Our nation has changed. Over the past 10 years, we have seen an attack on a federal building by a home-grown terrorist in Oklahoma, the destruction of the World Trade Center on September 11, a massive hurricane in the Gulf the likes of which have not been seen in recent history, and the outbreak of a deadly virus in pandemic proportions. But beyond the sheer terror and destruction of these incidents lies one fundamental point—each of these disasters affected children in very profound ways.
Across the United States, scores of professionals are attempting to prepare for the unique medical, social, and psychological needs of children in disasters. But we can and should do more. This article will not only focus on preparing for the “big one,” but will also focus on the important needs of the “disaster of one.” In other words, a nation and a medical system that are well prepared for the one child seriously injured in rural America will be even more prepared for mass casualty events involving children. We will emphasize the need to improve our nation’s regionalization efforts when it comes to pediatric care in general and how that in turn leads to not only better outcomes for individual children, but improved outcomes for children involved in mass casualty or disaster incidents. We will also issue a challenge to all medical planners and providers to assess their area’s preparedness level for caring for children—even if taking care of kids is not part of their daily roles.
Children As Unique Patients
Indeed, children are unique patients, and this fact alone can bring havoc in the emergency or disaster setting. There are key anatomic, physiological, and psychological differences in children that all health care providers need to understand to adequately care for children in both small-scale and large-scale crises. While a complete review of pediatric physiology is beyond the scope of this review, readers are directed to several great resources on pediatric resuscitation.1,2 For example:
- The younger child’s large occiput and large tongue can lead to anatomic airway obstruction in the unconscious or semiconscious child.
- The child’s vocal cords are more anterior and more superior than those of an adult.
- Children have a larger head for overall body surface area, making them more prone to head injuries.
- Children lose heat rapidly and can become hypothermic very quickly.
- Children’s “normal” vital sign ranges change with age.
- It is KEY to know a child’s weight as all resuscitation medications are based on a per kilogram dosing.
- Children’s veins are smaller and more delicate, and can be a source of much difficulty when obtaining IV access.
When examining potential bioterrorism issues:
- Younger children are lower to the ground with a higher respiratory rate—potentially increasing their intake of inhaled toxins.
- Children have thinner skin—potentially increasing their load of absorbed agents.
- Children can become dehydrated very quickly from infectious diarrhea.
- Children require precise dosing of medical countermeasures for weapons of mass destruction.
While this is just a broad overview of the unique characteristics of pediatric patients, it is obvious that any emergency medical services (EMS) squad, emergency department (ED), general ward, or transport team that potentially will care for children not only needs to understand these fundamental differences but also needs to be prepared with the right equipment, the right training, and the right networks of support in place before the disaster or the traumatic event happens—more on that later in the article.
To understand America’s readiness for mass casualty events involving children, it is helpful to examine the day-to-day readiness of local emergency responders and EDs to handle critically ill and injured children. The Institute of Medicine (IOM) report of 2006, unfortunately, paints a less than ideal picture.3 The IOM found the nation’s preparedness for children “uneven.” Some important data from the IOM report:
- The majority of children are seen in nonpediatric emergency departments, yet only 6% of EDs have all the recommended equipment for stabilizing children.
- Emergency medical services systems see few critically ill or injured children per year, raising the potential for “rusty” clinical skills needed to stabilize and treat children in crisis.
- While some regions of the country have formal regional pediatric transport systems, the nation is lacking in true regional pediatric care.
- Emergency medical services and ED personnel often lack in-depth pediatric training.
In other parts of the IOM report, the nation’s readiness for large-scale disasters is examined as well. Not surprisingly, the nation’s disaster preparedness level for children was not, in the eyes of the IOM, where it should be. Very few state or local disaster plans took into account the needs of children. EMS units did not feel prepared for massive numbers of pediatric patients, EMTs typically received less than 1 hour of training in disaster responses … and the list goes on.
So now that 4 years have passed since the IOM report, what strides have been made? According to the National Commission on Children and Disasters’ Interim Report, the state of readiness for America’s children in times of crisis remains problematic. Children’s needs are still to be integrated into local, regional, and state response plans. Emergency medical services, EDs, and regional planning efforts still are not as fully focused on the needs of children as they should be. The Commission has also made recommendations on a wide variety of nonmedical issues surrounding children and disasters such as day care centers, shelters, and juvenile justice facilities.
The H1N1 pandemic of 2009-2010 was a wakeup call for emergency planners across the world. Scores of children and adults were stricken with the potentially deadly virus; and, for the first time in recent history, surge planning became more than an academic exercise. From the distribution of mass quantities of vaccine to the real threat of hospital bed shortages, local and state officials faced a true disaster. Luckily, the pandemic was short lived and had a lower mortality rate than was feared. However, health care officials and emergency planners should not rest. The H1N1 pandemic also helped identify gaps in the preparedness for mass pediatric illness. From local EDs to non-children’s hospitals, planners need to ensure that pediatric patients can be cared for. Likewise, just as a regional approach helps ensure high-quality care in day-to-day operations, local hospitals partnering with regional pediatric experts will help deal with a massive pandemic more efficiently. Several excellent reviews on preparing for a pediatric surge have been written recently.4-7
One item of keen interest to the respiratory care professional in surge is the issue of mechanical ventilation and triage of scarce resources. While the ethical and logistic dilemmas are far beyond the scope of this review, three highlights of recent work on mechanical ventilation in surge deserve mention.
1) Scenarios that may require mass mechanical ventilation:
Mass casualty event;
Chemical attacks; and
Epidemics and febrile respiratory events.
2) Areas of clinical care that may require mass mechanical ventilation:
Transport to emergency departments and local hospitals;
Transfer to higher levels of care and/or children’s hospitals;
Tertiary care facilities and children’s hospitals.
3) Pediatric needs in ventilators:
Lower tidal volume;
Use of pressure support or other “patient initiated modes” to overcome tube resistance; and
Trained personnel to use ventilators in children.
Obviously, the characteristics of the ventilators used in these different scenarios and different clinical areas will vary. However, just as in other areas of disaster preparedness and response, the needs of children need to be addressed. Specifically:
1) Local and state planners need to ensure that stockpiled ventilators can ventilate children;
2) The strategic national stockpile also needs to ensure that children’s lower tidal volume needs can be met; and
3) Emergency responders and local medical resources need to take into account the needs of children in their training and disaster drills.
A group brought together by the CDC is more closely examining the needs of children (and their respiratory care needs) in pandemics. A report is due in October 2010.
Recommendations For Better Preparedness
The news is not all doom and gloom. Many organizations from local EMS to children’s hospitals to the federal government are engaged in improving the nation’s preparedness for children in disasters. A highlight of the recommendations is categorized below8:
Emergency Medical Services
- Integrate pediatric training, equipment, and drills into all EMS systems.
- Examine the role for a new federal oversight body for EMS.
- Increase local EMS preparedness funding for disasters.
- Require ambulances to maintain 100% of the recommended pediatric equipment.
Local Emergency Departments
- Emergency departments should maintain 100% of the recommended pediatric stabilization equipment.
- Health care professionals in EDs should receive and maintain resuscitation training for children (PALS, APLS, etc).
- Every ED should have a pediatric coordinator who is responsible not only for ED readiness for children but also for creating and maintaining a strong relationship of the local ED with the regional pediatric facility (children’s hospital).
- Local hospitals should review their pediatric surge capabilities.
- Community hospitals need to work with their regional pediatric experts to develop and maintain regional approaches to pediatric care.
- Develop and maintain an internal disaster plan for mass casualty and surge events.
- Develop and maintain a regional approach to not only disaster care but also rapid referral and transfer of critically ill and injured children.
- Act as regional and state asset for pediatric planning and disaster response.
- Engage in national efforts to recruit medical personnel for the national disaster response by joining a Disaster Medical Assistance Team (DMAT), participating in National Association of Children’s Hospitals and Related Institutions (NACHRI) lead disaster initiatives, and becoming involved in AARC and American Academy of Pediatrics (AAP) disaster initiatives.
- Assure that state disaster plans include the needs of children.
- Develop networks of pediatric experts to not only develop response plans but to act as content experts for real-time advice during a crisis.
- Develop “crisis” standards of care that include the unique needs of children.
- Increase the number of pediatric professionals on DMAT teams (HHS).
- Develop new avenues of enrolling and precredentialing pediatric professionals (physicians, nurses, respiratory therapists) in disaster response teams.
- Examine the National Disaster Medical System (NDMS) (originally created during the Cold War to serve injured adults) and determine how it can better serve the needs of children.
- Establish and maintain close relationships with nongovernmental experts on children’s issues, eg, AAP, NACHRI, National Association of Pediatric Nurse Practitioners (NAPNAP).
- Develop a family disaster plan.
- Consult resources such as Ready.gov and redcross.org for helpful preplanning advice.
National Commission On Children And Disasters
The NCCD was created by Congress in 2008 and is charged with examining the needs of children in disasters and recommending to the president and Congress steps that need to be taken to better serve children in disasters. The Commission’s interim report was issued in October 2009 and the final report will be presented to President Obama in October 2010. The report highlights not only the medical needs of children and how to better serve them, but also the needs of children in shelters, the need for careful attention to children during evacuation, and the critical issue of reuniting families separated during a disaster. The reader is referred to the Commission’s Web site www.childrenanddisasters.acf.hhs.gov for more details.
Children are the future hope of our world; but their unique physiological and anatomic features, combined with the fact that they rarely become critically ill, make children very vulnerable in times of crisis. As we have seen from Hurricane Katrina and, more recently, the H1N1 pandemic, all health care workers and facilities have an obligation to prepare for the needs of children in disasters. From EMS squads ensuring they have the right equipment, to the federal government adding pediatric professionals to its disaster response teams, each health care entity can make our country more ready for both the disaster of one as well as mass casualty events involving children. Our nation and our children deserve no less.
Michael R. Anderson, MD, FAAP, is vice president and associate chief medical officer, University Hospitals, and associate professor of pediatric critical care, Rainbow Babies & Children’s Hospital, Cleveland. For further information, contact [email protected]
- de Caen AR, Amelia Reis A, Adnan Bhutta A. Vascular access and drug therapy in pediatric resuscitation. Pediatr Clin N Am. 2008; 55:909-27.
- Doniger SJ, Sharieff GQ. Pediatric resuscitation update. Emerg Med Clin N Am. 2007;25:947-60.
- Emergency Care for Children; Growing Pains/Committee of the Future of Emergency Care in the United States Health System. Board on Health Care Services. Institute of Medicine of the National Academies. Washington, DC: National Academies Press; 2007.
- Ginter PM, Wingate MS, Slay M, et al. Creating a regional pediatric medical disaster preparedness network: imperative and issues. Matern Child Health J. 2006;10:391-6.
- Wilgis J. Strategies for providing mechanical ventilation in a mass casualty incident: distribution versus stockpiling. Respir Care. 2008;53:96-103.
- O’Lauglin DT, Hick JL. Ethical issues in resource triage. Respir Care. 2008;53:190-200.
- Branson RD, Johanningman JA, Daughterty EL, Rubinson L. Surge capacity mechanical ventilation. Respir Care. 2008;53:78-90.
- National Commission on Children and Disasters Interim Report; October 14, 2009. Available at: www.childrenanddisasters.acf.hhs.gov. Accessed June 15, 2010.