Public Health Emergency Preparedness
This resource was part of AHRQ's Public Health Emergency Preparedness program, which was discontinued on June 30, 2011, in a realignment of Federal efforts.
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Chapter 11. Conclusion
This report has presented detailed information to assist pediatricians—both those based in the community and those based in hospitals and other health care systems—in becoming active participants in disaster planning, preparedness, and response. Additional sources of information and many other valuable resources are provided in the bibliographies that follow each chapter. In addition, valuable lessons can be drawn from several disasters, both manmade and natural, that have occurred in the United States.
The hurricanes in the Gulf Coast and their aftermath serve as a reminder that nature is capable of destruction greater than that of most terrorist attacks. An important lesson regarding the organization and focus of disaster response is to include natural as well as manmade events in planning and preparedness efforts. Consideration also should be given to the organizational and logistical issues involved in evacuating a major city.
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Activities pertaining to disaster planning, preparedness, and response take place at all levels, including Federal, State, regional, and local, and everyone has a role to play. For example, at the Federal level, the Centers for Disease Control and Prevention (CDC) has provided excellent information on the impact of hurricanes and on methods to help mitigate the impact and facilitate management immediately after the event (go to: http://www.bt.cdc.gov/disasters/hurricanes/). Much of this information can be applied to both natural disasters and terrorism. The Web site includes information on family readiness, evacuation, power loss, recovery (including keeping food and water safe, preventing injury, monitoring infections, etc.), animal and insect hazards, environmental issues, clean-up safety, returning home, and mental health issues.
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Regional, State, and Local Efforts
Valuable lessons have been learned from our experiences with Hurricane Katrina and its aftermath. A large part of the problem was insufficient coordination and planning at all levels. The situation was exacerbated by the need for evacuation of large numbers of people and their long-term displacement from their homes and schools.
Future planning and preparedness efforts in major U.S. cities should recognize the potential for severe and long-term consequences. In disasters, State and Federal aid is always going to take some time to arrive. Local and regional authorities, as well as individual families, should have an effective plan in place that includes efforts to be undertaken before other outside assistance can arrive. This should include an effective evacuation plan that covers quickly setting up emergency shelters, providing food and managing water sanitation for large numbers of people, and providing affected individuals—including children who may or may not have chronic illnesses and other special needs—with medical and mental health care.
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In a disaster, the most vulnerable are going to suffer the most and need the most assistance. Clearly, vulnerable populations include the poor, the infirm, individuals with mental illness, the elderly, and children. Hospitalized patients, people in nursing homes, and incarcerated individuals are at special risk in a natural or manmade disaster.
Hospitalized children, particularly premature infants and those in neonatal intensive care units, are particularly vulnerable. Their lives may depend on the ability of hospitals to maintain critical emergency power and life support equipment until transfer to other regional specialty facilities can be arranged.
These situations highlight the need for including large numbers of technologically dependent patients, many of whom require highly specialized regionalized care, in planning efforts to mitigate the impact of a disaster.
Separation of Children from Families
Hurricane Katrina also highlighted the need to plan for the likelihood of numerous children being separated from their parents or other caregivers. The National Center for Missing and Exploited Children has a hotline (1-800-843-5678) and Web link (http://www.missingkids.com) to report missing children, missing adults, and found children. The Red Cross also has a hotline (1-866-GET-INFO) and Web link (http://www.redcross.org) to help separated family members find each other. As of March 2006, the National Center reported that all children separated from families as a result of Hurricane Katrina have been reunited with their families.
This issue should receive more attention in preparedness and mitigation plans. Pre-disaster identification of children (e.g., name tags, other forms of ID, etc.), especially for those who are not verbal, or who cannot give their own name, a parent's name, or other critical information, should be considered. Neonates and their mothers are purposefully given matching ID bracelets in hospitals immediately after delivery so the identity of the maternal-child pair is never in doubt. Similar identification of parent-child pairs at the time of separation (e.g., during rescue or evacuation) could greatly aid in the identification of the child and more accurately track and reunite children separated from their parents.
The immediate first response to a disaster the magnitude of Hurricane Katrina includes the mobilization and evacuation of a large region. Subsequently, those displaced from their homes, schools, and neighborhoods will require basic necessities, including a place to stay, water, food, clothing, health and mental health care, etc.
The unique needs of children in shelter situations include the need for special foods (e.g., formula), clothing and sanitation (e.g., diapers), and sleeping accommodations (e.g., cribs). Efforts to distract, entertain, comfort, and even separate families with crying newborns and toddlers will help calm other evacuees in the shelter who find these sounds discomforting. Planning for special medical needs and for mental health care that focuses on children';s unique developmental stages is also critical.
The immediate issues of emergency sheltering, providing food and water, and other necessities do not take into account the problem of returning some semblance of stability and normalcy to children and families. These significant issues will likely create severe mental health issues for an extended period of time for many of these displaced children.
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Providing Urgent Medical Care to Large Populations of Displaced Children
Following Hurricane Katrina, a Mobile Pediatric Emergency Response Team (MPERT) staffed a temporary pediatric clinic near the displaced population. As Houston, TX, became the new home for 300,000 people, a percentage of evacuated children needed medical triage, evaluation, and management. They otherwise would have been likely to seek care at local emergency departments, many of which were already at surge capacity. To prevent severe overcrowding in these local emergency departments, a large children's hospital expended the resources necessary to care for these displaced children near the site of their temporary shelter.
A temporary pediatric clinic provided a high level of care for the evacuated children. The clinic cared for approximately 2,000 patients. Notably, not a single child died, and less than 50 required emergency medical services (EMS) transport to area hospitals. Other cites—e.g., Dallas, Birmingham, Ft. Worth, and Baton Rouge—also set up temporary clinics.
Setting up a Temporary Pediatric Clinic—Lessons Learned
In every large metropolitan area that received evacuees, temporary pediatric clinics evolved. These temporary clinics matched caregivers who were comfortable with and accustomed to providing care to children with incoming newborns, children, and adolescents with medical needs. Equally important, children were removed from adult waiting lines, allowing more effective care to be given to that population as well.
- Physicians and nurses who are trained and experienced in the emergency care of children should always be included, even at the most basic level, when planning for and responding to a disaster.
- Access to local tertiary pediatric care resources should be arranged for in advance, and the tertiary care provider supplying those resources should be involved in the planning discussions.
- While volunteerism is essential in the event of a mass casualty, guaranteed staffing of the MPERTS should be a priority.
- The medical director of the MPERTS should be knowledgeable in pre-hospital medicine and associated or familiar with the local EMS system.
- The appropriate allocation of physician and nursing resources is vitally important to patient flow:
- Physicians trained and experienced in pediatric emergency management should be placed at main triage and as charge physicians at the pediatric arena clinic.
- A good charge nurse will either make or break patient flow.
- MPERTS should be able to mobilize rapidly.
- Cooperation with regional disaster command is essential.
- Choosing the appropriate venue for the staging of the disaster response is critical:
- Providing enough room upfront to create a scaled-down version of an emergency department, including an area for observation and isolation, is critical.
- Mental health care and social services should be made available to the evacuated population as early as possible.
- A centrally located functional communication device (e.g., phone, cell phone, radio) is crucial to successful implementation; it provides access to additional essential staff and services quickly, on an ongoing basis.
- There should be a planned exit strategy:
- The clinic should not be allowed to outlive its resources.
- Once the cost of running the clinic outweighs the cost of referring those patients to the emergency department, the clinic should close its doors.
Many of the environmental problems that occur after a natural or manmade disaster are typical and predictable. These problems include temperature extremes; lack of clean water, food, and electricity; and environmental hazards not usually present before the event. Go to Table 11.1 for some of the more common environmental conditions and hazards that are likely to be present following a disaster.
The medical needs of children and families are also predictable and consistent because they closely match the needs of the affected children and communities before the disaster. Go to Table 11.2 for common pediatric medical issues, challenges, and adaptations that can be expected after a disaster.
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A Final Word
Timely response and appropriate medical management are essential to minimizing injuries and maximizing survival when a disaster occurs. Being prepared ahead of time is the key to timely and appropriate medical care. Children and other vulnerable populations have special needs that must be considered in the course of planning for a mass casualty event.
Pediatricians can play a very important and unique role in advocating for the needs of children and families who seldom receive enough attention in disaster planning. Response resources dedicated to pediatric populations remain unavailable or extremely limited for most emergency medical response activities related to disasters, even though victims often include children. To address this shortcoming, it is vitally important that pediatricians and other representatives of special populations take part in local, State, regional, and Federal disaster planning to ensure appropriate care for the most vulnerable populations.
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