CE Article: EMS Response to Pediatric Disasters

It’s a spring afternoon, and you and your partner have just finished eating lunch when you get a call for a reported gas explosion at a nearby elementary school. You are the first EMS unit to arrive, and you are confronted with utter chaos: As you pull up, a frantic utility crew tells you they were conducting a small excavation in front of the school and that they ruptured a gas line just before it exploded. There is an uncontrolled fire with a partial building collapse in front of the school. They report several construction workers are severely injured, and they want you to come and help them. At the same time, multiple burned and unconscious children are being brought out of the school by teachers and the first-arriving firefighters and police. Where do you begin?

Pediatric patients who present to EMS are generally of mild severity and manageable number. In a disaster, the number of pediatric patients could easily overwhelm an EMS system. Children are more susceptible to being critically injured and sickened during a disaster due to their size and underdeveloped capacity to recognize danger and protect themselves.^1,2

EMS systems in the U.S. are built around a focus on assessment, treatment and transport of adult patients. This is consistent with the day-to-day calls for service in which overwhelmingly adults (approximately 90%)³ use their services. This leaves EMS systems and practitioners both ill-prepared to respond to a disaster involving pediatric casualties. Figure 1 depicts a small number of events in which children were the primary target within the U.S. and internationally. This article will detail some of the key elements required to plan for and respond to a disaster involving a large number of pediatric patients.

Pediatric Mass-Casualty Events

It is important to plan thoroughly for disaster response while at the same time acknowledging that the initial response to most disasters has never gone (nor will go) completely as any plan outlines. The early phase of a disaster will be chaotic and range from the first 30 minutes to the first few hours, depending on the extent of the catastrophe, the number and severity of patients and the ability of the system to bring trained EMS leadership to the scene to manage the response.

The involvement of a large number of injured children will prolong and complicate this chaotic phase; children invariably elicit an emotional response that can inhibit responders’ rational and clinical judgment. From a systems standpoint, though most prehospital agencies report having a written plan for MCI response, only 13% report having a plan for a pediatric mass-casualty incident.^1,4 While the timeline provided clearly shows that children are often affected by (and sometimes targeted for) disaster, many systems fail to account for a reasonable number of pediatric patients in disaster drills (based on one study, nearly 50%).⁴

Pediatric Disaster Triage

Most EMS systems in the U.S. utilize some version of Simple Triage and Rapid Treatment (START). Other triage systems include JumpSTART (a variation designed for pediatric patients), triage sieve, Pediatric Triage Tape and the Sacco Triage Method (STM). With the exception of the STM, none of these methods are evidence-based. Each of these systems uses four to five triage color categories, with red, yellow, green and black as the basis of sorting.

Currently there is no national standard for triage systems; thus there are several types and variations employed by EMS systems, each with different criteria, tagging procedures and terminology. MCIs, by virtue of their definition, overwhelm the available resources of the affected jurisdiction and often necessitate activation of mutual-aid agreements. EMS units that respond from other jurisdictions may employ different triage protocols and tags, further complicating the process.

There is little to no scientific evidence that the triage schemes utilized by EMS systems across the country are efficacious from an outcomes standpoint. That is to say, with the exception of the STM, no one triage system can empirically claim to decrease mortality and/or morbidity.⁵ Compounding this is that few EMS professionals in their lifetimes will have the opportunity to participate in a large-scale MCI and not only perform field triage, but receive feedback or quality assurance as to whether they triaged correctly. While many EMS providers may participate in disaster drills, those often do not emphasize proper triage, and many do not involve critically injured children as players.

Children complicate this process even further, as seriously injured children are often simply rushed away from the scene, if not by EMS, then by police or bystanders. The result is that pediatric patients who undergo the triage process are often overtriaged or uptriaged, meaning they are triaged to a category greater than the actual severity of their injuries (for instance, green to yellow) just because they are children. While this is primarily an emotional response to our human instinct to not wish to see children harmed, it is also a clearly stated policy of some EMS systems. While it may seem a desirable and reasonable disaster management policy to “just get the kids off the scene,” it places an immense burden on the receiving hospital(s) to perform a proper triage. Beyond the burden of triage, hospitals inundated with a surge of less-critical pediatric patients will have difficulties treating the truly acute patients when they arrive.

Another method that has been recommended for field triage during disasters is to have a pediatric emergency physician brought to the scene of a protracted, large-scale disaster involving a significant number of pediatric casualties. The physician can be utilized solely as a triage asset to assess the patients’ level of acuity, liaison with local hospitals and help to determine the most appropriate transport facility.

There is currently an ongoing effort to standardize triage methods on a national level. The Model Uniform Core Criteria for Mass Casualty Triage (MUCC) is an attempt to close this gap by providing a framework by which all EMS systems can speak the same language and perform the same core functions when it comes to MCI triage.⁶ This model is being incorporated in EMS systems across the country and is based on 24 core criteria guided by four principles:

• Sort casualties into triage groups;

• Perform an individual assessment of the triaged patient;

• Provide lifesaving interventions; and

• Provide treatment and/or transport.

The SALT triage system is grounded by scientific and evidence-based principles, and has been introduced by an expert panel of leaders from across the EMS community as a consensus-based model.

Beyond fundamental triage principles, pediatric disaster experts universally agree that where possible, pediatric patients should never be separated from their caretakers. This is irrespective of their triage categories. For instance, if a 5-year-old child (green) is with her father (yellow) and they are sorted into different triage categories, they should both go in the higher triage category assigned (yellow). The exception to this is obviously grey and black tags.

Moreover, noncritically injured children should not need to bear witness to the death and destruction from whence they emerged. Children do not need to be rapidly removed from the scene; however, they should be removed from the immediate action. When possible, sorting, treatment and staging of noncritical pediatric patients should be performed out of sight from the disaster scene (and obviously away from danger). They should also be physically (if not visually) separated from critically and mortally injured children and adults.

The Pediatric ‘Golden Hour’

Children possess different physiological strengths and weaknesses when faced with physical trauma. They can maintain their blood pressure longer in the face of hemodynamic shock; they can increase their heart and respiratory rates to rates unobtainable for adults to compensate for respiratory and metabolic acidosis. These are strengths. Yet once these compensatory mechanisms begin to fail, children decompensate far more rapidly than adults. While their softer skeletal structures allow for more pliability and fewer fractures, they do not provide the protection to underlying organs of a more rigid adult skeleton. As such, trauma to children’s softer bone structures often results in “hidden” injuries to the underlying organs that are not easily detectible by field assessment methods.^7,8 Inspection and palpation for deformities, crepitus and bruises/contusions may initially find nothing. The child may be assigned (or remain) a green or yellow triage based upon this. Upon reinspection, any of these findings on the trunk or pelvis could herald a rapid deterioration in status. This is where the conventional triage system fails to meet the medical needs of children.

Smaller and rural systems may, due to manpower issues, face a serious challenge in being able to utilize an effective triage system early in an event, and they may also have limited availability of appropriate trauma and pediatric-capable ERs. In systems where transport times to pediatric trauma centers are prolonged, pediatric patients may have a favorable outcome by being transported to a local or regional Level 1 adult trauma center or pediatric-capable ER. Once stabilized, they should be transported by critical care ambulance to a facility with a PICU.

Treatment of Casualties

Nationwide, very few EMS calls involve children (on average 10%),⁹ and even fewer produce pediatrics with a level of acuity that challenges an EMT’s or paramedic’s skills (less than 1% of EMS calls).³ This presents a scenario in which there are too few critically injured pediatric patients for EMS crews to encounter and become comfortable with in advance of a mass-casualty incident. Several studies have shown that prehospital ALS treatment of pediatric trauma patients is suboptimal when compared to their adult counterparts. In one particular study, researchers found that prehospital IV attempts for adult trauma patients were successful 85% of the time, compared to 65% for pediatrics. Moreover, those pediatric patients suffered from a lack of IVs, and 25% required fluid resuscitation.¹⁰ Accordingly, emphasis should be placed on delivering high-quality pediatric advanced life support (PALS) combined with minimal transportation times.

Another issue with providing treatment at the scene of a disaster is equipment. Few EMS systems outside large and medium-size cities have enough long spine boards, portable suction, oxygen, etc., to treat and transport 50-plus patients. Even fewer have the equipment necessary to treat this number of pediatric casualties. And beyond possessing the equipment lie the logistics of inventorying, rotating and transporting it to the scene. In an urban EMS system, this may not be as much of a concern (although many urban systems lack enough pediatric supplies for a disaster); however, the reality is that the majority of EMS systems in the U.S. are rural and small-town. To these systems, meeting the needs of a disaster is a huge challenge.

The federal government, through FEMA, can deliver Strategic National Stockpile (SNS) medications and supplies in what is known as a 12-hour push package.¹¹ This is a 747-sized cache of disaster supplies that can be flown or trucked into a disaster site. However, these resources will only be called up in a declared disaster (not like the scenario in the introduction) and will require your state’s governor or the president to mobilize. Also, as the name suggests, you should expect to wait up to 12 hours for delivery. All disasters are local. Your system should be self-reliant and plan to treat casualties with the assistance of local mutual aid.

We recommend that EMS systems develop a pediatric disaster response cache that can be quickly brought to the scene to support operations. The cache should contain the same ALS and BLS equipment and supplies that are in your current formulary, in quantities sufficient to support an incident that would constitute a pediatric disaster for the population your system covers. The goal is to be able to initially (for the first 12 hours) support your units at a protracted incident involving more pediatric patients than the equipment in your units can handle. Smaller jurisdictions should join resources with their mutual-aid partners to create and manage a single regional cache.

Lastly, current American Heart Association recommendations call for the use of “weight-based measuring tape with precalculated doses” for pediatric patients. Research shows overwhelmingly that in emergent situations, healthcare providers routinely under- or overestimate children’s weights.^12,13 The Broselow tape and other weight-based measuring tape systems are designed to eliminate error by removing the need to estimate the child’s weight.

Transport

Transportation of the injured child after a disaster is a key decision point in your management of the incident. While pediatric patients account for nearly 25% of ED visits annually (29 million in the U.S.), only 6% of ERs are pediatric-capable according to the Institute of Medicine.¹⁴ That means roughly 94% of ERs across the country lack the proper equipment, expertise and training to manage critically injured children. A recent report found 17 million children live more than one hour by ground from a pediatric-capable trauma center.¹⁵ On a day-to-day basis, this is not an issue because most pediatric ER visits do not require advanced (intensive) care. However, during a disaster this gap in capabilities is exacerbated.

This leaves EMS professionals with the difficult challenge of performing a multistage triage and assessment process: initial on-scene triage, followed by a secondary assessment to determine the presence and extent of injuries, and then a third, more cerebral triage of “Can they actually make it to a pediatric ER or trauma center?” In the field this is a daunting task, especially with hidden injuries and children’s inability to properly communicate complaints after a traumatic event. Moreover, on-scene triage is not generally competent at performing the more nuanced secondary and tertiary triages required for pediatric patients. Since many hospitals lack pediatric ERs, the most prudent decision based on research and consensus is to transport the critically injured child to the nearest trauma center for immediate stabilization and utilize non-trauma adult ERs for less-acute pediatrics.^16,17

Unlike adults, green-tag pediatric patients cannot refuse medical aid at the scene unless there is a parent or caregiver present. Therefore EMS systems should be prepared to transport large numbers of noninjured children simply for the purposes of removal from the scene and family reunification. This is best accomplished in coordination with local emergency managers. Often, school or commuter buses are brought in for mass transport of the uninjured. These transportation decisions should not be made in a vacuum; consult area hospitals before transports begin—if not initially, then once formal triage, treatment and transport sectors are established. Often alternative sites can be secured for family reunification.

The EMS officers heading the treatment and transport groups must collaborate to determine transportation modes and priorities. The transport group supervisor must make an active effort to notify each hospital in their catchment area of what is known and what can be expected (number of red tags, extent of traumatic injuries, etc.). Electronic patient tracking is key to not only properly performing the function of mass-casualty transportation, but from a pediatrics standpoint tracking where separated children are taken. This will benefit the overall management of the incident and improve continuity of care.

Conclusion

Of 3,700 EMS agencies surveyed in 2005, 86% lacked a pediatrics-specific mass-casualty plan, and 80% did not use a pediatric triage plan.⁴ EMS agencies need to do more to provide supplemental training and ensure competency in pediatric care and disaster response. Furthermore, jurisdictions should conduct regular disaster drills with at least 25% of the patients being pediatric (that’s the percentage of children in the population),¹ with varying levels of acuity.

Any disaster will include an early chaotic period where efforts at performing triage, treatment and transport to appropriate facilities will be marginalized. Within this context, pediatric care is often reduced to “scoop and run,” especially when more critical patients may emerge shortly. EMS agencies are advised to adopt the MUCC/SALT methodology into their disaster triage protocols and procedures, and to institute proper triage, treatment and transport (and electronic tracking) early in the incident. Agencies and jurisdictions are also need to develop disaster caches of medical supplies and equipment specifically geared toward pediatrics, and explore alternative methods of transportation. EMS systems and professionals must see themselves in the larger context of disaster health and partner with their local healthcare, emergency management and disaster mental health experts to plan and respond to pediatric disasters.

References

1. Burke RV, Iverson E, Goodhue CJ, Neches R, Upperman JS. Disaster and mass casualty events in the pediatric population. Semin Pediatr Surg, 2010 Nov; 19(4): 265–70.

2. Weiner DL. Lessons learned from disasters affecting children. Clin Pediatr Emerg Med, 2009 Sep; 10(3): 149–52.

3. Little WK. Golden hour or golden opportunity: Early management of pediatric trauma. Clin Pediatr Emerg Med, 2010 Mar; 11(1): 4–9.

4. Shirm S, Liggin R, Dick R, Graham J. Prehospital preparedness for pediatric mass-casualty events. Pediatrics, 2007 Oct; 120(4): e756–61.

5. Bass RR. Model uniform core criteria for mass casualty triage. NEMSAC briefing, 2012.

6. Federal Interagency Committee on Emergency Medical Services. National implementation of the model uniform core criteria for mass casualty incident triage, 2013.

7. Lyle K, Thompson T, Graham J. Pediatric mass casualty: Triage and planning for the prehospital provider. Clin Pediatr Emerg Med, 2009 Sep; 10(3): 173–85.

8. Waltzman M, Fleegler E. Preparing for natural disasters. Clin Pediatr Emerg Med, 2009 Sep; 10(3): 144–8.

9. Stroud MH, Prodhan P, Moss MM, Anand KJ. Redefining the golden hour in pediatric transport. Pediatr Crit Care Med, 2008 Jul; 9(4): 435–7.

10. Baker TW, King W, Soto W, Asher C, Stolfi A, Rowin ME. The efficacy of pediatric advanced life support training in emergency medical service providers. Pediatr Emerg Care, 2009 Aug; 25(8): 508–12.

11. Office of Public Health Preparedness and Response, Division of Strategic National Stockpile. National Stockpile Fact Sheet, www.cdc.gov/phpr/documents/DSNS_fact_sheet.pdf.

12. Rowe C, Koren T, Koren G. Errors by paediatric residents in calculating drug doses. Arch Dis Child, 1998 Jul; 79(1): 56–8.

13. Lesar TS. Errors in the use of medication dosage equations. Arch Pediatr Adolesc Med, 1998 Apr; 152(4): 340–4.

14. Mace SE, Sharieff G, Bern A, Benjamin L, Burbulys D, Johnson R, Schreiber M. Pediatric issues in disaster management, part 1: the emergency medical system and surge capacity. Am J Disaster Med, 2010 Mar–Apr; 5(2): 83–93.

15. Nance ML, Carr BG, Branas CC. Access to pediatric trauma care in the United States. Arch Pediatr Adolesc Med, 2009 Jun; 163(6): 512–8.

16. Ross DW, Rewers A, Homan MB, Schullek JR, Hawke JL, Hedegaard H. Factors association with the interfacility transfer of the pediatric trauma patient: implications for prehospital triage. Pediatr Emerg Care, 2012 Sep; 28(9): 905–10.

17. Shah MI. Prehospital management of pediatric trauma. Clin Pediatr Emerg Med, 2010 Mar; 11(1): 10–7.

Donell Harvin, DrPHc, MPH, MPA, EMT-P, is an assistant professor and program coordinator of emergency management at John Jay College in New York City, and a former NYC paramedic of 20 years. Contact him at dharvin@jjay.cuny.edu.

Nora Caplan, MPA, EMT-B, is project manager for the New York City Pediatric Disaster Coalition and a research associate at Cornell Medical College. Contact her at nora.caplan@jjay.cuny.edu.

Sean M. Kivlehan, MD, MPH, NREMT-P, is the emergency medicine chief resident at the University of California San Francisco and a former New York City paramedic for 10 years. Contact him at sean.kivlehan@gmail.com.