Pediatric Disaster Preparedness

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Pediatric Disaster Preparedness

Contents

EDITORS & CONTRIBUTORS

FOREWORD

01 Introduction The Editors02 How Children Are Different George Foltin MD, Jane Knapp, MD03 Pediatric Triage On-Scene in Disasters Lou Romig MD04 EMS System Disaster Plan Arthur Cooper MD05 Pediatric Regional Triage & Transport Robert Kanter, MD06 Urgent Care Paul Sirbaugh, DO07 Shelter Care Richard Bradley, MD

08 Disaster Drills Bonnie Arquilla DO, Marsha Treiber MPS09 Topical Decontamination of Children Michael Shannon MD, Sarita Chung MD10 Psychological First Aid David Schonfeld MD11 Patient Identification and Tracking Connie Maxin EMT-P12 Natural, Technological & Intentional Disasters Baruch Fertel MPA EMT-CIC13 Physical Disasters Daniel Fagbuyi MD,Fred Henretig MD14 Biological Disasters Stephan Kohlhoff,Daniel Fagbuyi MD, Fred Henretig MD15 Children with Special Health Care Needs Michael Tunik, MDAPPENDIX: Pediatric Equipment List


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Editors and Contributors

Editors

George L. Foltin, MD, FAAP, FACEPAssociate Professor of Pediatrics &Emergency MedicineBellevue Hospital Center/New York University School of Medicine

Michael G. Tunik, MD, FAAPAssociate Professor of Pediatrics &Emergency Medicine

Bellevue Hospital Center/New York University School of Medicine

Marsha Treiber, MPSExecutive DirectorCenter for Pediatric Emergency MedicineNew York University School of Medicine

Arthur Cooper, MD, MS, FAAP, FACSProfessor of SurgeryColumbia University Medical Center

Affiliation at Harlem Hospital

Contributors

Bonnie Arquilla, DOAssistant Professor of Emergency MedicineDirector Emergency PreparednessSUNY Downstate/Kings County Hospital Center

Richard N. Bradley, MD, FACEPChief of the Division of EMS and Disaster Medicine

Department of Emergency MedicineUniversity of Texas Health Science Center at Houston

Sarita A. Chung MDProject Scientist, Center for BiopreparednessChildren's Hospital BostonInstructor in PediatricsHarvard Medical School


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Daniel Fagbuyi, MDMember of the Army Medical Corpwith recent experience serving in IraqPediatric Emergency MedicineChildrens Hospital of Pittsburgh

Baruch S. Fertel, MPA, EMT-CICCenter for Pediatric Emergency MedicineNew York University School of Medicine

Fred Henretig, MD, FAAP, FACMTSenior Toxicologist and Associate Medical DirectorPoison Control Center, Philadelphia, PADirector, Section of Clinical ToxicologyProfessor of Pediatrics and Emergency Medicine-Children's Hospital of PhiladelphiaUniversity of Pennsylvania School of Medicine

Robert F. Kanter, MDProfessor of PediatricsDirector Critical Care & Inpatient PediatricsSUNY Upstate Medical University

Jane Knapp, MD, FAAP, FACEPProfessor of PediatricsUniversity of Missouri-Kansas City School of MedicineVice Chair PediatricsMedical Director of Graduate Medical EducationChildrens Mercy Hospital

Stephan A. Kohlhoff, MDAssistant Professor, PediatricsDivision of Pediatric Infectious DiseasesSUNY Downstate/Kings County Hospital Center

Connie Maxim, EMT-PEducation and Project CoordinatorEMSC Michigan Family RepresentativeRegion 6 BioDefense Network Coalition of MichiganMichigan Department of Community Health (MDCH)

Lou Romig, MD, FAAP, FACEPFlorida Pediatric EMS Medical DirectorPediatric Emergency MedicineMiami Childrens Hospital

Paul Sirbaugh, DO,FAAP, FACEP


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Assistant Professor of PediatricsEmergency Medicine SectionBaylor College of MedicineDirector of EMSTexas Childrens Hospital

David Schonfeld, MD, FAAP,Director, Division of Developmental and Behavioral Pediatrics;Director, National Center for School Crisis and BereavementThelma and Jack Rubinstein Professor of PediatricsCincinnati Childrens Hospital

Michael W. Shannon, MD, MPH, FAAP

Professor of PediatricsHarvard Medical SchoolChair, Division of Emergency MedicineDirector, Center for Biopreparedness

Childrens Hospital of Boston


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Foreword Pediatric Disaster Preparedness

1

Foreword

Areviewofthecurrentstateofreadinessfordisastersandterrorismwithregardtothe

needsofchildrenrevealssignificantgapsbothinemergencypreparedness(preparationand

protection)andindisastermanagement(responseandrecovery).Historically,theunique

characteristicsofchildrenandtheirliveshavenotbeenwellorfullyconsideredinthemultidisciplinaryplanningprocessforresponsetoterrorism,mostespeciallyinthe

prehospitalenvironment.Whyisthisso?Inthepast,muchoftheterrorismresponse

planningintheUnitedStateshascenteredonmilitarypreparedness.Therefore,planshave

focusedontheneedsofadults.Unfortunately,theentirepopulationisnowatrisk.Asthe

planningfordisastersandterrorismisundertaken,itistimetoreassesseducationand

preparationforallcatastrophiceventstoensurethatchildrenandtheirfamiliesareincluded.

Unfortunately,thecareofchildrenduringsucheventscannotbeapproachedsimplyby

modifyingcurrentpractices.Basicdaytodayissuesinvolvingfamiliesthathavenotbeen

previouslyconsidered(incorporatingschoolsandchildcarecentersintodisasterpreparation

andprotection)mustnowbeaddressed.Thelikelihoodofadisasteroccurringwhilechildren

areinschooloratchildcarecentersishigh.Disasterscouldalsooccurataschool,onaschool

busoratachildcarecenter.

EmergencyMedicalServices(EMS)agenciesandtheirdedicatedproviderscomprisethe

initialmedicalresponsetoeverydayemergencies,disasterswhethernaturalormanmade

andotherpublichealthemergenciessuchaspandemicinfluenzathatmayarise.

Regional,stateandnationalplanningrequiresEMSleadersandemergencymanagerstoplan

togetherandcoordinateservices.Itiswelldocumentedthatpreparingfortheneedsof

childrenischallenging,thereforeuneven.ResourcessuchastheAHRQAAPpublished

PediatricTerrorismandDisasterPreparedness Resource

http://www.ahrq.gov/research/pedprep/pedtersum.htm andtheNewYorkCityDepartment

ofHealthandMentalHygienePediatricDisasterToolkit:HospitalGuidelinesforPediatrics

duringDisasters(2ndEdition,2006)http://www.nyc.gov/html/doh/html/bhpp/bhppfocus

pedtoolkit.htm(3rdEditionpending)areavailableforreference.

Thislatestdocument,PediatricDisasterPreparedness:AResourceforPlanning,Management

andProvisionofOut-of-HospitalEmergencyCarepreparedbyCenterforPediatric

EmergencyMedicinefortheEmergencyMedicalServicesforChildren(EMSC)National

ResourceCenter,underfundingprovidedbytheFederalEMSCProgramoftheMaternaland

ChildHealthBureau(MCHB),HealthResourcesandServicesAdministration(HRSA),United

StatesDepartmentofHealthandHumanServices(HHS)hasbeendesignedtofocusonthe

practicalandessentialelementsofpediatricprehospitalemergencycareinEMSsystem

planningfordisastersandterrorism.ItisdesignedforusebyEMSagencyandsystemmedical

directorsandadministrators,emergencymanagers,andanyotherkeystakeholderswhowill

beconcernedwiththefunctionsandactivitiesofEMScareprovidersduringadisaster,terror

event,orotherpublichealthemergency.Contenthasbeencompiledbyexpertsfromaroundthecountrytoreflectthecurrentevidencebase,bestpracticesandpracticalapplication,and

coversclinical,administrative,andpolicyissues.Thehopeistofacilitateplanningandsave

valuabletime.Thepurposeofeachsectionistosupplementtheplanning,approaches,and

knowledgethatalreadyexisttofacilitateintegratingspecificpediatrictopicsthatwill

enhancepreparationsinapracticalandadditivemanner.


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2

Incorporatingtheneedsofchildrenandfamiliesintoterrorismanddisasterplanning

requiresmultidisciplinarypediatricexpertiseatallphases. PediatricDisasterPreparedness

includestheinformationavailableusingthebestevidenceknowntoincludechildrenand

familiesinalltypesandatalllevelsofterrorismanddisasterplanning.Afewofthemany

considerationsincludethefollowing:

Writingandimplementingchildspecificprotocols Planningforchildrenwhoareseparatedfromtheirparentsandatschoolsandchildcare

centerswhendisasterstrikes

Trainingproviderstocareforthepediatricpatient Developingequipmentandmedicationdosageformsanddeliverysystemsappropriate

forchildren

Providingeducationontherecognitionandcareofmentalhealthneedsofchildrenintheaftermath

PlanningforchildrenwithspecialhealthcareneedsThefollowingtopicsarecovered,butweplantoexpandthecoverageinfutureeditionsbasedonfeedbackandidentifiedneeds.

HowChildrenareDifferent Triage EMSSystemDisasterPlan TransportPlan ShelterCare DisasterDrills Decontamination Psychosocial PatientIdentificationandTracking TypesofDisasters PhysicalDisasters BiologicalDisasters ChildrenwithSpecialHealthCareNeeds EquipmentPlanningandpreparationforterrorismanddisasterscanbebothdauntingandchallenging.Forall,butespeciallyforchildrenandfamilies,therearemanyrecognizedgapsinknowledge,

resources,andprofessionaleducation.Thisresourcehasbeenprovidedtoincreasepediatric

expertiseofthosewhoarewillingandreadytotakeonthechallengeofpreparationand

planning.Thisresourcecanalsobeusedbyotherpediatrichealthcareproviders,public

healthprofessionals,healthadministrators,andpolicymakerswhoarecommittedto

ensuringthatplanningforterrorismanddisastersincludesthespecialneedsofchildren.


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3

GeorgeFoltinMD

MichaelTunikMD

MarshaTreiberMPS

ArthurCooperMD


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1: Introduction Pediatric Disaster Preparedness

Chapter 1: IntroductionArthur Cooper MD

Introduction

Pound for pound, children breathe, drink, and eat more than adults.1

Disastermedicineisdefinedasthefieldofmedicalspecializationthatprovidesmedicalcare

todisastersurvivors,andisconcernedwithmedicallyrelateddisasterpreparation,

mitigation,responseandrecoveryleadershipthroughoutthedisasterlifecycle.2Whilethe

overridingpurposeofallemergencypreparednessanddisastermanagementisthe

preservationofhumanlifestabilizationofthedisasterresponseandprotectionofvital

property,bothpublicandprivate,arealsoimportant,butareclearlysecondarytothe

preservationoflife.Disastermedicinediffersfromdaytodaymedicineinthatafarlarger

arrayofpublichealthandsafetyservicesmustbeinvolvedinthedisasterresponsetoensure

asafeenvironmentforpatientsandprovidersalike.Thatchildrenhavespecialneedsin

disastersshouldnotbesurprisingtheyalsohavespecialneedsonadailybasis.Thus,all

emergencyresponders,mostespeciallyemergencymedicalservices(EMS)personnel,must

acceptthefactthatsincenearlyalldisasterswillinvolvechildren,theymustbereadyto

providefortheirneeds.

Readinessforpediatricdisastermedicalcareisbestaccomplishedthroughreadinessfor

pediatricdaytodaymedicalcare.TheEMSagenciesandsystemsthatarebestsituatedto

respondtodisastersinvolvingchildrenarethosewhichhavemadespecialprovisionfor

pediatriccareateveryleveloforganizationmedicaloversight,providertraining,proper

equipmentandmedications,inallappropriatesizesanddosages,aswellaspatientsafetyand

performanceimprovementprogramsthataddresspediatricissues.Theothersectionsinthis

resourcewillprovideEMSleaderswiththetoolstheyneedtoprepareforthedaywhendisasterstrikes,andchildrenarehitastheywere,attheverymomentofthiswriting,bya

tornadothattoucheddowninaBoyScoutcampinsouthwesternIowa,anareasparsely

populatedandevenmoresparselyservedbyspecializedpediatricclinicsandhospitals.This

sectionwillfocusonthedesignandfunctionoftheEMSsystemindisastersinvolvingadults

andeldersaswellaschildrenunderstandingthatchildrencanbeexpectedtofarenobetter

thantheseothers,sincetheintegrityofthepediatricdisasterresponsewillbedependenton

theintegrityofthemedicaldisasterresponseoverall.

The Public Health Paradigm of Disaster Medicine:

Preparation, Mitigation, Response, Recovery

Thepublichealthparadigmofdisastermedicineconsistsoffourdistinctphases.Thefirst

twopreparationandmitigationtogethercomprisewhatiscalledemergency

preparedness,thelasttworesponseandrecoverydisastermanagement.Thefirst

threearewithinthedomainofallhealthcarepersonnel,sinceallhealthcareagenciesand

organizationsmust1)preparethemselvesthroughplanningandeducationtorespondto

disastersrequiringamedicalresponse,2)mitigatetheimmediatelydetrimentalhealth

effectsofdisastersthroughuseoforganizedsystemsofcaredelivery,andregulardrillsthat

refinetheabilityofhealthcareorganizationstorespondinaneffectivemanner,and3)


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respondinpriorityordertosuddenlyillorinjuredpatientswithsufficientresourcesand

personneltomeettheirneeds,throughapplicationofascientificallyvalidatedtriagetool,and

mobilizationofsurgecapabilityadequatetoprovideminimallyacceptablecaretoallpatients

requiringhealthcareservices.Thelastphase,recovery,ischieflytheresponsibilityofthe

publichealthsystem,althoughacutecareprofessionals,includingemergencymedicalpersonnelaswellasacutecarephysiciansandnursesfromthedisciplinesofemergency

medicine,trauma,andcriticalcaremedicine,maybecalledupontoassistbothprimarycare

andpublichealthphysiciansandnursesprovideurgenthealthcaretoapopulationrequiring

bothprimarycareandacutecareduringtheintervalduringwhichthepublichealthand

healthcareinfrastructureisreestablishedandrebuilt.

Thepublichealthparadigmofdisastermedicineisdirectlyanalogoustothepublichealth

paradigmofinjuryprevention.

Thefirstphaseofinjurypreventionprimary injury prevention, or avoidanceisdesignedtokeepinjuriesfromoccurringinthefirstplace,chieflythroughplanningandeducation,based

ontheepidemiologyofinjuriesinthecommunitybeingserved;preparationfordisasters,

throughplanningandeducation,alsoforestallsmanyoftheuntowardmedicaleffectsofdisasters.

Thesecondphaseofinjurypreventionsecondary injury prevention, or attenuationisdesignedtolessentheimpactofinjuriesastheyareoccurring,baseduponengineering

solutionsthatalterthesystemsandenvironmentwithinwhichtheseinjuriescommonly

occurandtreatmentisprovided;mitigationofdisasters,viaimplementationofanincident

commandsystem,andregulardisasterdrills,lessensthemedicaleffectsofdisastersby

ensuringaprompt,organizedmedicalresponse.

Thethirdphaseofinjurypreventiontertiary injury prevention, or amelioration isdesignedtoreducetheeffectsofinjuriesthathavealreadyoccurred,baseduponevaluationstrategies

thataddresspatientsneedsinorderofphysiologicimportant;responsetodisasters

similarlydecreasesmedicalcomplicationsbyprioritizingcarewhenmultiplecasualtiesareinvolved,viatriage,anddeterminingtheimmediateneedforandurgentavailabilityof

additionalassetsintermsofequipmentaswellasemployees,knownassurgecapability

ratherthansurgecapacity,sinceitmattersnotwhatadditionalassetsmaybeonhand,but

rather,whichcanactuallybeused.

Key Differences between Disaster Medical Care and Day-to-Day Medical Care:

Circumstances Extraordinary, Care Ordinary

Themostimportantdifferencebetweendisastermedicalcareanddaytodaymedicalcareis

thenumberofpatientswhomustbeassessedandmanaged.Multiple casualty incidents

(MCIs)typicallyinvolvefiveormorepatients;theresourcesoftheinvolvedEMSagenciesmaybestrained,butarenotoverwhelmed.Bycontrast,mass casualty events(MCEs)typicallyinvolvetwentyormorepatients;theresourcesoftheinvolvedEMSsystemsaswell

asagencieswillbespent,andarecompletelyoverwhelmed.Understandingthemassivegap

thatmaysuddenlyappearbetweenpatientsneedsandavailableresources,andthechaos

thatinevitablyresults,iscriticaltoEMSsystemdesignandfunctioninthedisastersituation

statedsuccinctly,carewillhavetoberationed,ifonlyforashorttime;desperatelyillor

injuredadultsandchildrenmayneedtowaituntilotherswithgreaterlikelihoodofsurvival


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aretreatedfirst;andEMSproviderswillneedtomakesuchlifeanddeathdecisionsinthe

blinkofaneye,andinthemidstoftheworstpossibleenvironmentforhealthcare:a

crowded,possiblysmokeorgasfilledscene,characterizedbyloudnoises,screaming

patients,putridodors,gruesomedeformities,andcrowdsofindividualswithlittleorno

trainingeithertryingtohelpbutgettingintheway,orworse,tauntingEMSprovidersastheyattempttomakethebestofabadsituation.

Theotherkeydifferencesbetweendisastermedicalcareanddaytodaymedicalcareinvolve

themechanismsofillnessandinjuryencountered,andtheenvironmentinwhichemergency

medicalcaremustbedelivered.Asmostnaturalandhumanmadedisastersinvolvephysical

trauma,EMSpersonnelmustbepreparedtoprovideurgentcaretomanytypesofbluntand

penetratinginjuries,whichmayresultfromnumeroustypesofeventscrushinjuriesfrom

earthquakesandstructuralcollapses,neardrowningsfromhurricanesandfloods,blastand

burninjuriesfromexplosiveandincendiarydevicessuchasbombsandindustrialmishaps,

andfirearminjuriesfromgunshotsandmilitaryordnance,tonamebutafew,nottomention

thecontaminatedwoundsassociatedwithalltheabove.Chemical,radiological,andnuclear

disastersincludingbothhazmatexposuresandterroreventsarelikephysicaltraumain

thattheonsetanddurationofmostsucheventsaresuddenandlimited,althoughspecific

medicaltreatmentsmayberequiredforcareofinjuredpatients.Biologicaldisasters,

however,requireanentirelydifferentapproachtotheircaresinceinfectedpatientsarenot

likelytorequireemergencymedicalcareatpreciselythesametime,butratherwillpresentin

clustersofindividualpatientswithlikesymptomcomplexeswhich,whenrecognizedas

such,willlikelyrequireanapproachtomanagementthatinvolvescohortingofpatients,and

specializedpersonalprotectiveequipment(PPE)foremergencymedicalproviders,and

sometimesforpatientsaswell.

Approach to Emergency Medical Care in Pediatric Disaster Medicine:

KISS Keep It Simple, Sister (And Brother)Theemergencymedicalcareprovidedduringdisastersisbutoneaspectoftheoverall

emergencyresponsetodisasters.Emergencymanagementofdisastersfollowsanall

hazardsapproach,toallowoneeasilyrememberedapproachtobeappliedtoalltypesof

disasters,reservingandlimitingspecializedplansforandtoonlythosecomponentsofthe

disasterresponsethatrequirespecializedinterventions.Emergencymedicalresponderswill

rarely,ifever,findthemselvesincommandofadisasterscene,sincetheirskillsarefartoo

valuabletowasteonscenesafetyandcrowdcontrol,taskswhicharefarbetterhandledby

publicsafetyofficialsspeciallytrainedandauthorizedtoperformthesetasks.Ontheother

hand,itmustbeunderstoodthatthehighestrankingmedicalprofessionalonthesceneis

responsibleformedicalincidentcommand,andhisorhermedicalordersareregardedas

binding,unlessthereisanurgentthreattothesafetyofpatientsorproviders.

Theapproachtoemergencymedicalcareindisastersmustfollowastandardizedpatternifall

involvedprovidersaretounderstandtheirrolesandcollaborateeffectively.Onesuchmodel

istheDISASTERParadigmdevelopedbytheNationalDisasterLifeSupport(NDLS)

Foundation,anddisseminatedviatheNDLSseriesofcoursesCoreDisasterLifeSupport

(CDLS),BasicDisasterLifeSupport(BDLS),andAdvancedDisasterLifeSupport(ADLS)thatit

nowoffersincollaborationwiththeAmericanMedicalAssociation(Table1).3Thecritical

elementsoftheDISASTERParadigmwillbefamiliartoallEMSleaders,managers,and

providers,inthatSafetyandSecurity,andAssessmentofHazards,precedeTriageand


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Treatmentinallcases,astheydoforroutinecare.Theonlydifferences,asidefromRecovery,

whichisnotordinarilywithinthepurviewofEMSare1)DetectionandDeclarationofthe

disaster,2)implementationofanIncidentCommandStructure,beforeemergencymedical

careisprovided,3)useofdisasterspecificTriageandTreatmentprotocolsthatpermitonly

minimallyacceptablecaretobeprovidedtosalvageablepatients,priorto4)rapidEvacuationfromthesceneideally,inthecaseofchildren,topediatriccapablehealthcarefacilities,

eitherfixedordeployablerecognizingthatsinceallhealthcarefacilitiesmaybecalledupon

tocareforchildrenindisasters,allmustpreparethemselvestodoso;fortunately,toolsare

nowavailablethatcanassistnonpediatricfacilitiesinmeetingtheirresponsibilitiesto

childrenindisasters(http://www.nyc.gov/html/doh/html/bhpp/bhppfocusped

toolkit.shtml).

Environment of Emergency Medical Care in Pediatric Disaster Medicine:

Uphill, Upwind, Upstream

Asforanyemergencymedicalresponse,scenesafetyandpersonalprotectionareofparamountimportanceinthedisastermedicalresponse.Theenvironment,inwhich

emergencymedicalcaremustbedelivered,however,presentsspecialchallengesto

emergencymedicalresponders.Thesceneitselfmaybecontaminated,orcontainsingleor

multiplesecondaryhazards,placedunintentionallyorintentionally,thatmayfurtherinjure

patientsandprovidersalike.Thus,despitetheriskoffurtherpatientdeterioration,

emergencymedicalrespondersmustNOTenterthesceneunlessanduntilithasbeendeclared

safebytheappropriatepublicsafetyauthorities adirectivethatwillbeveryhard,ifnot

impossible,toenforcewhenchildrenarevictims,butwhichmustbeenforcednonetheless,

sinceEMSpersonnelwhobecomeillorinjuredwhilecaringforothers,bydefinition,become

partoftheproblemratherthanpartofthesolution,andunwittinglyservetodiminishthe

capabilityoftheveryemergencyresponsetheyseektoaugment.

Theenvironmentinwhichemergencymedicalcareisprovidedindisastersdependsuponthespecifictypeofdisasterinvolved.However,thedeploymentofemergencymedicalpersonnel

inthefieldalwaysfollowsthesamegeneralpatternwhichkeepsspecializedpersonnel

especiallyvitalmedicalpersonneluphill,upwindandupstream,ofthedangersposedby

thescenetoprovidersuntrainedinrescue(Figure1).EMSpersonnelneverenterthesearch

andrescue(SAR)area(hotzone)unlessdirectedbyresponsibleauthoritiesonceithasbeen

declaredfreeofhazards,eventorescuedistressedpediatricpatients ,butreceiveallsuddenly

illandinjuredpatients,whetheradultsorchildrenoncetheyhavebeenatleastgrossly

decontaminated,ifdecontaminationisindicatedfortransporttonearbyfixedor

deployablemedicalfacilitiesatoneormorecasualtycollectionpoints(CCPs)withinthe

overallareaofoperations(warmzone)locatedinsidetheexternalperimeter,whichisnever

crossedwithoutspecificorders.InsomedisastersparticularlythoseinwhichEMS

resources,especiallyambulancesandmultipleemergencyresponsevehicles(MERVs)areof

limitedavailabilityitmaybenecessaryonatemporarybasistoestablishastagingareafor

initialtreatmentofvictimsbyemergencymedicalpersonnel,inwhichcaseitmaybe

advisabletoseparatechildrenfromadults,thoughnotfromtheirfamilies;still,rapid

evacuationisalwaysthepriority,ideally,inthecaseofchildren,tohealthcarefacilitiesthat

havemadespecialprovisionsfortheirneeds,andofwhichEMSpersonnelmustbeawareas

partoftheirtraining.


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The Role of Emergency Medical Services in Pediatric Disaster Medicine:

Children Are Not Small Adults

Emergencymedicalpersonnel,asacutecareprofessionals,arechieflyinvolvedwiththethird

phaseofthepublichealthdisasterparadigm,namely,disasterresponseand,underthe

revisedNationalResponseFramework(NRF)thatbecameeffectiveinMarch2008,functionas

partofEmergencySupportFunctionNumber8 (ESF#8).Thefundamentalprincipleof

emergencymedicalcareindisastersistoprovidethegreatestgoodforthegreatestnumber.

Thisisincontrasttowhatemergencymedicalprofessionalsdoeveryday,namely,toprovide

allnecessarycare,withinthelimitsofequipment,resources,andpersonnelavailableinthe

prehospitalenvironment,topatientsrequestingemergencyaid.Toprovideemergency

medicalcareindisasterthereforerequiresanimportantshiftinthemindsetofemergency

medicalpersonnel,fromtheoptimalcareprovidedtothesuddenlyillandinjuredpatient,to

theminimallyacceptablecareofferedtoadistressedpopulation.

Minimumacceptablecareisthatwhichisurgentlynecessarytosavelifeorlimb,butnomore

carewhich,byitsverynature,issustentativeratherthandefinitive.Temporizingbasiclifesupport(BLS)measuresinsupportoftheairway,breathing,andcirculationtheABCsare

thefundamentalelementsofminimallyacceptablecareforchildrenandadultsalike,

recognizingthatsuchcareinchildrenrequiresthereadyavailabilityoftheappropriate

pediatricequipment.However,notethatinmasscasualtyevents(MCEs),whentreatment

resourcesmaybeseverelylimited,therewilllikelybetimeonlyfortheprimary,orinitial,

assessment,notforthesecondaryassessment,alsoknownasthefocusedhistoryanddetailed

physicalexaminationjustastherewillbenotimeforadvancedlifesupport(ALS)

interventionsthatconsumescarce,andvaluable,minutes.EMSpersonnelmustalsobeaware

that,despitetheirnaturalandadmirabletendencytowanttosavethelivesofchildrenbefore

thoseofadults,notimeshouldbespentinfutileattemptsatcaringforchildrenwhoare

deemedunsalvageablealthoughcomfortcare,andpsychologicalfirstaid,canandmustbe

madeapriorityforallchildren,especiallyiftheyhavebeenseparatedfromtheirlovedonesortheirregularcaregivers,onceminimallyacceptablecarehasbeengiventoallsalvageable

patients,childoradult.

Application of Incident Command Systems (ICS) in Pediatric Disaster Medicine:

Whos In Charge? Theyre All In Charge!

TheIncidentCommandSystem(ICS)nowincommonuseintheUnitedStatesresultedfrom

theexperiencesofthosebattlingCaliforniawildfiresinthe1970sand1980s.Tocontain

thesefires,theservicesofnumerousagenciesfromseveralstateswererequired.

Unfortunately,theinvolvedagenciesuseddifferentcommandstructuresaswellasradio

frequencies,makingitdifficult,andinmanycasesimpossible,tocommunicatebetweenagencies.Asaresult,thelivesofseveralfirefighterswereunnecessarilylost,leadingexperts

infirematicstopartnerwiththoseinmanagementtodevelopauniversalsystemforincident

commandbuiltontheprinciplesofManagementbyObjectivesandResultsasystem

recentlyadoptedandendorsedbytheDepartmentofHomelandSecurity(DHS)asa

fundamentalcomponentoftheNationalIncidentManagementSystem(NIMS)andthe

NationalResponseFramework(NRF),andtaughtinallitstrainingcourses(Table2).The

IncidentCommandSystem(ICS)nowinplaceemploysfourStaffOfficersaspartofits


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CommandStaff,Liaison,Medical/Technical,PublicInformation,andSafety,easily

rememberedbythemnemonic,[Mount]OLMPS;andfourSectionChiefstocompriseits

GeneralStaff,Finance/Administration,Logistics,Operations,andPlanning,easily

rememberedbythemnemonic,C-FLOP(Figure2).

Inaddition,theIncidentCommandSystem(ICS)nowinplaceisbasedontheprincipleofUnityofCommandthepremisethat,whileinformalsharingofinformationisstrongly

encouragedateveryleveloftheIncidentCommandStructure,formalbriefings,orders,and

reportsflowfrom,to,orthroughonlyasinglesupervisor,whoseSpanofControldoesnot

exceedthreetoseven,andideallyonlyfive,subordinates.WhileIncidentCommandmaybe

sharedbydesignatedofficersofmultipleagencieswithprimaryjurisdictionalauthorityand

responsibility,oneofwhomwillactasthespokespersonastructureknownasUnified

IncidentCommandallparticipatingagenciesandpersonnel,eventhoughtheirfocuswillbe

toprovideaneffectivedisasterresponsewithintheirindividualareasofexpertise,agreeto

reportviavariousSectionChiefstoasinglelocusofIncidentCommand,supportedbyStaff

OfficerswhoassistIncidentCommandwithcertaincommandfunctions.Theimplementation

andoperationofthisIncidentCommandSystemshouldbewellknowntoEMSleaders

makinguseofthisresource,andthuswillbesummarizeddiagrammaticallyratherthan

explainedindetail(Figure2).Sufficeittosaythat1)underallthebutmostunusual

circumstances,EMSwillserveasasupportratherthanacommandagency,andconfineits

operationstotriage,treatment,andtransportoftheacutelyillandinjured,and2)the

provisionofpediatricemergencycaremustbetheresponsibilityofallinvolvedEMSagencies

andpersonnel,sincechildrenrequiringsuchcarewillbeencounteredinalldisastervenues.

Planning for the Care of Children in Disasters:

Plans are nothing. Planning is everything.4

Theenormousvariabilityindisastertypeandvenuemakesdisasterplanningadaunting

challenge,evenforexperiencedprofessionals;however,absentcomprehensiveplanning,andwithoutdueconsiderationofalllikelydisasterscenarios,itwillbeimpossibletomountan

effectivedisasterresponse.Fortunately,theveryactofplanningforeveryeventualityyields

richdividendsintermsofpreparation;numeroussourceshavecitedtheirextensive

preparationsforY2Kasinstrumentalinmanagingdisastersthatoccurredsubsequently.

Withrespecttochildren,sufficeittosaythatpediatricvictimsshouldbeexpectedfollowing

mostdisasterevents,andmaybethespecifictargetsofcertainterrorevents;disastervenues

mostlikelytoharborpediatricpatientsincludeschools,schoolbuses,playgrounds,

recreationalareas,athleticfields,amusementparks,shoppingmalls,andentertainment

complexes.EMSleadersmustworkwiththemanagersofallsuchfacilitieswellinadvanceof

anypossibleterrorthreattoensuretheyhavedevelopeddetaileddisasterplans,especially

forevacuation,intheeventofterrorattackplansthatmustbecoordinatedwiththoseof

localpublichealthandsafetyagenciesandlocalandregionalemergencymedicalservicesand

traumacarefacilities,inadditiontoEMS.

Indevelopingsuchplans,EMSleadersmustinvolvenotonlychildhealthprofessionalsexpert

inbothphysicalandpsychologicaltrauma,butalsopeers,parents,religiousleaders,andcivic

leaders,toensurethatdisasterandevacuationplanshaveaddressedallforeseeable

calamities.Mostvenuesdelineatedabovehavecommunityadvisoryboardsorliaisons,who

togetherwithfacilitydirectorsmusttaketheleadinensuringthatplansarenotonly

developedandreviewed,butalsoarecurrent,realistic,sensible,andflexible,andperhaps


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mostimportant,botheasytoremember,andeasytoimplement.Exitsmustbewelllighted,

preferablywithnaturallightasmostterrorattackstargetingchildrenwilloccurduringthe

day,andwellmarked,atceiling,wall,andfloorlevels,tofacilitaterapidrecognitionevenby

smallchildrenorwhenvisibilityispoor.Alldisasterandevacuationplansmustthenbe

testedandrefinedthroughregulardrills,toensurethatchildrenwillunderstand,andwillhavepracticed,whattodoifandwhenadisastershouldoccur.

Training for the Care of Children in Disasters:

Remember the ABCs, But If Thats Too Difficult, Remember the AAAs5

AllEMSpersonnelinvolvedindisastersmustbewelltrainedintheapplicationofthe

NationalIncidentManagementSystem(NIMS),andmustbethoroughlyfamiliarwiththe

specificsoftheIncidentCommandSystem(ICS).Ataminimum,therefore,allEMS

professionalsmusthavesuccessfullycompletedtheIS100(IntroductiontotheIncident

CommandSystem),IS200(ICSforSingleResourcesandInitialActionIncidents ),IS700

(NationalIncidentManagementSystemAnIntroduction ),andIS800B(NationalResponseFrameworkAnIntroduction)coursesofferedbymanystates,andeducationalconsortium

partnersoftheDepartmentofHomelandSecurity(DHS)FederalEmergencyManagement

Agency(FEMA),readilyaccessedonlineathttp://training.fema.gov,whileallEMSleaders

andmostEMSsupervisorsshouldalsohavesuccessfullycompletedIS300(IntermediateICS

forExpandingIncidents)andIS400(AdvancedICSforCommandandGeneralStaffComplex

Incidents),accessedatthesameaddress,butwhichmustbetaughtbyqualifiedinstructors

overthreedayseach,duetothebreadthanddepthofthematerialtobecovered,andthe

largeamountofsmallgroupworkinvolved.AllEMSpersonnelmustalsobewelltrainedin

theEMSresponsetoMCIsandMCEspotentiallyinvolvingweaponsofmassdestruction

(WMD).Thus,allEMSprofessionalsshouldhavesuccessfullycompletedAWR160(WMD

AwarenessLevelTraining),whileallEMSleadersandmostEMSsupervisorsshouldalsohave

successfullycompletedPER211(EMSOperationsandPlanningforWMDIncidents),offeredbyDHSandFEMA.

Trainingspecifictopediatricemergencycareindisastersisbaseduponasolidgroundingin

pediatricemergencycarefordaytodaypediatricemergenciesrecognizingthatformost

pediatricemergencies,respiratorydistress,failure,andarrest,ratherthanshock,arethefinal

commondenominatorsofphysiologicdeterioration.AllEMSpersonnelshouldsuccessfully

completethePediatricEmergenciesforPrehospitalProfessionals (PEPP)Courseofthe

AmericanAcademyofPediatricsateitherthebasiclifesupport(BLS)ortheadvancedlife

support(ALS)level,asappropriate(http://www.pepp.org),whileadvancedlifesupport

(ALS)personnelshouldalsosuccessfullycompletethePediatricAdvancedLifeSupport(PALS)

CourseoftheAmericanHeartAssociationandtheAmericanAcademyofPediatrics.6,7The

BasicDisasterLifeSupport(BDLS)andAdvancedDisasterLifeSupport(ADLS)Coursesofthe

AmericanMedicalAssociationandtheNationalDisasterLifeSupport(NDLS)Foundation

directlyaddresspediatricdisasteremergencycarewithinthecontextofdisastercareforall

illorinjuredpatients(http://www.bdls.org).3Finally,thePediatricDisasterLifeSupport

(PDLS)CoursedevelopedbytheUniversityofMassachusettsSchoolofMedicineatWorcester

fortheFederalEMSCProgramoffersacompact,andhighlyeffective,reviewofthe

fundamentalprinciplesofdisastermedicineandpediatricdisasteremergencycare.8


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Equipment for the Care of Children in Disasters:

Amateurs study tactics. Professionals study logistics.4

Childrencannotberesuscitatedoptimallyusingtoolsdesignedforadults.EveryEMS

professionalmustthereforebetrainedusingpediatricequipment,andsuchequipmentmust

beuniversallyavailableonambulancesandsimilarrescuevehiclesthroughouttheEMS

system.Thecostsofequippingevenasingleambulancewiththeproperequipmentinall

appropriatepediatricsizespalebeforetheexpenseofprovidingasingleautomatedexternal

defibrillatorforthesameambulance.Theopportunityforasuccessfulresuscitationisfar

higher,giventhatmostpediatricemergenciesarerespiratoryinnature.Sinceassisted

ventilationisthemostimportantskillemergencymedicaltechniciansandparamedicsmay

possess,theprovisionofbagvalvedevicesandclearplasticfacemaskswithinflatablerimsin

allappropriatepediatricsizesisofparamountimportancetotheprehospitalcareofacutely

illandinjuredchildrenasisthereadyavailabilityofalengthbased,colorcoded

resuscitationtape,toensureproperequipmentanddosageselection.

TheFederalEMSCProgramperiodicallyrevisesarecommendedpediatricequipmentlistforambulances,asdotheAmericanCollegeofSurgeonsandtheAmericanCollegeofEmergency

Physicians,whojointlyproduceasimilardocumentatregularintervals.9,10AllEMSagencies

shouldendeavortoensurethatitsfleetmaintainsthisequipmentonallitsvehicles,whichis

availableoftenfromaffiliatedhospitalsattrivialexpense.Whilenospecialequipmentis

requiredformanagementofphysicaltrauma,respiratoryillnessesspreadbyairborne

dropletsmandatetheavailabilityofproperlyfittestedN95respiratorsforallfrontlinestaff.

Otherthantheproperpersonalprotectiveequipment(PPE)requiredforuseincontaminated

environmentsmosturbanEMSagenciesoutfittheirpersonnelwithLevelCequipment,

includingliquidimpenetrablesuitsandpoweredpartialairpurifyingrespirators(PAPRs)

theonlyadditionalequipmentneededbymostEMSagencieswillbeatropine,pralidoxime,

anddiazepamautoinjectorsinpediatricandinfantsizesasantidotesfornerveagent

poisoning,andforEMSagencieslocatednearnuclearpowerfacilities,potassiumiodidetablets,whichcanbehalvedorquarteredasneeded.

Drilling for the Care of Children in Disasters:

Talkin The Talk vs. Walkin The Walk

Drillsandexercisesareavitalcomponentofthemitigationactivitieseveryhealthcare

organization,whetheranEMSagencyorahealthcarefacility,mustundertaketobereadyto

providedisastercare.Thefirststepforallthoseresponsibletoconductdisasterdrillsand

exercisesistoperformahazardvulnerabilityanalysis(HVA)afullandcompleteinventory

ofpossibledisastersthatmightaffecttheEMSagencyorhealthcarefacility.Aproperly

performedhazardvulnerabilityanalysiswill1)focusoneventsinternalaswellasexternaltotheagencyorfacility,2)emphasizethosehazardsfeltlikelytohavethegreatestimpacton

thefunctionoftheorganization,3)considerthelikelihoodthatsucheventsmightoccur,and

4)determinehowsucheventsmightaffecttheagencyorfacility.Disasterdrillsandexercises

canthenbeconstructedtotestorganizationalreadinessforoneormoreofthepossible

scenariosthathavebeenconsideredtheresultsofwhich,summarizedinAfterAction

Reports(AARs),areusedtofurtherrefinethedisasterplan.


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Readinessfordisastersisfirsttestedviatabletopexercisesverbalorwrittenscenariosthat

evaluatetheeffectivenessofanagencysorfacilitysemergencymanagementplanand

coordination.Nextutilizedaredisasterdrillssupervisedactivitieswithalimitedfocus

designedtotestproceduresthatarelimitedcomponentsofanagencysorfacilitys

emergencymanagementplan.Onlythenare functionalexercisesmountedtosimulateadisasterinthemostrealisticmannerpossiblewithoutmovingrealpeopleorrealequipment

toarealsite,ideallyasapreludetofieldexercisesculminationofpreviousdrillsand

exercisesthatteststhemobilizationofasmanyaspossibleoftheresponsecomponentsin

realtime,usingrealpeopleandrealequipment.Toaccuratelyassessanagencysorfacilitys

responsewithrespecttothepediatriccomponentofanydisaster,ofcourse,itisnecessaryto

includepediatricvictimsaspartofthesedrillsandexercisesmostauthoritiesrecommend

that510%ofalldisastervictimsbechildrenandinfants.

Special Considerations in the Care of Children in Disasters:

Failing To Plan Is Planning To Fail12

Reunificationofchildrenwithparents,siblings,andclassmatesmustbeaddressedaspartof

alldisasterplans.Disastersinvolvingchildrennaturallyresultinprofoundemotionaland

behavioralresponsesonthepartofallconcerned.Provisionsmustbemadetoassurethe

safetynotonlyofthechildrenthemselves,butalsoofconcernedrelativeswhoappearon

scenetorescuetheiryoungsters.Supportservicesmustbeimmediatelyavailableinsuch

crisiscircumstances,particularlypastoralcareandmentalhealthservices,aswellassocial

servicestoseetotheimmediateneedsofinvolvedfamiliesespeciallyforinformationabout

thewhereaboutsofchildrenwhoareinjured,thosewhoseparentsorsiblingshavebeen

injuredorkilled,andthosenotyetbeenreunitedwiththeirfamilies.

Asisalsotrueofadultnursinghomepatients,childrenwithspecialhealthcareneeds

(CSHCN)duetochronicillnessesorinjuries,includingtechnologyassistedchildren(TAC),

presentspecialchallengestoEMSagenciesandsystems.Firstandforemostisknowingwhoandwheretheyaremanysuchchildrenarecaredforathome,withouttheknowledgeofthe

localEMSagencyorregionalEMSsystem.Parentsofchildrenwithspecialhealthcareneeds

areencouragedtocompleteaspecialform,availablefromtheAmericanAcademyof

PediatricsandtheAmericanCollegeofEmergencyPhysicians,detailingthenatureandextent

oftheirchildsmedicalproblems,andkeepitonhandforEMSpersonnelwhomayfromtime

totimebecalleduponforassistance. 11Ifpossible,acopyoftheformshouldbeprovidedto

thelocalEMSagency,sothatadvanceplanscanbemadeforachildwithspecialhealthcare

needswhomayrequirerapidevacuation.

Summary

Itisselfevident,basedontheforegoing,thatchildrenandyoungadultsareathighriskofinjuryfollowingdisasters.Theyareathigherriskofseriousphysicalinjurythanadults,for

severalreasons:1)flexiblebonescausefewerfracturestoserveastraumamarkers,2)

internalorgandamageisoftenoverlooked,3)vitalsignscreeningisfrequentlyinadequate,

and4)bodyheatlossisnaturallyincreasedduringexposureorfollowingdecontamination,

duetothelargerbodysurfaceareatomassratiointhechild.Theyarealsoathigherriskof

exposuretobiological,chemical,radiological,andnucleartoxinsthatadults,againforseveral

reasons:1)theirimmunesystemsarelesswelldeveloped,owingbothtoimmaturity,andto


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Table1.TheDISASTERParadigm

D Detection/Declaration

I IncidentCommand

S Safety/Security

A AssessHazards

S SupportServices

T Triage/Treatment

E Evacuation

R Recovery


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Table2.DepartmentofHomelandSecurityICSandEMSCourses *

IS100 IntroductiontoIncidentCommandSystems

IS200 ICSforSingleResourcesandInitialActionIncidents

IS300 IntermediateICSforExpandingIncidents

IS400 AdvancedICSforCommandandGeneralStaffComplexIncidents

IS700 NationalIncidentManagementSystemAnIntroduction

IS800.B NationalResponseFrameworkAnIntroduction

AWR160 WMDAwarenessLevelTrainingCourse

PER211 EMSOperationsandPlanningforWMDIncidents

PER212 WMD/TerroristIncidentDefensiveOperationsforFirstResponders

*Accessedathttp://www.training.fema.gov.


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Figure1.SchematicDiagramofaDisasterSite

A.DisasterScene*

*Source:CenterforDomesticPreparedness,Anniston,AL

B.DisasterZones

Source:SocietyofCriticalCareMedicine,DesPlaines,IL


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Figure2.IncidentCommandSysteminCommonUseintheUnitedStates

A.Structure*

*Source:CenterforDomesticPreparedness,Anniston,AL

B.Function

Source:CenterforDomesticPreparedness,Anniston,AL


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2: How Children Are Different Pediatric Disaster Preparedness

1

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3

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9

Practical Considerations for Children and Families during Disasters

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3: Triage Pediatric Disaster Preparedness

1

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References

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A5 %*&%2&%2,#+15**+)+)4+%9%.$+&&0%$+)&)-+$*&+*+)&')+(,"5 @HHE3@@4@@F6@AC5

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C5 +&%#**+),''&)+,+&%#&%*&)+,$5 &,)**5&24$)%#**&+&%2A??G52AF:F;4DA6EB20A??A5

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4: Prehospital Disaster Medical Systems Pediatric Disaster Preparedness

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5: Transpor t Pediatric Disaster Preparedness

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5: Transpor t Pediatr

Pediatric Disaster Preparedness

Documents

Transcript of Pediatric Disaster Preparedness