Pediatric Disaster Preparedness

Pediatric Disaster Preparedness
Cont ent s

EDI TORS & CONTRI BUTORS
FOREWORD

01 Introduction The Editors
02 How Children Are Different George Foltin MD, Jane Knapp, MD
03 Pediatric Triage On-Scene in Disasters Lou Romig MD
04 EMS System Disaster Plan Arthur Cooper MD
05 Pediatric Regional Triage & Transport Robert Kanter, MD
06 Urgent Care Paul Sirbaugh, DO
07 Shelter Care Richard Bradley, MD
08 Disaster Drills Bonnie Arquilla DO, Marsha Treiber MPS
09 Topical Decontamination of Children Michael Shannon MD, Sarita Chung MD
10 Psychological First Aid David Schonfeld MD
11 Patient Identification and Tracking Connie Maxin EMT-P
12 Natural, Technological & Intentional Disasters Baruch Fertel MPA EMT-CIC
13 Physical Disasters Daniel Fagbuyi MD, Fred Henretig MD
14 Biological Disasters Stephan Kohlhoff, Daniel Fagbuyi MD, Fred Henretig MD
15 Children with Special Health Care Needs Michael Tunik, MD
APPENDIX: Pediatric Equipment List


Edit ors and Cont ribut ors
Editors

George L. Foltin, MD, FAAP, FACEP
Associate Professor of Pediatrics &
Emergency Medicine
Bellevue Hospital Center/
New York University School of Medicine

Michael G. Tunik, MD, FAAP
Associate Professor of Pediatrics &
Emergency Medicine
Bellevue Hospital Center/

Marsha Treiber, MPS
Executive Director
Center for Pediatric Emergency Medicine

Arthur Cooper, MD, MS, FAAP, FACS
Professor of Surgery
Columbia University Medical Center
Affiliation at Harlem Hospital

Contributors

Bonnie Arquilla, DO
Assistant Professor of Emergency Medicine
Director Emergency Preparedness
SUNY Downstate/Kings County Hospital Center

Richard N. Bradley, MD, FACEP
Chief of the Division of EMS and Disaster Medicine
Department of Emergency Medicine
University of Texas Health Science Center at Houston

Sarita A. Chung MD
Project Scientist, Center for Biopreparedness
Children's Hospital Boston
Instructor in Pediatrics
Harvard Medical School


Daniel Fagbuyi, MD
Member of the Army Medical Corp
with recent experience serving in Iraq
Pediatric Emergency Medicine
Childrens Hospital of Pittsburgh

Baruch S. Fertel, MPA, EMT-CIC
Center for Pediatric Emergency Medicine

Fred Henretig, MD, FAAP, FACMT
Senior Toxicologist and Associate Medical Director
Poison Control Center, Philadelphia, PA
Director, Section of Clinical Toxicology
Professor of Pediatrics and Emergency Medicine-
Children's Hospital of Philadelphia
University of Pennsylvania School of Medicine

Robert F. Kanter, MD
Professor of Pediatrics
Director Critical Care & Inpatient Pediatrics
SUNY Upstate Medical University

Jane Knapp, MD, FAAP, FACEP
University of Missouri-Kansas City School of Medicine
Vice Chair Pediatrics
Medical Director of Graduate Medical Education
Childrens Mercy Hospital

Stephan A. Kohlhoff, MD
Assistant Professor, Pediatrics
Division of Pediatric Infectious Diseases
SUNY Downstate/Kings County Hospital Center

Connie Maxim, EMT-P
Education and Project Coordinator
EMSC Michigan Family Representative
Region 6 BioDefense Network Coalition of Michigan
Michigan Department of Community Health (MDCH)

Lou Romig, MD, FAAP, FACEP
Florida Pediatric EMS Medical Director
Pediatric Emergency Medicine
Miami Childrens Hospital

Paul Sirbaugh, DO, FAAP, FACEP
Assistant Professor of Pediatrics
Emergency Medicine Section
Baylor College of Medicine
Director of EMS
Texas Childrens Hospital

David Schonfeld, MD, FAAP,
Director, Division of Developmental and Behavioral Pediatrics;
Director, National Center for School Crisis and Bereavement
Thelma and Jack Rubinstein Professor of Pediatrics
Cincinnati Childrens Hospital

Michael W. Shannon, MD, MPH, FAAP
Harvard Medical School
Chair, Division of Emergency Medicine
Director, Center for Biopreparedness
Childrens Hospital of Boston
Foreword Pediatric Disaster Preparedness

1

Foreword
Areviewofthecurrentstateofreadinessfordisastersandterrorismwithregardtothe
needsofchildrenrevealssignificantgapsbothinemergencypreparedness(preparationand
protection)andindisastermanagement(responseandrecovery).Historically,theunique
characteristicsofchildrenandtheirliveshavenotbeenwellorfullyconsideredinthe
multidisciplinaryplanningprocessforresponsetoterrorism,mostespeciallyinthe
prehospitalenvironment.Whyisthisso?Inthepast,muchoftheterrorismresponse
planningintheUnitedStateshascenteredonmilitarypreparedness.Therefore,planshave
focusedontheneedsofadults.Unfortunately,theentirepopulationisnowatrisk.Asthe
planningfordisastersandterrorismisundertaken,itistimetoreassesseducationand
preparationforallcatastrophiceventstoensurethatchildrenandtheirfamiliesareincluded.
Unfortunately,thecareofchildrenduringsucheventscannotbeapproachedsimplyby
modifyingcurrentpractices.Basicdaytodayissuesinvolvingfamiliesthathavenotbeen
previouslyconsidered(incorporatingschoolsandchildcarecentersintodisasterpreparation
andprotection)mustnowbeaddressed.Thelikelihoodofadisasteroccurringwhilechildren
areinschooloratchildcarecentersishigh.Disasterscouldalsooccurataschool,onaschool
busoratachildcarecenter.
EmergencyMedicalServices(EMS)agenciesandtheirdedicatedproviderscomprisethe
initialmedicalresponsetoeverydayemergencies,disasterswhethernaturalormanmade
andotherpublichealthemergenciessuchaspandemicinfluenzathatmayarise.
Regional,stateandnationalplanningrequiresEMSleadersandemergencymanagerstoplan
togetherandcoordinateservices.Itiswelldocumentedthatpreparingfortheneedsof
childrenischallenging,thereforeuneven.ResourcessuchastheAHRQAAPpublished
PediatricTerrorismandDisasterPreparednessResource
http://www.ahrq.gov/research/pedprep/pedtersum.htmandtheNewYorkCityDepartment
ofHealthandMentalHygienePediatricDisasterToolkit:HospitalGuidelinesforPediatrics
duringDisasters(2ndEdition,2006)http://www.nyc.gov/html/doh/html/bhpp/bhppfocus
pedtoolkit.htm(3rdEditionpending)areavailableforreference.
Thislatestdocument,PediatricDisasterPreparedness:AResourceforPlanning,Management
andProvisionofOutofHospitalEmergencyCarepreparedbyCenterforPediatric
EmergencyMedicinefortheEmergencyMedicalServicesforChildren(EMSC)National
ResourceCenter,underfundingprovidedbytheFederalEMSCProgramoftheMaternaland
ChildHealthBureau(MCHB),HealthResourcesandServicesAdministration(HRSA),United
StatesDepartmentofHealthandHumanServices(HHS)hasbeendesignedtofocusonthe
practicalandessentialelementsofpediatricprehospitalemergencycareinEMSsystem
planningfordisastersandterrorism.ItisdesignedforusebyEMSagencyandsystemmedical
directorsandadministrators,emergencymanagers,andanyotherkeystakeholderswhowill
beconcernedwiththefunctionsandactivitiesofEMScareprovidersduringadisaster,terror
event,orotherpublichealthemergency.Contenthasbeencompiledbyexpertsfromaround
thecountrytoreflectthecurrentevidencebase,bestpracticesandpracticalapplication,and
coversclinical,administrative,andpolicyissues.Thehopeistofacilitateplanningandsave
valuabletime.Thepurposeofeachsectionistosupplementtheplanning,approaches,and
knowledgethatalreadyexisttofacilitateintegratingspecificpediatrictopicsthatwill
enhancepreparationsinapracticalandadditivemanner.

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Incorporatingtheneedsofchildrenandfamiliesintoterrorismanddisasterplanning
requiresmultidisciplinarypediatricexpertiseatallphases.PediatricDisasterPreparedness
includestheinformationavailableusingthebestevidenceknowntoincludechildrenand
familiesinalltypesandatalllevelsofterrorismanddisasterplanning.Afewofthemany
considerationsincludethefollowing:
Writingandimplementingchildspecificprotocols
Planningforchildrenwhoareseparatedfromtheirparentsandatschoolsandchildcare
centerswhendisasterstrikes
Trainingproviderstocareforthepediatricpatient
Developingequipmentandmedicationdosageformsanddeliverysystemsappropriate
forchildren
Providingeducationontherecognitionandcareofmentalhealthneedsofchildreninthe
aftermath
Planningforchildrenwithspecialhealthcareneeds
Thefollowingtopicsarecovered,butweplantoexpandthecoverageinfutureeditionsbased
onfeedbackandidentifiedneeds.
HowChildrenareDifferent
Triage
EMSSystemDisasterPlan
TransportPlan
ShelterCare
DisasterDrills
Decontamination
Psychosocial
PatientIdentificationandTracking
TypesofDisasters
PhysicalDisasters
BiologicalDisasters
ChildrenwithSpecialHealthCareNeeds
Equipment
Planningandpreparationforterrorismanddisasterscanbebothdauntingandchallenging.
Forall,butespeciallyforchildrenandfamilies,therearemanyrecognizedgapsinknowledge,
resources,andprofessionaleducation.Thisresourcehasbeenprovidedtoincreasepediatric
expertiseofthosewhoarewillingandreadytotakeonthechallengeofpreparationand
planning.Thisresourcecanalsobeusedbyotherpediatrichealthcareproviders,public
healthprofessionals,healthadministrators,andpolicymakerswhoarecommittedto
ensuringthatplanningforterrorismanddisastersincludesthespecialneedsofchildren.

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GeorgeFoltinMD
MichaelTunikMD
MarshaTreiberMPS
ArthurCooperMD

1: Introduction Pediatric Disaster Preparedness

1
Chapter 1: Introduction
Arthur Cooper MD
Introduction
Pound for pound, children breathe, drink, and eat more than adults.
1
Disastermedicineisdefinedasthefieldofmedicalspecializationthatprovidesmedicalcare
todisastersurvivors,andisconcernedwithmedicallyrelateddisasterpreparation,
mitigation,responseandrecoveryleadershipthroughoutthedisasterlifecycle.
2
Whilethe
overridingpurposeofallemergencypreparednessanddisastermanagementisthe
preservationofhumanlifestabilizationofthedisasterresponseandprotectionofvital
property,bothpublicandprivate,arealsoimportant,butareclearlysecondarytothe
preservationoflife.Disastermedicinediffersfromdaytodaymedicineinthatafarlarger
arrayofpublichealthandsafetyservicesmustbeinvolvedinthedisasterresponsetoensure
asafeenvironmentforpatientsandprovidersalike.Thatchildrenhavespecialneedsin
disastersshouldnotbesurprisingtheyalsohavespecialneedsonadailybasis.Thus,all
emergencyresponders,mostespeciallyemergencymedicalservices(EMS)personnel,must
acceptthefactthatsincenearlyalldisasterswillinvolvechildren,theymustbereadyto
providefortheirneeds.
Readinessforpediatricdisastermedicalcareisbestaccomplishedthroughreadinessfor
pediatricdaytodaymedicalcare.TheEMSagenciesandsystemsthatarebestsituatedto
respondtodisastersinvolvingchildrenarethosewhichhavemadespecialprovisionfor
pediatriccareateveryleveloforganizationmedicaloversight,providertraining,proper
equipmentandmedications,inallappropriatesizesanddosages,aswellaspatientsafetyand
performanceimprovementprogramsthataddresspediatricissues.Theothersectionsinthis
resourcewillprovideEMSleaderswiththetoolstheyneedtoprepareforthedaywhen
disasterstrikes,andchildrenarehitastheywere,attheverymomentofthiswriting,bya
tornadothattoucheddowninaBoyScoutcampinsouthwesternIowa,anareasparsely
populatedandevenmoresparselyservedbyspecializedpediatricclinicsandhospitals.This
sectionwillfocusonthedesignandfunctionoftheEMSsystemindisastersinvolvingadults
andeldersaswellaschildrenunderstandingthatchildrencanbeexpectedtofarenobetter
thantheseothers,sincetheintegrityofthepediatricdisasterresponsewillbedependenton
theintegrityofthemedicaldisasterresponseoverall.
The Public Health Paradigm of Disaster Medicine:
Preparation, Mitigation, Response, Recovery
Thepublichealthparadigmofdisastermedicineconsistsoffourdistinctphases.Thefirst
twopreparationandmitigationtogethercomprisewhatiscalledemergency
preparedness,thelasttworesponseandrecoverydisastermanagement.Thefirst
threearewithinthedomainofallhealthcarepersonnel,sinceallhealthcareagenciesand
organizationsmust1)preparethemselvesthroughplanningandeducationtorespondto
disastersrequiringamedicalresponse,2)mitigatetheimmediatelydetrimentalhealth
effectsofdisastersthroughuseoforganizedsystemsofcaredelivery,andregulardrillsthat
refinetheabilityofhealthcareorganizationstorespondinaneffectivemanner,and3)


2
respondinpriorityordertosuddenlyillorinjuredpatientswithsufficientresourcesand
personneltomeettheirneeds,throughapplicationofascientificallyvalidatedtriagetool,and
mobilizationofsurgecapabilityadequatetoprovideminimallyacceptablecaretoallpatients
requiringhealthcareservices.Thelastphase,recovery,ischieflytheresponsibilityofthe
publichealthsystem,althoughacutecareprofessionals,includingemergencymedical
personnelaswellasacutecarephysiciansandnursesfromthedisciplinesofemergency
medicine,trauma,andcriticalcaremedicine,maybecalledupontoassistbothprimarycare
andpublichealthphysiciansandnursesprovideurgenthealthcaretoapopulationrequiring
bothprimarycareandacutecareduringtheintervalduringwhichthepublichealthand
healthcareinfrastructureisreestablishedandrebuilt.
Thepublichealthparadigmofdisastermedicineisdirectlyanalogoustothepublichealth
paradigmofinjuryprevention.
Thefirstphaseofinjurypreventionprimary injury prevention, or avoidanceisdesignedto
keepinjuriesfromoccurringinthefirstplace,chieflythroughplanningandeducation,based
ontheepidemiologyofinjuriesinthecommunitybeingserved;preparationfordisasters,
throughplanningandeducation,alsoforestallsmanyoftheuntowardmedicaleffectsof
disasters.
Thesecondphaseofinjurypreventionsecondary injury prevention, or attenuationis
designedtolessentheimpactofinjuriesastheyareoccurring,baseduponengineering
solutionsthatalterthesystemsandenvironmentwithinwhichtheseinjuriescommonly
occurandtreatmentisprovided;mitigationofdisasters,viaimplementationofanincident
commandsystem,andregulardisasterdrills,lessensthemedicaleffectsofdisastersby
ensuringaprompt,organizedmedicalresponse.
Thethirdphaseofinjurypreventiontertiary injury prevention, or amelioration isdesigned
toreducetheeffectsofinjuriesthathavealreadyoccurred,baseduponevaluationstrategies
thataddresspatientsneedsinorderofphysiologicimportant;responsetodisasters
similarlydecreasesmedicalcomplicationsbyprioritizingcarewhenmultiplecasualtiesare
involved,viatriage,anddeterminingtheimmediateneedforandurgentavailabilityof
additionalassetsintermsofequipmentaswellasemployees,knownassurgecapability
ratherthansurgecapacity,sinceitmattersnotwhatadditionalassetsmaybeonhand,but
rather,whichcanactuallybeused.
Key Differences between Disaster Medical Care and Day-to-Day Medical Care:
Circumstances Extraordinary, Care Ordinary
Themostimportantdifferencebetweendisastermedicalcareanddaytodaymedicalcareis
thenumberofpatientswhomustbeassessedandmanaged.Multiple casualty incidents
(MCIs)typicallyinvolvefiveormorepatients;theresourcesoftheinvolvedEMSagencies
maybestrained,butarenotoverwhelmed.Bycontrast,mass casualty events(MCEs)
typicallyinvolvetwentyormorepatients;theresourcesoftheinvolvedEMSsystemsaswell
asagencieswillbespent,andarecompletelyoverwhelmed.Understandingthemassivegap
thatmaysuddenlyappearbetweenpatientsneedsandavailableresources,andthechaos
thatinevitablyresults,iscriticaltoEMSsystemdesignandfunctioninthedisastersituation
statedsuccinctly,carewillhavetoberationed,ifonlyforashorttime;desperatelyillor
injuredadultsandchildrenmayneedtowaituntilotherswithgreaterlikelihoodofsurvival


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aretreatedfirst;andEMSproviderswillneedtomakesuchlifeanddeathdecisionsinthe
blinkofaneye,andinthemidstoftheworstpossibleenvironmentforhealthcare:a
crowded,possiblysmokeorgasfilledscene,characterizedbyloudnoises,screaming
patients,putridodors,gruesomedeformities,andcrowdsofindividualswithlittleorno
trainingeithertryingtohelpbutgettingintheway,orworse,tauntingEMSprovidersasthey
attempttomakethebestofabadsituation.
Theotherkeydifferencesbetweendisastermedicalcareanddaytodaymedicalcareinvolve
themechanismsofillnessandinjuryencountered,andtheenvironmentinwhichemergency
medicalcaremustbedelivered.Asmostnaturalandhumanmadedisastersinvolvephysical
trauma,EMSpersonnelmustbepreparedtoprovideurgentcaretomanytypesofbluntand
penetratinginjuries,whichmayresultfromnumeroustypesofeventscrushinjuriesfrom
earthquakesandstructuralcollapses,neardrowningsfromhurricanesandfloods,blastand
burninjuriesfromexplosiveandincendiarydevicessuchasbombsandindustrialmishaps,
andfirearminjuriesfromgunshotsandmilitaryordnance,tonamebutafew,nottomention
thecontaminatedwoundsassociatedwithalltheabove.Chemical,radiological,andnuclear
disastersincludingbothhazmatexposuresandterroreventsarelikephysicaltraumain
thattheonsetanddurationofmostsucheventsaresuddenandlimited,althoughspecific
medicaltreatmentsmayberequiredforcareofinjuredpatients.Biologicaldisasters,
however,requireanentirelydifferentapproachtotheircaresinceinfectedpatientsarenot
likelytorequireemergencymedicalcareatpreciselythesametime,butratherwillpresentin
clustersofindividualpatientswithlikesymptomcomplexeswhich,whenrecognizedas
such,willlikelyrequireanapproachtomanagementthatinvolvescohortingofpatients,and
specializedpersonalprotectiveequipment(PPE)foremergencymedicalproviders,and
sometimesforpatientsaswell.
Approach to Emergency Medical Care in Pediatric Disaster Medicine:
KISS Keep It Simple, Sister (And Brother)
Theemergencymedicalcareprovidedduringdisastersisbutoneaspectoftheoverall
emergencyresponsetodisasters.Emergencymanagementofdisastersfollowsanall
hazardsapproach,toallowoneeasilyrememberedapproachtobeappliedtoalltypesof
disasters,reservingandlimitingspecializedplansforandtoonlythosecomponentsofthe
disasterresponsethatrequirespecializedinterventions.Emergencymedicalresponderswill
rarely,ifever,findthemselvesincommandofadisasterscene,sincetheirskillsarefartoo
valuabletowasteonscenesafetyandcrowdcontrol,taskswhicharefarbetterhandledby
publicsafetyofficialsspeciallytrainedandauthorizedtoperformthesetasks.Ontheother
hand,itmustbeunderstoodthatthehighestrankingmedicalprofessionalonthesceneis
responsibleformedicalincidentcommand,andhisorhermedicalordersareregardedas
binding,unlessthereisanurgentthreattothesafetyofpatientsorproviders.
Theapproachtoemergencymedicalcareindisastersmustfollowastandardizedpatternifall
involvedprovidersaretounderstandtheirrolesandcollaborateeffectively.Onesuchmodel
istheDISASTERParadigmdevelopedbytheNationalDisasterLifeSupport(NDLS)
Foundation,anddisseminatedviatheNDLSseriesofcoursesCoreDisasterLifeSupport
(CDLS),BasicDisasterLifeSupport(BDLS),andAdvancedDisasterLifeSupport(ADLS)thatit
nowoffersincollaborationwiththeAmericanMedicalAssociation(Table1).
3
Thecritical
elementsoftheDISASTERParadigmwillbefamiliartoallEMSleaders,managers,and
providers,inthatSafetyandSecurity,andAssessmentofHazards,precedeTriageand


4
Treatmentinallcases,astheydoforroutinecare.Theonlydifferences,asidefromRecovery,
whichisnotordinarilywithinthepurviewofEMSare1)DetectionandDeclarationofthe
disaster,2)implementationofanIncidentCommandStructure,beforeemergencymedical
careisprovided,3)useofdisasterspecificTriageandTreatmentprotocolsthatpermitonly
minimallyacceptablecaretobeprovidedtosalvageablepatients,priorto4)rapidEvacuation
fromthesceneideally,inthecaseofchildren,topediatriccapablehealthcarefacilities,
eitherfixedordeployablerecognizingthatsinceallhealthcarefacilitiesmaybecalledupon
tocareforchildrenindisasters,allmustpreparethemselvestodoso;fortunately,toolsare
nowavailablethatcanassistnonpediatricfacilitiesinmeetingtheirresponsibilitiesto
childrenindisasters(http://www.nyc.gov/html/doh/html/bhpp/bhppfocusped
toolkit.shtml).
Environment of Emergency Medical Care in Pediatric Disaster Medicine:
Uphill, Upwind, Upstream
Asforanyemergencymedicalresponse,scenesafetyandpersonalprotectionareof
paramountimportanceinthedisastermedicalresponse.Theenvironment,inwhich
emergencymedicalcaremustbedelivered,however,presentsspecialchallengesto
emergencymedicalresponders.Thesceneitselfmaybecontaminated,orcontainsingleor
multiplesecondaryhazards,placedunintentionallyorintentionally,thatmayfurtherinjure
patientsandprovidersalike.Thus,despitetheriskoffurtherpatientdeterioration,
emergencymedicalrespondersmustNOTenterthesceneunlessanduntilithasbeendeclared
safebytheappropriatepublicsafetyauthoritiesadirectivethatwillbeveryhard,ifnot
impossible,toenforcewhenchildrenarevictims,butwhichmustbeenforcednonetheless,
sinceEMSpersonnelwhobecomeillorinjuredwhilecaringforothers,bydefinition,become
partoftheproblemratherthanpartofthesolution,andunwittinglyservetodiminishthe
capabilityoftheveryemergencyresponsetheyseektoaugment.
Theenvironmentinwhichemergencymedicalcareisprovidedindisastersdependsuponthe
specifictypeofdisasterinvolved.However,thedeploymentofemergencymedicalpersonnel
inthefieldalwaysfollowsthesamegeneralpatternwhichkeepsspecializedpersonnel
especiallyvitalmedicalpersonneluphill,upwindandupstream,ofthedangersposedby
thescenetoprovidersuntrainedinrescue(Figure1).EMSpersonnelneverenterthesearch
andrescue(SAR)area(hotzone)unlessdirectedbyresponsibleauthoritiesonceithasbeen
declaredfreeofhazards,eventorescuedistressedpediatricpatients,butreceiveallsuddenly
illandinjuredpatients,whetheradultsorchildrenoncetheyhavebeenatleastgrossly
decontaminated,ifdecontaminationisindicatedfortransporttonearbyfixedor
deployablemedicalfacilitiesatoneormorecasualtycollectionpoints(CCPs)withinthe
overallareaofoperations(warmzone)locatedinsidetheexternalperimeter,whichisnever
crossedwithoutspecificorders.InsomedisastersparticularlythoseinwhichEMS
resources,especiallyambulancesandmultipleemergencyresponsevehicles(MERVs)areof
limitedavailabilityitmaybenecessaryonatemporarybasistoestablishastagingareafor
initialtreatmentofvictimsbyemergencymedicalpersonnel,inwhichcaseitmaybe
advisabletoseparatechildrenfromadults,thoughnotfromtheirfamilies;still,rapid
evacuationisalwaysthepriority,ideally,inthecaseofchildren,tohealthcarefacilitiesthat
havemadespecialprovisionsfortheirneeds,andofwhichEMSpersonnelmustbeawareas
partoftheirtraining.


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The Role of Emergency Medical Services in Pediatric Disaster Medicine:
Children Are Not Small Adults
Emergencymedicalpersonnel,asacutecareprofessionals,arechieflyinvolvedwiththethird
phaseofthepublichealthdisasterparadigm,namely,disasterresponseand,underthe
revisedNationalResponseFramework(NRF)thatbecameeffectiveinMarch2008,functionas
partofEmergencySupportFunctionNumber8(ESF#8).Thefundamentalprincipleof
emergencymedicalcareindisastersistoprovidethegreatestgoodforthegreatestnumber.
Thisisincontrasttowhatemergencymedicalprofessionalsdoeveryday,namely,toprovide
allnecessarycare,withinthelimitsofequipment,resources,andpersonnelavailableinthe
prehospitalenvironment,topatientsrequestingemergencyaid.Toprovideemergency
medicalcareindisasterthereforerequiresanimportantshiftinthemindsetofemergency
medicalpersonnel,fromtheoptimalcareprovidedtothesuddenlyillandinjuredpatient,to
theminimallyacceptablecareofferedtoadistressedpopulation.
Minimumacceptablecareisthatwhichisurgentlynecessarytosavelifeorlimb,butnomore
carewhich,byitsverynature,issustentativeratherthandefinitive.Temporizingbasiclife
support(BLS)measuresinsupportoftheairway,breathing,andcirculationtheABCsare
thefundamentalelementsofminimallyacceptablecareforchildrenandadultsalike,
recognizingthatsuchcareinchildrenrequiresthereadyavailabilityoftheappropriate
pediatricequipment.However,notethatinmasscasualtyevents(MCEs),whentreatment
resourcesmaybeseverelylimited,therewilllikelybetimeonlyfortheprimary,orinitial,
assessment,notforthesecondaryassessment,alsoknownasthefocusedhistoryanddetailed
physicalexaminationjustastherewillbenotimeforadvancedlifesupport(ALS)
interventionsthatconsumescarce,andvaluable,minutes.EMSpersonnelmustalsobeaware
that,despitetheirnaturalandadmirabletendencytowanttosavethelivesofchildrenbefore
thoseofadults,notimeshouldbespentinfutileattemptsatcaringforchildrenwhoare
deemedunsalvageablealthoughcomfortcare,andpsychologicalfirstaid,canandmustbe
madeapriorityforallchildren,especiallyiftheyhavebeenseparatedfromtheirlovedones
ortheirregularcaregivers,onceminimallyacceptablecarehasbeengiventoallsalvageable
patients,childoradult.
Application of Incident Command Systems (ICS) in Pediatric Disaster Medicine:
Whos In Charge? Theyre All In Charge!
TheIncidentCommandSystem(ICS)nowincommonuseintheUnitedStatesresultedfrom
theexperiencesofthosebattlingCaliforniawildfiresinthe1970sand1980s.Tocontain
thesefires,theservicesofnumerousagenciesfromseveralstateswererequired.
Unfortunately,theinvolvedagenciesuseddifferentcommandstructuresaswellasradio
frequencies,makingitdifficult,andinmanycasesimpossible,tocommunicatebetween
agencies.Asaresult,thelivesofseveralfirefighterswereunnecessarilylost,leadingexperts
infirematicstopartnerwiththoseinmanagementtodevelopauniversalsystemforincident
commandbuiltontheprinciplesofManagementbyObjectivesandResultsasystem
recentlyadoptedandendorsedbytheDepartmentofHomelandSecurity(DHS)asa
fundamentalcomponentoftheNationalIncidentManagementSystem(NIMS)andthe
NationalResponseFramework(NRF),andtaughtinallitstrainingcourses(Table2).The
IncidentCommandSystem(ICS)nowinplaceemploysfourStaffOfficersaspartofits


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CommandStaff,Liaison,Medical/Technical,PublicInformation,andSafety,easily
rememberedbythemnemonic,[Mount]OLMPS;andfourSectionChiefstocompriseits
GeneralStaff,Finance/Administration,Logistics,Operations,andPlanning,easily
rememberedbythemnemonic,CFLOP(Figure2).
Inaddition,theIncidentCommandSystem(ICS)nowinplaceisbasedontheprincipleof
UnityofCommandthepremisethat,whileinformalsharingofinformationisstrongly
encouragedateveryleveloftheIncidentCommandStructure,formalbriefings,orders,and
reportsflowfrom,to,orthroughonlyasinglesupervisor,whoseSpanofControldoesnot
exceedthreetoseven,andideallyonlyfive,subordinates.WhileIncidentCommandmaybe
sharedbydesignatedofficersofmultipleagencieswithprimaryjurisdictionalauthorityand
responsibility,oneofwhomwillactasthespokespersonastructureknownasUnified
IncidentCommandallparticipatingagenciesandpersonnel,eventhoughtheirfocuswillbe
toprovideaneffectivedisasterresponsewithintheirindividualareasofexpertise,agreeto
reportviavariousSectionChiefstoasinglelocusofIncidentCommand,supportedbyStaff
OfficerswhoassistIncidentCommandwithcertaincommandfunctions.Theimplementation
andoperationofthisIncidentCommandSystemshouldbewellknowntoEMSleaders
makinguseofthisresource,andthuswillbesummarizeddiagrammaticallyratherthan
explainedindetail(Figure2).Sufficeittosaythat1)underallthebutmostunusual
circumstances,EMSwillserveasasupportratherthanacommandagency,andconfineits
operationstotriage,treatment,andtransportoftheacutelyillandinjured,and2)the
provisionofpediatricemergencycaremustbetheresponsibilityofallinvolvedEMSagencies
andpersonnel,sincechildrenrequiringsuchcarewillbeencounteredinalldisastervenues.
Planning for the Care of Children in Disasters:
Plans are nothing. Planning is everything.
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Theenormousvariabilityindisastertypeandvenuemakesdisasterplanningadaunting
challenge,evenforexperiencedprofessionals;however,absentcomprehensiveplanning,and
withoutdueconsiderationofalllikelydisasterscenarios,itwillbeimpossibletomountan
effectivedisasterresponse.Fortunately,theveryactofplanningforeveryeventualityyields
richdividendsintermsofpreparation;numeroussourceshavecitedtheirextensive
preparationsforY2Kasinstrumentalinmanagingdisastersthatoccurredsubsequently.
Withrespecttochildren,sufficeittosaythatpediatricvictimsshouldbeexpectedfollowing
mostdisasterevents,andmaybethespecifictargetsofcertainterrorevents;disastervenues
mostlikelytoharborpediatricpatientsincludeschools,schoolbuses,playgrounds,
recreationalareas,athleticfields,amusementparks,shoppingmalls,andentertainment
complexes.EMSleadersmustworkwiththemanagersofallsuchfacilitieswellinadvanceof
anypossibleterrorthreattoensuretheyhavedevelopeddetaileddisasterplans,especially
forevacuation,intheeventofterrorattackplansthatmustbecoordinatedwiththoseof
localpublichealthandsafetyagenciesandlocalandregionalemergencymedicalservicesand
traumacarefacilities,inadditiontoEMS.
Indevelopingsuchplans,EMSleadersmustinvolvenotonlychildhealthprofessionalsexpert
inbothphysicalandpsychologicaltrauma,butalsopeers,parents,religiousleaders,andcivic
leaders,toensurethatdisasterandevacuationplanshaveaddressedallforeseeable
calamities.Mostvenuesdelineatedabovehavecommunityadvisoryboardsorliaisons,who
togetherwithfacilitydirectorsmusttaketheleadinensuringthatplansarenotonly
developedandreviewed,butalsoarecurrent,realistic,sensible,andflexible,andperhaps


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mostimportant,botheasytoremember,andeasytoimplement.Exitsmustbewelllighted,
preferablywithnaturallightasmostterrorattackstargetingchildrenwilloccurduringthe
day,andwellmarked,atceiling,wall,andfloorlevels,tofacilitaterapidrecognitionevenby
smallchildrenorwhenvisibilityispoor.Alldisasterandevacuationplansmustthenbe
testedandrefinedthroughregulardrills,toensurethatchildrenwillunderstand,andwill
havepracticed,whattodoifandwhenadisastershouldoccur.
Training for the Care of Children in Disasters:
Remember the ABCs, But If Thats Too Difficult, Remember the AAAs
5
AllEMSpersonnelinvolvedindisastersmustbewelltrainedintheapplicationofthe
NationalIncidentManagementSystem(NIMS),andmustbethoroughlyfamiliarwiththe
specificsoftheIncidentCommandSystem(ICS).Ataminimum,therefore,allEMS
professionalsmusthavesuccessfullycompletedtheIS100(IntroductiontotheIncident
CommandSystem),IS200(ICSforSingleResourcesandInitialActionIncidents),IS700
(NationalIncidentManagementSystemAnIntroduction),andIS800B(NationalResponse
FrameworkAnIntroduction)coursesofferedbymanystates,andeducationalconsortium
partnersoftheDepartmentofHomelandSecurity(DHS)FederalEmergencyManagement
Agency(FEMA),readilyaccessedonlineathttp://training.fema.gov,whileallEMSleaders
andmostEMSsupervisorsshouldalsohavesuccessfullycompletedIS300(IntermediateICS
forExpandingIncidents)andIS400(AdvancedICSforCommandandGeneralStaffComplex
Incidents),accessedatthesameaddress,butwhichmustbetaughtbyqualifiedinstructors
overthreedayseach,duetothebreadthanddepthofthematerialtobecovered,andthe
largeamountofsmallgroupworkinvolved.AllEMSpersonnelmustalsobewelltrainedin
theEMSresponsetoMCIsandMCEspotentiallyinvolvingweaponsofmassdestruction
(WMD).Thus,allEMSprofessionalsshouldhavesuccessfullycompletedAWR160(WMD
AwarenessLevelTraining),whileallEMSleadersandmostEMSsupervisorsshouldalsohave
successfullycompletedPER211(EMSOperationsandPlanningforWMDIncidents),offered
byDHSandFEMA.
Trainingspecifictopediatricemergencycareindisastersisbaseduponasolidgroundingin
pediatricemergencycarefordaytodaypediatricemergenciesrecognizingthatformost
pediatricemergencies,respiratorydistress,failure,andarrest,ratherthanshock,arethefinal
commondenominatorsofphysiologicdeterioration.AllEMSpersonnelshouldsuccessfully
completethePediatricEmergenciesforPrehospitalProfessionals(PEPP)Courseofthe
AmericanAcademyofPediatricsateitherthebasiclifesupport(BLS)ortheadvancedlife
support(ALS)level,asappropriate(http://www.pepp.org),whileadvancedlifesupport
(ALS)personnelshouldalsosuccessfullycompletethePediatricAdvancedLifeSupport(PALS)
CourseoftheAmericanHeartAssociationandtheAmericanAcademyofPediatrics.
6,7
The
BasicDisasterLifeSupport(BDLS)andAdvancedDisasterLifeSupport(ADLS)Coursesofthe
AmericanMedicalAssociationandtheNationalDisasterLifeSupport(NDLS)Foundation
directlyaddresspediatricdisasteremergencycarewithinthecontextofdisastercareforall
illorinjuredpatients(http://www.bdls.org).
3
Finally,thePediatricDisasterLifeSupport
(PDLS)CoursedevelopedbytheUniversityofMassachusettsSchoolofMedicineatWorcester
fortheFederalEMSCProgramoffersacompact,andhighlyeffective,reviewofthe
fundamentalprinciplesofdisastermedicineandpediatricdisasteremergencycare.
8


8
Equipment for the Care of Children in Disasters:
Amateurs study tactics. Professionals study logistics.
4

Childrencannotberesuscitatedoptimallyusingtoolsdesignedforadults.EveryEMS
professionalmustthereforebetrainedusingpediatricequipment,andsuchequipmentmust
beuniversallyavailableonambulancesandsimilarrescuevehiclesthroughouttheEMS
system.Thecostsofequippingevenasingleambulancewiththeproperequipmentinall
appropriatepediatricsizespalebeforetheexpenseofprovidingasingleautomatedexternal
defibrillatorforthesameambulance.Theopportunityforasuccessfulresuscitationisfar
higher,giventhatmostpediatricemergenciesarerespiratoryinnature.Sinceassisted
ventilationisthemostimportantskillemergencymedicaltechniciansandparamedicsmay
possess,theprovisionofbagvalvedevicesandclearplasticfacemaskswithinflatablerimsin
allappropriatepediatricsizesisofparamountimportancetotheprehospitalcareofacutely
illandinjuredchildrenasisthereadyavailabilityofalengthbased,colorcoded
resuscitationtape,toensureproperequipmentanddosageselection.
TheFederalEMSCProgramperiodicallyrevisesarecommendedpediatricequipmentlistfor
ambulances,asdotheAmericanCollegeofSurgeonsandtheAmericanCollegeofEmergency
Physicians,whojointlyproduceasimilardocumentatregularintervals.
9,10
AllEMSagencies
shouldendeavortoensurethatitsfleetmaintainsthisequipmentonallitsvehicles,whichis
availableoftenfromaffiliatedhospitalsattrivialexpense.Whilenospecialequipmentis
requiredformanagementofphysicaltrauma,respiratoryillnessesspreadbyairborne
dropletsmandatetheavailabilityofproperlyfittestedN95respiratorsforallfrontlinestaff.
Otherthantheproperpersonalprotectiveequipment(PPE)requiredforuseincontaminated
environmentsmosturbanEMSagenciesoutfittheirpersonnelwithLevelCequipment,
includingliquidimpenetrablesuitsandpoweredpartialairpurifyingrespirators(PAPRs)
theonlyadditionalequipmentneededbymostEMSagencieswillbeatropine,pralidoxime,
anddiazepamautoinjectorsinpediatricandinfantsizesasantidotesfornerveagent
poisoning,andforEMSagencieslocatednearnuclearpowerfacilities,potassiumiodide
tablets,whichcanbehalvedorquarteredasneeded.
Drilling for the Care of Children in Disasters:
Talkin The Talk vs. Walkin The Walk
Drillsandexercisesareavitalcomponentofthemitigationactivitieseveryhealthcare
organization,whetheranEMSagencyorahealthcarefacility,mustundertaketobereadyto
providedisastercare.Thefirststepforallthoseresponsibletoconductdisasterdrillsand
exercisesistoperformahazardvulnerabilityanalysis(HVA)afullandcompleteinventory
ofpossibledisastersthatmightaffecttheEMSagencyorhealthcarefacility.Aproperly
performedhazardvulnerabilityanalysiswill1)focusoneventsinternalaswellasexternalto
theagencyorfacility,2)emphasizethosehazardsfeltlikelytohavethegreatestimpacton
thefunctionoftheorganization,3)considerthelikelihoodthatsucheventsmightoccur,and
4)determinehowsucheventsmightaffecttheagencyorfacility.Disasterdrillsandexercises
canthenbeconstructedtotestorganizationalreadinessforoneormoreofthepossible
scenariosthathavebeenconsideredtheresultsofwhich,summarizedinAfterAction
Reports(AARs),areusedtofurtherrefinethedisasterplan.


9
Readinessfordisastersisfirsttestedviatabletopexercisesverbalorwrittenscenariosthat
evaluatetheeffectivenessofanagencysorfacilitysemergencymanagementplanand
coordination.Nextutilizedaredisasterdrillssupervisedactivitieswithalimitedfocus
designedtotestproceduresthatarelimitedcomponentsofanagencysorfacilitys
emergencymanagementplan.Onlythenarefunctionalexercisesmountedtosimulatea
disasterinthemostrealisticmannerpossiblewithoutmovingrealpeopleorrealequipment
toarealsite,ideallyasapreludetofieldexercisesculminationofpreviousdrillsand
exercisesthatteststhemobilizationofasmanyaspossibleoftheresponsecomponentsin
realtime,usingrealpeopleandrealequipment.Toaccuratelyassessanagencysorfacilitys
responsewithrespecttothepediatriccomponentofanydisaster,ofcourse,itisnecessaryto
includepediatricvictimsaspartofthesedrillsandexercisesmostauthoritiesrecommend
that510%ofalldisastervictimsbechildrenandinfants.
Special Considerations in the Care of Children in Disasters:
Failing To Plan Is Planning To Fail
12

Reunificationofchildrenwithparents,siblings,andclassmatesmustbeaddressedaspartof
alldisasterplans.Disastersinvolvingchildrennaturallyresultinprofoundemotionaland
behavioralresponsesonthepartofallconcerned.Provisionsmustbemadetoassurethe
safetynotonlyofthechildrenthemselves,butalsoofconcernedrelativeswhoappearon
scenetorescuetheiryoungsters.Supportservicesmustbeimmediatelyavailableinsuch
crisiscircumstances,particularlypastoralcareandmentalhealthservices,aswellassocial
servicestoseetotheimmediateneedsofinvolvedfamiliesespeciallyforinformationabout
thewhereaboutsofchildrenwhoareinjured,thosewhoseparentsorsiblingshavebeen
injuredorkilled,andthosenotyetbeenreunitedwiththeirfamilies.
Asisalsotrueofadultnursinghomepatients,childrenwithspecialhealthcareneeds
(CSHCN)duetochronicillnessesorinjuries,includingtechnologyassistedchildren(TAC),
presentspecialchallengestoEMSagenciesandsystems.Firstandforemostisknowingwho
andwheretheyaremanysuchchildrenarecaredforathome,withouttheknowledgeofthe
localEMSagencyorregionalEMSsystem.Parentsofchildrenwithspecialhealthcareneeds
areencouragedtocompleteaspecialform,availablefromtheAmericanAcademyof
PediatricsandtheAmericanCollegeofEmergencyPhysicians,detailingthenatureandextent
oftheirchildsmedicalproblems,andkeepitonhandforEMSpersonnelwhomayfromtime
totimebecalleduponforassistance.
11
Ifpossible,acopyoftheformshouldbeprovidedto
thelocalEMSagency,sothatadvanceplanscanbemadeforachildwithspecialhealthcare
needswhomayrequirerapidevacuation.
Summary
Itisselfevident,basedontheforegoing,thatchildrenandyoungadultsareathighriskof
injuryfollowingdisasters.Theyareathigherriskofseriousphysicalinjurythanadults,for
severalreasons:1)flexiblebonescausefewerfracturestoserveastraumamarkers,2)
internalorgandamageisoftenoverlooked,3)vitalsignscreeningisfrequentlyinadequate,
and4)bodyheatlossisnaturallyincreasedduringexposureorfollowingdecontamination,
duetothelargerbodysurfaceareatomassratiointhechild.Theyarealsoathigherriskof
exposuretobiological,chemical,radiological,andnucleartoxinsthatadults,againforseveral
reasons:1)theirimmunesystemsarelesswelldeveloped,owingbothtoimmaturity,andto


10
lackofpreviousexposuretomanybiologicalvectors,2)theyaresmallerandclosertothe
ground,thereforemorelikelytoinhaleandingestheavierthanairgasesorcontaminated
particulatematter,3)theirmetabolicratesarehigher,resultinginfasterratesofbreathing,
hencemorerapidabsorptionoftoxicvapors,and4)theirskinisthinner,makingthemmore
vulnerabletotheeffectsofbetaradiation.Moreover,childrencanbeexpectedtobeinvolved
inmost,ifnotall,disastersinvolvinganycommunity,andhavebeentheactualtargetsof
terrorattacksincertainsituationswitnessthenumberofsenselessshootingsthathave
plaguedournationshighschools.
Toensurethatthespecialneedsofchildrenareaddressedintheprehospitalenvironment,
childhealthprofessionalsmustbeinvolvedinallaspectsofemergencymanagement.The
termemergencymanagementreferstoanewpublicsafetydiscipline,theroleofwhichisto
coordinateallaspectsofaregionalresponsetoanaturalormanmadedisaster,whilethe
termemergencypreparednessreferstothestateofreadinessneededbyacommunityto
respondoptimallytoanaturalorhumanmadedisaster.Althoughitistheunequivocal
responsibilityofEMSagencyandsystemleadersandmanagerstoinvolvepediatricexpertsin
bothlocalandregionaldisasterplanningandemergencypreparednessactivities,their
trainingoftenoverlooksthespecialneedsofpediatricpatients.Thus,itisencumbentupon
childhealthprofessionalstoinvolvethemselvesinallaspectsoftheEMSsystemresponse
commensuratewiththescopeandrangeoftheirpractices,throughgovernmentaland
communityadvisoryboards,andmultidisciplinarycommitteesonpediatricemergency
medicineanddisastermanagementorganizedandsupportedbylocalbranchesofthe
AmericanAcademyofPediatricsandAmericanCollegeofEmergencyPhysicians,in
partnershipwithlocalandregionalhealthcarefacilitiesandorganizations.
References
1. AttributedtoRobertS.Amler.
2. Disastermedicine.Wikipedia,accessedJune13,2008.
3. AmericanMedicalAssociationandNationalDisasterLifeSupportFoundation.Core,Basic,
andAdvancedDisasterLifeSupportCourses.Chicago,IL:AmericanMedicalAssociation,
4. AttributedtoDwightD.Eisenhower.
5. AttributedtoMartinR.Eichelberger.
6. DieckmannR,BrownsteinD,GauscheHillM,eds.PediatricEmergenciesforPrehospital
Professionals,2nded.ElkGroveVillage,IL:AmericanAcademyofPediatrics,2006.
7. ZaritskyA,ed.TextbookofPediatricAdvancedLifeSupport,4thed.Dallas:American
HeartAssociation,2008.
8. AghababianR,ed.PediatricDisasterLifeSupportCourse,2nded.Worcester,MA:
UniversityofMassachusetts,2008.
9. EMSCambulanceequipmentlist.
10. ACS/ACEPambulanceequipmentlists.
11. EMSCCSHCNform.
12. AttributedtoBenjaminFranklin.


11
Table1.TheDISASTERParadigm
D Detection/Declaration
I IncidentCommand
S Safety/Security
A AssessHazards
S SupportServices
T Triage/Treatment
E Evacuation
R Recovery


12
Table2.DepartmentofHomelandSecurityICSandEMSCourses*
IS100 IntroductiontoIncidentCommandSystems
IS200 ICSforSingleResourcesandInitialActionIncidents
IS300 IntermediateICSforExpandingIncidents
IS400 AdvancedICSforCommandandGeneralStaffComplexIncidents
IS700 NationalIncidentManagementSystemAnIntroduction
IS800.B NationalResponseFrameworkAnIntroduction
AWR160 WMDAwarenessLevelTrainingCourse
PER211 EMSOperationsandPlanningforWMDIncidents
PER212 WMD/TerroristIncidentDefensiveOperationsforFirstResponders
*Accessedathttp://www.training.fema.gov.


13
Figure1.SchematicDiagramofaDisasterSite
A.DisasterScene*
*Source:CenterforDomesticPreparedness,Anniston,AL
B.DisasterZones
Source:SocietyofCriticalCareMedicine,DesPlaines,IL


14
Figure2.IncidentCommandSysteminCommonUseintheUnitedStates
A.Structure*
*Source:CenterforDomesticPreparedness,Anniston,AL
B.Function
Source:CenterforDomesticPreparedness,Anniston,AL
2: HowChildren Are Different Pediatric Disaster Preparedness

1

Chapter 2: How Children are Different
ueoige Foltin NB, }ane Knapp NB
Principles of Disaster Triage
Nany impoitant uiffeiences uistinguish chiluien fiom auults anu aie the oiigin of the oft useu
tiuism "you can't tieat chiluien as small auults." Chiluien have many unique anatomic,
physiologic, immunologic, uevelopmental, anu psychological consiueiations that potentially
affect theii vulneiability to injuiy anu iesponse in a uisastei. Failuie to account foi these
uiffeiences in piepaieuness effoits, tiiage, uiagnosis, anu management of chiluien is most
often uue to lack of knowleuge oi expeiience, oi both. 0nfoitunately, giave eiiois can iesult,
incieasing the chilu's iisk of seiious haim, anu even ueath.
Anatomic Differences
An obvious uiffeience between chiluien anu auults is size. Chiluien aie smallei than auults
anu vaiy in size uepenuing on stage of giowth anu uevelopment. Theii small size makes
them moie vulneiable to exposuie anu toxicity fiom agents that aie heaviei than aii such as
saiin gas anu chloiine. These agents accumulate close to the giounu in the bieathing zone of
infants, touuleis, anu chiluien.
A chilu's smallei mass means gieatei foice applieu pei unit of bouy aiea. The eneigy
impaiteu fiom flying objects, falls, oi othei blunt oi blast tiauma is tiansmitteu to a bouy
with less fat, less elastic connective tissue, anu closei pioximity of chest anu abuominal
oigans. The iesult is a highei fiequency of multiple oigan injuiy.
A smallei bouy has smallei ciiculating bloou volume (on aveiage 8u mLkg) anu less fluiu
ieseive. These uiffeiences have seveial impoitant implications. volumes of bloou loss that
woulu be easily hanuleu by the auult can piouuce hemoiihagic shock in chiluien. Chiluien
aie moie vulneiable to the effects of agents such as staphylococcal enteiotoxins oi vibiio
choleiae that piouuce vomiting anu uiaiihea. Theiefoie, infections that might cause milu
symptoms in auults coulu leau to hypovolemic uehyuiation anu shock in infants, small
chiluien, oi chiluien with special health caie neeus.
The chilu's skeleton is moie pliable than that of auults. It is incompletely calcifieu with active
giowth centeis that aie moie susceptible to fiactuie. 0ithopeuic injuiies with subtle
symptoms anu physical finuings aie easily misseu in pieveibal chiluien. Inteinal oigan
uamage can occui without oveilying bony fiactuie. It is common to have seiious caiuiac oi
lung injuiies without having incuiieu iib fiactuies.
The peuiatiic ceivical spine is subject to uistiacting foices that aie moie likely to uisiupt the
uppei ceivical veitebia anu ligaments. Theie aie numeious bony anatomic vaiiations that
ienuei the inteipietation of iauiogiaphs potentially confusing.
The meuiastinum is veiy mobile in chiluien. As a iesult, a tension pneumothoiax can become
quickly life-thieatening when the meuiastinum is foiceu to the opposite siue compiomising
venous ietuin anu caiuiac function.

2
The thoiacic cage of a chilu uoes not pioviue as much piotection of uppei abuominal oigans
as that of an auult. Bepatic oi splenic injuiies fiom blunt tiauma can go uniecognizeu anu
piouuce significant bloou loss leauing to hypovolemic shock.
Beau injuiy is common in chiluien. The heau is a laigei, heaviei poition of a chilu's bouy
compaieu with that of an auult. It is suppoiteu by a shoit neck that lacks well-uevelopeu
musculatuie. The calvaiium is thin anu vulneiable to penetiating injuiy, thus allowing
gieatei tiansmission of foice to the giowing biain of a chilu. The biain uoubles in size in the
fiist 6 months of life anu achieves 8u% of its auult size by 2 yeais of age. Buiing chiluhoou,
theie is ongoing biain myelinization, synapse foimation, uenuiitic aiboiization, anu
incieasing neuional plasticity anu biochemical changes.
The aiiway uiffeis between chiluien anu auults. The tongue is ielatively laige compaieu with
the oiophaiynx, which cieates the potential foi obstiuction of a pooily contiolleu aiiway.
The laiynx is highei anu moie anteiioi in the neck, anu the vocal coius aie at a moie
anteiocauual angle. The epiglottis is omega-shapeu anu soft. The naiiowest poition of the
aiiway is the ciicoiu iing, not the vocal coius as in auults. Aiiway uiffeiences combine to
make the chilu's aiiway moie uifficult to maintain as well as to intubate. The shoit length of
the tiachea incieases the iisk of a iight mainstem bionchus intubation. The lungs aie smallei
anu subject to baiotiaumas, iesulting in pneumothoiax with inappiopiiate ventilation.
The bouy suiface aiea (BSA) to mass iatio is highest at biith anu giauually uiminishes as the
chilu matuies. The uistiibution of BSA also uiffeis between chiluien anu auults. Chiluien
have a highei peicentage of BSA uevoteu to the heau ielative to the lowei extiemities. This
must be taken into account when ueteimining the peicentage of BSA involveu foi buin
injuiies anu in situations of hypotheimia tieatment oi pievention. The highei BSA to mass
iatio also leaus to moie iapiu absoiption anu systemic effects fiom toxins that aie absoibeu
thiough thinnei, less keiatinizeu, highly peimeable skin.
Physiologic Differences
Chiluien uiffei physiologically in many ways fiom auults. They can compensate anu maintain
heait iate uuiing the eaily phases of hypovolemic shock, which cieates a false impiession of
noimalcy iesulting in iesuscitation with too little fluiu auministiation. This can be followeu
by a piecipitous ueteiioiation with little waining.
vital signs incluuing heait iate, iespiiatoiy iate, anu bloou piessuie vaiy with age.
Caietakeis must be able to quickly inteipiet whethei a chilu's vital signs aie noimal oi
abnoimal foi age. Tempeiatuie is an often foigotten but impoitant vital sign in injuieu
chiluien. The chilu's ability to contiol bouy tempeiatuie is affecteu not only by the BSA to
mass iatio but also by thin skin anu lack of substantial subcutaneous tissue. These factois
inciease evapoiative heat loss anu caloiic expenuituie. Consiueiations of methous to
maintain anu iestoie noimal bouy tempeiatuie aie ciitical to the iesuscitation of chiluien.
These can incluue theimal blankets, waimeu iesuscitation iooms, waimeu intiavenous
fluius, anu waimeu inhaleu gases.
Chiluien have a highei minute ventilation than auults. This means that ovei the same peiiou
of time, they aie exposeu to ielatively laigei uoses of aeiosolizeu biological anu chemical
agents than aie auults. The iesult is that chiluien suffei the effects of these agents much
moie iapiuly. Chiluien aie also moie likely to absoib moie of the substance fiom the lungs
befoie it is cleaieu oi uiffuseu thiough ventilation.

3

Fluiu iesuscitation anu uiug uosages aie baseu on the chilu's weight. It is uifficult to estimate
the weight of a chilu, paiticulaily foi health caie woikeis with limiteu peuiatiic expeiience.
An easy, quick methou foi ueteimining the chilu's weight is to use the Bioselow-Binkle
Peuiatiic Resuscitation Neasuiing Tape . This tool iapiuly pioviues many common uiug
uosages anu fluiu iesuscitation volumes. Bealth caie pioviueis must also make appiopiiate
fluiu choices foi iesuscitation. Chiluien who ieceive laige volumes of hypotonic fluiu aie at
iisk of hyponatiemia anu seizuies.
Immunologic Differences
Chiluien have immatuie immunologic systems placing them at highei iisk of infection (see
also Biological Teiioiism). Immunologically, chiluien have less heiu immunity fiom
infections such as smallpox anu a unique susceptibility to many infectious agents. 0ne
example, venezuelan equine encephalitis, is usually a biief, self-limiting infection in auults. In
chiluien it can be seveie with life-thieatening encephalitis ueveloping in 4% of victims.
Chiluien immunizeu with the cuiiently available smallpox vaccine aie moie likely than auults
to expeiience seiious siue effects such as encephalitis.
Developmental Differences
Bevelopmental uiffeiences between chiluien anu auults aie also ieauily appaient. Chiluien,
especially infants anu touuleis, might be unable to uesciibe symptoms oi localize pain.
Chiluien iely on paients oi otheis caietakeis foi foou, clothing anu sheltei. Infants especially
aie vulneiable when theii foou souices aie eliminateu oi contaminateu.
In situations of uisastei, the caietakeis can be injuieu, killeu in the inciuent, oi not piesent.
Chiluien, especially infants anu touuleis, aie limiteu in theii veibal ability to communicate
theii wants anu neeus. Chiluien also have limiteu motoi skills neeueu to escape fiom the site
of the inciuent. Auuitionally, theii cognitive uevelopment may limit theii ability to figuie out
how to flee fiom uangei oi to follow uiiections fiom otheis oi even to iecognize a thieat. The
young chilu has a ielatively limiteu ability to inteiact in stiessful situations anu an emotional
state fiequently uictateu by that of theii caietakeis. A chilu's ieaction to uangei oi thieat is
influenceu by theii uevelopmental stage, iequiiing familiaiity with age-appiopiiate
inteiventions.
Newborn Developmental Characteristics (Birth1 Month)
Muscle tone and body position
Nostly ieflex movements
Equal movement in aims anu legs
Extiemities flexeu at elbows anu knees
Cannot sit up
Tightly giasps fingei oi othei object placeu in palm but uoes not ieach foi objects
Reacts to louu hanu clap oi suuuen movement with staitle ieflex (Noio ieflex),
stiaightening elbows anu opening aims, then flexing elbows in a hugging motion

4

Mental status and social interaction
Appeais aleit when awake, but uoes not tuin to sounu
Looks at faces anu objects but cannot follow theii movement
Bas little facial expiession
Is not yet afiaiu of stiangeis
Verbal abilities
No language abilities
Ciies when hungiy, colu, staitleu, oi in pain
Cognitive abilities
Looks, listens, smells, anu tastes to leain about the woilu
Cannot unueistanu woius, but finus calm, continuous speech soothing

Infant Developmental Characteristics (112 Months)
Bas equal movement in aims anu legs
Flexion of extiemities anu Noio ieflex begin to ueciease at 4-6 mo
Reaches foi objects at 4-6 mo
Begins to ciawl at 4-1u mo
Can be pulleu into sitting position at 2 mo, but iequiies suppoit
Sits upiight without suppoit at 6-8 mo
Stanus at 12 mo
Appeais aleit when awake
Can focus on objects anu follow theii movement at 2 mo
Smiles at 2 mo
Tuins to sounu at 4-6 mo
Begins ueveloping feai of stiangeis at 6-8 mo
Is consoleu by piesence of caiegiveis

5

Verbal abilities
Begins imitating woiu sounus at 6-8 mo ("ua ua ua," "ma ma ma")
Ciies when hungiy, staitleu, oi in pain
Cognitive abilities
Notivateu by basic neeus (foou, watei, waimth, touch)
Looks, listens, smells, anu tastes to leain about the woilu
Cannot unueistanu woius, but finus calm, continuous speech soothing

Toddler Developmental Characteristics (13 Years)
Walks by 18 mo
Climbs staiis 1 step at a time by 18 mo
Climbs staiis alteinating steps by S yi
Wiiggles anu squiims when iestiaineu
Falls moie often uue to incieaseu mobility
Is active when awake
Social inteiaction is unpieuictable: may feai stiangeis oi act inuiffeient; may ieach foi
objects oi push hanu away
Nay iun away if fiighteneu
Nay want to paiticipate in caie
Feels mouest about unuiessing
0sually tiusts those whom caiegiveis seem to tiust
Verbal abilities
Bas basic language skills: a young touulei can unueistanu simple woius anu phiases, an
oluei touulei unueistanus sentences
0nueistanuing of speech exceeus ability to expiess own thoughts
Nay be talkative, but won't always talk to stiangeis

6

Cognitive abilities
Reasoning is just emeiging
Inuepenuence incieases
Ranuom cuiiosity peaks, iesulting in fiequent injuiies while exploiing enviionment
views clothing anu possessions as pait of self anu uoes not like having them iemoveu
Remembeis anu feais pain
Nay believe illness oi injuiy is punishment foi bau behavioi oi thoughts
Boes not make up false symptoms
Cannot ieliably point to pain
Preschooler Developmental Characteristics (36 Years)
Can walk, iun, skip, anu climb with gieat skill, fiequent associateu minoi injuiies
Can iiue a tiicycle
Is active when awake, but can sit still on iequest
Accepts anu inteiacts with stiangeis moie ieauily, but may be slow to tiust when ill oi
injuieu
Can incluue otheis in games of make-believe
Wants to initiate anu contiol activities, which shoulu be suppoiteu
Nay be mouest about being unuiesseu
Verbal abilities
Imitates auult conveisation
Nay use woius that aie not unueistoou
Believes otheis see things fiom own viewpoint, theiefoie may not explain cleaily
Cognitive abilities
Thinking is liteial, conciete, anu iooteu in piesent time; may not unueistanu concept of
futuie events
Thinks in absolutes (things aie eithei goou oi bau; a laceiation eithei huits oi uoesn't
huit)

7

Nay not unueistanu cause anu effect (such as swallowing meuicine to make pain go
away)
views clothing anu possessions as pait of self anu uoes not like having them iemoveu
Nay believe illness oi injuiy is punishment foi bau behavioi oi thoughts
Engages in fantasy anu magical thinking
Nay attiibute lifelike qualities to toys anu objects
Feais pain, sepaiation fiom caiegiveis
Begins to feai uisfiguiement
0luei pieschoolei may make up symptoms, which uisappeai with uistiaction
Can ieliably uesciibe location of pain beginning aiounu age S

School-Aged Developmental Characteristics (612 Years)
Physical skills aie well-uevelopeu; bettei cooiuination ieuuces mishaps
Injuiies uue to iisk-taking behavioi inciease
Bas cleai social skills
Can appieciate anothei's point of view
Quickly senses shame, angei, fiustiation in auults
Is usually mouest about being unuiesseu
Verbal abilities
0ses language to communicate thoughts anu leain what otheis aie thinking
Cognitive abilities
Sees the woilu objectively anu iealistically
0nueistanus concepts involving past anu some futuie events
Engages in moie flexible, ielative thinking (a laceiation may huit a little oi a lot)
0nueistanus cause anu effect, anu may be ieasoneu with (meuicine will help pain go
away)
Nay make up symptoms, which become inconsistent with uistiaction

8

Can ieliably explain location of pain
Quickly sees thiough falsehoous
Feais pain, uisfiguiement, anu loss of function
Begins to giasp concept of ueath

Adolescent Developmental Characteristics (1218 Years)
Physical skills anu cooiuination aie similai to an auult's, but may lack auult stiength anu
enuuiance
Risk-taking oi impulsive behavioi may iesult in injuiies oi illness
Relates in uiiect, stiaightfoiwaiu mannei to auults who uemonstiate iespect
Appieciates honesty
values piivacy
Is conceineu about maintaining inuepenuence
Verbal abilities
Language abilities appioach auult levels, paiticulaily in late auolescence
Cognitive abilities
Engages in neai-auult levels of abstiact, objective, anu iational thinking, but may have
uifficulty seeing auult peispectives
Bas soliu unueistanuing of iight anu wiong
Nay be self-centeieu
Is conceineu about bouy image, scaiiing, anu uisfiguiement
Nay be gieatly influenceu by opinions of peeis
Is capable of making up oi misiepiesenting physical oi mental symptoms
Can ieliably uesciibe location of pain
Can make uecisions about caie

9
Practical Considerations for Children and Families during Disasters
The anatomic, physiologic, immunologic, uevelopmental, anu emotional uiffeiences between
chiluien anu auults give iise to many piactical consiueiations foi planning. (See also 0nique
Peuiatiic Neeus.)
Emeigency meuical seivices (ENS) agencies shoulu consiuei auopting tiiage tools such as
}umpSTART that use physiologic uecision points auapteu foi ianges of peuiatiic noimals
anu consiuei apnea as a potentially salvageable iespiiatoiy emeigency.
Ambulances, clinics, anu emeigency uepaitments typically caiiy only limiteu quantities of
peuiatiic equipment. Sufficient supplies anu equipment must be ieauily available to tieat
laige numbeis of chilu victims. Because equipment choices anu uiug uosages, incluuing Iv
iates, uepenu on the chilu's size, a quick, convenient system to guiue appiopiiate equipment
sizes anu uiug uosages must be in place. The system useu must be compiehensive enough to
incluue uosages foi antiuotes anu othei meuications that may be ielevant uuiing a teiioiist
event.
The iesuscitation of chiluien can be fuithei complicateu by the technical uifficulty of
pioceuuies such as intubation anu intiavenous access. Alteinative methous foi maintaining
anu secuiing the aiiway shoulu be consiueieu. When veins aie small anuoi constiicteu fiom
shock oi hypotheimia, the equipment foi alteinative methous, such as intiaosseous access,
must be ieauily available.
Planning must consiuei all potential aspects of a chilu's life. Theiefoie, it must account foi
chiluien who aie at home, in school oi chilucaie, oi in tiansit, as well as chiluien who cannot
be ieuniteu with theii families. School uisastei plans shoulu cooiuinate with community
plans anu shoulu also consiuei post-inciuent stiess management. Chilucaie centeis anu
community youth centeis shoulu have uisastei plans that focus on ensuiing safety, accessing
anu inteiacting with community emeigency iesponueis, notifying guaiuians, anu ieuniting
families.
Chiluien aie pieuisposeu to illness anu injuiy aftei a uisastei foi a vaiiety of ieasons. Theie
can be lack of auult caietakei supeivision, anu the usual iesouices of school oi chilucaie may
be unavailable. Enviionmental hazaius can be incieaseu fiom collapseu builuings powei
tools, chemicals oi unsecuieu fiieaims. Incieaseu stiess on auults might leau to a highei iisk
of uomestic paitnei violence oi chilu abuse. Infectious illnesses piesent in the community,
especially infections such as iespiiatoiy syncytial viius oi influenza, may spieau iapiuly in
gioup shelteis. Contaminateu foou oi watei can leau to epiuemic outbieaks of infectious
uiseases, iesulting in gastioenteiitis anu uehyuiation. Changes in the enviionment can leau
to heat-ielateu illness oi hypotheimia. 0se of alteinative souices foi heating oi geneiatois
can leau to caibon monoxiue exposuie. Chiluien with asthma may have acute exaceibations
uue to stiess oi enviionmental contaminants. Neuications may be foigotten oi the supply
may be exhausteu, iesulting in exaceibations of chionic illnesses. Stiess can piouuce a
vaiiety of symptoms in chiluien incluuing heauaches, abuominal pain, chest pain, vomiting,
uiaiihea, constipation, changes in sleep, anu changes in appetite.
Planning must also incluue piegnant women anu the unboin. The stiess of a uisastei can
contiibute to piematuie laboi anu ueliveiy. Infection acquiieu by the fetus in uteio can leau
to fetal uemise oi uevastating consequences if the fetus suivives. The iisk of ueveloping
cancei is highei in chiluien who have been exposeu to iauiation in uteio. Rauioactive iouine
is tiansmitteu to human bieast milk anu thieatens infants who aie bieastfeeuing. Cows' milk

10

can also be quickly contaminateu if iauioactive mateiial settles onto giazing aieas,
thieatening alteinative souices of nutiition.
References
1. Ameiican College of Suigeons Committee on Tiauma, Peuiatiic Tiauma in Auvanceu
Tiauma Life Suppoit Nanual (6th eu). Chicago IL, Ameiican College of Suigeons, 1997. pp
SSS-S7S.
2. Cieslak T}, Benietig FN. Bioteiioiism. Peuiati Annals. 2uuS;S2(S);1-12.
S. Naikenson B. C0PEN Peuiatiicians Role in Bisastei.
4. Naikenson B, Reulenei I. Peuiatiic piepaieuness foi uisasteis anu teiioiism: a national
consensus confeience. 2uuS.
S. Romig LE. Peuiatiic tiiage: a system to }umpSTART youi tiiage of young patients at NCIs.
}ENS. 2uu2;27(7):S2-6S.
6. Romig LE. Bisastei Nanagement. In APLS: The Peuiatiic Emeigency Neuicine Resouice
4th eu, uausche-Bill N, Fuchs S, Yamamoto L (eus). Suubuiy NA, }ones anu Baitlett, 2uuS.
pp S42-S67.
7. Schonfelu B}. Almost one yeai latei: looking back anu looking aheau. } Bev Behav Peuiati.
2uu2;2S(4):292-294.
8. Schonfelu B}. In times of ciisis, what's a peuiatiician to uo. Peuiatiics 2uu2;11u(1 Pt
1):16S.
9. Schonfelu B}. Suppoiting auolescents in times of national ciisis: potential ioles foi
auolescent health caie pioviueis. } Auolesc Bealth. 2uu2;Su(S):Su2-Su7.

3: Triage Pediatric Disaster Preparedness

1

Chapter 3: Pediatric Triage On-Scene in Disasters
Lou Romig NB
We've all hau that sick feeling in the pit of oui stomach when confionteu with a bauly injuieu
oi ciitically ill chilu. Imagine how you might feel when faceu with numeious injuieu chiluien
anu auults at a chaotic anu peihaps hazaiuous scene. Bow woulu you pioceeu to set youi
piioiities anu tiy to assuie that eveiy patient ieceiveu the best possible caie unuei the
pievailing ciicumstances. With ciying, scieaming anu ominously silent small victims befoie
you, coulu you make the objective uecisions that will help youi team maximize suivival foi
the gieatest numbei of youi patients.
But let's suppose you'ie one of the lucky ones who has hau appiopiiate tiaining is uisastei
tiiage. Bo you know anu unueistanu the uiffeiences between the event-baseu tiiage useu in
uisasteis causeu by physical injuiies, anu the population-baseu tiiage useu in laige scale
biological illnesses. If not, you may finu youiself oveiwhelmeu in a situation when panuemic
influenza thieatens youi community.
Principles of Disaster Triage Following Physical Events
In oiuei to giasp the piinciples of uisastei tiiage, you must iemembei thiee "R's" (Figuie 1).
The fiist "R" is resources. 0ne of the most common uefinitions of a uisastei is a situation in
which neeus outstiip the immeuiately available iesouices. In the ENS context, this means
theie aie insufficient immeuiately available iesouices to meet the meuical neeus of all the
uisastei victims. In such a setting, the usual stanuaius of meuical caie may not be iealistically
achievable.
The seconu "R" is relotive. The scope of a uisastei is ielative to the amount of iesouices
available in the local system. A multi-vehicle ciash with 1u bauly injuieu victims may
constitute a uisastei in a small town with veiy limiteu emeigency caie iesouices. You may
neeu to make uecisions that will iesult in iesouices being uiveiteu fiom one oi moie of those
victims in oiuei to assuie the suivival of the gieatest numbei of patients. The same ciash in a
laige metiopolitan aiea might be easily hanuleu by a system iich in iesouices. Each patient
might be able to ieceive the level of caie they woulu ieceive if they hau been the only victim
in the ciash.
The thiiu "R" is rotionol. Rational action is one way to biing oiganization anu contiol to a
chaotic event. Tiiage in a uisastei is piobably moie effective when meuical uecisions aie
maue baseu on iational, objective ciiteiia that aie applieu equally to all victims. No victim
shoulu ieceive a uiffeient level of tieatment baseu only on iiiational, emotion-baseu
uecisions. Piefeiential tieatment foi any victim oi gioup of victims (such as chiluien oi a
socially- oi cultuially-uefineu gioup) may iesult in an imbalance of iesouices that auveisely
affects the suivival of othei uisastei victims. Without objective guiuelines, pioviueis may
consistently eii on the siue of oveitiiaging kius because we instinctively want to give them
eveiy possible chance. If we tiiage all chiluien to the most ciitical categoiies, we'ie ieally not
tiiaging them at all. Resouices that will bettei benefit chiluien (anu auults) with suivivable
injuiies may be consumeu in fiuitless iesuscitative effoits foi chiluien with a low piobability
of suivival. Rational, objective guiuelines help assuie that iesouices aie uiiecteu in the most
effective anu efficient mannei.

2

In summaiy, uisastei-style tiiage shoulu only be useu in the setting of seveie iesouice
constiaints that manuate a change in the stanuaiu of caie that can be iealistically ueliveieu.
In oui uaily meuical piactice we attempt to give eveiy patient the best possible caie, often
consuming numeious iesouices, even when the chances of suivival aie veiy low. In uisasteis,
when iesouices aie insufficient to meet neeus, oui appioach must change fiom uoing the
best foi each inuiviuual to using the iesouices wheie they will pioviue the gieatest benefit,
even if that means some of the most ciitical patients will ieceive little to no meuical caie.
Becisions about when to use uisastei-style tiiage must be maue on a system-by-system basis
because they must take into account the ielative amount of iesouices available locally. Tiiage
must be peifoimeu baseu on objective, iational uecisions in oiuei to achieve the goal of uoing
the best foi the gieatest numbei of patients anu maximizing suivival.
Why do we need pediatric disaster triage tools?
The tools we use eveiy uay to make meuical tiiage uecisions in the piehospital anu hospital
settings aie piimaiily baseu on obseivations of physiology. Assessment of mental status,
iespiiatoiy function anu ciiculation aie incluueu in eveiy tiiage uecision. Patients who aie
able to maintain a compensateu physiologic state aie usually tiiageu at a lowei piioiity level
than those who have uecompensateu. The physiology of chiluien is uiffeient fiom that of
auults; they have uiffeient physiologic stiengths anu vulneiabilities as well as uiffeient injuiy
patteins uue to theii immatuie anatomy. It stanus to ieason that physiology-baseu tiiage
tools must take into consiueiation the uiffeiences between auult anu peuiatiic physiology. It
coulu also be aigueu that we shoulu have geiiatiic tiiage tools because the baseline
physiology of the elueily vaiies fiom that of youngei healthiei auults. Auults anu chiluien
must be tiiageu baseu on age-appiopiiate guiuelines. This is tiue not only in oui noimal
piactice settings, but also in uisasteis.
Pediatric triage tools must address pediatric physiology
lists some of the ways tiiage tools might neeu to be stiuctuieu to be appiopiiate foi
peuiatiic physiology. Thiesholus foi vital signs must be appiopiiate foi the wiue ianges of
noimal founu in chiluien of uiffeient ages oi stiatifieu accoiuing to age gioups. The
paiameteis assesseu must be quickly anu accuiately obtainable anu commonly evaluateu as a
pait of the noimal meuical piactice of the pioviueis peifoiming tiiage. Two paiticulai
physiologic uiffeiences shoulu be auuiesseu.
Fiist, chiluien usually uie fiom piimaiy iespiiatoiy causes iathei than the caiuiac anu
ciiculatoiy causes usually seen in auults. Chiluien's heaits often uon't stop until they've been
iiieveisibly uamageu uue to anoxia. Except when theie is an acute bloou oi fluiu loss,
ciiculatoiy collapse follows iespiiatoiy failuie. Auults' heaits most often stop because of lack
of ciiculation to the caiuiac muscle; iespiiatoiy aiiest usually follows ciiculatoiy
ueteiioiation. Apnea in an auult is moie often an enupoint, wheieas a chilu with apnea has a
goou chance of having ciiculation iestoieu if bolsteieu immeuiately by effective ventilation
anu auequate oxygenation.
Seconu, appiopiiate peuiatiic neuiological iesponses aie uepenuent on age anu
uevelopmental status. If the abilities to ambulate anuoi follow commanus aie the only
neuiological paiameteis specifieu by the tiiage tool, all veiy young chiluien anu many oluei
chiluien with chionic uisabilities anu special meuical neeus woulu be tiiageu to moie ciitical

3

categoiies simply because they weie not juugeu by appiopiiate neuiological stanuaius.
Although it's piobably bettei to oveitiiage than to unueitiiage, oveitiiage may iesult in
chiluien being subjecteu to stiesses such as unnecessaiy pioceuuies (Iv inseition, spinal
motion iestiiction) oi unnecessaiy sepaiation fiom theii guaiuians anu loveu ones. At least
one stuuy of auult tiauma tiiage algoiithms suggests that the Notoi Response component of
the ulasgow Coma Scoie is a valiu ieflection of seveiity of injuiy.
1
Because the Notoi
Response Scoie is easily applieu to chiluien, this may be the most appiopiiate measuie of
neuiological status to use in a peuiatiic uisastei tiiage tool.
Pediatric Multicasualty (Disaster) Triage Tools
Numeious ENS systems in the 0niteu States use theii uaily tiiage piotocols oi auult-oiienteu
multicasualty tiiage tools to tiiage chiluien in uisasteis. Tiauma tiiage piotocols in uaily use
often utilize the ulasgow Coma Scoie, Peuiatiic Tiauma Scoie, mechanism of injuiy oi othei
elements to ueteimine which chiluien neeu to go to establisheu tiauma centeis. These tools
weie not uevelopeu to be useu in the uisastei setting anu assume that auequate iesouices aie
available to meet the neeus of all patients, no mattei how giavely injuieu. This is a faulty
assumption in a tiue uisastei.
It is foi this ieason that the AJvonceJ Troumo life Support
)
Couise of the Ameiican College of
Suigeons makes a uistinction between multiple cosuolty inciJents (NCIs) anu moss cosuolty
events (NCEs). In the foimei, ENS iesouices aie stiaineu, but not outstiippeu. A goou
example might be a motoi vehicle ciash involving five oi moie victims foi whom caie must
be piioiitizeu, but is most often available within minutes. In the lattei not only local ENS
iesouices, but also iegional ENS iesouices, aie completely oveiwhelmeu. In such
ciicumstances, auuitional ENS iesouices may not be available foi houis, oi even uays. As
such, existing ENS iesouices must ueciue which patients will ieceive caie fiist, anu who must
wait foi caie. Such uecisions may be among the most uifficult ENS piofessionals will evei be
calleu upon to make, especially when they involve chiluien, anu it is foi this ieason that
multicasualty tiiage tools aie of such gieat impoitance to ENS piofessionals in uisasteis -
they help the ENS piofessional make a goou uecision unuei bau ciicumstances. In actual
piactice, the teims "NCI" anu "NCE" aie useu inteichangeably in most ENS systems. Even so,
multicasualty tiiage tools may useful even in NCIs, wheie it may be somewhat moie obvious
which patients iequiie piioiity caie. Bowevei, they aie absolutely inuispensible in NCEs,
when uecisions must be maue quickly, with a minimum of eviuence, yet with a high level of
accuiacy.
MASS Triage
4

The National Bisastei Life Suppoit (NBLS) Couises of the Ameiican Neuical Association anu
the National Bisastei Life Suppoit Founuation - which incluue Core Bisoster life Support
(CBLS), Bosic Bisoster life Support (BBLS), anu AJvonceJ Bisoster life Support (ABLS) - all
auuiess these conceins, baseu on a two-step tiiage piocess. In the fiist step, "NASS" tiiage is
applieu. "NASS" is an acionym that stanus foi ove, ssess, ort, anu enJ. To apply NASS
tiiage in the fielu, the Inciuent Commanuei uses a megaphone oi similai uevice to uiiect all
patients within the sounu of his oi hei voice to Hove to a specifieu location, usually a staging
aiea aujacent to the aiea of opeiations, foi tianspoit to a uistant health caie facility. Bisastei
victims who iesponu to this call have intact mentation, iespiiation, ciiculation, anu
ambulation, hence uo not iequiie immeuiate caie. 0nce the scene has been ueclaieu safe, the

4

Inciuent Commanuei then uiiects small teams of piopeily gaibeu ENS piofessionals to
biiefly Assess the iemaining victims baseu on physiologic status, using a scientifically vetteu
tiiage tool (uiscusseu below), while simultaneously pioviuing the minimum acceptable caie
to auuiess the patient's most immeuiate neeu, such as manual aiiway opening anuoi
exteinal hemoiihage contiol. ENS piofessionals next Sort the victims baseu on both the
acuity, anu the seveiity, of theii conuitions, hence the uigency of the ongoing tieatment
neeueu - mmeJiote, eloyeJ, inor, oi xpectont ("IBNE") - then SenJ them via an
appiopiiate tianspoit vehicle, eithei ambulance, multiple emeigency iesponse vehicle
(NERv), ambulette, oi bus, to the closest health caie facility appiopiiate to pioviue auequate
caie. The "Soit" step is the step when tiiage actually occuis, anu foi puiposes of simplicity
anu convention, the foui steps aie typically coloi-coueu as follows: lmmeJiote = ieu, BeloyeJ
= yellow, Hinor = gieen, Fxpectont = black. In some ENS systems, a fifth tiiage categoiy is
auueu foi patients who aie obviously ueau, anu will still be coloi-coueu black, in which case
Fxpectont patients aie coloi-coueu blue.
The most common auult-baseu NCI tiiage tool in use in the 0S anu in aieas aiounu the woilu
is START (Simple Tiiage Anu Rapiu Tieatment), uevelopeu as a collaboiative effoit between
staff at Boag Bospital anu the Long Beach Fiie anu Naiine Bepaitment in Long Beach,
Califoinia.
2
The tool assigns tiiage categoiies baseu on the ability to walk, piesence of
spontaneous bieathing anu iespiiatoiy iate, palpable pulses oi capillaiy iefill anu the ability
to obey commanus. The use of the ability to walk anu obey commanus anu the iespiiatoiy
iate thiesholu of Su bieaths pei minute make this tool suboptimal foi use foi peuiatiic
victims. Foi moie infoimation, go the START website at www.stait-tiiage.com.
0thei auult-baseu NCI tiiage tools useu aiounu the woilu but not commonly utilizeu in the
0S incluue Caieflight Tiiage (Austialia), the Bomebush Nethou (Austialia), anu the Tiiage
Sieve (0K).
1,S

Two tools uesigneu specifically foi peuiatiic NCIs anu one tool with a peuiatiic mouification
aie in use in the 0S anu elsewheie inteinationally. The }umpSTART Peuiatiic NCI Tiiage Tool
is the tool most commonly useu in the 0S, followeu by the Smait Tape". The Sacco Tiiage
Nethou" (STN) auuiesses all ages anu incoipoiates age-baseu aujustment factois foi
chiluien anu the elueily.
Recently, unuei the auspices of the Feueial Centeis foi Bisease Contiol anu Pievention (CBC),
a woik gioup was conveneu at the behest of seveial laige ENS oiganizations acioss the
nation to ueciue which of the available multicasualty tiiage tools was best suiteu to use in the
fielu by ENS. This action is analogous to that which leu to the uevelopment of a single
national mouel Inciuent Commanu System foi common use in the 0niteu States, which is now
taught by the Bepaitment of Bomelanu Secuiity (BBS) in all its Inciuent Commanu System
(ICS) couises. Known as "SALT" tiiage, foi ort, ssess, ife Sovinq lnterventions, incluuing
hemoiihage contiol, aiiway opening, chest uecompiession, as well as autoinjectoi antiuote
auministiation, anu ronsport, this novel appioach - which has not as yet been scientifically
valiuateu by ENS piofessionals in the fielu - seeks to combine the best featuies of all
cuiiently available tiiage tools, giving ENS piofessionals nationwiue a single, stanuaiuizeu
appioach to fielu tiiage. In fact, most tiiage tools cuiiently in use alieauy compoit with the
SALT paiauigm, so theie may be little neeu to ietiain of laige numbeis of ENS piofessionals
in what is in ieality an accuiate mnemonic foi the steps of ENS uisastei caie.
S


5

JumpSTART
6

The }umpSTART Peuiatiic NCI Tiiage Tool was uevelopeu by Lou Romig NB, FAAP, FACEP, a
peuiatiic emeigency physician at Niami (FL) Chiluien's Bospital with fielu expeiience in ENS
anu uisastei meuicine. Besigneu to follow the same template as the START tiiage tool, which
the uesigneis state is to be useu foi patients weighing moie than 1uu pounus, }umpSTART
(}S) can be useu foi chiluien fiom biith to auolescence. Bi. Romig iecommenus that patients
appeaiing to be 'young auults" be tiiageu with an auult tool such as START anu patients
appeaiing to be less matuie be tiiageu using }S. She avoius a stiictly uefineu age cut-off
because it is often uifficult to accuiately estimate the age of unconscious auolescent patients
anu anticipates that most ENS pioviueis woulu uefine a "young auult" as being in the miu-
teens, wheie the physiologic tiansition to auulthoou is accomplisheu.
shows the }S algoiithm. Patients aie tiiageu into the conventional foui coloi
categoiies of Reu (Ciitical oi Emeigent), Yellow (Inteimeuiate oi Belayeu), uieen (Ninoi)
anu Black (Beceaseu oi Expectant). Tiiage uesignations aie baseu on an assessment of
iespiiations, peifusion, anu mentation (RPN) that shoulu take up to Su seconus to peifoim.
Tiiage begins by uiiecting all ambulatoiy victims to move to a uesignateu site foi fuithei
evaluation. As with START, all patients who can walk aie initially taggeu oi otheiwise
uesignateu in the uieen categoiy. Note that chiluien may be caiiieu into the uieen tiiage aiea
by othei ambulatoiy victims. These chiluien must be tiiageu inuiviuually in the uieen aiea as
quickly as possible (using }S) because they have not pioven theii physiologic stability by
walking.
Nonambulatoiy victims iemaining in place aie tiiageu by iesponueis as they come to them.
The next step in both the }S anu START algoiithms is to assess the patient foi spontaneous
iespiiations. The uppei aiiway is positioneu by the tiiage pioviuei if the patient is apneic.
Pei START, auults who iemain apneic aftei uppei aiiway opening aie taggeu Black without a
pulse check. In }S, chiluien who iemain apneic aie quickly checkeu foi the piesence of a pulse
because they may be in the biief stage wheie they still have uetectable ciiculation. Chiluien
without a uetectable pulse aie taggeu Black. Apneic chiluien with a pulse ieceive five iescue
bieaths via a baiiiei uevice (not a bag-valve-mask) as a lowei aiiway opening maneuvei. The
five bieath ventilatoiy tiiallowei aiiway opening maneuvei is the "jumpstait" pait of the
tiiage tool. Some systems have chosen to waive the pulse check anu give a "jumpstait" to all
apneic chiluien. Patients who begin to bieathe spontaneously with the ventilatoiy tiial aie
taggeu Reu. The tiiage pioviuei moves on to the next patient without stopping to pioviue
tieatment. In some systems, tiiage pioviueis caiiy oial aiiways anu may use them on these
Reu patients to tiy to maintain an aiiway without active suppoit. Patients who iemain apneic
aftei both uppei anu lowei aiiway opening aie taggeu Black, as it is unlikely they will be able
to continue to geneiate auequate ciiculation without ventilatoiy suppoit. In small inciuents
with auuitional iesouices becoming quickly available such suppoit may be possible; in laige
inciuents oi those with scant iesouices it will not. These patients, although not yet ueau, aie
not expecteu to suivive unuei the iesouice constiaints of a uisastei.
Chiluien bieathing at a iate of 1S-4S bieaths pei minute aie then assesseu foi peifusion.
Those bieathing fastei than 4S oi slowei than 1S bieaths pei minute aie taggeu Reu anu not
assesseu fuithei by the tiiage pioviuei. The auult thiesholu foi Reu uesignation is Su bieaths
pei minute; theiefoie the combineu }SSTART iespiiatoiy iate thiesholus aie 1S-Su-4S, easy
to iemembei multiples of 1S.

6

Chiluien with acceptable iespiiatoiy iates aie assesseu foi the piesence of a pulse. Although
a peiipheial pulse is piefeiable, iesponueis shoulu assess whatevei pulse they'ie most
confiuent in assessing. Chiluien with no palpable pulse oi a weak pulse aie taggeu Reu anu
the pioviuei moves on, pausing only to quickly attempt to contiol active bleeuing. Nental
status is assesseu next in those patients with goou pulses.
AvP0 is the gauge of mental status useu by }umpSTART. Chiluien who have acceptable
iespiiatoiy iates, goou pulses anu who aie eithei Aleit, iesponsive to veibal stimulus, oi
who iesponu appiopiiately to Pain with a localizing iesponse aie taggeu Yellow. Those who
have goou iespiiations anu peifusion but who have an inappiopiiate geneializeu iesponse to
Pain, postuiing oi who aie tiuly 0niesponsive aie taggeu Reu. Note that the thiesholu of
appiopiiate vs. inappiopiiate iesponse to pain coiiesponus to a bieak between levels 4 anu S
in the Notoi Response poition of the ulasgow Coma Scoie.
Chiluien who oiuinaiily can't walk because of age, uevelopmental uelay oi uisability aie
auuiesseu using a mouification of the }S algoiithm. Noimally- nonambulatoiy chiluien who
meet Yellow ciiteiia aie quickly scanneu foi exteinal signs of significant injuiy such as
significant buins oi tissue avulsionsamputations, penetiating injuiies, oi abuominal
uistention. Those with these signs iemain taggeu Yellow. Those without exteinal signs of
significant injuiy aie taggeu uieen, even though they can't walk.
Bi. Romig has maue all }umpSTART mateiials available foi fiee uownloau fiom hei website at
www.jumpstaittiiage.com. Pioviueis aie able to use anu iepiouuce the mateiial without
explicit peimission so long as it is useu only foi piotocol anu euucational puiposes.
}umpSTART is in wiue use thioughout Noith Ameiica anu is taught in many aieas
inteinationally. In 2uu6 it was iecommenueu by a national auvisoiy committee foi auoption
thioughout Isiael.
7,8
}umpSTART has also been auopteu by numeious hospitals foi use in
theii Emeigency Bepaitments when uisasteis iesult in laige numbeis of incoming victims
not alieauy tiiageu on scene by ENS. A mouifieu veision of }umpSTART has also been
uevelopeu foi use by iescue peisonnel woiking in a hot zone wheie the ability to access anu
apply bag-valve-mask (BvN) uevices may be limiteu.
9


7

Smart Tape
The Smait Tape", uesigneu anu uistiibuteu by TSu Associates in uieat Biitain, is in use in
New Yoik, Connecticut, Nassachusetts, Illinois anu Noith Caiolina, as well as othei locations
aiounu the woilu. This uevice is also iefeiieu to as the Peuiatiic Tiiage Tape (PTT). This
length-baseu tool uefines the stanuaiu tiiage categoiies baseu on an NRP oi RPN
(NobilityNotoi, Respiiatoiy, PeifusionPulse) assessment, with age-aujusteu paiameteis in
foui length age gioups. The thiee peuiatiic gioups aie: Su-8u cm S-1u kg; 8u-1uu cm
11-18 kg, 1uu-14u cm 19-S2 kg, >14u cm >S2 kg. Each compaitment length age section
has a tiiage algoiithm with vital signs coiiecteu foi age 1u.
The tiiage appioach is uiviueu into thiee assessments: mental status & walking; bieathing;
anu ciiculation (incluues capillaiy iefill anu heait iate). The fiist uecision point is baseu on
mental status anu mobility. If the chilu is aleit anu moving all limbs oi walking they aie
tiiageu to a low piioiity (gieen); if not, the tape is openeu anu the assessment of bieathing is
peifoimeu.
If the chilu is not bieathing, they have theii aiiway openeu, anu they aie still not bieathing,
they aie consiueieu ueceaseu (black). If the chilu begins bieathing aftei theii aiiway is
openeu, they aie consiueieu highest piioiity (ieu). If the chilu is bieathing, the iespiiatoiy
iate is counteu. The "noimal" iespiiatoiy iates baseu on length age aie: S-1u kg - 2u-Su
bieaths pei minute; 11-18 kg - 1S-4u bieaths pei minute, 19-S2 kg 1u-Su bieaths pei
minute. 0vei S2 kg they aie assesseu baseu on auult noims. If the iespiiatoiy iate is above
oi below noimal bounus foi age, the chilu is given the highest (ieu) piioiity. If the iate is
within the noimal bounus, capillaiy iefill (foieheau oi chest) oi pulse iate is assesseu.
If the capillaiy iefill is > 2 seconus then the chilu is given a miuule level piioiity (yellow). If
the capillaiy iefill is < 2 seconus then the pulse iate is assesseu. The "noimal" pulse iates
baseu on length age aie: S-1u kg - 9u-18u beats pei minute; 11-18 kg - 8u-16u beats pei
minute, 19-S2 kg 7u-14u beats pei minute. 0vei S2 kg they aie assesseu baseu on auult
noims. If the pulse iate is above oi below noimal bounus foi age the chilu is given the
highest (ieu) piioiity. If the iate is within the noimal bounus, the chilu is assigneu a miuule
piioiity (yellow).
The peuiatiic tiiage tape (PTT) was valiuateu against stanuaiu tiauma scoiing in an
emeigency uepaitment setting. Thiee thousanu foui hunuieu sixty one chiluien piesenting
to a chiluien's hospital in Cape Town ovei a nine month peiiou weie tiiageu using the PTT.
The PTT categoiy was compaieu to ISS (injuiy seveiity scoie), NISS (New Injuiy Seveiity
Scoie) anu peuiatiic inteivention scoie uevelopeu by uainei. Compaieu to an ISS > 1S the
PTT hau a sensitivity of S7.8%, specificity of 98.6%, oveitiiage iate of S8.8%, anu an
unueitiiage iate of S.S%. The peifoimance was similai compaiing to the NISS anu uainei
ciiteiia.
The PTT has a low sensitivity at iuentifying immeuiate piioiity chiluien by these ciiteiia, the
specificity (iuentify non high piioiity patients) is excellent. The oveitiiage anu unueitiiage
iates aie within the iange ueemeu unavoiuable by the Ameiican College of Suigeons.
18

Auuitional infoimation can be obtaineu fiom the TSu Associates website at
http:www.tsgassociates.co.uk.

8

Sacco Triage Method
The Sacco Tiiage Nethou (STN) is the only NCI tiiage tool cuiiently available that is baseu on
tiauma patient outcome uata. Nameu aftei its oiiginatoi, Bi. Bill Sacco, a ienowneu
mathematician with extensive backgiounu in tiauma scoiing, the STN was ueiiveu fiom
analysis of ietiospective uata fiom seveial hunuieu thousanu 0S tiauma iegistiy patients of
all ages.
11-1S
Scoies ueiiveu fiom an RPN assessment iange fiom u-12, with the lowei scoies
inuicating the most ciitically injuieu anu, ultimately, those with the lowest piobability of
suivival. Age aujustments aie maue aftei the RPN assessment; infants anu chiluien gain 1-2
auuitional points anu oluei patients lose 1-2 points.
14
Tiauitional tiiage categoiy coloi
uesignations aie not useu. Insteau, a piopiietaiy softwaie piogiam uynamically analyzes anu
matches iesouices anu patient neeus to foimulate a tianspoit plan that uesignates which
categoiy patients aie tianspoiteu, in what oiuei, wheie they shoulu go anu by what
tianspoit means. As auuitional iesouices become available oi aie satuiateu, the analysis can
be iepeateu anu an aujusteu tianspoit plan composeu. Theie is also a "iule-baseu" veision of
the STN that uoes not iequiie communication fiom the scene oi softwaie.
The Sacco Tiiage Nethou is gaining in acceptance in the 0S anu is unuei sciutiny by agencies
aiounu the woilu. Foi moie infoimation, go to the Think Shaip website at
http:www.shaipthinkeis.com.
Limitations of Existing Disaster Triage Tools
Because of the infiequent neeu to use uisastei tiiage anu the uifficulty of collecting accuiate
uata in uisasteis, none of the existing tiiage tools have been clinically valiuateu in the uisastei
setting. Seveial small stuuies baseu on uiill uata anu simulations have suggesteu that START
anu START-like tools such as }umpSTART lack sufficient sensitivity, specificity anu inteiiatei
ieliability to yielu significant auvantage. Reseaich is neeueu to ueteimine if any of the tools
cuiiently in use aie clinically valiu anu ieliable.
Tiiage is a uynamic piocess because patient conuitions anu neeus change ovei time. Nost
tiiage tools aie meant to be useu only in piimaiy tiiage, as a gioss soiting mechanism.
Subsequent patient anu iesouice assessments may iesult in up- oi uown-tiiaging of patients
at any time. The "Seconuaiy Assessment of victim Enupoint" oi "SAvE" methou is the only
stanuaiuizeu tool available to uiiect tiiage aftei moie uetaileu seconuaiy assessments of
uisastei patients have been maue on-scene oi at othei points of caie.
2
SAvE has also not
been clinically valiuateu.
Finally, the cuiiently useu NCI tiiage tools weie uevelopeu to ueal with victims of
conventional tiauma. They aie piobably not auequate foi use foi patients of any age with
potentially moie uiveise anu complex meuical conuitions. Tiiage tools foi multiple oi mass
casualty inciuents involving meuical uisasteis such as Buiiicane Katiina anu panuemic
influenza, inuustiial uisasteis anu the ueployment of weapons of chemical, biological anu
iauiological natuie must still be uevelopeu.
Principles of Disaster Triage during Biological Events
While physical disasters are usually associated with instantaneous occurrences, such as hurricanes,
building collapses, or intentional bomb blasts, biological disasters, whether naturally occurring, or
human made, do not present at a single moment in time, but over an extended period. They are

9

also contagious in a way that even dispersible chemical and radiological agents are not. Thus, the
goal of triage in biological disasters is to do the greatest good not only for the greatest number of
present victims of the illness in question, but also for the greatest number of future victims of the
illness those susceptible, but not yet exposed, to the responsible infectious agent, or its vector.
The teim "bioevent" has iecently been applieu to laige scale biologically inuuceu uisasteis,
whethei spontaneous oi uelibeiate. Such events have the innate ability to biing about
liteially thousanus of casualties ovei the couise of just a few uays oi weeks, which woulu
thence iequiie emeigency meuical seivices (ENS) to pioviue initial tiiage, tieatment, anu
tianspoit. Noieovei, uue to the infectious chaiactei of most biological illnesses, factois othei
than acuity anu seveiity neeu to be consiueieu uuiing tiiage. Nost impoitant among these
aie the intensity anu uuiation of exposuie to the uisease vectoi, as well as the infectiousness
of the involveu miciobe.
The goal of tiiage in bioevents, theiefoie, is not meiely, oi even piimaiily, the iuentification
of victims iequiiing the most immeuiate caie. Insteau, it is the prevention of furtber
tronsmission, as measuieu by the inciJence of seconJory infection in otheis, fiom the fiist
point anu moment of contact with the inuex case oi cases. Inueeu, by focusing on the neeu
foi acute caie of uisease victims, conventional tiiage actually impeues contiol of the
tiansmission iate. Foi example, ENS pioviueis who focus on immeuiate tieatment of
afflicteu patients without iegaiu foi appiopiiate piecautions, stanuaiu, aiiboine, oi uioplet,
iisk spieauing the uisease fiom the fielu into the hospital, potentially infecting scoies if not
hunuieus of othei patients anu health caie piofessionals. At the same time, failuie to
iecognize victims in the eaily stages of uisease, when tieatment is often moie effective, leaus
to fuithei spieau of the uisease outsiue the hospital, hence peipetuation oi piolongation of
the epiuemic.
Consequently, the fiist step in tiiage of patients in bioevents is to ueteimine whethei
potential victims piobably ore, oi piobably aie not, infecteu oi exposeu, then to assign them
to specific tiiage categoiies baseu upon this likelihoou, using a bioevent tiiage system such as
the "SEIRv" methouology uelineateu in Figuie 4.
1S
This iequiies a sciipteu seiies of
questions best poseu not by ENS pioviueis, but via piioiity access to a telephone "hotline" oi
public safety (oi health) answeiing point (PSAP), such as 911, oi in some cities (such as New
Yoik), S11. Baseu on the onset, uuiation, type, anu seveiity of symptoms, patients can then
be tiiageu uiiectly to specially uesignateu inpatient facilities, outpatient clinics, points of
uistiibution (P0Bs) foi antibiotic meuications, oi home foi self- oi assisteu-caie. The 0.S.
Centeis foi Bisease Contiol anu Pievention (CBC) have calleu foi such telephone tiiage
systems to be useu in guiuing emeigency tianspoits in case of a bioevent. The CBC has also
unuei such ciicumstances calleu foi 1) plans foi cooiuination with othei tianspoit iesouices
in case laige numbeis of patients neeu to be tianspoiteu at the height of an epiuemic, 2)
tianspoit of multiple patients uuiing a single iun, anu S) use of iesouices othei than
ambulances anu othei vehicles uesigneu foi meuical tianspoit, such as buses.
The neeu foi a centializeu, juiisuictional Emeigency Bealth 0peiations Centei (EB0C) with
the absolute authoiity to make uecisions affecting the health of the population afflicteu by a
bioevent uisastei is self eviuent. Beie, tactical opeiations anu tiaining activities can be
cooiuinateu, anu health systems anu pioviueis kept abieast of evolving ciicumstances anu
available iesouices that may iequiie ongoing changes in tiiage algoiithms. Foi example, the
piactice of laige-scale, population-baseu tiiage necessitates establishment of both "minimum
qualifications foi suivival" (NQS), consisting of pieviously ueteimineu, officially sanctioneu

10

ciiteiia that set foith which cases will not ieceive uefinitive caie; anu "exclusion ciiteiia",
unuei which ceitain specifieu meuical conuitions woulu not ieceive the optimal iesouices,
such as iesuscitation, noimally pioviueu to such cases unuei the usual "inclusion ciiteiia".
Baseu upon changing gaps between patients' neeus anu available health caie iesouices, both
the NQS anu the exclusion ciiteiia might neeu to be aujusteu by the EB0C, utilizing such
ciiteiia as 1) availability of ciitical caie iesouices, incluuing intensive caie unit beus anu
mechanical ventilatois, 2) acuity anu seveiity of patient illness, categoiizeu by stanuaiuizeu,
valiuateu clinical scoiing methouologies, such as the Sequential 0igan Failuie Assessment
(S0FA) scoie, anu S) ethical anu moial stanuaius of the community.
16
Tiiage uecisions must
then be maue accoiuingly, iecognizing that the public will accept such tiiage, hence iationing,
only if the tiiage ciiteiia aie honestly anu tianspaiently uevelopeu. Roles anu
iesponsibilities of the Emeigency Bealth 0peiations Centei (EB0C) aie listeu in Figuie S.
17

The success of the tiiage methouology applieu in any laige scale bioevent will be ueteimineu
by a numbei of factois. The most impoitant of these is a uecline in the numbei of patients
assigneu to the "usceptible" tiiage categoiy, which inuicates a ueciease in the iate of uisease
tiansmission. A tiansmission iate (Ru) > 1 inuicates the epiuemic will piogiess, while a
tiansmission iate (Ru) < 1 inuicates that the illness will eventually uisappeai, especially if this
is obseiveu among vulneiable populations. By contiast, if Ru = 1, the uisease will become
enuemic. 0thei factois that shoulu be consiueieu incluue uecieasing moitality anu moibiuity
associateu with the epiuemic, as well as appiopiiate iesouice uistiibution acioss the infecteu
population.
In conclusion, the iequiiements foi uisastei tiiage in bioevents aie funuamentally uiffeient
than in othei CBRNE events. Since the counteiintuitive goal in bioevents is primorily to
contiol seconuaiy infections, anu seconJorily to contiol piimaiy infections, piehospital tiiage
systems must be optimizeu thiough centializeu commanu anu contiol mechanisms. This will
facilitate ieuuction in the numbei of susceptible patients, theieby minimizing the buiuen of
caie among health management systems seiving the afflicteu population.
Summary
Although the iueal peuiatiic uisastei tiiage tool piobably uoes not yet exist, it is ieasonable
that having an objective peuiatiic-specific tool to use in multiple anu mass casualty inciuents
will help biing oiuei out of chaos, give those peifoiming tiiage objective guiuance, assuie
that chiluien aie given appiopiiate caie anu, hopefully, assist in maximizing suivival foi
uisastei victims of all ages.
The uisastei tiiage tools most commonly useu to meet the neeus of CBRNE-injuieu chiluien
in the piehospital setting in the 0niteu States aie }umpSTART, the Smait Tape anu the Sacco
Tiiage Nethou. Fuithei ieseaich is neeueu to valiuate oi mouify these tools anu to uevelop
new tiiage tools foi chiluien in meuical anu inuustiial uisasteis as well as those involving
weapons of mass uestiuction. By contiast, the uisastei tiiage tool most commonly useu to
meet the neeus of bioevent-infecteu chiluien in the piehospital setting in the 0niteu States is
SEIRv. uiven the likelihoou of an outbieak of panuemic influenza in the neai futuie, ENS
pioviueis must be piepaieu to shift theii focus to this tiiage tool as seamlessly as possible.


11

. The Thiee "R's" of Bisastei Tiiage

Resouices
Neeus outstiip the immeuiately available iesouices
Relative
Local iesouice constiaints uefine a uisastei
Rational
Tiiage shoulu be baseu on iational, objective uecisions

12

. Tiiage tool mouifications foi chiluien

SYSTEM

DIFFERENCES CHANGES TO TOOLS
Airway
Aiiway is vulneiable to obstiuction.
Apnea uue to obstiuction may be
ieveisible if caught quickly.
Piioiitize aiiway opening
maneuvei(s)
Noimal iespiiatoiy iate iange is highei

Altei iespiiatoiy iate
thiesholus
Breathing
Slow bieathing is moie ominous than
tachypnea
Incluue low iespiiatoiy iate
thiesholu

Noimal heait iate iange is highei Altei heait iate thiesholus
vulneiable to cool enviionments Capillaiy iefill may be
unieliable
Bifficult anu time consuming to obtain
accuiate bloou piessuie

Bon't use BP as an
assessment paiametei

Circulation
Beait uies aftei a peiiou of anoxia.
Ciiculation may be sustaineu foi a biief
time befoie the heait is iiieveisibly
uamageu

Check foi ciiculation in an
apneic chilu
Ability to veibalize anu obey commanus
vaiies with age
0se Best Notoi Scoie
Neuro
Ability to ambulate is uevelopmentally
uepenuent

Bon't use the ability to walk
as the only ueteiminant of
nonuigent status


13

. The }umpSTART Peuiatiic NCI Tiiage Tool (useu with peimission)

14

Figure 4. "SEIRv" bioevent tiiage methouology
Susceptible but not exposeu
Exposeu but not infecteu
Infecteu
Removeu by ueath oi iecoveiy
Vaccinateu oi piotecteu by meuication

15

Figure 5. Roles and responsibilities of the Emergency Health Operations Center (EHOC)
Situational awaieness
Link iegional iesouices
Bevelop anu maintain stiategic alliances
Facilitate anu integiate iesouices
Communicate anu ieinfoice
Tiiage iesouices anu uecisions
}ust-in-time tiaining
Neasuies of effectiveness


16

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16. Chiistian et al. A tiiage piotocol foi ciitical caie uuiing a panuemic. CHA} Novembei
2uu6.
17. Baibisch B. Tbe Proctice of Community Fmerqency Public Eeoltb.

17

18. Wallis LACailey . valiuation of the Peuiatiic Tiiage Tape. Fmerq HeJ } 2uu6;2S:47-Su.

Other resources:
Bisastei Nanagement chaptei in Auvanceu Peuiatiic Life Suppoit Couise, 4th euition,
Ameiican College of Emeigency Physicians anu Ameiican Acauemy of Peuiatiics, 2uu4. |Fix
iefeience.j
Peuiatiic Issues in Bisasteis anu Nulticasualty Inciuents in Teaching Resouice foi Instiuctois
of Piehospital Peuiatiics: Paiameuic, u. Foltin, eu. Centei foi Peuiatiic Emeigency Neuicine,
2uu1. |Fix iefeience.j
Sztanjnkiycei N, Nausen B, Baez A. 0nstable Ethical Plateaus anu Bisastei Tiiage. Fmerq HeJ
Clin N A 2uu6; 24(S).
Illinois ENSC Peuiatiic Bisastei Piepaieuness uuiuelines
http:www.luhs.oigueptsemscpeuuisasteiguiue.puf
Floiiua ENSC Piogiam Kius in Bisasteis Kit. Available fiom the ENSC National Resouice
Centei http:bolivia.hisa.govemsc
}umpSTART www.jumpstaittiiage.com
Smait Tape www.tgaassociates.co.uk
Sacco Tiiage Nethou www.shaipthinkeis.com
4: Prehospital Disaster Medical Systems Pediatric Disaster Preparedness

1

Chapter 4: Prehospital Disaster Medical Systems
Arthur Cooper, MD
Introduction
Patient caie, both in the fielu anu in the hospital, is noimally ueliveieu to one inuiviuual
patient at a time by health caie pioviueis woiking as inuiviuuals oi in one oi moie teams.
Piehospital piofessionals aie accustomeu to ienueiing emeigency caie in this mannei as a
ioutine, at the scene anu uuiing tianspoit, anu typically uo so inuepenuent of the uiiect
involvement of othei public health oi safety piofessionals. By contiast, patient caie in
uisasteis is ueliveieu to multiple patients by limiteu numbeis of health caie pioviueis
oiganizeu as small meuical iesponse teams. This iequiies collaboiation with othei public
health anu safety piofessionals, hence a cooiuinateu inciuent management system (INS).
Bospital-baseu health caie pioviueis take such oiganization foi gianteu: foi eveiy allieu
health piofessional, nuise, oi physician, theie aie numeious othei hospital employees whose
task it is to make suie patients have the facilities, iesouices, anu staff they neeu to ensuie a
speeuy iecoveiy fiom illness oi injuiy, anu that the inuiviuuals pioviuing health caie have
the tools iequiieu to caie foi patients when anu wheie they neeu them. While emeigency
meuical seivices (ENS) agencies also iequiie auministiative anu opeiational suppoit, few
such agencies appioach the complexity of mouein hospital oiganizations. Bowevei, in tiue
uisasteis, ENS agencies must uo exactly what hospitals ioutinely uo: biing to beai myiiau
healthcaie iesouices to the aiu of numeious patients moie oi less simultaneously, with
efficiency anu economy of effoit, lest any salvageable life be lost. It is the puipose of this
chaptei to uesciibe the inciuent management system (INS) in common use in the 0niteu
States, how ENS peisonnel iueally woik within it, anu the Feueial assets that can be biought
to beai to assist in a Piesiuentially ueclaieu uisastei.
National Incident Management System (NIMS)
Piehospital uisastei meuical systems in the 0niteu States aie baseu on the National Inciuent
Nanagement System (NINS). This was manuateu by EomelonJ Security PresiJentiol
Birective,ESPB-S, Subject: Honoqement of Bomestic lnciJents, issueu by Piesiuent ueoige W.
Bush on Febiuaiy 28, 2uuS, which unuei Sections (1), (S), anu (1S) uuly establisheu the
following as the official couise of action of the 0niteu States uoveinment, anu which as a
Piesiuential Biiective iemains legally in foice until such time as uuly iescinueu by the
Piesiuent himself, oi his successoi in that office:
1

Purpose
(1) To enhance the ability of the 0niteu States to manage uomestic inciuents by establishing
a single, compiehensive national inciuent management system. . . .
Policy
(S) To pievent, piepaie foi, iesponu uo, anu iecovei fiom teiioiist attacks, majoi uisasteis,
anu othei emeigencies, the 0niteu States uoveinment shall establish a single, compiehensive
appioach to uomestic inciuent management. The objective of the 0niteu States uoveinment
is to ensuie that all levels of goveinment acioss the Nation have the capability to woik

2

efficiently anu effectively togethei, using a national appioach to uomestic inciuent
management. In these effoits, with iegaiu to Jomestic inciJents, tbe 0niteJ Stotes 6overnment
treots crisis monoqement onJ consequence monoqement os o sinqle, inteqroteJ function, rotber
tbon os two seporote functions. . .
Tasking
(1S) The Secietaiy |of Bomelanu Secuiityj shall uevelop, submit foi ieview to the Bomelanu
Secuiity Council, anu auministei a National Inciuent Nanagement System (NINS). The
system will pioviue a consistent nationwiue appioach foi Feueial, State, anu local
goveinments to woik effectively anu efficiently togethei to piepaie foi, iesponu to, anu
iecovei fiom uomestic inciuents, iegaiuless of cause, size, oi complexity. To pioviue foi
inteiopeiability anu compatibility among Feueial, State, anu local capabilities, the NINS will
incluue a coie set of concepts, piinciples, teiminology, anu technologies coveiing the inciuent
commanu system; multi-agency cooiuination systems; unifieu commanu; tiaining;
iuentification anu management of iesouices (incluuing systems foi classifying types of
iesouices); qualifications anu ceitification; anu the collection, tiacking, anu iepoiting of
inciuent infoimation anu inciuent iesouices. . . .
This single, compiehensive appioach to the management of teiioi events anu uisasteis is
known as the "all hazaius" appioach, because it utilizes a single national fiamewoik foi
inciuent iesponse iegaiuless of the type of inciuent being manageu, with bianch points in the
iesponse piotocol that auuiess specific conceins ielateu to the actual type of inciuent,
whethei hemical, iological, auioactive, ucleai, oi xplosiveIncenuiaiy (). The
benefits of auopting the NINS in teims of cooiuinateu - theiefoie effective - action by all
peisonnel anu agencies iesponuing to a teiioi event oi a uisastei aie self eviuent.
The intent of NINS is to "pioviue a fiamewoik foi inteiopeiability anu compatibility by
balancing flexibility anu stanuaiuization." Its "flexible fiamewoik . . . facilitates goveinment
anu piivate entities at all levels woiking togethei . . . ." Its "stanuaiuizeu oiganizational
stiuctuies . . . impiove opeiability." The components of NINS, as uefineu by the Secietaiy of
Bomelanu Secuiity, incluue the following six elements, each of which will be auuiesseu in
fuithei uetail in the sections that follow the list below, in language quoteu uiiectly fiom the
lS-700 NlHS Course Summory to avoiu confusion
2
:
Commanu anu management
Piepaieuness
Resouice management
Communications anu inciuent management
Suppoiting technologies
0ngoing management anu maintenance
Command and Management
"NINS inciuent management stiuctuies aie compiiseu of thiee impoitant systems:
The Inciuent Commanu System (ICS), which uefines the opeiating chaiacteiistics,
management components, anu stiuctuie of inciuent management oiganizations
thioughout the life cycle of an inciuent.

3

Nultiagency Cooiuination Systems, which uefine the opeiating chaiacteiistics
management components, anu oiganizational stiuctuie of suppoiting entities.
Public Infoimation Systems, which incluue the piocesses, pioceuuies, anu systems foi
communicating timely anu accuiate infoimation to the public uuiing emeigency
situations.
Preparedness
"Effective inciuent management begins with a host of piepaieuness activities. These
activities aie conuucteu on a 'steauy-state' basis, as well as in auvance of any potential
inciuent. Piepaieuness involves a combination of:
Planning, tiaining, anu exeicises.
Peisonnel qualification anu equipment stanuaius.
Equipment acquisition anu ceitification stanuaius.
Publication management piocesses anu activities.
Nutual aiu agieements anu Emeigency Nanagement Assistance Compacts.
Resource Management
"When fully implementeu, NINS will uefine stanuaiuizeu mechanisms anu establish
iequiiements foi uesciibing, inventoiying, mobilizing, uispatching, tiacking, anu iecoveiing
iesouices ovei the life cycle of an inciuent.
Communications and Information Management
"NINS iuentifies the iequiiements foi a stanuaiuizeu fiamewoik foi communications,
infoimation management, anu infoimation-shaiing suppoit at all levels of inciuent
management.
Inciuent management oiganizations must ensuie that effective, inteiopeiable
communications piocesses, pioceuuies, anu systems exist acioss all agencies anu
juiisuictions.
Infoimation management systems help ensuie that infoimation flows efficiently thiough
a commonly accepteu aichitectuie. Effective infoimation management enhances inciuent
management anu iesponse by helping to ensuie that uecision-making is bettei infoimeu.
Supporting Technologies
"Technology anu technological systems pioviue suppoiting capabilities essential to
implementing anu iefining NINS. Examples incluue:
voice anu uata communication systems.
Infoimation management systems, such as iecoiukeeping anu iesouice tiacking.
Bata uisplay systems.

4

"Suppoiting technologies also incluue specializeu technologies that facilitate ongoing
opeiations anu inciuent management activities in situations that call foi unique technology-
baseu capabilities.
Ongoing Management and Maintenance
"BBS establisheu the NINS Integiation Centei to pioviue stiategic uiiection anu oveisight in
suppoit of ioutine ieview anu continual iefinement of both the system anu its components
ovei the long teim."

National Response Framework (NRF)
The Notionol Response Iromework (NRF), appioveu by the Piesiuent on }anuaiy 8, 2uu8,
ieplaces the Notionol Response Plon (NRP) calleu foi in BSPB-S, which was vieweu by many
as both too piesciiptive anu uetaileu to be useful in a uisastei iesponse, anu insufficiently
cognizant of the iole of piivate anu nongoveinmental oiganizations.
S
The NRF, again quoting
uiiectly fiom the lS-800.B NRI Course 0verview, "piesents the guiuing piinciples that enable
all iesponse paitneis to piepaie foi anu pioviue a unifieu national iesponse to uisasteis anu
emeigencies - fiom the smallest inciuent to the laigest catastiophe.
4
Builuing on the
National Inciuent Nanagement System, the Fiamewoik's cooiuinating stiuctuies align key
ioles anu iesponsibilities fosteiing iesponse paitneiships at all levels of goveinment, anu
with nongoveinmental oiganizations anu the piivate sectoi. uiven its flexibility anu
scalability, the National Response Fiamewoik is always in effect anu elements can be
implementeu at any level anu at any time.
"The Fiamewoik establishes a iesponse vision thiough five key piinciples. . . .
4
" These key
piinciples aie known as response doctrines. "Response uoctiine uefines basic ioles,
iesponsibilities, anu opeiational concepts foi iesponse acioss all levels of goveinment anu
with the piivate sectoi anu nongoveinmental oiganizations. It is impoitant to iemembei
that the oveiaiching objective of iesponse activities is life safety, followeu by piotecting
piopeity anu the enviionment."
S

Engaged partnership- "Leaueis at all levels |mustj uevelop shaieu iesponse goals anu align
capabilities so that no one is oveiwhelmeu in times of ciisis.
Tiered response- "Inciuent must be manageu at the lowest possible juiisuictional level anu
suppoiteu by auuitional capabilities when neeueu.
Scalable, flexible, and adaptable operational capabilities - "As inciuents change in size, scope,
anu complexity, the iesponse must auapt to meet iequiiements.
Unity of effort through unified command- "0nity of effoit iespects the chain of commanu of
each paiticipating oiganization while hainessing seamless cooiuination acioss juiisuictions
in suppoit of common objectives.
Readiness to act- "It is oui collective uuty to pioviue the best iesponse possible. Fiom
inuiviuuals, householus, anu communities to local, tiibal, State, anu Feueial goveinments,
national iesponse uepenus on oui ieauiness to act.

5

"The National Response Fiamewoik stiives to impioveu cooiuination among all iesponse
paitneis. Anu thiough these paitneiships, |Ameiicansj can woik togethei to help save lives
anu piotect |itsj communities."
4

Engaged Partnership
"Effective iesponse activities begin with a host of piepaieuness activities conuucteu well in
auvance of an inciuent. Piepaieuness involves a combination of planning, iesouices, tiaining,
exeicising, anu oiganizing to builu, sustain, anu impiove opeiational capabilities. Key
Concept: Engaged partnersbips are essential to preparedness. . . .

Tiered Response
"Inciuents begin anu enu locally, anu most aie manageu at the local level. Nany inciuents
iequiie unifieu iesponse fiom local agencies, the piivate sectoi, anu nongoveinmental
oiganizations. 0thei inciuents may iequiie auuitional suppoit fiom neighboiing
juiisuictions oi the State. A small numbei iequiie Feueial suppoit. National iesponse
piotocols iecognize this anu aie stiuctuieu to pioviue auuitional, tieieu levels of suppoit.
Key Concept: A basic premise of tbe Framework is tbat incidents are generally bandled
at tbe lowest |urisdictional level possible. . . .
Scalable, Flexible, and Adaptable Operational Capabilities
'The numbei, type, anu souices of iesouices must be able to expanu iapiuly to meet the neeus
associateu with a given inciuent. The Fiamewoik builus on the National Inciuent
Nanagement System (NINS). Togethei, the Fiamewoik anu NINS help to ensuie that all
iesponse paitneis use stanuaiu commanu anu management stiuctuies that allow foi
scalable, flexible, anu auaptable opeiational capabilities. . . . Key Concept: As incidents
cbange in size, scope, and complexity, tbe response must adapt to meet tbese
requirements.
Unity of Effort Through Unified Command
Success iequiies unity of effoit, which iespects the chain of commanu of each paiticipating
oiganization while hainessing seamless cooiuination acioss juiisuictions in suppoit of
common objectives. As a team effoit, unifieu commanu allows all agencies with juiisuictional
authoiity anuoi functional iesponsibility foi the inciuent to pioviue joint suppoit thiough
mutually uevelopeu inciuent objectives anu stiategies. Each paiticipating agency maintains
its own authoiity, iesponsibility, anu accountability. . . ."
4
Key Concept: "Unified command
benefits include a collective, strategic approacb, |oint priorities and resource
allocation, single plan and set of ob|ectives, improved information flow and
coordination. . . .
Readiness To Act
A foiwaiu-leaning postuie is impeiative foi inciuents that have the potential to expanu
iapiuly in size, scope, oi complexity, oi foi no-notice inciuents. 0nce iesponse activities have
begun, on-scene actions aie baseu on NINS piinciples. An effective national iesponse ielies
on uisciplineu piocesses, pioceuuies, anu systems. Key Concept: Readiness to act is a

6

collective responsibility. Effective national response depends on our readiness to act. .
. .
National Response Framework Organization
"The National Response Fiamewoik is compiiseu of the coie uocument, the Emeigency
Suppoit Function (ESF), Suppoit, anu Inciuent Annexes, anu the Paitnei uuiues. The coie
uocument uesciibes the uoctiine that guiues oui national iesponse, ioles anu iesponsibilities,
iesponse actions, iesponse oiganizations, anu planning iequiiements to achieve an effective
national iesponse to any inciuent that occuis."
4

National Response Framework Components
Core Document: The coie uocument piesents:
An Introduction to the uoctiine that guiues oui national iesponse.
Roles and Responsibilities incluuing who is involveu with emeigency management
activities at the local, tiibal, State, anu Feueial levels anu with the piivate sectoi anu
nongoveinmental oiganizations.
Response Actions that uesciibe what we as a Nation collectively uo to iesponu to
inciuents.
Response Urganization specifying how we as a Nation aie oiganizeu to implement
iesponse actions.
Planning iequiiements to achieve an effective national iesponse to any inciuent that
occuis.
Annexes:
S
"The following uocuments pioviue moie uetaileu infoimation in assist
piactitioneis in implementing the Fiamewoik:
Emergency Support Function Annexes gioup Feueial iesouices anu capabilities into
functional aieas that aie most fiequently neeueu in a national iesponse (e.g.,
Tianspoitation, Fiiefighting, Seaich anu Rescue, Nass Caie).
Support Annexes uesciibe essential suppoiting aspects that aie common to all inciuents
(e.g., Financial Nanagement, volunteei anu Bonations Nanagement, Piivate-Sectoi
Cooiuination). The actions uesciibeu in the Suppoit Annexes aie not limiteu to paiticulai
types of events, but aie oveiaiching in natuie anu applicable to neaily eveiy type of
inciuent. In auuition, they may suppoit seveial ESFs.
Incident Annexes auuiess unique aspects of how we iesponu to seven bioau inciuent
categoiies (e.g., Biological, NucleaiRauiological, Cybei, Nass Evacuation). The
oveiaiching natuie of functions uesciibeu in these annexes fiequently involves eithei
suppoit to oi coopeiation of all Feueial uepaitments anu agencies involveu in inciuent
management effoits to ensuie seamless integiation of anu tiansitions between
piepaieuness, pievention, iesponse, iecoveiy, anu mitigation activities.
Partner Cuides pioviue ieauy iefeiences uesciibing key ioles anu actions foi local,
tiibal, State, Feueial, anu piivate-sectoi iesponse paitneis."
4,S

"These uocuments aie available at the NRF Resouice Centei, http:www.fema.govnif."
4


7

Emergency Support Function (ESF) #8 Public Health and Medical Services
ENS peisonnel anu agencies iesponuing to a teiioi event oi uisastei aie consiueieu pait of
Fmerqency Support Iunction (ESF) #8, as uesciibeu in the Notionol Response Iromework
(NRF). It is paiamount that all ENS peisonnel anu agencies iesponuing to a teiioi event oi
uisastei uo so as pait of an oiganizeu iesponse. The uuly uesignateu leau public safety oi
health agency will be in chaige of mobilizing suppoit agencies as neeueu. Again quoting
uiiectly fiom the lS-808 FSI#8 Course Summory foi puiposes of claiity
6
:
Emergency Support Functions (ESFs) Review
"Cooiuination of Feueial inciuent iesponse is accomplisheu thiough the ESF fiamewoik.
ESFs aie oiganizeu gioups of goveinment anu piivate-sectoi entities that pioviue peisonnel,
supplies, facilities, anu equipment. Each ESF is compiiseu of:
Primary Agencies: The National Response Plan iuentifies piimaiy agencies on the basis
of authoiities, iesouices, anu capabilities.

Support Agencies: Suppoit agencies aie assigneu baseu on iesouices anu capabilities in
a given functional aiea.
ESFs may be selectively activateu baseu on the thieat, event, oi inciuent. ESF iesouices may
be assigneu to seive within any of the iesponse oiganizations.
ESF #8: Purpose
"Emeigency Suppoit Function (ESF) #8 - Public Bealth anu Neuical Seivices pioviues the
mechanism foi cooiuinateu Feueial assistance to supplement State, tiibal, anu local
iesouices in iesponse to a potential oi actual:
Public health anu meuical uisastei oi emeigency (e.g., panuemic flu outbieak,
bioteiioiism attack).
Natuial uisastei (e.g., huiiicane, eaithquake, floou).
Public Bealth anu Neuical Seivices incluue behavioial health neeus of inciuent victims anu
iesponse woikeis, auuitional meuical iesponse assistance foi meuical neeus populations, anu
veteiinaiy anuoi animal health issues.
ESF #8: Coordinator and Primary Agency
"The Bepaitment of Bealth anu Buman Seivices (BBS) is the ESF #8 cooiuinatoi anu piimaiy
agency. . . .
6
"
ESF #8: Support Agencies
Numeious Feueial agencies seive in a suppoitive capacity.
ESF #8: Actions
"Feueial assistance to supplement State, tiibal, anu local iesouices may incluue:

8

Public Health & Medical Needs Assessment - BBS, in collaboiation with the Bepaitment
of Bomelanu Secuiity (BBS), mobilizes anu ueploys ESF #8 peisonnel to suppoit national
oi iegional teams to assess public health anu meuical neeus. These assessments may
incluue: Language assistance seivices foi inuiviuuals with limiteu English pioficiency;
Accommouations anu seivices foi inuiviuuals with uisabilities; Bealth caie system oi
facility infiastiuctuie.
Public Health Surveillance- BBS, in cooiuination with suppoiting uepaitments anu
agencies: Enhances existing suiveillance systems to monitoi the health of the geneial
population anu special neeus populations; Caiiies out fielu stuuies anu investigations;
Nonitois injuiy anu uisease patteins, potential uisease outbieaks, bloou anu bloou
piouuct (e.g., plasma) safety, anu bloou supply levels.
Medical Care Personnel Deployment- Immeuiate meuical iesponse capabilities aie
pioviueu by: BBS assets; ESF #8 suppoiting oiganizations; Civilian volunteeis. The iole
of these meuical caie peisonnel is to assist State, tiibal, anu local public health anu
meuical peisonnel. BBS assets incluue: The 0.S. Public Bealth Seivice Commissioneu
Coips; The National Bisastei Neuical System (NBNS).

Medical Equipment & Supplies Distribution- ESF #8 may iequest the Bepaitment of
Befense (B0B) oi the Bepaitment of veteians Affaiis (vA) to pioviue meuical equipment
anu supplies in suppoit of immeuiate meuical iesponse opeiations anu foi iestocking
health caie facilities in an aiea affecteu by a majoi uisastei oi emeigency. ESF #8 may
also ueploy assets fiom the Stiategic National Stockpile (SNS). When a veteiinaiy
iesponse is iequiieu, assets may be iequesteu fiom the National veteiinaiy Stockpile,
which is manageu by the 0SBA |0niteu States Bepaitment of Agiicultuiej Animal anu
Plant Bealth Investigation Seivice (APBIS).
Patient Evacuation and Care- ESF #8 is iesponsible foi tianspoiting seiiously ill
(seiiously ill uesciibes peisons whose illness oi injuiy is of such seveiity that theie is
cause foi immeuiate concein, but theie is not imminent uangei to life) oi injuieu patients,
anu meuical neeus populations, fiom a casualty collection point (CCP) in the impacteu
aiea to uesignateu ieception facilities. Note that the State is iesponsible foi gatheiing
patients at CCPs. 0nce at the CCP, ESF #8 is then iesponsible foi patient evacuation. The
Bepaitment of Befense (B0B) is the only iecognizeu Feueial paitnei iesponsible foi
iegulating anu tiacking patients tianspoiteu on B0B assets to appiopiiate tieatment
facilities (e.g., National Bisastei Neuical System (NBNS) hospitals). ESF #8 may task BBS
components to engage civil seivice peisonnel, 0fficeis fiom the 0.S. Public Bealth
Commissioneu Coips, the iegional offices, anu States to engage civilian volunteeis anu
iequest the Bepaitment of veteians Affaiis (vA) anu the Bepaitment of Befense (B0B) to
pioviue available peisonnel to suppoit piehospital tiiage anu tieatment, inpatient
hospital caie, outpatient seivices, phaimacy seivices, anu uental caie to victims who aie
seiiously ill, injuieu, oi suffei fiom chionic illnesses who neeu evacuation assistance,
iegaiuless of location. ESF #8 may assist with isolation anu quaiantine measuies anu
with point of uistiibution opeiations (mass piophylaxis anu vaccination). Bealth caie
anu suppoit staff pioviueis will ensuie appiopiiate patient confiuentiality is maintaineu,
incluuing Bealth Insuiance Poitability anu Accountability Act |BIPAAj piivacy anu
secuiity stanuaius, wheie applicable.

9

ESF #8: Other Actions
"Below aie examples of othei ESF #8 actions:
Safety anu Secuiity
Bloou, 0igans, anu Bloou Tissues
Behavioial Bealth Caie
Public Bealth anu Neuical Infoimation
vectoi Contiol
Public Bealth Aspects of Potable WateiWastewatei anu Soliu Waste
Nass Fatality Nanagement
veteiinaiy Neuical Suppoit
A uetaileu uiscussion of these actions is beyonu the scope of this chaptei.

ESF #8: Specialized Resources and Capabilities
"ESF #8 also cooiuinates numeious specializeu iesouices anu capabilities, |incluuingj the
National Bisastei Neuical System (NBNS). NBNS pioviues a single, integiateu national
meuical iesponse capability foi assisting State anu local authoiities in iesponuing to: Natuial
uisasteis; Najoi tianspoitation acciuents; Acts of teiioiism incluuing weapons of mass
uestiuction |WNBj events. The NBNS teams aie staffeu by agency peisonnel anu piivate
citizens with specializeu tiaining anu expeitise These teams aie activateu as neeueu uuiing
uisasteis oi othei events to pioviue: Neuical caie, incluuing specializeu tieatment like ciush
injuiies oi buin tieatment; Patient movement fiom a uisastei site to unaffecteu aieas of the
Nation; victim iuentification anu moituaiy seivices; veteiinaiy seivices foi animals affecteu
by an inciuent.
"ESF #8 may also cooiuinate the ueployment of assets fiom the Stiategic National Stockpile
(SNS). The stockpile has laige quantities of meuicine anu meuical supplies to piotect the
Ameiican public in an inciuent seveie enough to cause local supplies to iun out. Push
Packages aie caches of phaimaceuticals, antiuotes, anu meuical supplies uesigneu to pioviue
iapiu ueliveiy. These Push Packages aie positioneu in stiategically locateu, secuie
waiehouses foi ueliveiy within 12 houis. Each State has plans to ieceive anu uistiibute the
meuicines anu meuical supplies to local communities as quickly as possible, incluuing
pioviuing auequate staffing of uispensing sites oi tieatment centeis, anu managing the
inventoiy. . . .
"NBNS incluues the following teams: Bisastei Neuical Assistance Teams (BNATs) |of which
theie aie __j stanuaiu BNATs |anuj highly specializeu BNATs, incluuing foui buin teams, two
peuiatiic teams, one ciush meuicine team, anu thiee inteinational meuicalsuigical teams;
National Neuical Response Teams (NNRTs); Bisastei Noituaiy 0peiational Response Teams
(BN0RTs); Family Assistance Centei Teams; Nental Bealth Teams; National veteiinaiy
Response Teams (NvRTs); National Nuise Response Teams (NNRTs); National Phaimacy
Response Teams (NPRTs). . . .

10

"The 0.S. Public Bealth Seivice Commissioneu Coips, a unifoimeu seivice leu by the Suigeon
ueneial, incluues the following teams, oi team suppoit: Inciuent Response Cooiuination
Team (IRCT); Applieu Public Bealth Team (APBT), |whichj can be uesciibeu as a 'public
health uepaitment in a box'; Nental Bealth Teams (NBTs); Rapiu Beployment Foice (RBF) .
. . compiiseu of 1uS 0.S. Public Bealth Seivice Commissioneu Coips 0fficeis . . . |whosej
capabilities incluue |piovision of public health measuie of immeuiate anu ciitical impoitance
to the health of the publicj.
ESF #8: Concept of Operations
"0nce a uecision has been maue to activate ESF #8 assets, staff aie aleiteu anu ueployeu. The
initial activities aie to:
Conuuct a iisk analysis, evaluate, anu ueteimine the capability iequiieu to meet the
mission objective.
Pioviue iequiieu public health anu meuical suppoit meuical assistance to State, tiibal,
anu local meuical anu public health officials.
"In the eaily stages of an inciuent, it may not be possible to fully assess the situation anu
veiify the level of assistance iequiieu. In such ciicumstances, BBS may pioviue assistance
unuei its own statutoiy authoiities. In these cases, eveiy ieasonable attempt is maue to
veiify the neeu befoie pioviuing assistance.
6
"

Any iequest foi Feueial assistance must follow upon a Piesiuential uisastei ueclaiation, in
accoiuance with the piovisions of the Staffoiu Act, since unilateial Feueial action in a State is
piohibiteu by the Posse Comitatus Act. Such ueclaiation can only be maue upon iequest of
the uoveinoi(s) of the involveu State(s). Befoie iequesting Feueial aiu, the uoveinoi(s) of
the involveu State(s) must alieauy have maue a uisastei ueclaiation. The Piesiuent can then
uiiect the Secietaiy of Bealth anu Buman Seivices to activate ESF #8, which unuei the
Panuemic anu All Bazaius Piepaieuness Act (PABPA), is the iesponsibility of the Assistant
Secietaiy foi Piepaieuness anu Response (ASPR).
Incident Command System(ICS)
The Inciuent Commanu System (ICS) now in common use in the 0niteu States iesulteu fiom
the expeiiences of those battling Califoinia wilufiies in the 197us anu 198us. To contain
these fiies, the seivices of numeious agencies fiom seveial states weie iequiieu - but the
involveu agencies unfoitunately useu uiffeient commanu stiuctuies as well as iauio
fiequencies, making it uifficult, anu in many cases impossible, to communicate between
agencies. As a iesult, the lives of seveial fiiefighteis weie unnecessaiily lost, leauing expeits
in fiiematics to paitnei with those in management to uevelop a univeisal system foi inciuent
commanu built on the piinciples of Nanagement by 0bjectives anu Results - a system
iecently auopteu anu enuoiseu by the Bepaitment of Bomelanu Secuiity (BBS) as a
funuamental component of the National Inciuent Nanagement System (NINS) anu the
National Response Fiamewoik (NRF), anu taught in all its tiaining couises (Table 1). The
Inciuent Commanu System (ICS) now in place employs foui Staff fficeis as pait of its
Commanu Staff, iaison, euicalTechnical, ublic Infoimation, anu afety, easily
iemembeieu by the mnemonic, "|Nountj "; anu foui Section hiefs to compiise its

11

ueneial Staff, inanceAuministiation, ogistics, peiations, anu lanning, easily
iemembeieu by the mnemonic, "" (Figuie 1A).
In auuition, the Inciuent Commanu System (ICS) now in place is baseu on the piinciple of
0nity of CommonJ - the piemise that, while infoimal shaiing of infoimation is stiongly
encouiageu at eveiy level of the Inciuent Commanu Stiuctuie, foimal biiefings, oiueis, anu
iepoits flow fiom, to, oi thiough only a single supeivisoi, whose Spon of Control uoes not
exceeu thiee to seven, anu iueally only five, suboiuinates. While Inciuent Commanu may be
shaieu by uesignateu officeis of multiple agencies with piimaiy juiisuictional authoiity anu
iesponsibility, one of whom will act as the spokespeison - a stiuctuie known as 0nifieJ
lnciJent CommonJ - all paiticipating agencies anu peisonnel, even though theii focus will be
to pioviue an effective uisastei iesponse within theii inuiviuual aieas of expeitise, agiee to
iepoit via vaiious Section Chiefs to a single locus of Inciuent Commanu, suppoiteu by Staff
0fficeis who assist Inciuent Commanu with ceitain commanu functions. The implementation
anu opeiation of this Inciuent Commanu System shoulu be well known to ENS leaueis
making use of this iesouice, anu thus will be summaiizeu uiagiammatically iathei than
explaineu in uetail (Figuie 1B). Suffice it to say that 1) unuei all the but most unusual
ciicumstances, ENS will seive as a suppoit iathei than a commanu agency, anu confine its
opeiations to tiiage, tieatment, anu tianspoit of the acutely ill anu injuieu, anu 2) the
piovision of peuiatiic emeigency caie must be the iesponsibility of all involveu ENS agencies
anu peisonnel, since chiluien iequiiing such caie will be encounteieu in all uisastei venues.
As stateu by the 0niteu States Bepaitment of Bomelanu Secuiity in the lS-700 Course
Summory, "The Inciuent Commanu System (ICS) is a stanuaiu, on-scene, all-hazaiu inciuent
management system. The ICS allows useis to auopt an integiateu oiganizational stiuctuie to
match the neeus of single oi multiple inciuents. . . . ICS is a pioven system that is useu wiuely
foi inciuent management by fiiefighteis, iescueis, emeigency meuical teams, anu hazaiuous
mateiials teams. ICS iepiesents oiganizational 'best piactices' anu has become the stanuaiu
foi inciuent management acioss the countiy."
2

In auuition, the 0niteu States Bepaitment of Bomelanu Secuiity states that, "ICS is
inteiuisciplinaiy anu oiganizationally flexible to meet the neeus of inciuents of any kinu, size,
oi level of complexity. 0sing ICS, peisonnel fiom a vaiiety of agencies can melu iapiuly into a
common management stiuctuie. ICS has been testeu foi moie than Su yeais anu useu foi:
Planneu events; Fiies, hazaiuous mateiials spills, anu multicasualty inciuents; Nulti-
juiisuictional anu multi-agency uisasteis, such as eaithquakes anu wintei stoims; Seaich anu
iescue missions; Biological outbieaks anu uisease containment; Acts of teiioiism. ICS helps
all iesponueis communicate anu get what they neeu when they neeu it. ICS pioviues a safe,
efficient, anu cost-effective iecoveiy stiategy.
ICS Features
"ICS has seveial featuies that make it well suiteu to managing inciuents. These incluue:
Common teiminology |incluuing use of 'cleai text' in lieu of agency-specific couesj.
0iganizational iesouices |incluuing use of common uesignations foi iesouice typej.
Nanageable span of contiol |uesciibeu abovej.
0iganizational facilities |incluuing use of common teiminology foi similai facilitiesj.
0se of position titles |to ieuuce confusion between uay-to-uay anu uisastei positionsj.

12

Reliance on an Inciuent Action Plan |to effectively communicate uisastei objectivesj.
Integiateu communications |to ensuie that infoimation is accuiately tiansmitteuj.
Accountability |to ensuie that all peisonnel act as a pait of the inciuent iesponsej.
"In some situations, NINS iecommenus vaiiations in inciuent management. The two most
common vaiiations involve the use of 0nifieu Commanu anu Aiea Commanu.
Unified Command
"0nifieu Commanu is an application of ICS useu when: Theie is moie than one iesponuing
agency with iesponsibility foi the inciuent; Inciuents cioss political juiisuictions (Figuie 2A).
0nuei a 0nifieu Commanu, agencies woik togethei thiough the uesignateu membeis of the
0nifieu Commanu to: Analyze intelligence infoimation; Establish a common set of objectives
anu stiategies foi a singe Inciuent Action Plan |IAPj. 0nifieu Commanu uoes not change any
othei featuies of ICS. It meiely allows all agencies with iesponsibility foi the inciuent to
paiticipate in the uecision-making piocess.
Area Command
"Aiea Commanu is an oiganization establisheu to: 0veisee the management of multiple
inciuents that aie each being manageu by anu ICS oiganization; 0veisee the management of
laige inciuents that cioss juiisuictional bounuaiies (Figuie 2B). Aiea Commanus aie
paiticulaily ielevant to public health emeigencies because these inciuents aie typically: Not
site specific; Not immeuiately iuentifiable; ueogiaphically uispeiseu anu evolve ovei time. . . .
The Aiea Commanu has the iesponsibility foi: Setting oveiall stiategy anu piioiities;
Allocating ciitical iesouices accoiuing to the piioiities; Ensuiing that inciuents aie piopeily
manageu; Ensuiing that objectives aie met; Ensuiing that stiategies aie followeu. . . . An
Aiea Commanu is oiganizeu similaily to an ICS stiuctuie but, because opeiations aie
conuucteu on-scene, theie is no 0peiations Section in an Aiea Commanu |althoughj othei
Sections anu functions aie iepiesenteu in |itsj stiuctuie.
Multidisciplinary Coordination Systems
"Nulti-agency Cooiuination Systems aie a combination of facilities, equipment, peisonnel,
pioceuuies, anu communications integiateu into a common fiamewoik foi cooiuinating anu
suppoiting inciuent management |in expanuing anu complex inciuents that iequiie highei-
level iesouice management oi infoimation managementj. . . . The piimaiy functions of Nulti-
agency Cooiuination Systems aie to: Suppoit inciuent management policies anu piioiities;
Facilitate logistics suppoit anu iesouice tiacking; Nake iesouice allocation uecisions baseu
on inciuent management piioiities; Cooiuinate inciuent-ielateu infoimation; Cooiuinate
inteiagency anu inteigoveinmental issues iegaiuing inciuent management policies,
piioiities, anu stiategies. Biiect tactical anu opeiational iesponsibility foi the conuuct of
inciuent management activities iests with the on-scene Inciuent Commanuei. Nulti-agency
Cooiuination Systems incluue Emeigency 0peiations Centeis (E0Cs), the locations fiom
which the cooiuination of infoimation anu iesouices to suppoit inciuent activities takes
place, |anuj which aie typically establisheu by the emeigency management agency at the
local anu State levels; anu, in ceitain multi-juiisuictional oi complex inciuents, Nulti-agency
Cooiuination Entities, |whichj typically consist of piincipals fiom oiganizations with uiiect
inciuent management iesponsibilities oi significant inciuent management suppoit oi

13

iesouice iesponsibilities, |anu whichj may be useu to facilitate inciuent management anu
policy cooiuination.
Emergency Operations Centers (EOCs)
"E0C oiganization anu staffing is flexible, but shoulu incluue: Cooiuination; Communications;
Resouice uispatching anu tiacking; Infoimation collection, analysis, anu uissemination. E0Cs
may be staffeu by peisonnel iepiesenting multiple juiisuictions anu functional uisciplines.
The size, staffing, anu equipment at an E0C will uepenu on the size of the juiisuiction, the
iesouices available, anu the anticipateu inciuent neeus. E0Cs may also suppoit multi-agency
cooiuination anu joint infoimation activities.
Multidisciplinary Coordination Entities
"Regaiuless of theii foim oi stiuctuie, Nulti-agency Cooiuination Entities aie iesponsible
foi: Ensuiing that each involveu agency is pioviuing situation anu iesouice status
infoimation; Establishing piioiities between inciuents anuoi Aiea Commanus in conceit
with the Inciuent Commanu oi 0nifieu Commanu; Acquiiing anu allocating iesouices
iequiieu by inciuent management peisonnel; Cooiuinating anu iuentifying futuie iesouice
iequiiements; Cooiuinating anu iesolving policy issues; Pioviuing stiategic cooiuination.
|Buiing the iecoveiy phasej following inciuents, Nulti-agency Cooiuination Entities aie
typically iesponsible foi ensuiing that |necessaiyj ievisions aie acteu upon. Revisions may
be maue to: Plans; Pioceuuies; Communications; Staffing; 0thei capabilities necessaiy foi
impioveu inciuent management. These ievisions aie baseu on lessons leaineu fiom the
inciuent |as iecoiueu in veibal oi wiitten Aftei Action Repoitsj. They shoulu be cooiuinateu
with the emeigency planning team in the |involveuj juiisuiction anu with mutual aiu paitneis
|in aujacent involveu juiisuictionsj."
6

Incident Action Planning
The cieation anu implementation of an Inciuent Action Plan (IAP) aie the funuamental task of
any Inciuent Commanu System (ICS), iegaiuless of the stiuctuie utilizeu. The planning cycle
useu by Inciuent Commanu is well establisheu (Figuie S). It begins with notification of a
potential event, which is followeu immeuiately by the Initial Response anu Thieat
Assessment. 0nce these aie unueiway anu completeu, an Initial Inciuent Biiefing is helu,
aftei which Inciuent Commanu - iueally 0nifieu Inciuent Commanu -fiist meets, ueteimines
its stiategic objectives, anu uevelops the Inciuent Action Plan.
The cycle iepeats itself thiough each 0peiational Peiiou. Each new 0peiational Peiiou
begins with a biiefing, facilitateu by the Planning Section Chief, uuiing which the outgoing
0peiations Section Chief summaiizes the cuiient inciuent status. Aftei ieview of othei
ielevant issues, incluuing conuitions affecting the safety of inciuent iesponueis, the incoming
0peiations Section Chief outlines tactical objectives foi the new 0peiational Peiiou. Review
of stiategic goals by Inciuent Commanu enus the meeting.
Public Information
"Because public infoimation is ciitical to uomestic inciuent management, it is impeiative to
establish Public Infoimation Systems anu piotocols foi communicating timely anu accuiate

14

infoimation to the public uuiing emeigency situations. . . . 0nuei NINS, the PI0 |Public
Infoimation 0fficeij is a key membei of the |ICSj commanu staff. The PI0 auvises the
Inciuent Commanu on all public infoimation matteis ielateu to the management of the
inciuent, incluuing meuia anu public inquiiies, emeigency public infoimation anu wainings,
iumoi monitoiing anu contiol, meuia monitoiing, anu othei functions iequiieu to cooiuinate,
cleai with piopei authoiities, anu uisseminate accuiate anu timely infoimation ielateu to the
inciuent. The PI0 establishes anu opeiates within the paiameteis establisheu foi the }oint
Infoimation System (}IS), |whichj pioviues an oiganizeu, integiateu, anu cooiuinateu
mechanism foi pioviuing infoimation to the public uuiing an emeigency, incluuing plans,
piotocols, anu stiuctuies useu to pioviue infoimation to the public, anu encompassing all
public infoimation ielateu to the inciuent.
"Key elements of a }IS incluue inteiagency cooiuination anu integiation, ueveloping anu
ueliveiing cooiuinateu messages, anu suppoit foi uecision-makeis. The PI0, using the }IS,
ensuies that uecision-makeis - anu the public - aie fully infoimeu thioughout a uomestic
inciuent iesponse. Buiing emeigencies, the public may ieceive infoimation fiom a vaiiety of
souices; pait of the PI0's job is ensuiing that the infoimation that the public ieceives is
accuiate, cooiuinateu, timely, anu easy to unueistanu. 0ne way to ensuie the cooiuination of
public infoimation is by establishing a }oint Infoimation Centei (}IC); using the }IC as a
cential location, infoimation can be cooiuinateu anu integiateu acioss |all involveuj
juiisuictions anu agencies, anu among all |involveuj goveinment paitneis, the piivate sectoi,
anu nongoveinmental agencies. . . ."
2

Summary
Piehospital uisastei meuical systems iange fiom simple oiganizations that manage single
inciuents with limiteu numbeis of patients, to complex multi-agency, multi-juiisuictional
oiganizations that manage expanuing oi complicateu inciuents involving laige numbeis of
victims. In the 0niteu States, the National Inciuent Nanagement System (NINS) - thiough the
National Response Fiamewoik (NRF) - pioviues a flexible, scalable, anu ieauily auaptable
system uesigneu to auuiess all hazaius appiopiiately anu consistently. This chaptei pioviues
a biief oveiview of this iueal system. Bowevei, it is incumbent upon all ENS pioviueis to
make this system a ieality within theii own agencies, thiough euucation anu tiaining, as well
as constant uiilling in its application to meuical uisasteis.
Although the puipose of this Resouice is to focus upon the neeus of chiluien in uisasteis,
uisasteis uo not sepaiate cleanly into those involving chiluien anu those involving auults. As
such, chiluien aie best seiveu by uisastei systems that ensuie theii special neeus aie met at
eveiy level of system oiganization. The othei chapteis in this Resouice will pioviue valuable
insight into how these special neeus aie iueally met. Bowevei, absent an oiganizeu system
within which state-of-the-ait peuiatiic caie can be pioviueu, chiluien will faie pooily in the
meuical iesponse to uisasteis - an outcome Ameiica can ill affoiu.
References
1. Bush uW. EomelonJ Security PresiJentiol Birective,ESPB-S, Subject: Honoqement of
Bomestic lnciJents. Washington, BC: The White Bouse, Febiuaiy 28, 2uuS (accesseu at
http:www.whitehouse.govnewsieleases2uuSu22uuSu228-9.html).

15
2. Anonymous. Couise Summaiy. lCS-700, Notionol lnciJent Honoqement System {NlHS),
An lntroJuction. Washington, BC: 0niteu States Bepaitment of Bomelanu Secuiity, 2uuS
(accesseu at http:tiaining.fema.govISNINS.asp).
S. Anonymous. Notionol Response Iromework. Washington, BC: 0niteu States Bepaitment
of Bomelanu Secuiity, 2uu8 (accesseu at http:www.fema.govemeigencynif).
4. Anonymous. 0veiview. lS-800.B, Notionol Response Iromework {NRI), An lntroJuction.
Washington, BC: 0niteu States Bepaitment of Bomelanu Secuiity, 2uu8 (accesseu at
http:tiaining.fema.govISNINS.asp).
S. Anonymous. Auuitional Resouices anu Summaiy. lS-800.B, Notionol Response
Iromework, An lntroJuction. Washington, BC: 0niteu States Bepaitment of Bomelanu
Secuiity, 2uu8 (accesseu at http:tiaining.fema.govISNINS.asp).
6. Anonymous. Couise Summaiy. lS-808, Fmerqency Support Iunction { FSI) #8 - Public
Eeoltb onJ HeJicol Services. Washington, BC: 0niteu States Bepaitment of Bomelanu
Secuiity, 2uu8 (accesseu at http:tiaining.fema.govENIWebISIS8u8.asp).

16

Table 1. Department of Homeland Security ICS and EMS Courses*

IS-1uu Intiouuction to Inciuent Commanu Systems

IS-2uu ICS foi Single Resouices anu Initial Action Inciuents

IS-Suu Inteimeuiate ICS foi Expanuing Inciuents

IS-4uu Auvanceu ICS foi Commanu anu ueneial Staff - Complex Inciuents

IS-7uu National Inciuent Nanagement System - An Intiouuction

IS-8uu.B National Response Fiamewoik - An Intiouuction

AWR-16u WNB Awaieness Level Tiaining Couise

PER-211 ENS 0peiations anu Planning foi WNB Inciuents

PER-212 WNBTeiioiist Inciuent Befensive 0peiations foi Fiist Responueis

*Accesseu at http:www.tiaining.fema.gov.

17

Figure 1. Incident Command System in Common Use in tbe United States
A. Structure*

*Souice: Centei foi Bomestic Piepaieuness, Anniston, AL

B. Function
|

|
Souice: Centei foi Bomestic Piepaieuness, Anniston, AL

18

Figure 2. Variations in Incident Command Systems

A. Unified Command*


B. Area Command
|

|
Souice: Centei foi Bomestic Piepaieuness, Anniston, AL

19

Figure 3. Incident Command System {ICS] Planning "P"*


5: Transport Pediatric Disaster Preparedness

1

Chapter 5: Pediatric Regional Triage & Transport
Robeit Kantei NB
Introduction
Pediatric non-disaster regional needs &resources
1
Seveiely ill oi injuieu chiluien typically aie iefeiieu to a peuiatiic hospital aftei piehospital
anu emeigency uepaitment (EB) stabilization. Those hospitalizeu with milu low-iisk
conuitions aie often aumitteu neai home at a non-peuiatiic hospital. Foi complex, high-iisk
peuiatiic conuitions, outcomes tenu to be bettei at high volume hospitals offeiing
compiehensive peuiatiic seivices. Fewei peuiatiic than auult patients have complex high-iisk
conuitions. Thus the highest level of compiehensive peuiatiic emeigency anu hospital
seivices tenu to be clusteieu at a few peuiatiic hospitals that may be wiuely sepaiateu. As a
iesult peuiatiic anu auult iegions uiffei when uefineu by iefeiial patteins. In ioutine non-
uisastei ciicumstances, uecisions about the uistiibution of patients to hospitals aie only
paitly ueteimineu by meuical ciiteiia. Bospital piefeiences of pioviueis anu families aie
sometimes baseu on familiaiity anu convenience. In the 0S, health caie seivices aie typically
piivately owneu anu opeiateu. Thus payeis anu business affiliations of health caie
oiganizations also influence hospital choice.
Regional disaster triage
In uisasteis involving substantial numbeis of peuiatiic patients, the neeus of a uisastei suige
will quickly exhaust the capacity of inuiviuual facilities foi chiluien. Effective use of iesouices
acioss an entiie iegion will be essential to seive laige patient suiges in a uisastei
2
. It may be
necessaiy to maximize outcomes foi populations acioss a iegion insteau of maximizing
inuiviuual caie.
In this chaptei, uisastei tiiage will be consiueieu on a iegional basis. Eviuence iegaiuing
peuiatiic iegional uisastei neeus anu iesouices will be uesciibeu. In the piocess of iegional
tiiage, patients neeuing specifieu levels of inteivention aie matcheu with available facilities.
Efficient use of inpatient iesouices is impoitant in accommouating new uisastei patients into
EBs. In laige uisasteis, piivate anu public seivices must be integiateu. Regional uisastei
tiiage iequiies up-to-uate infoimation about neeus anu vacant available capacity, authoiity
to cooiuinate iesponses, anu the ability to tianspoit patients. 0ne uefinition of a iegion is the
geogiaphical aiea coveieu by uecision-making authoiity. In this iegaiu, peuiatiic anu auult
health seivice iegions aie iuentical.
Pediatric Regional Needs in Disasters
All-hazard and event-specific estimates
An almost infinite iange of potential uisasteis can be imagineu. Since it is impossible to
piepaie specifically foi eveiy contingency, most authoiities iecommenu all-hazaiu planning,
with auuitional piepaiation foi specific neeus. The Table iuentifies iepiesentative uisasteis

2

incluuing teiioiism, acciuents, natuial uisasteis, anu natuial uiseases. The table uesciibes
majoi caie neeus associateu with each.
Severe patients
Cuiient feueial guiuelines call foi hospitals to iapiuly accommouate suiges of Suu inpatients
pei million population with infections, anu Su inpatients pei million population in othei mass
casualty events
S,4
. This taiget foi mass casualty events is lowei than pievious guiuelines of
Suu pei million population foi any type of mass casualty event, but no mouel oi methouology
has been publisheu to justify taiget levels. In tiauma intensive uisasteis, appioximately 1S%
of casualties neeu immeuiate caie in oiuei to suivive
S
. In pievious mass casualty events up to
Su% of suivivois who weie hospitalizeu neeueu a high level of caie waiianting intensive
caie unit (IC0) aumission
6,7,8
.
Less severe patients
In auuition to those iequiiing hospitalization, much laigei numbeis woulu iequiie outpatient
emeigency tieatment. Suiveillance following two iecent huiiicanes inuicateu that foi eveiy
inuiviuual neeuing hospitalization, appioximately nine weie tieateu as outpatients foi acute
conuitions
9,1u
. Inuiiect health consequences may occui as a iesult of exposuies to haish
enviionments oi uisiuption of the usual caie of chionic conuitions
11,12
. Significant community
uisiuption with powei anu utility failuie foices chionically ill inuiviuuals neeuing technology
assisteu caie to seek help even when they iemain in theii usual state of health
1S
. These
patients may only neeu a souice of electiical powei anu sheltei, while usual caiegiveis
continue theii chionic caie.
Acute illnesses unielateu to the uisastei aie likely to continue at usual oi incieaseu iates. The
"woiiieu well" aie those inuiviuuals who aie not seiiously ill oi injuieu, but may have
symptoms oi exposuies that cause them concein. They may seek tieatment oi piophylaxis in
laige numbeis. Young chiluien sepaiateu fiom theii families may be uifficult to evaluate
uiagnostically if no histoiy fiom a caiegivei is available.
Age-specific numbers of children
In oiuei to plan foi peuiatiic caie in uisastei iesponses, it is useful to anticipate the numbeis
of chiluien who will neeu caie. Anticipating the volume of peuiatiic suiges uepenus on
uefinitions. 0S Census uata inuicate that in the total population, chiluien in the following
categoiies, biith to 4 yeais, S to 9 yeais, 1u-14 yeais, anu 1S to 19 yeais account foi 6.8%,
6.6%, 6.9%, anu 7.2% of the population, iespectively
14
. If a uisastei affects all ages equally,
then chiluien woulu account foi 2u.S% oi 27.S% of the uisastei victims, foi those 14 anu
youngei, oi 19 anu youngei, iespectively. The youngei the patient, the moie unique the age-
specific neeus foi caie.
In a laige event inuisciiminately affecting all segments of the population, it is likely that
chiluien will neeu caie in piopoition to theii numbeis in the population. Neeus of vulneiable
populations might be oveiiepiesenteu (chiluien, elueily, uisableu, chionically ill, non-English
speaking, low income). Alteinatively, one can imagine events in which chiluien aie
uispiopoitionately affecteu. This may occui on the basis of acciuents involving a facility that
seives chiluien such as a school, as a iesult of a natuial pathogen to which chiluien aie
especially susceptible, oi in a teiioi-ielateu event intentionally taigeting chiluien
1S,16
.

3

Although feueial agencies have uefineu hospital inpatient suige taigets foi planning
puiposes, no guiuance has been pioviueu iegaiuing planning foi the numbei of chiluien.
Pediatric Resources: Total & Surge Capacity
Benchmarks, local data, and definitions
Whethei iesouices aie expiesseu as national benchmaiks, oi iepoiteu foi iepiesentative
iegions, such uata aie not as useful to uisastei iesponse planneis as empiiical local uata
peitaining to the paiticulai iegion. In auuition, planneis shoulu be awaie of the local
uefinitions of "peuiatiic" capability in each facility. "Peuiatiic" seivices may be iuentifieu by
self iepoit, by accieuitation (an impaitial agency ceitifies that specifieu seivices aie available
at a hospital), oi by uesignation (a goveinment authoiity iuentifies specifieu hospitals that
shoulu be useu foi specifieu types of patients)
17
.
Prehospital resources
Peuiatiic piehospital emeigency iesouices have impioveu in iecent yeais uiiven, in pait, by
feueial Emeigency Neuical Seivices (ENS) foi Chiluien uiants, iequiiing peifoimance
measuiement anu annual piogiess iepoiting. These incluue peuiatiic meuical uiiection foi
piehospital pioviueis, peuiatiic equipment in ambulances, systems to classify hospitals
accoiuing to theii peuiatiic emeigency capabilities, inteifacility tiansfei guiuelines anu
agieements, anu peuiatiic euucation of piehospital pioviueis
18
. State-by-state uata on these
peifoimance measuies have not yet been publisheu. uaps in planning piehospital peuiatiic
mass casualty iesponses have been iuentifieu
19
. Nationwiue, 7S% of ENS agencies have a
wiitten plan foi mass casualty iesponses, but only 1S% have peuiatiic plans. 0nly 19% have
peuiatiic tiiage piotocols. Although 69% of agencies paiticipateu in uisastei uiills in the
pievious yeai, fewei than half of the uiills incluueu peuiatiic consiueiations.
Emergency department resources
Emeigency uepaitments offei wiuely vaiying levels of caie foi chiluien ianging fiom teams
of subspecialists at compiehensive iegional peuiatiic centeis, to the most basic capabilities at
small non-peuiatiic hospitals. All hospital EBs must be capable of pioviuing initial peuiatiic
iesuscitation anu stabilization. Infants oi chiluien with life-thieatening conuitions may aiiive
at any hospital any time
2u
.
Recent suiveillance
22
inuicates that among the 48uu nationwiue hospitals with a full time EB,
SS% seive fewei than 4,uuu chiluien annually, while 17% seive moie than 1u,uuu. Fifty
thiee peicent of EBs aumit chiluien to theii own hospital even though no sepaiate peuiatiic
aiea is available. Thiity seven peicent iepoit having a peuiatiic waiu, anu 1u% iepoit having
a peuiatiic IC0 (PIC0) within theii own facility. Foi those lacking a PIC0, 2.S% aumit chiluien
neeuing intensive caie to an auult IC0 within theii hospital, while 97.S% senu them to
anothei facility. Fouiteen peicent of EBs iepoit having a peuiatiic tiauma seivice within the
hospital. Foui peicent use othei seivices to pioviue inpatient tiauma caie at that hospital,
while the otheis tiansfei peuiatiic tiauma patients to othei facilities foi inpatient caie.
Foi tiauma-intensive uisasteis, suige capacity may be ueteimineu moie by tiauma team
capacity iathei than othei EB oi inpatient iesouices. It is estimateu that a hospital that can

4

pioviue S tiauma teams can manage Su-4u casualties in the fiist houis aftei an inciuent,
incluuing S-7 with injuiies neeuing immeuiate caie
S
.
Pediatric hospital resources
The most compiehensive peuiatiic hospitals may be uefineu as those with the highest patient
volume anu wiuest uiveisity of patient uisoiueis. In a stuuy of New Yoik State hospitals, 11
peuiatiic hospitals uefineu in this way each seive iegional populations (all ages) of 1.7 u.S
(SB) million in 8 statewiue iefeiial iegions. These 11 hospitals caie foi 29% of all peuiatiic
hospitalizations, u-14 yeais of age
22
. Nost of the iemaining chiluien aie hospitalizeu at less
compiehensive peuiatiic hospitals, with a smallei numbei at non-peuiatiic facilities
2S
. Among
states theie aie wiue vaiiations in iegulatoiy piactices to iuentify peuiatiic hospitals anu to
piomote the utilization of paiticulai hospitals.

Inpatient total peak capacity
Bettei iuentification of peuiatiic inpatient iesouices foi uisastei caie is a cuiient piioiity of
feueial agencies
24,2S
. In paiticulai, impiovements aie neeueu in tiacking the availability of
peuiatiic non-IC0 hospital beus anu PIC0 beus. Feueial effoits also seek to iuentify total
numbeis of buin, negative piessuie isolation, anu opeiating ioom capabilities available foi
patients of all ages, as well as auult meuical-suigical anu auult IC0 beus.
Complete uata on peuiatiic inpatient iesouices aie not available on a nationwiue basis. Even
wheie infoimation on auministiatively ceitifieu beus is available, this may oveiestimate
functioning capacity foi which staff, equipment, anu supplies aie ieally available
24
. No
publisheu uata uesciibe numbeis oi uistiibution of negative piessuie isolation beus.
A stuuy in New Yoik uefineu iegional hospital peak capacity empiiically foi all peuiatiic
inpatient caie. Capacity was estimateu as the sum of each hospital's 9Sth peicentile highest
occupancy by chiluien, ages u-14 yeais, ovei a seveial yeai peiiou
26
. This pioviues a measuie
of functional, iathei than auministiatively uefineu, capacity. Statewiue, a peak of 7uS
peuiatiic inpatients pei million age-specific population, u-14 yeais, can ieceive caie. This is
much fewei than the peak capacity foi oluei patients of Su4S inpatients pei million age-
specific population.
PICU total peak capacity
National suiveillance inuicates a capacity of S4 PIC0 beus (iegionally vaiying fiom S6-66)
pei million age-specific population, u-17 yeais (equivalent to 6S PIC0 beus pei million age-
specific population, u-14 yeais)
27
. A similai estimate of 68 PIC0 beus pei million age-specific
population, u-14 yeais, is available in the New Yoik City metiopolitan aiea
28
. A negligible
numbei of ueuicateu peuiatiic tiauma oi buin IC0s aie available nationally
27
. Nost peuiatiic
tiauma anu buin patients ieceive theii caie in geneial PIC0s, auult tiauma units oi auult
buin units.

5

Vacant capacity for newdisaster surge patients
Functional peak capacity is a useful measuie of iesouices available foi uisastei caie. It is even
moie impoitant to know how many new patients coulu be seiveu in a uisastei suige, above
the numbei of patients alieauy occupying beus in each pait of the system
24
.
Emergency department surge capacity
In many iegions, existing plans foi piehospital anu EB uisastei iesponses tenu to be bettei
uevelopeu anu piacticeu than inpatient caie. Bowevei, national obseivations inuicate that
EBs fiequently opeiate neai theii peak capacity, with 1u% of hospitals uiveiting ambulances
at least 2u% of the time. In auuition, limiteu inpatient capacity foices EBs to boaiu inpatients
awaiting aumission; 9u% of 0S EBs boaiu inpatients foi at least 2 houis, anu 2u% boaiu
inpatients foi at least 8 houis
29
. Thus EB suige capacity is often limiteu by piioi anu ongoing
patient caie neeus.
Hospital surge capacity
In many communities, vacant peuiatiic beus to accommouate uisastei suiges aie fai moie
limiteu than beus foi auults. Foi example, New Yoik State can pioviue an aveiage of 268
vacant functioning beus (PIC0 plus non-IC0) pei million age-specific population, u-14 yeais.
vacancies uecline to 19Smillion uuiing peiious of high baseline occupancy on wintei
weekuays, anu inciease to S28million uuiing peiious of low baseline occupancy on summei
weekenus
26
. Acioss eight NY State iegions, aveiage peuiatiic vacant capacity ianges fiom 1S6
to SS9 beus pei million. These uata inuicate that mass casualty events involving Su peuiatiic
hospitalizations pei million population usually coulu be accommouateu, but events exceeuing
2uumillion often coulu not
28
. Compaiable NY statewiue uata foi auults aie SSS aveiage
vacancies pei million age-specific population, (seasonal iange = S28-7SSmillion)
26
.
PICU surge capacity
With an aveiage baseline occupancy of PIC0 beus well ovei Su%
27
, iegional PIC0 iesouices
woulu be quickly oveiwhelmeu even by a moueiate uisastei. Foi example, New Yoik City's 1S
PIC0s pioviuing just ovei 1uu PIC0 beus foi 1.6 million chiluien, u-14 yeais olu, often woulu
be unable to accommouate 1S new PIC0 patientsmillion, anu woulu almost nevei be able to
accommouate Sumillion
28
. Functional PIC0 capacity may be limiteu moie by available
mechanical ventilatois than by physical space.
Regional Triage: Matching Needs & Resources
Challenges
Nany factois in a uisastei woulu inteifeie with iegional tiiage. The cause of patients' illness
may not be unueistoou at an eaily phase in the event. If theie is ieason to suspect that a
communicable infection oi uangeious toxin is involveu, the safety of pioviueis anu secuiity
of facilities woulu be tiiage conceins. volunteeis at a uisastei scene may hinuei the woik of
piofessional pioviueis anu enuangei themselves.
Self tianspoitation of casualties oi uncooiuinateu uistiibution of patients by ENS pioviueis
woulu oveiciowu hospitals neai a uisastei scene. Non-peuiatiic hospitals shoulu expect to

6

ieceive peuiatiic patients. Tianspoitation may be obstiucteu by uamageu infiastiuctuie,
heavy tiaffic, lack of fuel, oi community uisoiuei. Communication may fail as a iesult of
system oveiloau, incompatible equipment, lack of tiaining in use of equipment, anu uamageu
communications infiastiuctuie.
Bealthcaie staff may not be available if they aie uiiectly affecteu by the uisastei, oi because
of conflicts between theii piofessional anu family iesponsibilities. Bospital supply
inventoiies may neeu iestocking at fiequent inteivals. Bospitals acioss a iegion must iapiuly
shift fiom acting as inuepenuent competing businesses, anu insteau cooiuinate theii seivices
unuei public authoiity.
Chiluien must be supeiviseu continuously, especially if sepaiateu fiom theii families.
Pioviueis woulu have to ueal with families seeking chiluien oi iefusing to be sepaiateu fiom
theii chiluien neeuing caie.
Triage strategies
The following options aie available to uecision makeis, but the appiopiiate combination anu
sequence of inteiventions must be inuiviuualizeu foi each event anu community. Betaileu
uiscussions of iegional tiiage stiategies have been publisheu
S,12,Su-S4
, but peuiatiic issues have
not been consiueieu in a quantitative way, pieviously.
Incidents
In an inciuent that stiesses local piehospital seivices anu a single hospital, tiiage woulu
usually be conuucteu by on-scene anu in-hospital uecision makeis. Inciuent Commanu
piinciples incluue the appointment of an inciuent commanuei, tiiage officei, oiganization of
peisonnel, vehicles, equipment, supplies, anu secuiity. Piehospital pioviueis fiom
neighboiing aieas might paiticipate in the iesponse. At the involveu hospital, elective
pioceuuies might be cancelleu, anu selecteu inpatients uischaigeu iapiuly, thus ieuucing
inpatient occupancy by 1u-2u% below usual levels
26,SS,S6
. Inuiviuual patient tiiage at the
scene anu again on hospital aiiival woulu iuentify neeus foi caie. Becontamination anu
immeuiate inteiventions woulu be pioviueu to those who iequiie it. Appiopiiate uelayeu oi
minimal caie woulu be given to otheis. Rapiu movement of patients fiom the EB to opeiating
iooms, inpatient (IC0 oi non-IC0) aieas, oi alteinative caie sites in the hospital woulu allow
the EB to accommouate auuitional patients. Fiequent ieevaluation of neeus anu iesouices
woulu optimize ongoing tiiage uecisions.
Bospital iesouices woulu be extenueu by any of the following actions: tempoiaiy cieuentials
given to auuitional pioviueis by pieueteimineu ciiteiia, use of stanuing oiuei templates,
simplification of the meuical iecoiu (maintaining infoimation on iuentification, tiiage status,
uiagnosis, tieatments given), less iauiogiaphic anu lab testing with moie ieliance on clinical
juugment, ieuse of some uisposable equipment, ieuucing stanuaius of piivacy anu
confiuentiality, incieasing the numbei of patients in each ioom, anu placing patients in aieas
not usually useu foi inpatient caie.
Peuiatiic-specific iesouices may be extenueu by any of the following actions: Two-tieieu
staffing in which specialists supeivise teams of less expeit pioviueis (whethei in IC0 oi non-
IC0 aieas) to caie foi expanueu numbeis of patients, just-in-time tiaining, caie of auolescents
anu oluei chiluien in auult aieas, anu caie of seveiely ill infants in neonatal IC0s. Nechanical

7

ventilatois foi oluei chiluien may be obtaineu fiom auult IC0s, while ventilatois foi infants
may be available in neonatal IC0s. Patients woulu be iuentifieu foi tiansfei when possible,
incluuing: miluly ill chiluien to alteinative non-hospital sites; inpatients fiom a non-peuiatiic
to peuiatiic hospitals, oi fiom an oveiciowueu to less ciowueu peuiatiic hospitals; anu veiy
seveie patients to moie compiehensive peuiatiic, buin, oi tiauma centeis. 0utsiue peisonnel
anu supplies coulu be biought into the hospital.
Large disaster
In a laige uisastei the seivices of an entiie iegion may be oveiwhelmeu. Some oi all of the
stiategies outlineu above foi an inciuent woulu be implementeu. A cential authoiity foi that
juiisuiction woulu cooiuinate the flow of infoimation anu woulu make uecisions about the
uistiibution of patients anu the allocation of iesouices. Infoimation must be available about
patients anu iesouices acioss the iegion, incluuing caie of piioi patients unielateu to the
uisastei.
The cooiuinating authoiity woulu attempt to maintain a balance between neeus anu
iesouices at hospitals neai the scene of a suuuen impact event. Nany patients woulu be sent
to iemote hospitals with vacant capacity. The most ciitically ill patients may waiiant
tianspoit to neaiby facilities foi immeuiate lifesaving inteiventions. Some veiy seveie
patients might be uiiecteu to appiopiiate compiehensive hospitals even if these weie not
close to the scene. It woulu be impoitant to avoiu oveiloauing neaiby hospitals with eaily
waves of milu patients, inteifeiing with latei iesponses to laige numbeis of seveie patients,
especially if the neaiby facility happeneu to be one of the few available chiluien's hospitals.
Communications with the public anu effoits of secuiity seivices woulu attempt to contiol the
uestination of self tianspoits. Alteinative sites (evaluation centeis, non-hospital acute caie
centeis) woulu be openeu as neeueu to supplement the seivices of hospitals foi patients not
iequiiing inpatient caie. It may be possible to aiiange mass tianspoitation of miluly ill oi
injuieu patients in buses oi vans, keeping ambulances fiee foi seveie patients. As
ciicumstances of the uisastei become cleai, the cooiuinating authoiity woulu also pioviue
infoimation to piehospital pioviueis anu hospital staff to help them anticipate specific
patient caie neeus anu tieatment iecommenuations.
It may become necessaiy foi the cooiuinating authoiity to altei stanuaius of caie acioss the
iegion, attempting to maximize population outcomes by pioviuing inteiventions only to
those immeuiately in neeu, insteau of maximizing inuiviuual outcomes. This appioach may
have alieauy been implementeu by tiiage officeis at the scene oi at inuiviuual hospitals.
Bowevei, imposing such changes on a iegional basis piematuiely coulu woisen population
outcomes
S7
. Quantitative mouels pioviuing ieal time analysis of the consequences of
alteinative iegional tiiage stiategies may assist uecision makeis
S8
.
When possible, ieuistiibution of patients to othei hospitals, incluuing those in aujacent
iegions, may be necessaiy to bettei match theii neeus anu levels of caie. Auuitionally,
iesouices may be biought into the iegion, incluuing equipment, supplies, anu supplemental
peisonnel.

8

Communications
In oiuei foi iegional cooiuination to succeeu, infoimation on neeus anu iesouices must be
shaieu among pioviueis, uecision makeis, anu the public. State anu feueial effoits aie in
piogiess to tiack anu shaie such infoimation
24,S9
. Communication among agencies iequiies
functioning anu compatible equipment, useu by tiaineu pioviueis, anu piotecteu against
oveiloau by the high volume of communications, anu piotecteu against othei uisiuption.
Communication about health conceins anu tieatment iecommenuations fiom uecision
makeis to the public is iueally pioviueu via public meuia by a iecognizeu spokespeison fiom
the public health oi meuical community. Public coopeiation is ielateu to the consistency anu
cieuibility of infoimation they ieceive
4u
.
Transportation
Tianspoitation is a vital iesouice necessaiy to match neeus anu iesouices acioss a
iegion
SS,41
. Local piehospital pioviueis using stanuaiu ambulances may be sufficient in a
mouest size inciuent. In laige emeigencies, the iesouices of neighboiing communities woulu
be calleu in to help. 0thei public anu piivate vehicles may be useu, incluuing vans anu buses
to tianspoit less seveie patients. In veiy laige uisasteis, the tianspoitation iesouices of the
feueial Bepaitment of Befense, veteians Auministiation, oi Feueial Emeigency Nanagement
Agency may be necessaiy to assist in evacuation of the geneial population anu mass
tianspoit of casualties
4u
.
Authority
The legal anu iegulatoiy basis to caiiy out iegional tiiage has been outlineu by the feueial
Bepaitment of Bomelanu Secuiity in the National Response Fiamewoik, 2uu8
42
. Inciuents
aie always manageu at the lowest possible juiisuictional level. Nost inciuents aie successfully
hanuleu at the local (city oi county) level of authoiity. Responses to some uisasteis neeu
suppoit fiom neighboiing juiisuictions oi the state. 0nly a small numbei of events iequiie
feueial suppoit oi authoiity. In an event potentially ielateu to teiioiism, feueial authoiities
woulu be involveu at an eaily stage. The Inciuent Commanu System pioviues a uecision-
making anu cooiuinating piocess that enables agencies with vaiious legal, juiisuictional, anu
functional iesponsibilities to plan anu cooiuinate the iesponse. The Inciuent Commanu
System can be scaleu to any type oi size of event, anu is compatible with authoiity at any
juiisuictional level. The usual chain of commanu within each paiticipating oiganization
shoulu be maintaineu, with cooiuination acioss oiganizations anu juiisuictions. Effective
iesponses iequiie piioi planning anu piactice by paiticipating oiganizations, all tailoieu to
the ciicumstances of the iegion
4S
. In a public health oi geneial emeigency, authoiity is
available to give public uecision makeis tempoiaiy powei to uiiect the use of piivate
iesouices.
Preparing for difficult regional triage choices
Ethical as well as piactical meuical issues must be auuiesseu in oiuei to plan iegional
uisastei tiiage
S,S1,S2
. Public anu piofessional coopeiation will be best obtaineu fiom those
who aie well infoimeu of plans, anu who have an unueistanuing of the inteiests involveu.
Pooily infoimeu health caie pioviueis may have as gieat a uifficulty alteiing caie stanuaius

9

in uisastei tiiage as the geneial public. The peiception of faiiness is essential in gaining
acceptance of tiiage uecisions. Some of the following aieas neeu attention:
Bow much of scaice public anu piivate iesouices shoulu be allocateu to uisastei-specific
piepaiation veisus all-hazaiu piepaiation that seives ioutine uaily neeus as well as
uisasteis.
Who gets caie when some must be uenieu caie.
Within a tiiage categoiy, shoulu inteiventions be pioviueu on a fiist come - fiist seiveu
basis. 0i aie some inuiviuuals assigneu a highei piioiity than otheis. Who ueciues.
In woiking to maximize population outcomes, is the goal to save the most lives, the most
life-yeais (favoiing the young), oi quality-aujusteu life-yeais.
Bow woulu outcomes, incluuing age-specific uiffeiences, be pieuicteu in oiuei to make
these uecisions.
What is the minimally acceptable level of caie, ethically.
What is the minimally acceptable meuical level of caie to achieve uesiieu outcomes.
What inteiventions shoulu we attempt to guaiantee, anu what inteiventions shoulu we
foigo, in attempts to accommouate specifieu incieaseu numbeis in a uisastei suige.
44

Population outcomes may uiffei substantially uepenuing on small uiffeiences in tiiage
iules |iefeience S, pg 18-2uj. uiven that the legal basis foi uisastei caie iemains
incompletely uefineu, what is the liability foi pioviueis who limit, withholu, oi withuiaw
caie.
4S

0nueistanuing must be uevelopeu by public uebate anu uiscussion. Some of these questions
may be answeieu as lessons leaineu in iesponses to futuie inciuents anu uisasteis. Collection
of empiiical eviuence peitaining to iegional tiiage is a piioiity.
Planning
ueneial consiueiations foi the iegional tiiage planning piocess have been outlineu by vaiious
agencies anu piofessional expeits |12,Su,S1,SS,42,46j. The elements outlineu in this chaptei
must be auuiesseu with local uata in oiuei to uevelop plans foi each iegion.

10

References
1. New Yoik State Emeigency Neuical Seivices foi Chiluien Auvisoiy Committee; Peuiatiic
iegional ciitical caie hospitals; White papei on eviuence anu impiovement oppoitunities
in New Yoik, New Yoik State Bepaitment of Bealth, Albany, NY 2uu7.
2. Biavata BN, NcBonalu KN, 0wens BK, et al; Regionalization of bioteiioiism
piepaieuness anu iesponse. Eviuence RepoitTechnology Assessment No. 96. (Piepaieu
by Stanfoiu 0niveisity of Califoinia San Fiancisco), ABRQ Publication No. u4-Eu16-2.
Rockville, NB: Agency foi Bealthcaie Reseaich anu Quality, 2uu4.
S. Kaji AB, Koenig KL, Lewis R}; Cuiient hospital uisastei piepaieuness. }ANA
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non-teiioi-ielateu tiaumatic injuiy in chiluien. Peuiatiics 2uuS;112:e28u.
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Suig 2uu4;2S9:S11-S18.
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acute caie facilities aftei huiiicanes Katiina anu Rita- New 0ileans aiea, Louisiana,
Septembei 2S-0ctobei 1S, 2uuS. NNWR 2uu6;SS:SS-S8.
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Katiina, New 0ileans, Louisiana, Septembei 8-2S, 2uuS. NNWR 2uuS;S4:1u18-21.
11. Noji EK; The public health consequences of uisasteis. Piehospital anu Bisastei Neuicine
2uuu;1S:147-1S7.
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piepaieuness. Agency foi Bealthcaie Reseaich anu Quality, Rockville, NB, Publication No.
u6 (u7)-uuS6, 2uu6.
1S. Piezant B}, Claii }, Belyaev S, et al; Effects of the August 2uuS blackout in the NYC
healthcaie ueliveiy system. Ciit Caie Neu 2uuS;SS:S96-S1u1.
14. 0S Census Buieau; Age anu sex, Table Su1u1, Ameiican Community Suivey, Washington,
BC, 2uu6.
1S. Naikenson B, Reynolus S; The peuiatiician anu uisastei piepaieuness. Peuiati
2uu6;117:eS4u-S62.
16. uiaham }, Shiim S, Liggin R, et al; Nass-casualty events at schools. Peuiati 2uu6;117:8-1S.

11

17. AAP, ACCCN; Consensus iepoit foi iegionalization of seivices foi ciitically ill oi injuieu
chiluien. Peuiatiics 2uuu;1uS:1S2-1SS.
18. ENSC National Resouice Centei; ENSC Peifoimance Neasuies Implementation Nanual
foi State Paitneiship uiantees. Washington, BC, 2uu7. Available at:
http:uev.ciiclesolutions.comemscasp2PeifoimanceNeasuiesPeifoimanceNeasuies
Complete.htm#measuie. Inteinet access 229u8.
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events. Peuiatiics 2uu7;12u:e7S6-761.
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uuiuelines foi peuiatiic emeigency caie facilities. Peuiatiics 199S;96:S26-SS7.
21. Niuuleton KR, Buit CW; Availability of peuiatiic seivices anu equipment in emeigency
uepaitments: 0S, 2uu2-S. Auvance Bata fiom vital anu Bealth Statistics 2uu6; No. S67.
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iefeiial iegions. } Peuiatiics 2uuS;146:26-29.
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BBBS, Washington, BC. 2uu7. Available at www.hhs.govaspiopeohpp, Inteinet
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stuuy. Ann Emeig Neu 2uu7;Su:S14-S19.
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199S to 2uu1. } Peuiati 2uu4;144:792-8j.
28. Kantei RK, Noian }R; Peuiatiic hospital anu intensive caie unit capacity in iegional
uisasteis. Peuiatiics 2uu7;119:94-1uu.
29. Stiatton S}, Tylei RB; Chaiacteiistics of meuical suige capacity uemanu foi suuuen impact
uisasteis. Acau Emeig Neu 2uu6;1S:119S-1197.
Su. Centeis foi Bisease Contiol & Pievention; In a moment's notice: Suige capacity foi
teiioiist bombings. Atlanta uA, 2uu7.
S1. Phillips S}, Knebel A (eus); Pioviuing mass meuical caie with scaice iesouices: A
community planning guiue. Agency foi Bealthcaie Reseaich anu Quality, Rockville NB,
ABRQ Publication No. u7-uuu1, 2uu6.
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foi Bealthcaie Reseaich anu Quality, Rockville NB, ABRQ Publication No. uS-uu4S, 2uuS.
SS. Centei foi Bioteiioiism Piepaieuness Planning Peuiatiic Task Foice; Peuiatiic Bisastei
Toolkit. NY City Bepaitment of Bealth anu Nental Bygiene, NY, NY, 2uu6.

12

S4. Skiumoie S, Wal WT, Chuich }K; Nouulai Emeigency Neuical System: Concept of
opeiations foi the Acute Caie Centei. Bomelanu Befense Business 0nit, Abeiueen Pioving
uiounu, NB, 2uuS Available at
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access 22u6.
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casualty inciuent. Piehosp Bisastei Neu 2uuS;2u:169-176.
S6. Kelen uB, Kiaus CK, NcCaithy NL, et al; Inpatient uisposition classification foi the
cieation of hospital suige capacity. Lancet 2uu6;S68:1984-9u.
S7. Kantei RK; Stiategies to impiove peuiatiic uisastei suige iesponse: Potential moitality
ieuuction anu tiaueoffs. Ciit Caie Neu 2uu7;SS:28S7-42.
S8. Laige Scale Emeigency Reauiness Pioject; Computational moueling of a laige scale
casualty uisastei. Centei foi Catastiophe Piepaieuness anu Response, New Yoik
0niveisity, NY, 2uu8. Available at www.nyu.euuccpilaseiplanc.html. Inteinet access
S12u8.
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RANB Centei foi Bomestic anu Inteinational Bealth Secuiity. Santa Nonica, CA, 2uuS.
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feueial assistance in suppoit of the National Response Fiamewoik. Washington, BC,
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Bisastei Neuicine, Seconu Euition, Lippincott Williams & Wilkins, Philauelphia, 2uu7.
42. Bepaitment of Bomelanu Secuiity; National Response Fiamewoik. Washington BC, 2uu8.
4S. Bogan AE, Local goveinment emeigency uisastei planning, in Bogan BE, Buistein }L
(eus); Bisastei Neuicine, Seconu Euition, Lippincott Williams & Wilkins, Philauelphia,
2uu7.
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hospital caie in uisastei suiges. Acau Emeig Neu 2uu7;14:S19u (Absti).
4S. 0kie S; Bi. Pou anu the huiiicane: Implications foi patient caie uuiing uisasteis. N Engl }
Neu 2uu8;SS8:1-S.
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(eus); Bisastei Neuicine, Seconu Euition, Lippincott Williams & Wilkins, Philauelphia,
2uu7.
47. Bogan BE, Buistein }L (eus); Bisastei Neuicine, Seconu Euition, Lippincott Williams &
Wilkins, Philauelphia, 2uu7.

6: Urgent Care Pediatric Disaster Preparedness

1

Chapter 6: Pediatric Urgent Care
Paul Siibaugh NB
Mobile Pediatric Emergency Response Team(MPERT): An Acute Care Pediatric
Response Operating within an Alternate Care Facility
Introduction
All uisastei planneis shoulu focus on iegional iesouice utilization iathei than iesouice
iecieation when piepaiing foi a multifaceteu iesponse. While auheiing to the local inciuent
commanu system (ICS), expeiienceu anu iesouice-iich expeits fiom eveiy subspecialty (i.e.
peuiatiics, geiiatiics, obstetiics, etc) anu eveiy sectoi (i.e. piivate, non-piofit, municipal, etc)
of the community must be inviteu to paiticipate in the planning of a iegions uisastei
iesponse. The iesouices must also be alloweu to opeiate inuepenuently within theii fielus of
expeitise. These iecommenuations may sounu inheiently obvious to most, but intentionally
oi unintentionally, the leau goveinmental agencies in chaige of uisastei planning anu
iesponse (LuAs) too often uiscount the impoitance of accessing anu involving iegional
iesouices, citing conceins ovei battling egos, too many "cooks in the kitchen", buugetaiy
constiaints, anuoi scheuule conflicts. While those conceins aie legitimate, anu often in fact
the ieality, the benefits of collaboiation incluue a moie efficient piouuct that iesults in:
A shoiteneu piepaiation time
A bettei uistiibution of the woikloau among knowleugeable paitneis
Piactice uiills that focus moie on maintenance anu less on the iecieation of pieexisting
piocesses that have alieauy been testeu, ietesteu, anu fine-tuneu by the iesouice
A moie functional anu iepiouucible mouel foi an all-hazaius multi-faceteu uisastei
iesponse
Sounu exit stiategies
The content of this chaptei is applicable anu essential to existing peuiatiic teitiaiy caie
iesouices, as well as to the LuAs that iequiie theii expeitise befoie, uuiing, anu aftei a
uisastei iesponse. Regional teitiaiy caie centeis will be affecteu by any uisastei iesponse in
theii community anu iegaiuless of whethei oi not they aie inviteu to the table, those centeis
must be pioactive anu foice theii way into the planning of the eveiy phase of a uisastei
iesponse. This chaptei uetails an example of one iegion's utilization of a willing anu able
teitiaiy peuiatiic caie iesouice, iesulting in the successful cieation anu implementation of a
fielu-testeu mobile peuiatiic emeigency iesponse team (NPERT)
1
. 0sing the iesouices of a
iegional teitiaiy peuiatiic caie hospital (RTPCB), the NPERT, in less than 24 houis, iecieateu
a scaleu-uown veision of the iesouice's emeigency centei anu pioviueu aiounu-the-clock
staffing, equipment anu supplies to the county's alteinate caie facility (ACF). In less than 12
uays, appioximately SSuu chiluien (- 29u patientsuay) weie tieateu anu ieleaseu by the
NPERT with fewei than fifty of those patients iequiiing tianspoit to the RTPCB. The NPERT
viitually uoubleu the RTPCB's suige capacity.

2

0f note, the authoi of this chaptei has focuseu on one veiy small but ciitical piece of a
uisastei iesponse - the peuiatiic clinical iesponse. It is baseu on the simple assumption that
the infiastiuctuie (e.g. stiuctuie, plumbing, beus, etc) foi the iesponse is oichestiateu
thiough the effoits of anothei iesouice (i.e. LuA uesignee).
Pre-event planning:
Invitation to participate (out of sight, out of mind)
Pie-event planning is paiamount to a successful uisastei iesponse. Pait of that planning
must incluue an "invitation to paiticipate" by LuAs to all legitimate entities likely to be
affecteu by an all hazaius uisastei iesponse. Too often anu without explanation, peuiatiic
expeitise anu iepiesentation is left off of the local anu iegional invite list. Recognizing this
ieality makes it essential that the RTPCB inseit itself into the iegional planning piocess.
Feueial iecognition of the impoitance of incluuing the vulneiable populations into national
uisastei piepaieuness effoits has impioveu ovei the yeais, mostly thiough the woik of
national oiganizations like the Ameiican Acauemy of Peuiatiics (AAP)
2
. Bowevei, iegional
peuiatiic hospitals must continue to focus theii effoits locally in an effoit to establish
woiking ielationships with theii community uisastei planneis. 0nueistanuably, not eveiy
RTPCB will be iushing to paiticipate in this enueavoi. It is the opinion of this authoi that
theie aie ieally only two options foi the RTPCB; paiticipate eaily (pie-event) anu exeicise
some contiol ovei the planning, implementation, outcome, expense anu ieimbuisement of
the iesponse oi ieact post-event anu hope foi the best. Eithei way, the RTPCB will be
paiticipating in the iesponse.
Regional Pediatric Disaster Response Preparedness Group (Pediatric Preparedness
Group or PPG)
In the event that theie aie seveial RTPCBs in the iegion they shoulu oiganize anu
collaboiate, peihaps with the assistance of LuAs, in an effoit to cooiuinate theii iesponse.
0ne methou of achieving this unifieu subspecialty iesponse is to cieate a iegional PPu that
meets thioughout the yeai anu whose membeis incluue essential iepiesentatives fiom each
of the iespective RTPCBs. As a gioup, they coulu cieate bounuaiies foi theii iesponse. In
Bouston, uuiing the iesponse to Buiiicane Katiina, theie weie two main sites establisheu in
an effoit to meet the sheltei anu meuical neeus of the ovei 2S,uuu evacuees fiom the New
0ileans Supeiuome. Baiiis County anu the Bayloi College of Neuicine pioviueu the
iesouices foi one location (Reliant Complex), anu the City of Bouston in collaboiation with
the 0niveisity of Texas supplieu the iesouices foi the othei (ueoige R. Biown Centei). Both
locations, while opeiating inuepenuently of one anothei, iemaineu in constant
communication anu shaieu iesouices whenevei the neeu aiose. While this gioup of
iepiesentatives fiom RTPCBs was not in existence befoie the Katiina iesponse, it has since
been foimeu anu among othei things is cuiiently ueveloping memoianuums of
unueistanuing (N00s) between institutions anu contiacts with LuAs to help assuie
coopeiation anu funuing uuiing the next uisastei iesponse. Anothei example of this
cooiuinateu iesponse is the shaiing of subspecialty seivices. RTPCBs can plan aheau to shaie
the buiuen of a suige in patients by woiking as a gioup with LuAs anu local emeigency
meuical seivices (ENS) agencies to cieate algoiithms that will assist in the uistiibution of

3

specific patient populations to uesignateu centeis baseu on ciiteiia such as age, type of injuiy,
oi even acuity of illness.
Reimbursement
Aiiangements foi ieimbuisement shoulu be maue eaily in the planning phase. This effoit is
usually uone on the pait of the RTPCB financial officei anu LuA officials thiough N00s anu
contiacts. The NPERT leaueiship team will play a ciucial iole in getting buy-in fiom RTPCB
auministiation (incluuing the boaiu of uiiectois) anu estimating the outlay of expenses. The
RTPCB uuiing the Katiina iesponse was not involveu in the planning anu unfoitunately not
pait of the FENA ieimbuisement package that was aiiangeu between FENA anu the LuA. As
a iesult, the RTPCB was not ieimbuiseu foi its effoits.
Creation of a Mobile Pediatric Emergency Response Team
The ouus of actually implementing an NPERT is slim to none in many iegions, so its cieation
shoulu theiefoie involve institutions with pieexisting, fielu-testeu anu opeiational piocesses
foi pioviuing emeigency meuical seivices with little oi no waining. Those uepaitments must
also be able to manage laige volumes of patients with vaiiable acuity. Theie is no bettei
iesouice foi this talent than a RTPCB emeigency centei (RTPCB-EC). With the piopei
leaueiship, hospital suppoit, anu pie-event planning anu piactice any RTPCB-EC coulu
ielocate its uay to uay opeiations into an establisheu ACF.
leoJersbip onJ bospitol support is poromount. Selecting the medical director shoulu be the
fiist phase in the piocess of cieating an NPERT. Qualifications shoulu incluue tiaining anu
expeiience in piehospital, emeigency anu uisastei meuicine. Beshe shoulu have the full
suppoit of the RTPCB's auministiation anu be given the authoiity to make uecisions on-the-
fly uuiing a uisastei iesponse.
The meuical uiiectoi shoulu then oiganize a small, talenteu anu focuseu team of essential
playeis who will ultimately make the NPERT a ieality. Again, those essential team players
shoulu be expeiienceu in the peuiatiic emeigency meuical seivices enviionment anu
assigneu to uuties that iepiesent theii cuiient job uesciiptions at the RTPCB. Each team
membei must have the authoiity, iesouices anu capability to opeiate inuepenuently of one
anothei. The puipose of the team is to cooiuinate each of those seivices utilizing existing
RTPCB iesouices at an ACF. Theii effoit shoulu miiioi what occuis eveiy uay in the RTPCB.
Tbot experienceJ utilizotion of existinq resources is tbe centerpiece of tbe HPFRT. They shoulu
meet fiequently anu make eveiy effoit to base the uesign of the iesponse on a geneial all-
hazaius appioach to uisastei planning. When they aie not iesponuing to uisasteis, these
team membeis may fulfill vaiious ioles in uisastei planning foi the RTPCB (i.e. evacuation,
special neeus shelteis, etc.) but theii assignment to the NPERT shoulu be baseu on theii
inuiviuual capabilities as they team up to cieate the peuiatiic emeigency meuicine clinical
iesponse in an ACF. Nembeis shoulu not be assigneu to the team solely baseu on theii
availability.
At an absolute minimum, each team membei shoulu be ceitifieu in the National Inciuent
Nanagement Systems (NINS)
S
as well as Basic anu Auvanceu Bisastei Life Suppoit (BBLS anu
ABLS)
4
. The team shoulu incluue:

4

Mobile Pediatric Emergency Response Team
MPERT Medical Director - The physician managing the NPERT shoulu be expeiienceu in both
piehospital anu emeigency meuicine. The meuical uiiectoi shoulu also be closely aligneu
with hishei iespective RTPCB uisastei liaison (see job uesciiption below) anu togethei both
shoulu builu coiuial anu long-lasting woiking ielationships with community leaueis anu
othei RTPCBs. In the peifect woilu the NPERT meuical uiiectoi shoulu have an official
position within the LuA meuical iesponse uesignee inciuent commanu (IC). The meuical
uiiectoi of the NPERT uuiing the Katiina iesponse was cieuentialeu full-time faculty in the
peuiatiic emeigency section as well as uiiectoi of piehospital peuiatiics foi the RTPCB
assistant meuical uiiectoi foi the City of Bouston, ENS. Be was in constant communication
with the RTPCB's uisastei liaison (now the RTPCB's Assistant Biiectoi of Emeigency
Nanagement). Soon aftei the clinic began opeiations, the LuA meuical iesponse uesignee
iecognizeu the vital iole that the NPERT playeu in the caie of peuiatiic patients anu as a
iesult foimally maue the meuical uiiectoi pait of onsite meuical inciuent commanu. The
meuical uiiectoi attenueu anu actively paiticipateu in the twice uaily IC meetings. The bettei
option is to have the NPERT meuical uiiectoi assume a position with IC befoie the iesponse
(e.g. eaily in the planning anu piepaiation phase).
MPERT Nursing Director - In auuition to having expeiience in emeigency anu uisastei
meuicine, the nuising uiiectoi shoulu also be expeiienceu in fielu tiiage. The ability to tiiage
is a unique talent often genetically possesseu anu expeiientially fine tuneu by emeigency
nuises. This is not always the case foi physicians who histoiically have uifficulty oveilooking
a challenge, anu theie is no bettei challenge than attempting to iesuscitate a iecently
ueceaseu oi uying patient.
Disaster Liaison- Eveiy peuiatiic hospital shoulu employ a uisastei liaison. As the hospital's
community iepiesentative foi uisastei planning anu piepaiation, the liaison will maintain
close connections with community uisastei planneis anu iegional LuAs. The position also
allows the RTPCB to maintain a "pulse" on community planning effoits, anu visa veisa. The
uisastei liaison coulu iepiesent the RTPCB at PPu meetings anu coulu also fulfill the iole as
go-to peison foi LuAs. Foi example, whenevei a uisastei uiill oi iesponse is imminent, the
LuA woulu simply contact the iespective uisastei liaison (oi hishei iepiesentative) by
phone. It is then the iesponsibility of the liaison to activate hishei RTPCB's iesponse. This
single phone call coulu leau to a well-oichestiateu effoit by an expeiienceu, capable, anu
willing paitnei in uisastei iesponse. Baseu on qualifications anu peisonal inteiest this
position was filleu by the Biiectoi of Nuising foi the Emeigency Centei (EC) uuiing TCB's
iesponse to Katiina. As a iesult, this uual iole of uisastei liaison anu nuising uiiectoi
iesulteu in the loss of leaueiship in the EC piioi to, uuiing, anu foi some time aftei the
iesponse. Foi that ieason it is iecommenueu that someone without a competing job iole fill
this position.
Lead hospital administrator liaison- This liaison was not cleaily uefineu uuiing the Katiina
iespose but foi all piactical puiposes incluueu the RTPCB's Chief Nuising 0fficei (CN0) anu
Chief 0peiations 0fficei (C00). The hospital cieateu an aiounu-the-clock (ATC) commanu
centei with one cential phone numbei at which each of these auministiatois weie accessible
foi on-the-fly uecision making. A phone line was cieateu onsite at the NPERT anu as a iesult,
any anu eveiy clinic neeu was quickly auuiesseu by the RTPCB commanu centei leaueiship.

5

Pharmacy liaison- An onsite phaimacy, with peuiatiic-specific meuication anu supplies anu
ATC staffing, is essential to the effoit. The iesponse shoulu incluue an on-site phaimacist
ATC to fill piesciiptions, piotect supplies, anu manage inventoiy. TCB's Biiectoi of Phaimacy
assumeu the leaueiship iole uuiing the Katiina iesponse anu was veiy involveu in viitually
eveiy segment of the iesponse. Bisastei planneis shoulu consiuei making the phaimacy
liaison a co-leauei in the piepaiation anu implementation of any uisastei iesponse. Theii
tiaining anu expeitise is integiateu into almost eveiy facet of the emeigency meuical
iesponse.
Central supply (CS) liaison- Chiluien aie not little auults. Foi that ieason alone, equipment
anu supplies specifically inuicateu foi chiluien must be ieauily accessible uuiing a uisastei
iesponse. The CS liaison shoulu know the complete inventoiy of supplies anu equipment as
well as the limitations of hishei uepaitment. Beshe shoulu be ieauily available uuiing the
implementation of an NPERT, anu theie shoulu be a mechanism by which NPERT staff can
oiuei anu expect to ieceive neeueu supplies uuiing the iesponse. Piioi to a uisastei
iesponse, heshe shoulu also take into account the potential neeus of opeiating an NPERT foi
7 uays anu incluue those neeus into the inventoiy when calculating off-site stoiage of
meuications, supplies, anu equipment foi any uisastei iesponse. The team leauei
iepiesenting cential supply uuiing the Katiina iesponse was the Biiectoi of Phaimacy but
this shaieu iole may not be applicable in othei centeis.
Physician staffing coordinator - This is a full-time position uuiing a uisastei iesponse anu the
job uesciiption incluues finuing, cieuentialing, scheuuling, anu cooiuinating the assignments
of physicians anu miu-level pioviueis fiom eveiy subspecialty. This inuiviuual shoulu woik
in physician staff seivices at the RTPCB anu be familiai with anu pioficient at each of the
ioles listeu above. Buiing the Katiina iesponse, the iesponsibilities foi this iole weie uiviueu
among specialty lines. Initially a senioi faculty membei of the RTPCB section of emeigency
meuicine was assigneu the job of scheuuling sub-boaiu peuiatiic emeigency meuicine (PEN)
faculty anu fellows - the leaueiship of the clinic. A leau hospital auministiatoi whose
uaytime job incluueu hospital liaison to community peuiatiicians, assumeu the iole as
cooiuinatoi of peuiatiicians anu miu-level piactitioneis - the woikfoice foi the clinic. Theie
was no shoitage of physician anu nuising volunteeis uuiing the Katiina iesponse anu as a
iesult locating staff to covei the clinic was often easiei than pioviuing coveiage foi the
RTPCB-EC. This woulu not have been the case without a sounu exit stiategy. Eaily in the
effoit, the RTPCB leaueiship maue it veiy cleai to the LuA that the RTPCB iesponse woulu be
limiteu anu baseu on necessity. 0nce the leaueiship of the NPERT felt that the LuA meuical
pioviuei uesignee (e.g. Bayloi College of Neuicine anu the Baiiis County Bospital Bistiict)
coulu take ovei the meuical management of the NPERT, the RTPCB woulu plan foi a giauual
tiansition anu an oiganizeu exit.
Nursing and ancillary staffing coordinator - This position shoulu be filleu by a nuise oi
auministiatoi knowleugeable anu expeiienceu in the RTPCB woikfoice capabilities anu
scheuuling. Bepenuing on the neeus of the NPERT this position may incluue moie than one
peison. Foi example, if ancillaiy seivices othei than nuising aie neeueu foi the NPERT (e.g.
iauiology anu lab), iepiesentatives fiom those sections shoulu be piesent to offei insight into
theii scheuuling anu peisonnel capabilities. This was not necessaiy uuiing the Katiina
iesponse because the all lab anu iauiology seivices pioviueu by the LuA meuical iesponse
uesignee weie auequate.

6

Infection control liaison- The job uesciiption foi this position is self-explanatoiy, anu the
iole shoulu be filleu by someone with an expeitise in epiuemiology anu uisease suiveillance.
0utbieaks of infectious uisease can be expecteu uuiing a uisastei iesponse, especially one
involving shelteis anu chiluien. Eaily iuentification, suiveillance anu containment within the
sheltei anu NPERT aie ciucial to the pievention of an outbieak involving the geneial
population.
Social services liaison- Social issues, such as sepaiation of chiluien fiom theii paients
anuoi guaiuians anu mental illness, weie not auuiesseu well in the initial phase of the
Katiina iesponse. Chiluien, elueily, anu mentally ill patients piesenting to the Katiina ACF
without family membeis to guiue them thiough the piocess went unnoticeu at times. The
iole of social seivice liaison is an impoitant one anu shoulu be filleu by someone with a
woiking knowleuge of available non-piofit, faith-baseu, piotective seivices, local, state, anu
feueial iesouices.
Handbook
Eaily in the Katiina iesponse the buiuen of euucating eveiy new pioviuei anu volunteei on
the policies anu pioceuuies of the clinic was uistiacting anu oveiwhelming to the NPERT
leaueiship. 0n the thiiu uay of clinic opeiation the meuical anu phaimacy uiiectois cieateu a
hanubook. Eveiy new pioviuei was iequiieu to take 1S minutes to familiaiize themselves
with the contents of the hanubook. Items weie auueu to anu ueleteu fiom the hanubook on a
uaily basis, allowing it to evolve with the clinic.
All of the team membeis neeu to collaboiate on the cieation of a hanubook foi pioviueis.
While some policy anu piotocols will be unique to each NPERT, all shoulu incluue:
0iientation to the NPERT
Summaiy of NINS anu a biief uesciiption of IC
Names, titles anu phone numbeis of LuA inciuent commanu anu NPERT leaueiship
Policies anu pioceuuies foi the clinic (e.g. iegistiation, oiueiing of labs anu xiays, houis
of opeiation, scheuuling, clinic access, secuiity, paiking, tianspoitation to anu fiom the
clinic foi patients anu family membeis, etc)
Physician, nuising anu staff uuties anu iesponsibilities
What it means to be a volunteei at the NPERT
Cieuentialing anu iuentification
Essential phone numbeis
0iientation to phaimacy anu cential supply
Infection contiol pioceuuies
Nap of the ACF (incluue piovisions anu locations of bathiooms, showeis, anu sinks)
Bow to contact anu mobilize emeigency meuical seivices
Social anu mental health seivices available to the patient, family, anu health caie pioviuei

7

Injuiy pievention on the job
Practice drills
Reheaisal foi the NPERT occuis eveiy uay the RTPCB-EC is in opeiation. The NPERT shoulu
ieflect the uay-to-uay opeiations of the RTPCB-EC. The only significant uiffeience peitains to
the mobility of its paits. Essential team membeis must be flexible enough to mobilize each of
theii seivice lines to an ACF site. Sample scheuules, inventoiies anu uiills will of couise help
to make that plan a ieality.
Notification, Activation, and Implementation of the MPERT
The notification and activation of the MPERT
Bistoiically the piocess of notification with iegaiu to an impenuing uisastei is less than
peifect. It was no uiffeient uuiing the Katiina iesponse. Local meuia outlets iecognizeu that
LuA officials weie oveiwhelmeu anu unueimanneu by the laige volume of patients fiom New
0ileans. They ieacteu by making an on-aii iequest foi auuitional meuical suppoit. In
iesponse to that iequest, peuiatiic emeigency meuicine physicians fiom the local RTPCB
appeaieu onsite anu began tiiaging, evaluating, managing anu uispositioning chiluien
numbeiing in the hunuieus. Although the waiting ioom anu clinic layout was unfamiliai anu
the physical space anu beu capacity weie inauequate, the ioutine was the same foi the
seasoneu RTPCB staff - laige volumes of patients with multiple conuitions of vaiiable acuity.
The only thing missing was the oppoitunity to plan aheau foi such an event.
In a well planneu anu oichestiateu iesponse baseu on the existence of a goou woiking
ielationship between the LuAs anu the RTPCB, an LuA uesignee woulu immeuiately notify
the RTPCB's uisastei liaison of an impenuing uisastei iesponse involving chiluien. If an ACF
is in the woiks anu the neeu foi peuiatiic expeitise is imminent, the RTPCB woulu then
activate the NPERT anu begin the planning anu piepaiation foi its implementation.
Implementation of the MPERT
Aftei the activation the essential team membeis woulu convene a meeting with the RTPCB
commanu centei staff anu the piocess of assessing the neeus, builuing the NPERT, anu
oiganizing the iesponse woulu begin. This is the easy pait. The iesouice is not ueveloping a
new piouuct; it is meiely tiansplanting its expeit seivices to anothei location.
COMMUNICATION
MPERT and the RTPCH- If a phone line (oi cell phone) is available the pioblem is solveu.
Biiect communication between the RTPCB commanu centei anu the NPERT leaueiship is
helpful with managing inventoiy, staffing, patient tiansfeis, etc. If cell phones aie being useu
to maintain communication between the RTPCB anu the NPERT, theie shoulu be one main
line that iemains affixeu in some mannei anu cential to the chaige nuise. In auuition,
electiical outlets anu extia batteiies aie essential. Eaily in the Katiina iesponse,
communication was fiequently inteiiupteu uue to ueau batteiies. Also impoitant is the
communication between the RTPCB boaiu of uiiectois (B0B) anu the NPERT leaueiship.
Fiequent upuates with iefeience to an exit stiategy helps keep the focus on the NPERT anu

8

its impoitant but limiteu mission. The NPERT will cost the hospital money anu it will also
save the hospital money. It is the iesponsibility of the NPERT leaueiship to keep the B0B
infoimeu. At an upuate to the B0B uuiing the Katiina iesponse one of the membeis pleugeu
a laige uonation towaiu the effoits of the RTPCB anu its NPERT.
MPERT and LGA IC - The best possible outcome foi both the LuA IC anu the NPERT is foi the
NPERT meuical uiiectoi to assume an official position with the onsite IC staff. If that is not
set up eaily in the planning, it is unlikely to occui uuiing the iesponse. If not pait of the IC,
the meuical uiiectoi shoulu make eveiy effoit to opeiate efficiently anu foi the most pait,
unuei the iauai with fiequent anu open communication with the LuA IC.
LGA IC and the RTPCH- Even moie impoitant is the communication between the RTPCB
leaueiship anu the LuA IC. Respecting the LuA IC stiuctuie is uifficult foi anyone, especially
those who aie accustomeu to being in contiol at theii uay job. The iesouice will iaiely be in
contiol of the oveiall iesponse. The iesouice may anu shoulu be iespecteu foi theii influence
anu effoit, but iaiely uoes the LuA IC stiuctuie shaie ianks with the iesouice. Stay focuseu
on the goal at hanu (managing the neeus of the chiluien) anu if necessaiy anu within ieason,
acquiesce to the iequests of the IC. The IC is often maue up of law enfoicement, goveinment,
anuoi militaiy peisonnel anu if they suspect insuboiuination, they can anu will shut uown
even the most functional piocess in seconus.
MPERT leadership and the workforce volunteers - volunteeis aie the backbone of the clinic.
They iesponu well to cleai anu concise instiuctions but not to abusive iants. Scheuuleu anu
unscheuuleu meetings involving clinic staff that summaiizeu iecent upuates, weie founu to
be useful uuiing Katiina, as was the hanubook that was ieviseu uaily.
Media and the MPERT - This is an easy one - uon't uo it. Theie is usually a veiy stiuctuieu
public ielations (PR) piece built into the LuA anu its PR uesignee. Bon't iisk haiming the
ielationship between the NPERT anu the LuA. 0nly pioviue PR iegaiuing the clinic when
given peimission by the LuA. The same is tiue foi the RTPCB when it comes to uiscussing
anything that is taking place at the ACF.
Phone list- A list of impoitant phone numbeis shoulu be cieateu anu shaieu with essential
team leaueis uuiing the planning phase of the NPERT. That list is likely to evolve gieatly
inciease in numbei uuiing the implementation phase.
STRUCTURE AND FLOW
The team will iaiely have any input into the physical uesign anu location of the NPERT. The
focus of the NPERT leaueiship is on clinical caie. Bowevei if feeuback is welcome feel fiee to
pioviue input. The focus shoulu be on:
Square footage- 0ne thiiu of the patients aie likely to be chiluien, so Su% of the space
shoulu be ieseiveu foi the NPERT.
Limited access - Theie shoulu only be one entiance to the clinic, anu it shoulu be closely
guaiueu anu monitoieu by unaimeu secuiity. Equipment will walk, so secuiity is
essential. Theie shoulu also be limiteu access to the phaimacy anu cential supply to
pievent theft of uiugs anu supplies.

9

Roomfor expansion or retraction- A laigei-than-expecteu numbei of peuiatiic patients
piesenteu to the Katiina NPERT. In iesponse to that fact, the LuA auueu hunuieus of
squaie feet to the uesignateu NPERT aiea within 24 houis. Within 48 houis a uiaiihea
outbieak occuiieu anu as a iesult, the LuA IC cieateu auuitional isolation beus which
weie useu to isolate the illness, infuse fluius, anu keep families togethei. Squaie footage
was iemoveu fiom aieas that uiu not iequiie the space; this shoulu be expecteu.
Waiting room- Theie must be sufficient space foi patients to wait to be seen anu
uischaigeu.
Privacy and bed space- This is obviously impoitant to all patient populations anu easy to
accomplish with cuitains anu cots.
Flow- If theie is time to plan anu auvice is welcome, clinic flow uesigns shoulu be baseu
on publisheu successful EC mouels.
Bathrooms, sinks and showers - Staff anu patient hygiene is one piimaiy tool of
pievention when it comes to infection contiol, especially uuiing a uisastei iesponse. The
best option will always be iunning watei anu soap. That fact notwithstanuing, instant
hanu sanitizeis anu antibacteiial hanu wash weie mainstays at the Katiina NPERT.
Bathiooms anu showeis shoulu be plentiful anu in close pioximity to the clinic.
Decontamination
Becontamination shoulu occui befoie the patient evei aiiives at the NPERT. If that tuins out
not to be the case (which is likely), showeis anu fiesh clothes shoulu be ieauily available to
the clinic anu its patients.
Triage
At least one PEN nuise shoulu be piesent at each tiiage location to insuie that the piopei
assessment is pioviueu anu level of acuity is assigneu to eveiy peuiatiic patient. They aie
usually welcomeu by the LuA uesignee staff, but consiuei the impoitance of communication
skills when choosing the nuise. If tiiage is piopeily peifoimeu at the point of patient aiiival,
auuitional tiiage at the NPERT is piobably not necessaiy.
Patient identification, registration, tracking, and online medical records
0ne of the biggest pioblems uuiing the Katiina iesponse was the lack of patient iuentification
anu tiacking anu the timeliness of patient iegistiation. Technology has iesponueu to each of
those pioblems, anu theie is no excuse foi any LuA to ignoie these issues in the futuie. While
patient iuentification, iegistiation, tiacking anu online meuical iecoiu keeping aie piobably
not going to be the sole iesponsibility of the NPERT, the staff will neeu to be familiai with
each of the piouucts that aie chosen by the LuA anu coopeiation with the piocess is ciitical.
Sepaiation of family membeis shoulu also be avoiueu anu clinic staff shoulu also be ieminueu
of anu attentive to BIPAA iegulations.
STAFFING AND SCHEDULING
Bistoiically, theie aie laige numbeis of volunteeis fiom eveiy walk of life inteiesteu in uoing
theii pait to suppoit a uisastei iesponse. While appieciateu anu essential to an NPERT, most

10

of those volunteeis have full-time jobs, families, anuoi othei obligations that pievent them
fiom woiking extenueu peiious, night shifts, holiuays, anu weekenus. The Katiina iesponse
began ovei the Laboi Bay weekenu. Initially theie seemeu to be an infinite numbei of
qualifieu volunteeis, all willing to woik foi a common cause. Bowevei, by Laboi Bay it was
cleai that most of the clinic staff weie limiteu to paiu faculty anu staff.
Patient volume, conuition anu acuity as well as staff availability will uictate staffing anu
scheuuling. The scheuuling of nuises anu ancillaiy peisonnel is ciitical to the success of the
NPERT. Filling slots with staff fiom the RTPCB is the fiist step anu eveiything else is helpful
but supeifluous. Incluueu below is a geneiic mouel baseu on the Katiina iesponse.
The schedule- Scheuules shoulu be cieateu weekly anu absenteeism shoulu be stiongly
uiscouiageu. The ability to pieuict the woikfoice foi a given uay is essential anu making the
expectations cleai anu concise eaily on in the piocess is ciitical. The only clinic uuiing
Katiina with auequate 24-houi coveiage foi the entiie 12-uay peiiou was the NPERT, anu
pait of that was because scheuules weie cieateu fiom uay one anu expectations weie
enfoiceu oi volunteeis weie not inviteu back.
Physician and nursing recruitment, credentialing and licensure- Theie was no shoitage of
supply oi lack of neeu foi volunteeis eaily in the Katiina iesponse. Nost of the physicians
anu nuises weie ieciuiteu locally anu fiom within the RTPCB anu LuA meuical uesignee
iostei. 0thei physicians anu nuising volunteeis simply showeu up foi woik at the NPERT.
Even moie aiiiveu aftei a call went out to the local, state anu national AAP offices iesulting in
numeious physician volunteeis fiom all ovei the state anu countiy. While lack of state
licensuie was initially an issue, the State of Texas iesponueu by allowing institutions to
cosponsoi physicians fiom othei states. The issue of state licensuie was less of a concein foi
nuising because tiaveling nuises aie much moie common than tiaveling physicians anu as a
iesult, iecipiocity among states is much moie common. Cieuentialing was a completely
sepaiate issue, anu conflicts aiose iegaiuing which agency was ultimately the authoiity ovei
cieuentialing. Cieating a national system of cieuentialing uisastei iesponse physician anu
nuise volunteeis is long oveiuue. Cuiiently theie aie seveial national oiganizations that aie
making inioaus into the effoit, but a lot moie has to be uone befoie the concept becomes
wiuely accepteu
6,7
.
Pbysician staffing
HPFRT meJicol Jirector - 0ne (24 houi shiftsuay anu 7 uays pei week) oi two (12
houi shiftsuay anu 7 uays pei week) physicians with ENS anu PEN tiaining anu
expeiience aie piefeiieu. These faculty aie iesponsible foi oveiall meuical uiiection
of the clinic as well as pioviuing feeuback to the LuA IC anu RTPCB. Eveiything in the
NPERT ultimately falls unuei theii oveisight.
Sbift meJicol Jirector - Two physicians - 12 houi shifts. These faculty membeis
manage the woikfoice anu flow.
Pbysicion workforce - Patient volumes of Suu patients pei uay weie hanuleu well
using a minimum of foui peuiatiicians8 houi shift.
Subspeciolty services - 24 houis7 uay pei week availability is iequiieu - on site
availability is piobably not iequiieu but uepenus on the iesponse. Baving
aiiangements with the outpatient seivices at the RPTCB is piobably sufficient as it

11

was uuiing Katiina. This is especially impoitant when managing chiluien with
special health caie neeus (e.g. tiansplants, neutiopenia, anu ienal uialysis). Baving an
off-site location to caie foi these fiagile chiluien is piobably waiianteu.
Nurse staffing
HPFRT nursinq Jirector - Two (12 houi shiftsuay anu 7 uays pei week) nuises with
ENS anu PEN tiaining anu expeiience. These nuises manage anu tiain the NPERT
chaige nuises on a shift by shift basis.
Cborqe nurses - Thiee PEN nuises - 8 houi shifts. The iole of the NPERT chaige
nuise cannot be oveistateu. As in the EC, patient flow is uiiectly ielateu to the talents
of the chaige nuise, anu choosing the chaige nuise shoulu be not be taken lightly by
the NPERT physician anu nuising leaueiship.
Nursinq workforce - Foui peuiatiic nuises - 8 houi shifts.
Pbarmacy and central supply staffing (can be combineu)
Pbormocy onJ centrol supply Jirector - 0ne (24 houi shift7 uays pei week) oi two
(12 houi shift7 uays pei week).
Pbormocist - one pei 8 houi shift. Buiing Katiina the phaimacist anu a membei of
hishei woikfoice was also iesponsible foi maintaining the meuication, supply anu
equipment inventoiy. The chaige nuise woulu veibalize hishei neeus to the
phaimacist who woulu phone is oiueis to the RTPCB twice uaily unless emeigent
neeus uictateu moie fiequent iequests.
Pbormocy onJ centrol supply workforce - two pei 8 houi shift.
Clerk staffing
0ne cleik pei 8 houi shift. The cleik shoulu nevei leave theii post. Theii piimaiy iole
uuiing Katiina was to iuentify patients anu staff. In auuition they helpeu with viitually
eveiything else but nevei left theii secuie post.
Environmental services staffing
The cleaning staff is essential anu shoulu come fiom the RPTCB to insuie that beu
tuinovei is piopeily maintaineu in the NPERT. This is a limiteu iesouice in a uisastei
iesponse, anu uue to the laige volume of auult patients theie weie nevei enough cleaning
staff to go aiounu until the RTPCB shaieu its iesouice.
Social services staffing
Eaily on in the iesponse, social seivice peisonnel shoulu be on site 24 houisuay. This
scheuule can be ieuuceu uepenuing on neeu, but off-site availability shoulu be
maintaineu 24 houisuay until clinic closuie.
Laboratory and Diagnostic Imaging {DI] staffing

12

Pioviuing laboiatoiy anu BI seivices aie piobably cost-piohibitive foi the RPTCB unless
a contiact is negotiateu with the LuA. Shaiing the seivices pioviueu by the LuA with the
iest of the clinics woulu piobably be the best option.
EQUIPMENT, SUPPLIES, AND MEDICATION
Equipment, supply, anu meuication neeus will vaiy anu evolve with the clinic anu shoulu
miiioi, within ieason anu clinical uemanu, the RTPCB-EC. Foi example, asthma anu
attention ueficit meuications, antibiotics (topical, oial, intiavasculai, anu intiamusculai), anu
immunizations, as well as splinting, sutuie anu Iv hyuiation supplies, weie useu with
gieatest fiequency uuiing the Katiina iesponse. 0nless the LuA is in the business of caiing
foi chiluien, most of the equipment foi the NPERT will have to come fiom the RTPCB.
Whenevei possible that equipment shoulu be bolteu to the flooi oi chaineu to columns.
Theie shoulu also be at least one peuiatiic coue cait with a peui-enableu automateu exteinal
uefibiillatoi anu paus.
EMS
ENS anu tianspoit to anu fiom the NPERT will likely be oiganizeu by the LuA. Theie shoulu
be one contact peison (e.g. cleik) who oiganizes, cieates backups anu maintains an up-to-
uate list of aiiival, uisposition anu final uestination of eveiy patient enteiing anu leaving the
clinic. To maintain consistency only one peison (e.g. chaige nuise) shoulu be iesponsible foi
communicating uiiectly with ENS. Buiing the Katiina iesponse, the City of Bouston ENS
system tianspoiteu all 9-1-1 calls fiom within the city but not fiom within the Reliant
Complex (home to the Bouston Texans anu at the time was the tempoiaiy location of the
Katiina Clinics which incluueu the NPERT). A foi-piofit ENS pioviuei manageu all ENS
tiaffic coming fiom within the Reliant Complex. The Bouston's Catastiophic Neuical
0peiations Centei (CN0C) then cooiuinateu the uestination of eveiy iegional ENS tianspoit
iegaiuless of its staiting point. The CN0C, which was cieateu in 2uu1 as a iesult of Tiopical
Stoim Allison , becomes opeiational uuiing a uisastei, anu its puipose is to cooiuinate the
iegional uistiibution of ENS tianspoits baseu on beu availability anu hospital capability (e.g.
chiluien's hospital, Level I tiauma centei, buin unit, etc).
TRANSFERS
0nless iuentifieu as a hospital oi emeigency ioom, tiansfeis fiom the NPERT piobably uo not
have to follow ENTALA iegulations. Bowevei, unless theie is a cential uispatch similai to
Bouston's CN0C that is attempting to uistiibute patients only to institutions who have
available beu space, communication with the uestination hospital is waiianteu.
ATTIRE
Clothing shoulu be nonuesciipt (e.g. sciubs) anu shoulu not iuentify the sponsoiing iesouice
unless otheiwise iequesteu by the LuA. 0nfoitunately anu uespite a majoi effoit to the
contiaiy, the Katiina NPERT assumeu the name of the sponsoiing iesouice, which ultimately
cieateu uivisions between the non-iesouice staff anu the RTPCB staff.

13

CHANGE
Change is not always welcome but it is often necessaiy. Leaueiship shoulu become
comfoitable with collaboiation anu change. They must make eveiy effoit to listen closely to
theii staff, act quickly to change the outcome, anu ieassess the iesults continuously.
Piocesses that uon't woik shoulu be uiscontinueu anu those that uo shoulu be moueleu.
SOUND EXIT STRATEGY
The auministiation of most RTPCBs is accustomeu to time-lines anu exit stiategies. uoing
into the iesponse without planning foi an exit is unwise anu likely to cieate unuue confusion
anu expense. Buiing the Katiina iesponse it was cleai to eveiyone in the RTPCB
auministiation (incluuing the B0B), NPERT leaueiship anu LuA that the iesouice hospital
woulu begin to tiansition its seivices ovei to the LuA's meuical uesignee as soon as the clinic
no longei iequiieu 24 houis anu 7 uay pei week clinical coveiage. That tiansition occuiieu
on Bay 12 without complication.
Reexamination and Reflection
Aftei the uust settles, the NPERT team membeis shoulu meet collectively to shaie
expeiiences anu to uiscuss the successes anu failuies of the iesponse. 0ltimately, leaining
expeiiences shoulu be uocumenteu anu inseiteu into a new plan that can then be shaieu with
the RTPCB (anu with othei RTPCBs fiom aiounu the countiy) anu LuA (anu with all state anu
feueial agencies involveu in uisastei piepaiation) in piepaiation foi a futuie iollout.
Summary
No local, state oi feueial goveinmental agency can oi shoulu evei attempt to iecieate the
talents that exist within eveiy teitiaiy peuiatiic caie iesouice. Those iesouices exist in eveiy
iegion anu like piouigies they piactice theii talents on a uaily basis as they seaich foi the
most effective anu efficient means of caiing foi theii peuiatiic patients. Any goveinmental
agency inteiesteu in utilizing a iegional iesouice as opposeu to iecieating a new one can
contact the authoi of this chaptei at siibaughbcm.tmc.euu oi call at 8S2-824-SS89 oi the
Ameiican Acauemy of Peuiatiics at BisasteiReauyaap.oig oi call at 847-4S4-71S2.
References
1. Siibaugh PE, uuiwitch KB, Nacias Cu, Ligon BL, uavagan T, Feigin RB. Caiing foi
Evacuateu Chiluien Bouseu in the Astiouome: Cieation anu Implementation of a Nobile
Peuiatiic Emeigency Response Team: Regionalizeu Caiing foi Bisplaceu Chiluien Aftei a
Bisastei. Peuiatiics. 2uu6; 117(S): S428-4S8.
http:peuiatiics.aappublications.oigcgicontentfull117SS2S428
2. http:www.aap.oiguisasteis
S. http:www.fema.govemeigencynimsnims_tiaining.shtm
4. http:www.buls.com
S. Siibaugh PE, uuiwitch KB, Nacias Cu, Ligon BL, uavagan T, Feigin RB. Caiing foi
Evacuateu Chiluien Bouseu in the Astiouome: Cieation anu Implementation of a Nobile

14

Peuiatiic Emeigency Response Team: Regionalizeu Caiing foi Bisplaceu Chiluien Aftei a
Bisastei. Peuiatiics. 2uu6; 117(S): S4S1-4SS.
http:peuiatiics.aappublications.oigcgicontentfull117SS2S428
6. http:www.aap.oiguisastei
7. http:www.meuicalieseivecoips.govNessageSuigeonueneial
8. uavagan, Thomas. Co- Authoi: Siibaugh, PE, et.al Buiiicane Katiina: Neuical Response at
the Bouston AstiouomeReliant Centei Complex (uu6-1S). Southein Neuical }ouinal.
2uu6.
9. Siibaugh PE, Biauley RN, Nacias Cu, Enuom EE. The Bouston floou of 2uu1: The Texas
Neuical Centei anu lessons leaineu. Clinical Peuiati Emeig Neu. 2uu2; S(4):27S-8S.
7: Shelter Care Pediatric Disaster Preparedness

1

Chapter 7: Shelter Care Set-up
Richaiu Biauley NB
0nless exclusively seiving an auult population, shelteis must ensuie that the physical anu
mental health neeus of chiluien aie appiopiiately auuiesseu, anu that chiluien iemain with
theii families oi caiegiveis to the maximum extent possible.
S

Identification of need
Nass caie opeiations pioviue basic human neeus foi foou anu sheltei, anu theii piompt
establishment aftei a uisastei is essential. Well-iuentifieu shelteis aie often one of the fiist
inuications to uisastei victims anu affecteu communities that officials aie initiating ielief
effoits.
2

Pioviuing emeigency sheltei is ultimately a iesponsibility of the local goveinment. The Chief
Electeu 0fficial of the local juiisuiction usually has a statutoiy iole as the Emeigency
Nanagei. This inuiviuual will usually manage a ciisis thiough a local goveinment Emeigency
0peiations Centei (E0C). 0ne of the piimaiy iesponsibilities of the E0C is to obtain a cleai
unueistanuing of the neeus that exist as the iesult of the emeigency. This noimally occuis in
the Situation Status 0nit, which is pait of the Planning Section. This unit has the
iesponsibility to ueteimine the scope of iesouices neeueu, incluuing shelteis, if necessaiy.
The Emeigency Nangei usually appoints a Nass Caie Cooiuinatoi who actually makes the
uecision to open a sheltei. While the local goveinment may staff the shelteis, moie
commonly, nonpiofit oi piivate-sectoi oiganizations will supeivise anu staff the
juiisuiction's mass caie facilities.
4

In most juiisuictions, the Ameiican Reu Cioss (ARC) will seive as the piincipal oiganization
iesponsible foi opeiating mass caie facilities uuiing uisasteis. If ARC seivices aie not
available locally, othei public oi nonpiofit oiganizations in the community may opeiate these
facilities. These oiganizations may incluue the Salvation Aimy, chuiches, schools, oi local
seivice agencies.
S

It is impoitant to note that mass caie shelteis aie tempoiaiy public living quaiteis that
pioviue physical sheltei, feeuing anu fiist aiu. They uo not pioviue specializeu meuical caie.
Identification of location
Shelteis shoulu be locateu outsiue of floouplains anu have sufficient stiuctuial integiity to
pioviue physical piotection fiom the effects of high winu, eaithquake afteishocks, anu
iauiological contamination. Relation to evacuation ioutes anu seivices available in facilities
aie also factois to consiuei. Iueally, shelteis sites will be pie-iuentifieu anu have a
completeu hazaiuvulneiability analysis on file.
4

Auvance infoimation to collect foi each sheltei is its piecise location, uiiections fiom typical
access ioutes, occupant capacity, quantity anu type of kitchens, beus available, iestioom
facilities, vehicle-paiking capacity, stock levels of meuical anu sanitation supplies, foou anu
watei. These iesouice lists shoulu iuentify the communication systems available, on-site
telephone numbeis, anu inuicate if theie is an emeigency powei system available.
4


2

Anticipated pediatric volume
Although subject to wiue vaiiation uepenuing upon socioeconomic factois anu the natuie of
the uisastei, appioximately eighty peicent of evacuees will seek sheltei with fiienus oi
ielatives iathei than go to an establisheu mass caie facility. Thus, about twenty peicent of
evacuees will seek public shelteis. In the 0niteu States 21% of the population is unuei age
1S, anu 7% is unuei age S.
6
Thus, the expecteu peuiatiic volume in shelteis will be foui
peicent of the evacuateu population.
When calculating sheltei capacity uuiing auvanceu planning, incluue any space that evacuees
coulu feasibly use as sleeping space. Foi tempoiaiy evacuation shelteis, calculate capacity by
allocating 1S to 2u squaie feet pei peison. Foi geneial shelteis, plan foi 4u to 6u squaie feet
pei peison.
Physical layout and activities
Emeigency peisonnel establishing a sheltei that will seive chiluien shoulu consiuei seveial
factois. These incluue:
iecieation - assess available iesouices within the sheltei foi keeping clients enteitaineu
anu occupieu;
availability of viueo, music anu iecieational items (ensuie the appiopiiateness of the
mateiials in teims of age iange, language, etc.);
plan to ietuin any equipment useu foi iecieational puiposes to the facility oi paitnei
who pioviueu it when no longei neeueu;
establish a scheuule foi iecieational activities;
iuentify space that can be useu as ueuicateu aieas foi iecieation anu chilucaie, anu
cleaily iuentify these aieas;
inteinet access to senu anu ieceive welfaie messages;
chilucaie - peuiatiic occupants of the sheltei may neeu chilucaie if paients oi guaiuians
must ietuin to woik while still iesiuing in the sheltei. The sheltei supeivisoi shoulu
auvise the Nass Caie Cooiuinatoi in the E0C of the neeu foi chilucaie seivices; anu
evaluate the neeu to pack lunches foi chiluien ietuining to school.
uive special attention to the selection of inuiviuuals that will be woiking with chiluien.
These inuiviuuals shoulu be cieuentialeu employees oi volunteeis of an existing
oiganization. Nonitoi the chilucaie piogiam to ensuie that activities aie both
appiopiiate anu seive the inteiests of the clients. Biiect chilucaie staff to keep a log of
clients seiveu. The log shoulu incluue the following:
the names of the chiluien anu theii guaiuians,
the ages of the chiluien, anu
the uays anu times that the seivices weie utilizeu.
S


3

Staffing
The Sheltei Supeivisoi is iesponsible foi pioviuing supeivision anu auministiative suppoit
foi all actions within the sheltei. This peison's iesponsibilities incluue pioviuing iesouices to
meet the neeus of sheltei occupants.
Shelteis shoulu have a law enfoicement piesence to pioviue secuiity anu tiaffic contiol. Law
enfoicement officeis may also pioviue an alteinative communications link between the mass
caie facility anu the E0C thiough lanu mobile iauios.
Public Woiks agencies shoulu be involveu with sheltei opeiations to ensuie maintenance of
powei, watei supply, anu sanitaiy seivices at mass caie facilities uuiing emeigency
conuitions.
The National Resouice Typing System has establisheu Sheltei Nanagement Teams that aie
available to assist in mass caie (see Table 1).
CF0C Stanuaiu (1992): ST uu2Chilustaff iatios foi centeis anu laige family chilu caie
homes shall be maintaineu as follows uuiing all houis of opeiation:
Age Chilu-staff iatio Naximum gioup size
Biith-12 months S:1 6
1S-24 months S:1 6
2S-Su months 4:1 8
S1-SS months S:1 1u
S yeai olus 7:1 14
4 yeai olus 8:1 16
S yeai olus 8:1 16
6-8 yeai olus 1u:1 2u
9-12 yeai olus 12:1 24
When theie aie mixeu age gioups in the same ioom, the chilustaff iatio anu gioup size shall
be consistent with the age of the majoiity of the chiluien when no infants oi touuleis aie in

4

the mixeu age gioup. When infants oi touuleis aie in the mixeu age gioup, the chilustaff
iatio anu gioup size foi infants anu touuleis shall be maintaineu.
Food - age appropriate
Encouiage evacuees coming to shelteis to biing foou with them. Since this may not occui,
plan foi pioviuing feeuing in shelteis. Foi most emeigencies, plan foi thiee to five uays of
meals with no outsiue assistance. 0ne simple foimula foi ueteimining the initial numbei of
meals is to multiple the piojecteu sheltei population by five. As a veiy iough guiue, consiuei
that 1% of the sheltei population, oi about u.2S% of all evacuees will iequiie infant foimula
while in shelteis.
Feeuing Nethous:
Fast Foou
Bistiibute pie-piepaieu anu packageu meals - Neals-Reauy-to-Eat (NREs),
BeateiNeals oi othei similai items
Cateieu meals
School meals piepaieu by school cafeteiia staff
Chuich oi community gioups anu kitchens
S

Sheltei Supeivisois shoulu plan foi one gallon of watei pei evacuee pei uay. If the
emeigency inteiiupts the local potable watei supply, plan to have a thiee-uay supply, oi
thiee gallons of potable watei pei occupant.
Sleeping accommodations age appropriate
While piovision foi sepaiating people of opposite genueis is appiopiiate, uo not sepaiate
chiluien fiom theii families. 0btain sufficient blankets to pioviue two pei occupant. Nany
evacuees may be able to sleep on the flooi if necessaiy, but a minimum of one cot foi eveiy
ten evacuees shoulu pioviue foi those who cannot sleep on the flooi.
Sanitation, Hygiene
Nanageis shoulu assuie that theie is a minimum of one toilet foi eveiy 4u occupants in the
sheltei. Count only those facilities that will be accessible to sheltei iesiuents anu sheltei staff.
Nake up ueficits with poitable toilets. Theie shoulu be one sink foi eveiy two toilets. An
iueal sheltei will also have one showei foi eveiy foity iesiuents.
Infants anu touuleis iequiie fiequent uiapei changing. Foi infants, theii uiapeis neeu to be
checkeu foi wetness anu feces houily, visually inspecteu at least eveiy two houis, anu
whenevei the chilu inuicates uiscomfoit oi exhibits behavioi that suggests a soileu oi wet
uiapei. Biapeis shoulu be changeu when they aie founu to be wet oi soileu. A sufficient
supply of uiapeis as well as a changing aiea with gloves anu mateiial to clean the suiface anu
the hanus of the caie givei sheltei staff aftei uiapei changing shoulu be available. Sufficient
supply of uiapeis shoulu be available - infants shoulu have appioximately 12 uiapeis pei
chilu pei uay.

5

Safety
Bespite the existence of an emeigency, shelteis aie not exempt fiom fiie anu life safety oi
builuing coues. Piotection of sheltei staff shoulu fall unuei guiuelines establisheu by state
anu feueial agencies such as the 0ccupational Safety anu Bealth Auministiation. Failuie to
comply with safety stanuaius may place inuiviuuals at unnecessaiy iisk. Regulatoiy agencies
may issue citations that caiiy significant penalties. In auuition, uespite the existence of a
uisastei, oiganizations anu staff that opeiate a sheltei aie not immune fiom civil liability
shoulu someone become ill oi injuieu because of unsafe conuitions in the sheltei. Please see
the table foi a list of safety, health anu secuiity consiueiations in sheltei opeiation.
Some facilities that appeai to be suitable foi shelteiing might not meet fiie coues baseu on
builuing capacity. Sheltei supeivisois shoulu contact the local fiie uepaitment to ensuie
compliance.
Safety issues aie an impoitant consiueiation foi chiluien in a sheltei. A iepoit fiom the
expeiience in a sheltei set up at a militaiy camp (Camp uiubei) foi chiluien evacuateu aftei
huiiicane Katiina, publisheu in Piehospital anu Bisastei Neuicine, uesciibes piactical
iecommenuations to impiove the safety enviionment in shelteis foi chiluien.
8

Bazaius iuentifieu in the sheltei incluueu those in the table below. A uesciiption of the safety
hazaiu, the potential iisk, anu solution aie listeu.
Hazard Potential Risk Safety Action Taken
Chemicals left near children Poisoning Removal
Small hard food, objects Choking in infants toddlers Food removed from child area
Open electric outlets Electrocution Covered outlet with safety cap
Missing Smoke Detector Fire, inhalation, suffocation Place Smoke Detectors in
Shelter Kitchen / Sleeping
Area
Windows Falls Window guards
Stair wells Falls Gate stair well
Open water tubs, buckets Drowning Remove open water sources
Fire extinguishers accessible Poisoning, Inhalation Fire Department Assessment
Biking and skateboarding
without helmets
Head trauma Provide helmets to children
Kids in cars without car seats MV crash injury Provide child car and booster
seats
Infants toddlers sleeping in
cots, with adults
Risk of choking
Risk of fall from cot
Provide cribs, mats on floor
near cot
The types of hazaius, theii iuentification, anu safety actions taken to eliminate these hazaius
aie familiai to any one who ioutinely counsels paients on chilu safety.

6
Shelteis aie likely to be set up in enviionments that have not been scieeneu foi hazaius to
chiluien, noi mouifieu to eliminate these iisks. Theiefoie an impoitant pait of sheltei
piepaiation anu maintenance is a chilu safety analysis, anu iemoval of items oi mouification
of the enviionment, oi auuition of safety uevices to impiove the safety foi chiluien anu
auults.

7
Equipment / Disposable Supplies
Sheltei supeivisois shoulu up-channel iequests foi equipment anu supplies to the Nass Caie
Cooiuinatoi in the E0C.
4

Shelter supervisor Kit
1uu Bisastei Sheltei Registiation foims
2u Tempoiaiy Name Bauges anu holueis
Office Supplies
12 ballpoint pens
1 package of S"xS"caius
2 clipboaius
4 papei tablets
2 stapleis
1 box of staples
2 boxes of papei clips
1 manual hole punch
2 laige peimanent maikeis
1 box of thumbtacks
2 iolls of masking tape
1 iole of scotch tape
1 package of iubbei bans
1 paii of scissois
1 box of file folueis
1 pau of easel papei
1 S-iing binuei with tab uiviueis
1 whistle
1 ioll of oiange oi yellow suiveyoi's tape
1 box of tiash bags
2 iolls of papei towels
1 bottle of all-puipose cleanei
1 flashlight
1 electiic lantein
flashlight batteiies
lantein batteiies
1 batteiy-opeiateu iauio
1 pkg. of uisposable uiapeis
1 box of sanitaiy napkins
2 boxes of facial tissue
6 iolls of toilet tissue
1 package of antiseptic pie-moisteneu
towelettes (4u)
S

Baby and Infant Support Supplies
Plan foi sufficient uiapeis (in a vaiiety of sizes) anu wipes foi 1% of the total numbei of
evacuees oi 4% of the population in each sheltei. Biapei changing tables shoulu also be pait
of the sheltei's equipment. A plan foi stoiage anu uisposal of soileu uiapeis is impoitant.
Identification and Tracking
Shelteis shoulu follow guiuance given in local emeigency plans foi iegisteiing sheltei
occupants. Ninimum uata elements incluue full name anu pie-uisastei auuiess anu

8

telephone numbei foi each occupant. Recoiu the evacuee's post-uisastei auuiess anu phone
upon final uepaituie.
The sheltei supeivisoi shoulu ueteimine the iepoiting peiious establisheu by the E0C anu
pioviue iepoits as iequiieu. Common uata elements incluue the cuiient sheltei population;
the numbei of new inuiviuuals iegisteieu in the peiiou; the numbei of iegistiations to uate;
the numbei of meals seiveu in the peiiou; the numbei of meals to uate; the numbei of snacks
in the peiiou anu to uate.
S

Reunification
An impoitant task foi sheltei opeiations is to assist with the ieunification of families anu
fiienus. The Safe anu Well Website is a public website that allows those affecteu by a uisastei
to post stanuaiu messages about theii well-being. Conceineu family membeis anu loveu ones
anywheie can seaich foi the messages posteu by those who self-iegistei.
The Safe anu Well Website is publicly available via the inteinet at
https:uisasteisafe.ieucioss.oig. When using the Safe anu Well Website, clients must ieau
anu agiee to the Piivacy Statement. Clients must accept anu agiee to the Piivacy Statement
teims in oiuei to complete the "Registei" oi "Seaich" functions on the website. Chiluien
unuei the age of 1S shoulu not entei peisonal infoimation into this website without auult
supeivision.
In oiuei to iegistei on the Safe anu Well Website:
The inuiviuual must complete the "List Nyself as Safe anu Well" foim, ensuiing that the
infoimation pioviueu is complete anu accuiate.
The inuiviuual shoulu check that at a minimum the iequiieu fielus aie completeu,
incluuing choosing at least one "Safe anu Well" Nessage.
The inuiviuual must click the button inuicating that they agiee to the Piivacy Statement
teims.
A iegistiation may be "upuateu" by cieating a new entiy at a latei time.
Auuitional iefeiials aie available on the "Seivice Paitneis" page, such as the Contact
Loveu 0nes voice messaging seivice (www.contactloveuones.com).
To seaich the website foi missing family membeis:
The usei completes the "Seaich" template, by enteiing a last name anu EITBER a phone
numbei 0R an auuiess foi the peison they aie seeking.
The usei ensuies that the iequiieu infoimation is complete anu accuiate.
The usei must click the button inuicating that they agiee to the Piivacy Statement teims.
Any matching iesult(s) will be uisplayeu with the name, uate anu time that the
iegistiation was cieateu anu the "Safe anu Well" messages weie posteu.
Closing the shelter
It is always piefeiable to give 48-houi auvance notice of a site closuie if possible. Bowevei,
situations occui wheie this is not economically oi opeiationally piactical. If officials allow
iesiuents access to theii homes, sheltei populations may iapiuly uiop to zeio. It is not

9

ieasonable to commit staff, vehicles, peisonnel anu iesouices, just to allow posting of a
notice.
If a sheltei unexpecteuly becomes empty, post a notice on the uooi with a message inuicating
a telephone numbei people can call if they neeu sheltei. List all numbeis that inuiviuuals may
neeu to call foi assistance, incluuing the local Ameiican Reu Cioss chaptei. The Nass Caie
Cooiuinatoi shoulu keep the sheltei on stanu-by, but not staff it, foi 24 houis piioi to
ieleasing the facility.
Tables and Figures
1. Shelter Management Team

2. Resources Required
Per occupant
4u-6u squaie feet
Two blankets
Five meals
Thiee gallons of watei

0ne toilet pei 4u occupants
0ne sink pei 8u occupants
0ne showei pei 4u occupants
Shelf-stable Meals:
Shelf-stable meals anu meals-ieauy-to-eat (NREs) have a longei shelf life, but iequiie ample
stoiage space anu monitoiing in oiuei to ensuie fieshness. Theie aie many venuois of this
type of meal incluuing:
AlpineAiie Foous - www.aa-foous.com

10
APack Reauy Neal - www.ameiiqual.com
Chef S Ninute Neals - www.chefSminutemeals.com
uA FoousSunmeauow - www.sunmeauow.net
BeateiNeals - www.heateimeals.com
La Biiute (koshei) - labiiutemeals.commain.htm
Naiketienu - www.maiketienu.com
Tiauitions Neal Solutions - www.tiauitionsi.com

11

S. Safety, Health and Security Considerations

Safety Healtb Security
Slips, tiips anu falls Biologicalchemical exposuies Check-incheck-out
Nusculoskeletal injuiies Communicable
uiseasesinfections
Safe uiivingcommuting
Electiical hazaius Bloou boine pathogens Ciiminal acts
Shaip mateiials Sleepiest cycle uisiuption Emeigency evacuation
Animalinsect bitesstings Tiaumatic stiess violence in the woikplace
Beatcolu stiess Foou anu watei
contamination
Fiie hazaius
ueneiatoi fumes (caibon
monoxiue)
Aggiavation of pie-existing
health conuitions

http:www.osha.govutsoohnmasscaieshelteiinuex.html

4. Fire and Life Safety Checklist

Boes the facility have inspecteu fiie
extinguisheis.
Yes No
Boes the facility have functional fiie spiinkleis.

Yes No
Boes the facility have a fiie alaim.

Yes No
If yes, is it (one oi both): Nanual (pull-uown) Automatic
Boes the fiie alaim uiiectly aleit the fiie
uepaitment.
Yes No
Comments fiom fiie uepaitment, if available:


12

TABLE 5. PEDIATRIC DIETARY RECOMMENDATIONS*

0-6 months
6 months to
1 year
1 to2 years
2 years and
above
Healthy
Children
These chiluien aie

bieast feu oi
foimula feu by
bottle only.
Comments: Some
bieast feu chiluien
may not
immeuiately take
bottle-feeuing.
Continue to feeu;
eventually the chilu
will feeu fiom the
bottle.
RecommenJotion:
Reauy-to-feeu
foimula is piefeiieu
since it is
immeuiately ieauy
foi use anu iequiies
no iefiigeiation oi
piepaiation.
Bowevei, powueieu
baby foimula may
be useu as well.
Powueieu foimula
will have a longei
shelf life.
6-9 months -
baby ceieal,
jaiieu baby
foou oi
masheu table
foou is
appiopiiate -
along with
foimula oi
bieast milk
9-12 months -
soft, bite sizeu
pieces of
foous, i.e.
vegetables,
masheu
potatoes, anu
meats - along
with foimula
oi bieast milk
This age gioup
eats table foou.
Young chiluien
will neeu soft bite
sizeu foous.
Avoiu foous that
can cause choking
such as hot uogs,
giapes, chunks of
meat unless cut in
pea size pieces
EyJrotion: Watei,
Peuialyte
This age gioup
eats table foou.
Young chiluien
will neeu fingei
foous.
Avoiu foous that
can cause
choking such as
hot uogs, giapes,
foi youngest
chiluien.
EyJrotion:
Watei, Peuialyte


13

Children
With
Special
Needs
Patients witb feeding tubes: Theie aie (S) types of tube feeuing:
Nasogastiic (Nu), 0iogastiic, anu uastiostomy (uT). The fiist two aie useu
foi acute patients; the thiiu is useu foi chionic patients.
NJC and UJC Tube: 0seu foi both nasal anu oiogastiic feeuings anu aie
tempoiaiy measuies, mostly useu in Peuiatiic Emeigency Rooms oi Peuiatiic
In-Patients aieas foi acute feeuing issues, gastiic uecompiession, anuoi
ueliveiy of oial meuications such as activateu chaicoal.
CJT Tube: 0seu with a 6ucc syiinge, cathetei tip anu is useu with a bolus
continuous feeu oi pump.
Infants {0-12montbs]: Infant foimula shoulu be useu thiough the tube.
12 months to18 yeais of age: Peuiatiic foimulas shoulu be useu, Resouice
}ust foi Kius, PeuiaSuie oi Nutien }i. Foi auolescents, baseu on clinical
juugment auult enteial piouuct may be appiopiiate.
Hydration: Tap oi bottleu watei.
Comments:
The same feeuing pump useu foi auults can also be useu to feeu chiluien
0se saline watei to clean the aiea wheie the feeuing tube is inseiteu into the
patient.
Change feeuing bags eveiy 8 houis anu clean piioi to auuing moie foimula.
Diabetic
Children
The nutiitional neeus of this gioup will be ueteimineu by the patient's bouy
weight anu insulin iequiiements.

Recommendation: Patients may iequiie between meal snacks to contiol
bloou glucose.
*Peuiatiic Bisastei Toolkit: Bospital uuiuelines foi Peuiatiics uuiing Bisasteis (2nu Euition
2uu6) Accesseu 88u8 http:home2.nyc.govhtmluohhtmlbhppbhpp-focus-peu-
toolkit.shtml

14

Table 6 Children with Special Health Care Needs Sample Infant Menu

Age Breakfast Mid
Morning
Luncb Mid
Afternoon
Evening Nigbt
Infants
Biith
thiough
S months
4-6 oz
foimula oi
bieast milk
4-6 oz
foimula oi
bieast
milk
4-6 oz
foimula oi
bieast milk
4-6 oz
foimula oi
bieast
milk
4-6 oz
foimula oi
bieast milk
4-6 oz
foimula
oi
bieast
milk
Infants
4 months
thiough
7 months
4-8 oz
foimula
oi bieast
milk
4-8 oz
foimula
oi bieast
milk
4-6 oz
foimula oi
bieast milk

4-6 oz
foimula oi
bieast
milk
4-6 oz
foimula oi
bieast milk
4-6 oz
foimula
oi
bieast
milk
Infants
8 months
thiough
11
months
6-8 oz
foimula oi
bieast milk

2 to 4
tablespoons
infant
ceieal

1 to 4
tablespoons
fiuit
anuoi
vegetable
2-4 oz
foimula,
bieast
milk, oi
fiuit juice

6-8 oz
foimula oi
bieast milk

2 to 4
tablespoons
infant
ceieal
ANB0R
1 to 4
tablespoons
meat,
fish, poultiy,
egg yolk, oi
cookeu uiy
beans oi
peas
0R
12 to 2
ounces
cheese
0R
1 to 4
tablespoons
fiuit anu
oi vegetable
2-4 oz
foimula,
bieast
milk, oi
fiuit juice

6-8 oz
foimula oi
bieast milk

1 to 4
tablespoons
fiuit
anuoi
vegetable
2-4 oz
foimula,
bieast
milk, oi
fiuit juice
Reference: United States Department of Agriculture. Building Blocks for Fun and Healthy Meals: A Menu Planner for the
Child and Adult Care Food Program, Washington, D.C; 2000.


15

References
1. Ameiican Reu Cioss (2uu6). Bisoster operotions monoqement bonJbook.
2. Ameiican Reu Cioss (2uu7). Nass caie: Tools anu iesouices. Washington.
S. Ameiican Reu Cioss (2uu7). Sheltei opeiations management toolkit. Washington.
4. Feueial Emeigency Nanagement Agency (1996). uuiue foi all-hazaiu emeigency
opeiations planning. F. E. N. Agency.
S. 0.S. Bepaitment of Agiicultuie. Builuing Blocks foi Fun anu Bealthy Neals: A Nenu
Plannei foi the Chilu anu Auult Caie Foou Piogiam, Washington, B.C; 2uuu.
6. 0. S. Bepaitment of Bomelanu Secuiity (2uu8). National iesponse fiamewoik.
7. 0.S. Census Buieau (2uu7). Annual estimates of the population by five-yeai age gioups
anu sex foi the 0niteu States: Apiil 1, 2uuu to }uly 1, 2uu6.
8. Bianuenbuig NA, 0gle NB, Washington BA, uainei N}, Watkins SA, Bianuenbuig
KL:"0peiation Chilu-Safe": A stiategy foi pieventing unintentional peuiatiic injuiies at a
Buiiicane Katiina evacuee sheltei. Piehosp Bisast Neu 2uu6;21(S):SS9-S6S.)
9. Peuiatiic Bisastei Toolkit: Bospital uuiuelines foi Peuiatiics uuiing Bisasteis (2nu
Euition 2uu6) Accesseu 88u8 http:home2.nyc.govhtmluohhtmlbhppbhpp-
focus-peu-toolkit.shtml
1u. Caiing foi 0ui Chiluien:National Bealth anu Safety Peifoimance Stanuaius: uuiuelines
foi 0ut-of-Bome Chilu Caie, 2nu Euition Accesseu 812u8 http:nic.uchsc.euuCF0C

8: Disaster Drills Pediatric Disaster Preparedness

1

Chapter 8: Disaster Drills
Bonnie Aiquilla B0, Naisha Tieibei NPS

Introduction
Reviewing the types of exeicises anu uiills that aie possible to plan anu execute will help
ueciue what type of uiill is iight foi youi gioup anu when to stait planning a uiill. It is also
necessaiy to ueteimine the goals anu objectives that neeu to be establisheu anu evaluateu in
oiuei to move foiwaiu.
Biills anu exeicises aie conuucteu to piactice skills anu test pioceuuies, to impiove existing
piotocols, anu test new iueas anu new piotocols. The mission statement of the Bepaitment of
Bomelanu Secuiity is "to leau the unifieu national effoit to secuie Ameiica; pievent anu uetei
teiioiist attacks; piotect against anu iesponu to thieats anu hazaius to the nation; ensuie
safe anu secuie boiueis, welcome lawful immigiants anu visitois, anu piomote the fiee-flow
of commeice."
1
The types of uiills anu exeicises, anu when each shoulu be planneu, is baseu on each gioups'
neeus, baseu on ieal events anu baseu on known hazaiu vulneiabilities. Bisastei uiills aie
necessaiy because while it is hopeu theie will be no neeu to iesponu to a natuial oi man
maue uisastei, histoiy pioves that theie aie many challenges in the natuial enviionment anu
theie will be events iequiiing a iesponse. Testing systems anu peisonnel help piepaie,
mitigate anu iesponu in a moie effective mannei. Planning anu piactice is all well anu goou;
but it is ciucial to test systems anu be willing to change baseu on exeicise iesults. Biills aie
also a way to uevelop new woiking ielationships.
Conuucting exeicises anu uiills piepaie agencies to claiify ioles anu iesponsibilities.
Resouice gaps become cleai while piacticing foi exeicises anu stiessing systems. The
exeicise oiganizeis anu the uiill paiticipants will be able to juuge inuiviuual peifoimance,
iuentify aieas wheie auuitional oi in-uepth tiaining may be neeueu. They will also be able to
iecommenu changes. The knowleuge gaineu fiom iegulai uisastei uiills will enable
oiganizations to uevelop anu implement an impiovement plan anu ueciue what othei types
of uiills will be necessaiy.
Types of Exercises
Seminars
A seminai is an infoimal uiscussion-baseu exeicise leu by a piesentei oi facilitatoi, useu to
teach oi oiientate paiticipants. Seminais anu woikshops oiient paiticipants to new oi
existing plans, policies, oi pioceuuies. They assess inteiagency capabilities oi intei-
juiisuictional opeiations. They also constiuct a common fiamewoik of unueistanuing. A
seminai takes place in a casual atmospheie, with minimal time constiaints, anu is lectuie-
baseu. Seminai paiticipants uevelop new iueas, piocesses, oi pioceuuies. They constiuct a
wiitten piouuct as a gioup in cooiuinateu activities, obtain consensus, anu collect oi shaie
infoimation.

2

Tabletop Exercises
A tabletop exeicise involves senioi staff, electeu oi appointeu officials oi othei key peisonnel
in an infoimal gioup uiscussion centeieu on a hypothetical scenaiio. Tabletops iuentify
stiengths anu shoitfalls, enhance unueistanuing of new concepts anu seek to change existing
attituues anu peispectives. They iequiie an expeiienceu facilitatoi. Buiing the exeicise theie
aie in-uepth uiscussions anu slow-paceu pioblem solving.
Games
A game is a simulation of opeiations using iules, uata, anu pioceuuies uesigneu to uepict an
actual oi assumeu ieal-life situation. uames exploie the piocesses anu consequences of
uecision-making, conuuct "what-if" analyses of existing plans, anu test existing anu potential
stiategies. A game uoes not involve the use of actual iesouices. Noie often it involves two oi
moie teams, anu incluues mouels anu simulations of incieasing complexity as the game
piogiesses.
Operations-Based Exercises
0peiations-Baseu Exeicises involve ueployment of iesouices anu peisonnel. They aie moie
complex than uiscussion-baseu types. The iequiie execution of plans, policies, agieements,
anu pioceuuies, as well as claiify ioles anu iesponsibilities of playeis. Theii aim is to
impiove inuiviuual anu team peifoimances. Biills anu both functional anu full-scale exeicises
aie incluueu in this categoiy.
A drill is a supeiviseu activity that tests a specific opeiation oi function of a single agency. The
goals of a uiill aie to:
uain tiaining on new equipment
Test new pioceuuies
Piactice anu maintain skills
Piepaie foi moie complex exeicises
A uiill pioviues immeuiate feeuback. It is iealistic, but is helu in an isolateu enviionment.
A functional exerciseis a single oi multi-agency activity uesigneu to evaluate capabilities anu
multiple functions using simulateu iesponse. The goals of a functional exeicise aie to:
Evaluate management of Emeigency 0peiations Centeis, commanu posts, anu
heauquaiteis
Assess the auequacy of iesponse plans anu iesouices
A functional exeicise uses simulateu ueployment of iesouices anu peisonnel, iapiu pioblem
solving in a highly stiessful enviionment.
A full-scale exerciseis a high-stiess multi-agency, multi-juiisuictional activity involving
actual ueployment of iesouices in a cooiuinateu iesponse, as if a ieal inciuent hau occuiieu.
The goals of a uiill aie to
Assess plans anu pioceuuies unuei ciisis conuitions
Evaluate cooiuinateu iesponses unuei ciisis conuitions

3

A full-scale exeicise involves mobilization of units, peisonnel, anu equipment. It occuis in a
stiessful, iealistic enviionment using a sciipteu exeicise scenaiio.
Before Conducting an Exercise
Conduct Needs Assessment /Hazard Vulnerability Analysis
The planning team's fiist uuty is to uevelop a neeus assessment. 0nce uevelopeu, the type of
exeicise that shoulu be planneu becomes eviuent. The best way to ueteimine the appiopiiate
exeicise uesign is to assess youi oiganization's oi juiisuiction's capability neeus.

A compiehensive exeicise piogiam will alieauy have evaluateu its oiganization's capabilities.
Refeiiing to anu upuating that assessment is an impoitant step whenevei a new exeicise is
consiueieu foi uevelopment.
The neeus assessment will iuentify what paits of the oiganization neeu to be piacticeu oi
testeu:
Functions most iequiiing ieheaisal
Potential exeicise paiticipants
Existing exeicise iequiiements anu capabilities
Plausible hazaius anu the piioiity levels of those hazaius
Create an Exercise Planning Team
Eveiy exeicise iequiies an Exeicise Planning Team - the coie gioup iesponsible foi the
uesign, uevelopment, conuuct, anu evaluation of an exeicise. A team consists of a Leau
Plannei anu planning team membeis.
The Exeicise Planning Team:
Beteimines exeicise objectives
Cieates the scenaiio
Bevelops exeicise uocumentation
Conuucts pie-exeicise biiefing anu tiaining sessions
Because of theii high level of involvement, planning team membeis aie iueal selections foi
exeicise contiollei anu evaluatoi positions. As a geneial iule, howevei, they uo not
paiticipate as playeis. Planning Team 0iganization natuially follows Inciuent Commanu
Stiuctuie (ICS).
Tasks assignments aie often baseu on the following functions:
Commanu
Logistics
0peiations
AuministiationFinance

4

Planning
Planneis use the ICS stiuctuie because it cieates a uistinct chain of commanu anu
accountability that enus with the Leau Exeicise Plannei.
Plan Exercise
Bevelop anu cooiuinate an exeicise.
Confeiences pioviue an oppoitunity foi the team to:
Befine the exeicise puipose anu objectives.
Bevelop the scenaiio
Cooiuinate logistics.
Tiack uesign anu uevelopment piogiess
Tioubleshoot uesign oi uevelopment pioblems
The scope, type, size, anu complexity of the exeicise ueteimine the type anu numbei of
confeiences the planning team ueciues to conuuct.
Types of Planning Conferences
Five uiffeient types of planning confeiences oi meetings may occui uuiing the planning
piocess.
Concept and Objectives (C&O) Meeting
0ptionalmay be iolleu into the Initial Planning Confeience (below).
Exeicise type, scope, scenaiio, anu objectives aie iuentifieu
0fficial Exeicise Planning Team selection occuis
Sponsoiing agency anu senioi officials attenu
Initial Planning Conference (IPC)
If theie is no C&0 meeting, the IPC has the same chaiacteiistics, as well as the following:
Refines exeicise scope, scenaiio, anu objectives
Soliuifies exeicise timeline anu task list
Sets task assignments foi planning team membeis
Mid-TermPlanning Conference (MPC)
Settles outstanuing logistical oi oiganization issues
Site walkthiough is conuucteu
0sually only helu foi opeiations-baseu exeicises

5

Master Scenario Events List (MSEL) Conference
Bevelops (oi continues ueveloping) scenaiio injects foi exeicise conuuct
0sually only helu foi opeiations-baseu exeicises
Final Planning Conference (FPC)
Final uiafts of exeicise mateiials aie completeu
Logistics anu pioceuuies foi exeicise conuuct aie finalizeu
Last oppoitunity to settle outstanuing issues

Planning and Managing an Exercise
An exeicise piogiam pioviues the auministiation, suppoiting iesouices, anu stiategic goals
foi an oiganization's exeicise effoits. It involves ueveloping anu executing an exeicise
piogiam, incluuing
Nultiyeai tiaining anu exeicise piogiam planning
Buugeting anu giant wiiting
Planning anu executing inuiviuual exeicises
Tiacking impiovements
Exeicise piogiam management can vaiy in size anu scope, with staff membeis iesponsible
foi all oi paits of the uuties.
Exercise Project Management
Pioject manageis aie iesponsible foi the uesign, uevelopment, anu execution of a specific
exeicise, followeu by evaluation anu impiovement planning. uoou pioject management
involves:
Beveloping a pioject management timeline
Establishing pioject milestones
Iuentifying the exeicise planning team
Scheuuling planning confeiences
These tasks aie the founuation of eveiy exeicise - without them, othei tasks anu stages of the
exeicise planning cycle coulu not happen.
Multiyear Training &Exercise Planning
The Nultiyeai Tiaining & Exeicise Plan is essential to managing an exeicise piogiam. The
plan is a uocument that outlines a piogiam's long-teim stiategy foi builuing capabilities
thiough exeicises anu tiaining. A multiyeai tiaining & exeicise plan:

6

Takes stock of cuiient piogiam plans anu capabilities
Lays out long-teim piogiam goals anu objectives
Bevelops a mix of exeicises to meet goals anu objectives
Beteimines what tiaining is neeueu as a pieiequisite to planneu exeicises
Sets a multiyeai scheuule of exeicises anu tiaining events
Piogiam manageis use the Nultiyeai Tiaining anu Exeicise Scheuule to:
Avoiu uuplicating theii effoits
Combine exeicises anu ensuie the exeicises uon't conflict
Combine tiaining anu ensuie tiaining uoes not conflict
0ptimize anu combine funuing wheie possible
Pievent "ovei" tiaining anu exeicising
Design and Development
Besign anu uevelopment helps to set the exeicise into motion. Besign is the fiamewoik of an
exeicise, anu uevelopment is the builuing of that exeicise.
Step One: Bevelop a uesign by asking these questions:
What aie the neeus to be assesseu.
What is the scope of the exeicise.
What is the puipose. (must be wiitten out)
What aie the exeicise objectives. (this is a list of what is to be test which will best
evaluate the puipose anu test each goal)
What is the exeicise scenaiio.
Step Two:Bevelopment
Cieate exeicise uocumentation.
Aiiange logistics, actois, anu safety.
Cooiuinate paiticipants anu meuia.
Execute othei suppoiting planning tasks (e.g., tiaining contiolleis, evaluatois, anu
exeicise staff).
The Purpose Statementis baseu on the Neeus Assessment which shoulu be cleaily uefineu in
wiiting. The puipose of an exeicise shoulu be captuieu in a simple phiase that communicates
the intent of the exeicise. It uoes not uesciibe in uetail how the intent will be achieveu. This is
a key element to a successful exeicise.
An Objectiveis a uesciiption of the peifoimance you expect fiom paiticipants. ueneially, the
numbei of exeicise objectives shoulu be limiteu in oiuei to enable timely execution, facilitate
uesign of a ieasonable scenaiio, anu piomote successful completion of the exeicise puipose.

7

0se the SMART Acronymto uefine objectives.
Simple-Bon't tiy to covei too bioau an aiea.
Measuiable-Ensuie evaluatois can ueteimine whethei the objective was achieveu.
Achievable-The objective shoulu not be too uifficult to achieve.
Realistic-The objective shoulu piesent a iealistic expectation of the situation.
Task-oiienteu-The objective shoulu focus on a behavioi oi pioceuuie.
A Scenario is the stoiyline that uiives an exeicise. Its thiee basic elements aie geneial
context oi compiehensive stoiy, technical uetails of the stoiy's conuitions anu events, anu
conuitions foi assessing uemonstiating capabilities. Scenaiios shoulu be thieat-baseu anu
peifoimance-baseu, iealistic, anu challenging. Bowevei, they shoulu not be so uemanuing
that paiticipants become oveiwhelmeu. In auuition to stiess, Playeis must feel the challenges
aie achievable.A scenaiio shoulu involve the paiticipants, the thieat, anu the aiea iuentifieu
in the scope.

Exercise Documentation
A Situation Manual (SITNAN) is the paiticipant hanubook foi uiscussion-baseu exeicises. It
pioviues backgiounu infoimation on the scope, incluues a scheuule, anu iuentifies objectives
foi the exeicise. It also can piesent the scenaiio naiiative foi paiticipant uiscussions uuiing
the exeicise.
The Exercise Plan(EXPLAN) is the paiticipant hanubook foi opeiations-baseu exeicises. The
EXPLAN pioviues contiolleis, evaluatois, playeis, anu obseiveis with infoimation such as the
exercise purpose, scope, objectives and logistical information.
Contiollei Evaluatoi (CE) Banubooks supplement EXPLANs foi opeiations-baseu exeicises.
The CE Banubook contains moie uetaileu infoimation. It is not foi the playeis of the
exeicise. Scenaiio guiue uefines the ioles anu iesponsibilities of contiolleis anu evaluatois.
The Master Scenario Events List(NSEL) contains a chionological listing of the events anu
injects that uiive opeiations-baseu exeicise play. Exeicise injects aie bits of scenaiio-specific
infoimation pioviueu to paiticipants to enhance the value of the exeicise expeiience.
Exercise Evaluation Guides (EEus) pioviue evaluatois with a checklist of ciitical tasks to be
completeu by playeis uuiing an exeicise. EEus contain infoimation to be uiscusseu by
paiticipants baseu on the scenaiio, space to iecoiu evaluatoi obseivations, anu questions to
consiuei aftei the exeicise.
Responsibilities of Exercise Participants and Personnel
Biscussion-baseu exeicise peisonnel incluue:
Piesenteis - Belivei the exeicise piesentation.
FacilitatoisNoueiatois - Leau gioup uiscussion
Contiolleis - Inteipiet iules anu pioviue playeis with infoimation

8

Evaluatois - 0bseive anu collect exeicise uata
Playeis - Biscuss issues baseu on piofessional knowleuge
0bseiveisvIPs - view but uo not paiticipate in exeicise
The positions of piesenteis, facilitatoismoueiatois, anu contiolleis may be combineu
uepenuing on the size anu scope of the exeicise.
Controllers and evaluators have two piimaiy iesponsibilities: Keep an exeicise on tiack anu
assess its peifoimance.
Contiolleis plan anu manage exeicise play, set up anu opeiate the exeicise inciuent site,
sometimes simulate non-paiticipating oiganizations, anu paiticipate in post-exeicise
meetings anu ciitiques.
Evaluatois uo not inteifeie with exeicise flow. They tiack action ielative to evaluation
objectives, iuentify any iesolveu anu uniesolveu issues, anu help analyze the exeicise iesults.
They paiticipate in post-exeicise meetings anu ciitiques.
N0TE: Because of theii familiaiity with the exeicise, planning team membeis make excellent
contiolleis anu evaluatois.

Site Setup
Site Setup is uone by the planning team at least a uay befoie conuucting an opeiational
exeicise. 0ften an outuooi venue is useu, which shoulu be pie-ueteimineu uuiing the
planning phase. Any necessaiy peimits shoulu be obtaineu in a timely mannei. The site setup
may incluue:
Response Route - ioutes to the simulateu inciuent
Response Aiea - location of exeicise activities
Assembly Aiea - location of ueployable iesouices paiticipating in the exeicise
0bseiveiNeuia Aiea - uesignateu viewing aiea
Simulation Cell - location geneiating scenaiio injects
Registiation - to ensuie only authoiizeu peisonnel aie alloweu on scene
Paiking
Briefings
All biiefings must be caiefully planneu. A Pre-Exercise Briefingseives to tiain anuoi infoim
exeicise paiticipants anu pioviue safety infoimation to all peisonnel. They aie uiffeient foi
contiolleis, evaluatois, playeis, anu actois baseu on the exeicise uocuments. This biiefing is
useu to explain exeicise play iules (which vaiy foi each exeicise).

9

Buiing a Post-Exercise Debriefingpaiticipant feeuback foims aie ievieweu. A Hot Wash
occuis immeuiately following a tabletop exeicise to ieview key uecisions maue uuiing the
exeicise anu allows the paiticipants the oppoitunity to pioviue immeuiate feeuback. A hot
wash:
Enables the moueiatoi to captuie thoughts, uecisions maue anu othei events while they
iemain fiesh in the paiticipants' minus anu to uesciibe what was leaineu
To ueteimine any issues oi conceins in the Emeigency Nanagement Plan
To iuentify emeigency piepaieuness gaps anu pioposeu aieas of impiovement anu next
steps foi mouifying the Emeigency Nanagement Plan
Evaluation Process
Theie aie eight Bomelanu Secuiity Exeicise Evaluation Piocess (BSEEP) steps in the
evaluation piocess (as uefineu anu manuateu by Bomelanu Secuiity):
1. Plan anu oiganize the evaluation
2. 0bseive the exeicise anu collect uata
S. Analyze uata
4. Bevelop the uiaft Aftei Action Repoit (AAR)
S. Conuuct an Aftei Action Confeience
6. Iuentify impiovements to be implementeu
7. Finalize the AAR anu Impiovement Plan (IP)
8. Tiack implementation
The Exercise Evaluation Guide(EEu) is a key uocument useu by evaluatois uuiing the
exeicise. EEus pioviue stiuctuieu evaluation measuies of paiticipant conuuct, listing ciitical
activities anu tasks to be completeu uuiing an exeicise. They tell evaluatois what they shoulu
expect to see, give them space to iecoiu obseivations, anu list questions to auuiess aftei the
exeicise as a fiist step in the analysis piocess.
An Euu might incluue such questions as:
Weie ioles anu iesponsibilities of the vaiious goveinment agencies anu piivate
oiganizations cleai.
Bow weie vaiious uecisions maue. Who hau authoiity.
What infoimation about the scenaiio, the weapon, the victims, anu the iisks to
iesponueis anu the public was collecteu in the couise of the exeicise.
The Exercise Evaluationassesses how well the exeicise objectives weie achieveu. It also
iuentifies oppoitunities foi impiovement. Evaluatois accomplish this by obseiving the
exeicise anu collecting suppoiting uata, gauging peifoimance against expecteu outcomes,
anu ueteimining what changes aie neeueu to ensuie uesiieu outcomes. Evaluation is the
yaiustick by which an oiganization measuies its capabilities. uoou evaluations iesult in
suggestions foi filling anu biiuging capability gaps oi making neeueu impiovements.

10

The Evaluation Methodology of the Bepaitment of Bomelanu Secuiity assesses exeicise
peifoimance at thiee levels. The Task Level evaluates the ability of inuiviuual playeis oi
teams to peifoim a iequiieu task uuiing an exeicise. The
UrganizationJDisciplineJFunction Level assesses the ability of an oiganization (e.g.,
}onesville ENA), uiscipline (e.g., law enfoicement), oi function (e.g., BazNat iesponse) to
peifoim its iole in iesponuing to an event. The Mission Level ieviews the ability of the
inteigoveinmental community as a whole (acioss uisciplines anu juiisuictions) to achieve
expecteu outcomes in iesponuing to an event.
The main instiument of exeicise evaluation is the After Action Report(AAR) which often is
piepaieu by the membeis of the planning team anu evaluation team. The Aftei Action Repoit
(AAR) pioviues paiticipant officials with feeuback on the exeicise's iesults anu suggests
iecommenuations foi impiovement. AARs shoulu be piepaieu aftei eveiy type of exeicise.
They shoulu summaiize what happeneu uuiing the exeicise, pioviue feeuback to paiticipants
on theii peifoimance, anu iecommenu impiovements foi bettei piepaieuness.

Recommended DHS (HSEEP) AAR Format(https://hseep.dhs.gov/pages/1001_Toolk.aspx)
Executive Summaiy
Exeicise 0veiview Incluues backgiounu infoimation: paiticipating
oiganizations, exeicise conuuct uate anu time, location,
exeicise type, hazaiu, evaluation methouology.
Exeicise uoals anu 0bjectives
Exeicise Events Synopsis Chionological synopsis of majoi events anu actions.
Analysis of Nission 0utcomes

Summaiizes how the peifoimance oi nonpeifoimance of
tasks anu inteiactions affecteu achievement of the mission
outcomes.
Analysis of Ciitical Task
Peifoimance

Summaiizes anu auuiesses issues iegaiuing each task in
teims of consequences, analysis, iecommenuations, anu
impiovement actions.
Conclusion
Appenuix: Impiovement Plan
Natiix
Pioviues a task list of iecommenuations, uue uates, anu
iesponsible oiganizations.

Improvement Planning Process
Impiovement planning completes the cycle of piepaieuness. Those neeus iuentifieu in the
AAR become the next step foi futuie exeicises. They help uefine an exeicise piogiam's
uiiection anu scheuule. They also help uevelop a stiategy foi impioving tiaining, puichasing
equipment anu cieating policy, as well as scenaiios anu objectives foi futuie exeicises.
Exeicises help assess anu impiove peifoimance. Evaluations iuentify what aieas neeu
impioving. Impiovement planning iuentifies actions uesigneu to ensuie impiovements aie
maue.

11

Improvement Plan
A task list anu timeline of coiiective actions, calleu the Improvement Plan(IP), is pait of the
AAR, which geneially incluues summaiies anu evaluations of the exeicise scenaiio, playei
activities, pieliminaiy obseivations, anu majoi issues. AARs vaiy in size anu uetail, uepenuing
on the complexity of an exeicise. Souices foi AAR uata incluue evaluatoi obseivation;
Exeicise Evaluation uuiues; Bot wash, uebiiefing, oi paiticipant feeuback foims; anu plans
anu pioceuuies of paiticipant oiganizations.
0nce iecommenuations anu action items have been iuentifieu, oiganizations shoulu ensuie
that each item is tiackeu to completion anu impiovements aie implementeu. When no
iesouices aie available, alteinative shoit anu long-teim solutions such as mutual aiu
agieements shoulu be consiueieu.

References
1. Bepaitment of Bomelanu Secuiity http:www.uhs.govxaboutstiategicplan
2. Lessons Leaineu Infoimation Shaiing, Bepaitment of Bomelanu Secuiity
http:www.llis.gov
S. Peuiatiic Teiioiism anu Bisastei Piepaieuness: A Resouice foi Peuiatiicians. ABRQ
Publication Nos. u6(u7)-uuS6 anu u6(u7)-uuS6-1, 0ctobei 2uu6. Agency foi Bealthcaie
Reseaich anu Quality, Rockville, NB.
http:www.ahiq.govieseaichpeupiepiesouice.htm
9: Decontamination Pediatric Disaster Preparedness

1
Chapter 9: Topical Decontamination of Children
Nichael Shannon NB, Saiita Chung NB
Relevant Epidemiology
Cuiiently, we live in an age wheie theie is a ieal iisk of teiioiism with the ielease of
biological, chemical oi iauioactive agents. Auuitionally, the constant tianspoit of hazaiuous
mateiials (tiains, aiiplanes) can iesult in unintentional hazaiuous mateiials (BAZNAT)
inciuents; these hazaiuous substances can even be ieleaseu intentionally as "weapons of
oppoitunity". Even schools anu chiluien can be taigeteu as tiagically uisplayeu in the Beslan
school hostage ciisis of 2uu4.
Inciuents such as those uesciibeu above can leau to toxic substances lanuing on the skin anu
clothes of victims. In such a case it is necessaiy to quickly iemove the toxins in oiuei to
ieuuce the victim's fuithei exposuie anu to assuie that health caie pioviueis aie not
themselves haimeu by theii exposuie to the toxin(s). The 199S saiin attacks in }apan viviuly
uemonstiateu the impoitance of uecontaminating victims befoie they aie tieateu by fiist
iesponueis anu fiist ieceiveis. In that inciuent, health caie pioviueis weie sickeneu by the
toxic agent because they began caie foi victims piioi to uecontamination. Nany health caie
woikeis weie unable to pioviue caie, ultimately becoming victims themselves (Table 1.)
1

Conditions Requiring Decontamination
Theie is a bioau iange of substances that can contaminate the skin of chiluien aftei
intentional (teiioiist) oi unintentional inciuents. ueneial categoiies of these substances,
piototypical agents, anu theii associateu clinical manifestations aie:
Chemical and Biological Agents
Nerve Agents (saiin, soman, malathion): Signs of intoxication: cential neivous system
(weakness, stupoi , coma), neuiomusculai (weakness, fasciculation), anu iespiiatoiy uistiess
(bionchospasm, bionchoiihea).
Vesicants (mustaiu, ammonia, chloiine): Signs of intoxication: seveie eye, skin anu aiiway
iiiitation, blisteiing, iespiiatoiy uistiess
Choking Agents (phosgene, chloiine): Signs of intoxication: iespiiatoiy uistiess (cough,
uyspnea, bionchospasm, pulmonaiy euema)
Cyanogens (cyaniue, souium aziue): Signs of intoxication: uyspnea, cential neivous system
uepiession, metabolic aciuosis
Industrial Solvents (gasoline, oil, anu othei petioleum uistillates): Signs of intoxication:
iespiiatoiy uistiess, skin iiiitation, cential neivous system uepiession
Biologicals (anthiax spoies): Signs of intoxication: iespiiatoiy uistiess, wiueneu
meuiastinum on chest x-iay if spoies aie inhaleu; skin finuings if nonintact skin is exposeu2-4

2

Radiation
Theie aie thiee geneial categoiies of iauiation with uiffeiing mechanisms of injuiy:
Ionizing radiationtiansfeis eneigy to living cells, iesulting in uiiect tissue injuiy.
Electromagnetic radiation(e.g., gamma iays anu x iays) pass thiough tissues iiiauiating cells
iesulting in tissue uamage. These iays uo not leave behinu iauioactivity anu typically uo not
iequiie topical uecontamination.
Particle radiation(e.g., u- paiticles, - paiticles, neutions). Alpha paiticles uo not penetiate
the skin. In high uoses, beta paiticles can penetiate the epithelium, piouucing skin uamage.
Neutions aie an uncommon type of iauiation; theii penetiation is highly uestiuctive to
tissues.
Not all foims of iauiation leau to contamination of the skin anu clothes; many agents can be
inhaleu oi ingesteu (incoipoiation), making topical uecontamination neeuless. Exteinal
contamination iequiiing topical uecontamination occuis when paiticles fall on the skin. Foi
example, iauioactive uispeisal uevices (RBBs, "uiity bombs") aie conventional explosives
placeu neai iauioactive mateiial to uispeise iauiation.
S
The paiticles ieleaseu fiom an RBB
can iesult in significant exteinal contamination.
6
Even so, iauioactive contaminants pose little
oi no iisk to the piopeily gaibeu health caie piofessional. Rauioactive paiticles (both alpha
anu beta) will not penetiate the gowns oi gloves commonly useu as peisonal piotective
equipment (PPE) foi the "stanuaiu piecautions" taken foi any patient with an emeigency
conuition. As such, while it is auvisable foi patient uecontamination to pieceue iesuscitation
foi most peuiatiic patients who iequiie emeigency caie, uecontamination shoulu not pieceue
iesuscitative effoits foi patients in extiemis. These patients shoulu be iesuscitateu fiist,
followeu by uecontamination of both patient anu pioviuei, iecognizing, again, that the iisk to
the piopeily gaibeu health caie pioviuei appioaches zeio, anu will be fuithei minimizeu by
uoffing contaminateu PPE anu othei clothing, anu washing with soap anu watei in a piopeily
outfitteu uecontamination unit befoie uonning fiesh clothing.
Unique Pediatric Considerations with Decontamination
Anatomic. The small size of infants anu young chiluien can make safe, thoiough
uecontamination uifficult. Also, chiluien have less subcutaneous fat than auults, placing them
at iisk foi hypotheimia.
Physiologic. 0n a pei weight basis, chiluien have a highei minute ventilation. Auuitionally,
theii shoit statuie places them closei to the giounu which potentially incieases theii
exposuie to chemicals anu biological, paiticulaily those heaviei then aii. The gieatei skin to
bouy mass iatio of chiluien pieuisposes them to incieases tiansueimal injuiy fiom toxicants
as well as an incieaseu iisk of hypotheimia.
Developmental. The immatuie motoi skills of chiluien make it moie uifficult foi them to
flee. Infants anu touuleis cannot uecontaminate themselves, iequiiing gieatei iesouice
utilization. 0luei chiluien neeu special guiuance uuiing the uecontamination piocess in
oiuei to ieuuce theii feai anu gain theii coopeiation foi the pioceuuie.
Psychological. Chiluien aie at inciease iisk of ueveloping post tiaumatic stiess uisoiuei
anu enuuiing behavioial uistuibances aftei being exposeu to toxic agents anu, potentially, to

3
the somewhat fiightening scene of pioviueis in peisonal piotective enviionments anuoi
laige, uaik uecontamination chambeis.
S

Decontamination Principles and Techniques
Any uecontamination plan must have scalability, that is, an ability to uecontaminate a few
chiluien (as few as two oi thiee) as well a laige numbei (>Su). Piehospital pioviueis anu
health caie facilities shoulu geneially consiuei a two-pait plan. Also, while iemoval of
clothing accounts foi up to 9u% of topical uecontamination, showeis aie an integial pait of
any plan, necessaiy to wash toxic mateiials fiom the skin. Showeis shoulu have tempeiatuie
anu piessuie contiol, pioviuing watei at S7-S8 uegiees Celsius anu 6u pounus pei squaie
inch (psi) of piessuie. Consiuei using aujustable piessuie hanu helu showeis foi infants anu
touuleis. In oiuei to have an effective, all-weathei uecontamination plan theie must also be
an auaptable plan foi tempeiatuies extiemes. Foi example, piepaiation foi colu weathei
iequiies waimei watei, heateis, anu insulating blankets to pievent hypotheimia. Bot
weathei conuitions iequiie coolei watei anu immeuiate sheltei to pievent hypeitheimia.
Decontamination Staging
The aiea wheie uecontamination is to be peifoimeu can eithei be neai the site of exposuie,
pioviueu by piehospital peisonnel, oi at the health caie facility which ieceiveu patients.
Typically, hospital uecontamination staging aieas aie placeu neai the emeigency uepaitment
in oiuei to pioviue close access to life-saving equipment aftei showeiing has been completeu.
Peisonal piotective equipment (PPE) is an essential pait of uecontamination. All health caie
peisonnel who will pioviue initial caie foi contaminateu victims must weai piopei
equipment to avoiu becoming exposeu. Theie aie foui categoiies of PPE ianging fiom Class A
(fully piotective, incluuing self-containeu bieathing appaiatus) to Class B, consisting of
gowns, gloves anu masks. A complete uiscussion of each class anu theii use is beyonu the
scope of this chaptei. In geneial, howevei, Class C PPE, which incluues chemical-iesistant
gowns anu gloves anu a iespiiatoi (typically a so-calleu N-9S) oi peisonal powei-assisteu
iespiiatoi (PAPR).
7

Becontamination Aieas have a chaiacteiistic configuiation, uesigneu to pievent the
contamination of unaffecteu aieas. These zones, outlineu below, shoulu be cleaily uelineateu;
they shoulu not be bieacheu. Police anu othei secuiity officeis shoulu be stationeu at the
uecontamination staging aiea so that victim flow is one-way, pieventing cioss contamination.
Hot Zone: This is the area where all exposed patients should be placed. All healthcare workers
must be in protective gear. Designate a tiiage cooiuinatoi to uiiect sickei victims who most
uigently neeu meuical attention. Communication between health caie peisonnel is uifficult
thiough piotective geai; consiuei ueveloping laige posteispictuies to show victims what
will neeu to be uone. Alteinate methous foi communication incluue the use of pieiecoiueu
messages oi a viueo that instiucts victims (in uiffeient languages that aie common in that
iegion) on what to expect anu uo.
WarmZone: This zone contains the area where the actual process of uecontamination occuis.
victims shoulu fiist uisiobe. Scieen baiiieis shoulu be useu to help with peisonal mouesty.
Foi young chiluien, segiegation by genuei is unnecessaiy. Bowevei, school age chiluien anu
auolescents shoulu be sepaiateu into sepaiate lines foi males anu females. All clothing anu

4
items must be gatheieu anu labeleu as eviuence foi law enfoicement officials. victims shoulu
be leu thiough the showeis by health caie woikeis in piotective geai. Families shoulu be
encouiageu to stay togethei uuiing this piocess.
Clean (Cold) Zone: The cold area, placed immediately after the shower, is the area where
decontaminated victims are received and transported for medical care. Clothing and blankets
should be provided for personal modesty and pievent hypotheimia. victims shoulu be ietiiageu
accoiuing to neeu foi meuical caie anu then be tianspoiteu to the appiopiiate meuical caie
facilities.
8

Age-based Issues in Decontamination
Infants and Toddlerswill be slippeiy when wet anu can not be expecteu to coopeiate foi the
entiiety of uecontamination. Consiuei placing infants in a laige containei oi stietchei so that
they will not be uioppeu. Iueally, the containei shoulu be poious to allow foi uiainage of
watei uuiing the showei, e.g., a bassinet oi launuiy basket. Special attention shoulu be paiu
to keeping the aiiway patent uuiing the showei.
Preschoolerscan be fiighteneu by the uecontamination piocess, iefusing to paiticipate oi
even ueveloping tantiums. To ieuuce this iisk, families shoulu be biought into the
uecontamination aiea togethei. Paients can also assist in washing theii chiluien although
they shoulu not be solely iesponsible foi uecontaminating the chilu. If possible, enlist the aiu
of othei auults who aie familiai with the chilu, e.g., a teachei in the case of a school-baseu
event.
School Age Children and Adolescentsmay not want to uisiobe in public anu may
auamantly iefuse uecontamination uue to feai of embaiiassment. It is theiefoie essential to
have paititions (scieen oi cuitain) in place to maintain peisonal mouesty.
Children with Special Healthcare Needspose a paiticulai challenge to uecontamination.
Fifteen to twenty peicent of the peuiatiic population consists of chiluien with special health
caie neeus, incluuing those who aie technology-uepenuent (i.e., those who iequiie motoiizeu
wheelchaiis, ventilatois, oi continuous monitoiing). Non-ambulatoiy chiluien may iequiie
uecontamination on a stietchei oi in a wheelchaii. Foi chiluien who aie ventilatoi-
uepenuent, manual ventilation will be necessaiy uuiing uecontamination since ventilatois
aie not manufactuieu to be wateipioof. Becontamination peisonnel must pay caieful
attention to the aiiway of chiluien with tiacheostomies. Chiluien may also have cential Iv
lines, pumps, anu feeuing tubes that can not be uetacheu fiom the bouy. Any exteinal
equipment shoulu be consiueieu contaminateu. If it cannot be cleanseu with watei oi
otheiwise effectively uecontaminateu, it shoulu be uiscaiueu.
Pitfalls in Management
Theie aie many challenges to the uecontamination of chiluien. Foi example, communication
is a significant pioblem foi peisonnel weaiing peisonal piotective equipment. The thick,
chemical iesistant gloves that aie pait of uecontamination effectively eliminate manual
uexteiity, making it uifficult foi peisonnel to hanule infants oi pioviue meuical tieatment,
e.g., Iv inseition uuiing the uecontamination piocess. These factois can piolong
uecontamination, iesulting in impoitant uelays in uefinitive meuical management; the

5

geneially iecommenueu S-minute pei victim peiiou of uecontamination can be uoubleu oi
tiipleu. To plan foi such a situation, uecontamination plans shoulu incluue piotocols that
cieate a meuical inteivention aiea within the hot zone wheie lifesaving measuies aie
peifoimeu piioi to uecontamination.
Challenges and Complications of Decontamination
Removal of identifiers:Chiluien spenu 8u% of theii waking houis in school oi activities,
away fiom theii families; uisasteis may theiefoie sepaiate them. Infants anu othei pieveibal
chiluien aie unable to iuentify themselves. Removal of clothing may iemove the only means
of chilu iuentification. Becontamination plans shoulu theiefoie incluue a tiacking system to
account foi all chiluien biought into the facility. This is paiticulaily tiue aftei mass casualty
inciuents, in which theie may be laige numbeis of chiluien iapiuly enteiing the health caie
system. Consiuei taking pictuies (uigital images) of each chilu, piioi to theii uisiobing, which
can be useu foi iuentification by caiegiveisfamily membeis.
9,1u

Hypothermia:Chiluien aie at incieaseu iisk of ueveloping hypotheimia if attention is not
paiu to enviionmental conuitions.
S
Fear and anxiety:Chiluien aie at iisk foi ueveloping significant anxiety oi post tiaumatic
stiess uisoiuei aftei being involveu in oi witnessing tiaumatic events. A cleaiei
unueistanuing of chiluien's neeus anu immeuiate psychosocial suppoit aie a key pait of
initial caie in oiuei to ieuuce this iisk.
11,12
Personnel safety: The peisonnel woiking in piotective peisonal equipment can easily
become oveiheateu. It is theiefoie impoitant foi occupational health pioviueis to be piesent
to monitoi the health of peisonnel. Stiong auheience must be maue to only allow peisonnel
to woik 2u minutes oi less when weaiing PPE. Also, peisonnel aie at significant iisk of
ueveloping anxiety oi uistiess in theii caie of victims. Nental health staff shoulu be ieauily
available to caie foi pioviueis.
11

Summary
Becontamination continues to be a challenge in events wheie chiluien aie exposeu. Special
attention shoulu be uiiecteu to unueistanuing chiluien's anatomical, physiological,
uevelopmental anu psychological uiffeiences to ieuuce complications. Becontamination plans
shoulu be scalable, equally effective foi small as well as laige numbeis of chiluien. 0thei
peuiatiic issues incluue post uecontamination caie, tiacking of uniuentifieu chiluien anu
mitigation of psycho-behavioial uistiess. A compiehensive plan foi the uecontamination of
chiluien shoulu be pait of eveiy piehospital anu hospital (peuiatiic anu non-peuiatiic)
uisastei plan.
References
1. 0kumuia, T., et al., The Tokyo subway saiin attack: uisastei management, Pait 2: Bospital
iesponse. Acau Emeig Neu, 1998. S(6): p. 618-24.
2. Benietig, F.N., T.}. Cieslak, anu E.N. Eitzen, }i., Biological anu chemical teiioiism. }
Peuiati, 2uu2. 141(S): p. S11-26.

6

S. Committee on Enviionmental Bealth anu C.o.I. Biseases, Chemical-Biological Teiioiism
anu Its Impact on Chiluien. Peuiati, 2uu6. 118: p. 1267-1278.
4. Chung, S. anu N. Shannon, Bospital Planning foi Acts of Teiioiism anu 0thei Public
Bealth Emeigencies Involving Chiluien. Aich Bis Chilu, 2uuS. 9u: p. 1Su-1Su7.
S. Shannon, N., et al., Rauiation Bisasteis anu Chiluien. Peuiati, 2uuS. 111: p. 14SS-1466.
6. Scalzo, A., et al., Bisastei Piepaieuness anu Toxic Exposuies in Chiluien. Clinical Peuiatiic
Emeigency Neuicine, 2uu8. 9: p. 47-6u.
7. Bick, }.L., et al., Piotective equipment foi health caie facility uecontamination peisonnel:
iegulations, iisks, anu iecommenuations. Ann Emeig Neu, 2uuS. 42(S): p. S7u-8u.
8. Rotenbeig, }.S., T.R. Buiklow, anu }.S. Selanikio, Weapons of mass uestiuction: the
uecontamination of chiluien. Peuiati Ann, 2uuS. S2(4): p. 26u-7.
9. Chung, S. anu N. Shannon, Reuniting Chiluien with Theii Families Buiing Bisasteis: A
Pioposeu Plan foi uieatei Success. Ameiican }ouinal of Bisastei Neuicine, 2uu7. 2: p.
11S-117.
1u. Foice, C.f.B.P.P.P.T., N.B.P.B.A. uioup, anu N.B.B.B.P. Piogiam. Bospital uuiuelines foi
Peuiatiics in Bisasteis. 2uu6 |citeu 2uu8 Naich 1j; Available fiom:
http:www.nyc.govhtmluohuownloauswoiubhppbhpp-focus-peu-toolkit.uoc.
11. Foltin, u., B. Schonfelu, anu N. Shannon. Peuiatiic Teiioiism anu Bisastei Piepaieuness:
A Resouice foi Peuiatiicians. 2uu6 |citeu 2uu8 Febiuaiy 2uj; Available fiom:
http:www.ahiq.govieseaichpeupiepiesouice.htm.
12. Naikenson, B., et al., The Peuiatiician anu Bisastei Piepaieuness. Peuiati, 2uu6. 117: p.
eS4u-eS62.
Web Based Resources:
ABRQ anu Chiluien's Bospital Boston Tiaining viueo: Becontamination of Chiluien Available
at http:www.ahiq.govieseaichuecontam.htm
NYC Bepaitment of Bealth anu Nental Bygiene Peuiatiic Bisastei Toolkit: Bospital
uuiuelines. Available at http:www.nyc.govhtmluohhtmlbhppbhpp-focus-peu-
toolkit.shtml
Foltin u, Schonfelu B, Shannon N. Peuiatiic Teiioiism anu Bisastei Piepaieuness: A
Resouice foi Peuiatiicians. Available at
http:www.ahiq.govieseaichpeupiepiesouice.htm

Table 1: Secondary Exposure Rates by Hospital Occupational Category and Site of
Care Delivery in the Sarin Tokyo Subway Attack at St. Lukes Hospital, Japan
1

Occupational Category
Nuise Assistants S9.S% (1128)

7

Nuises 26.S% (4S17u)
volunteeis 2S.S% (14SS)
Boctois 21.8% (12SS)
Cleiks 18.2% (1266)

Site of Care
Chapel 4S.8% (S88S)
IC0 S8.7%(12S1)
0utpatient Bepaitment S2.4% (S41uS)
Waiu
EB
17.7% (1479)
16.7% (848)

10: Psychological First Aid Pediatric Disaster Preparedness

1

Chapter 10: Providing Psychological First Aid and Identifying
Mental Health Needs in the Aftermath of a Disaster or
Community Crisis
Baviu Schonfelu NB
Introduction
Attention to distress is important in all prehospital emergency encounters.
Piehospital pioviueis encountei chiluien anu families in stiessful situations viitually eveiy
uay; in many ways, stiess is intiinsic to the natuie of piehospitalemeigency meuical
iesponse. Since this may become ioutine foi the piehospital pioviuei, it is sometimes easy to
foiget that the expeiience foi the vast majoiity of patients anu theii families iemains novel
anu highly stiessful. The following is a list of some of the ieasons why unueistanuing the
impact of stiess on chiluien anu theii families anu leaining effective anu efficient stiategies
to piomote aujustment anu coping of patients anu theii families can theiefoie have gieat
benefit on a uaily basis:
Psychological uistiess may piesent as symptoms that mimic seiious physical conuitions -
tachypnea, tachycaiuia, uisoiientation, confusion, complaints of pain, etc. may emanate
fiom psychological factois iathei than physical etiologies.
Even if physical etiologies aie the piimaiy cause of symptoms, an oveilay of psychological
uistiess may woisen symptoms anu complicate meuical management. Physiologic anu
psychosocial factois fiequently co-occui anu contiibute uiiectly to the elaboiation,
peisistence, anuoi mannei of manifesting symptoms.
Inuiviuuals who aie uistiesseu have uifficulty pioviuing accuiate anu timely histoiical
infoimation, theieby impeuing the evaluation anu tieatment piocess.
Patients who aie agitateu aie less likely to coopeiate with necessaiy tieatments anu may
unueimine the piovision of emeigent caie (e.g., an agitateu chilu may iefuse to keep an
oxygen mask in place oi iesist being placeu on a stietchei foi tianspoit to the hospital).
Time spent on unueistanuing the patient's psychological uistiess anu implementing effective
biief inteiventions may actually shoiten the oveiall time foi the encountei anu expeuite the
ueliveiy of appiopiiate emeigency meuical caie. Bettei engagement with the patient anu
family, moie efficient acquisition of accuiate histoiical infoimation anu uesciiption of
symptoms, time avoiueu on unnecessaiy anu ineffective tieatments iesulting fiom
misattiibution of the cause of symptoms, anu incieaseu active paiticipation of the patient anu
family in the tieatment piocess all contiibute to the ultimate time savings as well as an
impiovement in outcome.

2

Psychological First Aid in the Aftermath of a Disaster or Other Crisis
Especially in the afteimath of a uisastei, piehospital pioviueis may not only be the fiist
iesponueis who have an oppoitunity to iuentify psychological uistiess, but may in fact be the
only health caie piofessionals to iuentify, tiiage, anu begin inteiventions to piomote
aujustment anu coping foi chiluien anu theii families. All piofessionals anu
paiapiofessionals that have the potential to inteiact with inuiviuuals aftei a uisastei oi othei
ciisis shoulu unueistanu the piinciples of psychological fiist aiu (PFA). PFA involves offeiing
psycho-euucation anu suppoitive seivices to fostei effective anu noimative coping stiategies
anu aujustment anu to acceleiate the natuial healing piocess. The following aie some basic
fiist steps that pie-hospital pioviueis can take:
Establish open communication with the chiluien anu theii families. Ask the chiluien
uiiectly what they know about the uisastei oi ciisis anu explain to them in simple anu
uiiect teims the basic infoimation about the event, without pioviuing unnecessaiy
elaboiation oi giaphic uetail. Then ask the chiluien what fuithei infoimation they woulu
like anu encouiage them to shaie theii conceins anu questions as they aiise. Remembei,
chiluien may have veiy uiffeient conceins than auults about the ciisis event, theii health,
oi the health caie inteiventions. Nany of these conceins will be baseu on misinfoimation
oi misunueistanuings. Pioviue claiification anu ieassuiance as appiopiiate, without
pioviuing inaccuiate oi false ieassuiance.
Ask chiluien anu families about how they aie coping as well as theii peisonal
expeiiences. Some chiluien will withuiaw anu many will feel uncomfoitable talking
uiiectly about what has happeneu oi theii peisonal ieactions - uo not foice the
conveisations. valiuate chiluien's iepoits of feelings anu expiessions of concein.
Allow chiluien to show theii uistiess; uo not tiy to cheei them up oi encouiage them to
hiue oi mask theii uistiess. Bealth caie pioviueis shoulu feel fiee to uemonstiate
empathy, but shoulu avoiu inuicating they know exactly what victims aie going thiough
(only they can know) oi telling them how they ought to feel ("Nany chiluien that I take
caie of in emeigencies aie scaieu anu upset - how aie you uoing." is piefeiable to "You
must be scaieu.").
Belp chiluien to unueistanu the infoimation you aie pioviuing about the evaluation anu
tieatment piocess. 0se simple anu uiiect explanations, avoiu jaigon anu unnecessaiy
uetails, anu invite anu answei questions. Bo the same foi theii paientscaiegiveis anu
othei family membeis, since unuei stiess even well euucateu auults will have uifficulty
piocessing meuical infoimation.
Neet chiluien's basic neeus foi safety, foou anu uiink, anu ieunification with loveu ones
as impoitant fiist steps in meeting theii mental health (anu by extension theii physical
health) neeus. Let them know that they aie safe anu what you aie uoing to keep them
safe. State actions in positive teims, foi example, "I am going to put this belt aiounu youi
waist so you iemain secuie anu safe in the beu as we move it into the ambulance anu
uiive to the hospital" iathei than "I am going to put this belt aiounu youi waist so if we
get in a cai acciuent you uon't go flying out the winuow anu get even moie injuieu."
Allow paients anu othei impoitant caiegiveis anu family membeis to iemain with the
chiluien to the extent possible; guiue these auults in how they can be helpful to theii
chiluien anu the health caie team (e.g., how they can assist with uistiacting oi calming

3

the chilu; how they can help keep the oxygen mask in place, etc.) - pioviuing an active
anu appiopiiate iole foi the paients in the evaluation anu tieatment piocess minimizes
the likelihoou (but uoes not eliminate the possibility) that theii piesence will be
uisiuptive. Paients anu othei caiegiveis may iefuse to be sepaiateu fiom theii chiluien
in the afteimath of a uisastei, even if they themselves aie in neeu of emeigency meuical
caie. As a iesult, piehospital pioviueis anu emeigency iooms shoulu be piepaieu to
tieat families as intact units in the afteimath of a uisastei oi majoi ciisis.
To the extent possible, locate oi move chiluien in oiuei to shielu them fiom unnecessaiy
auuitional exposuie to tiaumatic aspects of the event; be conscious that even young
chiluien can anu will oveiheai conveisations among membeis of the health caie team,
whethei ielateu to theii own meuical caie oi the uisastei oi ciisis event. Also be
conscious if televisions oi iauios may be oveiheaiu.
Belp chiluien iuentify suppoits anu coping techniques that have been effective in the past
foi othei stiessois anu suggest they tiy them now. Foi example, if uistiaction has
woikeu in the past, consiuei allowing the chiluien to listen to theii NPS playei if that will
not inteifeie with the evaluation oi tieatment. Suggest othei coping techniques, such as
talking with tiusteu auults, cuuuling a stuffeu animal, etc.
Consiuei offeiing tiansitional objectives, such as something familiai anu comfoiting fiom
theii paientscaiegiveis oi home (e.g., theii beuioom pillow oi pillow case that has a
familiai scent, a pictuie of a paient who can't be with the chilu, one of the chilu's stuffeu
animals, etc.), being caieful not to take anything of significant value (monetaiy oi
peisonal) that woulu be uifficult to ieplace.
Psychotiopic meuication is iaiely inuicateu in the immeuiate afteimath of a ciisis anu
shoulu be piesciibeu in consultation with a chilu psychiatiist oi othei peuiatiic health
caie pioviuei familiai with the assessment anu management of tiaumatizeu chiluien.
Attempts to use psychotiopic meuications immeuiately aftei an event in oiuei to blunt
the chilu's awaieness of what is occuiiing oi to ieuuce typical ieactions (e.g., ciying)
shoulu be uiscouiageu - such awaieness anu oppoitunities to expiess uistiess aie
iequiieu in oiuei to unueistanu anu ultimately aujust to what has occuiieu.
Specific guiuelines on how to appioach ueath notification with chiluien can be founu
elsewheie.
1

Be conscious of the impact of the event anu its afteimath on the membeis of the health caie
team. Chiluien anu family membeis aie veiy iesponsive to the affective tone of the health
caie pioviuei. Attempt to convey a sense of contiol of the situation anu iesponu in a gentle,

1
Foltin uL, Schonfelu B}, Shannon, NW (euitois). PeJiotric Terrorism onJ Bisoster
PreporeJness: A Resource for PeJiotricions. ABRQ Publication No. u6-uuS6-EF. Rockville,
NB: Agency foi Bealthcaie Reseaich anu Quality. 0ctobei 2uu6.


4

compassionate, anu suppoitive mannei. Panic oi anxiety conveyeu by the emeigency
iesponuei will geneially exaceibate the stiess ieactions of the chiluien anu theii families.
Childrens Reactions to Disaster and Crisis
Chiluien's iesponses to a uisastei oi ciisis situation uepenus to a laige extent on theii
uevelopmental anu cognitive level, theii pie-existing mental health anu coping skills, theii
piioi expeiiences with tiaumatic situations, anu the iesouices within theii families anu
communities foi pioviuing suppoit anu assistance. Common ieactions that may be seen
shoitly aftei a uisastei oi othei ciisis that will be appaient foi piehospital pioviueis incluue
the following:
Inciease in feais - the feais may be associateu with a iecuiience of the ciisis event (such
as a feai of the winu aftei a uevastating huiiicane) oi an inciease in feais chaiacteiistic of
the uevelopmental peiiou (e.g., feai of the uaik) even if unielateu to the ciicumstances of
the paiticulai ciisis event. Remain conscious of this ieaction anu inquiie of the chilu anu
family membeis about potentially fiightening situations anu attempt to minimize such
exposuies (e.g., shielu the chilu fiom winu, explain why uiafts uo not inuicate an
impenuing stoim, keep a light on insiue the ambulance uuiing tianspoit, etc.).
Anxiety oi woiiies, which may incluue feai about sepaiation fiom family anu othei
significant inuiviuuals; this sepaiation anxiety is often associateu with feais that haim
may come to themselves oi those close to them if they weie to be physically sepaiateu.
Youngei chiluien may uemonstiate an inciease in clinginess. Emeigency evaluations of
young chiluien who aie having uifficulty with sepaiation may be best accomplisheu,
when possible, while they aie being helu by a paient oi caiegivei oi least able to holu
hanus.
Bifficulty concentiating oi appeaiing confuseu oi uisoiienteu. Speak slowly anu cleaily
anu offei oiienting statements as neeueu.
Iiiitability, aggiession, anu immatuie behavioi.
Regiessive behavioi -- young chiluien may communicate as if a youngei age (e.g., "baby-
talking") oi have uifficulty acting inuepenuently to the extent they weie able piioi to the
ciisis event.
Stiess ielateu physical symptoms such as heauaches oi stomachaches. Foi inuiviuuals
with a pieuisposition, stiess can also piecipitate oi exaceibate symptoms of unueilying
meuical conuitions such as asthma.
If the ueath of a family membei oi fiienu is a iesult of the ciisis event, chiluien may also
uemonstiate signs of active giief.
Chiluien may also uemonstiate withuiawal anu become silent.
Even when unuei tiemenuous uistiess, chiluien may not show any signs oi be ieluctant to
shaie theii conceins with otheis, especially auults they uo not know oi tiust. Bealth caie
pioviueis theiefoie neeu to woik quickly to establish a tiusting ielationship with the chilu
anu family membeis (e.g., by explaining in cleai anu simple teims who you aie, what you plan
to uo, why you aie taking ceitain actions anu how those actions aie intenueu to help anu
piotect them, anu by asking them to shaie with you theii conceins, woiiies, anu questions).

5

Conduct a brief triage to identify children most likely to benefit fromadditional mental health
service.
Piehospital pioviueis can play an impoitant iole by valiuating chiluien's (anu othei family
membeis') feelings anu ieactions anu by encouiaging them to expiess theii conceins anu
seek anu accept assistance anu suppoit. Theie is a gieat ueal of stigma associateu with
mental illness anu it uoes not go away in the afteimath of a majoi uisastei oi ciisis, even
when many, if not most, inuiviuuals aie having aujustment uifficulties.
An initial tiiage shoulu be conuucteu to iuentify those chiluien most likely to have uifficulty
with aujustment so that they can ieceive eaily iefeiial to suppoitive seivices. A histoiy of
selecteu iisk factois, many of which ielate to the uegiee oi extent of peisonal involvement oi
exposuie, shoulu be obtaineu incluuing:
If the chiluien aie uiiect victims, especially if they suffei seiious physical injuiy, oi if
close ielatives oi fiienus uieu oi weie seiiously injuieu.
If they uiiectly witnesseu ueath, seiious injuiy oi othei hoiiific images, especially if the
victim is a family membei oi fiienu oi someone known peisonally.
If the chiluien peiceiveu at the time of the event that theii life, oi that of a family membei
oi fiienu, was in jeopaiuy (since young chiluien's peiceptions of iisk may ueviate gieatly
fiom actual iisk, it is impoitant to leain what chiluien believeu to be the level of iisk).
If the event iesults in sepaiation fiom paientscaiegiveis oi loss of piopeity, pets, oi
peisonal belongings.
If the chiluien hau pie-existing mental health pioblems.
If the chiluien have a histoiy of piioi unaccommouateu losses (e.g., ueath of a family
membei) oi tiaumas.
In auuition, ceitain behaviois seen in the immeuiate afteimath of the event also iepiesent
iisk factois foi longei-teim aujustment pioblems, incluuing:
Intense feai oi anxiety, panic, helplessness, oi hoiioi
0ncontiollable anu intense giief
Bissociative symptoms (such as uetachment, ueiealization, anu uepeisonalization)
Extieme cognitive impaiiment, veiy intiusive thoughts, confusion, oi pooi concentiation
anu uecision-making skills
Naikeu physical complaints that aie inconsistent with physical examination oi histoiy
The health caie team shoulu also assess the cuiient coping of the paientscaiegiveis.
Paients who aie having uifficulty coping themselves oi who lack the skills to facilitate
communication oi to pioviue suppoit to theii chiluien aie moie likely to have chiluien who
woulu benefit fiom auuitional mental health oi suppoitive seivices in the afteimath of
uisastei oi ciisis.

6

Prehospital providers often play an important role in identifying and addressing
mental health concerns.
Piehospital pioviueis geneially appieciate the ciitical iole they can play in ensuiing the
ultimate health of chiluien thiough timely anu accuiate iuentification of emeigent health
conceins, eaily inteivention, anu effective anu iapiu tiiage. Such is the case as well foi
mental health conceins, especially in the afteimath of a uisastei oi othei ciisis event.
In auuition, the piehospital pioviuei will often be the fiist point of contact foi the health caie
system aftei a ciisis event. Even though it is not possible noi appiopiiate to conuuct a
lengthy evaluation oi to begin long-teim tieatment foi mental health conceins, conuucting
effective tiiage foi emeigent mental health neeus anu establishing a suppoitive, but not
intiusive, ielationship that encouiages fuithei assessment anu tieatment by otheis within
the health caie system is a ciitical fiist step in auuiessing mental health neeus.
Piehospital pioviueis shoulu also be cognizant that they may have uiiect access to impoitant
infoimation about the natuie of the event oi chiluien's peisonal involvement in the event
fiom theii uiscussions at the scene that will be lost if not iecoiueu oi tiansmitteu to othei
piofessionals. As they stiive to make sense of the ciisis event in the futuie, chiluien anu theii
families will be helpeu if they aie able to ieconstiuct the stoiy of the events of that uay - what
happeneu, wheie they weie at the time anu what they weie uoing, how anu why they weie
effecteu by the event, how they weie helpeu, etc. By iecoiuing a biief naiiative of the events
as known oi uesciibeu by victims oi otheis at the scene at the time oi othei ielevant
infoimation (e.g., "the chilu was founu unconscious unueineath a poition of the staiicase that
appeais to have fallen anu hit the chilu in the back of the heau - suggesting that the chilu was
injuieu while attempting to exit the house"), infoimation can latei become known to the
family that may assist them in the iecoveiy piocess. In some situations, it may be possible foi
the piehospital pioviuei to offei piofessional contact infoimation so that inteiesteu family
membeis can latei ieconnect to obtain uiiectly such infoimation (that may not be possible oi
appiopiiate to communicate at the time of the ciisis).
Piehospital pioviueis may also wish to assist in community iesponses to a uisastei oi othei
ciisis event that will help chiluien aujust ovei time. Foi example, they may offei tiaining to
school-baseu staff in fiist aiu anu emeigency iesponse oi volunteei to become an active
membei of a school ciisis iesponse team.
2

Selected References:
Foltin uL, Schonfelu B}, Shannon, NW (euitois). Peuiatiic Teiioiism anu Bisastei
Piepaieuness: A Resouice foi peuiatiicians. ABRQ Publication No. u6-uuS6-EF. Rockville,
NB: Agency foi Bealthcaie Reseaich anu Quality. 0ctobei 2uu6.

2
For further information, see: Schonfeld D, Lichtenstein R, Pruett MK, Speese-Linehan D: How to Prepare
for and Respond to a Crisis (2
nd
edition). Alexandria, VA: ASCD; 2002 or Schonfeld D, Kline M, and
Members of the Crisis Intervention Committee: School-based crisis intervention: an organizational model.
Crisis Intervention and Time-Limited Treatment. 1994; 1(2):155-166.

7
Bagan } anu the Committee on Psychosocial Aspects of Chilu anu Family Bealth anu the Task
Foice on Teiioiism: Psychosocial implications of uisastei oi teiioiism on chiluien: a guiue
foi the peuiatiician. Peuiatiics 2uuS; 116(S):787-79S.
Schonfelu B: Belping chiluien ueal with teiioiism. In 0sboin L, BeWitt T, Fiist L, anu Zenel }
(eus.): Peuiatiics. Philauelphia, PA, Elseviei Nosby, 2uuS, pp. 16uu-16u2.
Schonfelu B: Suppoiting chiluien aftei teiioiist events: Potential ioles foi peuiatiicians.
Peuiatiic Annals 2uuS; S2:S:182-187.
Schonfelu B: Talking with chiluien about ueath. }ouinal of Peuiatiic Bealth Caie 199S; 7:
269-274.
veinbeig E, vogel }: Inteiventions with chiluien aftei uisasteis. } Clin Chilu Psychol. 199S;
22(2):48S-498.
vogel }, veinbeig E: Chiluien's psychological iesponses to uisasteis. } Clin Chilu Psychol.
199S; 22(2):464-484.
Suggested Websites:
www.aap.oiguisasteis (Ameiican Acauemy of Peuiatiics)
www.cincinnatichiluiens.oigschool-ciisis (National Centei foi School Ciisis anu
Beieavement)
11: Patient Identification &Tracking Pediatric Disaster Preparedness

1

Chapter 11: Pediatric Patient Identification and Tracking: A
Practical Approach to Implementation
Connie Naxim ENTP
Background: The Issue of Fractured Families, Hurricanes Katrina and Rita
Reviewed
In the wake of Buiiicanes Katiina anu Rita, lessons leaineu inuicate the neeu foi accuiate
accountability of patients, victims, anu evacuees. The peuiatiic population specifically
iequiies special consiueiations when involveu in a uisastei of any kinu. Ameiica watcheu as
stoiies unfolueu in newspapeis anu television bioaucasts acioss the countiy of chiluien
stianueu, lost, anu unaccounteu foi. Peuiatiic patients iequiie unique anu specializeu
consiueiations when iuentifying anu tiacking uisasteis victims, all peuiatiic uisastei victims
shoulu be tiackeu electionically by both iesponueis anu ieceiveis thioughout the uisastei
iesponse piocess.
Accoiuing to National Centei foi Nissing & Exploiteu Chiluien (NCNEC), it is estimateu that
about 411,uuu people uispeiseu to 48 0.S. states in the afteimath of Katiina anu Rita. 0f
those 411,uuu people, an estimateu S,uuu weie chiluien listeu as sepaiateu oi missing fiom
theii families. A total of S,182 cases of missing chiluien weie iepoiteu to the NCNEC. Some
S,uSu of those cases weie consiueieu iesolveu, a 98 peicent success iate. Nost of the
chiluien weie consiueieu to be lost, iathei than missing. uiven space limits on buses, in
shelteis, anu at hospitals, chiluien weie often given fiist piioiity in evacuation. These
"fiactuieu families" often weie compiiseu of paients in one state, with chiluien in anothei
state.
S
Nany chiluien iepoiteu missing, eventually weie founu to be with othei ielatives oi
fiienus, unbeknownst to the paients. This sepaiation occuiieu uuiing iescue effoits,
shelteiing effoits, anu facility evacuation piocesses.
The piessuie to iuentify anu mitigate each component of a uisastei is oveiwhelming. You uo
the best you can with what you have. As families tiy to ieach safety, iesponueis become
oveiwhelmeu by the sheai numbei of victims involveu. A victim may not necessaiily become
a patient. Limiteu iesouices become an even moie tioubling pioblem to oveicome.
As evacuees of Buiiicanes Katiina anu Rita knew, chiluien took piioiity, paients weie
willing to senu theii chiluien to safety anu wait foi the next bus, but what if the next bus
uiun't come. What if the next bus went to anothei sheltei, in a uiffeient state. This was
common in the iesponse to Katiina. The floouing piesenteu a neeu foi eveiyone to sheltei in
alteinative locations, most out of state.
Chiluien given piioiity weie sepaiateu fiom theii paients anu ielatives, even sepaiateu fiom
othei siblings. In many instances, oluei siblings woulu take youngei siblings with the
unbelievable iesponsibility of making suie that eveiyone aiiiveu at a sheltei safely. Paients
shaieu stoiies of chiluien being passeu foiwaiu thiough a ciowu of people in the hopes that

2

theii chiluien woulu make it on a bus out of New 0ileans.
S
Some chiluien weie sent with
elueily ielatives who took pieceuence ovei auults as well, the oluei chilu becomes
iesponsible foi both the youngest anu eluest of the family, anu paients weie left to sciounge
foi the next iiue out.
States acioss the southein poition of the 0niteu States weie chaigeu with housing all of the
evacuees in Katiina's afteimath. Shelteis emeigeu eveiywheie, iun by the Reu Cioss, some
by non-piofit oiganizations, otheis by faith baseu oiganizations, all without a way to
communicate with one anothei. Bisconnect at iescue anu tianspoitation cieateu a floou of
evacuees aiiiving at shelteis sepaiateu fiom one anothei, most having veiy little infoimation
about wheie theii ielatives may have gone. Sheltei woikeis leaineu quickly that most
chiluien weie unsupeiviseu anuoi unaccounteu foi. Chiluien in shelteis became piouucts
of fostei caie systems until paients oi ielatives coulu be founu.
Thioughout the piocess of facility evacuation in New 0ileans, immeuiate tiansfei became a
challenge. Finuing beus foi sick chiluien was uifficult, cooiuinating a ieceiving site foi the
paients anu the chiluien, uaunting. Peuiatiic patients weie loaueu onto helicopteis fiom the
ioofs of hospitals, while paients at home oi with ielatives, weie taken by boat to a bus station
foi tiansfei to the Bouston Astiouome, oi shelteis similai to this. Neithei evacuation
opeiation was awaie of the family connection, all concentiating on tianspoit out of the
effecteu aiea, uespeiate to finu safety. Paients may oi may not have been at the hospital at
the time of evacuation, anu may veiy well be evacuees themselves.
Senuing, tiansfeiiing, anu ieceiving facilities, pioviueis, anu volunteeis woulu have benefiteu
fiom a centializeu, ieal-time tiacking system. The entiie uisastei piocess neeueu victim
accountability. A centializeu uatabase of iuentity specific uemogiaphic infoimation,
combineu with associateu stait anu enu points in the stages of evacuation, sheltei, anu facility
tiansfei woulu have easeu the ieunification piocess.
Identification and Tracking of Separated and Displaced Children
Time Imperative
Time is of the essence when consiueiing sepaiateu anu uisplaceu peuiatiic population in a
uisastei. Real time technology, like web-baseu patient tiacking systems, pioviues an ability
to tiack basic infoimation as it occuis. A baseline of peitinent uemogiaphics allows foi
geneial iuentification anu flow of patients in the uisastei iesponse piocess. Lessons leaineu
by the NCNEC pointeu uiiectly to the ciitical impoitance of time when chiluien become
sepaiateu fiom paients oi loveu ones.
2
Baving existing technology anu infiastiuctuie
associateu with patient tiacking will eliminate factois associateu with playing catch-up at the
time of the event.
Photography as a Tool for Identification and Reunification
Photo technology is a majoi component associateu with peuiatiic patient iuentification. In
the Katiina anu Rita iesponse, NCNEC useu photo technology foi ieunification of peuiatiic

3

patients. At the time of evacuation, peisonal piepaieuness is essential. Among the cache of
impoitant uocuments suggesteu foi evacuation of peuiatiic victims incluue a iecent
photogiaph of chiluien as well as othei family membeis anu close fiienus. Chiluien can
easily iuentify close ielatives anu family fiienus oi uaycaie pioviueis by photogiaph.
Chiluien may not know last names oi fiist names, uepenuing on theii age, but a photogiaph is
univeisal. A chilu can veiy easily say, "That's my Nana."
Tiacking systems aie capable of attaching a simple .jpeg oi .gif photo taken by uigital
cameias. Immeuiate access to photogiaphic infoimation is ciucial to uevelopment of
ieunification flyeis anu posteis in the minutes, houis, uays, weeks, oi months aftei the onset
of a uisastei situation. Photogiaphs aie easily uisseminateu thiough multiple meuia anu
technology channels. Bata captuieu immeuiately uuiing the uisastei iesponse piocess,
combineu with uigital photogiaphy aie essential to limitation of sepaiateu anu uisplaceu
chiluien involveu in a uisastei.
Data Collection
Infoimation is ciucial at the time of a uisastei, the question becomes what infoimation is
necessaiy vs. optional. This can be a topic of uebate amongst uiffeient uisciplines vesteu in
peuiatiic uisastei iesponse. Emeigency Neuical Seivices (ENS) may neeu infoimation
peitinent to movement of a patient fiom one place to anothei. Public Bealth may be
inteiesteu in the epiuemiological components associateu with the peuiatiic uisastei victims.
Emeigency Nanagement may be moie inteiesteu in the geneial numbei of peuiatiic patients
taken to a sheltei, anu the iesouices necessaiy to suppoit them. The solution ielates back to
iuentification of an inuiviuual, the location fiom which they staiteu, anu theii enu uestination.
Bata associateu with iuentification incluue a unique numbei, age iange, genuei, ethnicity, anu
agency with initial contact. Patient tiacking systems can be multi-functional foi both
iuentification anu infoimation shaiing amongst vaiious agencies within the uisastei iesponse
piocess. Some multi-functional uata components incluue tiiage categoiy, geneial chief
complaint, anu the piioiity of the victim if necessaiy. This type of infoimation is helpful to
both fiist iesponueis managing mass casualties on scene, as well as fiist ieceiveis oi sheltei
oiganizeis anticipating the influx of victims oi patients. The unique iuentifying numbei can
be associateu with a tiiage tag oi cieateu within a tiacking system. It is essential that eveiy
entiy into a tiacking system be uate anu time stampeu with each scanneu upuate.
When consiueiing uata peitinent to uisastei iesponse, vaiious gioups want uiffeient but vital
pieces of uata. It is uifficult to speculate which components of patient infoimation aie helpful
to whom. The best suggesteu stiategy is to biing all playeis vesteu in tiacking infoimation to
the same table. Public Bealth, Bealthcaie, ENS, Ameiican Reu Cioss, Emeigency
Nanagement, anu many otheis all have a piece of the tiacking puzzle. This gioup of vesteu
paitneis can uiscuss common uata points of inteiest, while auuiessing aieas not thought to
be helpful to othei uisciplines. Listing each piece of uata helpful to all paitneis pioviues a list
of common ciossovei. The gioup can then iuentify the oveilapping uata sets, anu uefine the
piimaiy aieas of patient infoimation neeueu.

4

0ne example of the kinu of woiking paitneiship is the Region 6 Bioteiioiism Befense
Netwoik Coalition of Nichigan. Taskeu with setting up a patient tiacking system, paitneis
iuentifieu what they felt woulu be helpful anu vital infoimation. A gioup of hospital, Neuical
Contiol Authoiity (NCA), Public Bealth, Emeigency Nanagement, anu State Auministiation
sat uown anu uevelopeu a list of uata. The gioup iuentifieu piioiity infoimation to be
captuieu on scene, as well as helpful infoimation that coulu be enteieu into the system at a
hospital oi sheltei aftei tianspoit. A patient tiacking system shoulu be flexible enough to
uepict which pieces of infoimation aie gatheieu uuiing specific phases of uisastei iesponse.
Piimaiy on-scene uata iuentifieu by the Region 6 Coalition weie: uate, time, unique
iuentifying numbei (uisastei specific), genuei, age iange, START tiiage categoiy, geneial
chief complaint, uestination, tianspoiting agency, piioiity (if applicable), anu ethnicity. 0pon
aiiival oi tiansfei necessaiy uata incluueu: uate, time, unique iuentifying numbei, agency
unit numbei, meuical iecoiu numbei (if tianspoiteu to a hospital), uate of biith, fiist name,
last name, anu uestination county. Any agency using the tiacking system woulu have the
ability to entei in as much of the uata as possible, but at the veiy least, on scene uata pioviues
a naiiow maigin of patients to seaich. Bestination infoimation pioviues specific patient
infoimation anu cioss iefeience infoimation that may be necessaiy when tiying to ieunify
chiluien with paients.
Approaches to Identification and Tracking
Identification of Tracking Systems
Theie aie many uiffeient patient tiacking systems on the maiket touay. Some tiacking
systems aie locally installeu on inuiviuual uesktop computeis connecteu thiough a shaieu
seivei. Some systems use stanu alone units ueployeu at the time of uisastei to specific ioles
within the Inciuent Commanu stiuctuie i.e. tiiage officei, oi tianspoit officei. Theie is
wiuespieau uebate ovei tiacking on a uaily basis as opposeu to just in times of uisastei.
Tiacking systems may oi may not be compatible with each othei, oi capable of shaiing
common uata sets. This is a veiy impoitant consiueiation when evaluating system neeus.
When consiueiing mutual aiu iesponse, the optimal goal is infoimation shaiing anu
inteiopeiability. Caiefully investigating the type of platfoim the system opeiates within is
ciucial. Some tiacking systems aie compatible with Niciosoft 0ffice piogiams like Access oi
Excel, othei tiacking systems opeiating on piopiietaiy platfoims, this may limit it's
capability foi shaiing uata acioss multiple juiisuictions. Iueally, a tiacking system shoulu be
flexible in its stiuctuie to accommouate the specific neeus of an agency oi agencies. Any
tiacking system being consiueieu shoulu be configuieu foi both uay-to-uay use anu mass
casualty iesponse.
Some systems have pieset uata sets anu associateu infoimation; this can limit a gioup's
ability to captuie uesiieu anu necessaiy infoimation. Theie aie some systems that uo not
pieset the uata fielus, anu can be tailoieu to the neeus of that specific gioup, these aie iueal
foi multiple juiisuictions inteiesteu in gatheiing a vaiiety of infoimation peitinent to

5

iuentification anu tiacking. Baiuwaie anu softwaie configuiations aie veiy impoitant; both
gioups have unique consiueiations that neeu to be uiscusseu piioi to implementation. Bealth
Insuiance Poitability anu Accountability Act (BIPPA) issues neeu to be taken into
consiueiation, patient infoimation must be shaieu as secuiely as possible.
Hardware and Associated Infrastructure
When consiueiing haiuwaie configuiations, assessing existing haiuwaie will be veiy helpful.
With the uevelopment of electionic uocumentation, ENS agencies may alieauy have some
haiuwaie neeueu foi a patient tiacking system. Theie aie a vaiiety of haiuwaie setups, anu
they iange foi laptop computeis, hanuhelu 2-B anu S-B baicoue scanneis, cellulai phones
with scanning capabilities, pocket peisonal computeis capable of scanning, mouem anu
wiieless caiu connections, anu a cential seivei. Theie aie iuggeu haiuwaie components that
can withstanu the elements of scene iesponse.
PBA hanuhelus aie being useu foi othei meuical iecoius neeus within facilities like Nonash
Neuical Centie in victoiia, Austialia. Nonash Neuical Centie uses the iuggeu PBA foi beusiue
iegistiation. These hanuhelus aie capable of wiieless communication anu baicoue scanning.
The wiieless functionality cieates a ieal time tiacking enviionment foi iegistiation of
patients. Nonash Neuical Centie is an example of existing infoimation technology
infiastiuctuie, wiieless hot spots, having anothei functional iole within the patient caie
enviionment.
S
The beusiue patient infoimation piocess useu at Nonash Neuical Centie can
be paialleleu against ENS iesponuing to a scene. The ability to entei peitinent patient
infoimation on scene pioviues immeuiate, ieal time infoimation foi accountability.
Software Considerations
Softwaie has unique challenges. Inteiopeiability is essential to any tiacking system that may
be useu in a mutual aiu enviionment. The softwaie platfoim is veiy impoitant. Any system
that functions within a Niciosoft Access oi Sequel Seivei enviionment can be tailoieu foi
shaiing anu inteiopeiability. Consulting with infoimation technology piofessionals involveu
in ENS, NCA, anu hospital systems is veiy helpful. Softwaie may compiomise fiiewall
stiuctuies, BIPPA consiueiations neeu to be iuentifieu. Pie-planning with infoimation
technology piofessionals is ciucial foi successful softwaie ueployment.
When investigating softwaie packages available, theie aie a vaiiety of licensing
aiiangements that can be puichaseu. As these licensing aiiangements aie uiscusseu, it is
impoitant to consiuei the funuing useu to pay foi such systems, anu whethei oi not paitneis
aie willing to pay licensing fees each yeai. Some licensing fees can be astionomical, anu may
neeu to be paiu yeaily. Tiacking systems puichaseu unuei an enteipiise license allow foi
owneiship of the piogiam anu usei licenses without maintaining a consiueiable licensing fee
each yeai. Bepenuing on the size of the healthcaie system, enteipiise licensing may be the
best option to ensuie continuation of the tiacking system inuepenuent of funuing. Technical
suppoit may also be incluueu in any contiact foi puichase of tiacking softwaie. Incluueu in
the technical suppoit shoulu be allowances foi softwaie upgiaue anu twenty foui houi access

6

to technicians. At the veiy minimum, yeaily costs may be associateu with wiieless access
abilities in the fielu anu costs associateu with cential seivei hosting anu maintenance.
Patient tiacking systems shoulu be capable of both enteiing uata, as well as seaiching foi
uata. It is not necessaiy foi eveiy usei to have the ability to entei uata, but may be helpful to
allow access to multiple useis foi seaiching uata within the system. Some tiacking systems
allow foi uata entiy anu queiy, otheis will pioviue a limitation component that woulu only
allow useis the ability to seaich with piotecteu useiname anu passwoiu. 0ne system
iuentifies useis acioss any juiisuiction with passwoiu access to simply seaich unique
infoimation, oi combinations of infoimation immeuiately to locate patients involveu in a
uisastei iesponse. It is veiy similai to systems cuiiently being useu by shipping companies,
as a customei shipping a package, they aie able to access a website, entei in specific tiacking
infoimation pioviueu to them, anu tiack the piogiess of the package being ueliveieu. Real
time, web-baseu seaiching capabilities woulu have been incieuibly beneficial in the
iesponses to huiiicanes Katiina anu Rita. With a web-baseu seaiching component of the
tiacking softwaie, most entities can use existing infiastiuctuie, lessening the buiuen to
puichase auuitional softwaie anu haiuwaie that may not be buugeteu.
}ohns Bopkins Bospital in Baltimoie, Naiylanu utilizes this type of softwaie configuiation to
tiack anu locate meuical supplies flowing thioughout the system, ovei 1,uuu packages a uay.
6

Piioi to implementing the 0PS TiackPau system, anytime an employee neeueu to locate
necessaiy meuical supplies, the ieceiving uepaitments weie iequiieu to soit thiough vaiious
files anu papeis to locate a piece of equipment oi meuical supply. With systems like the
TiackPau system, }ohns Bopkins Bospital scans eveiy package upon aiiival anu
automatically assigns a unique tiacking numbei. This infoimation is uownloaueu to cential
seivei foi all useis to seaich.
6
The hospital seivei is alieauy being useu to shaie anu
stieamline patient iecoius, the tiacking system was just a softwaie installation that pioviueu
staff immeuiate access to seaiching capabilities foi supplies necessaiy foi patient caie.
Accoiuing to auministiatois at }ohns Bopkins Bospital, the system implementeu has
"significantly ieuuceu pioblems with misplaceu packages."
6
This can be tianslateu to
misplaceu patients; it is a mattei of shipping anu ieceiving. Iuentification anu tiacking
systems exist, anu can be implementeu seamlessly, if the iight consiueiations aie uiscusseu.
Other Methods to Track Pediatric Patients
Red Cross Safe and Well Website
The Ameiican Reu Cioss hosts a website calleu safe anu well. The puipose is to allow
inuiviuuals who have been sepaiateu fiom theii family to post infoimation about theii well-
being anu location. The infoimation iegaiuing an inuiviuuals name & location anu pie-
foimatteu message can be accesseu by fiienus oi family by seaiching the web site using the
inuiviuual's phone numbei anu oi home auuiess.
0nly people who seaich foi a paiticulai phone numbei oi auuiess will be able to access that
inuiviuual's name, piefoimatteu message which incluues: wellness status, location, anu how

7

they will contact family. The exact location oi best specific phone contact can not be left on
the website. 0nly pie foimatteu messages incluuing: I am safe anu well; Family anu I aie safe
anu well; Cuiiently at Sheltei, home, neighbois, hotel; Will call, email, senu postcaiu when I
am able; can be left anu accesseu. Exact infoimation iegaiuing peison's location, anu contact
info aie not accessible uue to piivacy conceins.
Although useful foi oluei chiluien anu auults who aie able to pioviue theii home phone oi
home auuiess to log theii message, this contact methou of looking foi youngei chiluien, oi
uevelopmentally uelayeu inuiviuuals etc. will not woik if a pie uisastei phone anu auuiess
aie not available. Young chiluien cannot pioviue this infoimation so an auult assisting them
will not be able to log infoimation on to this website. Also exact location anu contact
infoimation cannot be tiansmitteu. This makes it uifficult foi those seaiching foi the
uisplaceu peison to exactly iuentify the peison's location oi how to get in contact with them.
The Safe anu Well website can be accesseu at: https:uisasteisafe.ieucioss.oigBefault.aspx.
Accompanied Child in a Disaster
Chiluien anu the accompanying iesponsible auult shoulu be able to be tiackeu anu linkeu to
each by having a matching auult anu chilu tiacking numbei oi coue. 0ne possible solution to
tiacking these paiis is to use a system of iuentification banus. These paiieu IB banus shoulu
be uistiibuteu as soon as the iesponsible auult anu chilu make contact with official caiegiveis
in the uisastei aiea. The IB banus oi othei uevices shoulu be placeu iapiuly anu accuiately on
both auult anu chilu. Completing this paiieu iuentification will help to ensuie that the paiieu
iuentification is completeu befoie the auult anu chilu can be sepaiateu, anu also ieuuces the
possibility of human eiioi uuiing the matching anu placing of the banus. Similai policies aie
useu to tiack motheis anu theii newboin babies on newboin anu mateinity waius.
The paiieu iuentification banus useu shoulu incluue the following infoimation, which will be
useful in maintaining a tight link between chilu anu auult:
Name of chilu
Chilu's uate of biith
Name of auult
Auult's uate of biith
A moie sophisticateu appioach to tiacking coulu be implementeu by the use of paiieu bai
coueu biacelets. These woulu be available in paiis oi sets. The iuentical bai coue IB woulu be
affixeu to the chilu anu iesponsible auult. The bai coue woulu have a unique seiies of letteis
anu numbeis that woulu be the same on the chilu anu auult's IB uevice.
Displaced or Unaccompanied Child in a Disaster
Rapiu iuentification anu piotection of uisplaceu chiluien (less than 18 yeais) is a ciitical pait
of uisastei management, as iapiu iuentification anu ieunification will ieuuce the possibility

8

foi maltieatment, neglect, exploitation, anu emotional injuiy. The sepaiation of chiluien fiom
paients also incieases the iate of tiaumatic stiess iesponses in chiluien aftei a uisastei.
All hospitals, meuical clinics, anu shelteis pioviuing caie to chilu suivivois of uisasteis
shoulu immeuiately implement appiopiiate chilu-safety measuies in uiiect iesponse to this
ciisis. The CBC has ievieweu anu appioveu a piotocol to iapiuly iuentify anu place
unaccompanieu chiluien in a safe aiea aftei a uisastei. The CBC founu this useful iesouice
impoitant enough to shaie with its paitneis to piomote a safei anu healthiei enviionment
foi uisplaceu chiluien in shelteis.
7

Protocol to Rapidly Identify and Protect Displaced Children
Suivey all chiluien in youi hospital, meuical clinic oi sheltei to iuentify chiluien who aie not
accompanieu by an auult; these chiluien have a high piobability of being listeu as missing by
family membeis. Finu out wheie they aie sleeping being helu anu the name anu age of
peison(s) who isaie supeivising them, if available.
Place a hospital-style iuentification biacelet (oi, iueally, a pictuie iuentification caiu) on the
chilu anu a matching one on the supeivising auult(s), if such an auult is available. Check
fiequently to make suie that the wiistbanu matches that of the auult(s) seen with the chilu in
the hospital oi sheltei. If theie is no supeivising auult, the chilu shoulu be taken to the
hospital's pie-ueteimineu peuiatiic safe play aiea wheie heshe can be appiopiiately caieu
foi until a safe uisposition oi ieunification can be maue.
The names of all chiluien iuentifieu thiough the suivey as not being with theii legal
guaiuians oi who aie unaccompanieu shoulu be consiueieu at high-iisk anu immeuiately
iepoiteu to the hospital's emeigency opeiations centei. Auuitional iepoiting shoulu also be
maue to the National Centei foi Nissing anu Exploiteu Chiluien (NCNEC) at 1-888-S44-S47S.
The NCNEC can then ciosscheck them with the names of chiluien who have been iepoiteu
missing.
Aftei the "high iisk" chiluien have been iepoiteu, a complete list of all chiluien names in the
hospital, clinic oi sheltei shoulu be sent to the office of emeigency management oi othei
agency iesponsible foi tiacking (if activateu anu the infoimation is iequesteu.)
0naccompanieu chiluien anu those who aie not with theii legal guaiuians shoulu unueigo a
social anu health scieening taking into consiueiation an assessment of the ielationship
between the chilu anu accompanying auult, iueally peifoimeu by a physician with peuiatiic
expeiience.
7
This piotocol is most useful foi accompanieu chiluien, oi unaccompanieu oluei
chiluien who can pioviue theii name anu uate of biith.

The most uifficult tiacking anu iuentification pioblem incluues chiluien alieauy sepaiateu
fiom theii iesponsible auults families, aie too young to pioviue theii family name, oi any
name at all. These chiluien may be tiackeu by pioviuing an iuentification uevice (tag oi
banu), which incluues a unique tiacking numbei. Infoimation on this tag, linkeu to this
numbei shoulu incluue chilu-iuentifying infoimation (eg. appiox age, genuei, haii, eye, skin
coloi, othei iuentifying maiks; a pictuie of the chilu woulu also be useful but this iequiies

9

technology to piouuce instant piinteu photogiaphs that aie laminateu piotecteu). 0thei
infoimation shoulu incluue agencies involveu in initial iuentification, anu the stait,
inteimeuiate anu enu points in the chilu's jouiney fiom the uisastei site to a hospital, oi
sheltei.
Tracking without Bar Codes, Pictures or Pre prepared Tags
In some ciicumstances tiacking of chiluien must be initiateu without the benefit of pie maue
matching bai coue tags, IBs, oi photogiaphs. If a chilu anu auult aie going to be sepaiateu, an
inuelible maikei can be useu to wiite the following infoimation on both the chilu anu auult's
skin: The chilu's name anu uate of biith, auult's name anu uate of biith. This methou
pioviues a iapiu, low tech methou to match the chilu anu auult that can last foi weeks to
months.
Summary
Peuiatiic patients may piesent challenges foi all involveu in the uisastei iesponse piocess.
Reunification is a veiy impoitant piece of the uisastei puzzle. 0tilizing ieal time patient
tiacking systems may significantly ieuuce the numbei of chiluien sepaiateu oi uisplaceu
fiom ielatives. Patient tiacking systems aie iueal foi both uay-to-uay anu uisastei iesponse
scenaiios. Responueis anu ieceiveis shoulu be veiy familiai with tiacking systems in place
foi accuiate accountability of all victims impacteu by a uisastei.

10

Region 6 BioDefense Network Coalition Tracking System
Barcode Triage Tag Each barcode on the front side of the tag is a sticker

11

SystemSet-Up

0iange: Bata Tiansmission via wiieless infiastiuctuie
Blue: ENS vehicle(s) enioute to uestination(s).

0nce uata is enteieu by one oi moie ENS units, it is sent
to
stoieu in a SQL Seivei visible to paitneis with softwaie.

12

Tracking SystemComponents
The Region 6 tiacking system pioviues iesponueis anu
ieceiveis the ability to entei in vital infoimation at
besiue oi on scene. The patient can be given a
geneiateu numbei by the system, oi use a baicoue tag
pioviueu by the Region to paitneis.

Fiist ieceiveis aie able to input auuitional iuentifying
infoimation upon aiiival at eithei a hospital oi sheltei.

0seis aie able to seaich the tiacking system by eight
uiffeient categoiies, as well as uate, uate iange, time,
oi location. The agency oi unit seaiching is able to
iuentify themselves anu seaich accoiuingly as well.

Each patient is tiackeu by a unique iuentifying numbei, when
any usei enteis the patient into the system, a time anu uate
stamp is auueu to the iecoiu. The iecoiu becomes a time
thieaueu account of the patient's movement thiough the uisastei
iesponse piocess. This is an example of the iepoit cieateu, the
patient uata shown is hypothetical. All uata in the thieaueu
iecoiu is seaichable, pioviuing a veiy quick anu accuiate system
that all fiist iesponueis anu ieceiveis can use on both a uaily
basis, as well as in the time of uisastei.


13

The Region 6 tiacking system has foui haiuwaie components neeueu to achieve ieal time
web baseu patient tiacking: hanuhelu baicoue scanneis with wiieless capabilities oi a laptop,
a wiieless mouem oi caiu, cential seivei foi hosting all uata fiom acioss the west siue of the
State of Nichigan, anu uesktop computeis at each uestination.
Softwaie is installeu on hanuhelu PBA's anu local uesktop anu laptop systems. The softwaie
is configuieu to connect anu upuate automatically each time the piogiam is launcheu in any
of the haiuwaie uevices. All patient infoimation is uownloaueu by eithei tapping a senu
button on the hanuhelu, oi immeuiately following key entiy into the laptop oi uesktop units.
Seaiching is both within the softwaie itself, oi by a web baseu application that is useiname
anu passwoiu piotecteu. This pioviues the ability foi many useis to seaich without the
ability to entei uata.
References
1. Chiluien of the Stoim: Fiist theii homes came unmooieu. Then theii lives came unglueu.
Now, many youths aie stiuggling to cope with stiange suiiounuings--anu missing
paients. Sept 19, 2uuS v64 i12 p68 People Weekly. , 64, 12. p.68. Retiieveu }anuaiy 24,
2uu8, fiom Acauemic 0neFile via uale:
http:finu.galegioup.comitxinfomaik.uo.&contentSet=IAC-
Bocuments&type=ietiieve&tabIB=TuuS&piouIu=A0NE&uocIu=A1SS948627&souice=ga
le&useiuioupName=lom_accessmich&veision=1.u
2. Emini, Ben Naich, 2uu6 Bealth Refeience Centei Acauemic: Reuniting fiactuieu families
aftei a uisastei: the iole of the National Centei foi Nissing & Exploiteu Chiluien, Fiom
The Police Chief, vol. 7S, no. S, Inteinational Association of chiefs of Police.
S. Nieves, Evelyn 'Lost' chiluien caseloau giows; Expeits on missing kius believe most
suiviveu. Sept 2S, 2uuS pA9The uianu Rapius Piess (uianu Rapius, NI). , p.A9. Retiieveu
Naich u6, 2uu8, fiom InfoTiac Custom Newspapeis via uale:
http:finu.galegioup.comitxinfomaik.uo.&contentSet=IAC-
Bocuments&type=ietiieve&tabIB=Tuu4&piouIu=SPN.SPu2&uocIu=C}1S6664uuS&souic
e=gale&useiuioupName=lom_falconbakei&veision=1.u
4. Robyn, Kathiyn. Apiil 2uu6, ENS Nagazine's Resouice uuiue: Technology in ENS -
Patient Tiacking Systems, posteu Apiil 27, 2uu6 u4:27 AN PBT,
http:www.emsiesponuei.comolinepiintei,.jsp.iu=S227, accesseu on Naich 12, 2uu8.
S. Symbol Technologies, Symbol Technologies Belps 0nplug the Wiies at Nonash Neuical
Centie, 2uuS
6. 0PS Piofessional Seivices, 2uuS, }ohns Bopkins Bospital Sews 0p Receiving Solution,
0niteu Paicel Seivice of Ameiica, Inc.
7. CBC Bealth Auvisoiy, "Instiuctions foi Iuentifying anu Piotecting Bisplaceu Chiluien."
Sept. 28, 2uuS.
12: Natural, Tech &Intentional Disasters Pediatric Disaster Preparedness

1
Chapter 12: Natural, Technological & Intentional Disasters
Baiuch Feitel NPA ENT-CIC
Overview
In ENS teims, multiple-casualty inciuents (NCIs) anu mass-casualty events (NCEs) aie
uefineu in teims of theii impact on local iesouices. An NCI is an inciuent that has multiple
patients that can be hanuleu by one agency oi juiisuiction, while an NCE, also calleu a
uisastei oi a catastiophe, is an event that oveiwhelms the local ENS system's iesouices so
that auuitional ENS agencies must be mobilizeu to assist. Because of this uefinition, an event
coulu be consiueieu a uisastei oi a catastiophe in a community with limiteu iesouices, while
in anothei community with extensive iesouices anu auequate mutual aiu coveiage it woulu
have a negligible effect. Fuitheimoie, an event that woulu noimally be hanuleu as an NCI
coulu be upgiaueu to an NCE because of unusual ciicumstancesa nuises' stiike at the
ieceiving hospital, foi example, oi a multi-vehicle collision that occuis when the local tiauma
uepaitment is unusually busy.
1
This iesouice uses the teim "uisastei" since that is the teim in most common use. The woiu
"uisastei" is ueiiveu fiom the Latin woius foi "evil stai". Neiiiam Webstei's uictionaiy
uefines a uisastei as "a suuuen calamitous event biinging gieat uamage, loss oi uestiuction".
ENS pioviueis anu agencies must be piepaieu to iesponu anu tieat chiluien in all types of
uisasteis.
The wiuespieau injuiy anu uisiuption associateu with uisasteis can pose uifficult pioblems
foi ENS pioviueis as outlineu in the vaiious chapteis of this iesouice. Fuitheimoie, the
uegiee of injuiy, ueath, anu uamage causeu by uisasteis is influenceu by many factois,
incluuing population location anu uensity, timing of the event, anu community piepaieuness
(e.g., emeigency iesponse infiastiuctuie, local builuing coues, etc). Similaily, iecoveiy aftei a
uisastei is influenceu by iesouices (e.g., ielief aiu), pieexisting conuitions (e.g., season, local
infiastiuctuie, etc), expeiience, anu access to infoimation.
2

Nost uisasteis uo not iesult in unusual peuiatiic injuiies oi illnessesjust moie of the same
types of pioblems ENS peisonnel aie useu to tieating. Attacks involving bomb blasts oi
chemical, biologic, oi iauiologic weapons, howevei, aie likely to cause unusual piesentations
thioughout the affecteu population. Because chiluien's anatomy anu physiology may make
them moie susceptible to such weapons, ENS pioviueis will piobably encountei laige
numbeis of ill oi injuieu chiluien aftei an attack. Factois unique to teiioiist acts anu waifaie
aie uiscusseu below.
Types of Disasters
Bisasteis fall into thiee categoiies accoiuing to cause: natuial uisasteis, technological
uisasteis, anu intentional, oi human-maue uisasteis. Natuial uisasteis aie causeu by weathei
oi geologic phenomena, such as huiiicanes, uioughts, eaithquakes anu avalanches.
Technological uisasteis aiise when human safeguaius fail, iesulting in plane ciashes, toxic
spills, inuustiial explosions, anu similai events. Intentional uisasteis, which often involve
technology, aie uelibeiately tiiggeieu by one oi moie inuiviuuals (often iefeiieu to as
teiioiists), using such means as inuustiial sabotage, toxic ielease of CBRNE (chemical,

2
biological, iauiological, nucleai, explosive & incenuiaiy) oi WNB (weapons of mass
uestiuction), hijackings, bombings, anu snipei attacks. Theie is often oveilap between these
aieas. Foi example, an eaithquake (natuial uisastei) can cause explosions anu toxic spills
(technological uisastei). Consequently, these injuiies, while only uiscusseu in one section of
this chaptei, still apply to othei scenaiios. ENS pioviueis must be flexible anu piepaieu to
iesponu anu tieat injuieu chiluien in any of these ciicumstances. It is also impoitant foi ENS
agencies to tiain foi these uisasteis, as stuuies have shown that emeigency iesponse tiaining,
safety uiills anu simulations, anu meuical tiaining in appiopiiate iesponses to hazaiuous
agents can gieatly limit subsequent injuiy anu ueath when acciuents occui.
1

Natural Disasters
Natuial uisasteis aie causeu by seveie weathei oi geologic phenomena, such as huiiicanes,
toinauoes, floous, tsunamis, uioughts, wilufiies, eaithquakes, lanusliues, anu avalanches.
Some of these events, such as eaithquakes anu toinauoes, can occui suuuenly, with veiy little
waining. An ENS agency in a community at high iisk foi such inciuents must theiefoie
maintain a constant state of ieauiness. 0thei natuial uisasteis, such as huiiicanes anu floous,
aie moie pieuictable anu may have a giauual onset, allowing agencies time to implement
uisastei plans.
1,2
Floodsaie the most common of all natuial uisastei, accounting foi ioughly Su% of uisasteis
woiluwiue. Recently the news has been uominateu with the uevastating effects of floouing
seen in Iowa uuiing }une of 2uu8. In fact, the uamage of many othei foims of natuial uisasteis
is often exaceibateu by floouing.
2
Flash floous aie especially hazaiuous. They occui uuiing suuuen heavy iains, tiual suiges, oi
when uams oi levees give way. Nost of the ueaths uuiing flash floous aie causeu by
uiowning, usually fiom people wauing oi uiiving thiough moving watei. Chiluien aie moie
vulneiable to neai uiowning anu uiowning, anu aie at iisk with smallei volumes of watei
than auults. ENS pioviueis must be piepaieu to iecognize the signs of neai-uiowning anu be
piepaieu to tieat accoiuingly.
The hazaius poseu by iapiuly moving watei aie often uniecognizeu. A gallon of watei weighs
8 pounus; hunuieus of gallons of iushing watei iepiesent thousanus of pounus of foice.
Rushing watei only two feet ueep can caiiy a vehicle away. Chiluien aie ceitainly chiluien no
less susceptible.
2
Foitunately, with the exception of flash floouing, floous aie geneially not uiiectly associateu
with significant loss of life. Bowevei, floouing iesults in consiueiable uestiuction anu
uisiuption, anu has the potential foi wiuespieau uisease. Floouwateis fiequently contain
human oi animal waste fiom sewage oi agiicultuial systems that can leau to epiuemics of
infectious uisease. Biinking watei must be uisinfecteu thiough boiling anuoi chloiination,
oi an alteinative clean watei supply (e.g., bottleu watei) must be iuentifieu anu maue
accessible. An ENS agency shoulu consiuei maintaining a stockpile of watei foi the use of
iescueis uuiing these events. Watei supplies anu householu suifaces can also become
contaminateu with petioleum piouucts (e.g., fuel oil oi keiosene), householu chemicals, anu
molus. These uiseases can have a piofounu affect on chiluien. Nany of these uiseases can
cause vomiting anu uiaiihea, symptoms that can be quite seveie in chiluien, who have
ieuuceu suiface to volume aiea, anu aie veiy sensitive to losses of bouily fluius electiolytes.

3
The ENS pioviuei must constantly monitoi vital signs, be vigilant foi signs of hypovolemia
(shock) oi electiolyte uistuibances anu be piepaieu to pioviue appiopiiate suppoitive caie.
2
ENS pioviueis aie taught that scene safety is of paiamount impoitance lest iescueis become
patients themselves. Since contamination of floouwateis also poses a hazaiu to ENS
pioviueis, iubbei boots anu gloves shoulu be woin, anu open wounus anu soies piotecteu.
Banus shoulu be washeu fiequently, especially when hanuling foou oi foou containeis. Foous
that may have been contaminateu shoulu be uiscaiueu anu eating utensils shoulu be
thoioughly washeu anu uisinfecteu. Nateiials that cannot be ieauily uisinfecteu shoulu be
uiscaiueu

The afteimath of a uisastei (especially natuial) is also the souice of consiueiable injuiy anu
uestiuction. Bence, the meuical management pioviueu in the afteimath of a uisastei is
ciitically impoitant. The uisiuption causeu by uisasteis can iesult in wiuespieau uisease
fiom unhygienic conuitions. Fuel leaks, live wiies, anu othei hazaius can cause injuiy oi stait
fiies. The physical anu emotional stiess associateu with the event anu cleanup can iesult in
heait attacks, musculoskeletal injuiies, mental illness, anu othei stiess-ielateu uisoiueis.
Bisplaceu wilulife can hampei ielief effoits anu enuangei woikeis. Injuiies can also iesult
fiom impiopei use of chain saws oi othei mechanical equipment involveu in clean-up effoits.
Chiluien aie especially pione to injuiy oi poisoning thiough access to uebiis, chemicals,
equipment, anu othei agents uiscoveieu while exploiing in the afteimath of the uisastei.
When ietuining to a builuing oi stiuctuie aftei a uisastei, occupants neeu to check foi
stiuctuial uamage, gas leaks, uowneu powei lines, oi othei potentially hazaiuous situations.
Sites shoulu be inspecteu uuiing uaylight so that hazaius aie visible, anu only batteiy-
poweieu flashlights oi lanteins shoulu be useu foi auxiliaiy light, iathei than canules, gas
lanteins, oi othei open-flame uevices, to minimize the possibility of seconuaiy explosions.

Immeuiately aftei a uisastei, goveinments anu community oiganizations will be calleu upon
to pioviue safe (e.g., bottleu) uiinking watei, as well as sheltei, foou, clothing, anu meuical
caie foi uisplaceu people. victims will also look to these oiganizations foi othei seivices,
incluuing counseling anu assistance with insuiance claims anu othei souices of emeigency
funus.
Earthquakes aie a potential hazaiu thioughout the continental 0niteu States, especially in
the iegions of Califoinia, Iuaho, 0tah, anu the Pacific Noithwest. 0f note is that only pait of
the uestiuction causeu by eaithquakes anu theii afteishocks occuis uuiing the event.
Subsequent events tiiggeieu by the quake, such as fiies, tiual waves, anu so on, can cause
significant uestiuction.
Hurricanes and tornadosaie similai weathei events that uiffei in magnituue anu location.
Both involve iotating masses of aii associateu with seveie weathei. Toinauos usually affect a
small geogiaphic aiea, while a huiiicane can affect a iathei laige aiea. Both can have winus of
up to 2uu mph, but huiiicanes aie associateu with much moie eneigy anu have much moie
potential foi uestiuction. Toinauos uevelop piimaiily ovei lanumasses, especially those
within the Niuwestein anu Southwestein 0niteu States, while huiiicanes aie associateu with
the coastal 0niteu States, piimaiily the East anu uulf coasts.
Although huiiicanes aie associateu with high winus, much of the uestiuction they cause is
fiom the so-calleu "stoim suige" anu subsequent floouing. This can iesult in all the pioblems

4
noteu above foi floouing, incluuing the iisk of uiowning, electiocution, anu uisease
associateu with contaminateu uiinking watei.
Tsunamis aie tiual waves iesulting fiom unueiwatei eaithquakes. They can cioss
thousanus of miles of ocean at speeus up to Suu mph. When these gigantic waves bieak, they
can uestioy pieis, builuings, anu human life fai inlanu fiom the seveie floouing.
Wildfires(biush oi foiest fiies) can uisiupt communities anu cause substantial piopeity
uamage, uisplacement, seiious buins, anu ueath. In auuition, smoke fiom wilufiies can iesult
in iiiitation anu iespiiatoiy uifficulties, especially among those with pieexisting meuical
conuitions oi impaiiment. ENS pioviueis must be piepaieu to tieat chiluien with iespiiatoiy
uistiess anu potential aiiway buins, as well as suiface buins anu heat exhaustion.
Technological and Intentional Disasters
Theie is consiueiable oveilap between technologic anu intentional uisasteis. Technological
uisasteis aiise when human safeguaius fail, while intentional uisasteis utilize malicious
means to ciicumvent these safeguaius. The key uiffeience between these two types is that
inheient in the intentional uisastei is the uesiie to instill feai anu cause chaos, theieby
magnifying the uestiuction.
Accidental technological disasters
We live in an eia of auvanceu technological capabilities. These technologies may pose a
hazaiu to humans. With incieaseu sighting of technological facilities in iesiuential aieas, the
potential foi exposuie to chiluien is gieat. Possible scenaiios involve the unintenueu ielease
of inuustiial toxins, iauioactive mateiials, oi othei hazaiuous mateiials uuiing theii
manufactuie, stoiage, tianspoitation, oi use. This was illustiateu in the Bhopal chemical
ielease anu the Thiee-Nile Islanu nucleai acciuent. 0thei foims of laige uisasteis incluue
plane ciashes, tiain ueiailments, anu othei failuies involving mass tiansit systems as well as
stiuctuial failuie of builuings, biiuges, mine shafts, anu othei constiucts. Beie too theie is
consiueiable oveilap in the types of uisasteis encounteieu. Foi example, a tiain caiiying
chemicals that ueiails biings about both physical uamage, anu the ielease of toxic
substances.
1,2
Intentional disasters
Intentional uisasteis, which also often involve technology, aie uelibeiately tiiggeieu by a
peison oi gioup. The ieasons foi committing such acts vaiy wiuely, anu may iesult fiom
political, social, ieligious, oi emotional motivation. Intentional uisasteis aie the least
pieuictable of all uisasteis, anu can take place on the spui of the moment as in school oi
woikplace shootings, oi they may involve uetaileu auvance planning as in the 9-11 teiioiist
attacks on the Woilu Tiaue Centei anu the Pentagon. Teiioiists uo not spaie chiluien, anu in
fact may specifically taiget chiluien as victims. Theii main consiueiation is the impact of
theii act on fuitheiing theii cause.
1
Chiluien have been anu will be victims of teiioiist acts.
Schools, gyms, spoiting events, conceits, amusement paiks, shopping malls, oi any othei
place wheie theie aie mass gatheiings aie all potential teiioiist taigets. The hostage taking
in a school at Beslan in Russia anu the selective bombing of the uay caie centei in 0klahoma
City viviuly illustiate the thieat to chiluien.
2


5
The natuie of these uisasteis can vaiy fiom simple aison oi sabotage, to ielease of chemical
oi biological agents, oi even to uetonation of a piimitive nucleai uevice. These uisasteis aie
also associateu with most of the hazaius uesciibeu foi acciuental, anu sometimes even
natuial, uisasteis. Bowevei, the malicious natuie of the event anu the feai associateu with
biological, chemical, anu nucleai agents iesult in even gieatei stiess anu social uisiuption.
Release of a piouuct such as an agent of oppoitunity, i.e., items noimally founu in hospitals oi
othei technological enviionments that can be tuineu into uestiuctive weapons, into the
ventilation system of a local school oi othei such sites coulu iesult in iapiu spieau of an agent
thioughout a community.
To compounu the uamage they cause anu inflict fuithei feai anu chaos, planneu attacks may
incluue a uelayeu oi "seconuaiy" event that is timeu to coiiesponu with the aiiival of iescue
peisonnel. This can be in the foim of an auuitional accomplice oi anothei uevice. It is
impoitant that ENS pioviueis be piepaieu foi this possibility. Extieme caution shoulu be
useu when enteiing a uisastei scene, anu confiimation of scene safety shoulu be veiifieu by
public safety peisonnel piioi to the entiy of ENS peisonnel. 0nce cleaieu, scene time shoulu
be ieuuceu to a minimum to avoiu fuithei exposuie. Bisasteis involving chiluien aie
especially stiessful foi the ENS pioviuei. Although theie is a stiong emotional uesiie to
"jump in" anu begin iescuing, scene safety is of paiamount impoitance anu must be veiifieu,
lest the injuiies become magnifieu.
Compounding factors
The peiiou immeuiately following a uisastei (especially natuial) is a iisky time foi chiluien.
As a iesult of the uamage inflicteu, electiic tiansmission lines oi capabilities may be uown,
leauing to motoi vehicle collisions at inteisections wheie tiaffic lights aie out, the absence of
aii conuitioning in waim weathei, oi the inability to pioviue watei puiification. Buins oi
inhalation injuiies may aiise as suivivois use open flames foi light oi heat. Chiluien may also
wanuei in aieas of unstable builuings oi othei stiuctuies, oi be caught in the miuule of
looting oi lawless behavioi uuiing peiious of civil uisiuption. The piesence of uisplaceu pets
oi wilu animals ioaming the stieets seeking foou oi sheltei can also leau to bites anu othei
injuiies when chiluien encountei them.
Enviionmental factois can also exaceibate oi cieate existing oi auuitional injuiies. Bot
weathei incieases the iisk foi hypeitheimia, uehyuiation, seveie sunbuin, anu complications
of insect bites, while colu weathei incieases the iisk foi hypotheimia as well as caibon
monoxiue poisoning fiom impiopeily ventilateu combustion heateis oi geneiatois.

References
1. Tunik N, Tieibei N, Kim }, Coopei A, Foltin u eus. TRlPP Teocbinq Resource for lnstructors
in Pre-bospitol PeJiotrics, 2nu Euition. Centei foi Peuiatiic Emeigency Neuicine, New
Yoik, NY 2uu7.
2. Foltin, u., B. Schonfelu, anu N. Shannon. PeJiotric Terrorism onJ Bisoster PreporeJness: A
Resource for PeJiotricions 2uu6; Available fiom:
http:www.ahiq.govieseaichpeupiepiesouice.htm.

13: Physical Disasters Pediatric Disaster Preparedness

1

Chapter 13: Physical Disasters
Daniel Fagbuyi MD, Fred Henretig MD

Epidemiology
Most authorities predict that a terrorist attack with chemical agents would utilize an aerosol route
of exposure. Radiologic attacks might include explosions at a nuclear reactor, a dirty bomb
utilizing conventional explosives to disperse radioactive material, or conceivably detonation of a
nuclear weapon. Chemical or radiological attacks would likely combine elements of the traditional
mass casualty event (MCE) and a hazardous materials (HAZMAT) incident. Most victims affected
would be afflicted in one place, almost simultaneously, and recognized early on, and many would
receive field care and decontamination by EMS personnel. Still, many parents, exposed or not, will
transport themselves, with their children, to nearby hospitals without prior care, so that hospitals
will need to be vigilant and prepared to provide some decontamination and triage capacity, as well
as definitive care. Every EMS agency should be prepared for such an incident, through familiarity
with these agents, the stocking of appropriate antidotes, a quickly deployable decontamination unit,
and personal protective equipment (PPE) for those staff who will be expected to assist with
extrication or will provide emergent resuscitative care prior to or coincident with decontamination.
In contrast, a biological event would likely result in patients presenting in various locales over
time, similarly to a natural infectious disease outbreak. The epidemiology of such an event is
further outlined in a following section. Of note, such an intentional epidemic would likely be more
compressed in time due to the synchronous exposure, perhaps involving more exotic diseases
than usually encountered in a given geographic area, while the patients themselves might exhibit a
particularly high degree of morbidity and mortality. Some of the diseases caused by agents of
bioterrorism are highly contagious, and special isolation precautions will be necessary for the
safety of EMS personnel.
Specific Vulnerabilities in Children
Important physiologic, developmental, and psychological considerations unique to children may
increase their vulnerability to a WMD attack.
1
Children have relatively greater ventilation for body
size than do adults (minute ventilation), and live closer to the ground, potentially increasing their
exposure to airborne toxins, infectious particles, or radioactive fallout, which are usually heavier
than air. Infants and toddlers are limited in their ability to escape danger, particularly if adult
caretakers are critically injured or dead. The witnessed loss of parents and siblings might lead to
extraordinary post-traumatic stress reactions. In addition, EMS systems may be less capable of
handling a large surge in pediatric patients than might be the case for adults, given the considerably
less frequent EMS experience with critical pediatric patients, and less capacity for rapid expansion
of pediatric hospital beds. EMS staff garbed in bulky PPE might be particularly handicapped when
challenged by the need for emergency procedures on infants and small children.
Chemical Agents
The major chemical weapons of concern are the nerve agents, such as sarin, used by Japanese
terrorists in the infamous Tokyo subway attack in 1995.
2
Other potential chemical agents include
vesicants, cyanide, pulmonary agents such as chlorine or phosgene and riot-control or lacrimating

2

(tear-gas) agents (Table 3).
3,4
Because nerve agents and cyanide have specific antidotes, while
nerve agents and vesicants pose a significant contamination hazard to pre-hospital and in-hospital
personnel, these are the chemicals focused upon here (see also Chapter 8, Decontamination).
5,6
The
other agents are highlighted in Table 3. In general, chemical agents can be expected to cause
relatively rapid onset of clinical effects, ranging from seconds or minutes (potent nerve agent) to
several hours (e.g., skin blistering and eye inflammation after vesicant contact, or pulmonary
edema after phosgene exposure).
Nerve Agents
These agents are organophosphate compounds that act as acetylcholinesterase inhibitors, causing a
clinical syndrome similar to that caused by organophosphate pesticide poisoning, though of
potentially much greater lethality, and with greater immediate brain injury. Significant vapor
exposure causes rapid onset of rhinorrhea (runny nose), miosis (pupil constriction), and dyspnea,
due to excessive respiratory secretions and bronchospasm; with severe vapor exposure, this could
progress rapidly to coma, seizures, paralysis, apnea and death unless immediate antidotal therapy
was provided.
7
The toxidromes commonly associated with nerve agent poisoning are shown in
Table 4.
Patients exposed to nerve agent vapor represent a slight contamination hazard to EMS providers,
since some off-gassing can occur from contaminated hair or clothing. Disrobement and a brief
shower with soap and water should suffice for decontamination. For patients exposed to liquid
nerve agent, more scrupulous decontamination with thorough soap and water cleansing would be
warranted; contaminated clothes and skin would be highly toxic to unprotected caregivers, so
appropriate PPE must be worn by involved EMS staff. Mainstays of prehospital care include
cardiopulmonary resuscitation (CPR) and adequate provision of oxygen, as well as emergent
antidotal therapy and supportive care. Atropine is used to counter excess secretions and
bronchospasm compromising respiratory status. Pralidoxime (2-PAM), if used prior to induction of
irreversible enzyme changes (aging), is particularly effective in reversing muscle weakness
(Table 3 details dosing considerations).
8,9
Benzodiazepines should be used aggressively to control
seizures, and may be considered in severe cases even prior to seizure onset.
Vesicant Agents
Vesicant, or blister, agents, such as mustards and Lewisite, have been used by the military as
chemical weapons, and are now feared as potential terrorist agents. There was considerable clinical
experience with sulfur mustard as a military weapon in World War I. This agent caused skin
blistering, eye injury (conjunctivitis, keratitis) and, with heavier exposures, pulmonary tract
inflammation several hours after exposure. In severe cases, bone marrow suppression and
gastrointestinal mucosal injury was also observed. Therapy consists chiefly of decontamination as
soon as possible after exposure, and supportive care. Mustard-contaminated patients, and their
clothing, pose considerable cross-contamination risk to caregivers, and thus require similar
precautions to those used in managing liquid nerve-agent victims.
Cyanide
Cyanide inhibits cellular oxidative metabolism, especially in the brain and heart. Terrorist use
would most likely involve a vapor release within an enclosed space. Victims with high vapor
exposure would rapidly lose consciousness, convulse, and become apneic, though without the
typical muscarinic signs (e.g., excess secretions, bronchospam, miosis) of the comparably poisoned
nerve agent victim. Management begins with CPR and provision of 100% oxygen. In severe cases

3

antidotal therapy may be of additional benefit. Sodium nitrite is one antidote. However, since it
may compromise oxygen delivery in patients whose cellular oxidation is already inhibited, careful
dosing based on weight and estimated hemoglobin concentration in pediatric patients must be
employed (Table 3).
4
An additional antidote sodium thiosulfate is often added. In mild to moderate
cases, sodium thiosulfate alone may be beneficial, and safer than the combination. Recently,
hydroxocobalamin, a new, potentially safer cyanide antidote has been approved for use in the
United States, and some EMS units may now be stocking this antidote instead of the traditional
sodium nitrite/sodium thiosulfate combination.
Radiological/Nuclear Exposure
Experiences from Nagasaki and Hiroshima, Bikini Atoll, Three-Mile Island, and Chernobyl have,
unfortunately, given the medical community particular insight on radiological injuries and their
potential health effects. Fears of intentional use of such substances to harm the civilian population,
including children, have been heightened. Radiological and nuclear terrorism in the pediatric
population will result in significantly greater short-term and long-term sequelae versus the adult.
10

Such terrorist attacks may occur via any of four possible scenarios: non-explosive dispersal of
radioactive substance (e.g., nuclear waste material), explosive dispersal of radioactive substance
(e.g., dirty-bomb), attack on a nuclear power plant with subsequent radioisotope release, or the
dreaded detonation of a nuclear weapon. The first two of these are currently believed to be most
likely, since nuclear power plants are extremely well protected, while state use of nuclear weapons
is limited by treaty. Radiation can be detected only with specialized equipment, such as Geiger
counters, so in many cases children who have been exposed have no way of knowing their danger.
In order to manage the pediatric patient with acute radiation exposure/injury and appreciate the
gravity of such an attack, EMS personnel must first review radiation terminology, characteristics,
biology and physics.
Types of Exposure, Biology, and Clinical Effects
Radiation exposure can be whole body, partial body (local), and internal (ingestion of contaminated
foods or inhalation of radioactive gas) and external (wound contamination and skin absorption), or
both. Ionizing radiation results in free radical formation with subsequent breaks in strands of
DNA and RNA of affected tissues. Because of damage to the genetic material, rapidly dividing
cells (gastrointestinal cells, bone marrow and blood producing cells) are most significantly injured.
Clinical radiation health effects are multifactorial, and depend on the type of exposure, dose,
duration of exposure, type and amount of shielding, distance from radiation source, frequency of
exposure (continuous versus intermittent), history surrounding the exposure (concomitant blast or
thermal injury) and age of the patient. As a general rule, the earlier the onset of symptoms, the
greater the amount and duration of exposure.
Health outcomes in radiation victims can be viewed as short-term and long-term. Short-term
effects occur within days to weeks after exposure, while long-term effects commence months to
years later. Short-term effects typically include nausea, vomiting, bone marrow and lymphoid
immune system suppression with subsequent bleeding, fluid and electrolyte loss, hypovolemic
shock, and mental status change that can progress to death. Long-term effects involve the
increased risk for cancer and psychological injury.
Localized radiation injury may occur after handling radioactive substances, commonly involving
burns to the hands, upper thighs, and buttocks as a result of touching and carrying radioactive
material in pant pockets. Radiation burns present with redness that progresses to blistering and
ulceration, which may further progress to tissue damage and death as a result of vascular

4

insufficiency. Radiation burns differ from thermal burns in that they are somewhat painless and
develop over a period of several days.
Whole body irradiation will result in acute radiation syndrome if doses exceed 200 rad (2 Sv). It
has a prodromal phase that begins within 6 to 12 hours of exposure, followed by abrupt onset of
fever, headache, malaise, nausea, vomiting and diarrhea. An asymptomatic, latent phase then
ensues within 24 to 48 hours of the prodromal phase, which may last for 2 weeks or beyond.
Following the latent phase is the radiation dose-dependent, manifest illness phase, which includes
the gastrointestinal, hematopoietic, and neurovascular syndromes. The gastrointestinal syndrome
(mucosal disruption and destruction) is seen within 1 week of the prodromal phase and manifests as
recurrent nausea, vomiting and diarrhea with severe metabolic disturbances. The hematopoietic
syndrome involves bone marrow and lymphoid immune system suppression. Symptoms include
overwhelming infections, bleeding disorders, and death. The neurovascular syndrome runs a
fulminant course, and ensues as a result of diffuse central nervous system and blood vessel injury.
Within 24 to 72 hours, patients progress from nausea and vomiting to frank prostration to shock
and seizures to cerebral edema and other central nervous system complications, resulting in death.
Patients in whom nausea and vomiting begin within 4 hours of exposure rarely if ever survive.
Pediatric Vulnerabilities
Children are susceptible to radiation injury for many reasons. Compared to adults, children breathe
at a faster rate and are likely to have inhaled a greater amount of radioactive gases were there to be
radioactive gas release. Nuclear fallout tends to settle to the ground (a zone familiar to children)
resulting in a higher concentration of radioactive material in the space that children inhabit. Both
breast and cow milk are main sources of nutrition for children. Exposure to radioactive iodine via
ingestion of milk from cows whose grazing areas have been contaminated by fallout, or inhalation
or ingestion of milk from nursing mothers exposed to fallout, would place children at risk for
internal contamination, and possible development of thyroid cancer in the young child over time.
Small head circumference and mental retardation may manifest in the unborn child if a pregnant
woman is exposed to radioactive iodine. As alluded to previously, children exposed to similar
doses as the adult, are more likely to develop radiation-induced cancers. Psychological and
behavioral disturbances are also more likely in children after any traumatic event.
10,11

Immediate Management
Radiation disasters require Federal, state, and local government intervention in addition to EMS,
and would involve one or more of the following: evacuation, sheltering in place, and, if radioactive
fallout is expected, administration of potassium iodide. Such detailed planning is beyond the
scope of this chapter.
It is important for providers to minimize the time spent at or near the detonation site during rescue
operations as a radiation event. It is also important to maximize distance from the source of
radiation: doubling distance reduces exposure by 75%; tripling distance reduces it by almost 90%.
Since radiation travels in straight lines, some radiation is blocked by concrete or other building
materials. If circumstances permit, EMS providers should position themselves so that the source of
radiation is around the corner of a building, or far enough away so that several large buildings are
between them and the source.
Emergency management of radiation injury involves the following primary objectives:
maintaining the ABCs (airway, breathing, and circulation); reducing the risk of internal
contamination; recognizing and treating acute radiation syndrome; minimizing radioactive
contamination and spread to the caregiver and others. Disaster management principles should be

5

instituted and include containment, decontamination, prehospital care, and field triage.
6
Patients
should be decontaminated in the field and then transported to the medical treatment facility.
Persons caring for pediatric radiation victims should, by dosimeter or history, determine whether
the victim is contaminated (deposition of radioactive material internally or externally) or irradiated
(exposure to a source of radiation, i.e., -rays or x-rays, that does not render the victim radioactive).
Contaminated victims require decontamination and should have all clothing removed
(disrobement), as this accomplishes greater than 90% effective decontamination.
12
However, since
the risk of exposure to properly garbed health care providers is minimal, resuscitation should
precede decontamination if the patient is in extremis. Personnel caring for contaminated patients
should observe universal precautions, wearing protective masks, gowns, gloves and plastic shoe
covers or booties. Patients should be wrapped in cloth sheets to minimize contamination of
personnel and the medical treatment facility. Contaminated clothing and material should be placed
in designated containers or areas. If determined that the victim requires topical decontamination,
the skin should be washed with warm water and soap while avoiding the development of
hypothermia. Particles tend to become lodged in the skin folds, under the fingernails, behind and
around the ears, hair, hands and face. Open wounds should be covered so as not to contaminate
wounds. Patients with skin burns require irrigation only; avoid abrading the skin. All irrigation
solutions should be collected in designated containers and properly disposed. Decontamination
zones and treatment areas should have controlled access. Once decontamination is complete,
patients may be transported to the medical treatment facility. It should be abundantly clear that in
life-threatening situations, priority is given to establishing and maintaining the ABCs, followed by
rapid transport to the hospital with as lengthy a pre-notification as possible.
Pediatric victims without evidence of external contamination may be treated according to standard
protocol, but their bodily fluids may be contaminated, hence require special handling precautions.
Management of local radiation burn and acute radiation syndrome is mainly supportive. If surgical
intervention for local burn is warranted, it should be performed within 48 hours of irradiation to
afford good wound healing and prevent infection. Acute radiation syndrome victims will usually
become symptomatic within a few hours to days after initial exposure. However, for the exposed
prehospital provider, symptoms will likely begin a few days to weeks after the patients they
transported were initially hospitalized or evaluated.
Although the optimal treatment for internal contamination requires knowledge of the specific
contaminant and the sophistication offered at a medical treatment facility, the prehospital provider
may only have potassium iodide (KI) available. KI should be used in a scenario that involves
detonation of a nuclear weapon, attack on nuclear reactor or power plant meltdown. Guidance to
EMS personnel from the Federal government and state of local departments of health will
determine when to administer KI and whether or not EMS personnel should stock KI on their daily
missions. For further information on KI, the reader is directed to the references at the end of this
chapter. Other radioactive substances can cause internal contamination, but specific treatment will
require expert consultation, and is therefore, not addressed in this chapter.
Explosive/Blast Injuries
Emphasis on terrorism preparedness has mainly focused on chemical, biological, radiological, and
nuclear events, while explosive events, according to some authors, have been neglected. Whether
this belief is true or is not, it is established fact that physical injury is responsible for 98% of terror
events worldwide, with bomb blasts accounting for 75%, and firearms for 23%. It is also well-
known that instructions on how to build a bomb are readily available via the internet. In addition,
raw materials to further such causes are easily obtained. It is therefore not surprising that most

6

terrorist attacks to date involve explosive devices, and that the frequency of bombing directed at
civilians is increasing.
13,14
Most of the mass-casualty terrorist events in the United States have
involved the use of conventional explosives.
15
Experiences from Israel, Northern Ireland, Iraq,
Afghanistan, and other countries, including the United States (Oklahoma City bombing and
September 11 suicide airliner attacks on New York and Washington) have raised awareness among
non-military prehospital personnel, health professionals, and clinicians; it augmented their
understanding of blast injuries and its spectrum.
Bomb Types and Characteristics
Terrorist bombs are designed to detonate in crowded areas, typically optimizing injury severity and
fatality through release of metallic fragments (often called shrapnel, an outmoded term that refers
to a particular type of metallic fragment commonly used in World War I). These bombs are of three
main types: suicide bombs, package bombs, and vehicle bombs.
Suicide bombs are unique because they result in intentional death of the bomber, are more likely to
be successful as they evade detection (hidden on the person), and are difficult to prevent. Risk of
transmission of blood-borne infections (e.g., hepatitis B or C) in patient survivors of a suicide
bombing is possible; although there are few anecdotal cases of such transmission (transmission of
HIV has not been reported to date).
Car bombs involve heavy explosive material, produce big blasts, and often culminate in
infrastructure damage and collapse. Hundreds of victims will result. Many patients will require
extrication or some form of technical rescue and treatment for crush injury or crush syndrome.
When part of the patients body is trapped under pressure, dangerous chemicals and toxins
accumulate in the crushed body part after a long period of compression. When the limb or other
body part is released, a severe shock-like condition follows which is characterized by swelling,
blood in the urine, and ultimately kidney failure. To prevent this, intravenous fluids and sodium
bicarbonate should be administered before extrication. During extrication, the patient should be
monitored for changes in mental status. It is also important to maintain blood sugar levels and keep
the patient warm to prevent hypothermia. Car bombs are most likely to be incendiary, producing
burn injuries in patients as a result of secondary fires.
Package bombs are smaller in size by nature as they are carried into an attack site. They are easy to
delivery and usually in confined places (e.g. bus, section of a building). Although package or letter
bombs are smaller, the fact that they are detonated in a confined (closed) space results in
magnifying the resultant injury (see blast physics section below).
Blast Physics
When a bomb is activated, the explosive chemical rapidly converts from a solid or liquid state to a
gaseous state, which now occupies a significantly greater volume of space than before the
explosion. A rapidly expanding blast wave (instantaneous overpressure followed immediately
by underpressure) and blast wind (ensuing rapid air currents) then project outward in all
directions and occur within milliseconds. The processes of over- and under-pressurization and
subsequent rapid air currents occur at different speeds depending on the type of explosive.
16
When
treating victims of a bomb, it is important to know where it exploded (open or confined space) as
this may anticipate the number, type, and intensity of injuries observed.
High-pressure blast wave from a detonation exerts a compressive force on air molecules and moves
these air molecules through the environment. The blast wave exerts a crushing external force on
any object in its path; the effect is one of being first compressed, then exposed to low-pressure

7

(vacuum), and then back to a normal pressure.
17
In essence, the blast wave and wind involves a
squeezing, releasing, and re-squeezing mechanism.
Injury severity is directly related to the distance between the victim and the explosion sitethe
closer to the explosion, the greater the extent of injury.
18
Walls and ceilings, especially enclosed
areas (e.g., buses, cafes), augment and amplify the over-pressure effects as they reflect the blast
waves. Other factors that may determine the extent of injury include body mass of the victim
(grave implications for young children), orientation of the victim to the blast, and shielding present
between the victim and the blast.
19,20
Types of Blast Injuries and Blast Pathophysiology
Blast injuries are classified into four categories based on the mechanism of injury (blast effects):
these are referred to as primary, secondary, tertiary, and quaternary. As mentioned previously, the
types of injuries caused by blast depend on numerous factors, but the key factors are whether the
blast caused structural damage with collapse of the structure or other structures, and whether it
occurred in open air or within a building.
Primary blast injuries are a result of over-pressurization (blast wave). In this scenario, air-filled
organs are subject to the worst damage from high external overpressure of an explosive blast. It is
the effect of the blast wave at the air-body interface, especially at zones of differential tissue
densities and air-filled organs (e.g., ear, lung, and intestines).
17
Forms of primary blast injury
include the following:
Auditory blast injury: Tympanic membrane rupture is the most frequent primary blast injury.
Contrary to popular belief, it poorly correlates with blast injury elsewhere in the body, and some
authors say it is of no use as a predictive marker.
15,17
Patients may present with symptoms
including deafness, ringing in the ear, and vertigo. Bones in the middle ear may be dislocated as
well. Further damage may lead to long term deafness.
Blast Lung: The lung is the second most frequent organ injured in primary blast injury, and is the
most common critical injury to persons close to a blast center.
15
The alveolar-capillary interface is
disrupted by the blast wave, culminating in bruising of the lung tissue (pulmonary contusion),
blood in the lungs (hemothorax), air leak and compression of the lungs (pneumothorax and/or
pneumomediastinum), and lung blebs (surface blisters). These potential life-threatening lung
injuries can rapidly progress to pulmonary edema (wet drowning lungs) with frothing at the
mouth; it results from pressure differentials forcing fluid out of the capillaries into the air-sacs or
spaces. Patients usually complain of cough, difficulty breathing, and retrosternal chest pain. Cough
is initially dry in nature, but may progress to productive frothy type, or frank blood. On physical
examination, patients have rapid respiratory rate, cyanosis (blue spell), decreased breath sounds,
and diffuse rhonchi or coarse breath sounds. Pulse oximetry may reveal low oxygen saturation.
Other findings as a result of lung injury are brain or spinal cord blood vessel occlusion secondary
to acute systemic air embolism from lung disruption. Patients may present with stroke-like
symptoms.
Cardiac blast injury: Similar to blunt chest trauma, cardiac blast injury involves mainly
contusions (bruises). Arrhythmias like ventricular fibrillation, ventricular tachycardia, bradycardia,
and asystole have been reported in the medical literature. Hypotension and bradycardia have also
been reported and is thought to be secondary to direct blast wave effect on disrupting compensatory
vasoconstriction.
17
Cardiac blast injury related death is thought to be a result of air emboli within
the coronary circulation.
15
Cardiac monitoring is critical in this subset of patients.

8

Abdominal blast injury: Although relatively more common in underwater blasts and occult in
presentation, abdominal blast injury may result in overt bowel rupture. Very high energy blasts or
close proximity can result in rupture and bleeding of solid organs like the kidney, liver, and spleen.
Orthopedic primary blast injury (Traumatic amputation): Traumatic amputation occurs when the
blast wave that passes through shaft of long bones, causes bone failure, and the dynamic blast
overpressure separates the fractured extremity.
15,21
It is a potential marker of severe blast exposure,
is rare in blast survivors, and is distinguished from that obviously caused by a secondary fragment
or flying object (discussed later under tertiary blast injury).
22
Other primary blast injuries include eye injuries (e.g., hyphema and globe rupture); facial
fractures; concussion and traumatic brain injury.
Secondary blast injuries are a result of blast winds that cause objects to strike the victim.
Injuries are secondary to blunt trauma or penetration of energized, usually metallic, fragments or
debris. Except in cases of major building collapse, penetrating injuries from fragments are the
leading cause of death and injury in both military and civilian terrorist attacks.
14
Fragments usually
do not pass through the victim; they are multiple and retained in the body. Clothing does offer
slight protection against these projectile fragments, but exposed skin surfaces will likely be
traumatized with minor cuts, bruise and penetrations. Injuries can be expected mainly on exposed
area of the bodyhands, head and neck. Other injuries that may be anticipated include perforated
hollow organs, collapsed lungs, or lacerated and bleeding internal organs. Comminuted fractures of
the longs bones also may be noted.
Tertiary blast injuries are wounds sustained from acceleration-deceleration forces that occur as the
blast wind propels the victim against a fixed object. Any body part can be involved, resulting in
brain injury, traumatic amputation, and fractures. Although traumatic amputation results from a
combination of primary and tertiary effects, it is extremely rare in survivors, as traumatic amputees
usually die from significant blast wave effects, and rapid exsanguination from blood vessel
disruption.
15,17
In addition, structural collapse contributes to tertiary injuries, in that it involves
large airborne fragments, subsequent crush injury or crush syndrome (defined above), compartment
syndrome (compression from swelling of damaged muscle tissue within its elastic sheath that
promotes local tissue death; the patient usually has pain that is out of proportion to the injury), and
extensive blunt trauma.
Quaternary blast injuries are explosion-related injuries or disease not related to primary,
secondary, or tertiary injuries. It commonly involves thermal or chemical burns, inhalational
injury, asphyxiation (e.g. from carbon monoxide or cyanide), radiation exposure, and psychological
effects. Burns are usually on skin-exposed areas as mentioned previously. Psychological effects
have significant impact on children and are evident in both survivors and non-exposed children.
Management
The most important priority after an explosion or terrorist bombing is scene control, with emphasis
on safetyparticularly the avoidance of injuries to bystanders and rescuers from secondary device
explosion. Prehospital triage may begin on the scene, if appropriate, but in some cases the scoop
and run approach might be warranted (i.e., minimal medical intervention on scene with rapid
evacuation to the nearest medical treatment facility). The primary goal of prehospital personnel
should be to protect the critically injured but salvageable patients by ensuring that they are
evacuated first. Each subsequent evacuee should be the next most critical patient. It is paramount
that no casualty is overlooked.

9

Guidelines for the prehospital care of a general trauma victim and that of a bomb victim do not
differ significantly. Rapid triage following basic field medical care guidelines may increase the
chance of survival of the potentially salvageable critically injured patient as it augments rapid
evacuation by mitigating wasted efforts on patients not salvageable. These guidelines are as
follows: victims with amputated body parts and no signs of life are considered dead; victims
without breathing or pulse and having dilated pupils are dead; CPR should not be done on scene;
airway management with cervical immobilization is paramount; supplemental oxygen
administration and/or needle decompression of chest, application of direct pressure or tourniquets,
alignment of fractures, limb-to-limb splinting, and coverage of open wounds are performed as
necessary.
13,23
The initial stabilization of victims of blast injury involves prompt attention to the ABC concept
of managing the airway, breathing and circulation. Depending on the age of the pediatric patient,
intravenous fluid infusion should be initiated only to maintain adequate blood pressure, recognizing
that such an intervention consumes valuable time that may be far better used attending to other
victims. When used, however, the aforementioned risk of pulmonary edema and renal failure in
patients with blast lung or crush injuries must be carefully considered and fluid infusion judiciously
balanced to avoid both hypoperfusion and overhydration. Pulse oximetry and cardiac monitoring
may also reveal possible oxygen exchange problems resulting from lung injury or arrhythmias
associated with heart injury. Extremity fractures should be splinted while wounds and burns
should be covered with sterile dressings to prevent contamination, heat and insensible fluid loss.
Pressure dressing/packs should be placed on any active bleeding sites. Penetrating objects to eye
and other parts of the body should not be removed, but left in place.
14
Special Considerations
If a disaster is widespread or prolonged, emergency response times may be delayed due to high
demand, transport restrictions, or overloaded care facilities; therefore, EMS providers may be
treating injuries later in their course than they are usually accustomed to. Consequently there may
be an increase in the incidence of shock and infections associated with wounds.
Summary
In general, prehospital providers will be first on the scene when a terror event occurs, and should
have some general understanding of the various Chemical, Biological, Radiological, Nuclear, and
Explosive/Incendiary (CBRNE) agents likely to be encountered, in addition to medical disaster
management strategies in this acute setting. It is evident that there are enormous gaps in
knowledge and experience with pediatric patients and their unique qualities among EMS providers.
Continuing education and reviews on such pediatric topics must be an integral part of professional
development. It is of paramount importance to recognize that rapid response coupled with
appropriate treatment will likely increase patient survival.


10

References
1. Tunik M, Treiber M, Kim J, Cooper A, Foltin G eds. TRIPP Teaching Resource for Instructors
in Pre-hospital Pediatrics, 2nd Edition. Center for Pediatric Emergency Medicine, New York,
NY 2007.
2. Okumura T, Takasu N, Ishimatasu S, Miyanoki S, Mitsuhashi A, Kumada K et al. Report on
640 victims of the Tokyo subway sarin attack. Ann Emerg Med 1996; 28: 129-135.
3. Henretig FM, Cieslak TJ, Eitzen EM Jr. Biological and Chemical Terrorism. J Pediatr 2002;
141: 311-326.
4. US Army Medical Research Institute of Chemical Defense. Medical Management of Chemical
Casualties, 3rd ed. Aberdeen Proving Ground, MD, 1999.
5. Macintyre AG, Christopher GW, Eitzen E Jr, Gum R, Weir S, DeAtley G et al. Weapons of
mass destruction events with contaminated casualties: effective planning for health care
facilities. JAMA 2000; 283: 242-249.
6. Henretig FM, McKee MR. Preparedness for Acts of Nuclear, Biological and Chemical
Terrorism. In: Gausche-Hill M, Fuchs S, Yamamoto L ( eds). APLS The Pediatric Emergency
Medicine Resource, 4th ed. American Academy of Pediatrics and American College of
Emergency Medicine. Jones and Bartlett, Sudbury, MA. 2004, pp 568-591.
7. Horrocks CL. Blast injuries: biophysics, pathophysiology and management principles. Journal
of the Royal Army Medical Corps 2001;147(1):28-40.
8. Henretig FM, McKee MR. Preparedness for Acts of Nuclear, Biological and Chemical
Terrorism. In: Gausche-Hill M, Fuchs S, Yamamoto L ( eds). APLS The Pediatric Emergency
Medicine Resource, 4th ed. American Academy of Pediatrics and American College of
9. Foltin G, Tunik M, Curran J et al. Pediatric nerve agent poisoning: medical and operational
considerations for emergency medical services in a large American city. Pediatr Emerg Care
2006; 22: 239-244.
10. Bell DM, Kozarsky PE, Stephens DS. Clinical issues in the prophylaxis, diagnosis, and
treatment of anthrax. Emerging Infectious Diseases 2002;8(2):222-5.
11. National Institute of Mental health. Helping Children and Adolescents Cope with Violence
and Disasters. Nov 2002
12. Jarrett DG, Armed Forces Radiobiology Research Institute (U.S.). Military Medical Operations
Office. Medical management of radiological casualties handbook. 1st ed. Bethesda, MD:
Armed Forces Radiobiology Research Institute, Military Medical Operations Office; 1999.
13. Lucci EB. Civilian preparedness and counter-terrorism: conventional weapons. Surgical
Clinics of North America 2006;86(3):579-600.
14. DePalma RG, Burris DG, Champion HR, Hodgson MJ. Blast injuries.[see comment]. New
England Journal of Medicine 2005;352(13):1335-42.
15. Garner MJ, Brett SJ. Mechanisms of injury by explosive devices. Anesthesiology Clinics
2007;25(1):147-60.
16. Military Blue Book. http://usamriid.detrick.army.mil/education/bluebookpdf/USAMRIID

11

17. Crabtree J. Terrorist homicide bombings: a primer for preparation. Journal of Burn Care &
Research 2006;27(5):576-88.
18. Horrocks CL. Blast injuries: biophysics, pathophysiology and management principles. Journal
of the Royal Army Medical Corps 2001;147(1):28-40.
19. Boffard KD, MacFarlane C. Urban bomb blast injuries: patterns of injury and treatment.
Surgery Annual 1993;25 Pt 1:29-47.
20. Hill JF. Blast injury with particular reference to recent terrorist bombing incidents. Annals of
the Royal College of Surgeons of England 1979;61(1):4-11.
21. Hull JB, Cooper GJ. Pattern and mechanism of traumatic amputation by explosive blast.
Journal of Trauma-Injury Infection & Critical Care 1996;40(3 Suppl):S198-205.
22. Frykberg ER, Tepas JJ, 3rd. Terrorist bombings. Lessons learned from Belfast to Beirut.
Annals of Surgery 1988;208(5):569-76.
23. Stein M, Hirshberg A. Medical consequences of terrorism. The conventional weapon threat.
Surgical Clinics of North America 1999;79(6):1537-52.

Local/ State health departments
www.statepublichealth.org/index.php
www.cdc.gov/other.htm#states
Federal Bureau of Investigation (crisis management) www.fbi.gov
Federal Emergency Management Agency (consequence management) www.fema.gov
FEMA (202) 646-4600
US Military Agency Resources (educational and practical resources)
US Army Medical Research Institute of Infectious Disease www.usamriid.army.mil
US Army Medical Research Institute of Chemical Defense www.chemdef.apgea.army.mil
US Armed Forces Radiobiology Research Institute www.afrri.usuhs.mil
Center for Disease Control (at request of state/territory agency, clinical resource) www.bt.cdc.gov
Emergency Response Hotline (770) 488-7100
Center for Civilian Biodefense Strategies www.hopkins-biodefense.org
Nuclear, biological, chemical resources www.nbc-med.org
The Radiation Emergency Assistance Center/ Training Site (REAC/TS) www.orau.gov/reacts
(865)576-3131 ask for REACT/TS
Poison Control Centers (800-222-1222)
Adapted from: Henretig FM, McKee MR. Preparedness for Acts of Nuclear, Biological and
Chemical Terrorism. In: Gausche-Hill M, Fuchs S, Yamamoto L ( eds). APLS The Pediatric
Emergency Medicine Resource, 4th ed. American Academy of Pediatrics and American College of

Table 3. Primary Chemical Agents

Agent Toxicity Clinical Findings Onset Decontamination
1
Management
Nerve agents:
Tabun,
Sarin,
Soman,
VX
Anticholinesterase:
muscarinic,nicotinic
and CNS effects
Vapor: miosis, rhinorrhea, dyspnea
Liquid: Diaphoresis, vomiting
Both: coma, paralysis, seizures,
apnea
Seconds: vapor
Minutes-hours:
liquid
Vapor: fresh air, remove
clothes,wash hair
Liquid: remove clothes, copious
washing skin, hair with soap and
water, ocular irrigation
ABCs
Atropine: 0.05 mg/kg IV
2
, IM
3
(min 0.1mg, max 5 mg),
repeat q2-5 min prn for marked secretions, bronchospasm
Pralidoxime: 25 mg/kg IV, IM
4
(max 1 g IV; 2 g IM), may
repeat within 30-60 min prn, then again Q1 hr for 1 or 2
doses prn for persistent weakness, high atropine
requirement
Diazepam: 0.3 mg/kg (max 10 mg) IV; Lorazepam: 0.1
mg/kg IV, IM ( max 4 mg); Midazolam: 0.2 mg/kg (max
10 mg) IM prn seizures, or severe exposure
Vesicants:
Mustard

Lewisite

Alkylation

Arsenical
Skin: erythema, vesicles
Eye: inflammation
Respiratory tract: inflammation
Hours

(immediate
pain with
Lewisite)
Skin: soap and water
Eyes: water
(both: major impact only if done
within minutes of exposure)
Symptomatic care

( possibly BAL 3 mg/kg IM Q4-6hrs for systemic effects
of Lewisite in severe cases)
Pulmonary
agents:
Chlorine
Phosgene

Liberate HCL,
alkylation
Eyes, nose, throat irritation
(especially chlorine)
Respiratory: bronchospasm,
pulmonary edema (especially
phosgene)

Minutes: eyes,
nose, throat
irritation,
bronchospasm;
Hours:
pulmonary
edema
Fresh air
Skin: water
Symptomatic care
Cyanide Cytochrome
oxidase inhibition:
cellular anoxia,
lactic acidosis
Tachypnea, coma, seizures, apnea Seconds Fresh air
Skin: soap and water
ABCs, 100% oxygen
Na bicarbonate prn metabolic acidosis
Na nitrite (3%): Dose (ml/kg) Estimated Hgb (g/dL)
0.27 10
0.33 12 (est. for average child)
0.39 14
( max 10 ml)
Na thiosulfate (25%): 1.65 ml/kg (max 50 mL)
12


Agent Toxicity Clinical Findings Onset Decontamination
1
Management
Riot Control
agents:
CS
CN ( Mace
R
)
Capsaicin
(pepper spray)
Neuropeptide
substance P release;
alkylation
Eye: tearing, pain, blepharospasm
Nose and throat irritation
Pulmonary failure (rare)
Seconds Fresh air
Eyes: lavage
Ophthalmics topically, symptomatic care
1
Decontamination, especially for patients with significant nerve agent or vesicant exposure, should be performed by health care providers garbed in adequate personal protective equipment. For ED staff,
this consists of non-encapsulated, chemically-resistant body suit, boots and gloves with a full face air purifier mask/hood. (See also Chapter 8).

2
Intraosseous route is likely equivalent to intravenous.
3
Atropine might have some benefit via endotracheal tube or inhalation, as might aerosolized ipratropium. As of July 2004, the FDA has approved pediatric autoinjectors of atropine in 0.25, 0.5 and 1 mg
sizes. FDA recommendations are:
Approx Age Approx Wt Auoinjector size
< 6 mos < 15 lbs 0.25 mg
6 mos 4 yrs 15-40 lbs 0.5 mg
5-10 yrs 41-90 lbs 1 mg
> 10 yrs > 90 lbs 2 mg ( adult-sized )
4
Pralidoxime is reconstituted to 50 mg/ml (1 g in 20 ml water) for IV administration, and the total dose infused over 30 min, or may be given by continuous infusion ( loading dose 25 mg/kg over 30
min, then 10 mg/kg/hr). For IM use, it might be diluted to a concentration of 300 mg/ml (1g added to 3 ml water - by analogy to the US Armys Mark 1 autoinjector concentration), in order to effect a
reasonable volume for injection. Pediatric autoinjectors of pralidoxime are not FDA approved or available at this time. The Mark 1 autoinjector kits contain 2 mg ( 0.7ml) atropine, and 600 mg (2ml)
pralidoxime, delivered into two separate intramuscular sites; while not approved for pediatric use, the pralidoxime autoinjector might be considered as initial treatment in dire (especially pre-hospital)
circumstances, for children with severe, life-threatening nerve agent toxicity who lack intravenous access, and for whom more precise, mg/kg IM dosing would be logistically impossible. Suggested
dosing guidelines are offered; note potential excess of initial pralidoxime dose for age/weight, though within general guidelines for recommended total over first 60-90 min of therapy of severe
exposures:
Approximate Age Approximate Weight Number of Autoinjectors Pralidoxime dose range ( mg/kg)
3 7 yrs 13-25 kg 1 24-46
8-14 yrs 26-50 kg 2 24-46
>14 yrs >51 kg 3 35 or less
Key: ABCs = airway, breathing and circulatory support; BAL= British Anti-Lewisite; Hgb= hemoglobin concentration; est.= estimated hemoglobin concentration; max = maximum; min = minimum;
prn = as needed.
Note: some authorities
26
recommend simplified strategies for use of autoinjected pediatric nerve agent antidotes in children with exposure and signs of significant toxicity, such as:
Age Atropen (mg) 2-PAM (600 mg = 1 adult autoinjector)
<1 yr 0.5 none
1-8 y 2 600 mg
>8 y ( as per adult pts)

Adapted from Henretig FM, Cieslak TJ, Eitzen EM Jr. J Pediatr 2002; 141:311-326 and Foltin G, Tunik M, Curran J et al. Pediatric nerve agent poisoning: medical and operational considerations for
emergency medical services in a large American city. Pediatr Emerg Care 2006; 22: 239-244.

13


14

Table 4. Classic toxidromes associated with cholingeric crisis due to nerve agents

SLUDGEM* DUMBELS* MTW(t)HF

Salivation Diarrhea, Dyspnea, Diaphoresis Mydriasis
Lacrimation Urination Tachycardia
Urination Miosis Weakness
Defecation Bradycardia, Bronchorrhea, Bronchospasm (t)Hypertension
Gastrointestinal Emesis Fasciculations
Emesis Lacrimation
Miosis Salivation, Secretions, Sweating

*Muscarinic effects (treated with atropine)
Nicotinic effects

14: Biological Disasters Pediatric Disaster Preparedness

1

Chapter 14: Biological Disasters
Stephan Kohlhoff MD, Daniel Fagbuyi MD, Fred Henretig MD
Introduction
Prehospital providers are usually first on the scene when an incident occurs or a patient is in
urgent need of medical attention, but this may not necessarily be the case when it comes to
biological agents. Nonetheless, prehospital providers should be cognizant not only of the unique
characteristics of children, but also the various types, clinical features, and acute management of
biological agent exposure in the pediatric population.
Biological terrorism may be defined as the deliberate release of viruses, bacteria, or other germs
(vectors) used to cause illness or death in people, animals, or plants to cause disease, death,
destruction, or panic for political or social gains. Biological agents are divided into categories of
highest to lowest priority by the Centers for Disease Control and Prevention, or CDC
(http://www.cdc.gov). Category A agents are of highest priority, easily spread or transmitted from
person to person, result in high mortality, and may cause public panic and social disruption; these
agents pose the highest risk to the public and national security. In addition, they are easily
manufactured and deployed without sophisticated delivery systems, and have the ability to kill or
injure hundreds or thousands of people. A unique and challenging feature that distinguishes a
biological exposure from other types of exposure (chemical, radiological, nuclear, explosive &
incendiary), is the delay in the onset of illness (hours to days vs. seconds to minutes) associated
with biological weapons.
1,2
This unique feature elucidates how illness from biological agents may
go unrecognized, present to the non-traditional first responder (pediatrician or tertiary facility),
and culminate in widespread secondary exposure over large geographic areas.
Category A agents include anthrax, plague, botulinum toxin, smallpox, tularemia, and viral
hemorrhagic fevers (filoviruses or arenaviruses). These are summarized in Table 2. The reader is
directed to several relevant internet websites noted in Table 1 for a more detailed description of
other category agents, which are beyond the scope of this section.
General Guidelines for Pediatric Infection Control
When caring for children displaying symptoms thought to be due to a biological agent, current
Healthcare Infection Control Advisory Committee (HICPAC) Guidelines should be applied (the
2007 Guidelines for Isolation Precautions in Hospitals were in force at the time of this writing).
2

Note that recommendations (such as duration of isolation) sometimes differ between adults and
children.
Transmission of an infectious agent requires three elements: a source (or reservoir) of infectious
agents, a susceptible host with a port of entry receptive to the agent, and a mode of transmission for
the agent. Modes of transmission vary by type of organism, and are divided into three major
categories: contact (direct or indirect), droplet, or airborne. Table 1 indicates precautions by
disease. Whenever available, a clinical case definition for exposed/symptomatic and exposed/
asymptomatic children, to be provided by local health officials, should be applied. Exposure to a
known biological agent may not be always recognized. For patients who have symptoms that are
consistent with the biological agent in question, precautions should be instituted according to
guidelines. Asymptomatic patients with possible exposure are less likely to be contagious, although
specific guidelines for their evaluation and precautions may apply depending on the agent. The

2

goal is to promptly evaluate and separate unexposed and exposed/asymptomatic children as soon as
possible from symptomatic children and symptomatic adults. While there is a known risk of
transmission of infectious agents from infected children to caregivers, the presence of caregivers
(asymptomatic or symptomatic) may be in the best interest of the child (asymptomatic or
symptomatic). In order to minimize risk of transmission caregivers have to be instructed in relevant
isolation and care procedures.
For all children who are symptomatic and suspected of being infected with an agent of concern, the
following measures may need to be applied in addition to standard precautions:
y HICPAC isolation guidelines: Apply guidelines appropriate to the nature of the
illness/exposure
2

y Droplet precautions: Use of surgical face masks as source containment (e.g. during transport) is
inappropriate in infants; it may be possible to instruct toddlers in a age-appropriate manner to
wear masks if constant supervision is possible
y Respiratory hygiene/cough etiquette: This should be emphasized as an alternative to masking
y Airborne precautions: Care providers need to use N95 or higher respirator, gloves and gown
Droplet, airborne, and contact precautions should be combined for diseases caused by organisms
that have multiple routes of transmission
There are some special concerns regarding respiratory precautions in children. While there are no
masks or respirators designed to fit children, small-sized respirator face pieces may adequately fit
older children. While surgical masks are not required to fit as tightly to the face, they should not
interfere with eyesight, and gaps should be minimized. The likelihood that a child would use a
facemask or a respirator properly is a significant concern. Facemasks and respirators will not serve
their intended purpose if they are not worn during appropriate times. Children may not understand
the importance of wearing a mask, and they may not tolerate having them on their faces for
extended periods of time. Because handling used facemasks and respirators could also transmit the
influenza virus, wearers should be trained in how to remove and dispose of them safely. Careful
handling of a contaminated mask or respirator may not be a reasonable expectation of young
children.
Any space occupied by patients should be decontaminated; laundry and waste should be discarded
into biohazard bags; and laundry and bedding should be laundered in hot water with laundry
detergent, followed by hot air drying or incinerated.
Infections: Unknown biologic agent
Recognition of Illness Associated with the Intentional Release of a Biologic Agent
Health-care providers should be alert to illness patterns and diagnostic clues that might indicate an
unusual infectious disease outbreak associated with intentional release of a biologic agent and
should report any clusters or findings to their local or state health department. The covert release of
a biologic agent may not have an immediate impact because of the delay between exposure and
illness onset, and outbreaks associated with intentional releases might closely resemble naturally
occurring outbreaks. Indications of intentional release of a biologic agent include

3

y unusual temporal or geographic clustering of illness (e.g., persons who attended the same
public event or gathering)
y patients presenting with clinical signs and symptoms that suggest an infectious disease
outbreak (e.g., >2 patients presenting with an unexplained febrile illness associated with sepsis,
pneumonia, respiratory failure, or rash or a botulism-like syndrome with flaccid muscle
paralysis, especially if occurring in otherwise healthy persons)
y unusual age distribution for common diseases (e.g., an increase in what appears to be a
chickenpox-like illness among adult patients, but which might be smallpox
First responders play a critical role in recognizing and responding to illnesses caused by intentional
release of biologic agents. Becoming familiar with the following syndrome descriptions may help
recognizing an event and implementing appropriate precautions.
BioterrorismCategory A Agents
The United States Centers for Disease Control and Prevention (CDC) has defined those agents as
Category A agents that are easily disseminated or transmitted from person to person, result in high
mortality, can cause social disruption, require special public health interventions and pose the
greatest risk for national safety.
At the time of this publication the agents of highest concern (Category A) are the following
bacteria, viruses, and toxins: Bacillus anthracis (anthrax), Yersinia pestis (plague), and Francisella
tularensis (tularemia); variola major (smallpox), and the viral hemorrhagic fever filoviruses (Ebola
hemorrhagic fever, Marburg hemorrhagic fever) and arenaviruses (Lassa [Lassa fever], J unin
[Argentine hemorrhagic fever], and related viruses); and Clostridium botulinum toxin (botulism).
The following paragraphs give a short description of the clinical manifestations in children;
modes(s) of transmission, precautions and preventive measures are summarized in Table 1.
Bacterial Agents
Anthrax
Aerosolization would be the likely method of release if used as a biological weapon. Bacillus
anthracis is the causative agent. Natural human disease occurs after exposure to infected animals
or products. There are 3 forms of anthraxcutaneous, gastrointestinal, and inhalational.
Cutaneous anthrax results from inoculation of anthrax spores into broken skin, and starts as a
pruritic (itchy), painless papule (raised skin lesion) that rapidly progresses through various stages
from papule to vesicle to blister to painless, deep, necrotic ulceration with eschar (scab) formation
on a background of edema (swelling), induration (stiffness), and erythema (redness).
Gastrointestinal anthrax results from ingestion of anthrax spores (undercooked meat). Patients
are usually symptomatic within less than one week after ingestion. Signs and symptoms include
nausea, vomiting, fever, abdominal pain, bloody diarrhea or hematemesis (bloody vomiting),
ulcerating lesions at the tongue base, dysphagia, and systemic symptoms.
Inhalational anthrax is a biphasic illness with an incubation period of one to six days, although it
can take as long as sixty days to become manifest.
3
Phase 1 commences with a prodrome of
influenza-like symptoms, including fever, myalgia, cough, malaise or fussiness, and chest or

4

abdominal pain. Rhinorrhea (runny nose) is rare (<10%); this may be a useful distinguishing
feature from viral upper respiratory tract infections when faced with multiple cases requiring rapid
triage.
2,3
Phase 2 begins with persistent worsening fever and chest pain, subsequent dyspnea,
diaphoresis, and cyanosis, with rapid progression to shock and death within 24-36 hours.
Inhalational anthrax is complicated by meningitis in 50% of cases. There are no specific physical
exam findings.
Person-to-person spread of anthrax has not been reported, but standard precautions should be
observed and are considered to be sufficient.
3,4
Sporicidal agents (e.g., sodium hypochlorite, or
household bleach) may be used to decontaminate and disinfect invasive instruments and proximate
environment (e.g., body fluids spills, spores).
A case of cutaneous anthrax in a 7-month-old child during the recent outbreak in the United States
highlighted the additional features usually not seen in adults: fever, edema, renal failure,
disseminated intravascular coagulation (widespread miscroscopic clotting of small blood vessels),
and other hematologic abnormalities.
5

Plague
Aerosolization would be the likely method of release if used as a biological weapon. Yersinia
pestis is the causative agent. Natural spread to humans occurs via the bite of an infected flea.
Plague is extremely contagious and manifests three clinical syndromespneumonic (pneumonia),
bubonic (swollen lymphnodes), and septicemic (systemic infection).
After an incubation period of about two to fours days (range 1-6 days), pneumonic plague starts
with an abrupt onset of fever, chills, malaise, myalgias, nausea, vomiting, abdominal pain, diarrhea,
hemoptysis (cough blood), and cyanosis that rapidly progresses to respiratory failure and shock.
When naturally occurring plague manifests as the bubonic plague type, it is heralded by acute
febrile illness with tender, swollen lymph nodes (called buboes, usually found in the inguinal
region) with overlying skin redness.
Septicemic plague is similar to gram-negative sepsis (systemic infection caused by enteric, i.e.,
gastrointestinal, organisms). Patients present with high fever, chills, malaise, nausea, vomiting,
diarrhea, and hypotension, but progress to shock in the setting of thrombosis, necrosis, gangrene,
disseminated intravascular coagulopathy (DIC) and death, if untreated. Other findings on exam
include black necrotic extremities and proximal pupuric (blotchy purple) lesions.
6
All forms of plague can progress to the septicemic form, which can spread to any organ system.
As with most biological agents the early diagnosis requires a high index of suspicion. Large
numbers of previously healthy patients presenting with respiratory symptoms, fever, and coughing
up blood should raise ones suspicion.
Precautions include droplet isolation until plague pneumonia is excluded in suspected cases.
Isolation is recommended for patients for 72 hours while on antibiotics. Standard precautions are
appropriate for bubonic plague. Given that Yersinia pestis is susceptible to sunlight, heat,
disinfectants, and soap and water, decontamination is relatively easy.
6

BotulinumToxin
Clostridium botulinum is an anaerobic, spore-forming bacterium found in soil. It produces a very
potent neurotoxin (botulinum toxin) that is highly lethal if aerosolized (for instance, one gram of
botulinum toxin could kill nearly 1.5 million people). Botulism is the clinical syndrome of

5

intoxication with botulinum toxin. Three types of naturally occurring human botulinum are
infantile/intestinal (germinating bacteria elaborates toxin in the gut), food-borne (pre-formed toxin
in food), and wound (rare, but spores infect a wound and release toxin). Deliberate release of
botulinum toxin would likely occur via aerosol or contamination of food or water supplies.
Incubation period ranges from 6 hours to 10 days, usually 1 to 3 days. Children may present with
profoundly weak muscle tone, weak cry, poor feeding, lethargy, irritability, eyelid lag, and with
flaccid, symmetrical, descending, motor paralysis that progresses to profound respiratory failure
requiring intubation and mechanical ventilation. Sensory nervous system remains intact, but level
of consciousness may deteriorate as respiratory failure ensues.
The mainstay of therapy is supportive care, i.e., endotracheal intubation, mechanical ventilation.
Standard precautions should be instituted. Secondary spread from patient to healthcare worker is
unlikely. The toxin is sensitive to heat, sunlight, chlorine and soap and water. Treatment with
human-derived antitoxin is available for treatment of infant botulism.

Tularemia
Francisela tularensis is the causative agent. It is an aerobic, gram negative cocco-bacillus that
manifests when skin or mucous membranes contact the carcass or body fluids of an infected
animal. Other names are rabbit fever and deer fly fever.
There are seven clinical syndromes of tularemia, namely, pneumonic (pneumonia), typhoidal,
ulceroglandular (systemic symptoms with ulcerative lesion and lymphadenopathy), glandular
(lymphadenopathy and fever), oculoglandular (ocular symptoms with lymphadenopathy),
oropharyngeal (tonsillitis with lymphadenopathy), and septicemic (sepsis, plus any of the above).
As a bioweapon, this cocco-bacillus will likely be released as an aerosol, and the clinical syndrome
of typhoidal tularemia with pneumonia will predominate. The incubation period is about 3 to 5
days, but may range from 1 to 21 days. Signs and symptoms include an influenza-like febrile
illness with vomiting, diarrhea, headaches, cough, and substernal or pleural chest pain with
difficulty breathing and occasional productive bloody cough. Prophylaxis for healthcare providers
may not be necessary, as there is no reported human-to-human transmission. If prophylaxis is
necessary, as in direct aerosol exposure, doxyclyine is recommended. Observation of standard
precautions will suffice. Disinfectants or heat easily neutralizes the organism.

Viral Agents
Smallpox (Variola Major)
Smallpox is a virus whose incubation period is about two weeks, but ranges from 7 to 17 days.
Infection occurs via respiratory droplet and is highly contagious. Should a single case occur, it
would be an international public health emergency. Mortality is 30%. Clinical manifestations
include a prodromal phase of high fever, malaise, prostration, headache, and backache followed by
maculopapular rash on face, mouth, forearms, legs and trunk. Within 1-2 days, the rash evolves
from papular to vesicular to pustular (round, tense and deep pus), with coalescence to crust
formation approximately one week later. The lesions then separate and scab over. Although to the
untrained eye smallpox lesions may confused with chickenpox (varicella), it is distinguished by the
fact that smallpox rash progresses through different stages at the same rate and tends to concentrate
on the face, extremities, palms and soles (centrifugal, or center-fleeing, distribution). In contrast,

6

chickenpox lesions progress in clusters (lesions at different stages), concentrate on the trunk,,and
typically spare palms and soles (centripetal, or center-seeking, distribution). Diagnosis is made
clinically based on appearance of rash and symptoms. Confirmation of clinical diagnosis requires
sophisticated lab testing of the highly infectious vesicle fluid.
Smallpox is transmitted via contact with respiratory droplets, lesions, bedding or clothing.
Treatment is mainly supportive care. Isolation is recommended. Respiratory and contact
precautions should be instituted. Patients should be placed in negative pressure rooms and
quarantined till lesions are crusted over. Although it would be ideal for close contacts to be
quarantined for two weeks, it is not practical. Some authors have recommended a more pragmatic
approach of having close contacts of confirmed smallpox cases check their temperatures daily, and
if febrile (38 C) during the two week period of close contact, they should be quarantined at home
until lesions crust over or smallpox is ruled out.
Smallpox vaccination may prevent or, at least, attenuate major disease, if administered within 72
hours of smallpox exposure and may also provide up to five years protection, at minimum.
3,7

Smallpox vaccine has been associated with high rates of severe adverse reactions (encephalitis,
disseminated vaccinia, and death). There are no current approved antivirals.
Viral Hemorrhagic Fevers (VHF)
VHFs are caused by a family of RNA viruses and are transmitted to humans from animal reservoirs
or arthropod vectors. They comprise a diverse group of highly contagious illnesses that cause high
morbidity and mortality, and include Ebola, Marburg, Lassa fever, Venezuelan fever, hantavirus,
yellow fever, and Dengue fever. The incubation period is usually 5-10 days (range, 2-19 days). The
overall mortality is 20%, but may approach 100% for particular strains of these viruses. Signs and
symptoms range widely and include abrupt onset of fever, body aches, conjunctivitis, facial
flushing, prostration, petechiae, mucosal bleeding, vomiting, diarrhea, jaundice, hemorrhage, shock
and renal failure. The clinical picture is most helpful in diagnosis. Stool and nasal swabs may be
sent for viral culture. Sophisticated lab centers can test serum for the virus.
The mainstay of treatment is supportive care. Gentle fluid resuscitation with intravenous fluids and
intensive supportive care with invasive monitoring should be performed, as the ongoing pulmonary
capillary leak and bleeding disorder could worsen pulmonary edema and blood loss. Respiratory
and contact precautions with gloves, gown, mask and use of N-95 mask with eye protection will
reduce transmission. N-95 or higher respirators should be used for aerosol-generating procedures
(e.g., endotracheal intubation). Patients should be placed in respiratory isolation. Decontamination
is achieved with hypochlorite disinfectants.
Other Infections (Non-bioterrorism)
Avian Influenza/Pandemic Influenza
Identification of illness
The term epidemic is classically used to describe outbreaks of an infectious disease widespread
among a populations within, yet typically confined to, a specific geographic area. By contrast, the
term pandemic describes an infectious disease that more or less simultaneously afflicts large
populations in numerous geographic areas within a given region. In previous eras, epidemics
might be limited to individual population centers, i.e., cities. However, in the modern era, air travel
has the potential to convert local epidemics into worldwide pandemics in days to weeks.

7

Avian influenza A virus usually does not infect humans, but since 2003 more than 330 cases of
human infection due to the avian H5N1 influenza A virus have been reported, none of which have
as yet occurred in the U.S. Most cases were transmitted to humans from sick or dead poultry that
lived with or in close proximity to the infected humans. Ongoing spread in bird populations and
outbreaks of human illness are monitored worldwide. The clinical manifestations range from
conjunctivitis to influenza-like symptoms (fever, cough, sore throat, myalgias) to severe respiratory
illness. During the pandemic alert, the main epidemiologic exposure risks for human-to-human
transmission are international travel (e.g., visits to geographic areas affected by highly pathogenic
avian influenza A) and occupational exposure (e.g., handlers of infected poultry).
With ongoing genetic changes within strains of avian influenza viruses, there is the potential for
easier transmission between humans. It is at this point that an influenza pandemic might occur.
Currently the following criteria are suggested for identifying cases: Any suspected cases of human
infection with a novel influenza virus must first meet the criteria for influenza-like illness (ILI),
defined as temperature of >38C plus either sore throat or cough. Dyspnea should be considered as
an additional criterion. Therefore, the full clinical criteria are fever plus one of the following: sore
throat, cough, or dyspnea. However, in young children, the presentation may be more nonspecific
(sepsis-like picture), and might include additional symptoms such as diarrhea or neurologic
complications.
While cases of pandemic avian influenza have previously resulted in severe respiratory illness, the
next pandemic influenza virus may present with a different clinical syndrome. Updates of the
clinical criteria will be provided by the CDC at www.cdc.gov/flu.
The incubation period for seasonal influenza is 1-4 days, but may be different for pandemic
influenza, perhaps as long as 10 days. Precautions for symptomatic children during the pandemic
period will most likely be similar to influenza (droplet precautions), but may initially include
airborne and contact precautions. Definitive guidance will be provided following initial
epidemiologic investigations. The CDC gives detailed interim information on the use of face
masks and respirators during an influenza pandemic [see resource section below]. Antiviral
prophylaxis may be available. Development of a vaccine active against the next pandemic
influenza strain will be a high priority, but a vaccine may not be available early during a pandemic.
Infections Encountered After Natural disasters
Several recent disasters have demonstrated the increased occurrence of infectious diseases related
to changes in the environmental conditions such as lack of clean water, poor sanitary conditions
and crowding, and lack of access to medical care. During the first few days following a disaster,
one can expect injury and soft tissue infections, while gastroenteritis can occur up to 1 month after
a disaster.
1
Outbreaks of common pathogens which spread easily should be expected (e.g.
norovirus).
2
An additional concern is spread of multi-drug resistant bacteria, such as methicillin-
resistant staphylococcus aureus (MRSA).
3
In addition to standard precautions, contact precautions may be indicated when pathogens can be
transmitted by contact such as bacteria and viruses causing gastroenteritis or certain multi-drug
resistant bacteria. Alcohol-based hand hygiene products may be ineffective against norovirus. Hand
hygiene with soap and water is preferred for patients with diarrhea.

8

Other Medical Considerations
Respiratory problems may be exacerbated or triggered by wildfires, fires involving trash and
debris, or mold growing in damp buildings. Children with chronic or recurrent medical problems,
such as diabetes or asthma, may find that their conditions worsen due to stress and environmental
changes. Furthermore, post disaster conditions may make it difficult for families to seek medical
assistance for their children as promptly as they would under ordinary circumstances. Compliance
with medical instructions and follow-up care may be difficult as well. Therefore, children who
would normally be treated by a family physician may need to visit the emergency department or
urgent care center for necessary care, provided the hospital itself remains functional in the
aftermath of the disaster.
Widespread power outages can cause additional problems for children who require refrigerated
medications, such as those with diabetes. Children with special health care needs who depend on
electronic support devices may also be affected after emergency supplies and batteries give out
(discussed separately in chapter on special needs).


9

Table 1. Primary Biological Agents

Disease Etiology Clinical Findings
1
Incubatio
n Period
Diagnostic
Samples
Diagnostic
Tests
Isolation
Precautions
Initial Treatment
2
Prophylaxis
Anthrax Bacillus
anthracis
Inhalational: febrile
prodrome with
rapid progression to
mediastinal
lymphadenitis,
medastinitis
(chest xray: +/-
infiltrates,
widened mediastinum,
pleural effusions);
sepsis; shock;
meningitis.
Cutaneous: papule
progressing to
vesicle, to ulcer, then
to depressed black
eschar, with marked
edema
1-5 days
(up to 6
wks ?)
Blood
CSF
Pleural fluid

Skin biopsy
Culture
Gramstain
ELISA
PCR

Immunohisto-
chemical assay
Standard
Ciprofloxacin: 10-15 mg/kg (max 400 mg)
IV q 12 h , or
Doxycycline: 2.2mg/kg ( max 100mg) IV q
12h
2

Ciprofloxacin: 10-15 mg/kg
(max 500 mg) PO
q12h X 60 days, or
Doxycycline: 2.5 mg/kg (max
100 mg) PO q12h X 60 days
3
Plague Yersinia pestis Febrile prodrome with
fulminant pneumonia
with bloody sputum,
sepsis, DIC
2-3 days Blood
Sputum
Lymph node
aspirate
Culture
Gramor Wright-
Giemsa stain
ELISA, IFA
Ag-ELISA

Pneumonic: droplet
until patient treated
for 3 days
Gentamicin: 2.5 mg/kg IV q 8h
4
or
Doxycycline: 2.2 mg/kg IV ( max 100 mg)
IV q 12h, or
Ciprofloxacin 15 mg/kg ( max 500mg) IV
q12h, or
Chloramphenicol 25mg/kg (max 1 g ) q 6h
Doxycycline 2.2 mg/kg (max
100 mg) PO q12h X 7d, or
Ciprofloxacin 20 mg/kg ( max
500 mg) PO q12h X 7d, or
Chloramphenicol 25 mg/kg (
max 1 g) PO q6h X 7 days
Adapted fromHenretig FM, Cieslak TJ , Eitzen EM J r. Biological and chemical terrorism. J Pediatr 2002; 141:311-326


10

Disease Etiology Clinical Findings
1
Incubatio
n Period
Diagnostic
Samples
Diagnostic
Tests
Isolation
Precautions
Initial Treatment
2
Prophylaxis
Smallpox Variola virus Febrile prodrome
Synchronous
vesicopustular
eruption,
predominately on face
and extremities
7-17 days Pharyngeal
swab
Scab material
ELISA, PCR
Virus isolation
Airborne, droplet,
contact
Supportive care
Vaccination within 4 days
(consider Vaccinia
immunoglobulin: 0.6
mL/kg IM within 3 days of
exposure for vaccine
complications,
immunocompromised persons)

Tularemia Francisiella
tularensis
Pneumonic: abrupt
onset fever, fulminant
pneumonia ( chest
xray: prominent hilar
adenopathy)
Typhoidal: fever,
malaise, abdominal
pain
2-10 days Blood,
sputum,
Serum

Tissue
Culture
5
Serology:
agglutination

EM
Standard Gentamicin 2.5 mg/kg IV q8h
5
, or
Doxycycline 2.2 mg/kg ( max 100 mg) IV
q12h, or
Ciprofloxacin 15 mg/kg ( max 500 mg) IV
q12h, or
Chloramphenicol 15 mg/kg ( max 1 g) IV
q6h
Doxycycline 2.2 mg/kg
( max 100 mg) PO q12h, or
Ciprofloxacin 15 mg/kg
(max 500 mg) PO q12h
Botulism Clostridium
botulinum
toxin
Afebrile
Descending flaccid
paralysis
Cranial nerve palsies
Sensation and
mentation intact
1-5 days Nasal swab Mouse bioassay,
Ag-ELISA
Standard CDC trivalent antitoxin (serotypes A, B, E),
1 vial (10 mL) IV
DOD heptavalent antitoxin (serotypes A-G)
(IND)
California Dept of Health immunoglobulin
(IND)
None
Viral
hemor-
rhagic
fevers
Arenaviradae
(e.g. Lassa
fever)
Filoviradae
( Ebola,
Marburg)
Febrile prodrome;
shock, purpura,
bleeding diathesis
4-21 days Serum, blood Viral isolation
Ag-ELISA
RT-PCR
Serology:Ab-
ELISA
Contact, droplet;
consider airborne if
massive
hemorrhage
Supportive care
Ribavirin ( arenaviruses)
30mg/kg IV initially
15 mg/kg IV q6h X 4 days
7.5 mg/kg IV q8h X 6 days
None
1
Syndrome expected after aerosol exposure.
2
CDC recommended one or two additional antibiotics for inhalational anthrax in Fall, 2001 outbreak: rifampin, vancomycin, penicillin or ampicillin,
clindamycin, imipenem, or clarithromycin. Recommendations in future outbeaks may evolve rapidly, and frequent consultation with local health departments and CDC (1-770-488-7100;
www.bt.cdc.gov) is encouraged.
3
Amoxicillin 80 mg/kg/day divided q8h can be substituted if strain proves susceptible.
4
Streptomycin 15 mg/kg IM q12h may be substituted if available.
5
Laboratory
must be notified that tularemia is suspected.

11

Tables / Figures
Table 1 - overview
Fact Sheets
y Anthrax http://emergency.cdc.gov/agent/anthrax/basics/factsheets.asp
y Difference between flu and anthrax symptoms
http://www.fda.gov/oc/bioterrorism/symptoms.html
y Plague http://www.cdc.gov/ncidod/dvbid/plague/info.htm
y Tularemia http://jama.ama-assn.org/cgi/content/full/285/21/2763
y Smallpox poster http://emergency.cdc.gov/agent/smallpox/overview/disease-facts.asp
y Influenza protection guide http://www.cdc.gov/flu/avian/professional/protect-guid.htm
Web-based Material
CDC - general and specific information on bioterrorism:
http://www.bt.cdc.gov/bioterrorism/
http://www.bt.cdc.gov/firsthours/bioterrorism.asp
U.S. Army Medical Research Institute of Infectious Diseases:
http://www.usamriid.army.mil/education/bluebook.html
CDC - smallpox tools:
http://www.bt.cdc.gov/agent/smallpox/diagnosis/
CDC - viral hemorrhagic fevers manual:
http://www.cdc.gov/ncidod/dvrd/spb/mnpages/vhfmanual.htm
CDC - What You Should Know about Using Facemasks and Respirators during a Flu Pandemic:
http://www.cdc.gov/Features/MasksRespirators/
PandemicFlu.gov - Emergency Medical Services and Non-Emergent (Medical) Transport
Organizations Pandemic Influenza Planning Checklist:
http://www.pandemicflu.gov/plan/healthcare/emgncymedical.html
The Association for Infection Control Practitioners guidelines for infection control and
precautions:
http://www.apic.org


12

References
1. Anonymous. Chemical-biological terrorism and its impact on children: a subject review.
American Academy of Pediatrics. Committee on Environmental Health and Committee on
Infectious Diseases. Pediatrics 2000;105(3 Pt 1):662-70.
2. Bell DM, Kozarsky PE, Stephens DS. Clinical issues in the prophylaxis, diagnosis, and
treatment of anthrax. Emerging Infectious Diseases 2002;8(2):222-5.
3. Cherry CL, Kainer MA, Ruff TA. Biological weapons preparedness: the role of physicians.[see
comment]. Internal Medicine J ournal 2003;33(5-6):242-53.
4. Dixon TC, Meselson M, Guillemin J , Hanna PC. Anthrax.[see comment]. New England
J ournal of Medicine 1999;341(11):815-26.
5. Tunik M, Treiber M, Kim J , Cooper A, Foltin G eds. TRIPP Teaching Resource for Instructors
NY 2007.
6. Military Blue Book. http://usamriid.detrick.army.mil/education/bluebookpdf/USAMRIID
7. Breman J G, Henderson DA. Diagnosis and management of smallpox.[see comment]. New
England J ournal of Medicine 2002;346(17):1300-8.

15: CSHCN Pediatric Disaster Preparedness

1

Chapter 15: Prehospital and EMS Systems Care for Children
with Special Health Care Needs in Disasters
Michael Tunik MD
Introduction
There are approximately 80 million children in the USA. 12 million have special health care
needs
1
. Prehospital providers will likely encounter children with special health care needs
(CSHCN), given advances in medical care and improvements in technology allowing these
children to be supported in a home setting.
Problems caused by a disaster, including access to shelter, food, water and supervision, are only the
beginning for children with special health care needs. They are also dependent on medications,
specialized equipment (which frequently requires a source of electricity to operate), and the
knowledge and skill of their family or health professional caregivers to keep them alive.
Given the increased vulnerability of CSHCN, and the problems identified in organizing and
providing care for vulnerable populations in recent disasters (eg. hurricane Katrina)
2
, only
preparation at all levels will mitigate or prevent CSHCN from becoming unstable, or dying from
the chaos of a disaster situation.
Definition of CSHCN (Children with special health care needs)
The following definition of CSHCN was developed by an EMSC task force in 1997.
Those who have or are at increased risk for a chronic physical, developmental, behavioral, or
emotional condition and who also require health and related services of a type or amount beyond
that required by children generally.
This broad definition includes approximately 15 children in the USA. Clearly this large number of
CSHCN creates a great challenge in disaster preparation and care during an event.
Overview of CSHCN and TAC (Technologically Assisted Children)
Children with special health care needs encompass a broad spectrum of disease entities. These can
be classified as problems in the following areas: airway, pulmonary, cardiovascular, neurologic,
hematology/oncology, immunology, endocrine, genetic birth defects, traumatically induced
problems, and musculoskeletal injuries (adapted from SCOPE
3,4,5
program).
Medical Conditions
y Airway Pulmonary
y Asthma
y Bronchopulmonary Dysplasia (BPD)
y Cystic Fibrosis
y Tracheomalacia

2

y Tracheal Stenosis
y Tracheal Atresia
y Babies with Apparent Life Threatening Event
y Apnea
Cardiac
y Complex Congenital Cardiac Defects
y Acyanotic Defects
y Cyanotic Defects
Down Syndrome other congenital birth problems
Traumatically Disabled Children
Neurological Problems
y Epilepsy
y Hydrocephalus
y Mental Retardation
y Spina Bifida
y Cerebral Palsy
Hematology/Oncology
y Sickle Cell Disease
y Cancer
Immunologic
y HIV and AIDS
Endocrine
Musculoskeletal
y Children who have had meningitis
y Birth Defects
y Genetic Disorders
y Osteogenesis Imperfecta (OI or "Brittle Bone Disease")
Children with these health problems have unique health care needs that may include medications
and supportive health care equipment. Examples include: a child with diabetes who is dependant

3

on insulin, insulin syringes, and blood sugar monitoring devices; a child who has a tracheostomy,
who is dependent on a home ventilator. Examples of specialized medical technology for CSHCN
follow.
3,4
Technology needed to support CSHCN
y Tracheostomy and Tracheostomy tubes
y Home ventilators
y Bi Level Positive Airway Pressure (BiPAP)
y Central IV Catheters
y Internal Pacemakers Defibrillators
y Feeding Catheters / Gastrostomy Tubes
y Colostomies
y CSF Shunts (Cerebral Spinal Fluid Shunts)
y Vagal Nerve Stimulators
y Children with special health care needs have unique health care challenges on a day-to-day
basis. They are more dependent on their parents, home health care professional staff, teachers
and school nurses, and their physician providers of ongoing medical care than other children.
Role of Family Members and the Importance of Avoiding Caregiver Child
Separation
y CSHCN should not be separated from family members, as this places their lives at risk. The
families of CSHCN play a critical role in the ongoing assessment and care of their children.
They are familiar with what is normal for their children, and are able to provide for their
typical health care needs. In a disaster, separation of these children from their regular
caregivers creates a high risk for a stable child with special health care needs to become
unstable, simply due to this separation.
Education of Prehospital Providers in Caring for CSHCN
Prehospital providers (PHP) will encounter children with special health care needs as the numbers
of these children at home or in school increase. To educate PHP to be able to recognize and care
for many of the medical problems these children have, and to understand the function of the special
medical devices that support their vital functions is beyond the scope of this chapter. There are
excellent educational resources, originally developed through EMSC grants, available to educate
PHP is some of the more common medical problems and technologies. These include the SCOPE
program (Special Children's Outreach and Prehospital Education) available through the EMSC
NRC and NEDARC websites
3
, and student manual published by J ones and Bartlett
5
, as well as
chapters in the EMT and Paramedic TRIPP (Teaching Resource for Prehospital Providers), created
by CPEM
6,7
. These educational courses and resources are a good starting point, but are insufficient
to cover all the possible medical problems from which CSHCN may suffer.

4

Emergency Information Form
The AAP and ACEP have developed an Emergency Information Form (EIF)
8,9
. This form should
be completed by the childs physician, and family members / caregivers. The EIF contains a
summary of the childs and parents primary language, diagnoses, normal vital signs, appearance
and behaviors for CSHCN. It also contains information on current medications, dosing, allergies,
as well as settings for special medical equipment (eg. Ventilator settings). Other information
includes contact information for the childs family members, and physician(s). This form should be
completed and copies available with the child at all times, in the school, physicians office, day care
and other places the child spends time. EMS for Children grant demonstration projects have created
a secure web site to allow access to the CSHCN EIF from any web enable location. This has
demonstrated the viability of accessing this critical information via the internet. EMS agencies can
provide a valuable service, by identifying CSHCN in their region, insuring these children have an
EIF form completed, and targeting these children and families with focused resources during a
disaster.
Emergency Preparedness Checklist for families of CSHCN
Disasters create situations that place normal, healthy children and adults at great risk. Preparation
and planning for the eventuality of a disaster is recommended for all individuals. These
recommended preparations have been widely disseminated and include decisions to shelter in place
or to evacuate from the home. In case of evacuation, preparation should include a go pack, which
contains necessities such as water, light source, radio, important documents, and medications for
several days. CSHCN have increased needs and therefore require increased planning and
preparation. Public health agencies, and EMS agencies may provide families of CSHCN with
disaster evacuation plans. One example of a disaster plan checklist for CSHCN can be found
below, and is available on the EMSC NRC website
10
. Another example can be found on the web in
English and Spanish (Emergency and Disaster Planning for CSHCN Department of State Health
Services, Texas)
11
.
Disaster Preparedness Checklist for CSHCN
y Develop a plan that describes your childs daily care routines.
y Complete an emergency information form or health care summary that includes the names and
contact information for your childs primary health care provider and specialists.
y Have on hand a 2-week supply of medications (prescription and non-prescription).
y Store a 2-week supply of equipment and supplies (such as tracheotomy tubes, nasal cannulas,
suction catheters, diapers, dressing materials, feeding tube bags and tubing, etc.).
y Store a 2-week supply of food, including foods for special diets.
y Purchase battery back-up or a generator for any equipment that requires electricity.
y Identify a pre-planned location to shelter your child during a disaster.
y Store extra supplies to help care for your child should a disaster occur while he/she is at school
or with a childcare provider.

5

y Notify neighbors and emergency medical services providers that you have a child with special
health care needs and may need additional assistance during a disaster.
National, Regional and Local planning to support CSHCN
Children with special health care needs require special focus and efforts at many levels before and
during a disaster to ensure their unique needs will be met. They are clearly more vulnerable, and
have a greater need for specialized attention including: medications, equipment, electricity to
charge and run special equipment, and expert medical care (provided by family, physicians and
hospitals). This planning and preparation must not only occur within the family, and medical
home, but at community, regional, state and federal levels to be effective.
y A national consensus conference, held in 2003, focused on the needs of children during
disasters, and made recommendations for CSHCN.
12

Recommendations for CSHCN froma National Consensus Conference
y Incorporate considerations for CSHCN in all disaster and terrorism planning at the national,
state, and regional/local levels (eg, water, dialysis, medication).
y Identify all CSHCN to ensure each child has a medical home, adequate medical coverage, and
support mechanisms before a disaster or terrorist event.
y Ensure that all CSHCN are considered in emergency preparedness plans of the Department of
Homeland Security.
y Develop mechanisms for identification of and community planning for children with increased
vulnerability in disasters, including CHSCN and their families, at the national, state, and
regional/local levels.
y Provide federal, state, and local government funding for emergency preparedness planning and
implementation of services to meet the needs of CSHCN. This funding must be timely,
immediately accessible, and of sufficient duration.
y Explore, within government agencies, development of non-traditional, community-based
support systems for CSHCN and their families (eg, independent living centers, faith-based
groups, parent-based groups).
y Mandate continuity of operations and mutual aid planning among community health facilities
to address disaster and terrorist events for pediatric populations, including CSHCN
y Unfortunately the vast majority of the recommendations from this national consensus
conference have gone unheeded. The consequences of not following recommendations from
this consensus conference for CSHCN needs have been tragic. Children with special health
care needs suffered unnecessarily during and after hurricane Katrina struck the gulf coast.
Children who required electricity to power portable ventilators and asthma nebulizers suffered
due to lack of access to a power source. Some CSHCN were evacuated in family vehicles, due
to a lack of other evacuation methods. Besides no power for medical devices, some of these
children ran out of medication.
y This is not the only disaster in which lack of electrical power has caused individuals with
special health care needs to suffer. The failure of the US eastern seaboard electrical power grid

6

in August 200, created an unplanned increased demand for EMS runs. The majority were due
to respiratory device failure (mechanical ventilators, positive pressure breathing assist devices,
nebulizers, and oxygen compressors). The failure of the equipment was due to need for
electricity to power these medical devices.
13

Problems Identified in the Wake of Hurricane Katrina
2
Inadequate Disaster Planning at the Federal, State and Local Government Levels created a lack of
support and planning for:
y Care and evacuation of hospitalized children, infants, and premature newborns
y Structurally intact hospitals and other care facilities not supplied with adequate power, water,
food, supplies, and security
y Evacuation of children with their parents, families, or caretakers
y Reunification of children with their parents/caretakers (especially infants and preverbal
toddlers)
y Culturally and developmentally appropriate critical incident mental health interventions
y Increased risk of morbidity and mortality for CSHCN during and after the disaster
Only pre planning and focused action before and during a disaster can prevent CSHCN from
suffering worsening illness or death due to lack of critical medical resources. The pre planning
needs to occur at all levels to be effective. The levels of care that require special preparation for
these children include:
y Family
y Physician / Medical Home
y Community
y EMS system
y Shelter care
y Hospital Local and Regional Medical Care
Recommendations for Disaster Planning for CSHCN
Families of CSHCN
y Complete a Disaster Preparedness Checklist
y Stock sufficient medications and equipment for 2 weeks of care
y Complete EIF, keep 1 with the child, provide 1 to regional EMS agency
y Inform the regional EMS agency of the presence of a child with special needs
y Identify specialized local / regional medical care in case of a disaster
y Identify numbers to call for help with medical care, evacuation of CSHCN

7

EMS Providers
y Train Prehospital providers to care for common emergencies in CSHCN
y Request the CSHCN patients EIF
y Locate Special Equipment, or Medications for CSHCN (Go Pack, Hospital)
y Use specialized triage and transport methods to transport CSHCN to appropriate Hospitals or
Shelters equipped to handle CSHCN / TAC
EMS Agencies
y Work with local hospitals and community groups
y Identify CSHCN, request EIF forms for these children
y Assist families in locating and completing the EIF forms
y Identify local / regional shelters that have special provisions for CSHCN
y Identify local / regional hospitals that have special provisions for CSHCN
y Incorporate specialized triage for CSHCN to shelters / hospitals
y Provide for specialized transport for CSHCN
Federal, State and Regional Disaster and EMS Systems
y Incorporate considerations for CSHCN in all disaster planning
y Develop triage plans for all CSHCN
y Develop transport arrangements for CSHCN
y Prepare special shelters for CSHCN
y Prepare extra hospital / medical resources for CSHCN
y Include access to electricity for wheelchairs, ventilators other special equipment
y Identify all CSHCN
y Ensure each CSHCN has
y a medical home
y adequate medical coverage
y support mechanisms before a disaster or terrorist event
y Prepare for regional evacuation of CSHCN including those in hospital settings, when regional
disasters (eg. Hurricane Katrina) cause the closure of local hospitals
References
1. US Census web site http://www.census.gov/popest/national/asrh/NC-EST2007-sa.html
accessed 6/12/08

8

2. Dolan MA, Krug SE. Pediatric Disaster Preparedness in the Wake of Katrina: Lessons to be
Learned. Clin Ped Emerg Med 2006; 7:59-66.
3. SCOPE program (Special Children's Outreach and Prehospital Education) EMSC NRC
WEBSITE http://bolivia.hrsa.gov/emsc/SearchpubID.aspx?id=EP001045&from=results;
NEDARC Website http://www.nedarc.org/nedarc/emscProducts/EP001045.zip
4. Singh T, Wright J , Adirim T. Children with special health care needs: a template for
prehospital protocol development. Prehosp Emerg Care 2003;7:336251.
5. Adirim TA, Smith E, Singh T. Special childrens outreach prehospital education (SCOPE). 1st
ed. Sudbury (Mass): J ones and Bartlett; 2006. http://www.jbpub.com/catalog/0763724688/
accessed 6/12/08
6. Tunik M, Treiber M, Kim J , Cooper A, Foltin G eds. TRIPP Teaching Resource for Instructors
NY 2007.
7. Foltin G, Tunik M, Cooper C, Markenson D, Treiber M, Skomorofsky A eds. Paramedic
TRIPP, (Teaching Resource for Instructors in Pre-hospital Pediatrics) Center for Pediatric
Emergency Medicine, New York, NY April 2002.
8. Emergency Information Form http://www.aap.org/advocacy/eif.doc Accessed 6/11/08
9. Committee on Pediatric Emergency Medicine, American Academy of Pediatrics. Emergency
preparedness for children with special health care needs. Pediatrics 1999;104:e53.
10. Disaster Preparedness Planning for Children & Youth with Special Health Care Needs. EMSC
National Resource Center Website
http://bolivia.hrsa.gov/emsc/Downloads/DisasterPrepCSHCN/DisasterPreparednessforCSHCN
.htm accessed 6/12/08
11. Emergency and Disaster Planning for CSHCN (Checklist) Texas Department of State Health
Services http://www.dshs.state.tx.us/CSHCN/pdf/emer_plan.pdf accessed 6/12/08
12. Pediatric Preparedness for Disasters and Terrorism: A National Consensus Conference.
Columbia University Mailman School of Public Health 2003.
http://www.bt.cdc.gov/children/pdf/working/execsumm03.pdf Accessed 6/12/08
13. Prezant DJ . Clair J . Belyaev S, et al. Effects of the August 2003 blackout on the New York
City healthcare delivery system: a lesson for disaster preparedness. Critical Care Medicine
2005; 33(1 Suppl):S96-101.
Appendix: Equipment Pediatric Disaster Preparedness

1

APPENDIX
Michael G. Tunik, MD
Equipment for Care of Pediatric Patients in the Prehospital
Setting during Disasters
Equipment for care of children in the prehospital setting during disasters includes basic life
support and advanced life support ambulance equipment. National recommendations for BLS and
ALS ambulance equipment have been available for more than 10 years. The Committee on
Ambulance Equipment and Supplies of the National EMSC Resource Alliance was convened to
develop a list of essential and recommended pediatric equipment that should be carried on all
ambulances providing basic and advanced life support services. The committee included
representatives from the following organizations:
American Academy of Pediatrics American Ambulance Association, American College
of Emergency Physicians, American College of Surgeons, Bureau of Maternal and Child
Health (Health Resources and Services Administration, US Department of Health and
Human Services), Emergency Nurses Association, International Association of Fire
Chiefs, International Association of Fire Fighters, National Association of State EMS
Organizations, National Association of EMS Physicians, National Association of EMTs
and Paramedics, National Association of State Medical Directors, National EMSC
Resource Alliance, National Highway Traffic Safety Administration
The groups consensus report was published in Pediatric Emergency Care (Guidelines for
pediatric equipment and supplies for basic and advanced life support ambulances.
1996;12(6):452453).
The best way to prepare for children during disasters is to start by preparing for childrens
emergency care needs. Therefore the recommended ambulance equipment listed that follows
should be part of all EMS systems ambulance equipment.
There are many circumstances in which additional equipment or medications are needed for
children during disasters. Some examples, from other chapters in this resource include: pediatric
dosing of atropine and 2 PAM in auto-injector kits used for nerve agent intoxications; special
decontamination approaches for children - devices to keep infants secure on a stretcher during
decontamination shower (plastic basket with openings to allow water drainage); special shelter
needs (food, water, caregivers) for infants and young children.
Rather than repeat these additional equipment, supplies and medications here, we recommend that
they be located in their specific chapters.

2

BASIC LIFE SUPPORT AMBULANCE EQUIPMENT
Essential

Stethoscope, BP measurement
Stethoscope
BP cuffs (infant, child, and adult)
Length-based resuscitation tape or drug/dose chart

Oxygen, Suction, And Ventilation:
Oxygen Tank
Regulator
Oropharyngeal airways: infant, child, and adult (size 00 5)
Simple face masks (infant, child, and adult sizes)
Non-Rebreather masks (child, and adult sizes)
Nebulizer (with mask or T-piece) *
Bag valve device - self inflating (sized for neonates, infants, and
children) **
Masks for bag valve device (sized for neonates, infants,
children, and adults)
Portable suction unit with a regulator
Suction catheters (sizes 6F 14F) and tonsil-tip
Bulb syringe

Monitors / Defibrillator:
Automatic External Defibrillator with pediatric & adult pads***
Pulse oximeter ****


3

Immobilization:
Cervical immobilization collar (infant, child, adolescent & adult)
Backboard
Padding (blankets, towels, etc.)
Straps/cravats
KED/short board
Extremity splints (include pediatric sizes)

Additional Equipment:
Obstetric pack
Thermal blanket +
Water-soluble lubricant


4

Desirable

Desirable Equipment Set:
Infant car seat
Nasopharyngeal airways (18F 34F, or 4.5-8.5 mm) ++
Glasgow Coma Scale reference
Pediatric Trauma Score reference
Small stuffed toy
Electronic Thermometer (ear, forehead, rectal, armpit, oral)
Length Based Resuscitation Tape
Nasogastric and Orogastric tubes
20 mL syringe
Computer with CD-ROM (at base station)
EMS for Children training disks (at base station)

*The use of nebulized medications is based on regional protocols
**The ventilation bag should be self-inflating, with an oxygen reservoir and no pop-off valve.
The bag for a child has a reservoir of 450 mL; an adult bag has a reservoir of at least 1000 mL.
***The list was developed prior to the common use of Automatic External Defibrillators, which
are recommended by the AAP and carried by many BLS providers at an EMT-D level of training.
**** Pulse oximetry came into use after this article was published. If available, it can be a
valuable adjunct in determining the severity of respiratory compromise in children.
+A thermal blanket may help minimize heat loss, reducing the severity of hypothermia, a
potentially serious complication, particularly in infants and young children. Its composition
depends on local availability, regional protocols, and procedures. Possibilities include Mylar,
standard cotton or acrylic, or aluminum foil for young infants.
++If an oropharyngeal airway cannot or should not be used in a patient with respiratory
compromise due to upper airway obstruction, a nasopharyngeal airway may be substituted.
Providers must be trained in proper insertion techniques as well as indications and
contraindications for the device.


5

ADVANCED LIFE SUPPORT AMBULANCE EQUIPMENT

Stethoscope, BP, and Length-based resuscitation tape:
Stethoscope
BP cuffs (infant, child, and adult)
Length-based resuscitation tape or drug/dose chart

Oxygen, Suction, And Ventilation:
Oxygen Tank
Regulator
Oropharyngeal airways: infant, child, and adult (size 00 5)
Simple face masks (infant, child, and adult sizes)
Non-Rebreather masks (child, and adult sizes)
Nebulizer (with mask or T-piece)
Bag valve device - self inflating (sized for neonates, infants, and
children)
Masks for bag valve device (sized for neonates, infants,
children, and adults)
Portable suction unit with a regulator
Suction catheters (sizes 6F 14F) and tonsil-tip
Bulb syringe


6

Pediatric Advanced Airway:
Laryngoscope handle (adult and pediatric) with spare batteries,
light bulbs
Pediatric laryngoscope blades: Straight (Miller): 0,1,2 and
Curved (Macintosh): 2,3,4
Endotracheal tubes (sizes 2.5 6.0 uncuffed, 6.0 8.0 cuffed)
Stylettes for endotracheal tubes (2 sizes, 6F and 14F)
McGill forceps (pediatric and adult sizes)
Nasogastric / Orogastric tubes (8F 16F)
Meconium aspirator
End-tidal CO
2
detector
Eye protection

Monitors / Defibrillator:
Transport monitor
Defibrillator with pediatric and adult paddles
Monitoring electrodes in pediatric and adult sizes
Conductive medium
Pulse oximeter


7

Vascular Access:
IV catheters (16 - 24 gauge)
Intraosseous needles
Straight needles: sizes 20 to 25 gauge
Heparin or Saline lock
IV tubing
Venous Constricting Band
Alcohol swabs
Gloves
Arm boards in appropriate sizes
2" 2" dry sterile gauze pads
Adhesive tape
Transparent, adhesive dressing
Povidone-iodine prep pads
1.0, 3.0, and 5.0mL syringes
Isotonic fluid (0.9NS or LR)


8

Resuscitation drugs and IV fluids (based on local regional
protocols):
(Note: some drugs may fill more than one category, e.g.
epinephrine)
Resuscitation meds:
Epinephrine, atropine, lidocaine, sodium bicarbonate,
amiodarone, dopamine, dobutamine, calcium chloride,
magnesium sulfate, procainamide
Respiratory meds:
Albuterol, metaproterenol, terbutaline, ipratropium bromide,
methylprednisolone
Antihistamine:
Diphenhydramine
Anticonvulsants:
Diazepam, lorazepam, midazolam
Pain/sedation:
Morphine sulfate, nitrous oxide, fentanyl, thiopental, ketamine,
etomidate
Paralytics:
Succinylcholine, rocuronium, vecuronium, pancuronium
Poisoning/OD:
Activated Charcoal, naloxone, flumazenil
Endocrine:
Glucose, Glucagon
Intravenous fluids:
Normal Saline, Ringers Lactate


9

Immobilization:
Cervical immobilization collar (infant, child, adolescent & adult)
Backboard
Padding (blankets, towels, etc.)
Straps/cravats
KED/short board
Extremity splints (include pediatric sizes)

Additional Equipment:
Obstetric pack
Thermal blanket
Water-soluble lubricant

Desirable Equipment Set:
Infant car seat
Nasopharyngeal airway set (18F 34F, or 4.5-8.5 mm)
Glasgow Coma Scale reference
Pediatric Trauma Score reference
Small stuffed toy
Blood glucose analysis system
Umbilical vein catheter (5F) and umbilical tape

Computer with CD-ROM (at base station)
EMS for Children training disks (at base station)

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