Office Preparedness for Small- and Large-Scale

Emergencies

Sarita Chung MDCenter for Biopreparedness

The Division of Emergency MedicineChildren’s Hospital Boston

DISCLOSURE STATEMENT

Sarita Chung have nothing to disclose.

Outline

Single Office Emergencies Office Planning for Disasters Volunteering Syndromic Surveillance

Terrorism

Natural Disasters The Pediatrician’s Role during disasters Mental Health

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?

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; 150:249-256.

Heath BW, et al. Pediatrics 2000;106:1391-1396.

Types of Emergency

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

Altieri, et al. Pediatrics. 1990;85 710-714

Types of Emergencies

Seen in practice over the last year Meningitis Severe Asthma Severe Dehydration

Schweich et al. Pediatrics. 1991;88:223-229

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

71%66%

58%

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?

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. 1990;85 710-714Heath BW, et al. Pediatrics 2000;106:1391-1396.Schweich et al. Pediatrics. 1991;88:223-229

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?

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

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

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

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.

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 2003:291-295.Toback SL, et al. PEC 2006;22:415-422.

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

Chemical Plant Apex, NC 2006

Planning: Geographical Assessment

Regional Risks: floods, earthquakes, tornados

Historical significance Potentially Hazardous Infrastructure

Chemical Plants Nuclear Plants Trains

Chlorine Gas Spill South Carolina, 2005

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/aapfrkfull.pdf

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

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.

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

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

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)

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. 2006;117:340-362

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. 2006;117:340-362

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.

Bob’s Limousine Service

World Trade Center New York, 9/11/2001

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/

Volunteers: State

Medical Reserve Corps Respond to emergencies and provide education, outreach and various health services throughout the year Available at: http://www.mamedicalreservecorps.org/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/portalMain.do

Surveillance

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

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

“The goal of the terrorist is fear, injury, revenge, publicity, reaction or chaos”

Explosive

BiologicalChemical

-M. Shannon, MD MPH

Nuclear

Radiological

C.B.R.N.E.

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

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.

Biological

Anthrax Botulism Plague Small pox Tularemia Viral Hemorrhagic

Fever

Mimic Respiratory Illnesses

Skin Findings Nervous System

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.

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

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

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

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.

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 particlesOklahoma City Bombing

Alfred P. Murrah Federal Building 1995

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

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

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

Children’s 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

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.

Pediatrician’s 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

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 113:1367-1374.Phillips D et al America Journal of Orthopyschiatry. 2004 74;509-528.Hoven CW et al Archives of General Psychiatry 2005 62;545-551.

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

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

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

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/DisasterPrepPlanforPeds.pdf

Family Readiness Kit: Preparing to Handle Disasters (updated) http://www.aap.org/family/frk/frkit.htm

Acknowledgements

Division of Emergency Medicine Children’s Hospital Boston Michael Shannon MD MPH Debra Weiner MD PhD Stephen Monteiro, Emergency Management

Coordinator