Pediatric Disaster Life Support (PDLS © ) Continuing Medical Education University of Massachusetts Medical School A Course in Caring for Children During Disaster

Introduction – Course Overview PDLS is designed to give emergency/disaster personnel the knowledge and skills needed to effectively respond to disasters involving children. PDLS is designed to give emergency/disaster personnel the knowledge and skills needed to effectively respond to disasters involving children.

Lecture Objectives Fundamental Concepts Fundamental Concepts Pediatric focus Areas Pediatric focus Areas PDLS Teaching Techniques PDLS Teaching Techniques - The “Lessons Learned” approach in disaster simulations - Table top activities Psychosocial Issues Psychosocial Issues

PDLS © : Fundamental Concepts

PDLS © : Fundamental Concepts of Disaster Medicine I. Definitions/Terminology II. Basic Tenets III. Phases of Disaster Response – Activation & Implementation IV. Factors that Determine the Magnitude of a Disaster

PDLS © : Fundamental Concepts of Disaster Medicine (Continued) V. Obstacles to Emergency Responders VI. Establish Command Structure VII. Establish Communications VIII. Responder Safety

PDLS - Fundamental Concepts I. Definitions/Terminology:  For this purposes of this course disasters are defined as: - An exceptional event that disrupts community functioning, causes human suffering or fatalities, and/or creates needs that the victims can not alleviate without assistance  Mass casualty incident (MCI) are disasters involving significant injury or illness to many people

PDLS - Fundamental Concepts I. Definitions/Terminology (cont):  The patient demands that follow most disasters/MCIs generally exceeds the capacity of existing emergency medical service systems (EMS).  Disaster Mitigation – Actions taken to prevent human injury and illness when a disaster occurs in the future.

PDLS - Fundamental Concepts II. Basic Tenets Regarding Children Where Involved in Disasters Children are more susceptible to injury and illness than adults to the forces of a disaster. Children are more susceptible to injury and illness than adults to the forces of a disaster. During disaster the needs of children are different from those of adults (types of care and medical equipment). During disaster the needs of children are different from those of adults (types of care and medical equipment). Children pass through several developmental stages which correlate with a range of disaster related affects. Children pass through several developmental stages which correlate with a range of disaster related affects.

PDLS - Fundamental Concepts The Specific Needs of Children 1. Most disaster medicine concepts have grown from to military models where only adults are considered. 2. Pediatric medical and psychological needs demand specific planning. 3. Focus on vulnerabilities of children to tailor disaster response options already in place (e.g. school based disasters).

PDLS - Fundamental Concepts III. Phases of Disaster Response Activation: Activation: Notification and initial EMS response Notification and initial EMS response Organization of command and scene assessment Organization of command and scene assessment Communication at the scene initiated: hospital and community plans activated Communication at the scene initiated: hospital and community plans activated

PDLS - Fundamental Concepts IIIb. Phases of Disaster Response – (continued) Implementation Search and rescue; communicate assessment of injuries to victims Search and rescue; communicate assessment of injuries to victims Victim triage, initial stabilization and transport Victim triage, initial stabilization and transport Definitive management of scene hazards and victims Definitive management of scene hazards and victims Hospital - triage and victim management Hospital - triage and victim management

PDLS - Fundamental Concepts IIIc. Phases of Disaster Response – (continued) Recovery Scene withdrawal Scene withdrawal Return of pre-hospital services to normal operations Return of pre-hospital services to normal operations Debriefing of response personnel Debriefing of response personnel Address long term needs of injured, chronically ill and the displaced population Address long term needs of injured, chronically ill and the displaced population Revise disaster response plan Revise disaster response plan Take steps to decrease the impact of future disasters (mitigation) Take steps to decrease the impact of future disasters (mitigation)

PDLS - Fundamental Concepts IV. Factors That Determine the Magnitude of a Disaster Type of disaster, initial force, time course, time of day, secondary events Type of disaster, initial force, time course, time of day, secondary events Number of victim declared injured, and percent of total population displaced by the event Number of victim declared injured, and percent of total population displaced by the event Location and accessibility of site with most victims Location and accessibility of site with most victims Resources available in the area Resources available in the area Social, economic and political conditions at the time of the event Social, economic and political conditions at the time of the event

PDLS - Fundamental Concepts V. Early Obstacles to Emergency Care Providers Panicked Parents/Family Members/Friends Panicked Parents/Family Members/Friends Media Representatives Media Representatives Spectators and Min Spectators and Min Gangs/Rioters (terrorism) Gangs/Rioters (terrorism)

PDLS - Fundamental Concepts VI. Establish Command Structure – Incident Command System (ICS)

PDLS - Fundamental Concepts VII. Establish Command Communication Networks Insert man with hand held mic Insert man with hand held mic

PDLS - Fundamental Concepts VII. Address Responder Safety Issues Serin attack – Tokyo subway

VII. Responder Safety Issues - Continued World Trade Center Site Toxic Exposures (9/11 and after) Asbestos Asbestos Cement dust – crystalline silica Cement dust – crystalline silica CO CO Mercury Mercury Chlorodifluoromethane Chlorodifluoromethane Heavy metals Heavy metals Hydrogen sulfide Hydrogen sulfide MMWR, May 31, 2002;vol.51/no.21 PDLS - Fundamental Concepts

PDLS © : Pediatric Focus Areas

PDLS – Key Pediatric Focus Areas  I. Pediatric Disaster Triage Should Be Approached Differently Than Adults  Children are not Small Adults - What exactly is triage, how and where is it used? Why develop triage tools in the first place?Why develop triage tools in the first place? Mass casualty incidentMass casualty incident Mass casualty receivingMass casualty receiving Re-evaluation after initial triageRe-evaluation after initial triage

PDLS Pediatric Focus Areas II. Managing Children with Special Health Care Needs : (the vulnerable population during and post event) What functions may be affected? What functions may be affected? - Mobility - Communication (Visual/Verbal/Hearing) - May be technology-dependent (examples) - Resources required - Emphasize the integration, rather than separation of CSHCN - How will this affect the following two topics ShelteringSheltering DecontaminationDecontamination

PDLS Pediatric Focus Areas III. Sheltering – Post Event - What aspects of shelter management may not work well for children as they exist now? - Identify and plan for specific needs in advance: SecuritySecurity Safety (childproofing, etc.)Safety (childproofing, etc.) HygieneHygiene NutritionNutrition Health ScreeningHealth Screening Sleep scheduleSleep schedule CSHCNCSHCN RecreationRecreation - Should CSHCN be sheltered separately or integrated?

PDLS Pediatric Focus Areas IV. Decontamination (indications, methods) - What aspects of on scene and hospital decon need to be addressed for children? Patient flow (need to keep with parents) and timingPatient flow (need to keep with parents) and timing Prevention of heat and cold injuriesPrevention of heat and cold injuries Chemical decontamination dangerous to kids (e.g. bleach)Chemical decontamination dangerous to kids (e.g. bleach) Clothing for children after deconClothing for children after decon CSHCN durable medical equipment/hardwareCSHCN durable medical equipment/hardware Responding to surge capacityResponding to surge capacity Ensuring responder safetyEnsuring responder safety Tracking non-verbal naked childrenTracking non-verbal naked children - What do you do with exposed children before decon occurs?

PDLS Pediatric Focus Areas V. Exposure to Toxins Chemical/biological/Radiation Exposure Chemical/biological/Radiation Exposure - Personal Protection - Diagnosing exposures in children - Role of Primary Care - Immunization - Prophylaxis challenges - Treatment challenges

PDLS Pediatric Focus Areas VI. PDLS Pediatric Focus Areas – Psychological Impact of Disasters

VII. Children and Terrorism Children as an intentional target of terrorism increases the need for PDLS Children as an intentional target of terrorism increases the need for PDLS - Oklahoma City bombing daycare center - Tel Aviv Dolphinarium disco bombing - School Mass Murders: Columbine, Red Lake, Ma’alotColumbine, Red Lake, Ma’alot - Dubrovka Theater Seige - Beslan School hostage crisis PDLS Pediatric Focus Areas

PDLS © Teaching Techniques: 1. The “Lessons-Learned” Approach Classroom to Training 2. Designing Realistic Drills with Simulated Victims

Man-Made Disasters ( Examples ) Building fires Building fires Explosions Explosions Chemical / radioactive contamination Chemical / radioactive contamination Transportation accidents Transportation accidents Civil disturbances Civil disturbances Military actions Military actions

Lessons Learned: Case Study # 1: School Bus Accidents

Lessons Learned: Case Study # 1: School Bus Accidents

Lessons Learned: Case Study # 1: School Bus Accidents Minneapolis bridge collapse 8/2007

Lessons Learned: Case Study # 1: School Bus Accidents

Lessons Learned: Case Study # 1: School Bus Accidents Lessons Learned: Case Study # 1: School Bus Accidents A state trooper leaves the bus after examining the interior. C. Christo, T&G Photo, Sept. 5, 2006 Lessons Learned: Case Study # 1: School Bus Accidents

Passengers wait at the scene to be evaluated by medical personnel. C. Christo, T&G Photo, Sept. 5, 2006 Lessons Learned: Case Study # 1: School Bus Accidents

Many passengers were treated for neck or back injuries. J. Collins, T&G Photo, Sept. 5, 2006 Lessons Learned: Case Study # 1: School Bus Accidents

Rescue workers treat injured passengers of the Fung Wah bus. C. Christo, T&G Photo, Sept. 5, 2006 Lessons Learned: Case Study # 1: School Bus Accidents

An Injured passenger is treated for neck and head injuries. J. Collins, T&G Photo, Sept. 5, 2006 Lessons Learned: Case Study # 1: School Bus Accidents

Lessons Learned: School Bus Accident Hospital Chemical Tanker Schoolbus Decon Triage on scene Triage at hospital 1 driver 1 escort 14 children 1 child in wheelchair 1 deaf child * Sample Response Diagram

Lessons Learned: School Bus Accident Summary: Serious injuries and deaths uncommon Serious injuries and deaths uncommon Triage children to hospital with pediatric trauma capability Triage children to hospital with pediatric trauma capability Keep children with caregivers Keep children with caregivers

Lessons Learned: Case Study # 2: School Shootings

When does an MCI become a DISASTER? Consider dealing with -multiple victims -perpetrators -heroes -fatally injured as patients.

Beslan, Russia – 9/1/04

Virginia Tech Shooting 4/2007

Case Study # 2 – School Shooting Hospital School Shooting Triage on scene Triage at hospital 1 teacher 1 principal 20 children 1 child in wheelchair 1 visually impaired child * Sample Response Diagram

Lessons Learned: School Shootings Summary: Responder safety Responder safety Many uninjured victims Many uninjured victims Major psychological impact Major psychological impact

Lessons Learned: Case Study # 3: Airplane Crash

Case Study # 3 – Airplane Crash

Hospital Triage on scene Triage at hospital 2 pilots 20 children 80 adults 1 child in wheelchair 1 visually impaired child * Sample Response Diagram

Lessons Learned: Plane Crash

Lessons Learned: Airplane Crash Summary: Children may be unable to evacuate from plane. Children may be unable to reach O 2 masks or be improperly restrained

Avianca slide Avianca slide

Lessons Learned: Case Study # 4: Infectious Disease Outbreak

Case Study # 4 – Infectious disease outbreak Mass Contamination with E coli Mass Contamination with E coli Food contamination Food contamination Children – 5 – 12 on a field trip to a “petting zoo” Children – 5 – 12 on a field trip to a “petting zoo”

Lessons Learned: Infectious Disease Outbreak Summary: (TBA)

Natural Disasters ( Examples ) Forest fires Forest fires Hurricanes Hurricanes Floods Floods Tornadoes Tornadoes Winter storms Winter storms Earthquakes Earthquakes

PDLS © : Earthquake

Earthquake Forces Experienced at the Surface of the Earth horizontal horizontal vertical vertical circular circular fissuring fissuring

Impact of Earthquakes on Buildings Structural Damage Stresses of varying amplitude cause distortion on load carrying parts of buildings. Some parts of structures are unable to tolerate significant distortion Stresses of varying amplitude cause distortion on load carrying parts of buildings. Some parts of structures are unable to tolerate significant distortion Non-Structural Damage Furniture, fixtures, glass and unsecured equipment are thrown from their position by the impact Furniture, fixtures, glass and unsecured equipment are thrown from their position by the impact

Earthquake Summary: (TBA)

PDLS © : Hurricane

Hurricanes

Hurricane Summary: (TBA)

PDLS © : Tornado

Tornadoes

Tornado Summary: (TBA)

PDLS © : Floods

Floods

Floods Summary:

PDLS © : Volcano

Volcanoes, Mudslides, Lahars

Case Study Volcano – Columbia 11/13/85 Nevado del Ruiz – Mountain with a permanent ice cap. Nevado del Ruiz – Mountain with a permanent ice cap. - Volcanic eruption at 5,400 meter elevation - Ice and snow melted by gases and solid erosions from the volcanic cone (lahar) -The resulting mudflows travelled down the mountain at speeds of up-to 45km/hr mostly following existing river beds -Local people were unaware of the risk and had no warning system in place -Communities engulfed within hours 20,000 people were crushed and buried in their homes

The billowing smoke from Mount Pinatubo has long since blown away but the volcano’s effects on climate and ozone have endured.

Add bhopal Inda as case study: chemical contamination Add bhopal Inda as case study: chemical contamination

Volcano Summary:

PDLS © : Bombings

Oklahoma City Bombing - Alfred P. Murrah Federal Building

Disaster Exercises and Simulation 1. Triage exercises 2. Table top drills 3. Live disaster simulations (add pictures from prior exercises – Guatemala, DMAT Team, Etc. ) (add pictures from prior exercises – Guatemala, DMAT Team, Etc. )

Introduction to PDLS Lecture SUMMARY

Philosophy of Disaster Medicine When Children are Victims Children are more susceptible to certain injuries or environmental insults than adults Children are more susceptible to certain injuries or environmental insults than adults Children with acute injuries or illness are more likely to respond to rapid and efficient medical care than adults Children with acute injuries or illness are more likely to respond to rapid and efficient medical care than adults Since children are not small adults they require equipment and pharmaceuticals designed for their needs Since children are not small adults they require equipment and pharmaceuticals designed for their needs

Routine Medical Practices Unaltered in a Mass Casualty Situation Attend immediately to airway, breathing and circulatory emergencies in a potentially viable patient Attend immediately to airway, breathing and circulatory emergencies in a potentially viable patient Provide appropriate management of pain Provide appropriate management of pain Perform systematic patient assessments Perform systematic patient assessments Re-evaluate patients for changes in status Re-evaluate patients for changes in status Maintain patient dignity Maintain patient dignity

Routine Medical Practices Altered in a Mass Casualty Situation Extent of resuscitation efforts Extent of resuscitation efforts Acceptable results Acceptable results Timeliness of surgery Timeliness of surgery Indications for hospitalization Indications for hospitalization Use of ancillary services Use of ancillary services Increase patient care responsibility of nurses Increase patient care responsibility of nurses Decision to transfer Decision to transfer

Problems Common to Major Disasters Inadequate rescue personnel and supplies for the initial few days Inadequate rescue personnel and supplies for the initial few days Inadequate medical equipment, medical personnel and hospital space - particularly for children Inadequate medical equipment, medical personnel and hospital space - particularly for children Inadequate food, clothing and shelter for victims and the displaced population - particularly for children Inadequate food, clothing and shelter for victims and the displaced population - particularly for children Inadequate communications, assessment of victims’ needs and initial on-site coordination Inadequate communications, assessment of victims’ needs and initial on-site coordination

Disaster Medical Relief Recommendations to Rescuers Bring the right stuff - include supplies for newborn infants/children Bring the right stuff - include supplies for newborn infants/children Bring the right staff - Pedi experience Bring the right staff - Pedi experience Plan to be fairly self-sufficient Plan to be fairly self-sufficient Control your own supplies and avoid careless distribution Control your own supplies and avoid careless distribution Maintain accurate records, logs and photo documentation to verify your efforts and to teach from your experience Maintain accurate records, logs and photo documentation to verify your efforts and to teach from your experience

Accept That The Risk Exists No community is exempt from the risk of a disaster No community is exempt from the risk of a disaster As healthcare providers we have a responsibility to prepare for the care of children and adults- the whole community As healthcare providers we have a responsibility to prepare for the care of children and adults- the whole community

The Pediatric Patient Newborn 0-3 mos Newborn 0-3 mos Infant 3-18 mos Infant 3-18 mos Toddler 1-3 1/2 yrs Toddler 1-3 1/2 yrs Pre-school 3-5 yrs Pre-school 3-5 yrs School Age 6-10 yrs School Age 6-10 yrs Adolescent / Teen yrs Adolescent / Teen yrs Are not all alike