pediatric disaster preparedness
TRANSCRIPT
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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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Foreword Pediatric Disaster Preparedness
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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Foreword Pediatric Disaster Preparedness
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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1: Introduction Pediatric Disaster Preparedness
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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1: Introduction Pediatric Disaster Preparedness
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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1: Introduction Pediatric Disaster Preparedness
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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1: Introduction Pediatric Disaster Preparedness
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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1: Introduction Pediatric Disaster Preparedness
Figure1.SchematicDiagramofaDisasterSite
A.DisasterScene*
*Source:CenterforDomesticPreparedness,Anniston,AL
B.DisasterZones
Source:SocietyofCriticalCareMedicine,DesPlaines,IL
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1: Introduction Pediatric Disaster Preparedness
Figure2.IncidentCommandSysteminCommonUseintheUnitedStates
A.Structure*
*Source:CenterforDomesticPreparedness,Anniston,AL
B.Function
Source:CenterforDomesticPreparedness,Anniston,AL
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1
Chapter 2: How Children are Different
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also contagious in a way that even dispersible chemical and radiological agents are not. Thus, the
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(!!
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Figure 5. Roles and responsibilities of the Emergency Health Operations Center (EHOC)
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References
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A5 %*&%2&%2,#+15**+)+)4+%9%.$+&&0%$+)&)-+$*&+*+)&')+(,"5 @HHE3@@4@@F6@AC5
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F5 &)2*$%4)')%'#*%$***,#+0*+,+&%*%--%#)%9+*)#/')%5" 2,,*+A??A:++'488...5'$6
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:A2!!'&!-2!($#$((&&%2;99?0;92
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Chapter 4: Prehospi tal Disaster Medical SystemsArthur Cooper, MD
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Chapter 5: Pediatric Regional Triage & Transport""
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