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Policy Statement |
| Pediatrics | Volume 99, Number 1 | January 1997, p 130-133 |
ABSTRACT. This statement provides pediatricians with an overall view of disasters and disaster management and delineates the role of the pediatrician in disaster preparedness.
ABBREVIATIONS. FEMA, Federal Emergency Management Agency; AAP, American Academy of Pediatrics; EMS, Emergency Medical Services.
Dealing with disasters is not a day-to-day occurrence. Since 1987 events such as the bombing in Oklahoma City; hurricanes Hugo, Iniki, and Andrew; and the Loma Prieta and Northridge earthquakes have provided a perspective on the needs of children and the challenges facing pediatricians in event of disasters[1-4]
A disaster is an event that destroys property, includes injury and/or loss of life, and affects a large population or area. Disasters are usually described as natural, including earthquakes, hurricanes, tornados, and floods; and man-made, including fire, mass transportation incidents, environmental toxins, and civil unrest. More narrowly defined and distinct are mass casualty incidentsMevents that cause large numbers of injuries but do not threaten or harm large segments of the community.[5-7]
The effects of each disaster are different. Considerations are given to the size of the area involved, the extent of damage, and the effect on community resources. The extent of damage includes the physical injury to persons and damage to property, especially destruction of infrastructure (roadways, bridges, and communication lines). The effects on community resources include the absence of electricity, gas, sanitation, and potable water; the necessity for portable shelters; and the potential for recurrence (eg, earthquakes with aftershocks).[1,8]
The planning for and response to disasters traditionally have been the responsibilities of federal, state, and local governments. The Federal Emergency Management Agency (FEMA) is involved in declared national emergencies, providing Disaster Medical Assistant Teams (DMATs). [2,9,10] Other federal agencies include the Department of Transportation, Department of Defense, Department of Housing and Urban Development, and the Federal Aviation Administration. On a regional level, state and local Emergency Management Authorities (often within the state or local department of health services) have area-wide response plans. These authorities organize emergency operation centers (EOCs), whose duties include (1) hospital damage assessment; (2) allocation, designation, and distribution of casualty collection points; (3) identification, prevention, and elimination of public health hazards; (4) coordination of activities with support departments, agencies, and public utilities; and (5) coordination of requests for mutual aid.
Hospitals are required by the Joint Commission on Accreditation of Health Organizations to have disaster plans and to practice them twice a year. These plans include the hospital's response to mass casualty incidents and internal disasters such as fire or loss of utilities. The responsibilities of physicians and other professionals are usually included in the hospital disaster plan.
Volunteer organizations such as the Red Cross and Salvation Army have key roles in disaster response. In addition, recent concepts have involved planning for disasters at the neighborhood, family, and personal level.[6,8]
Children who have experienced a disaster may suffer a sense of loss (eg, home, family, friends, pets, and possessions), sustain physical injury, and develop stress-induced problems. An understanding of children and family dynamics is needed to deal appropriately with disaster situations. Information on the psychosocial issues can be found in the booklet entitled Psychosocial Issues for Children and Families in Disasters: A Guide for the Primary Care Physician, by the American Academy of Pediatrics Work Group on Disasters.[11] Pediatricians can provide the expertise to address the needs and special problems of children in all three phases of a disaster:
Pediatricians, individually or collectively, as part of their community (eg, American Academy of Pediatrics [AAP] Chapter, local pediatric society, or hospital pediatric staff) should participate in the development of a community disaster plan. AAP members should provide input into the state and local offices of Emergency Medical Services (EMS) to assure that the needs of children are incorporated into every plan, including contingency plans for meeting the needs of critically ill and injured children. Pediatricians should take part in local community response team planning and help identify the numerous problems a disaster poses based on experiences gained from responses and drills from previous potentially similar disasters.[13]
Lessons learned from recent disasters emphasize that the fire department, police department, and other agencies that respond to emergencies may be overburdened. Neighborhood groups may have to take initial emergency response actions and fend for themselves for at least the first 72 hours after the disaster strikes.[2,3,9,14] Training programs for community response teams in basic emergency response techniques have been developed in several areas of California to prepare for loss of community services (see Resource Directory).[15] Although physicians in the community have often volunteered after disasters, the response is often not organized or coordinated through official disaster agencies. As part of the disaster planning, arrangements need to be made to guarantee medical liability coverage for pediatricians caring for disaster victims. Pediatricians should have an ongoing role in the EMS system by training first responders in pediatric assessment, assisting in the development of prehospital pediatric protocols, helping establish protocols for dealing with minors (especially issues regarding consent and identification when parents or guardians are not available), and assuring the availability of pediatric medical equipment.
The pediatric staff should assist in developing a realistic hospital disaster plan. The pediatric staff in local children's hospitals are usually involved in the development of the disaster plan. In general hospitals this may not be the case. It is important that local pediatricians meet with the hospital staff responsible for implementing the hospital disaster plan to review it, learn their roles, and ensure that preparations have been made for the proper care of children.[12]
Pediatricians in the community can assist in both triage and treatment of patients. Important questions to ask include: (1) Where should the pediatrician go during the disaster? (2) How should pediatricians be notified that they are needed to respond to the disaster (disaster trees, check-in)? (3) How should hospital physicians be identified and notified to go to the scene to attend to victims of the disaster? (4) How should transfers of pediatric patients in the hospital and discharges be handled? In addition, alternatives need to be considered in the event of a loss of power and conventional telephone use. Backup systems such as cellular phones, direct telephone lines that are not part of the regular telephone system, two-way radios, beepers, and ham radios should be considered. In areas where pediatricians cover several hospitals, initiate pools through the county medical or pediatric society to provide uniform pediatric coverage of area hospitals.
Pediatricians can aid schools and child care centers in developing disaster plans. In California, state law requires each state-licensed child care facility and all schools to develop and maintain a disaster and mass casualty plan.
After a distaster, offices or clinics may become sites for care if area hospitals are unable to provide services. Recent experiences have demonstrated that health care may be administered in parking lots, malls, and tents using limited power and water sources. Local offices were unusable and alternative sites for primary care had to be identified. Pediatricians should prepare, regularly update, and practice an office disaster plan addressing response and recovery issues. Office training programs in emergency procedures, including first aid, cardiopulmonary resuscitation, evacuation, search and rescue, the use of fire extinguishers, and participation in community disaster drills, should routinely occur as part of the office's overall emergency preparedness.[13] It may be advisable for pediatricians to consult local building codes to ensure that their office buildings meet current structural safety standards. Agreements with vendors need to be obtained for post-disaster operations. It is important to assemble emergency kits with water, first aid supplies, radios, flashlights, batteries, heavy-duty gloves, food, and sanitation supplies.[3,16]
In many areas of the country the threat of natural disasters is ongoing, and anticipatory guidance on home disaster preparedness can be provided in the pediatric office or as a community focus. Family preparedness includes training in cardiopulmonary resuscitation, rendezvous points, lists of emergency telephone numbers, and an out-of-state friend or relative to whom all family members can contact after the event to report their whereabouts and conditions. Home preparedness such as storm shutters or earthquake proofing should be covered. Parents should maintain emergency supplies of food, water, medicine, a first aid kit, and clothing (see Table 1 and Table 2 and Resource Directory). Family members should know the safest place in the home, make special provisions, know community resources, and have a plan to reunite. Medications for chronic illness and resources for technically dependent children should be included in the action plan.
The pediatrician's role during a disaster will be predicated by the disaster plan; hence familiarity with the plan is paramount. Once the disaster is recognized, institute office and home disaster plans and participate in the community or hospital predesigned plan, as a scene, hospital, or clinic resource. Pediatricians may be involved in disaster triage, direct patient care (including adults), patient discharge/transfer, facilitation and reception of patients at other sites including offices, and hospital evacuation. On the basis of studies from several recent disasters, affected hospitals experienced a 15% to 40% increase in emergency department visits. Minor trauma, especially involving wounds, was the most common diagnosis, with an increased need in physician staffing. Depending on the disaster, there may be no or only a slight increase in hospitalization.[3,14]
The length of the recovery period depends on the nature of the disaster. Pediatricians should be prepared to deal with continued disruptions of services that will affect their ability to care for patients and have plans to provide on-site emergency and primary health care at emergency shelters. Issues to be addressed include inpatient and outpatient treatment, infectious disease control, alternatives for lost services/utilities, logistics and resupply, physical rehabilitation, mental rehabilitation, and critical incident stress debriefing. Protocols for critical incident stress debriefing have been developed to help victims and health care providers cope with the emotional toll of disasters. During the aftermath, changes in practice location, a lack of refrigeration for medications and vaccines, continued disruption of communications, power outages, and lack of sanitation will force changes in practice standards and require inventiveness and flexibility. Assisting families coping with the emotional toll of the disaster may be an ongoing responsibility of the pediatrician.[3,11,12]
1. Before a disaster, pediatricians need to:
2. During a disaster, pediatricians need to:
3. During the recovery period, pediatricians need to:
COMMITTEE ON PEDIATRIC EMERGENCY MEDICINE, 1995 TO 1996
Joseph A.
Weinberg, MD, Chairperson
Barbara Barlow, MD
George L. Foltin, MD
Jerome
A. Hirschfeld, MD
Dee Hodge III, MD
Jane Knapp, MD
William J.
Lewander, MD
Karin A. McCloskey, MD
Robert A. Wiebe, MD
LIAISON REPRESENTATIVES
Jean Athey, PhD
Maternal And Child Health
Bureau
Richard M. Cantor, MD
American College Of Emergency Physicians
Deborah Mulligan-Smith
National Association Of Ems Physicians
Max
L. Ramenofsky, MD
American College Of Surgeons
James S. Seidel, MD
National Emsc Resource Alliance
AAP SECTION LIAISONS
Patricia J. Davidson, MD
Section On
Anesthesiology
Steve Krug, MD
Section On Emergency Medicine
David
S. Markenson, MD
Section On Residents
Michele Moss, MD
Section On
Critical Care
Dennis W. Vane, MD
Section On Surgery
American Red Cross (please check your telephone directory or your local chapter. Publications available on request include Adventures of the Disaster Dudes: A Children's Disaster Preparedness Program, Helping Children Cope With Disaster, Disaster Preparedness and After the Flood coloring books).
Federal Emergency Management Agency, PO Box 70274, Washington, DC 20024 (catalog of publications available on request, Your Family Disaster Supplies Kit [FEMA L-189], Your Family Disaster Plan [FEMA L-191], Helping Children Cope With Disasters [FEMA L-196], Are You Ready? A Guide to Disaster Preparedness [FEMA H-34]).
American Civil Defense Association, PO Box 910, Starke, FL 32091
Center for Mental Health-Studies of Emergencies, National Institute of Mental Health, US Public Health Service, 5600 Fishers Lane, Room 6C-12, Rockville, MD 20857
Disaster Preparedness Office, National Weather Service, 8060 13th Street, Silver Spring, MD 20910
Disaster Research Center, Publication List, University of Delaware, Newark, DE 19716
Governor's Office of Emergency Services, Office of Information and Public Affairs, 2800 Meadowview Rd, Sacramento, CA 95832, (916) 262-1843
Community Preparedness Unit, Disaster Preparedness Division, Los Angeles City Fire Department, 543 E Edgeware Rd, Los Angeles, CA 90026
Citizens of Oakland Respond to Emergencies (CORE), 475 14th St, 9th Floor, Oakland, CA 94612
Neighborhood Emergency Response Team Training, San Francisco Fire Department, 260 Golden Gate Ave, San Francisco, CA 94102
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The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
PEDIATRICS (ISSN 0031 4005). Copyright © 1997 by the American Academy of Pediatrics.
No part of this statement may be reproduced in any form or by any means without prior written permission from the American Academy of Pediatrics except for one copy for personal use.