6
Improving Emergency Preparedness and Response for Children Involved in Disasters

The term “disaster” denotes a low-probability but high-impact event that causes a large number of individuals to become ill or injured. The International Federation of Red Cross and Red Crescent Societies defines a disaster as an event that causes more than 10 deaths, affects more than 100 people, or leads to an appeal by those affected for assistance (Bravata et al., 2004). This report expands this definition to include any event that creates a significant, short-term spike in the demand for emergency care services that can be adequately addressed only through extraordinary measures.

During the development of this report, the most destructive natural disaster in the nation’s history occurred. On August 29, 2005, Hurricane Katrina struck the Gulf Coast of Louisiana and Mississippi, leaving more than 1,300 people dead, countless injured, and more than 1 million displaced. The aftermath of the hurricane created a humanitarian crisis unparalleled in U.S. history, with federal disaster declarations covering 90,000 square miles (Associated Press 2005a,c). More than 4,500 children were reported missing to the National Center for Missing and Exploited Children after the storm; a month later, only half of those children had been located (Ong, 2005).

Hurricane Katrina is an extreme example of a disaster in terms of its scope and impact; most disaster incidents tend to be smaller in size and affect a fraction of these numbers of people. However, all disasters present special challenges for emergency providers. These types of incidents create a sharp imbalance between the supply of and demand for existing resources (Noji, 1996). The coordination of personnel, equipment, and medical capacity involved in responding to a disaster in a timely manner presents a number of difficulties. Understaffed and overcrowded emergency departments (EDs)



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Emergency Care for Children: Growing Pains 6 Improving Emergency Preparedness and Response for Children Involved in Disasters The term “disaster” denotes a low-probability but high-impact event that causes a large number of individuals to become ill or injured. The International Federation of Red Cross and Red Crescent Societies defines a disaster as an event that causes more than 10 deaths, affects more than 100 people, or leads to an appeal by those affected for assistance (Bravata et al., 2004). This report expands this definition to include any event that creates a significant, short-term spike in the demand for emergency care services that can be adequately addressed only through extraordinary measures. During the development of this report, the most destructive natural disaster in the nation’s history occurred. On August 29, 2005, Hurricane Katrina struck the Gulf Coast of Louisiana and Mississippi, leaving more than 1,300 people dead, countless injured, and more than 1 million displaced. The aftermath of the hurricane created a humanitarian crisis unparalleled in U.S. history, with federal disaster declarations covering 90,000 square miles (Associated Press 2005a,c). More than 4,500 children were reported missing to the National Center for Missing and Exploited Children after the storm; a month later, only half of those children had been located (Ong, 2005). Hurricane Katrina is an extreme example of a disaster in terms of its scope and impact; most disaster incidents tend to be smaller in size and affect a fraction of these numbers of people. However, all disasters present special challenges for emergency providers. These types of incidents create a sharp imbalance between the supply of and demand for existing resources (Noji, 1996). The coordination of personnel, equipment, and medical capacity involved in responding to a disaster in a timely manner presents a number of difficulties. Understaffed and overcrowded emergency departments (EDs)

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Emergency Care for Children: Growing Pains are unlikely to be able to absorb the influx of patients from such an incident (Shute and Marcus, 2001). Emergency medical services (EMS) systems lacking sufficient resources even for day-to-day operations are overwhelmed in the event of a large-scale disaster. Deficiencies in the emergency care system for children that are evident during normal operations in the areas of pediatric equipment, medication and supplies, and pediatric training are greatly exacerbated during a disaster. The available evidence reveals that the nation’s emergency care system is poorly prepared for disasters (Schur et al., 2004): Surge capacity. Surge capacity refers to a hospital’s ability to manage a sudden, unexpected increase in patient volume that would otherwise severely challenge or exceed its normal capacity (Hick et al., 2004). Few American hospitals have the capacity to handle the increased volume of patients likely to result from a large-scale disaster or an epidemic, particularly if the patients are infants or small children (Kaji and Lweis, 2004; Oster and Chaffee, 2004). Surveillance. In public health parlance, surveillance refers to the ability to collect and analyze morbidity, mortality, and other relevant ED data in order to identify and control health threats. Few automatic, real-time surveillance systems are in operation across the United States that can accurately alert public health officials to an impending crisis (GAO, 2003a). Coordination/communication. In the event of a disaster or public health emergency, emergency care personnel may have to coordinate their efforts with personnel from other hospitals; EMS agencies; and public safety agencies, such as fire and police. A high level of coordination is required. However, communications systems are often not secure or reliable during such an event. Many communications systems are incompatible across regions or even across agencies within the same community (GAO, 2001). Training. The medical and nonmedical needs of victims of a disaster or public health emergency may vary from the type of care normally delivered by emergency care providers. Emergency personnel must be able to recognize and meet these needs. Overwhelmingly, research indicates that academic, on-the-job, and continuing education training in disaster response for emergency care personnel is insufficient, particularly when it comes to treating victims of chemical, biological, and nuclear events (Treat et al., 2001; GAO, 2003a; Rivera and Char, 2004). Protective equipment. Protective equipment refers to clothing and garments, respiratory equipment, and other barriers designed to shield emergency care personnel from chemical, biological, or other physical hazards. Evidence suggests that many emergency care providers are inadequately equipped for routine practice, and disasters make it difficult or impos-

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Emergency Care for Children: Growing Pains sible for providers to follow even normal safety procedures (Jackson et al., 2004). Since September 11, 2001, much attention has been focused on disaster preparedness. While significant resources have been spent on protecting and securing the nation’s infrastructure, fewer resources have been devoted to improving the readiness of the emergency care system (National Advisory Committee on Children and Terrorism, 2003; Sears, 2005). EMS systems, for example, have received only 4 to 6 percent of federal disaster preparedness funds from the Department of Homeland Security (DHS) and the Department of Health and Human Services (DHHS) (GAO, 2003b; Center for Catastrophe Preparedness and Response, 2005). Funding for hospital preparedness has been limited and slow to reach hospitals (McHugh et al., 2004). Even less has been done to safeguard the health and well-being of children (National Advisory Committee on Children and Terrorism, 2003), the most vulnerable age group in many types of disasters (National Center for Disaster Preparedness, 2003). Though it is still too early to assemble all of the lessons learned from Hurricane Katrina, we have learned enough from this and other disasters to recognize that improved pediatric planning for disasters is necessary. In Chapter 3, the committee emphasized the importance of integrating pediatric planning for emergency care and disasters at the regional level. In this chapter, the committee focuses on concrete actions that federal agencies and regional emergency care systems should take to address pediatric needs in the event of a disaster. First, however, the chapter reviews what is known about the challenges of caring for children in a disaster and recent efforts to improve preparedness for treating these especially vulnerable disaster victims. CARING FOR CHILDREN IN DISASTERS Children react differently than adults to medical emergencies because of anatomical, physiological, developmental, and emotional differences. Because of these differences, children are among the most vulnerable individuals in the event of a disaster. Children are more prone to injury in a fire or a biological or chemical attack because they take more breaths per minute, and their breathing zone is closer to the ground. They also have thinner skin, which provides less protection and allows greater absorption of toxic chemicals (AAP, 2002). They are more vulnerable to the effects of infectious agents that produce vomiting and/or diarrhea because they have less fluid reserve than adults and can become dehydrated more rapidly (Illinois EMS-C, 2005; CNN.

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Emergency Care for Children: Growing Pains com, 2005). If they sustain burns, children have a greater likelihood of life-threatening fluid loss and susceptibility to secondary infections (Shannon, 2004). Additionally, if they sustain injuries that cause blood loss, children develop irreversible shock and die more quickly than adults (AAP, 2002). Finally, very young children’s cognitive and motor abilities limit their ability to escape dangerous situations. Younger patients require specialized equipment and different approaches to treatment in the event of a disaster. Children cannot be properly decontaminated in adult decontamination units (National Center for Disaster Preparedness, 2003) because they require adjustments to the water temperature and pressure (heated, high-volume, low-pressure water). Rescuers also need to have child-size clothing on-hand for use after the decontamination (NASEMSD, 2004). Children require different antibiotics and different dosages to counter many chemical and biological agents (National Center for Disaster Preparedness, 2003). Natural disasters pose similar challenges to pediatric care. Hurricane Katrina highlighted the social service needs of children during evacuation and sheltering—identification, supervision, special food (formula), clothing and sanitation (diapers), and sleeping accommodations (cribs) must be available (Foltin et al., forthcoming). Like adults, children require mental health services after a disaster, and these services must be age appropriate. The most common indicators of distress in children are changes in their behavior—for example, a shift from being an outgoing child to being shy and withdrawn and behavior regression, in which past behaviors such as thumb sucking or baby talk reemerge. At the same time, children’s reactions vary based on their age, their cognitive level, their family’s proximity and reactions to the disaster, and whether their exposure to the disaster was direct. Preschool-aged children lack the skills needed to cope with stress, and the reactions of their parents strongly affect them. They worry about abandonment, whether they have lost a toy, a favorite pet, or a family member. School-aged children understand the concept of permanent change and loss and will therefore suffer from fears and anxieties. They may become preoccupied by the disaster and want to discuss its details at length, sometimes to the extent of interfering with other activities. Preadolescents want to know that their fears are appropriate and shared by others. Adolescents have childlike reactions mixed with adult responses. They may feel overwhelmed by their emotions and therefore be unable to discuss them with their family. They also may demonstrate more acting out and risk-taking behaviors than normal (NIMH, 2001). Evidence from Previous Disasters Only a handful of published studies address the effects of disasters on children and their specific needs during such an event (National Center for

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Emergency Care for Children: Growing Pains Disaster Preparedness, 2003). Primarily, the available studies provide insight into the epidemiology of pediatric injury after a disaster. One example describes ED visits at Miami Children’s Hospital in the weeks following Hurricane Andrew, which struck 30 miles south of Miami, Florida, in 1994. In the week following the hurricane, the hospital experienced a 41 percent increase in ED visits, or an average of 57 additional patients per day. The ED also saw an increase in patients over age 18 (2.4 versus 1 percent). This increase was likely due to the loss of electricity and structural damage that occurred after the storm, leaving few options for medical care beyond EDs for local residents and rescuers alike (Quinn et al., 1994). Although Hurricane Andrew was an extraordinary event, the medical needs of children affected by hurricanes and other large-scale natural disasters are rather ordinary. In the week following the hurricane, conditions such as acute gastroenteritis, impetigo (bacterial skin infection), and open wounds were diagnosed more frequently, while genitourinary problems, nonspecific abdominal pain, and soft tissue injuries were seen less often. In the second week after the hurricane, the ED noted increases in dermatological problems, including cellulitis, and in injuries, including open wounds; a decrease was noted in respiratory problems, including upper respiratory infections. The increase in open wounds seen in the weeks following the hurricane was due largely to incidents related to the cleanup effort, and in children likely reflected their increasing curiosity about their changed environment. Open-wound management is a time-consuming task, particularly for uncooperative and frightened pediatric patients; thus although patient volume had returned to normal levels by the second week after the hurricane (Quinn et al., 1994), additional physician staffing was necessary. Other studies of single incidents have been conducted. One such study showed that in the event of a school bus crash, head, neck, and spine injuries are common (Lapner et al., 2003). Another study, analyzing pediatric deaths and injuries after the Oklahoma City bombing in 1995, provided some information on the spectrum of pediatric injuries after a bomb blast, which in this case produced a high incidence of cranial injuries. Among the 19 children who died in the blast, the most common injuries were skull fractures, cerebral evisceration, abdominal or thoracic injuries, amputations, arm and leg fractures, and burns. All had extensive cutaneous contusions, avulsions, and lacerations. Understanding the spectrum of injuries that occur in a disaster not only helps emergency providers better anticipate what to expect from pediatric victims, but also provides insight into possible preventive measures that could mitigate the effects of such an incident. For example, changes to the design of school buses might be able to mitigate some of the injuries likely to occur in the event of a crash (Lapner et al., 2003). Some studies also provide insight into how well the emergency care system responds to pediatric patients in a disaster. After the 1990 crash on

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Emergency Care for Children: Growing Pains Long Island, New York, of a plane that carried 25 children among its 160 passengers, records were obtained on the 22 child survivors. The county had a disaster plan in place, which stated that cases involving severe burns, severe trauma, or severed limbs must be transported to hospitals capable of providing care for those injuries. The plan also called for EMS to distribute the balance of casualties with serious injuries to the closest hospitals, while individuals with minor injuries were supposed to be transported farther away. However, only 1 of the 7 critically injured children was transported to a level I pediatric center. Of the remaining 6 children, 1 was transported to a level II center and 5 to a level III center. Only two of the 5 critically injured children transported to level III facilities were subsequently transported to a high-level pediatric center. The closest level I pediatric trauma center, which was equipped with a helipad, received no patients from the crash. It is unclear why transport destinations were unrelated to the severity of injuries (van Amerongen et al., 1993). While the majority of studies of pediatric disaster victims indicate that trauma is a major risk, the experience of Hurricane Katrina indicates that this is not always the case. Initial reports from front-line medical providers at the Astrodome in Houston, Texas, which served as a shelter for 23,000 hurricane evacuees, revealed an almost complete absence of trauma cases (Mattox, 2005). Thus disaster and mass casualty guidelines heavily based in trauma planning may not be appropriate for all disaster scenarios. In the immediate aftermath of Hurricane Katrina, emergency care providers from disaster management teams dealt with numerous cases involving exacerbation of asthma and diabetes. Reportedly, a great number of people needed prescription refills. By day 4 in the Astrodome, gastroenteritis had become a common ailment (one that is potentially more severe in infants and the elderly). Cholera was also a concern (Mattox, 2005). Pediatric Disaster Planning and the Current State of Preparedness The needs of children have traditionally been overlooked in disaster planning. Historically, the military was considered the only target of potential biological, chemical, and radiological attacks, so the focus for training, equipment, and facilities was on the care of healthy young adults (National Center for Disaster Preparedness, 2003). But even initial guidelines for civilian disaster preparedness were not appropriate for the care of children (National Center for Disaster Preparedness, 2003). A 1997 Federal Emergency Management Agency (FEMA) survey found that none of the states had incorporated pediatric components into their disaster plans (National Advisory Committee on Children and Terrorism, 2003; Illinois EMS-C, 2005). Recognizing the absence of pediatric concerns in disaster planning,

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Emergency Care for Children: Growing Pains the first field triage model developed specifically for children was created in 1995, then revised in 2001. Triage is a primary and critical component of disaster management since resources must quickly be put to their most efficient use to do the greatest good for the greatest number of casualties. The pediatric triage model, called JumpSTART, is based on the adult triage tool START and helps prehospital providers make decisions so under- and overtriage will be minimized (Romig, 2002). JumpSTART is widely used today and allows emergency workers to triage children within 30 seconds. However, the model is the product of expert consensus; it has not been empirically validated and therefore is not evidence based (Ohio Pediatric Disaster Preparedness Committee, 2004). Attention to the issue of pediatric disaster preparedness grew considerably after September 11, 2001. A number of initiatives to address pediatric disaster planning and preparedness began to emerge. In October 2001, the American Academy of Pediatrics (AAP) created a Task Force on Terrorism consisting of 12 pediatricians (Hicks, 2003), with the aim of ensuring that pediatricians and other providers will have the information they need as it becomes available and that children’s needs will be considered in all planning efforts. In 2006, the task force published Pediatric Terrorism and Disaster Preparedness: A Resource for Pediatricians, designed to give pediatricians and other providers practical advice and information on best practices in the area of disaster preparedness. In February 2003, a 3-day national consensus conference was held to discuss the particular vulnerabilities of children to terrorist attacks and possible responses. This represented one of the first efforts to define issues in pediatric disaster preparedness. The conference was sponsored by the Agency for Healthcare Research and Quality (AHRQ) and the Maternal and Child Health Bureau (MCHB) and was attended by nearly 70 subject matter experts, as well as representatives from government agencies and professional organizations. Conferees developed recommendations on a number of broad and specific issues and published them later that year (National Center for Disaster Preparedness, 2003). Because of a lack of evidence, however, these recommendations are largely a product of expert consensus. At around the same time, the National Advisory Committee on Children and Terrorism (NACCT) released a report to the Secretary of Health and Human Services that contained a number of recommendations regarding areas in need of funding and program development. The NACCT was created by Congress through the Public Health Security and Bioterrorism Preparedness and Response Act of 2002. The committee’s goal was to prepare a comprehensive public health strategy for ensuring the safety of children and meeting their needs in the face of the threat of terrorism. Unfortunately, the majority of the recommendations developed by the NACCT have not been implemented. In July 2005, an expert meeting on pediatric bioterrorism

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Emergency Care for Children: Growing Pains preparedness was convened to review the 2003 NACCT recommendations and update steps for moving forward. The meeting attendees agreed on the need to move quickly to disseminate the recommendations of the 2003 NACCT report and to elevate pediatric bioterrorism preparedness to the forefront of the national agenda. There is some evidence of progress on pediatric disaster preparedness at the federal level. The Health Resources and Services Administration (HRSA) has set a benchmark for all states to establish a system that allows for the triage, treatment, and disposition of 500 adult and pediatric patients per 1 million population who suffer from acute illness or trauma requiring hospitalization following a biological, chemical, radiological, or explosive terrorist incident (AHRQ, 2004). Inclusion of pediatric patients in the benchmark language was a direct result of lobbying by the pediatric community. Additionally, guidance for the bioterrorism grants offered by HRSA, AHRQ, and the Office of Domestic Preparedness indicates that all projects should consider the needs of children. Disaster preparedness has also been a key area of focus for the Emergency Medical Services for Children (EMS-C) program. The program has focused in particular on the inclusion of pediatric issues in state disaster plans, since a 1997 FEMA survey indicated that no states had done so. One of the objectives in the EMS-C 5-Year Plan, 2001–2005, was to increase to 100% the number of states, Tribal Reservations, or Federal Territories that include pediatric issues in State emergency disaster plans (DHHS et al., 2000). By 2003, at least 13 states had formally assigned a pediatric representative to their state disaster preparedness committee. More detailed information on state disaster plans was available in 2004 in a report from the National Association of State EMS Directors (NASEMSD). Through a survey of all states and territories (to which 46 of 56 state EMS directors responded), the NASEMSD found that states continued to fall short of including the needs of children in their plans. For example, only 85 percent of respondents noted that according to their state plan, hospitals were required to have sufficient pediatric equipment and medications, as well as capacity for appropriate assessment, treatment, and decontamination of children exposed to radiological, chemical, or biological agents. More troubling, only 6 states said their hospitals were currently equipped with sufficient pediatric equipment and medications (NASEMSD, 2004). Many state respondents did indicate that they were in the process of improving the pediatric components of their state plan. This effort will likely be assisted by a model pediatric component for state disaster plans being developed under an EMS-C program Targeted Issues Grant at the time of this writing. While there is clearly more work to be done at the federal and state levels with regard to pediatric disaster preparedness, progress is needed at the

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Emergency Care for Children: Growing Pains regional and provider levels as well. For example, a study of EMS agencies in Arkansas revealed that only one-quarter of the agencies with a written plan for responding to mass casualty events had specific provisions in that plan for the care of children (Dick et al., 2004). Regions and providers must consider a number of important issues as they develop disaster plans. For example, in developing regional disaster plans, many planning bodies have identified shelter sites for the public. However, few have taken the necessary steps to ensure that these sites have in place the resources—diapers, formula, and other pediatric supplies—that will be required if children are sheltered at these locations. Additionally, protocols are being developed to guide emergency care providers on how to conduct a mass decontamination, but these protocols infrequently account for the needs of children—for example, the strength of the water stream, the water temperature, and who (parent versus rescuer) should carry an infant or a young child through the decontamination unit. The absence of these considerations and others points to the importance of having pediatric representation on planning bodies involved in emergency care, trauma, and disaster planning. Another consideration is the extent to which emergency care and other medical providers should educate the public regarding the care of children in disasters. Well-meaning but misinformed parents may not act in the best interest or safety of their children. For example, after postal workers in New York City were exposed to anthrax spores in 2001, some of the workers said they intended to give the antibiotics they received (Cipro in most cases) to their children “to protect them from anthrax.” Not only is anthrax not contagious, but the antibiotics given to the postal workers were never intended for use in children. Additionally, some workers said they were reluctant to hug or touch their children out of fear that they might transfer the anthrax spores (Aghababian, 2002). IMPROVING RESPONSE TO DISASTERS FOR PEDIATRIC VICTIMS The evidence summarized above indicates that the nation’s emergency care system is not well prepared for disasters involving children and that the needs of children in disasters are frequently overlooked. This is not necessarily an indication that planners fail to recognize or appreciate the needs of children, but rather a sign that planners are overwhelmed by the number of competing needs. There are so many shortcomings in disaster preparedness that children’s needs often fall to the wayside. The committee believes pediatric concerns should be in the forefront of disaster planning and recommends that federal agencies (the Department of Health and Human Services, the National Highway Traffic Safety Administration, and the Department of Homeland Security), in partnership with states and regional

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Emergency Care for Children: Growing Pains planning bodies and emergency care providers, convene a panel with multidisciplinary expertise to develop strategies for addressing pediatric needs in the event of a disaster. This effort should encompass the following: Development of strategies to minimize parent–child separation and improved methods for reuniting separated children with their families. Development of strategies to improve the level of pediatric expertise on Disaster Medical Assistance Teams and other organized disaster response teams. Development of disaster plans that address pediatric surge capacity for both injured and noninjured children. Development of and improved access to specific medical and mental health therapies, as well as social services, for children in the event of a disaster. Development of policies to ensure that disaster drills include a pediatric mass casualty incident at least once every 2 years. (6.1) Minimizing Separation of Families Hurricane Katrina highlighted a critical problem associated with evacuation and sheltering in the event of a disaster—the separation of children from their parents. As caregivers and children first fled from the impending hurricane and later were moved from evacuation shelters, many children became separated in the chaos. For almost a week, for example, 16-year-old Reshad B. was separated from his grandmother, his primary caregiver. The two were separated during the chaotic evacuation of the Louisiana Superdome, which served as a shelter for 10,000 New Orleans residents. He was taken to Texas, while she was transported to Kentucky. For nearly a week, Rashad lived in a Houston shelter not knowing what had happened to his grandmother. They were reunited through the efforts of the National Center for Missing and Exploited Children (Associated Press, 2005b). There are hundreds of stories like that of Reshad B. Even weeks after the storm, Texas Child Protective Services workers reported caring for nearly 50 unaccompanied children in shelters (Associated Press, 2005b); others were temporarily placed in foster care. While organizations such as the National Center for Missing and Exploited Children and the Red Cross, as well as state agencies, worked actively to reunite families and could report many examples of success, too many children remained separated from their family members months after the storm. One of the challenges for officials was not knowing whether the missing child or parent had survived the storm,

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Emergency Care for Children: Growing Pains since many of the recovered bodies were not identified for a prolonged period of time. Another challenge was reuniting young, preverbal children with their parents, since these children were too young to give rescuers and social workers their name or identify family members in photographs. There are currently no clear guidelines to direct planning in the event of parent–child separation (Freishtat, 2002). In developing such guidance, policy makers and planners should consider a number of issues. First, in the event of a disaster, particularly one that occurs without warning, children may be away from their parents in the custody of a school, day care center, babysitter, or other nonfamily caretaker; older children may be with friends or even alone. Disaster plans should not assume that children are in the custody of their parents when a disaster strikes. Second, during evacuation and sheltering, care should be taken to minimize the separation of children from their caretakers. Emergency workers overseeing the process should, to the extent possible, see that children remain paired with a parent or caretaker at all times. If children must be separated from their parents—for example, if they must be triaged to different medical institutions—emergency workers should obtain complete identification information on the child from the parent before the separation occurs. Emergency workers should also assign an individual to the task of overseeing the child until the government or family assumes custody. Third, the steps taken to reunite families—registering children and adults and showing pictures of missing children on television—are reactive and should be evaluated (Foltin et al., forthcoming). Steps to make the identification of children easier in the future, such as widespread use of identification bracelets, name tags, or other means, should be considered. More sophisticated technologies should also be explored; for example, electronic tracking devices that contain a child’s identification information, medical conditions, and medications would be helpful to officials trying to reunite families. Even if all children are easily identified, however, there will still be a need for reactive steps to reunify families if they are separated. Ideally, the most efficient and effective strategies should be used, but those strategies must take into account the loss of electricity and communications that may occur after a disaster. The nontraditional family structures that many children have must also be considered. Simply matching a child to a parent may not be sufficient; noncustodial parents or other relatives may need assurance of a child’s whereabouts after a disaster as well. These concerns are not hypothetical. Approximately 4,000 foster children were affected by Hurricane Katrina (Freddy Mac Foundation, 2005). One official from Louisiana’s Department of Social Services reported that about a fourth of foster children in the custody of the state (approximately 500 children) had not been located almost a month after the storm (Cottman,

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Emergency Care for Children: Growing Pains TABLE 6-1 Pediatric Preparedness of Disaster Medical Assistance Teams (DMATs) Question to DMAT Leaders Average Response (Likert Scale: 1 = not at all, 6 = a great degree) How well does the standardized DMAT curriculum meet the needs of pediatric patients? 3.33 (+/–0.25) How well is the team prepared for pediatric patients? 3.91 (+/–0.22) How well does the team respond to a disaster with pediatric patients? 3.94 (+/–0.31) How well is the team equipped to respond to a disaster with pediatric patients? 3.22 (+/–0.24) How well is pediatric equipment organized? 3.08 (+/–0.29) Agree that the system needs more pediatric specialty teams? 3.37 (+/–0.31) Agree that current teams need more pediatric training? 3.68 (+/–0.34) SOURCE: Mace and Bern, 2004. practices were absent from the curriculum for 40 percent of DMATs (Mace and Bern, 2004). The survey also provided insight into the DMAT members and their training and experience with regard to pediatric patients. The majority of DMAT physicians (74 percent) reported that they specialize in emergency medicine. Slightly more than half (54 percent) of physicians, 40 percent of nurses, 44 percent of midlevel providers (nurse practitioners and physician assistants), and 44 percent of paramedics reported working with children on a daily basis. Many of the problems apparent in the emergency care system for children, particularly lack of equipment and training, are also apparent on DMATs. To address these shortcomings, strategies to improve the level of pediatric expertise on DMATs and other organized disaster response teams need to be developed. This can be accomplished by improving the pediatric training required of teams, equipping them with appropriate pediatric resources, and taking active steps to recruit pediatricians and pediatric emergency medicine physicians to serve on the teams. Improving Pediatric Surge Capacity While children represent approximately 25 percent of the U.S. population (U.S. Census Bureau, 2004), they consume a smaller proportion of inpatient hospital services (Freishtat, 2002). Since most children are relatively healthy, the U.S. hospital system is designed for a large number of adults, not children (Holbrook, 1991; Freishtat, 2002). As a result, compared with

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Emergency Care for Children: Growing Pains the resources available for adults, there are fewer pediatric hospital beds, pediatric specialists, and providers with experience caring for critically ill and injured children (Freishtat, 2002). In the event of a disaster, the capacity of the health care system to care for a large number of children is likely to be inadequate. Although much of the focus of disaster planning has been on large-scale disasters, even modest incidents have the potential to push system resources to their limits. For example, a number of victims of the Rhode Island nightclub fire in 2003 required supplemental staff and specialized resources that overwhelmed local capacity (Hick et al., 2004). A total of 273 victims sought care at local hospitals. The closest hospital to the nightclub (3 miles away), Rhode Island’s second largest, is a 359-bed acute care hospital that handles 58,000 ED visits per year. It received 82 patients, 25 percent of whom were admitted, while 25 percent were transferred to other hospitals. A level I trauma center located 12 miles away from the nightclub received 68 patients, approximately 63 percent of whom were admitted (Gutman et al., 2003). A number of other Rhode Island hospitals, as well as Mass General, University of Massachusetts Medical Center, and Shriners Hospital for Children, also received patients. It was only the second time Shriners had opened its doors to adult patients (Ginaitt, 2005). What would have happened had the fire occurred in a venue filled with children? The hospitals most proximate to a disaster may not normally care for children but must still be ready to receive some pediatric victims. Children’s hospitals, those with pediatric EDs, and others designated as having pediatric capabilities will be looked upon to provide the majority of care to children in critical condition, but their resources and capacities may be stretched to the limit. Other hospitals must be prepared to handle pediatric patients with more minor conditions and stabilize those in critical condition until they can be transported to a pediatric center. Pediatric centers should have predetermined means of communicating with one another so they can share patients in the event those in critical condition need to be evacuated. DMATs may be able to offer local emergency care providers some relief, but given that there are only two pediatric specialty DMATs nationwide, their reach would be limited in the event of a large-scale event. A review of one pediatric disaster in England provides some insight into what could happen in the absence of regional planning for such disasters. In 1993, a double-decker bus full of school children was involved in a crash. Two children were killed and 56 injured. The local hospital received notification of the crash just as the first victims began to arrive. At that hospital, 42 injured children were taken to the ED. Most injuries were minor in nature, although 15 children were admitted; 4 had serious head injuries, and 2 required neurosurgical intervention. Although the hospital had a disaster plan in place, the lack of advance notification, the rapid influx of patients, and

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Emergency Care for Children: Growing Pains the lack of providers familiar with handling pediatric trauma injuries created difficulties (Wass et al., 1994). This incident also highlights the importance of all hospitals being prepared for pediatric emergencies, particularly in areas that lack pediatric centers. Disaster planning must also take into account children who are not hurt but need evacuation and sheltering. The importance of having pediatric resources (e.g., formula, diapers) available in shelter locations was discussed earlier. Steps to ensure that these resources are on hand must be taken before a disaster strikes. Involvement of pediatric experts in disaster planning is critical to ensure that evacuation and sheltering plans can meet the needs of children, particularly those with special needs, as the plans are operationalized. Disaster plans should include protocols for schools and day care centers and other places where children congregate. Planners need to think about where children might be at different times of day. For example, had the September 11 attacks occurred a half hour earlier, while more than 500,000 New York City school children were in transit to school, where would the bus drivers have taken these children? Would the places selected have been adequately equipped to handle the surge of children? Promoting Specific Therapies for Children Children affected by disasters have a number of medical, mental health, and social service needs that must be met. Under the current system, however, services appropriate for children may not be available. As discussed in Chapter 5, medications appropriate for children are not always available; the same is true for antidotes in the event of a terrorist attack. Additionally, resources and therapies developed specifically for children may not be accessible when needed. Potassium iodide prevents thyroid cancer and is highly recommended for children in the event of exposure to radioactive material. However, potassium iodide is currently available only in tablet form and therefore cannot be readily administered to infants and very young children. The pill can be dissolved in water, but since the resulting fluid is so salty, it must be mixed with something to disguise the taste. The tablet can be crushed and mixed with raspberry syrup, low-fat chocolate milk, or other drinks, but these mixtures will keep for only 7 days and must be stored in a refrigerator. Parents would have to crush a new tablet every 7 days to have the medication on hand when needed (FDA, 2006). Even if parents went through these steps every 7 days, however, the stability of potassium iodide when mixed with other liquids is not well known. There are also issues related to the strategic national stockpile (SNS), which would be used in the event of a disaster severe enough to deplete local resources. Within the SNS are 12-hour push packages that contain pharma-

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Emergency Care for Children: Growing Pains ceuticals, antidotes, and medical supplies designed for use during the early hours of an event. They are positioned in strategically located, secure warehouses ready for immediate deployment in the event of a disaster (CDC, 2004). Historically, the SNS did not meet the needs of most children, but that has changed somewhat. Today, there are pediatric representatives on every SNS advisory committee, and every new item for the SNS is reviewed for pediatric implications. However, the SNS must comply with Food and Drug Administration (FDA) labeling requirements, and if a medication is not approved for pediatric patients, it cannot be included in the push packages for children. Since most antidotes for terrorism agents are designed for adult use and not approved by the FDA for pediatric patients, they are not available for use in children (Markenson, 2005). Even with pediatric representation on SNS advisory committees, pediatric concerns are not fully addressed in developing the push packs because of the absence of approved antidotes for children. There are also controversies regarding the use of Mark 1 kits for children. Mark 1 kits contain two antidotes—atropine and pralidoxime chloride—that are effective if a person is exposed to certain types of nerve gas. The consensus in the medical community is that this treatment is appropriate for infants and children with severe, life-threatening nerve agent toxicity (National Center for Disaster Preparedness, 2004). However, there are no protocols for providers with regard to using a Mark 1 kit to treat children because it is not approved by the FDA. Pediatric dosing for atropine was approved by the FDA in June 2003, but it remains unclear how emergency providers should treat children exposed to nerve gas; some may give children only the pediatric dose of atropine, while others may give them the full dose in the Mark 1 kit. The Mark 1 kit is not a unique example—no specific pediatric dosage guidelines exist for a large number of drugs used in disaster situations. There is also some evidence that children’s mental health needs often go unmet after a disaster. Based on a survey of parents, it is estimated that approximately 18 percent of children aged 6–17 in New York City had severe or very severe post-traumatic stress reactions after September 11, 2001, but only 10 percent received counseling (Fairbrother et al., 2003). A survey of New York City public school children yielded similar findings: 8–15 percent of the students showed elevated rates of post-traumatic stress disorder, major depression, separation anxiety, panic disorder, and/or conduct disorder. Approximately two-thirds of children with probable post-traumatic stress disorder may not have received mental health services (Hoven et al., 2002). The system’s capacity to identify and treat the large number of children needing such services should be expanded. Hurricane Katrina highlighted the vast social service needs of all displaced victims, regardless of age. It would be a challenge for disaster plan-

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Emergency Care for Children: Growing Pains ners to address all the social service needs associated with a disaster of that magnitude. However, the development of evacuation plans should take into account how children can attend schools in different areas, the availability of health care services for children, pediatric capacity in the SNS, ways to expedite Medicaid enrollment for pediatric disaster victims, and long-term sheltering options available for children. Although difficult for disaster planners to address, these issues must be considered. Conducting Pediatric Disaster Drills It is widely believed that medical professionals do not receive as much disaster preparedness training as they should (AAMC, 2003; NASEMSD, 2005). The American College of Emergency Physicians (ACEP) has reported that the lack of bioterrorism training for medical responders is so severe that patient treatment could be seriously compromised (Maniece-Harrison, 2005). It is perhaps not surprising that pediatric training is particularly lacking. Most bioterrorism training initiatives, for example, make no reference to the needs of children (Maniece-Harrison, 2005). Disaster drills have long been central to disaster preparedness efforts for all types of emergency responders. Such drills have proven to be effective in training hospital providers to respond to mass casualty incidents (Hsu et al., 2004) and indeed are required of most hospitals. The Joint Commission on Accreditation of Healthcare Organizations’ (JCAHO) 2006 accreditation standards require hospitals to conduct two disaster drills per year, 4 to 8 months apart, one of which must include an influx of volunteers or simulated patients. Hospitals must also participate in at least one communitywide drill per year to assess the communications, coordination, and effectiveness of hospital and community command structures (JCAHO, 2005). However, the JCAHO requirements do not specifically address conducting disaster drills with children, and in fact, many disaster drills do not include pediatric patients. For example, one hospital held a disaster drill for a mock earthquake, in which a pediatric patient was simulated by a 5-gallon water bottle on which was taped a list of symptoms (Fields, 2003). Obviously, this is a poor means of simulating a pediatric patient. Some disaster drills do not consider children at all. Most (68 percent) of DMATs include pediatric patients in disaster drill scenarios (Mace and Bern, 2004), but it is significant that 32 percent do not. An assessment of EMS agencies in Arkansas found that few had participated in school disaster drills or planned for school responses (Dick et al., 2004). The exception is, of course, children’s hospitals, where all drills involve an influx of critical pediatric patients. In September 2003, for example, Children’s Hospital of Atlanta held a drill during which it received 20 critically injured pediatric patients. Yet while children’s hospitals are among the

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Emergency Care for Children: Growing Pains most prepared for treating pediatric victims of a disaster, the vast majority of such patients are seen not in children’s hospitals, but in general hospitals. With few exceptions, natural and man-made disasters affect children as well as adults, and there is no better way to expose weaknesses in current preparedness than to demonstrate how poorly children fare in disaster drills. Children are often located in large groups (schools, day care centers) (Romig, 2002), and it is unclear how the system would respond if a disaster incident occurred at one of those locations and a large number of children required care. Therefore, disaster drills should include a meaningful pediatric component. SUMMARY OF RECOMMENDATIONS 6.1 Federal agencies (the Department of Health and Human Services, the National Highway Traffic Safety Administration, and the Department of Homeland Security), in partnership with state and regional planning bodies and emergency care providers, should convene a panel with multidisciplinary expertise to develop strategies for addressing pediatric needs in the event of a disaster. This effort should encompass the following: Development of strategies to minimize parent–child separation and improved methods for reuniting separated children with their families. Development of strategies to improve the level of pediatric expertise on Disaster Medical Assistance Teams and other organized disaster response teams. Development of disaster plans that address pediatric surge capacity for both injured and noninjured children. Development of and improved access to specific medical and mental health therapies, as well as social services, for children in the event of a disaster. Development of policies to ensure that disaster drills include a pediatric mass casualty incident at least once every 2 years. REFERENCES AAMC (American Association of Medical Colleges). 2003. Training Future Physicians About Weapons of Mass Destruction: Report of the Expert Panel on Bioterrorism Education for Medical Students. Washington, DC: AAMC. AAP (American Academy of Pediatrics). 2002. The Youngest Victims: Disaster Preparedness to Meet the Needs of Children. Washington, DC: AAP. Aghababian R. 2002. Preparing EMS for acts of violence/terrorism involving children. EMSC News 15(2):1.

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Emergency Care for Children: Growing Pains AHRQ (Agency for Healthcare Research and Quality). 2004. Optimizing Surge Capacity: Hospital Assessment and Planning (AHRQ Pub. No. 04-P008). Rockville, MD: AHRQ. Associated Press. 2005a, September 12. Hurricane Katrina: By the numbers. The Sun Herald. Associated Press. 2005b, September 13. Volunteers try to reunite children separated from parents. Union Tribune. Available: http://www.signonsandiego.com/news/nation/katrina/20050913-0050-katrina-missingchildren.html [accessed February 1, 2007]. Associated Press. 2005c, December 22. Katrina is voted top story of 2005. USA Today. [Online]. Available: http://www.usatoday.com/news/nation/2005-12-22-top-stories_x.htm [accessed February 7, 2007]. Bravata D, McKonald K, Owens D, Wilhelm ER, Brandeau ML, Zaric, GS, Holty, JC, Sundaram V. 2004. Regionalization of Bioterrorism Preparedness and Response. Rockville, MD: AHRQ. CDC (Centers for Disease Control and Prevention). 2004. Strategic National Stockpile. [Online]. Available: http://www.bt.cdc.gov/stockpile/ [accessed December 1, 2005]. Center for Catastrophe Preparedness and Response. 2005. Emergency Medical Services: The Forgotten First Responder—A Report on the Critical Gaps in Organization and Deficits in Resources for America’s Medical First Responders. New York: New York University. CNN.com. 2005. Influenza (Flu). [Online]. Available: http://www.cnn.com/HEALTH/library/ DS/00081.html [accessed November 27, 2005]. Cottman M. 2005, September 26. More than 2,000 young Katrina survivors still separated from their parents. Blackamericaweb.Com. [Online]. Available: http://www.blackamericaweb.com/site.aspx/bawnews/youngsurvivors927 [accessed February 1, 2007]. DHHS, HRSA, MCHB (Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau). 2000. Five-year Plan: Emergency Medical Services for Children, 2001–2005. Washington, DC: EMS-C National Resource Center. Dick RM, Liggin R, Shirm SW, Graham J. 2004. EMS preparedness for mass casualty events involving children. Academic Emergency Medicine 11(5):559. Fairbrother G, Stuber J, Galea S, Fleischman AR, Pfefferbaum B. 2003, June. Traumatic stress reaction in New York City children after the September 11th terrorist attacks and subsequent use of counseling services. Presentation to the AcademyHealth Annual Meeting. Nashville, TN. FDA (Food and Drug Administration). 2006. Home Preparation Procedure for Emergency Administration of Potassium Iodide Tablets to Infants and Small Children. [Online]. Available: http://www.fda.gov/cder/drugprepare/kiprep.htm [accessed May 2006]. Fields H. 2003, May 7. Hospital disaster drill follows mega-quake scenario. Stanford Report. [Online]. Available: http://news-service.stanford.edu/news/2003/may7/disaster.html [accessed February 1, 2007]. Foltin G, Schonfeld D, Shannon M. Forthcoming. Pediatric Terrorism and Disaster Preparedness Resource. Washington, DC: AAP. Freddy Mac Foundation. 2005. Freddie Mac Foundation Announces $1 Million for Foster Children Affected by Hurricane Katrina. [Online]. Available: http://www.freddiemacfoundation. org/news/20050922_foster.html [accessed November 29, 2005]. Freishtat R. 2002. Issues in children’s hospital disaster preparedness. Clinical Pediatric Emergency Medicine 3(4):224–230. GAO (General Accounting Office). 2001. Emergency Medical Services: Reported Needs Are Wide-Ranging, with a Growing Focus on Lack of Data (GAO-2-28). Washington, DC: GAO. GAO. 2003a. Infectious Diseases: Gaps Remain in Surveillance Capabilities of State and Local Agencies (GAO-03-1176T). Washington, DC: GAO.

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Emergency Care for Children: Growing Pains GAO. 2003b. Hospital Preparedness: Most Urban Hospitals Have Emergency Plans but Lack Certain Capacities for Bioterrorism Response. Washington, DC: GAO. Ginaitt PT. 2005. Statewide Emergency Preparedness in Rhode Island: Lessons Learned “The Station” Nightclub Fire. Orlando, FL: Hospital Association of Rhode Island. Glaeser P, Linzer J, Tunik M, Henderson D, Ball J. 2000. Survey of nationally registered emergency medical services providers: Pediatric education. Annals of Emergency Medicine 36(1):33–38. Gutman D, Biffl WL, Suner S, Cioffi WG. 2003. The station nightclub fire and disaster preparedness in Rhode Island. Medicine and Health Rhode Island 86(11):344–346. Hick JL, Hanfling D, Burstein JL, DeAtley C, Barbisch D, Bogdan GM, Cantrill S. 2004. Health care facility and community strategies for patient care surge capacity. Annals of Emergency Medicine 44(3):253–261. Hicks M. 2003. Comprehensive Clinical and Policy Resource Guide to Assess Children’s Needs. Rockville, MD: AHRQ. Holbrook PR. 1991. Pediatric disaster medicine. Critical Care Clinics 7(2):463–470. Hoven CW, Duarte CS, Lucas CP, Mandell DJ, Cohen M, Rosen C, Wu P, Musa GJ, Gregorian N. 2002. Effects of the World Trade Center Attack on NYC Public School Students: Initial Report to the New York City Board of Education. New York: Columbia University Mailman School of Public Health, New York State Psychiatric Institute and Applied Research and Consulting, LLC. Hsu EB, Jenckes MW, Catlett CL, Robinson KA, Feuerstein CJ, Cosgrove SE, Green G, Guedelhoefer OC, Bass EB. 2004. Training to hospital staff to respond to a mass casualty incident. Evidence Report/Technology Assessment (Summary) 95:1–3. Illinois EMS-C (Illinois Emergency Medical Services for Children). 2005. Pediatric Disaster Preparedness Guidelines. Chicago, IL: Illinois Department of Public Health, Loyola University Medical Center. Jackson BA, Baker JC, Ridgely MS, Bartis JT, Linn HI. 2004. Safeguarding Emergency Responders during Major Disasters and Terrorist Attacks. Santa Monica, CA: Rand Corporation. JCAHO (Joint Commission on Accreditation of Healthcare Organizations). 2005. 2006 Hospital Accreditation Standards for Emergency Management Planning, Emergency Management Drills, Infection Control, and Disaster Privileges (Standard EC.2.20). Oakbrook Terrace, IL: JCAHO. Kaji AH, Lweis RJ. 2004. Hospital disaster preparedness in Los Angeles County, California. Annals of Emergency Medicine 44(4). Lapner PC, Nguyen D, Letts M. 2003. Analysis of a school bus collision: Mechanism of injury in the unrestrained child. Canadian Journal of Surgery 46(4):269–272. Lawrence T. 2002. EMSC comrades help NYC victims: Reflections on the 9/11 disaster. EMSC News 15(2):6–7. Mace SE, Bern AI. 2004. Needs assessment of current pediatric guidelines for use by disaster medical assistance team members in response to disaster and shelter care. Annals of Emergency Medicine 44(4):S35. Mace SE, Jones G. 2004. An analysis of disaster medical assistance team deployments in the United States. Annals of Emergency Medicine 44(4):S35. Maniece-Harrison B. 2005. Training. Unpublished document of the National Advisory Committee on Children and Terrorism. [Online]. Available: http://www.bt.cdc.gov/children/word/working/training.doc [accessed October 2005]. Markenson D. 2005. Model Pediatric Components for State Disaster Plans and Additional Resources. 2005 EMSC Annual Grantee Meeting. Washington, DC: MCHB. Mattox K. 2005, October. Life in astrocity, population: 23,000. Emergency Medicine News. p. 13.

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Emergency Care for Children: Growing Pains McHugh M, Staiti AB, Felland LE. 2004. How prepared are Americans for public health emergencies? Twelve communities weigh in. Health Affairs (Millwood) 23(3):201–209. NASEMSD (National Association of State Emergency Medical Services Directors). 2004. Pediatric Disaster and Terrorism Preparedness. Falls Church, VA: NASEMSD. NASEMSD. 2005. Domestic Terrorism: Issues of Preparedness. Resource Document. Falls Church, VA: NASEMSD. National Advisory Committee on Children and Terrorism. 2003. Recommendations to the Secretary. Washington, DC: DHHS. National Center for Disaster Preparedness. 2003. Pediatric Preparedness for Disasters and Trauma. New York: Columbia University Mailman School of Public Health. National Center for Disaster Preparedness. 2004. Atropine Use in Children after Nerve Gas Exposure (Info. Brief 1(1)). New York: Columbia Mailman School of Public Health. National Disaster Medical System. 2005. What Is a Disaster Medical Assistance Team (DMAT)? [Online]. Available: http://ndms.dhhs.gov/dmat.html [accessed November 29, 2005]. NIMH (National Institute of Mental Health). 2001. Helping Children and Adolescents Cope with Violence and Disasters (NIH Publication No. 01-3518). Bethesda, MD: NIMH. Noji EK. 1996. Disaster epidemiology. Emergency Medicine Clinics of North America 14(2):289–300. Nufer KE, Gnauck K. 2004. Clarifying needs of the pediatric disaster patient: A descriptive analysis of pediatric patient encounters from four disaster medical assistance team deployments. Annals of Emergency Medicine 44(4):S40. Ohio Pediatric Disaster Preparedness Committee. 2004. Pediatric Issues in Disaster Preparedness. [Online]. Available: http://www.prepareohio.com/members/pediatric/OHPedsPrep.ppt [accessed January 2006]. Ong B. 2005. Fractured families. Newsweek Web Exclusive. [Online]. Available: http://www. msnbc.msn.com/id/9615369/site/newsweek/ [accessed February 1, 2007]. Oster NS, Chaffee MW. 2004. Hospital preparedness analysis using the hospital emergency analysis tool (The HEAT). Annals of Emergency Medicine 44(4):S61. Quinn B, Baker R, Pratt J. 1994. Hurricane Andrew and a pediatric emergency department. Annals of Emergency Medicine 23(4):737–741. Rivera AF, Char DM. 2004. Emergency department disaster preparedness: Identifying the barriers. Annals of Emergency Medicine 44(4). Romig L. 2002. JumpSTART: A disaster preparedness tool for the times. EMSC News 15(2):3–4. Schur CL, Berk ML, Mueller CD. 2004. Perspectives of Rural Hospitals on Bioterrorism Preparedness Planning (W Series, No. 4). Bethesda, MD: NORC Walsh Center for Rural Health Analysis. Sears M. 2005, January 2. Organized effort aims to improve response when a child is hurt; club supplies bags that streamline ambulance care. Milwaukee Journal Sentinel. [Online]. Available: http://www.findarticles.com/p/articles/mi_qn4196/is_20050102/ai_n11008378 [accessed February 1, 2007]. Shannon M. 2004. Addressing Pediatric and School-based Surge Capacity in a Mass Casualty Event. Rockville, MD: AHRQ. Shute N, Marcus MB. 2001. Crisis in the ER. Turning away patients. Long delays. A surefire recipe for disaster. US News World Report 131(9):54–61. Treat K, Williams J, Furbee P, Manley W, Russell F, Stamper C. 2001. Hospital preparedness for weapons of mass destruction incidents: An initial assessment. Annals of Emergency Medicine 38(5):562–565.

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Emergency Care for Children: Growing Pains U.S. Census Bureau. 2004. Annual Estimates of the Resident Population by Selected Age Groups for the United States and States: July 1, 2003 and April 1, 2000. Table STEST2003-01res. [Online]. Available: http://cber.utk.edu/Census/03stage.xls [accessed October 2005]. van Amerongen RH, Fine JS, Tunik MG, Young GM, Foltin GL. 1993. The Avianca plane crash: An emergency medical system’s response to pediatric survivors of the disaster. Pediatrics 92(1):105–110. Wass AR, Williams MJ, Gibson MF. 1994. A review of the management of a major incident involving predominantly pediatric casualties. Injury 25(6):371–374.

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