Managing Pediatric Patients After Managing Pediatric Patients After Hurricanes: Perspectives from the Hurricanes: Perspectives from the
2004/2005 Hurricane Seasons2004/2005 Hurricane Seasons
©Lou Romig MD 2006. Used with permission.
ObjectivesObjectives
Describe post-storm environmental constraints that may prevent optimal care.
Discuss the most common pediatric complaints seen in the emergency medicine setting after hurricanes.
Describe adaptations to standard practice that may enhance care of children after hurricanes.
The medical needs of children and families after hurricanes are predictable and consistent…
because they closely match the needs of children and families of the affected
communities before the events.
Universal ThreatsUniversal Threats
Injury
Acute infections
Chronic illness
Lack of access to care
Compromised caregivers
Key ConceptKey Concept
The changed environment is the biggest challenge
to excellent medical care after a
large disaster
FEMA Photo Library
FEMA Photo Library
Environmental Constraints:Environmental Constraints:PhysicalPhysical
Temperature/exposure
Sunburn, dehydration, heat-related illness
Sweating, dirt, topical chemicals
Environmental Constraints:Environmental Constraints:PhysicalPhysical
Lack of clean water
Dehydration
Poor hygiene
Limitations in wound care
Environmental Constraints:Environmental Constraints:PhysicalPhysical
Lack of appropriate food
Inadequate nutrition
Inappropriate diet
Environmental Constraints:Environmental Constraints:Physical Physical
Lack of electricity
Nebulizers, other medical equipment
Refrigerators
Light, ventilation
Information deficit regarding hazards
Environmental Constraints:Environmental Constraints:PhysicalPhysical
Hazardous environments
Lacerations, punctures
Falls
Motor vehicle trauma
Tool-related injuries
Weapons
Environmental Constraints:Environmental Constraints:PhysicalPhysical
Hazardous environments
Chemical exposures
Allergens
Insects/animals
Environmental Constraints:Environmental Constraints:Social/InfrastructureSocial/Infrastructure
Disruption of healthcare systems
Primary medical care
Specialty medical care
Hospital-based care
Home health care
Third party payers
Environmental Constraints:Environmental Constraints:Social/InfrastructureSocial/Infrastructure
Disruption of supply chains
Pharmacies and other stores
Durable medical goods and consumable supplies
Environmental Constraints:Environmental Constraints:Social/InfrastructureSocial/Infrastructure
Disruption of schools/childcare
Interference with caregivers’ work and recovery activities
Lack of supervision in hazardous environment
Lack of usual counseling or other school-based medical services
Environmental Constraints:Environmental Constraints:Social/InfrastructureSocial/Infrastructure
Lack of security
Hesitancy to leave unsecured property to seek medical care
Lack of mobility
Loss of jobs and other financial support
Environmental Constraints:Environmental Constraints:EmotionalEmotional
Fear
Insecurity
Guilt
Helplessness/loss of control
Anger
Denial
CONSTRAINTS
ADAPTATIONS
Common Pediatric ProblemsCommon Pediatric Problems
Pulmonary
Gastrointestinal
Infectious diseases
Trauma
Psychosocial
PulmonaryPulmonary
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Pulmonary: ProblemsPulmonary: Problems
Bronchospasm is common in those with and without histories of asthma
Children with bad/labile asthma present early due to stress, environmental triggers, lack of meds
Stable asthmatics start showing up as triggers increase or meds run out
Pulmonary: ProblemsPulmonary: Problems
Bronchospasm due to respiratory infection starts to present after the first 3-5 days
October storms correspond to high allergy season and a slight peak in RSV incidence
Pulmonary: AdaptationsPulmonary: Adaptations
Need adequate supplies to treat patients
Premixed beta agonists for neb (infant and child dosing)
Neb capability with and without oxygen
Pedi neb masks and pipes
Oral and parenteral steroids
Peak flow monitoring nice but not necessary
Pulmonary: AdaptationsPulmonary: Adaptations
Outpatient treatmentAllow use of facility’s electricity for families giving their own nebs. (Do these patients need tx records?)
Consider using MDIs w/spacer chambers more frequently
Be liberal with steroids
Counsel regarding allergen exposure
Pulmonary: AdaptationsPulmonary: Adaptations
DO NOT yield to the temptation to treat every febrile pediatric wheezer with antibiotics.
Bacterial “bronchitis” is rare
in children. FL5 DMAT Photo
Pulmonary: DecisionsPulmonary: Decisions
Lower threshold for admission based on available resources and ongoing hazards
Consider recommendation to temporarily remove child from the area to a healthier environment
Temper decisions with consideration of family’s existing resources and demands on family members
GastrointestinalGastrointestinal
FEMA Photo Library/Dave Gatley
GI: ProblemsGI: Problems
Close living quarters may lead to transmission of GI viral illnesses
Limited water and facilities for washing. Limited diaper/hygiene supplies.
Inadequate sanitation in field kitchens/food distribution points
GI: ProblemsGI: Problems
Norovirus precautions go beyond soap and water or alcohol
Erratic availability of potable water and oral rehydration solutions
MRE’s have high sodium/high calorie content
Don’t forget Don’t forget aboutaboutcontaminatedcontaminatedice!ice!
FEMA Photo Library
GI: AdaptationsGI: Adaptations
Ask about sheltering situation. Give specific infection control instructions (written if possible).
Health care sites can act as distribution points for hygiene items such as alcohol solution, diaper wipes, diapers, soap, garbage (biohazard?) bags/gloves, bleach
Maintain contact with public health officials
GI: AdaptationsGI: Adaptations
Ask about diet specifics, including origin of drinking water and food storage conditions
Warn families of need to increase fluid intake if eating MREs
Consider unusual electrolyte abnormalities in clinically dehydrated children
GI: AdaptationsGI: Adaptations
Distribute oral rehydration solutions
Focus on oral rehydration protocols unless staff and IV fluids are in adequate supply
Limit use of antiemetics and antidiarrheals in children
GI: AdaptationsGI: Adaptations
Minimize infant formula-switching.
Use stool volume replacement techniques in cases of diarrhea
Staff must be protected against food poisoning!
GI: DecisionsGI: Decisions
Admission decisions must include consideration of shelter status
Lower admission threshold if adequate outpatient management is doubtful
If in doubt, schedule patient rechecks
Infectious DiseasesInfectious Diseases
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Infections: ProblemsInfections: Problems
Infections will mostly follow existing community patterns
“Third world” type epidemics have not occurred in the US
Isolation/segregation of infected is difficult in the post-storm environment
Infections: ProblemsInfections: Problems
Kids need different preparations of antibiotics, some requiring controlled environmental conditions
Pharmacies and drug supplies may be limited and may focus on adult medications
Skin infections are common; good hygiene is not.
Infections: ProblemsInfections: Problems
Penetrating injuries to the foot are common. Pseudomonas must be suspected.
Community acquired MRSA is an increasing problem.
Animal Control may be problematic. May need to prophylax patients against rabies.
Infections: ProblemsInfections: Problems
Local pharmacies may not honor prescriptions by non-local federal
responders
Infections: AdaptationsInfections: Adaptations
Contact local public health or hospital officials for intelligence regarding existing infection patterns
Cooperate with public health officials in monitoring efforts
Assist in informing shelter staff of infection patterns seen and what to look for
Infections: AdaptationsInfections: Adaptations
Educate patients and families about infection control issues, especially if they are shelter residents
Prescribe antibiotics judiciously. Use the simplest appropriate form for the shortest practical course.
Use alternative medication formulations (chewable tabs, crushed tabs) and those that don’t require refrigeration
Infections: AdaptationsInfections: Adaptations
Obtain and distribute information about pharmacies in operation
Inform local pharmacies about prescribing privileges for federal responders
Consider distribution of starter doses of medications
Infections: AdaptationsInfections: Adaptations
Distribute hygiene and wound care supplies, insect repellant and topical or oral meds for itching/inflammation
Plan follow-up for penetrating and contaminated injuries (especially nails into feet)
Consider using ciprofloxacin for children with penetrating wounds through shoes into feet
Infections: AdaptationsInfections: Adaptations
May use first generation cephalosporins for most skin infections
Consider adding TMP-Sx if CAMRSA is suspected
Dialogue with local public health about rabies exposure
Recognize that most children will NOT need a tetanus booster
Infections: DecisionsInfections: Decisions
Consider family’s environment and mobility when making decisions about admission vs. outpatient treatment with rechecks
May need to admit children with highly contagious diseases to avoid exposing others in a crowded environment
Infections: DecisionsInfections: Decisions
Consider sending infected children out of the area if more appropriate shelter is available
Maintain low admission threshold for the very young with fever and immunocompromised patients
Use antibiotics judiciously
TraumaTrauma
FL5 DMAT Photo
Trauma: ProblemsTrauma: Problems
The post-storm environment is hazardous!
Children may not have adequate supervision or may be asked to perform inappropriate tasks
Children are risk-takers
Trauma: ProblemsTrauma: Problems
Minor skin and musculoskeletal injuries are common
Penetrating injuries by contaminated small objects are common
Skin foreign bodies are common
Major trauma is not common
Trauma: ProblemsTrauma: Problems
Increased chance of:
Tool-related injuries
MVC due to unregulated intersections
Flame and contact burns
Firearm injuries
Trauma: ProblemsTrauma: Problems
Increased chance of:
Carbon monoxide exposure
Hydrocarbon and bleach ingestion/aspiration
Ingestion of medications
Drowning
Intentional injury
Trauma: AdaptationsTrauma: Adaptations
Carefully document mechanisms of injury
Be prepared to stabilize a badly injured child
Identify local pediatric trauma and burn care resources
Have access to Poison Control resources
Trauma: AdaptationsTrauma: Adaptations
If lacking x-ray, splint the injured extremity on any child with bony tenderness, regardless of lack of deformity
Emphasize elevation and splinting of an injured extremity for control of pain and swelling. Ice may not be a viable option.
Trauma: AdaptationsTrauma: Adaptations
Provide the best possible initial wound care. Do so in as comfortable an environment (for the patient) as possible.
Consider delayed/no closure for contaminated wounds or possible retained foreign body.
Consider self-absorbing sutures for children with lip, finger or toe lacs
Use skin glue only if wound is clean
Trauma: DecisionsTrauma: Decisions
Follow-up care may be the biggest issue. Patients may need to go to another facility to initiate contact with subspecialty care providers.
Make some allowances for unusual circumstances but be alert for potentially negligent or dangerous family situations
PsychosocialPsychosocial
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Psychosocial: ProblemsPsychosocial: Problems
When a child is sick or injured, their loved ones are also your patients
Families may have difficulty coping with their child’s illness or injury
Delay in seeking care may be more common than in ordinary circumstances
Psychosocial: ProblemsPsychosocial: Problems
Families may not have primary care resources to begin with
Compliance with treatment recommendations may be difficult
Stress may lead to higher risk for child abuse
Psychosocial: ProblemsPsychosocial: Problems
Pediatric mental health goes beyond PTSD
Children with mental health issues may present with acute or prolonged nonspecific physical symptoms
Parents are not educated about children’s reactions to catastrophic stress
Psychosocial: AdaptationsPsychosocial: Adaptations
Assume family members don’t get your message the first time.
Write down instructions for family
Always ask, “Is there anything else we can help you with?”
Psychosocial: AdaptationsPsychosocial: Adaptations
Address children directly. Let them know what they have to say is important and that they have a role in feeling better.
Encourage children to express their feelings
Make the visit as pleasant as possible for the child
Little Little things things
mean a lotmean a lot
FL5 DMAT Photo
Psychosocial: AdaptationsPsychosocial: Adaptations
Explore alternatives with the family to help assure compliance with treatment recommendations
Avoid judgmental attitudes
Identify local resources for family psychosocial support
Use available mental health resources
SummarySummary
Post-storm pediatric illness and injury is predictable.
The environment poses the greatest number of constraints on being able to provide excellent pediatric medical care
Emergency responders must adapt to the new practice environment in order to help families adapt and cope
SummarySummary
Minor injuries are a common cause for pediatric emergency care visits
Skin infections and problems are common complaints
Respiratory illness is another common medical complaint
Infections pose additional problems in the post-storm environment.
Safety education is a critical aspect of post-storm medical operations