parker handles and blades
Rib cutters
Long handle pruning shears
Gurneys and tables
Lighting (may be available from emergency government)
Photographic equipment
Computer hardware/software - (useful for large numbers of fatalities)
Copy machine(s) and paper
Consider having a backup available for all equipment.
(Redundancy is the hallmark of an excellent disaster plan - Murphys Law)
Immediate availability of supplies and equipment
Prior arrangements in place with potential suppliers are essential
Evening, weekend and Holiday contact numbers are a necessity. Disaster can strike anytime.
Consider an alternate source just in case
Advance financial arrangements eliminate the need for cash at the time of procurement
Annual review of equipment needs and contact numbers of personnel authorized to provide emergency use of the equipment or provide the supplies must be accomplished.
Supplies (Exact items required and quantity will be determined by the individual team resources and needs. Remember some supplies have a limited shelf life and must be replaced periodically.)
Dental X-ray film and mounts / photographic film
Dental charts (standardized format), manila envelopes, magic markers and colored pencils
Rubber gloves (heavy duty), rubber aprons and face masks and shields or eye protection
Protective footwear (rubber boots)
Banker boxes for files
The quantity of supplies is driven by the number of casualties
Foot lockers or storage boxes for small equipment
Responsibility for cleaning and sterilizing instruments and returning instruments and equipment
Responsibility for restocking supplies used
Consider the other agencies involved in the disaster response as a resource for coordination of the procurement of equipment and supplies.
Medical Examiner or Coroner offices
National Funeral Directors Association Mobile Disaster Mortuary (located at Sky Harbor Airport, Phoenix, Arizona)
Fire and Rescue Services
Emergency Government Coordinators
Cleanup, storage and restocking of equipment and supplies
Cleaning and sterilization of equipment can be accomplished by local hospitals as a public service or Medical Examiner facilities
Storage location between disaster responses (must be accessible at all times)
Airport warehouse facility
Emergency Government facility
Medical Examiner Office
Responsibility for restocking supplies
Coroner/Medical Examiner
Emergency Government Office - County, State, National - Federal Emergency Management Agency
The identification team
Safety and Health of Team Members Must be Considered
OSHA regulations in the United States and WHIMS Rules in Canada. Other regulations may apply internationally.
Team leaders must be aware of their responsibilities
Team leaders and team personnel must be properly trained and aware of:
Radiologic hazards
Bloodborne pathogens
Toxic chemicals
Hazardous sharp debris
Team members must receive biologic hazard and blood borne pathogens training annually and be documented.
A written plan and record of periodic training must be maintained
Avoid long hours or shifts7
Increase in critical incident stress Increase in mistakes and accidents Doesnt allow for adequate cleaning of the morgue site Safety and hygiene are compromised Professional appearance deteriorates Immunizations Immunizations should be required for: Tetanus Hepatitis B Special situation immunizations for foreign locations Cost borne by the sponsoring organization Records should be kept and updated per OSHA regulations A custodian of these records must be designated Protective gear for personnel is a necessity Team members must be trained in the use of this equipment Protective equipment must be immediately available Agency responsible for providing the protective equipment Storage location Responsibility for disbursing / maintaining it Psychological debriefing and counseling should be available. Since this is a situation common to all disaster workers, it ordinarily is not the responsibility of the dental identification team to arrange for this service. However, dental team members should be aware that their work can be psychologically taxing. Access to experts in post traumatic stress counseling Access to clergy
Facilities
Although this is responsibility of the Coroner or Medical Examiner, many smaller jurisdictions have never experienced a catastrophe involving mass fatalities. It should, therefore, be considered by the experienced dental identification team, since they may provide valuable advice.
Adequate temporary morgue sites must be selected in advance
All Coroner/Medical Examiner offices do not have a written disaster plan in place, so potential sites may not be in place Experienced odontologists may be able to assist them in developing this plan, because of their prior experience In general it is advantageous to plan for the use of existing facilities to their maximum before setting up a temporary morgue. Alternate sites also should be considered as a back upSanitation facilities must be available at all of the potential sites
Hot, running water and soap, toilets and toilet paperArrangements for food and a rest area for team members
Sources for food and drink Salvation Army Canteen Red Cross volunteers Volunteers Service clubs Church groups Consider the maximum length of time a team member should work This work is stressful Be aware of post traumatic stress disorder Provide for mandatory periodic breaks and rotate duties Rest in an area removed from the morgue is essential Consider rotating team members between sections frequently Provide chairs or stools for use of team members while working Standard working hours are the least stressful. Avoid shifts, if at all possible8 Immediate reservation of blocks of hotel or motel rooms by the office of emergency government, or other authorized agency, for the use of disaster personnel is necessary to prevent the media from tying up all of the rooms available for miles around. Area perimeter security is the responsibility of the ranking law enforcement official present. However, the dental team must be aware of the necessity for perimeter security and be readily identified. Protection of personal effects of victims Excluding the curious and unauthorized Prevention of unauthorized photography by the media Can be provided by governmental or private agencies
Once these concepts have been established, those organizing the team can begin to consider expansion of the team to handle the identifications, as the magnitude of the disaster increases.
9 The team can then be organized to be able to handle casualties in ranges, e.g. 1 to 50, 50 to 150, 150 to 300 and 300+.10 Working in shifts, around the clock, is to be avoided, unless absolutely necessary. The use of adequately cross-trained supervisory personnel is mandatory.
References
[1] Hazen, R.J., Phillips, C.E., "Field Disaster Identification-Preparation-Procedures," U.S. Department of Justice, Federal Bureau of Investigation.
[2] Morlang, Wm., "Mass Disaster Management," 1993, U.S. Air Force Medical Service, Brooks Air Force Base, San Antonio, TX.
[3] Bell, G.L., "Mass Disaster Dental Identification Team," State of Washington,1983, 9730 Third Ave., NE, Suite 204, Seattle, WA, 98115 (The first state dental disaster plan.)
[4] Wright, F., "Ohio State Disaster Dental Identification Team."
[5] Jones, G.F., "Idaho Dental Association Disaster Dental Identification Team Protocol."
[6] Wright, op. cit.
[7] Personal communication, Danny W. Greathouse, FBI Disater Squad.
[8] Id.
[9] Morlang, op. cit.
[10] Proceedings, American Board of Forensic Odontology Mass Disaster Committee, 1995.
[11] Kenney, J., "Cook County Medical Examiner Disaster Identification Team Protocol."
[12] A portable morgue is maintained by the National Funeral Directors Association at Sky Harbor Airport, Phoenix, AZ. It is available for authorized use in disasters resulting in multiple fatalities. All that is required for use of this equipment is that the user restock the supplies expended.