chapter 20samples.jbpub.com/9781449637774/onlinechapters/20_Disaster... · 20-3. Introduction. ... Chapter Outline. ... Emotional and mental health problems often : become evident

Disaster ManagementPaul E. Sirbaugh, DO, FAAPPeter J. Di Rocco, MD

chapter 20

Introduction

Phases of Disaster Response

Planning: Community Medical Practitioners

Planning: Out of Hospital

Planning: Hospitals

Planning: Community Agencies

Planning: Shelters

Response and Recovery Phases

Mitigation Phase

Pediatric Medical Issues After Community-Wide Disasters

Pediatric Mental Health Issues After Disaster

Summary

Resources

Chapter Outline

1 Recognize that early and active participation by pediatricians and other health care professionals in regional disaster planning is essential to ensuring an appropriate response to the needs of children.

2 Become familiar with the four phases of disaster response: planning, response, recovery, and mitigation.

3 Compare the roles of emergency medical services and local and federal agencies in their response to a disaster.

4 Describe the special vulnerabilities of children during and after a disaster.

5 Become familiar with federally supported programs that improve the process of credentialing and volunteering for a medical response to disasters: Community Emergency Response Team (CERT), Emergency System for Advance Registration of Volunteer Health Professional (ESAR-VHP), and the Medical Reserve Corps (MRC).

6 Access available resources for community disaster education, planning, and response.

Objectives

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians

20-3

IntroductionA disaster can be defined as any occurrence that taxes or overwhelms local response ca-pacity. For example, in a nonmedical setting, a disaster could be an irreversible crash of a company’s computer network or, in a medical setting, the loss of access to the electronic medi-cal record (EMR). Some disasters do not gener-ate unusual numbers of medical patients but can tax resources for shelters, nutrition, safety and law enforcement, or transportation. In the

medical setting, disasters usually entail the pres-ence or potential presence of a number of pa-tients that overwhelms agency-specific or local resources. A vehicle collision with six critical patients could constitute a disaster for a small EMS system and/or the local hospitals that a larger EMS and hospital system would be able to handle easily with the available resources.

Table 20-1 lists types of disasters, with ex-amples of each. Note that some disasters occur suddenly, with little to no warning. Risk-specific

CASE

SCE

NARI

O 1

A disaster shelter with 130 evacuees is struck and heavily damaged by a tornado during a storm. Per local protocol, emergency medical services (EMS) units are unable to respond because of the intensity of the weather. Adult and pediatric survivors of the tornado start arriving by the carload at the nearby emergency department (ED), stating that others will be following them because it is impossible to travel further to other facilities.

1. Does your hospital disaster plan consider self-referred patients instead of just those arriving by EMS? Is your ED staff prepared to perform primary disaster triage?

2. Does your hospital disaster plan consider adequate staffing and resources to allow EMS to function at high demand levels with minimal outside assistance?

Chapter Outline


20-4 Disaster Management

planning and preparation are especially criti-cal in these types of disasters because response resources must be ready to be marshalled and dispatched immediately. Other disasters, such as floods and hurricanes, usually provide advance warning or have a gradual onset that allows for additional preparations before the critical stage ensues. Most often, natural disasters are thought of as geological or weather related; however, many disasters arise from the use or misuse of technology. Others are intentional, triggered by political or ideological motives. Humanitar-ian disasters (also sometimes called “complex emergencies”) usually involve multiple resource shortages for large, often displaced, popula-tions during long periods. Many disasters have some degree of physical, mental, or emotional impact on significant numbers of people, without regard to sex, age, ethnicity, or any factor other than proximity to the event. Indeed, terrorist at-tacks have demonstrated that disasters can have marked psychological effects on people who had no physical connection to the attack itself, and widespread psychological reverberations make these attacks so effective.1–3 To think that children are infrequently affected, directly or indirectly,

by disaster is to ignore reality. To fail to consider the needs of children in disaster planning and response at all levels is to potentially jeopardize one of our most precious resources.

Phases of Disaster Response

Planning PhaseEmergency management in the context of di-sasters is traditionally divided into four phases: planning, response, recovery, and mitigation. Although it is usually the emergency managers working for government and public safety agen-cies who adopt this structure for action, it is es-sential that pediatricians and other child-related health care professionals insert themselves into each phase. Historically, pediatricians have not always been invited to participate in regional disaster planning. However, when they are in-volved, the needs of children are anticipated and met.4 It is therefore necessary for pediatricians to develop relationships with regional partners before the disaster strikes. The goal is for the pediatrician to become indispensable to the planning process.

TABLE 20-1 Types of Disasters

Natural Terrorism or International Violence

• Hurricanesorcyclones

• Tornadoes

• Floods

• Mudslides

• Tsunamis

• Iceorhailstorms

• Droughts

• Wildfires

• Earthquakes

• Infestationsordiseaseepidemics

• Bombingsorexplosions

• Chemicalagentreleases

• Biologicalagentreleases

• Nuclearagentreleases

• Multipleormassshootings

• Cult-relatedviolence

• Riots

• Arson

Technological Humanitarian Disasters or Complex Emergencies

• Hazardousmaterialsreleasesorspills

• Nonintentionalexplosionsorcollapses

• Transportationcrashesorderailments

• Poweroutages

• Warorviolentpoliticalconflict

• Genocidalacts

• Droughts

• Famine

• Thecareofdisplacedpopulations


Phases of Disaster Response 20-5

Planning comprises all activities and actions taken in advance of a disaster and should be based on the analysis of a community’s or or-ganization’s risks for exposure to specific types of disasters. They should take into account the frequency of occurrence of each type of disas-ter, the anticipated magnitude of effect, the degree of advance warning, characteristics of the populations most likely to be affected, the amount and types of resources available within the community, their regional organization of access to these resources, and the ability to func-tion independently without additional outside resources for long periods.

Planning must not completely ignore low-probability disasters. Incidents that have a rela-tively small chance of occurring are likely to be overlooked and result in a disproportionately profound impact. An example of this is hospital preparedness for patients potentially contaminat-ed with nuclear, biological, or chemical agents. One unrecognized or inadequately decontami-nated or isolated patient can close an entire ED or hospital for hours, days, or weeks. Even though the probability of such an event at any given hospital remains relatively low, our new global awareness of the increasing possibility of such incidents has triggered a widespread de-mand for hospital-based training and planning. (See Online Chapter 21, Preparedness for Acts of Nuclear, Biological, and Chemical Terrorism.)

Disaster planners should locate and use all available resources within a region and avoid any tendency to re-create the wheel. Tertiary pediatric hospitals are a great repository of tal-ent, experience, supplies, and equipment, and most are willing and able to provide pediatric resources for regional disaster planning and response. For example, pediatric EDs are ac-customed to managing large patient volumes and adapt well to unexpected surge.5 The ap-propriate triage, evaluation, and treatment of the pediatric patient based on acuity and condition requires a team of individuals equipped with talent, experience, and resources. This collective response is not something that can be easily re-created by even the most well-meaning public health department. These resources are available in every region, and in most cases, planning can

be initiated with one telephone call. Of course, the leaders of these institutions must be willing to collaborate and share decision making with other essential players. They must also be able to work within the constraints of their regional incident command structure and the National Disaster Medical Systems (NDMS).

Mass casualty disaster drills are invaluable to the success of a region’s disaster response. They must be regularly scheduled (eg, every 2 to 3 years), involve regional partners, and include children and families as the patients. Scenarios should vary and be based on the community’s potential risk for a disaster.

Response PhaseResponse comprises all activities and actions taken during and immediately after a disaster, including initial search and rescue, damage as-sessment, evacuation, sheltering, and many other activities. Disaster response in the United States is usually coordinated by local agencies but can be augmented by state and federal response resourc-es. The response phase lasts until the initial casu-alties have either been rescued or acknowledged as lost and sufficient resources have been made available to allow the population to assess dam-ages and begin plans for restoration and recovery. This phase can last hours to weeks. Estimating the time frame for the response phase is crucial when planning. For immediate events, staffing community offices and hospitals by augment-ing work hours of existing personnel might be feasible. However, as the response phase moves from days to weeks, local infrastructure often will not support this strategy.

Recovery Phase The recovery phase is the period in which the af-fected organization or community works toward reestablishing self-sufficiency. This is the period of new community planning, rebuilding, and the reestablishment of government and public service infrastructure. It is also the period in which out-side support services are gradually withdrawn.

The response and recovery phases can represent a challenge from the medical stand-point because injuries can increase during damage assessment and physical rebuilding.



Emotional and mental health problems often become evident in this period as well; as reality sinks in, future challenges become much more overwhelming. Some individuals feel abandoned as immediate response resources withdraw and attention and assistance from other communi-ties wane.

Mitigation PhaseMitigation is the phase in which all other aspects of emergency management are scrutinized for “lessons learned”; the lessons are then applied in an effort to prevent the recurrence of the di-saster itself (for nonnatural events) or to lessen the effects of subsequent incidents. Mitigation and planning are continuous operations be-cause lessons learned from a previous disaster are rolled into planning for the next one. Miti-gation includes preventive and precautionary actions, such as changing building codes and practices, redesigning public utilities and ser-vices, revising mandatory evacuation practices and warning policies, and educating members of the community.

Planning: Community Medical PractitionersMedical practitioners should familiarize them-selves with disaster planning and response. Re-siliency as it relates to disasters must be built into every facet of the medical home. Every of-fice should possess a well-rehearsed and easily accessible disaster plan for their staff and one that they can share as a resource from which their patients’ families can build. Unfortunately, before Hurricane Katrina, there was a lack of available resources to guide pediatricians through this essential process of education, assessment, and preparation. The American Academy of Pediatrics (AAP) hosted a Web site (Children and Disasters; http://www.aap.org/disasters) and developed multiple policy and technical statements geared specifically to the pediatrician (see the Resources section at end of this chapter).6 If a disaster strikes suddenly during working hours, office staff members must know immediately what to do to ensure

their own safety, assist others in the office, and secure and protect the physical property of the practice, especially patient records. Similar pro-tective measures should be taken in the warn-ing period before a disaster of slower onset, especially if the office is in an evacuation zone. The physician must have plans for dealing with hospitalized patients during a disaster, know-ing which special needs patients to direct to special shelters, handling calls from patients, notifying patients of practice status, and con-tinuing to serve patient needs if the office is significantly damaged or disabled.7–9 How fast an office bounces back after a disaster strikes directly affects how quickly the community will get its needs met during the response and re-covery. That resilience to adversity is completely dependent on accepting the unavoidable reality that disasters will occur, that the practice will be affected, and that proper planning can often prevent a prolonged interruption in service to the community.

Primary care physicians can have a key role in encouraging and educating patients and their families to make home disaster plans. An-ticipatory guidance sessions and materials can provide families with information about their community’s specific disaster risks and provide preparedness checklists for the home. Practice and hospital Web sites can include links to local, regional, and national resources, such as those listed at the end of the chapter, and feature tar-geted disaster planning tips at appropriate times of the year, similar to targeted safety and injury prevention tips. After a disaster occurs, primary care offices can act as distribution centers for information about local and federal recovery re-sources, medical problems to anticipate in the aftermath, and critical incident stress reactions and subsequent interventions.9

Families and individuals should have their own disaster plans aimed at allowing them to remain self-sufficient for the first several days after a disaster.10 This is the period before which outside assistance could be feasibly rendered. Pediatricians should remind families to develop individual plans for specific disasters and be familiar with available resources to assist them in the process. Some of those references will be


Planning: Community Medical Practitioners 20-7

included at the end of this chapter. Table 20-2 lists some of the questions families must answer to assess their own risks in case of disas-ter. In addition, a family readiness toolkit was developed by the AAP, the American College of Emergency Physicians (ACEP), and 27 other state and national organizations to help families learn to deal with children in various disaster scenarios (Figure 20.1) (http://www.aap.org/fam-ily/frk/frkit.htm).11

Many health care practitioners have profes-sional and ethical obligations to respond before, during, and after disasters. They and their family members must acknowledge how their profes-sional duties will affect their families, especially when those duties place them at unusual per-sonal risk. Family members should recognize and respect their duty, training, and skills, but health care practitioners also must recognize and

respect the wishes and fears of their loved ones. Whenever possible, conflicts should be discussed and settled before an incident actually occurs.

Children With Special Health Care NeedsPediatricians should remind and help families with children with special health care needs (CSHCN) to plan for a disaster. If the family is planning to shelter-in-place during an an-ticipated event, arrangements should be made to have extra oxygen, batteries, replacement parts, medications, consumables, biohazard disposal equipment, generators, and fuel de-livered well in advance, with plans for automatic restocking as soon as possible after the event. Backup plans should also exist that include a set of circumstances under which the family absolutely must evacuate to ensure their own safety and adequate medical care. Department of Homeland Security offers one resource titled “Preparedness Planning for Home Health Care Providers,” which can assist in the planning for such an evacuation.12

Families of CSHCN planning to evacuate their homes before a disaster must identify in advance where they will go. Hospitals are

Figure 20.1 FamilyReadinessKitproducedbytheMississippi AAP Chapter, 2006.

TABLE 20-2 Risk Analysis for Family Disaster Planning

Analyzing Your Family’s Risks in Disasters• Whatnaturaldisastersaremostlikelyto

strike your community?

–Willyouhaveadequateadvancenotificationtofinishpreparations,ormustyou maintain constant preparedness?

– Is there a seasonal nature to your most likely disasters?

– Will you be able to ensure the safety and location of all family members before the disaster strikes, or will you need to make plansforreunification?

– Are your residence, schools, and places of businessinspecialriskzones,suchasfloodor storm surge zones?

– Is your residence as well constructed, reinforced,andpreparedforthespecifictypes of disasters as possible?

• Areyourhome,placesofbusiness,andschools and childcare facilities located in an area at risk as targets for terrorist attacks?

• Isanyfamilymemberobligatedtobeawayfrom the family, especially in an at-risk service position, during or immediately after a disaster strikes?

• Doesanymemberofyourfamilyhavespecialhealth care needs that would affect the resources you need during and after a disaster?



generally willing to open their doors as a shelter of last resort, but they should never be the first or even the second destination of choice during a disaster. Instead, the families of CSHCN should have a comprehensive knowledge of community resources and a well-rehearsed evacuation plan. If time permits, they should make every effort to get as far away from danger as soon as possible. Physicians and staff who care for these children should help families develop a strategy that in-cludes a primary plan for the most likely disaster and backup plans for other possible scenarios. Hospitals and emergency management agencies might have registries not only for special needs patients but also for those who are frail or might need assistance with evacuation. Families with

special health care needs should take advantage of these registries, which potentially may also provide additional educational materials and preparedness checklists. The AAP and ACEP have jointly developed the Emergency Infor-mation Form for CSHCN, which can provide a child’s critical medical information to any pro-vider.10 (Also see Chapter 13, Children With Special Health Care Needs: The Technologically Dependent Child.) The form is now available in electronic form and can be downloaded by going to the Web site http://www.aap.org/advo-cacy/eif.doc.13 In addition, some home health care agencies and durable medical equipment suppliers furnish disaster planning checklists and assistance.

CASE

SCE

NARI

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A car bomb is detonated in the basement car park of a large business that also providesdaycareservicestotheiremployees.Thefloorsupportingthedaycarepartially collapses. There are children and employees with fractures and burns, and several are unconscious.

1. Are your local EMS agencies prepared to appropriately rescue, triage, treat, and transport this number of patients, especially the seriously injured children? Does your local EMS agency use a pediatric triage tool?

2. Which of your local hospitals would be able to handle critically ill children? Will the closest trauma center be able to handle all of these patients? Is there a plan for triaging the most critically ill children to the hospital with the appropriate resources to manage the complexity of care and the less injured to other nearby hospitals that might be able to manage there? Some local EDs have low pediatric volumes. Will they be able to assist with some of the less critical patients?

Planning: Out of HospitalEmergency medical services agencies are crucial resources in disaster preparedness and response. They might be called on before a disaster to assist with evacuating hospitals, nursing homes, and other skilled care facilities and to provide medical staffing for shelters. After a disaster, EMS techni-cians perform search and rescue, provide medical care, and distribute information to the public.

Planning and preparation are the keys to the successful functioning of EMS tech-nicians before, during, and after a disaster. The most effective plans are often those that

most closely match an agency’s daily activities. Unfortunately, because children are an infre-quent part of most EMS technicians’ daily en-counters, they and their needs are often allotted only small consideration in EMS disaster plans. If the plan lacks pediatric-specific education and training components and does not promote skills retention through regularly scheduled drills, patient triage, treatment, and transport decisions made during the disaster will suffer.14

Emergency medical services agencies cus-tomarily have a plan for dealing with all aspects of multiple and mass casualty incidents (MCIs).


Planning: Out of Hospital 20-9

There is no universally acknowledged definition or patient count that distinguishes a multicasu-alty incident from a MCI. Such definitions are often agency specific and depend on the avail-able resources of the agency and its mutual aid partners. In general, multiple casualty incidents usually are those that can be handled by local resources. Those requiring aid from multiple agencies or from outside the community are deemed MCIs. For the purposes of this discus-sion, the abbreviation MCIs denotes both mass and multiple casualty incidents.

Out-of-Hospital TriageTriage is commonly used in both the field and ED settings, sometimes based on objective guide-lines, sometimes on instinct and experience. Tri-age in the MCI setting, however, demands a more restricted, objective approach than daily triage with a much more limited number of patients per call. The MCI primary triage is focused on a rapid limited patient assessment with the goal of assessing every patient in a short time and mak-ing initial judgments of patient salvageability and resource requirements. In a true MCI, designated triage personnel are often instructed to not render treatment, including cardiopulmonary resuscita-tion or continuing ventilation and airway man-agement, to any patient until primary triage has been completed for all patients on the scene. In primary triage, each patient is assumed to be as important as any other, without regard for age, sex, occupation, or other factors; the triage cat-egory is determined solely by the patient’s medi-cal status. Traditionally, EMS agencies use adult MCI triage guidelines, such as the START (Simple Triage and Rapid Treatment) system, when triag-ing adults involved in a MCI.15 Although START is one of the more widely recognized MCI al-gorithms in use today, evidence to support one triage algorithm over another is limited.16 The JumpSTART pediatric MCI triage tool parallels the START system’s algorithm, using physiologic decision points adapted for ranges of pediatric normal values (Figure 20.2). In addition, it incor-porates additional assessment elements designed to detect a child who might be apneic but still have some circulation before irreversible heart damage from anoxia. These children, potentially

salvageable if respiratory function can be sup-ported or restored, would not be recognized by the START system, in which no pulse check is performed on apneic patients who remain apneic after the upper airway is opened.17

Regardless of what system is used for MCI primary triage in the field, every patient must receive at least one detailed secondary assess-ment either on the scene (if transportation to an ED is delayed for any reason) or in the ED, at which time the triage category can be upgrad-ed or downgraded. Triage is a dynamic process and continues until the patient reaches a facil-ity where definitive assessment and care can be rendered. Note that no MCI triage system has been validated by research.18

IMMEDIATE

IMMEDIATE

JumpSTART Pediatric MCI Triage©

Able towalk?

Breathing?BREATHING

BREATHING

RespiratoryRate

YES

YES

YES

YES

NO

NO

NO

NO

APNEIC

APNEIC

<15 OR >45

IMMEDIATE

IMMEDIATE

IMMEDIATE

DELAYED

DECEASED

DECEASED

Lou Romig MD, 2002

15–45

PalpablePulse?

AVPU

“P” (INAPPROPRIATE),POSTURING OR “U”

“A,” “V” OR “P”(APPROPRIATE)

MINOR SecondaryTriage*

* Evaluate infants first insecondary triage usingthe entire JS algorithm

Positionupperairway

Palpablepulse?

5 rescuebreaths

©

Figure 20.2 JumpSTART pediatric MCI triage tool.



In large-scale MCIs, patients sometimes ar-rive at area EDs without being assessed, treated, or transported by EMS. This is particularly true for pediatric patients, who can be easily trans-ported by private vehicle or police car. The ED personnel might need to perform initial MCI-style triage instead of using their ordinary triage procedures if large numbers of patients arrive at a rate exceeding their capacity. In these cases, EMS-based objective tools such as START and JumpSTART can be helpful for initial patient categorization and assignment of ED resources.

Out-of-Hospital TreatmentEmergency medical services agencies must also plan to be able to provide at least basic treatment to an unusual number of pediatric patients. This requires not only adequate knowledge and training of the health care professionals but also sufficient supplies and pediatric equipment. At a bare minimum, all response and/or transport vehicles should contain all of recommended equipment and supplies.19 Although field in-terventions are usually limited in an MCI, pe-diatric-specific disaster supplies should include appropriate equipment for spinal immobiliza-tion, including pediatric-sized cervical collars, appropriate oxygen masks and airway manage-ment equipment, small intravenous catheters, intraosseous needles, and methods to prevent hypothermia. In addition, personnel should be able to recognize when minimal intervention is needed for a pediatric patient.

Out-of-Hospital Transport and TrackingEmergency medical services agencies must have knowledge of the pediatric capabilities of their area hospitals. Large MCIs might require hos-pitals that usually do not receive seriously in-jured or even stable pediatric patients to care for such patients in an effort to avoid overloading other facilities. The sickest children should be transported to facilities best equipped to treat them, and children with minor injuries should be directed to other EDs with lesser capabilities. At times it will be necessary to transport fam-ily members to different facilities. The issue of separation of family members during a disaster came to the forefront after Hurricane Katrina,

when as a result of limited space on buses, par-ents felt obligated to leave their children unac-companied on buses during the mass evacuation of New Orleans.20 Although family separation should be minimized during a disaster response, it should be expected and prepared for. Early identification of patients by first responders in combination with patient tracking technology and a process for family reunification should be a part of every out-of-hospital disaster plan and drill. There are numerous patient tracking products available, so coordination with re-gional resources (eg, emergency management personnel, hospitals, and EMS agencies) is es-sential to ensure compatibility and access.

The Red Cross was able to assist with family separation after the earthquake in Haiti through their Family Links database, where more than 14,000 people had registered within the first few days to reunite with their family in Haiti and more than 1,000 survivors had contacted the Red Cross.21

Planning: HospitalsHospitals are required by accrediting agencies such as the Joint Commission to have hospital disaster plans.22 These commonly cover two types of disasters: those occurring inside the hospital (internal disasters) and those occurring outside the hospital (external disasters), poten-tially leading to a large increase in patient load.

Internal DisastersInternal disasters include utility failures, fires, explosions, structural collapses, construction incidents, and hazardous materials releases. They also include interruptions in the flow of information technology, which will become a bigger issue in the near future as hospitals be-come more dependent on EMRs. Internal disas-ter plans should be risk specific and detail how to protect the staff, visitors, and patients, secure property, and contain hazards (Figure 20.3). They should also detail how and where each type of staff member should respond, as well as pro-vide methods to organize and maintain control over the staff’s response. Internal disasters can be particularly hazardous to staff members who


Planning: Hospitals 20-11

attempt rescues for which they are not trained. As a part of their disaster training, hospital staff members should be educated about the most common hazards in the hospital setting (especially hazardous materials), the training and equipment needed to respond safely in dif-ferent types of hazardous environments, basic safety precautions, and when they should wait for trained rescuers.6 Hospitals must be able to expand surge capacity within or external to the physical space directly affected by the internal disaster. Communication algorithms that are used to inform and update staff and regional partners (eg, EMS) regarding the incident must be clear, rehearsed, and accessible.

External DisastersMost hospital disaster planning and prepara-tion center on external disasters. External di-saster plans commonly detail how immediately available equipment, services, and personnel are deployed in anticipation of a large increase in patient load. The plan must address surge capacity and the possibility that additional per-

sonnel will be called into the hospital for a major incident. The tendency is to place emphasis on the potential large patient load, but the continu-ing care and welfare of patients already in the hospital must be maintained as well.

External disaster plans should also detail when and how hospital personnel and resourc-es might respond on or off site in the response to a disaster. As with staff responses to internal disasters, any such plans should focus on main-taining the safety of the responding personnel. Ideally, any response outside the hospital prop-erty should be planned with and integrated into the community’s established emergency response plans because untrained responders, however well-meaning, can become patients themselves. In recent years, several hospitals have made their resources available to the community offsite.4

As discussed earlier in this chapter, tertiary pediatric hospitals are great repositories for tal-ent, experience, equipment, and supplies. It is mutually beneficial for regional disaster planners and hospital leadership to collaborate early in the planning of any disaster response. This rela-tionship will allow regional disaster planners to have ready access to everything pediatric with little or no training required. It also benefits the hospital by providing control over the triage, treatment, and distribution of children affected by the incident. This bilateral benefit was well demonstrated in 2005 during Houston’s medical center response to the arrival of 25,000 Hurri-cane Katrina evacuees from the New Orleans Su-perdome. The regional tertiary pediatric hospitals mobilized their resources and treated more than 4,500 children offsite in the Astrodome. Only 50 children required transport to area hospitals.4 This effectively prevented what would have oth-erwise been a guaranteed surge of pediatric pa-tients to the regional pediatric hospitals.

Some external disaster plans, such as those for hurricanes, are designed to prepare for disas-ters of delayed onset, with the goal of ensuring that adequate personnel and resources are in the hospital before and during the disaster to handle an increased load after the disaster passes, safety precautions have been taken, and preparations for anticipated utility outages and supply short-ages have been completed. Rarely do hospitals

Figure 20.3 Hazardous materials drill at a hospital.



open their facilities as disaster shelters for staff and patient families, special needs patients, and the public. Sheltering has its own unique logistic challenges that must be covered in disaster plans.

Hospitals are increasingly adopting a modi-fied incident command system, which allows integration into the plans of responding outside agencies, with the result of maintaining a con-sistent structure despite turnover of personnel. The Hospital Emergency Incident Command System,23 developed at the direction of the Cali-fornia Emergency Medical Services Authority, has become a common platform for hospital di-saster planning throughout the United States.24

In large-scale, federally declared disasters, hospitals must be able to interface with disas-ter response agencies. Federal Disaster Medical Assistance Teams (DMATs) might set up field emergency care facilities that transfer patients to local EDs. They can also be of assistance with patient follow-up in their field units or during shelter sick calls. Members of the DMAT also might be used for hospital relief staffing. Hos-pitals might be asked to provide personnel for public health missions, to set up vaccination programs, to assist with public health surveil-lance and data collection, to provide telephone consultation for shelter personnel, or to assist with organization and distribution of medi-cal supplies. Hospital and ED administrators should have a basic understanding of the Na-tional Response Framework (NRF) and resource center, as well as the local emergency manage-ment plans and command structure.25 Hospitals might choose to designate and train one or more staff members to act as liaisons with local, state, and federal response agencies.

Hospitals might also plan to support com-munity physicians who have lost their practice locations by allowing them to use hospital fa-cilities to see their patients. These physicians might also be used as additional personnel to see patients presenting to the ED or clinic with simple primary care needs, allowing emergency medical staff to focus on the more urgent pa-tients. Community physicians can also be use-ful in staffing telephone hotlines for medical questions from shelters and the public, although liability might be a concern, even in the postdi-

saster setting. Another option is for community pediatricians whose practices have been dam-aged to see patients in the functional offices of other pediatricians.

Long-term responses to disasters will re-quire a parallel approach, uniting hospital-based surge planning with increasing community surge capacity by pediatricians. After local EDs were overwhelmed by an onslaught of nonemergency patients with suspected H1N1 2009 influenza A, the community pediatric response focused on enhancing communication among physician offices, local referral hospitals, and families. This decreased duplicative work and provided a consistent message to families. Also, commu-nity physicians increased access to families by employing additional clinicians, extending office hours, and locating additional space in which to see children. This enables families to continue to seek care in the community and also serves to decrease the number of nonemergency patients seen in local EDs.26

Hospital disaster plans should include criti-cal incident stress management services and interventions for staff members with survivor guilt, guilt for leaving their families, stress from personal losses, and other expected psychologi-cal consequences. Posttraumatic stress disorder (PTSD) and other stress-related syndromes are not uncommon after disasters. They can affect individual staff members and compromise staff morale, attendance, and work efficiency.

Planning: Community AgenciesMost accredited public schools are required to have disaster plans. Many private schools have plans as well. School disaster plans should cover a diversity of disasters as well as unusual occur-rences, such as fire, school violence, student abduction, terrorist attack, and community violence (riots) (Figure 20.4). Many schools act as community shelters; this aspect must also be addressed in school disaster plans and in-tegrated with those of the agency responsible for sheltering (Red Cross, local EMS, or local emergency management).

Plans should include continuous oversight of student medical and emergency contact


Planning: Shelters 20-13

personnel to pertinent records. Some EMS agen-cies keep registries of special needs children in their jurisdictions, with information on facility locations and building plans, usual patient cen-sus, hospital preferences, staff medical capabili-ties, and critical individual medical information. Agencies that routinely transport special needs children are increasingly keeping emergency medical information on board transport vehicles in case of crashes, sudden illness, or other inci-dents on the road.

Planning: SheltersAlthough children and families must be con-sidered in all aspects of planning, disaster shel-tering typically raises the most challenges, and most regions will do everything in their power to avoid it. For example, Texas plans created before and after Hurricane Katrina consider shelters as a last resort measure and call for ei-ther shelter-in-place (eg, home) or evacuation inland. However, during Hurricane Katrina and despite the wishes of optimistic emergency planners, shelters were erected from New Or-leans, Louisiana, to Chicago, Illinois, due to the influx of displaced families and the need for housing and support. In fact, Houston erected and operated two of the largest shelters with medical facilities to date due to the large in-flux of evacuees.4 For this reason, every region should at least plan for the possibility. Table 20-3 lists a number of issues that must be consid-ered in community shelter planning. Diapers and other disposable wastes (such as biomedical waste) present potential problems because they can create hazardous and nonhygienic condi-tions if they are not properly managed pending final disposal. Younger children and those with special dietary requirements might not be able to tolerate shelter food, especially ready-to-eat meals, which are typically high in salt content and increase free water requirements. Families with infants on elemental or other special for-mulas might not have access to additional sup-plies in the initial postdisaster phase, although part of their family plans should be to bring a significant supply with them to the shelter. Hospitals and stores with these special stocks

records and methods to reunite children with their family members. Procedures for seeking emergency medical care for students in the ab-sence of a guardian should be clearly delineated. Ideally, school staff members should be trained in basic life support and first aid and perhaps even in basic safety precautions, rescue tech-niques, and triage procedures.

The National Association of School Nurs-es has a position statement on Bioterrorism Emergency Preparedness and Response27 and has developed a course on managing school emergencies that covers much of the training needed not only by nurses but potentially by other school staff members.28 School disaster plans should also consider postincident stress management for both students and staff, as well as more formal psychologic monitoring and intervention for events involving violence, loss of a student or staff member, and those having community-wide impact.

Any facility that supervises children, such as childcare centers and community youth centers, should also have a disaster plan that focuses on ensuring the children’s safety, accessing and in-teracting effectively with community emergency responders, guardian notification, and family reunification. As with hospitals, schools, and public safety agencies, these facilities should not only have disaster plans on paper but should also educate staff members and exercise their plans.

Facilities providing supervision and/or medical care on a residential or periodic ba-sis for CSHCN should not only have basic disaster plans but also plans for medical record maintenance and access by emergency care

Figure 20.4 School-based disaster response involving EMS resources.



For those shelters that are not staffed by medically trained personnel, each shelter and their staff must remain prepared for emergen-cies among the evacuees, including children. Basic first aid supplies, automated defibrillators, and guidelines should be available. If possible, shelter staff should have direct access to EMS (perhaps by radio if telephone lines are not op-erable) and possibly have a designated resource to advise on medical issues. Charts with pictures of infectious diseases with rashes (eg, chicken-pox, measles) can help identify shelter families that should be isolated to minimize contagion. Ideally, shelter plans should include isolation protocols. Long-term sheltering might incor-porate plans for shelter sick calls, provided by community medical staff (public health staff or volunteer community practitioners). The NDMS might also be activated, allowing DMAT person-nel to conduct shelter sick calls.

Safety must be as much of a concern in a shelter as in any home. Both children and el-derly individuals must be considered in creating a safe shelter. Shelter residents must be warned to try to secure their medications and medi-cal supplies, such as lancets for blood glucose testing, as well as other personal supplies (eg, soaps, perfumes) that might cause injury to a child. Cords, oxygen tubing, and other trip hazards must be secured and watched carefully. Bathrooms and floors should be monitored for slip hazards. Rooms not actively in use for shel-tering should be locked, and exits should be monitored. Shelter residents must be informed about emergency exits and procedures. Chil-dren should be monitored when they are around frail persons to prevent unintentional injury. Fi-nally, shelter rules about smoking, alcohol, and other drug use and weapons should be explicit and enforced as strictly as possible. If weapons are to be allowed in a shelter, all possible precau-tions must be taken to keep them well secured.

Shelters must be prepared to care for CSHCN and their family members and/or care-givers. Ideally, there should be special needs shelters that are equipped for both the adult and pediatric resident. Caregivers who are fa-miliar with the child’s condition and needs are invaluable, and their involvement should be

might be the best suppliers of special formulas; advance planning might include arranging with these organizations to supply special nutrition to shelters as needed. Children in shelters must be kept safe, supervised, and constructively oc-cupied as much as possible. Supervised activi-ties are a good opportunity to provide children with the information and reassurance they need, while allowing them to participate in familiar ac-tivities and routines. Child life personnel are an invaluable resource and should be involved in all disaster planning, response, and recovery.29

TABLE 20-3 Pediatric Issues in Disaster Shelter Planning

Supplies and Services•Provideaccesstotelephoneconsultationfor

medicalquestions.

•Providebasicpediatricfirstaidequipmentandguidelines.

• Providechild-appropriatesnacksandfoods.

•Providediapersandothersuppliesforinfanthygiene.

•Providegamesandotherdistractionsforchildren.

•Provideinfantformulaandrehydrationsolutions.

Staffing•Preparestaffmemberstohelpsupervise

children when parents start recovery efforts.

•SetcontingenciessothattheentirefamilyofaCSHCNcanbetogether.

•Trainstaffmembersinbasicpediatricemergency care.

•Usefamilyvolunteerstohelpsupervisechildren.

Safety•Childproofthesheltertopromotesafetyfor

children and elderly family members.

•Sequestersickchildrenandtheirfamiliestoreduce the spread of illness.

•Setgroundrulesforahealthyenvironment(limit or forbid smoking, drinking, and weapons).

•Superviseinteractionsbetweenvulnerablepopulations (children, frail individuals, mentally ill individuals, those with developmental disability, and sensory impaired individuals) and other shelter occupants. Have systems in place for scheduled monitoring, tracking,andreunification.


Response and Recovery Phases 20-15

there is no time for relationship building. The first official trial run for Houston’s EOC (ie, Cat-astrophic Medical Operations Center [CMOC]) took place during the city’s response to the ar-rival of more than 300,000 evacuees from New Orleans before the impending arrival of Hurri-cane Katrina along the Louisiana coast. One of the CMOC’s greatest challenges was coordinat-ing the EMS response, transport, and distribu-tion of patients to regional emergency centers based on the availability of hospital beds.31 To date, it remains one of the best examples of the regionalized approach to disaster response.

Emergency Medical ServicesEmergency medical services and other public safety agencies are the first official line of response during and after disasters. They are integral to the success of every phase and arguably the best place for pediatricians and emergency physicians with training and expertise in prehospital care to input their education, experience, and wisdom to optimize the care of children. Response duties for EMS technicians might include search and rescue, multicasualty triage, initial treatment and transport, establishment of casualty collection points, damage assessment, and hazard mitiga-tion in addition to their usual EMS responsibili-ties. Nondisaster-related EMS and public safety demands continue and might even increase in a disaster. In community-wide disasters, mutual aid agreements allow outside EMS agencies to respond to assist local resources, both inside the damage zone and throughout the community. In large-scale disasters, especially those affect-ing the EMS system itself (as in the World Trade Center incident or when stations and equipment are damaged), outside EMS, fire, and law enforce-ment agencies from around the country send per-sonnel and apparatus to operate in the affected area under guidance by local authorities. Good emergency planning will ensure that the mutual aid effort is controlled under a unified command structure and monitored to ensure that the entire community’s EMS requirements are met.

The Federal Emergency Management Agen-cy (FEMA) CERT program is receiving increasing attention around the United States.32 The CERT concept was developed and implemented by the

welcomed. However, shelter personnel should not be dependent on their services. This was well demonstrated in the Austin, Texas, special needs shelters during Hurricane Rita in 2005. Shelters were ready to provide space, food, and supplies for the evacuees and their families. Their staff were, however, ill-prepared for the amount of bedside care that would be required by their personnel. Shelters must also stock and be familiar with the medication, supplies, and equipment specific to the needs of children. As demonstrated in the California fires of 2007, displaced families often leave their homes with-out their supplies and medications.30

Response and Recovery PhasesResponse comprises all activities and actions taken during and immediately after a disaster, including initial search and rescue, damage as-sessment, evacuation, sheltering, and many other activities. The response phase lasts until the initial casualties have either been rescued or acknowl-edged as lost and sufficient resources have been made available to allow the population to assess damages and begin plans for restoration and recovery. This phase can last hours to weeks. The recovery phase is the period in which the affected organization or community works toward rees-tablishing self-sufficiency. It is also the period in which outside support services are withdrawn.

To assist in the response and recovery phase, the emergency operation center (EOC) acts as the physical location where community representatives involved in decision making around the time of disasters meet. Positions rep-resented at the EOC during disasters depend on the size and needs of the community and, at a minimum, include decision makers from local and/or regional government, public health and safety, EMS, and the medical community. Some EOCs include representatives from lead agen-cies that represent the needs of the industry and population specific to that community (eg, oil and gas and vulnerable populations). Whether the response and recovery are considered suc-cessful depends greatly on the preparation done by those in the room before the disaster. Once the EOC is activated, collaboration is essential;



who spoke Creole. A command center was estab-lished in Miami, Florida, organizing the transport of additional medical relief workers, medical sup-plies, equipment, and medications. Within the first week, more than 100 volunteers were orga-nized to care for the multitude of sick and injured patients. Hospital tents were erected, and life- and limb-saving operations were performed.33

Hospitals and medical professional associa-tions might choose to send response resources into an affected area to set up independent pa-tient care sites or to augment existing medical fa-cility capabilities. This kind of response should be preplanned to ensure adequate credentialing and validation of staff, provision of adequate supplies and support services, and coordination with local emergency management to prevent duplication of services and ensure that resources are sent where they are needed most. Hospitals must consider the financial implications of such response services because their expenses might not be reimbursed through FEMA or other agen-cies. Disaster response starts in the communi-ty, and despite the extreme effort that it often requires to mobilize, it is always in the best interest of regional resources to work together before, during, and after a disaster. The ben-efits of collaboration during crisis were evident during the nation’s response to the Hurricane Katrina evacuees. Regional and not so region-al resources were mobilized and distributed directly to the epicenter of need. Ambulances and staff from locations as far away as Canada were used to transport patients from the Hous-ton Astrodome Shelter to area hospitals. Volun-teers included medical personnel from around the world. Although the incident was declared a federal disaster, the most effective part of the response came from the collaboration of region-al responders and volunteers, not the federal government.34 In a federally declared disaster, personnel from DMATs, the US Public Health Service, and the Veterans Administration might be assigned to assist with hospital staffing. Cur-rent federal initiatives include the development of a volunteer MRC. The MRC members would most likely be used to augment local medical resources, possibly to include supplementing clinic and hospital staffing.35

Los Angeles Fire Department in 1985 as a way to train and prepare volunteer civilian teams to augment emergency response resources after an earthquake. FEMA recognized the concept and now assists with the development of local CERTs using an all-hazards curriculum developed by the Emergency Management Institute and the National Fire Academy. CERTs have been es-tablished by neighborhood associations, church groups, community service organizations, spe-cial interest clubs, and many other types of orga-nizations. Team members are trained in disaster preparedness, emergency medical assessment and basic triage and treatment, light search and rescue, basic fire suppression, disaster psychol-ogy, and volunteer management.32

HospitalsIn disasters with large numbers of casualties or a disruption of the community’s medical in-frastructure, functional hospitals will be chal-lenged to deal with increased patient loads not only immediately after the disaster but also for subsequent weeks or months until infrastruc-ture is restored. Staffing requirements might increase at a time when staff members them-selves have been affected by the disaster and require time off to care for their families, secure their property, and begin the rebuilding process. Additional staffing needs can be met by using temporary agency personnel or pulling staffing from other hospitals in a network.

This was demonstrated by the 7.0 magni-tude earthquake that devastated Haiti on Janu-ary 12, 2010. The disaster both overwhelmed and destroyed the entire medical infrastructure of Haiti. The physical hospitals were destroyed, and hospital staff that survived and continued to work were not sufficient for the surge of sick and injured people who sought medical care in the aftermath of the event. Emergency medical relief was dispatched in teams from around the world, such as the response of project Medi-Share, a nonprofit organization that provided a rapid medical response within 20 hours of the earthquake. Medical staff volunteers included emergency physicians, internists, pediatricians, family physicians, anesthesiologists, pediatric and adult orthopedic surgeons, and bilingual nurses


Response and Recovery Phases 20-17

sometimes function as local and state resources and respond to state-declared disasters or provide medical coverage for local mass gathering events. There are also several specialty DMATs, including two pediatric DMATs, based in Boston, Massa-chusetts, and Atlanta, Georgia. Other specialty units address burn care and mental health.

Urban Search and Rescue (USAR) taskforces are teams of personnel trained in heavy rescue and special search operations; they are usually based in fire departments.37 Federally coordi-nated by FEMA, USAR taskforces also include medical specialists, communications specialists, and engineers. Although most USAR physicians are emergency physicians and surgeons, several are pediatricians. The USAR medical capabili-ties for dealing with children should be at or above the level of a well-trained and equipped advanced life support EMS service in the United States. The USAR medical team members are primarily responsible for the health and wel-fare of human and canine team members, who often work in very hazardous environments. A medical team’s secondary and tertiary duties are to care for entrapped individuals and other di-saster survivors. In a large-scale disaster, USAR taskforces perform search and rescue, provide initial treatment for entrapped individuals, and then turn the patients over to local hospitals or on-site DMATs. Most USAR taskforces respond domestically; however, several have been des-ignated for international response as well. The USAR taskforces have responded to numerous earthquakes in the United States and around the world, as well as major terrorist events in the United States. More information about USAR is available on the FEMA Web site.37

Individual Volunteerism, Credentialing, and the MRCNumerous opportunities exist for individuals with medical training who want to volunteer for disaster response. Disaster education and train-ing are, however, essential and relatively easy to obtain. No one should ever become directly in-volved in a disaster response without the support of the federal government (NDMS) or a reputable nongovernmental organization (NGO).

Federal AgenciesThe Federal Disaster Response Plan details the roles and coordination of various federal agen-cies and resources expected to respond to a federally declared disaster; Emergency Support Function 8 is the portion of the plan dealing with health and medical issues.25 The NDMS is a consortium of government, public, and private agencies responsible for providing medical as-sistance under Emergency Support Function 8. The NDMS was initially established to organize a domestic response to the evacuation of large numbers of casualties into the United States from a war zone. Its role now has expanded to include responses to all types of disasters, including ter-rorist events. The NDMS resources include US Public Health Service teams, Veterans Admin-istration personnel, DMATs, Veterinary Medical Assistance Teams, and Disaster Mortuary Teams. More information is available about these teams on the NDMS Web site36 (http://www.hhs.gov/disasters/index.html).

The DMATs are volunteer teams made up of physicians, nurses, EMS technicians, logisticians, and other administrative and support personnel. The original concept of a DMAT was to act as the civilian equivalent of a Mobile Army Surgi-cal Hospital (MASH) unit, with the capability of acting as a fully equipped emergency care unit with self-sufficiency for 3 days without resupply or other support. A fully deployed DMAT should have the capability to at least stabilize critically ill and injured children and provide basic inpatient-type care for stable children until other resources are available.

The first large-scale deployment of DMATs in the MASH-type role was after Hurricane An-drew in Miami-Dade County, Florida, in 1992. The DMAT missions since then have evolved to include replacement of hospital and EMS person-nel, special medical coverage for mass gather-ings such as the Olympics, shelter, sick-call and outpatient clinic services (New York State ice storms, several flood deployments), and medi-cal support for responders (World Trade Center and Pentagon attacks and wildfires). In some of these missions, the US Public Health Service requisitions the services of specific types of team members rather than entire teams. The DMATs



one should go solo. For an individual to pack his or her car with supplies and head into a chaotic disaster scene is potentially foolish and danger-ous, regardless of any altruistic motivation.

Just as individual physicians should care-fully plan and prepare in advance in the event that they encounter a disaster, they should also plan and prepare to be disaster response volun-teers. At the very least, predisaster preparation for volunteers should include NDMS training and certification36 and credentialing through the ESAR-VHP program. Other training programs include the American Medical Association’s Na-tional Disaster Life Support Foundation’s Basic and Advanced Disaster Life Support courses.38 Registering with the MRC, which is a national network of community-based volunteer units that support existing local agencies during di-saster response, is another option for providers of all levels who want to share their education, talents, and training during a disaster. The goal for the MRC is to identify, screen, train, and prepare volunteers for participation in any ac-tivity.39 Some medical professional associations also maintain registries of members available to respond after disasters. In reaction to the Janu-ary 2010 earthquake in Haiti, the AAP and the National Association of Children’s Hospitals and Related Institutions worked in collaboration to develop a structure to provide the federal gov-ernment ready access to their resources.

Federal OptionCurrently, the only nonmilitary method of join-ing the federal disaster response is through the NDMS and by joining a DMAT. The DMATs allow interested clinicians to become involved locally, regionally, nationally, and even inter-nationally (ie, Haiti). Once an applicant is se-lected, he or she goes through a lengthy process of training and credentialing. Choice of when and where a DMAT member is deployed is not usually an option. The teams are local and are often deployed outside their region. The perks include transportation to and from ground zero and the benefits of federal protection. Another option is CERTs, but in general they train and work within their own communities.

NGO OptionVolunteering with an NGO (eg, The Red Cross, Salvation Army, and Medi-Share) is often more productive and much safer than going into a disaster zone alone. Selecting the right NGO is the first step. Reputable volunteer organiza-tions have experience in the region, provide transportation to and from the site, ensure that safety measures are taken for the protection of personnel, have contingency plans for evacua-tion, ensure that supplies and support services are available, and will work within the emer-gency management command structure to put volunteers where they will be of most use. No

CASE

SCE

NARI

O 3

Amajorearthquakeseverelydamageslargeportionsofamajorcity,includingseveralmajorhospitalsandmanyprivatehealthcareofficesandfacilities.Thousands of people are left homeless, and many have been injured. Hospitals havealreadybeenoverloadedbecauseofaveryactiveinfluenzaseason.

1. Does your hospital or office have a realistic evacuation plan?2. Is your hospital or office prepared to take on extra loads for potentially long periods

when the local medical infrastructure is damaged?3. How can your hospital and community medical practitioners benefit from, interact

with, and assist response teams from the NDMS?


Pediatric Medical Issues After Community-Wide Disasters 20-19

their property from looters might have weapons that are not secured against curious children. Increased stress levels among adults might even lead to an increase in domestic violence and child abuse.43 The world can be a much more dangerous place after a disaster; supervision of children is even more important than usual and even more difficult if the normal supervisory re-sources of school and childcare are not available.

Acute infectious illnesses generally conform to the patterns existing in the community at the time of the disaster. An epidemic of bronchiolitis or chickenpox will continue to cause problems, pos-sibly to greater degrees because of group sheltering or lesser degrees because children are not crowded together in classrooms. A sudden change in diet can lead to food intolerances and gastroenteritis. Exposure to the sun and heat or a shortage of po-table water can cause dehydration. Cold environ-ments might lead to hypothermia. Generator and kerosene heater use can lead to carbon monoxide poisoning. Children with allergy-based diseases might have acute exacerbations due to increased and unavoidable allergens in the environment. Children with behavioral or psychiatric disorders might get acutely worse because of stress and dis-ruption of their daily routines. Finally, stress itself can produce a variety of symptoms in children, including headache, abdominal pain, chest pain, vomiting, diarrhea, constipation, changes in sleep-ing patterns, and changes in appetite. It can also induce separation anxiety, obsessive-compulsive symptoms, and severe stranger anxiety.44

After a community-wide disaster, public health officials commonly monitor for water- and food-borne diseases, such as cholera and other enteric diseases; however, such epidem-ics have not yet proved to be a problem in the United States. However, because of the close quarters and poor hygiene, it is not uncommon for a shelter to experience a bout of diarrhea ill-nesses caused by pathogens such as Norovirus.4

Another common concern after a disaster is the need for vaccinations. Older infants and children who are up to date based on the standard US immunization schedule are well prepared for most disasters that occur on US soil. However, if there is a controversy, the best resource for determining whether there is a need for

Mitigation PhaseMitigation is the phase in which all other aspects of emergency management are scrutinized for “lessons learned.” The lessons are then applied in an effort to prevent the recurrence of the disaster itself or to lessen the effects of subsequent inci-dents. Mitigation and planning are continuous operations because lessons learned from previous disasters are rolled into planning for the next one.

Pediatric Medical Issues After Community-Wide DisastersSmall-scale MCIs occur daily in the United States. Few present unusual challenges to the local med-ical systems other than in the number of patients that must be treated at one time. Except in earth-quakes, explosions, building collapses, and some types of terrorist attacks, the same holds true for large-scale disasters. Sudden, violent disaster mechanisms can produce major trauma cases, including patients needing field amputations or management of crush syndrome.40–42 For the most part, medicine after a disaster is much the same as it was before the disaster, with more mi-nor injuries, more people with exacerbations of their chronic illnesses, and a number of patients seeking what is ordinarily considered primary care. This is true for children and adults.

Predisposition of Children to Illness and Injury After DisasterChildren can be unusually predisposed to injury after a disaster. Adults who normally supervise them might be preoccupied with recovery tasks. They also can be at risk from increased environ-mental hazards, such as collapsed or exposed construction elements; the availability of dan-gerous tools, such as chainsaws; exposure to the elements, animals, and insects; and the avail-ability of hazardous chemicals and objects, such as kerosene, gasoline, candles, and generators. Children often want to assist with repairs and might wind up on rooftops or climbing around building or tree wreckage. Disruption of traffic control devices, such as traffic lights and signs, can lead to an increase in vehicle-related trau-ma. Families and business owners protecting



ordinarily be discharged with close outpatient follow-up. Supplies for injury and illness pre-vention and health maintenance can be distrib-uted by hospitals to patient families and visitors. Targeted patient and family education efforts should be increased in an environment in which access to care is restricted. The media can be very helpful in printing and airing safety and health tips, as well as the locations of temporary medical facilities and pharmacies.

After a disaster, the ED and primary care phy-sician’s office might become overwhelmed with the volume of patients presenting for evaluation, including both the truly sick and the worried well. This taxes the entire medical infrastructure if a plan does not currently exist to manage the surge of patients. The term “surge capacity” re-flects a measurable representation of a facility’s capability to manage an overwhelming amount of patients arriving at once or rapidly progressing with the current resources available.48 As demon-strated by the H1N1 influenza pandemic, where children were disproportionately affected by the illness, the baseline system needed to be scaled to handle the influx of patients. Many hospitals, including Dell Children’s Medical Center in Aus-tin, Texas, set up triage tents outside the ED to allow for improved patient flow and to prevent spreading the virus to the frail or already critically ill patients.49

For effective management of the surge in pediatric patients, all health care facilities and out-of-hospital health care professionals must be prepared to treat children who are critically ill through measures such as stocking adequate and up-to-date pediatric equipment and medi-cations. Having appropriate pediatric drug dosing resources, security protocols for unac-companied children, a patient tracking system, psychosocial support, and appropriate decon-tamination strategies is critical. The facility should be able to scale their daily operations and potentially suspend elective medical and surgical procedures to reallocate their space and resources toward managing the surge. If there are no regional pediatric hospitals, an ar-rangement should be made with local hospitals regarding how children will be treated during and after an event.50

additional immunization is the Centers for Dis-ease Control and Prevention (http://www.cdc.gov/).45 That is not the case for disasters that oc-cur on foreign soil. In Haiti, where only 58% of Haitian infants were reportedly immunized at baseline from 2004, the United Nations has reported an increase in cases of diarrhea, measles, and tetanus in the months after the earthquake.46

Access to Care After DisasterAfter disasters, families might not have the abil-ity to seek care for their ill or injured family members as quickly as they ordinarily would. Nearby medical facilities might not be opera-tional. Families might have lost their means of transportation, or the transportation and road system might be disrupted so badly by dam-age or disaster relief traffic that a trip outside the area for medical care could take an entire day. Standing in line for hours for basic survival needs, such as food, water, ice, and other sup-plies, might take precedence over seeking medi-cal attention for a seemingly minor issue. Once a family makes it to medical care, they might not be able to comply well with follow-up instruc-tions. Good home wound care becomes difficult when water for bathing is in short supply, and every-other-day wound checks can be impos-sible in the face of other challenges. The parents of an asthmatic child should be instructed in the use of metered-dose inhalers and aerocham-bers, which have equivalent efficacy to nebu-lized treatments47 and do not require electricity. Pharmacies might not be open in the affected area; families might need to take one or two trips out of the area to drop off and pick up prescrip-tions. These kinds of access-to-care limitations require changes in decision-making patterns on the part of emergency care practitioners.

Limitations on Practice and Surge Capacity After DisasterTable 20-4 lists some of the constraints of practic-ing emergency medicine in a postdisaster set-ting. Emergency and primary care practitioners might need to change their usual prescribing patterns to accommodate family needs, and they might have to admit children who would


Pediatric Medical Issues After Community-Wide Disasters 20-21

reached its maximum capacity. The US Depart-ment of Health and Human Services, Office of the Assistant Secretary for Preparedness and Re-sponse (ASPR) Hospital Preparedness Program, with funding, can aid in this planning. Hospitals should furthermore have disaster drills that in-clude pediatric patients.

This brings to light the importance of region-alization of pediatric surge capacity and capabil-ity planning. Planning for a surge in pediatric patients must be evaluated on local, regional, and national levels, with plans that integrate appro-priate transfer of patients who require evaluation by a specialist or when an office or hospital has

TABLE 20-4 Changing Emergency Department Decision Patterns

Constraint: Lack of Electricity at Home

Altered Decision Patterns:

•Prescribemetered-doseinhalerswithspacerchambersforinhaledmedications.

•Provideafewpoweroutletsorpressurizedoxygen/roomairtanksoroutletsforusebyfamiliesfornebulizer treatments with their own medications.

•Foryoungerchildren,prescribechewabletabletsandliquidmedicationpreparationsthatdonotrequirerefrigeration. Consider nonchewable tablets and use of a pill cutter.

•Loweradmissionthresholdforchildrenwhorequiretreatmentwithhardwiredelectricalequipment.

Constraint: Unavoidable Environmental Exposure


•Distributesunscreen,sunburncareproducts,insectrepellant,umbrellas,hats,disposablefans,andchemical cold or hot packs.

•Advisefamilyofongoingrisksandpossibleneedtosendthechildawayfromthearea.

•Distributesafetyliteratureaboutpreventivemeasuresandwhattolookforincasesofenvironmentalillness.

Constraint: Infectious Diseases


•Considerparenteralantibiotictreatmentasastarterdose.

•Consideracceptableshortercourseofantibioticsandincreaseddosingintervaltoimproveadherence.

•Considerneedforisolation.Decreaseadmissionthresholdifchildandfamilyarelivinginashelterenvironment and cannot make alternative arrangements.

•Demonstrateachild’sabilitytotakeandkeepdownfluidsbeforedischargewithgastroenteritis.Liberalizeintravenousand/orformaloralrehydrationpracticesandantiemeticadministration.

•Distributeoralrehydrationsolution,diapers,diaperwipes,andalcohol-basedhandcleansingsolutions.

•Distributeeducationalliteratureregardingmeasurestopreventspreadofdisease.

Constraint: Poor Follow-up/Decreased Access to Care


•Learnwhattemporarymedicalfacilitieshavebeensetupintheaffectedarea,andaskpatientsto follow up there if possible. Send a note with the patient describing what care is needed.

•Specificallyinstructfamiliesastowhatcomplicationsabsolutelyrequirefurthermedicalevaluation.

•Distributewoundcaresupplies.

•Instructfamiliesinsutureremovalprocedures.

•Confirmalternativecontactmethods(eg,leavingmessagewithrelative)forchildrendischargedwithpending test results, especially cultures.

•Confirmactualcurrentaddress(eg,shelter,relative’shouse)andusualaddress.

•Decreaseadmissiondecisionthresholdsforanyconditionthatmightrequirefrequentfollow-uporposea risk of sudden deterioration.



usual independent spirit. They can experience rapid mood changes, interrupted sleep, and nightmares.

It is important to explain a disaster to chil-dren in words they can understand, not to lie about loved ones or acquaintances who might have been injured or killed, and to encourage children to express their feelings in talk, play, or art. Adults should express their own concerns and feelings in front of their children but should not subject children to extreme emotional dis-plays. Children should be shown images of the disaster so they have an authentic picture of what happened, but this should be done in an environment that permits guided discussion. Do not allow children to watch television news clips that repeatedly display disturbing images or footage that graphically portrays injury and death. Children who exhibit signs of ongoing stress and depression, such as headaches, chron-ic abdominal pain, recurrent nightmares, chang-es in sleep patterns, deterioration in behavior or school performance, personality changes, drug abuse,66 or suicidal ideation should undergo full medical and psychological evaluation. Monitor-ing children for signs of mental illness after a disaster should be a part of recovery planning by families, school systems, social service agencies, primary care physicians, and mental health pro-fessionals.67–69 The Pediatric Symptom Checklist or the Pediatric Symptom Checklist17 are rec-ommended screening tools that can be used to identify children in need of referral for mental health services.70–72

SummaryDisasters of all types and sizes occur daily, strik-ing without regard for the ages of the survivors. Children can and will be directly and indirectly affected by many kinds of disasters. The issues of children and families must be included in disaster planning at all levels, from family pre-paredness, to office and hospital preparedness, to community emergency management.

The United States is fortunate to be rich in disaster response resources on local, state, re-gional, and national levels. All responders must be trained and equipped at their appropriate

Pediatric Mental Health Issues After DisasterChildren can and do experience acute and chronic emotional distress and mental illness after disasters. Many studies have shown that children experience a variety of psychological sequelae, including PTSD, even if they were not directly involved in the disaster themselves.51–60 In the months after the September 11th terrorist attacks, a large-scale study screening for mental disorders was performed that included children from grades 4 through 12, with 28.6% of the children identified as having probable mental health disorders, with the most prevalent be-ing agoraphobia (14.8%), probable separation anxiety (12.3%), and probable PTSD (10.6%). This study identifies an essential need for the identification and intervention of mental health disorders in children.61 Because pediatric prac-titioners have the ability to screen and advo-cate for their patients’ mental health, a survey of pediatric practitioners was conducted after September 11. This study overwhelmingly in-dicated that the practitioners felt that they had either lacked or were uncertain of their skills in identifying children with mental health prob-lems.62 Therefore, there was a disparity in the apparent need and receipt of mental health ser-vices in the aftermath of the attack.63 In another example, in the year after Hurricane Katrina, New Orleans schoolchildren were evaluated for mental health issues, and at baseline 60.5% of the children enrolled screened positive for PTSD. These children received either school- or clinic-based psychotherapies, leading to a sig-nificant reduction in PTSD symptoms.64 The health care professional can use psychological first aid, which offers practical assistance, in-cluding emotional support, information, and education, encourages positive coping skills, and identifies and assists patients who require additional support.65

In the immediate postdisaster stage, it is im-portant to reestablish a sense of order and routine and to ensure children that they are safe. Expect regressive behavior; children might wet the bed or cling to their parents instead of showing their


Resources 20-23

preparedness: policy statement. Pediatrics. 2006;117:560–565. http://aappolicy.aappublications.org/cgi/content/full/pediatrics;117/2/560.

5. Markenson D, Reynolds S, Committee on Pediatric Emergency Medicine and Task Force on Terrorism. The pediatrician and disaster preparedness: technical statement: Pediatrics. 2006;117:e340–e362. http://aappolicy.aappublications.org/cgi/reprint/pediatrics;117/2/e340.pdf and http://aappolicy.aappublications.org/cgi/content/full/pediatrics;117/2/e340.

6. Pediatric Disaster Readiness. Clin Pediatr Emerg Med. 2009;10:123–244. http://www.clinpedemergencymed.com/issues/contents?issue_key=S1522-8401%2809%29X0004-2.

7. Committee on Pediatric Emergency Medicine. Preparation for emergencies in the offices of pediatricians and pediatric primary care providers. Pediatrics. 2007;120:200–212. http://aappolicy.aappublications.org/cgi/content/abstract/pediatrics;120/1/200.

8. AAP Committee on Pediatric Emergency Medicine; ACEP Pediatric Committee; Emergency Nurses Association Pediatric Committee. Guidelines for care of children in the emergency department: joint policy statement. Pediatrics. 2009;124:1233–1243. http://pediatrics.aappublications.org/cgi/content/abstract/peds.2009-1807v1.

9. Preparedness Checklist: Guidelines for Children in the Emergency Department. http://www.aap.org/visit/Checklist_ED_Prep-022210.pdf.

10. Hogan Jr JF, Committee on Psychosocial Aspects of Child and Family Health and the Task Force on Terrorism. Psychosocial implications of disaster or terrorism on children: a

levels to address the unique physical, medical, and emotional needs of children and their fami-lies in a disaster setting. Many more responders are needed to ensure that all possible resources can be made available to disaster survivors. Medical professionals can find many opportu-nities to help. Some opportunities demand little time and energy, whereas others require a sig-nificant commitment to training, team manage-ment, and response. All volunteer efforts can be both personally and professionally rewarding.

Children are at increased risk for injury and illness both during and after disasters; however, with the exception of the more sudden, violent types of disasters, most injuries and illnesses are in keeping with typical childhood patterns. Emergency and primary care practitioners in the postdisaster setting must be prepared to adjust their normal practices to conform to the constraints placed on patients and their fami-lies. Mental health issues have been frequently identified in pediatric disaster survivors and can affect children and their families far beyond the time when physical injuries have healed. All child advocates must be aware of these potential problems and learn how to incorporate child-hood mental health surveillance and interven-tions into their ongoing disaster plans.

Resources

American Academy of Pediatrics Disaster Preparedness Resources

1. AAP Web site Children and Disasters. http://www.aap.org/disasters/index.cfm.

2. A Disaster Preparedness Plan for Pediatricians. http://www.aap.org/disasters/pdf/DisasterPrepPlanforPeds.pdf.

3. Disaster Preparedness for Pediatric Practices: An Online Tool. http://practice.aap.org/disasterpreptool.aspx.

4. AAP Committee on Pediatric Emergency Medicine; AAP Committee on Medical Liability; Task Force on Terrorism. Policy Statement: The pediatrician and disaster


http://www.aap.org/disasters/index.cfm

http://www.aap.org/disasters/pdf/DisasterPrepPlanforPeds.pdf

http://practice.aap.org/disasterpreptool.aspx

http://aappolicy.aappublications.org/cgi/content/full/pediatrics;117/2/560

http://aappolicy.aappublications.org/cgi/reprint/pediatrics;117/2/e340.pdf

http://aappolicy.aappublications.org/cgi/content/full/pediatrics;117/2/e340

http://www.clinpedemergencymed.com/issues

http://aappolicy.aappublications.org/cgi/content/abstract/pediatrics;120/1/200

http://pediatrics.aappublications.org/cgi/content/abstract/peds.2009-1807v1

http://www.aap.org/visit/Checklist_ED_Prep-022210.pdf


forms and emergency preparedness for children with special health care needs: policy statement. Pediatrics. 2010;125:829–837. http://aappolicy.aappublications.org/cgi/content/abstract/pediatrics;125/4/829. Emergency Information Form http://pediatrics.aappublications.org/cgi/content/abstract/125/4/829?maxtoshow=&hits=10&RESULTFORMAT=&fulltext=emergency+information+forms&searchid=1&FIRSTINDEX=0&sortspec=relevance&resourcetype=HWCIT.

Children With Special Health Care Needs 1. CSHCN evacuation: Homeland

Security offers one resource titled Preparedness Planning for Home Health Care Providers, which might assist in the planning for such an evacuation. Homeland Security Web site: http://www.dhs.gov/files/programs/gc_1221055966370.shtm.

Hospital Preparedness 1. Children in Disasters: Hospital

Guidelines for Pediatrics Preparedness. http://www.nyc.gov/html/doh/downloads/pdf/bhpp/hepp-peds-childrenindisasters-010709.pdf.

Volunteering, Credentialing, and Training

1. Pediatric Education in Disasters Manual: A Course of the “Helping the Children” Program. http://www.aap.org/disasters/peds.cfm#about.

2. Merchant RM, Leigh JE, Lurie N. Health care volunteers and disaster response—first, be prepared. N Engl J Med. 2010;362:872–873. http://content.nejm.org/cgi/content/full/362/10/872.

3. NDMS. http://www.hhs.gov/aspr/opeo/ndms/index.html

guide for the pediatrician. Pediatrics. 2005;116:787–795. http://aappolicy.aappublications.org/cgi/content/abstract/pediatrics;116/3/787.

11. Committee on Pediatric Emergency Medicine. Pediatricians’ liability during disasters. Pediatrics. 2000;106:1492–1493. http://aappolicy.aappublications.org/cgi/content/full/pediatrics;106/6/1492?fulltext=pediatrician’s%2Bliability%2Bduring%2Bdisaster&searchid=QID_NOT_SET.

12. Council on School Health. Disaster planning for schools. Pediatrics. 2008;122:895–901. http://aappolicy.aappublications.org/cgi/content/full/pediatrics;122/4/895.

13. Foltin GL, Schonfeld DJ, Shannon MW, eds. Pediatric Terrorism and Disaster Preparedness: A Resource for Pediatricians. Rockville, MD: Agency for Healthcare Research and Quality; October 2006. AHRQ publication 06(07)-0056. http://www.ahrq.gov/RESEARCH/PEDPREP/pedresource.pdf.

14. AAP Committee on Psychosocial Aspects of Child and Family Health. The pediatrician and childhood bereavement. Pediatrics. 2000;105:445–447. http://aappolicy.aappublications.org/cgi/content/full/pediatrics;105/2/445?fulltext=pediatricians%2Bchildhood%2Bbereavement&searchid=QID_NOT_SET.

15. AAP Committee on Environmental Health. Radiation disasters and children. Pediatrics. 2003;111(6 pt 1):1455–1466. http://aappolicy.aappublications.org/cgi/content/full/pediatrics;111/6/1455?fulltext=newborn%2Bscreening%2Bfact%2Bsheets&searchid=QID_NOT_SET.

16. AAP Committee on Pediatric Emergency Medicine and Council on Clinical Information Technology; ACEP Pediatric Emergency Medicine

Committee. Emergency information



http://aappolicy.aappublications.org/cgi/content/full/pediatrics;106/6/1492?fulltext=pediatrician%E2%80%99s%2Bliability%2Bduring%2Bdisaster&searchid=QID_NOT_SET

http://aappolicy.aappublications.org/cgi/content/full/pediatrics;122/4/895

http://www.ahrq.gov/RESEARCH/PEDPREP/pedresource.pdf

http://aappolicy.aappublications.org/cgi/content/full/pediatrics;105/2/445?fulltext=pediatricians%2Bchildhood%2Bbereavement&searchid=QID_NOT_SET

http://aappolicy.aappublications.org/cgi/content/full/pediatrics;111/6/1455?fulltext=newborn%2Bscreening%2Bfact%2Bsheets&searchid=QID_NOT_SET


http://pediatrics.aappublications.org/cgi/content/abstract/125/4/829?maxtoshow=&hits=10&RESULTFORMAT=&fulltext=emergency+information+forms&searchid=1&FIRSTINDEX=0&sortspec=relevance&resourcetype=HWCIT

http://www.dhs.gov/files/programs/gc_1221055966370.shtm

http://www.nyc.gov/html/doh/downloads/pdf/bhpp/hepp-peds-childrenindisasters-010709.pdf

http://www.aap.org/disasters/peds.cfm#about

http://content.nejm.org/cgi/content/full/362/10/872

Resources 20-25

2. Federal Government. http://www.ready.gov.

3. FEMA Publications Library—http://www.fema.gov/plan/index.shtm. FEMA for Kids—http://www.fema.gov/kids/index.htm.

4. ACEP Family Disaster Preparedness. http://www.acep.org/pressroom.aspx?id=25994.

5. American Red Cross Community Disaster Education Materials—Masters of Disaster Course for Youth. http://www.redcross.org/disaster/masters.Preparing and Getting Trained. http://www.redcross.org/prepare/. Talking About Disaster. http://www.redcross.org/portal/site/en/

4. American College of Surgeons—Disaster Management and Emergency Preparedness Course. http://www.facs.org/trauma/disaster/dmep_course.html.

5. Basic and Advanced Disaster Life Support. http://www.ndlsf.org/common/content.asp?PAGE=137.

6. MRC. http://www.medicalreserve corps.gov/HomePage.

7. Integration of ESAR-VHP and MRC. http://www.medicalreservecorps.gov/File/ESAR_VHP/ESAR-VHPMRCIntegrationFactSheet.pdf.

Family Readiness 1. AAP Family Readiness Kit: Preparing

to Handle Disasters. http://www.aap.org/family/frk/frkit.htm.


http://www.facs.org/trauma/disaster/dmep_course.html

http://www.ndlsf.org/common/content.asp?PAGE=137

http://www.medicalreservecorps.gov/HomePage

http://www.medicalreservecorps.gov/File/ESAR_VHP/ESARVHPMRCIntegrationFactSheet.pdf

http://www.aap.org/family/frk/frkit.htm

http://www.ready.gov

http://www.fema.gov/plan/index.shtm

http://www.fema.gov/kids/index.htm

http://www.acep.org/pressroom.aspx?id=25994

http://www.redcross.org/disaster/masters

http://www.redcross.org/portal/site/en


Check Your Knowledge1. After a disaster, families should plan to

be self-sufficient for at least:A. 12 hours.B. 24 hours.C. 48 hours.D. 72 hours.

2. Which of the following factors can precipitate problems for children with special health care needs after a disaster?A. Inability to avoid allergensB. Lack of electricityC. Lack of refrigeration or cooling

capabilitiesD. Stress and disruption in daily routinesE. All of the above

3. Which of the following statements about multicasualty triage is correct?A. An objective triage system helps to

optimize patient classification and resource allocation

B. Children should automatically be given the highest triage priorities

C. Responders should attempt to resuscitate all children in full cardiopulmonary arrest in a mass casualty incident setting

D. Triage personnel should treat the most critical patients first

E. All of the above4. Which of the following issues should be

included in hospital disaster planning?A. A command structure, such as

the Hospital Emergency Incident Command System

B. Critical incident stress monitoring and services

C. External disastersD. Internal disastersE. All of the above

References1. Cummings EM, Goeke-Morey MC, Schermerhorn AC, Merrilees

CE, Carins E. Children and political violence from a social ecological perspective: implications from research on children and families in Northern Ireland. Clin Child Fam Psychol Rev. 2009;12:16–38.

2. Hoven CW, Duarte CS, Wu P, et al. Parental exposure to mass violence and child mental health: the First Responder and WTC Evacuee Study. Clin Child Fam Psychol Rev. 2009;12:95–112.

3. Pfefferbaum B, Jeon-Slaughter H, Pfefferbaum RL, Houston JB, Rainwater SM, Regens JL. Media coverage and children’s reactions to disaster with implications for primary care and public health. J Okla State Med Assoc. 2008;101:312–317.

4. Sirbaugh PE, Gurwitch KD, Macias CG, et al. Caring for evacuated children housed in the Astrodome: creation and implementation of a mobile pediatric emergency response team: regionalized caring for displaced children after a disaster. Pediatrics. 2006;117:S428–S438.

5. Cruz AT, Patel B, DiStefano MC, et al. Outside the box and into thick air: implementation of an exterior mobile pediatric response team for North America H1N1 (swine) influenza virus in Houston, Texas. Ann Emerg Med. 2010;55:23–31.

6. Children in Disasters: Hospital Guidelines for Pediatric Preparedness. 3rd ed. November 2008. http://www.nyc.gov/html/doh/downloads/pdf/bhpp/hepp-peds-childrenindisasters-010709.pdf. Accessed June 10, 2011.

7. Jacob J. Disaster plan can safeguard your practice, records. American Medical Association Web site. http//www.amednews.com/2001/bica1022.htm. Accessed Sept 9, 2011.

8. Klinzing G, McClure C. Could your office cope with disaster? American Academy of Family Physicians Web site. http://www.aafp.org/fpm/990900fm/26.html. Accessed July 27, 2010.

9. Committee on Pediatric Emergency Medicine. The pediatrician’s role in disaster preparedness. Pediatrics. 1997;99:130–133.

10. American Academy of Pediatrics Committee on Pediatric Emergency Medicine and Council on Information Technology, American College of Emergency Physicians, Pediatric Emergency Medicine Committee. Policy statement: emergency information forms and emergency preparedness for children with special health care needs. Pediatrics. 2010;125:829–837.

11. American Academy of Pediatrics (AAP) Family Readiness Kit: Preparing to Handle Disasters. http://www.aap.org/family/frk/frkit.htm. Accessed June 10, 2011.

12. Homeland Security: Preparedness Planning for Home Health Care Providers. http://www.dhs.gov/files/programs/gc_1221055966370.shtm. Accessed June 10, 2011.

13. Emergency Information Form. American Academy of Pediatrics. http://www.aap.org/advocacy/eif.doc. Accessed June 10, 2011.

14. Van Amerongen RH, Fine JS, Tunik MG, et al. The Avianca plane crash: an emergency medical system’s response to pediatric survivors of the disaster. Pediatrics. 1993;92:105–110.

15. Benson M, Koenig KL, Schultz CH. Disaster triage: START then SAVE—a new method of dynamic triage for victims of a catastrophic earthquake. Prehosp Disaster Med. 1996;11:117–124.

16. Jenkins JL, McCarthy JL, Sauer LM, et al. Mass-casualty triage: time for an evidence-based approach. Prehosp Disaster Med. 2008;23:3–8.

17. Romig LE. Pediatric triage: a system to JumpSTART your triage of young patients at MCIs. JEMS. 2002;27(7):52–63.

C H A P T E R R E V I E W


Chapter Review 20-27

18. Wallis LA, Carley S. Prehospital care: comparison of paediatric major incident primary triage tools. Emerg Med J. 2006;23:475–478.

19. American College of Surgeons Committee on Trauma, American College of Emergency Physicians, NAEMSP, Pediatric Equipment Guidelines Comm-Emergency Medical Services for Children (EMSC) Partnership for Children Stakeholder Group and American Academy of Pediatrics. Policy statement: equipment for Ambulances. Pediatrics. 2009;124:e166–e171.

20. Blake N, Stevenson KJ. Reunification: keeping families together in crisis. Trauma. 2009;67(2 suppl):S147–S151.

21. Haiti relief work: how you can volunteer now. The Christian Science Monitor—Global News Blog. January 15, 2010. http://www.csmonitor.com/World/Global-News/2010/0115/Haiti-relief-work-How-you-can-volunteer-now. Accessed June 10, 2011.

22. Johnson WP, Lanza CV. After Hurricane Andrew: an EMS perspective. Prehosp Disaster Med. 1993;8(2):168–171.

23. Hospital Emergency Incident Command System Update Project. California Emergency Medical Services Authority Web site. http://www.emsa.cahwnet.gov/dms2/heics3.htm. Accessed June 24, 2002.

24. Hospital Incident Command System. http://www.heics.com/HEICS98a.pdf. Accessed June 16, 2011.

25. National Response Framework. http://www.fema.gov/NRF. Accessed June16, 2011.

26. Cruz AT, Tittle KO, Smith ER, Sirbaugh PE. Increasing Out-of-Hospital Regional Surge Capacity for H1N1 2009 Influenza A Through Existing Community Pediatrician Offices. Chicago, IL: Center for Public Health and Disaster Preparedness; in press.

27. Position Statement: School Nurse Role in Bioterrorism Emergency Preparedness and Response. National Association of School Nurses Web site. http://www.nasn.org/positions/emergencyprep.htm. Accessed July, 27, 2010.

28. Disaster Preparedness—Guidelines for School Nurses. National Association of School Nurses Web site. http://www.nasn.org/continuinged/mse.htm. Accessed July 27, 2010.

29. Madfis J, Martyris D, Triplehorn C. Emergency safe spaces in Haiti and the Solomon Islands. Disasters. 2010;34:845–846.

30. Kirsch TD, Jenkins JL, Sauer LM, Hsieh YH, Calvello E, Hsu E. Sheltering patterns and utilization following the 2007 southern California wildfires. Am J Disaster Med. 2009;4:113–119.

31. Upton LA, Frost MH, Havron DH. Operationalizing a regional unified medical command. J Homeland Security Manage. 2006:3:7. http://www.bepress.com/jhsem/vol3/iss2/7/. Accessed June 10, 2011.

32. Community Emergency Response Teams. http://www.citizencorps.gov/cert/certinaction/index.shtm. Accessed June 10, 2011.

33. Ginzburg E, O’Neill WW, Goldschmidt-Clermont PJ, et al. Rapid Medical Relief—Project Medishare and the Haitian Earthquake. N Engl J Med. 2010;362:e31(1–3).

34. Gavagan TF, Smart K, Palacio H, et al. Hurricane Katrina: medical response at the Houston Astrodome/Reliant Center Complex. South Med J. 2006;99:933–939.

35. Medical Reserve Corps. Citizen Corps Web site. http://www.citizencorps.gov/medical.html. Accessed July 27, 2010.

36. Disaster Teams (NDMS, VMATS, DMORTS) .http://www.hhs.gov/disasters/index.html. http:/www.hhs/gov/aspr/opeo/ndms/index.html. Accessed June 10, 2011.

37. National Urban Search and Rescue Response System. http://www.fema.gov/emergency/usr/index.shtm. Accessed July 27, 2010.

38. National Disaster Life Support Foundation. http://www.ndlsf.org. Accessed June 10, 2011.

39. Integration of the Medical Reserve Corps and the Emergency System for Advance Registration of Volunteer Health Professionals. Office of the Civilian Volunteer-Medical Reserve Web site. http://www.medicalreservecorps.gov/file/esar_vhp/esar-vhpmrcintegrationfactsheet.pdf. Accessed June 10, 2011.

40. Donmez O, Meral A, Yavuz M, Durmaz O. Crush syndrome in the Maramara earthquake, Turkey. Pediatr Int. 2001;43:678–682.

41. Iskit SH, Alpay H, Tugtepe H, et al. Analysis of 33 pediatric victims in the 1999 Marmara, Turkey earthquake. J Pediatr Surg. 2001;36:368–372.

42. Quintana DA, Parker JR, Jordan FB, et al. The spectrum of pediatric injuries after a bomb blast. J Pediatr Surg. 1997;32:307–310.

43. Curtis T, Miller BC, Berry EH. Changes in reports and incidence of child abuse following natural disasters. Child Abuse Negl. 2000;24:1151–1162.

44. Kim BN, Kim JW, Kim HW, et al. A 6-month follow-up study of posttraumatic stress and anxiety/depressive symptoms in Korean children after direct or indirect exposure to a single incident of trauma. J Clin Psychiatry. 2009;70:1148–1154.

45. Centers for Disease Control and Prevention (CDC). http://www.cdc.gov/. Accessed June 10, 2011.

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47. Delgado A, Chou KJ, Silver EJ, Crain EF. Nebulizers vs metered-dose inhalers with spacers for bronchodilator therapy to treat wheezing in children aged 2 to 24 months in a pediatric emergency department. Arch Pediatr Adolesc Med. 2003;157:76–80.

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51. Shaw JA, Applegate B, Tanner S, et al. Psychological effects of Hurricane Andrew on an elementary school population. J Am Acad Child Adolesc Psychiatry. 1995;34:1185–1192.

52. Shaw JA, Applegate B, Schorr C. Twenty-one month follow-up study of school-age children exposed to Hurricane Andrew. J Am Acad Child Adolesc Psychiatry. 1996;35:359–364.

53. La Greca A, Silverman WK, Vernberg EM, Prinstein MJ. Symptoms of posttraumatic stress in children after Hurricane Andrew: a prospective study. J Consult Clin Psychol. 1996;64:712–723.

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55. Yule W, Bolton D, Udwin O, et al. The long-term psychological effects of a disaster experienced in adolescence: I: the incidence and course of PTSD. J Child Psychol Psychiatry. 2000;41:503–511.

56. Yule W, Bolton D, Udwin O, et al. The long-term psychological effects of a disaster experienced in adolescence: II: general psychopathology. J Child Psychol Psychiatry. 2000;41:513–523.

57. Pfefferbaum B, Seale TW, McDonald NB, et al. Posttraumatic stress two years after the Oklahoma City bombing in youths geographically distant from the explosion. Psychiatry. 2000;63:358–370.




58. Goenjian AK, Molina L, Steinberg AM, et al. Posttraumatic stress and depressive reactions among Nicaraguan adolescents after hurricane Mitch. Am J Psychiatry. 2001;158:788–794.

59. Kitayama S, Okada Y, Takumi T, et al. Psychological and physical reactions on children after the Hanshin-Awaji earthquake disaster. Kobe J Med Sci. 2000;46:189–200.

60. Jones RT, Ribbe DP, Cunningham PB, et al. Psychological impact of fire disaster on children and their parents. Behav Modif. 2002;26:163–186.

61. Hoven CW, Duarte CS, Lucas CP, et al. Psychopathology among New York city public school children 6 months after September 11. Arch Gen Psychiatry. 2005;62:545–552.

62. Laraque D, Boscarino JA, Battista A, et al. Reactions and needs of tristate-area pediatricians after the events of September 11th: implications for children’s mental health services. Pediatrics. 2004;113:1357–1366.

63. Fairbrother G, Stuber J, Galea S, Pfefferbaum B, Fleischman AR. Unmet need for counseling services by children in New York City after the September 11th attacks on the World Trade Center: implications for pediatricians. Pediatrics. 2004;113:1367–1374.

64. Jaycox LH, Cohen JA, Mannarino AP, Walker DW, Langley AK, Gegenheimer KL, Scott M, Schonlau M. Children’s mental health care following Hurricane Katrina: a field trial of trauma-focused psychotherapies. J Trauma Stress. 2010;23:223–231.

65. Schonfeld DJ, Gurwitch RH. Addressing disaster mental health needs of children: practical guidance for pediatric emergency health care providers. Clin Pediatr Emerg Med. 2009;10:208–215.

66. Vlahov D, Galea S, Resnick H, et al. Increased use of cigarettes, alcohol, and marijuana among Manhattan, New York, residents after the September 11th terrorist attacks. Am J Epidemiol. 2002;155:988–996.

67. Dyregrove A. Family recovery from terror, grief and trauma. International Critical Incident Stress Foundation (ICISF) Web site. http://www.icisf.org/articles/Acrobat%20Documents/TerrorismIncident/Terrorovertime.htm. Accessed July 27, 2010.

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72. Hagan JF Jr, and the Committee on Psychosocial Aspects of Child and Family Health and the Task Force on Terrorism. A psychosocial implications of disaster or terrorism on children: a guide for the pediatrician. Pediatrics. 2005;116:787–795.



Chapter Review 20-29


CASE

SUM

MAR

Y 1 A disaster shelter with 130 evacuees is struck and heavily damaged by a tornado

during the storm. Per local protocol, emergency medical services (EMS) units are unable to respond because of the intensity of the weather. Adult and pediatric survivors of the tornado start arriving by the carload at the nearby emergency department (ED), stating that other patients will be following them because it is impossible to travel further to other facilities.

1. Does your hospital disaster plan consider self-referred patients instead of just those arriving by EMS? Is your ED staff prepared to perform primary disaster triage?

2. Does your hospital disaster plan consider adequate staffing and resources to allow EMS to function at high demand levels with minimal outside assistance?

The hospital activates its disaster plan and sets up a triage area in the parking lot, where all patients are sent initially. Emergency department nurses and a physician begin the process of patient triage. Those who are critically ill or injured (red) are taken into the emergency department. Those with serious problems (yellow) are triagedandtreatedintheurgentcare/fasttrackclinic,andthelessurgentpatients(green) are cared for in the parking lot, or await space inside the hospital ED or urgent care. The hospital disaster plan includes calling in additional physicians, nurses, social work, administrative and other support staff from all areas of the hospital.

CASE

SUM

MAR

Y 2 A car bomb is detonated in the basement car park of a large business that also

providesdaycareservicestotheiremployees.Thefloorsupportingthedaycarepartially collapses. There are children and employees with fractures and burns, and several are unconscious.

1. Are your local EMS agencies prepared to appropriately rescue, triage, treat, and transport this number of patients, especially the seriously injured children? Does your local EMS agency use a pediatric triage tool?

2. Which of your local hospitals would be able to handle critically ill children? Will the closest trauma center be able to handle all of these patients? Is there a plan for triaging the most critically ill children to the hospital with the appropriate resources to manage the complexity of care and the less injured to other nearby hospitals that might be able to manage there? Some local EDs have low pediatric volumes. Will they be able to assist with some of the less critical patients?



CASE

SUM

MAR

Y 2

CONT

.The emergency medical services system calls a mass casualty incident, activates its disaster plan, and calls for mutual aid ambulances. Children and adults are appropriately triaged, and contact is made with local hospitals regarding patient capabilities. The nearby pediatric trauma center receives all of the serious and moderately injured infants and children. Seriously and moderately injured adults are transported to the adult trauma center. Those with minor injuries are transported to a local hospital that is not a trauma center.

CASE

SUM

MAR

Y 3 Amajorearthquakeseverelydamageslargeportionsofamajorcity,includingseveral

majorhospitalsandmanyprivatehealthcareofficesandfacilities.Thousandsofpeople are left homeless, and many have been injured. Hospitals have already been overloadedbecauseofaveryactiveinfluenzaseason.

1. Does your hospital or office have a realistic evacuation plan?2. Is your hospital or office prepared to take on extra loads for potentially long periods when

the local medical infrastructure is damaged?3. How can your hospital and community medical practitioners benefit from, interact with,

and assist response teams from the National Disaster Medical Systems?

Oneofyourofficeshasbeenslightlydamagedbytheearthquake,buttheotherisintactandcanfunction.Yousecurethedamagedofficeandbringcomputers,drugs,andmedicalsuppliestotheotheroffice.Althoughyoucouldseepatientsinthisoffice,itisnotequippedtohandleseriouslyinjuredpatients,soyougotothehospitalwhereyou are on staff and lend assistance. It is important to realize that federal aid may not beavailableforthefirst72hoursofthedisaster,solocalresourcesarecriticalduringthat time.


Photo Credits

Opener © Skagit Valley Herald/Scott Terrell/AP PhotosUnless otherwise indicated, all photographs and illustrations are under copyright of Jones & Bartlett Learning, courtesy of Maryland Institute for Emergency Medical Services Systems, or the American Academy of Pediatrics. Some images in this book feature models. These models do not necessarily endorse, represent, or participate in the activities represented in the images.
