Download Office Preparedness for Small - Academic Pediatric Association

Office Preparedness for
Small- and Large-Scale
Emergencies
Sarita Chung MD
Center for Biopreparedness
The Division of Emergency Medicine
Children’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
71%
66%
 Severe Asthma
58%
 Severe Dehydration
 Ongoing seizure
45%
 Closed Head Trauma
40%
 Epiglottis
30%
 Anaphylaxis
14%
 Cardiopulmonary Arrest 6%
Schweich et al. Pediatrics. 1991;88:223-229
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;85 710-714
Heath 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
 Naloxone
 Atropine
 Glucose
 Albuterol
 Antiseizure: Diazepam,
 Racemic Epinephrine
 Diphenhydramine
 Activated Charcoal
 Ceftriaxone
Textbook of Pediatric Advanced Life Support
Phenobarbital, Lorazepam,
Fosphenytoin
 Sodium Bicarbonate
 Fluids: Normal saline,
Dextrose containing fluids
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
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
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 Registration
for 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”
-M. Shannon, MD MPH
Chemical
Biological
C.B.R.N.E.
Explosive
Radiological
Nuclear
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
 Mimic Respiratory
 Botulism
Illnesses
 Skin Findings
 Nervous System
 Plague
 Small pox
 Tularemia
 Viral Hemorrhagic
Fever
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
 Vulnerabilities in
Children:

Faster respiratory
rates

Closer to the
ground
Increase risk of
cancer
weapon
 Damage of nuclear
containing facility
(nuclear power plant)

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
Oklahoma City Bombing
Alfred P. Murrah Federal Building 1995
 Pulmonary
 collapse of building can
cause highly hazardous
dust particles
Natural Disasters:
Hurricanes/Floods/Tsunami
 Greater risk of drowning
 may not know how
to swim or float

Hurricane Katrina, New Orleans, 2005
less mass, strength,
stamina to get out or
hold onto objects
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




Limited access to care
Lack of electricity
Lack of pharmacies
Compliance with
instructions, follow-up
Dehydration;
Hypothermia
 Increased family stress
 Predisposition to illness

group sheltering, water
issues, medication
availability
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