Office Preparedness for Small- and Large-Scale Emergencies

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Office Preparedness for Small- and Large-Scale
Emergencies

• Sarita Chung MD
• Center for Biopreparedness
• The Division of Emergency Medicine
• Childrens Hospital Boston

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DISCLOSURE STATEMENT

• Sarita Chung have nothing to disclose.

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Outline

• Single Office Emergencies
• Office Planning for Disasters
• Volunteering
• Syndromic Surveillance
• Terrorism
• Natural Disasters
• The Pediatricians Role during disasters
• Mental Health

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Case Sick-Appearing Child

• 6 month old with trouble breathing
• Mom comes to the office without appointment
• Trouble sleeping last night, this AM looked pale
• Holding infant who looks grey with grunting with
  high pitched sound and has nasal flaring

How often does this happen in practice?
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Single Office Emergency

• Frequency of Emergencies
• Average median is 24 emergencies/year
• Range Pediatric offices reporting
• 1 - 20 emergencies/month
• Rural region Retrospective and Prospectively
• average 0.8 emergencies/office/year
• Flores G Weinstock D Arch Pediatr Adolesc Med
  1996 150249-256.
• Heath BW, et al. Pediatrics 20001061391-1396.

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Types of Emergency

• Severe Respiratory Distress
• Seizure
• Obstructed Airway
• Shock (Hypovolemia and Anaphylaxis)
• Cardiac Arrest
• Severe Trauma

Altieri, et al. Pediatrics. 199085 710-714
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Types of Emergencies

• Seen in practice over the last year
• Meningitis
• Severe Asthma
• Severe Dehydration
• Schweich et al. Pediatrics. 199188223-229

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66
58

• Ongoing seizure 45
• Closed Head Trauma 40
• Epiglottis 30
• Anaphylaxis 14
• Cardiopulmonary Arrest 6

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Case Sick-Appearing Child (cont.)

• 6 month old with trouble breathing
• Mom is at the front desk asking for the
  appointment
• Baby is starting to have some blueness around the
  lips and continues to make a high pitch sound
  with every breath

Will your staff recognize critically ill patients?
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Training

• Basic Life Support (BLS)
• 27-49 of eligible staff reported certification
• Pediatric Advance Life Support (PALS)
• 17-26 of eligible staff reported certification
• Advanced Cardiac Life Support (ACLS)
• 5-12 of eligible staff reported certification
• Advanced Pediatric Life Support (APLS)
• 58 trained in ACLS or APLS

Altieri, et al. Pediatrics. 199085 710-714 Heath
BW, et al. Pediatrics 20001061391-1396. Schweich
et al. Pediatrics. 199188223-229
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Case Sick-Appearing Child (cont.)

• 6 month old with trouble breathing
• Child is quickly taken to an exam room
• MD is called in to evaluate
• RR 70 O2 sat 75
• PE notable for ill appearing mottled infant with
  stridor, retractions.

What type of equipment and medications do you
have in your office to stabilize this child?
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Resuscitation Equipment Airway and Breathing

• Essential
• Portable oxygen tank with flowmeter
• Bag Mask Ventilator (child, adult)
• Nonrebreather masks (child adult)
• Suction Device with different catheters sizes
• Pulse oximetry
• Nebulizer
• Recommended but optional
• Oropharyngeal or Nasopharyngeal airways
• Laryngoscope and full set of blades
• Endotracheal tube and stylets

Textbook of Pediatric Advanced Life Support
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Resuscitation Equipment Circulation

• Essential
• Blood pressure cuffs
• Sphygmomanometer/ noninvasive BP monitor
• Portable ECG monitor/Defibrillator
• Highly Recommended
• Intravenous (IV) catheters and or butterflies
• Ancillary IV equipment (fluid administration
  sets, antiseptic materials, etc.)
• Intraosseous Needles

Textbook of Pediatric Advanced Life Support
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Resuscitation Medication

• Epinephrine
• Atropine
• Albuterol
• Racemic Epinephrine
• Diphenhydramine
• Activated Charcoal
• Ceftriaxone

• Naloxone
• Glucose
• Antiseizure Diazepam, Phenobarbital, Lorazepam,
  Fosphenytoin
• Sodium Bicarbonate
• Fluids Normal saline, Dextrose containing fluids

Textbook of Pediatric Advanced Life Support
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Case Sick-Appearing Child (cont.)

• EMS called
• Patient given Racemic epi nebulizer
• IV established Steriods and NS bolus given
• Sent to a local Emergency Department
• Given additional nebs. Persistent respiratory
  distress. Intubated
• Transferred to ICU.
• Discharged after one week.

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How do we prepare?

• Development of emergency pediatric protocols for
  the office
• Mock codes in the office (include EMS agencies)
• Resulted in development of written office
  protocols and additional BLS/PALS/ACLS training
• Improved practitioner confidence and decrease
  anxiety
• Systematic Review

Bordley WC, et al. Pediatrics 2003291-295. Toback
SL, et al. PEC 200622415-422.
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Disasters

• Event that overwhelms local capacity
  necessitating a request for external assistance
  and causes great damage, destruction and human
  suffering
• Natural or Man-Made
• All Hazards Approach

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Planning Geographical Assessment

• Regional Risks floods, earthquakes, tornados
• Historical significance
• Potentially Hazardous Infrastructure
• Chemical Plants
• Nuclear Plants
• Trains

Chlorine Gas Spill South Carolina, 2005
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Planning Prepare your family and patients

• Evacuation Plans
• Duplication of Important Documents
• Emergency supplies and food for 7 days
• Meeting place if separated
• Out of State Communication Plan
• Health care professionals Evacuate or Stay

Available at http//www.aap.org/family/frk/aapfrkf
ull.pdf
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Planning Office Communications

• Develop a chain of command and list
  responsibilities for each role
• Develop confidential emergency contact list of
  all staff physicians, nurses and office staff
• Compile a list of important phone numbers
  contact information for government and local
  emergency agencies

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Planning Office Communications

• Ensure all staff are aware of the office disaster
  plans
• Be aware that during a disaster, traditional
  methods may not work the internet, land line
  phones and cell phones.

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Planning Power and Electricity

• Anticipate a loss of power during a disaster that
  may last days
• Consider back-up generators
• Make arrangements for alternate storage of
  refrigerated medications and vaccines
• Emergency Kits medications, water, first aid
  supplies, flashlights, batteries, gloves,
  sanitation supplies

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Planning Medical Records

• The Health Insurance Portability and
  Accountability Act (HIPPA) mandates that copies
  of records be stored off site in case of
  catastrophe
• Consider an electronic medical records system
  with easy accessibility or computer data storage
  company
• Periodically test the back up system

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Planning Insurance

• Adequate Business insurance - determining how
  much revenue your practice can afford to lose
• Identify gaps in coverage does it cover
  terrorism, water damage, vaccines?
• Prepare a list of office inventory (videotape or
  paper record)

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Planning Technology Dependent Children

• Notifying utility companies to provide emergency
  services as well as create contingency plans if
  power is not available
• Knowing how to obtain additional medications and
  equipment in case availability is disrupted

Markenson et al. Pediatrics. 2006117340-362
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Planning Technology Dependent Children

• Determining best location during a disaster
  (evacuation, hospital, specialized shelters)
• Training of family members to assume role of in
  home health care providers

Markenson et al. Pediatrics. 2006117340-362
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Volunteers

• World Trade Center New York, 9/11//2001

• Public Announcement from a Local TV Network
• Physicians and Nurses needed. Will Drive to New
  York.
• Bobs Limousine Service

World Trade Center New York, 9/11/2001
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Volunteers Federal

• Disaster Medical Assistance Team (DMATS)
• Pediatric Specialty Team Pediatric physicians
  and nurses, Pediatric trauma surgeons, Pediatric
  pharmacists, Pediatric Respiratory therapists
• Annual Training
• Deployed nationally and Internationally
• Available at http//www.dmat.org/

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Volunteers State

• Medical Reserve Corps
• Respond to emergencies and provide education,
  outreach and various health services throughout
  the year
• Available at http//www.mamedicalreservecorps.o
  rg/index.php
• Massachusetts System for Advance Registrationfor
  Volunteer Health Professionals
• Statewide, secure database of pre-credentialed
  health care professionals who are interested in
  volunteering their services in the event of a
  public health emergency
• Available at https//www.msaronline.com/msar/por
  talMain.do

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Surveillance
Daily counts of ED visits for respiratory
syndromes from 1992 to 2002
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Pediatricians Surveillance

• Front Line
• Unusual presentations
• Know who to call
• Infectious Outbreak
• Local Public Health agencies
• Local Police or 24 hour CDC hotline 1
  770-488-7100
• Suspected Terrorism
• Local law enforcement or the National Response
  Center 1800-424-8802

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The goal of the terrorist is fear, injury,
revenge, publicity, reaction or chaos
-M. Shannon, MD MPH
Biological
Chemical
C.B.R.N.E.
Explosive
Radiological
Nuclear
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Chemical

• Nerve agents
• Acetylcholinesterase inhibitors
• Pulmonary
• Phosgene
• Cyanogens
• Vesicants
• Incapacitating agents
• Tear gas

• Vulnerabilities in Children
• Faster respiratory rates
• Closer to the ground
• More permeable skin

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Treatment Chemical

• Prevent entrance into Office
• Personal Protection
• 85-95 of decontamination is removal of clothing
• ABC
• Nerve Agents
• Atropine, Pralidoxmine, Diazepam (Mark-1 kits)
• Cyanide
• Sodium bicarbonate, Sodium nitrite. Sodium
  thiosulfate
• Vesicants, Pulmonary, Incapacitating agents
• Supportive care.

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Biological

• Anthrax
• Botulism
• Plague
• Small pox
• Tularemia
• Viral Hemorrhagic Fever

• Mimic Respiratory Illnesses
• Skin Findings
• Nervous System

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Anthrax Pediatrics

• Very few cases of Inhalational Anthrax in
  Children
• Cutaneous Anthrax is usually a benign course
  easily treated with antibiotics
• 7 month old with cutaneous anthrax developed
  severe hemolytic anemia, renal involvement,
  coagulopathy and hyponatremia
• Freedman et al. JAMA 2002 287 869 - 874.

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Treatment Biological Agents

• Anthrax Cutaneous/Inhalational
• Ciprofloxacin or Doxycycline and 1-2
  antimicorbials
• Botulinum
• Supportive Care/Immunization
• Hemorrhagic Fever virus
• Supportive care and Ribavirin
• Plague
• Streptomycin or Gentamicin
• Smallpox
• Vaccina immune globulin and vaccine
• Tularemia
• Streptomycin or Gentamicin

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Radiation Nuclear

• Dirty Bomb nuclear material with a
  conventional explosive
• Detonation of a nuclear weapon
• Damage of nuclear containing facility (nuclear
  power plant)

• Vulnerabilities in Children
• Faster respiratory rates
• Closer to the ground
• Increase risk of cancer

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Treatment Radiation Nuclear

• Prevent entrance into Office
• Personal Protection
• Most radiation injuries associated with blast
  injury
• 85-95 of decontamination is removal of clothing
• ABC

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Use of Potassium Iodide

• Example Nuclear Power Plant breech
• Prevent Thyroid Cancer
• Only effective if given in the first 8 hours.
• Current recommendations for stockpiling if within
  10 miles of a power plant (some have recommended
  within 50 miles)
• Consider placement in schools and daycare
  centers.

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Explosive Blast Injuries

• Trauma
• Smaller mass more likely to be propelled by force
  or explosion
• Projectile objects may penetrate vital organs
• Pulmonary
• collapse of building can cause highly hazardous
  dust particles

Oklahoma City Bombing Alfred P. Murrah Federal
Building 1995
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Natural Disasters Hurricanes/Floods/Tsunami

• Greater risk of drowning
• may not know how to swim or float
• less mass, strength, stamina to get out or hold
  onto objects

Hurricane Katrina, New Orleans, 2005
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Natural Disasters Earthquakes

• Less likely to be able to position self for
  safety
• More likely to be trapped in small places
• Sustain more serious blunt injuries given smaller
  mass

Turkey, 1999
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Natural Disasters Fire

• Less likely to escape
• Depending on developmental level, may run into
  fires rather than away
• More vulnerable to burns and smoke inhalation
• increase risk of severe burns and circumferential
  burns

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Childrens Vulnerabilities during a disaster

• Predisposition to injury
• less adult supervision, increased environmental
  hazards, children may want to help
• Increase risk of Dehydration Hypothermia
• Increased family stress
• Predisposition to illness
• group sheltering, water issues, medication
  availability

• Limited access to care
• Lack of electricity
• Lack of pharmacies
• Compliance with instructions, follow-up

Advanced Pediatric Life Support. 2006
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Reunification of Families

• Natural Disasters
• Hurricane Katrina/Rita 5192 children displaced
  from families.
• 6 months later the last child was reunited with
  her family
• Terrorist Attacks
• Happen during the day when children are in
  school, camps, and after school programs

Broughton DD et al. Pediatrics, May 2006 117
S442 - S445.
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Pediatricians Role during disasters

• Self Preparedness
• Individual/family emergency plan
• Work with communities/hospitals advocating the
  needs of children in disaster
• Provide medical care in office and or alternate
  sites
• Serve as information resource to families
• Attempt to convey information consistent with
  authorized medical agencies
• Including information about assistance, medical
  care, immunizations, critical incident stress
  reactions/interventions

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Mental Health

• After 9/11 in NYC
• 18 Severe post traumatic stress reactions
• school age kids 27 met criteria for 1 or more of
  7 psychiatric disorders
• 6 months later 28.6 had probable
  anxiety/depressive disorders
• After 9/11 in Washington DC
• Link to television exposure and negative
  reactions in children

Fairbrother G et al, Pediatrics 2004
1131367-1374. Phillips D et al America Journal
of Orthopyschiatry. 2004 74509-528. Hoven CW et
al Archives of General Psychiatry 2005 62545-551.
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Mental Health

• Persist years after the event
• Pediatricians can
• Help families cope after disaster
• Show families how to talk to children about
  disasters
• Referral to mental health specialists

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Summary Role of Pediatricians

• Review office preparedness protocols
• Educate families on disaster preparedness,
  especially children with chronic illnesses and
  special needs
• Work with local community organizations and
  hospital advocating needs of children during a
  disaster

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Summary Role of Pediatricians

• Surveillance children may be the first victims
• Participate in disaster planning for schools and
  daycare centers
• Recognize families with Mental Health needs

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Resources

• American Academy of Pediatrics
• http//www.aap.org/terrorism/index.html
• Program for Pediatric Preparedness, National
  Center for Disaster Preparedness
• www.pediatricpreparednesss.org
• Centers for Disease Control and Prevention
• www.bt.cdc.gov/children
• A Disaster Preparedness Plan for Pediatricians
• www.aap.org/terrorism/topics/DisasterPrepPlanforPe
  ds.pdf
• Family Readiness Kit Preparing to Handle
  Disasters (updated)
• http//www.aap.org/family/frk/frkit.htm

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Acknowledgements

• Division of Emergency Medicine Childrens
  Hospital Boston
• Michael Shannon MD MPH
• Debra Weiner MD PhD
• Stephen Monteiro, Emergency Management
  Coordinator

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