Major Incidents, Patient Care

Planning for Pediatrics in Disasters

Issue 9 and Volume 39.

The explosion from the passing freight train rocked the nearby buildings, shattering the windows and letting off a thick cloud of poisonous gas. The building inhabitants were smoothly evacuated by commands given over the loudspeakers of the responding emergency workers. They walked quickly through the decontamination tents, following the directions of the hazmat team, and were transported without difficulty by squads and buses to local hospitals and trauma centers, where teams of medical professionals quickly and efficiently cared for them, using familiar protocols and equipment.

Except that’s not what actually happened—because the nearby buildings were a preschool and daycare center.

The children inside couldn’t follow directions, didn’t understand what was going on, hid in terror from the sights and sounds of the disaster, were unable to self-evacuate, and ran screaming from the hazmat team in their frightening, alien-appearing chemical suits.

Although this particular scenario may not have occurred in your area, chances are unfortunately high that some sort of disaster or mass casualty involving a significant number of children will occur in your area before much longer. The frequency of both man-made and natural disasters is only increasing—we must be prepared to provide the best care possible to these little ones.1 Few events ever run 100% perfectly, but disasters involving children can certainly run much more smoothly with a little advance planning and preparation.

Children & Disasters
On 9/11, the first victim to arrive at a hospital was a 5-month-old, taken to the New York Veteran’s Administration Medical Center—a facility primarily equipped to care for adult patients. During Hurricane Katrina, several hundred children were separated from their families, and many weren’t reunited until up to six months later.

Children make up 25% of the U.S. population, yet in a recent survey of EMS agencies, only 13% have pediatric-specific mass casualty incident (MCI) plans.2 There are 1,313 hospitals in the U.S., of which 55% are children’s hospitals. And only 5% of U.S. adult hospitals have adequate resources to deal with pediatrics.3

Children are often forgotten, or simply included in the general population or the generic “special needs” group as we plan for disasters and MCIs.4,5 We forget children are a distinct group, at a distinct stage of development, with unique physical, psychological and communication needs. Even within the subset of pediatrics there are various considerations and needs based on age, ranging from babies to preteens.6 They have significantly higher mortality rates in disasters compared to adults, and that mortality rate increases even more in children less than 5 years old.7 Although there are many factors that contribute to these rates, our lack of sufficient preparation for children in disasters is certainly a factor.

Pediatric Physiology
What is it about children that makes them so susceptible to the physiological effects of disasters? Children’s heads are proportionally much larger than their bodies, making them more susceptible to head injuries from blunt trauma.8 In the Oklahoma City bombing, of the 19 children who died, 90% (17) of them had sustained a head injury.9

In fact, there have been recommendations in some tornado regions that children should wear helmets during a tornado for further protection.10

Children have a proportionally larger body surface area and are at greater risk for hypothermia.

Children have a proportionally larger body surface area and are at greater risk for hypothermia. It’s important to cover them quickly during a disaster.

 

Children’s organs are also proportionally larger, and not as well protected by the rib cage and abdominal musculature as in adults. They also have faster respiratory rates and heart rates, putting them at higher risk for airborne chemical and biological agents since their bodies absorb toxins at a much faster rate. Some of the toxic agents cause vomiting and diarrhea, which dehydrates children more rapidly than adults, since children have smaller reserves. Some of the molecules are heavier than air and settle close to the ground where children are more likely to be inhaling them, since they’re shorter. Kids also have a proportionally greater body surface area for their body mass, which allows them to take in more toxins more rapidly by that route as well. And due to their higher metabolic rate, they have a different response to both the toxins and the medications you may use to treat them.

More than just the physical differences, children also have different mental and psychological needs, especially in a disaster setting. They lack a sense of self-preservation, and don’t have the cognitive skills or physical ability to react appropriately to signs of danger or instructions for help. They have fewer coping skills than most adults, don’t always understand what’s happening and, as anyone with children knows, don’t always follow directions well. Despite all of that, children have great potential for resiliency when treated appropriately.

Taking the Right Steps
M.C. Escher, the famous mathematical artist, wrote, “We adore chaos because we love to produce order.” This is a good description of our job as EMS providers: We take control of the chaos of disasters and produce order for everyone involved—including the kids. It’s time for us to do better at including children in the planning, preparedness, response, and recovery phases of disaster medicine.

Include representatives from the pediatrics community on your EMS and planning committees. Give them a seat at the table and ask for their suggestions. Don’t have a children’s hospital in your area? Call some of the local pediatric primary care offices. Not only are they a great source of knowledge, but it’s quite likely you’ll be using some of their resources in the event of a disaster.5 Check out the disaster resources on the American Academy of Pediatrics website www.aap.org for more tips.

All hospitals need to be prepared to treat pediatric patients in a disaster, so that families can all be transported together to one location. Your agencies need to have pediatric MCI plans that include how to reunite families, interoperable patient tracking and pediatric movement/transport.

Small children don’t always travel securely in a large city bus the way adults can. Talk to a local daycare and arrange to use their vehicles, with smaller seats and car seats, in case you need to transport several small children. Arrange to add some car seats to your local stockpile. Appoint an agency and plan a process ahead of time that will handle separated families; in Hurricane Katrina, it was the National Center for Missing and Exploited Children. A system of armbands or tracking numbers can help with the reunification process.

Being Prepared
A functional disaster response system can only exist in an emergency care system capable of providing adequate EMS on a day-to-day basis.11 Your system needs to have a solid response system in place for regular pediatric calls before you can adequately prepare for these exceptional situations.

Drills are a large part of our preparedness stage. Conduct a pediatric-specific MCI drill, or make it even more complicated by designing an integrated adult/pediatrics disaster drill. Coordinate with the multiple groups that will be involved such as transport agencies, schools and hospitals. Include pediatric supplies in your local caches like diapers, formula, cribs and clothing.

One of the big lessons learned from disasters like the Joplin, Mo., tornados is that we may be pulled in many different directions when disaster strikes. Don’t forget to make plans for your family ahead of time, so that you can focus on your other assigned tasks when disaster strikes. You may even want to consider arranging for some kind of temporary day care for the children of EMS responders.4

Care Tips
As if a disaster scenario isn’t already chaotic enough, there are dozens of additional details to remember when children are involved.

Decontamination: It’s a natural instinct to rush to hold and comfort children immediately after an incident, but remember they may be contaminated initially in a chemical or biohazard incident. You’ll need an altered decontamination protocol, more communication, more personnel to help with all the children who can’t follow directions, and specialized, smaller equipment. Set up a pediatric-specific decontamination station, with higher volume/lower pressure warm water. Consider family stations, which will both keep families together and provide additional adult staff to help get the children through the process. Remember that you may need isolettes, warmers and smaller gowns for the children after they’ve been decontaminated. Because children have a larger body surface area, they’re at greater risk for hypothermia, so it’s important to get them covered again quickly.

Although adults are more likely to suffer from cardiac problems during an MCI, children are more likely to suffer from respiratory issues.

Although adults are more likely to suffer from cardiac problems during an MCI, children are more likely to suffer from respiratory issues.

 

Triage: Different triage and treatment protocols are indicated in children compared to adults. “Walk to the sound of my voice” won’t work in pre-ambulatory kids or those with special needs. It will likely take you longer to assess these children, even if you ultimately end up triaging them as green, requiring minimal care. Children typically suffer from respiratory problems rather than something cardiac, as in adults.

Airway: SALT and JumpSTART, two of the main triage algorithms commonly used in MCIs, both call for a few rescue breaths in children who have a pulse but aren’t breathing; if the rescue breaths restore spontaneous respirations, the child gets triaged to the “urgent” or red category, rather than the expectant (black) category.12,13

It will be extremely impractical to intubate every child in an MCI—consider planning for oro- or nasopharyngeal airway, or laryngeal mask placement, and positioning young patients on their left side with a leg bent to keep them from rolling over, as quick ways to secure the airway and assist with breathing.

Keep in mind that, while you may not have time to stop and manage every adult airway, it may be a productive use of time to pause and manage more pediatric airways, since they’re more likely to respond.

Drug dosage and delivery: You may need to place an intraosseous device for vascular access, rather than spending the time trying to find an IV on a child’s tiny veins. Drugs are dosed differently for adults and children. An antidote autoinjector, appropriately sized for an adult, may be far too much for a small child. Consider adding a quick-reference card in your pediatric kits to ensure rapid calculation of key pediatric dosages on scene. Try learning the Antevy Method for rapid pediatric drug calculations. (See “First-Hand Approach: A novel method to rapidly calculate pediatric drug dosages” from the August 2013 issue of JEMS.)

Psychological: Pay attention to children’s emotional state—a calm child is much more cooperative than a screaming one. Remember that children won’t always be with their parents/caregiver when disaster strikes. You may need to take a few extra seconds to calm a child in order to get them to cooperate, but this will pay off in the long run, as the child will be more cooperative afterward.

The event isn’t over until you’re through the recovery phase. Children continue to be susceptible to environmental problems—respiratory disease, contaminated water, malnutrition and dehydration—and abuse. The stress hormones released can have profound impact on both the child’s immediate health, as well as their long-term development; the psychological impact will certainly have long-lasting implications as well. The majority of secondary deaths in children under 5 years old are preventable.

Mental health is a major factor during all phases, but especially during recovery. Kids are viewed as high-value targets by terrorists; as the emotions of children go, so goes the rest of their community. Children are extremely sensitive to the attitude and psychological state of the adults around them. If the adults are fearful and upset, most children will be too, which just serves to make the adults even more upset.

Kids affect overall mental health of the community, so addressing their emotional response is crucial. Get children out of “bad” environments and back to normal as quickly as possible by establishing some kind of routine for regular meals and sleeping time. The structure will be beneficial to the child and to the whole community.

Feeding children during a disaster (especially infectious disease attacks) is a particular challenge. Babies can’t eat the same kinds of ready-to-eat meals and other food adults may turn to during a disaster. Children are more susceptible to various illnesses since their immune system isn’t fully developed, and more prone to serious effects from dehydrating food-borne illnesses like vomiting and diarrhea.

As much as possible, try to create a sense of safety and well-being. For younger children, provide simple explanations for what happened and avoid excess details. Older kids will usually benefit from a slightly more detailed explanation, perhaps emphasizing everything groups are doing to help fix the situation and prevent further mishap.

Try to limit their exposure to media—watching the events play out over and over again can be confusing and stressful. Research has shown that reestablishing familiar routines may be beneficial in helping children cope with psychological stress.7 Fortunately, children usually respond well to an open, honest and reassuring approach and rarely require more inten-
sive interventions.14

Reportedly, 13% of children exposed to Hurricane Katrina had post-traumatic stress disorder at 3–7 months after the hurricane, and were at increased risk for more chronic symptoms.15 Keep an eye out for signs and remember these may present differently than in adults.

Conclusion
The explosion from the freight train rocked the nearby buildings, shattering the windows of the daycare center, and letting off a thick cloud of poisonous gas. Using procedures that had been thoroughly drilled in the past, the daycare workers, familiar faces to the frightened children, quickly evacuated the building, moving everyone to an uphill, upwind location.

Emergency responders worked together to get the children through the decontamination process, assigning extra staff to the decontamination line, carrying the nonambulatory children, and assigning older children to assist the younger ones. The children weren’t as frightened of the emergency workers thanks to a field trip and classroom visit earlier that year.

Blankets and a supply of child-sized gowns were waiting to quickly warm the little ones. Patients were transported to a variety of local hospitals, both adult and pediatric, but all equipped to deal with patients of all sizes and ages.

References
1. Coleman, L. Frequency of man-made disasters in the 20th century. J Contingencies and Crisis Management. 2006;14(1):3–11.
2. National Commission on Children and Disasters (October 2010.) 2010 report to the president and congress. Agency for healthcare research and quality archive. Retrieved July 17, 2014, from www.ahrq.gov/prep/nccdreport/.
3. Shriver MK, Leslie S: Children and disasters: How can states meet their unique needs? National Conference of State Legislatures: Philadelphia, 2009.
4. American Academy of Pediatrics. (n.d.) Appendix to “The youngest victims: Disaster preparedness to meet children’s needs.” Retrieved June 1, 2014, from www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/children-and-disasters/Documents/Youngest-Victims-Final.pdf.
5. American Academy of Pediatrics. (February 2002.)The youngest victims: Disaster preparedness to meet children’s needs. Retrieved June 3, 2014, from www2.aap.org/advocacy/releases/disaster_preparedness.htm.
6. Allen GM, Parillo SJ, Will J, et al. Principles of disaster planning for the pediatric population. Prehosp Disaster Med. 2007;22(6):537–540.
7. Ciottone GR (Ed.): Disaster medicine. Elsevier Health Sciences: Maryland Heights, Mo., 2006.
8. Jaffe DH, Peleg K, Israel Trauma Group. Terror explosive injuries: A comparison of children, adolescents, and adults. Ann Surg. 2010;251(1)138–143.
9. Mallonee S, Shariat S, Stennies G, et al. Physical injuries and fatalities resulting from the Oklahoma City bombing. JAMA. 1996;276(5):382–387.
10. Crawford MS, Fine PR, Foster PJ, et al. (Jan. 12, 2012.) Safety helmets: A practical, inexpensive solution for reducing the risk of head injuries resulting from tornados. The UAB injury control research center. Retrieved July 17, 2014, from www.uab.edu/icrc/tornado_helmet_com.html.
11. Brandenburg MA, Arneson WL. Pediatric disaster response in developed countries: Ten guiding principles. Am J Disaster Med. 2007;2(3):151–162.
12. SALT mass casualty triage: Concept endorsed by the American College of Emergency Physicians, American College of Surgeons Committee on Trauma, American Trauma Society, National Association of EMS Physicians, National Disaster Life Support Education Consortium, and State and Territorial Injury Prevention Directors Association. Disaster Med Public Health Prep. 2008;2(4):245–246.
13. Romig LE. (May 29, 2012.) The JumpSTART pediatric MCI triage tool and other pediatric disaster and emergency medicine resources. JumpSTART Triage. Retrieved July 15, 2014, from www.jumpstarttriage.com.
14. American Academy of Pediatrics. (n.d.) Talking to children about disasters. Retrieved July 17, 2014, from www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/children-and-disasters/Pages/Talking-to-Children-About-Disasters.aspx.
15. Kelley ML, Self-Brown S, Le B, et al. Predicting posttraumatic stress symptoms in children following Hurricane Katrina: A prospective analysis of the effect of parental distress and parenting practices. J Trauma Stress. 2010;23(5):582–590.