Hospitals unprepared for a surge of child victims

U.S. schools vulnerable to attack

Media images of the smallest victims of terrorism and natural disasters are seared in the collective memory. Terrorist attacks on Russian schoolchildren and the tsunami disaster in Asia have shown that a horrific surge of pediatric patients is a possibility for today’s health care system.

"General emergency departments — those that take care of mixed populations [of] children as well as adults — are going to be challenged by having very large numbers of children with limited numbers of pediatric supplies," said Michael Shannon, MD, chief of emergency medicine and director of the center for biopreparedness at Children’s Hospital Boston.

"Remembering that an effective response at the hospital involves not only the emergency department, but the entire hospital, many hospitals will find themselves not as prepared as they should be for many pediatric casualties," he added.

Shannon spoke at a web-assisted conference call on health care system surge capacity sponsored by the Agency for Healthcare Research and Quality (AHRQ) in Rockville, MD.

The Oct. 26, 2004, conference dealt with the health care system’s ability to rapidly expand beyond normal services to meet the increased demand for qualified personnel, medical care and public health in the event of bioterrorism or other large-scale public health emergency. An influx of pediatric patients presents myriad challenges, he noted.

"In creating surge capacity plans for children, it’s important to keep in mind and consider every potential type of disaster, terrorist or otherwise," Shannon said. "So the all-hazards approach — which has become a new way of thinking in disaster response over the last few years — is particularly important." 

Schools must be involved in plans

Surge capacity plans for pediatric plans must involve area schools, where children spend most of their waking hours. Shannon cited two distinct scenarios that must be considered in making surge capacity plans that involve schools.

"The first, of course, would be a tragedy in which the school is a specific target for a terrorist event or a disaster of some type," he said.

"The second would be when the disaster occurs in the community; but while school is in session, and in such a situation, there is going to be potentially communication disruption, chaos on the street, unruly traffic, potentially even mass evacuation. It’s important to ask the question: Who will be taking care of the children? Who will be the contact? Who is in charge? Who will supervise that evacuation?" Shannon asks.

The necessity for such planning was painfully driven home last September, when terrorists targeted a school in Beslan, Russia. When it was over, 340 people were dead — more than half of them children. The attack sets a disturbing precedent because most U.S. schools are vulnerable to both terrorism and natural disasters.

"We’ve spent the last year investigating school districts around the country, and it continues to concern, if not frighten me, how few really are prepared for disasters of any type," he said.

While recommending the federal government issue a disaster planning template for schools, Shannon acknowledged that there is no one-size-fits-all solution. A comprehensive disaster plan for a school really must bear in mind the unique population and architecture of the school.

In general, however, creating school-sensitive emergency response plans should begin by establishing lines of communication between public health, clinical care, principals, and school nurses. From his work in the area, Shannon finds that school officials generally are more prepared to get the children out then shelter them within.

"We’ve found in virtually every school district that we’ve examined that again there is an evacuation plan, but there is rarely a sheltering and/or a lockdown plan," he said. "Those are equally important when thinking about disasters. If the disaster is outdoors — if there’s a cloud plume of some type that’s going toward the school — there’s nothing more important than keeping the children safe in the school."

In terms of attack or disaster management, injured and frightened children simply are more difficult to care for than adults. "All of the first responders — EMS, fire, police — are going to have a more difficult time when they’re taking care of many injured or traumatized children," he said. "[They will be] challenged by taking care of frightened children or children who are very small, particularly while wearing cumbersome personal protective equipment. If there are events involving an infectious agent or chemical agent with contaminated patients, it will be important to effectively triage those victims, usually out of doors, out of the facility so that the campus itself doesn’t become contaminated."

As a practical matter during medical triage, expect that information will be gleaned less easily from the pediatric patient.

"If takes 10 minutes to triage and screen [an adult] victim before you give them their antibiotic or antidote, it will take twice as long for a child," Shannon said. "Because that child is unable to provide details of that history. And so there has to be someone or there has to be some means of determining whether this child really can receive this antidote or antibiotic or if there’s a contraindication of some type."

The specific challenges of triaging and treating pediatric victims would depend on the agent used, and Shannon had no shortage of stark images to reinforce that point. "If there were a chemical event with large numbers of contaminated children — children 2 and 3 years old, frightened, unable to speak, difficult to console — [they will be] quite a challenge for anyone to assess," he said. "On the other hand, [following] a radiologic event, children are much more susceptible to the consequences, particularly development of cancer."

Pediatricians have long emphasized that children are not "little adults," and thus treatment is not simply a matter of dosing down. "Children have an immature immune system, which means that they are less able to resist an infection," he said.

Moreover, providing trauma treatment to an injured child — for example, after an attack involving explosives — would be fraught with challenges, he added.

"In the field of emergency medicine, we talk about the golden hour of trauma’ — all the things that must be done effectively, efficiently, completely in one hour," Shannon said. "When you try to do those things in young children, you find that it’s quite difficult. Things as simple as starting an intravenous line in an infant, really are more difficult than you think, particularly if that’s not part of your skill set. [Therefore], taking in large numbers of children who are victims of a blast injury is going to be quite challenging, and many will miss that golden hour."

In particular, the health care system overall is not well prepared for burn patient management, he noted.

Children have much less body fluid reserves than adults so that the fluid loss that occurs with major burns is going to be even worse. "We know that burn victims are susceptible to infection; children will be even more susceptible to that infection," Shannon noted.

Of course, long term, the mental health toll will be a substantial one for the children who survive. "There will be just enormous needs in terms of the mental health response and recovery since we know that disasters of any type — natural, terrorist, or otherwise — lead to psychological trauma, which can be enduring," Shannon said. "Who will take the lead on creating those teams, identifying those children or parents or staff in the post-event period to make sure that everyone is healthy?"