Download Managing Pediatric Patients After Hurricanes

Managing Pediatric Patients After
Hurricanes: Perspectives from the
2004/2005 Hurricane Seasons
©Lou Romig MD 2006. Used with permission.
Objectives
Describe post-storm environmental
constraints that may prevent optimal
care.
Discuss the most common pediatric
complaints seen in the emergency
medicine setting after hurricanes.
Describe adaptations to standard
practice that may enhance care of
children after hurricanes.
The medical needs of children and
families after hurricanes are
predictable and consistent…
because they closely match the
needs of children and families of
the affected communities before the
events.
Universal Threats
Injury
Acute infections
Chronic illness
Lack of access to care
Compromised caregivers
Key Concept
The changed
environment is the
biggest challenge
to excellent
medical care after a
large disaster
FEMA Photo Library
FEMA Photo Library
Environmental Constraints:
Physical
Temperature/exposure
Sunburn, dehydration, heatrelated illness
Sweating, dirt, topical
chemicals
Environmental Constraints:
Physical
Lack of clean water
Dehydration
Poor hygiene
Limitations in wound care
Environmental Constraints:
Physical
Lack of appropriate food
Inadequate nutrition
Inappropriate diet
Environmental Constraints:
Physical
Lack of electricity
Nebulizers, other medical
equipment
Refrigerators
Light, ventilation
Information deficit regarding
hazards
Environmental Constraints:
Physical
Hazardous environments
Lacerations, punctures
Falls
Motor vehicle trauma
Tool-related injuries
Weapons
Environmental Constraints:
Physical
Hazardous environments
Chemical exposures
Allergens
Insects/animals
Environmental Constraints:
Social/Infrastructure
Disruption of healthcare
systems
Primary medical care
Specialty medical care
Hospital-based care
Home health care
Third party payers
Environmental Constraints:
Social/Infrastructure
Disruption of supply chains
Pharmacies and other stores
Durable medical goods and
consumable supplies
Environmental Constraints:
Social/Infrastructure
Disruption of schools/childcare
Interference with caregivers’
work and recovery activities
Lack of supervision in
hazardous environment
Lack of usual counseling or
other school-based medical
services
Environmental Constraints:
Social/Infrastructure
Lack of security
Hesitancy to leave unsecured
property to seek medical care
Lack of mobility
Loss of jobs and other financial
support
Environmental Constraints:
Emotional
Fear
Insecurity
Guilt
Helplessness/loss of control
Anger
Denial
CONSTRAINTS
ADAPTATIONS
Common Pediatric Problems
Pulmonary
Gastrointestinal
Infectious diseases
Trauma
Psychosocial
Pulmonary
FEMA Photo Library
Pulmonary: Problems
Bronchospasm is common in those
with and without histories of asthma
Children with bad/labile asthma
present early due to stress,
environmental triggers, lack of meds
Stable asthmatics start showing up as
triggers increase or meds run out
Pulmonary: Problems
Bronchospasm due to respiratory
infection starts to present after the
first 3-5 days
October storms correspond to
high allergy season and a slight
peak in RSV incidence
Pulmonary: Adaptations
Need adequate supplies to treat
patients
Premixed beta agonists for neb
(infant and child dosing)
Neb capability with and without
oxygen
Pedi neb masks and pipes
Oral and parenteral steroids
Peak flow monitoring nice but
not necessary
Pulmonary: Adaptations
Outpatient treatment
Allow use of facility’s electricity
for families giving their own
nebs. (Do these patients need tx
records?)
Consider using MDIs w/spacer
chambers more frequently
Be liberal with steroids
Counsel regarding allergen
exposure
Pulmonary: Adaptations
DO NOT yield to
the temptation to
treat every febrile
pediatric wheezer
with antibiotics.
Bacterial
“bronchitis” is rare
in children.
FL5 DMAT Photo
Pulmonary: Decisions
Lower threshold for admission based
on available resources and ongoing
hazards
Consider recommendation to
temporarily remove child from the area
to a healthier environment
Temper decisions with consideration of
family’s existing resources and
demands on family members
FEMA Photo Library/Dave Gatley
Gastrointestinal
GI: Problems
Close living quarters may lead to
transmission of GI viral illnesses
Limited water and facilities for
washing. Limited diaper/hygiene
supplies.
Inadequate sanitation in field
kitchens/food distribution points
GI: Problems
Norovirus precautions go beyond
soap and water or alcohol
Erratic availability of potable
water and oral rehydration
solutions
MRE’s have high sodium/high
calorie content
Don’t forget
about
contaminated
ice!
FEMA Photo Library
GI: Adaptations
Ask about sheltering situation. Give
specific infection control instructions
(written if possible).
Health care sites can act as
distribution points for hygiene items
such as alcohol solution, diaper
wipes, diapers, soap, garbage
(biohazard?) bags/gloves, bleach
Maintain contact with public health
officials
GI: Adaptations
Ask about diet specifics,
including origin of drinking water
and food storage conditions
Warn families of need to increase
fluid intake if eating MREs
Consider unusual electrolyte
abnormalities in clinically
dehydrated children
GI: Adaptations
Distribute oral rehydration
solutions
Focus on oral rehydration
protocols unless staff and IV
fluids are in adequate supply
Limit use of antiemetics and
antidiarrheals in children
GI: Adaptations
Minimize infant formulaswitching.
Use stool volume replacement
techniques in cases of diarrhea
Staff must be protected against
food poisoning!
GI: Decisions
Admission decisions must
include consideration of shelter
status
Lower admission threshold if
adequate outpatient management
is doubtful
If in doubt, schedule patient
rechecks
Infectious Diseases
Infections: Problems
Infections will mostly follow
existing community patterns
“Third world” type epidemics
have not occurred in the US
Isolation/segregation of infected
is difficult in the post-storm
environment
Infections: Problems
Kids need different preparations of
antibiotics, some requiring
controlled environmental conditions
Pharmacies and drug supplies may
be limited and may focus on adult
medications
Skin infections are common; good
hygiene is not.
Infections: Problems
Penetrating injuries to the foot
are common. Pseudomonas must
be suspected.
Community acquired MRSA is an
increasing problem.
Animal Control may be
problematic. May need to
prophylax patients against rabies.
Infections: Problems
Local pharmacies may not honor
prescriptions by non-local federal
responders
Infections: Adaptations
Contact local public health or
hospital officials for intelligence
regarding existing infection
patterns
Cooperate with public health
officials in monitoring efforts
Assist in informing shelter staff
of infection patterns seen and
what to look for
Infections: Adaptations
Educate patients and families about
infection control issues, especially if
they are shelter residents
Prescribe antibiotics judiciously. Use
the simplest appropriate form for the
shortest practical course.
Use alternative medication
formulations (chewable tabs, crushed
tabs) and those that don’t require
refrigeration
Infections: Adaptations
Obtain and distribute information
about pharmacies in operation
Inform local pharmacies about
prescribing privileges for federal
responders
Consider distribution of starter
doses of medications
Infections: Adaptations
Distribute hygiene and wound care
supplies, insect repellant and topical
or oral meds for
itching/inflammation
Plan follow-up for penetrating and
contaminated injuries (especially
nails into feet)
Consider using ciprofloxacin for
children with penetrating wounds
through shoes into feet
Infections: Adaptations
May use first generation
cephalosporins for most skin
infections
Consider adding TMP-Sx if
CAMRSA is suspected
Dialogue with local public health
about rabies exposure
Recognize that most children will
NOT need a tetanus booster
Infections: Decisions
Consider family’s environment
and mobility when making
decisions about admission vs.
outpatient treatment with
rechecks
May need to admit children with
highly contagious diseases to
avoid exposing others in a
crowded environment
Infections: Decisions
Consider sending infected
children out of the area if more
appropriate shelter is available
Maintain low admission
threshold for the very young with
fever and immunocompromised
patients
Use antibiotics judiciously
Trauma
Trauma: Problems
The post-storm environment is
hazardous!
Children may not have adequate
supervision or may be asked to
perform inappropriate tasks
Children are risk-takers
Trauma: Problems
Minor skin and musculoskeletal
injuries are common
Penetrating injuries by contaminated
small objects are common
Skin foreign bodies are common
Major trauma is not common
Trauma: Problems
Increased chance of:
Tool-related injuries
MVC due to unregulated
intersections
Flame and contact burns
Firearm injuries
Trauma: Problems
Increased chance of:
Carbon monoxide exposure
Hydrocarbon and bleach
ingestion/aspiration
Ingestion of medications
Drowning
Intentional injury
Trauma: Adaptations
Carefully document mechanisms
of injury
Be prepared to stabilize a badly
injured child
Identify local pediatric trauma
and burn care resources
Have access to Poison Control
resources
Trauma: Adaptations
If lacking x-ray, splint the injured
extremity on any child with bony
tenderness, regardless of lack of
deformity
Emphasize elevation and
splinting of an injured extremity
for control of pain and swelling.
Ice may not be a viable option.
Trauma: Adaptations
Provide the best possible initial
wound care. Do so in as comfortable
an environment (for the patient) as
possible.
Consider delayed/no closure for
contaminated wounds or possible
retained foreign body.
Consider self-absorbing sutures for
children with lip, finger or toe lacs
Use skin glue only if wound is clean
Trauma: Decisions
Follow-up care may be the
biggest issue. Patients may need
to go to another facility to initiate
contact with subspecialty care
providers.
Make some allowances for
unusual circumstances but be
alert for potentially negligent or
dangerous family situations
Psychosocial
Psychosocial: Problems
When a child is sick or injured,
their loved ones are also your
patients
Families may have difficulty
coping with their child’s illness
or injury
Delay in seeking care may be
more common than in ordinary
circumstances
Psychosocial: Problems
Families may not have primary
care resources to begin with
Compliance with treatment
recommendations may be
difficult
Stress may lead to higher risk for
child abuse
Psychosocial: Problems
Pediatric mental health goes beyond
PTSD
Children with mental health issues
may present with acute or prolonged
nonspecific physical symptoms
Parents are not educated about
children’s reactions to catastrophic
stress
Psychosocial: Adaptations
Assume family members don’t
get your message the first time.
Write down instructions for
family
Always ask, “Is there anything
else we can help you with?”
Psychosocial: Adaptations
Address children directly. Let
them know what they have to say
is important and that they have a
role in feeling better.
Encourage children to express
their feelings
Make the visit as pleasant as
possible for the child
Little
things
mean a lot
Psychosocial: Adaptations
Explore alternatives with the
family to help assure compliance
with treatment recommendations
Avoid judgmental attitudes
Identify local resources for
family psychosocial support
Use available mental health
resources
Summary
Post-storm pediatric illness and
injury is predictable.
The environment poses the
greatest number of constraints on
being able to provide excellent
pediatric medical care
Emergency responders must
adapt to the new practice
environment in order to help
families adapt and cope
Summary
Minor injuries are a common cause
for pediatric emergency care visits
Skin infections and problems are
common complaints
Respiratory illness is another
common medical complaint
Infections pose additional problems
in the post-storm environment.
Safety education is a critical aspect
of post-storm medical operations