SCCM Resource Library-When a Mass Disaster Involves Kids, How Do We Tailor Our Response?

Video Transcription

Good morning. My name is Bruce Greenwald. I am going to be moderating this session. The session, in case you're unsure of what room you're in, is when a mass disaster involves  kids, how do we tailor our responses? I'll give anybody who went to the wrong room a moment to leave, and then we're going to get started.  Our first speaker is Matthew Borgman, who is the Chief of Pediatric Critical Care Medicine  at Brook Army Medical Center and an Associate Professor at the Uniformed Services University. Dr. Borgman will be speaking about pediatric triage in a mass critical care event.  All right. Thank you for that introduction for giving me a chance to talk. Obviously, I'm military looking, and so nothing I can say is representative of the Army, Department  of Defense, the government, et cetera, et cetera. So here are my objectives. So I'll first discuss a little bit of how often are children involved in mass cows.  I'll review the concept of triage. That may be a bit of a review for some of you, but maybe not.  But I think just to get us started, it's probably good just to put that information out there so that we're using the same terminology.  There's a bunch of tools out there, triage algorithms. I'll hit the main ones just that you need to be aware of if you want to be involved in this business.  There's not much out there in terms of literature. I'll hit a few highlights that describe the use of those tools, and then talk about some  resources and preparation for those events. So children in mass cows. So again, I'm cherry picking here, but just to put up a few numbers there, Parkland, Florida,  as you see, 14 children, three adults. The Boston Marathon bombing, a good proportion of kids.  The Newtown shooting, again, these school shootings are obviously going to involve kids. This airplane one, you see it's about 50-50.  The Oslo shooting in Norway, which was a devastating one, was at a youth camp. So primarily older kids, but nonetheless, quite a few kids and young adults there.  The Haiti earthquake, so a non-shooting type event. Thousands of people injured and sick, and just dealing with the consequences there.  And probably some of you, if you were involved in any of the relief, know that it was quite a few, more than half, were children. And then Southern Springs.  So this is actually in my neighborhood. So I had actually just gone to our church, we did the early service.  And then my daughter had, I think it was pinkeye, and as you know, with pinkeye, even though it's viral, you have to go to the doctor's office to get a little note to say that.  So I was in the ER, actually in our ER, with my daughter, and then noticed a little bit more chatter and stuff going on when they were getting initial word about this attack.  So suddenly things started moving a little quicker, right? So they finally sent a PA over to us to give us our ointment or whatever and a note for school.  I was actually on call, and so it happened that then I went up and dropped my daughter off at the hospital service in the workroom there for the hangout with the residents,  and then helped out down in the ER where we got a couple of the kids. It was split between Brooke Army Medical Center and University Hospital.  But then again, there's, I think, one important concept in terms of decompressing, right? So whether it's the ER decompressing those non-urgent things, decompressing people from  the ICU to the ward, ward to out, you know, if you start getting initial word about a potential event, shooting, or whatever it is.  So in general, you know, putting this out there, it's hard to give an exact number, but a significant proportion of mass cal events are going to involve children, and so we have  to be prepared, and that's why I think we're here today and having this discussion. So I don't think I need to go over the definition of triage, but, you know, every ER has a triage  nurse right at the beginning. In terms of mass casualties, though, we, you know, it changes slightly, right, in terms  of this utilitarian principle of doing the most good for the maximum number of people. When we look at all the systems that are out there, and, you know, I looked at, kind  of skimmed through about 20 of them that are out there, and they all follow this general pattern in looking at the ability to walk, right, because then you can kind of get people  that are walking up, they should be breathing and perfused relatively well to sort them out from the rest of the crew.  They next go through looking at who's breathing, you know, kind of this ABC approach, those  who, you know, looking at bleeding, perfusion stuff, and then, you know, are they, can they follow commands.  Obviously in that there's a few pediatric differences, right, so younger kids, especially if they can't walk, you know, that doesn't apply.  If they are nonverbal, they can't really answer questions or follow commands if you're trying to apply that to them, so stuff needs to be adapted for them.  And as you know, and you're probably well aware of, that, you know, children are a bit more susceptible to head injuries, airway obstructions, hypothermia, so that can be relevant.  And with a child, you just don't have one patient, so to speak, right, you have the family unit, and so the whole next talk will be dedicated to that, given that it's a topic  in and of itself. Again, just to hit some common definitions of triage categories, this is probably a review for most of you.  So the mnemonic DIME is how we typically talk about it, minimal, those who can, you know, walk, minor injuries, don't need much delayed, or those who need a significant intervention  but doesn't need to happen now. So there's varying definitions of what, how long to wait is, but anywhere from 12 to 24 hours, depending on which reference you're looking at.  So large fractures, you know, some burns, wounds that, but they're not in, you know, currently shocked, they don't need active resuscitation.  And then the immediate category are the ones you need to deal with right now, right? They need that life-saving intervention, whether it's surgery, some angioprocedure  for internal bleeding, the attention pneumo, airway obstructions, they need immediate stuff. And then the expectant or dead, or willed to die, and again, this is, again, based on  resources, and all these categories just emphasize is a dynamic process, right? So triage is a dynamic process, it's not just one point in time.  So things can change, it can change based on the patient's status, right, as they deteriorate or get better, and it can also depend on your resources, right?  If you suddenly run out of resources, that's going to affect in terms of what kind of care you can provide. So here's a few tools.  So here's just, you know, typical triage cards that can be put on patients. And again, I think it's important to, you know, that these need to be attached to the  patient, as well as I threw up some chemlights here. When we do these drills in the military, we're always doing them at night, and it just adds  a huge level of chaos when you're doing these, especially these point-of-care type triage stuff at night, in terms of identifying the casualties.  You know, once they're in a different place, it's just hard to track what's going on. So chemlights are just another important tool.  And I'll go over some other stuff, too, to talk about in terms of tools and pearls. All right, so going through the triage systems that are out there, I think, you know, I think  for our audience, this is probably the ones to remember, at least these first three. So the START algorithm, the simple triage and rapid treatment, that's the one that's  been around the longest. Probably the most common used in US, Canada, Australia, as well as Israel. It's made for those who are eight years and over.  So these are, you know, they need to be following commands. The vital signs in there are written for those kids who are a little older. And that would be the next slide.  SALT algorithm is a bit newer. And again, I'll have this up here shortly. Endorsed by the American College of Emergency Physicians, the American Academy for Surgery  and Trauma, so the American College of Surgery. So it's newer, but endorsed by the major groups that are out there. And then the jump start.  So this is one that's been written more recently for children. Basically ADAPT starts with some physiologic parameters that would make it applicable for children.  And then I'll show you an example of a pediatric triage tape. So here's the START algorithm. So again, it goes through that basic algorithm of anybody can walk first are sorted into  the minor, right? Those who can breathe. If they cannot, you do one attempt at opening the airway. If it works, great. They're immediate.  If not, they're considered deceased or expectant. For the airway people, yes. If they're breathing super fast, they're considered immediate.  Do they have potentially attention pneumo or some intervention that's necessary there? If they are breathing okay, and this is under 30 a minute as they categorize it, then there's  a perfusion check. If they have decent perfusion, if they have good mental status, they're considered delayed. If not, they're considered immediate. And you can read the rest there.  So the SALT, again, this is that newer one. So it begins with this sorting, global sorting. So those who can walk, again, are you check them out third.  The ones who can wave but can't move or walk are second. And those who are still or have potentially life-threatening injuries, those are the ones you go after first.  And again, these aren't triage categories. This is a global sorting event. So you do this global sorting, and again, this is probably best for the larger groups.  Then you do this individual assessment. So what's that individual assessment? So S-A-S-S, so sort, assess, and then these life-saving interventions. So what are they?  So controlling major hemorrhage, opening the airway, and if it's a child, consider giving a couple of rescue breaths, plus minus on there, chest decompression and auto-injectors  if it's a C-burn event. So if they're not breathing, they're considered dead. If they can breathe, you ask these questions. Can they obey commands? Do they have a peripheral pulse?  Are they not in respiratory distress? And is any major hemorrhage controlled? So I think this has the advantage of really addressing major hemorrhage like ATLS, the  big emphasis in ATLSs. So all those things are present. It's just minor injuries. They're minimal.  If they're not minor injuries, they're going to need major interventions, but it can be wait. They're delayed.  And then if any of those questions are no, it's really a question of resources, right? Do we have the resources to take care of it?  If we can and they have something potentially major here, then yes, they're immediate. If not, they're expectant. So again, that's a SALT algorithm.  The jump start, again, is similar to the START algorithm, but it adds a few unique physiologic things for children in terms of giving some rescue breaths.  Instead of can they follow commands, it inserts the AVPU scale for a better neurologic assessment.  And then there's a couple triage tapes out there, but essentially it looks like this where you rolled it next to the patient.  There's an algorithm here at the bottom and then essentially like a Braslow tape, right?  But depending on how tall they are, the appropriate vital sign type assessment will be appropriate based on their height. There's fairly limited use. It's fast.  It's pretty simple to use. Some of the references out there I looked at showed that it's pretty specific, but poor sensitivity for more severe injuries.  So again, not much out there in terms of evidence for these. A couple I picked out here, which seemed like the better studies on comparing and contrasting  these major tools was the SALT in general is overall more accurate and a start frequently under triages by this article in the American Journal of Disaster Medicine.  In children, they compared this one study, looked at SALT and JumpStart, found that both performed similar in terms of sensitivity specificity, but that at least the paramedics  in this group were able to typically do the JumpStart eight seconds faster per patient. Again, just one study, but that's what's out there.  So far, I think you may have caught on with these triage systems that they're typically geared towards disasters, collisions, car crashes, MBCs, typically what we see here  in the States, right? A building collapse, but less focused on seaburn and terrorism. So it's very hard to make one size fits all for these things.  So just to hit a few of those seaburn things at least, so chemical exposures. Potentially more risk, right, for these heavier gases that sink lower to the ground.  And so they could potentially get a higher dose effect by inhaling something like chlorine. So looking at this chlorine spill back in 05 in South Carolina, they reviewed applying  triage categories to that and how things worked out. Interestingly, the main lesson learned, I think, from this was that pulse oximetry,  which you didn't hear on any of those triage algorithms, was actually more predictive of outcome and how severe injury or, say, dose effect they got of a chemical event.  So I think that was the main pearl I took out of that. Another study reviewed some other chemical incidents, and again, this is hard to do studies on this kind of thing.  Blister agents. So thankfully, it's not a common thing we need to deal with. One of the main, I think, recent history events was back in the 80s with the Iran-Iraq War.  That was back when you had chemical Ali, right, and Saddam, subjecting the Kurds to all sorts of bad things. So they released a bunch of mustard gas.  There was also some other nerve agents, I think, mixed in there, and thousands injured. Typically, it's affecting the eyes, the skin, and respiratory stuff, but in these events,  they're not all presenting at once. So with blister agents, especially, it's kind of a delayed presentation.  If it's going to be burns, it's going to be 12, 24 hours plus as it starts to take effect. These patients that the—so it was an Iranian doctor that I was reading his report of this  event, because that's where they're—who was taking care of them at the time, also described pneumonia that occurred about a week after the exposure.  So just terrorism in general, looking at what's in the literature. So that horrible shooting event in Norway, they didn't have a nationally recognized triage  system at all that was used. They just kind of did basic triage as they understood it at the scene.  But looking at some of these other attacks in general, as this one study reviewed it, things are different, right?  So I think if you've ever been involved in a typical mass cow, that's typically not involving terrorism, it's still stressful, right?  Everybody's adrenaline is going, and it's pretty intense, right? So can you imagine adding the new level of, oh, jeez, there's somebody who might shoot me.  There's a lot of other stuff going on, and I think it added—just made it a lot more complex and made it difficult for the triage officer with having the fear of uncertainty  of what's—are there going to be additional attacks, secondary attacks, all that kind of stuff. So not necessarily something that's—it's harder to plan for that, right?  But it's certainly something that should be discussed. So just to throw out some potential tools, and we're going to have a talk upcoming about how to plan for this kind of stuff.  So just to put out a couple of these things, so here's just an example, some mass casualty incident kits.  You know, also, let me just plug the societies, you know, has a whole fundamentals of disaster management which goes over these kinds of things.  Hemorrhage kits, which involve—you know, has to involve tourniquets, right, and trauma dressings because, you know, after—you know, with the triage officer there, you definitely  need a treatment team to hit those immediate life-saving interventions at the scene. Head seals, needle decompression, in the setting of nerve agents, you should have antidote  kits because, again, they need to be given out at the scene as quickly as possible. And then, you know, I added this in terms of pulse ox for if it's going to be a chemical  type exposure event. So we've been talking about shootings and disasters and mass casualty, right, but, you  know, I think it's timely we should also talk about some more critical care type events. So that's the Leishenshan Hospital that was just made in, what, 10 days there in the  Wuhan province, you know, which just blows my mind. I think any of you all who've had an addition put on your house, that takes months, right?  I mean, just—it's—if you haven't, like, Googled or YouTube, like, you know, the video of how this is put together in 10 days, please do that. It's just remarkable.  So, but, you know, I think it's worth thinking about, right? I mean, you know, certainly I don't think we could put this up in 10 days here in the  States, but, you know, what if, you know, what if we do need to prepare for this kind of thing?  Thankfully, you know, with this coronavirus, it's hitting the older people more, but what if it's more like the Spanish flu, right? It's affecting children.  You know, this is 1,000 beds. Think about 1,000 beds here. What if half of them are kids? You know, the case mortality here is, what, around 2%, but, you know, what if it's higher?  The critical care proportion of the hospitalized patients in coronavirus is about a quarter, 25%, but, gosh, what if that was children? You know, how would we even approach that?  You know, I think we can talk about things now, but, you know, it certainly needs to go beyond talking and brainstorming ideas. It needs to be planned for.  You know, probably many of the audience, you know, I know taking care of children with respiratory stuff, you know, oftentimes it's just some high flow, and oftentimes you can  get by with room air, right, so, you know, I think that could be considered, but especially if oxygen becomes a limited resource, right, so how would we deal with that there?  Can we apply technology? You know, whether it's, you know, auto weaning, I think, you know, typically we're pretty  slow weaning oxygen in general, right, with our patients, but, you know, absolutely need to think about it in this setting, right, whether you have some sort of closed loop  weaning or, you know, intelligent weaning system or, you know, or would it be some sort  of system like, you know, like our Nest thermometers, right, where, you know, if you're giving too  much oxygen somewhere, you can divert it to the places that you need it, so, you know, I think we need to think about some future solutions, right?  We've talked a lot about AI machine learning, you know, could you apply that to putting a whole bunch of monitors on all the children there that can immediately do these triage  type stuff, figure out which of the patients you need to see if the nurse to patient ratio is, say, 30 or 40 to 1, I mean, who knows what it would be?  Can we do telemonitoring, right? You know, can we be the ones monitoring that hospital that's on the other side of the world?  Can we apply some, you know, other technologies in terms of telementoring those people who don't have that formal training, again, from anywhere in the world?  Should we digitize this whole process, right, in terms of tracking? I mean, I think it makes sense, but, you know, if it's not planned for, it could hinder, right?  I mean, it could have a great app, but it could also end up being, like, the Iowa caucus, right?  That would be a problem, you know, doing RFID tags on patients that come in, so great technology,  but if you're not, if you haven't planned for it, it just could be a mess when you instituted it, so I've got to go quickly here, but just a few pearls and principles.  We'll talk, again, about planning here. Essentially, communication is essential, right? Identification of the patients, of the provider, the triage person, where that triage area  is is essential. Note that the triage officer is not a treating officer. They've got to be focused on triage.  Limiting radiology to just life-threatening injuries, say, just doing head CTs, and then tourniquets, needle decompression, and works on kids, too.  So, we've pushed through these key points. Obviously, kids are going to be affected in mass call events.  Triage systems need to be adapted for CBRN and these unique hostile events or pandemic illness, and we've got to plan, so I'll leave this last reference slide out, because there's  a lot of great resources out there, and if you're going to take a picture, this would be the one to take a picture of, because a lot of smarter people have planned for this  and have a lot of resources out there, so, again, just look those up. Thank you for your time. Thank you, Matthew.  We'll take the questions at the end, so our next speaker is Karen Reuter-Rice, who is a Ph.D. acute care nurse practitioner.  She's associate professor in the Duke School of Nursing, School of Medicine, and the Duke  Institute for Brain Sciences, and Karen will be talking to us today about keeping the family  together during a disaster.  Thank you, and hello, everyone. Hope you're all hanging in there throughout the day. So, thank you to the Congress Organizing Committee for the invitation, and I'm really pleased  to be up here with Dr. Bergman and Dr. Upperman, who you'll meet shortly. So I've been given the task of talking more about communication and reunification, and  I'm just going to put it out there right now. It's kind of soft science, because there's not a lot of empiric data about what does this really mean for our populations.  Here we go, and I want to just say that I have no conflicts, and, again, that I'm talking about communication strategies and techniques.  I want to just see a show of hands, how many of you have been involved in some community chaos or disaster that has either displaced you from your family, your loved ones, or  had a communication failure in the room? How many of you have been involved in anything like that?  Okay, so quite a few, and you may actually be more expert in this than I am, but what I will share with you is that much of the information I'm going to provide you with,  and I have a ton of resources as well, are primarily from U.S.-based type of agencies. However, the World Health Organization has some nice material as well, and all of these  will have online links that you can go to. They have phenomenal information out there. There's just no real good research.  So what I wanted you to take away from this slide is that annually worldwide natural disasters  affect about 175 million children annually, and that's a really important caveat because I think, kind of as Dr. Borgman touched on, is that, you know, there are those natural  disasters that we can't even account for how many fatalities or how many morbidities children experience. We're going to walk through some of that today.  Okay, so in the U.S., think about this. More than 60 million children, including about 12 million infants and toddlers, are apart from their families daily.  So at any given time, if we were to have a mass disaster, whether that's a mass casualty  or whether that is an environmental disaster, there are a lot of children who are not connected  or tethered to their parents or their caregivers, and that means that we're, you know, we need  good communication strategies as well as good reunification, oh my gosh, that's a terrible word this afternoon, reunification strategies for our both our healthcare organizations,  our schools, our daycares. We need plans in place for children to be able to be reconnected. There's a lot of work that happens at the very high government levels, so if you're  thinking about the federal levels like FEMA, there are strategies in place, but what does it mean at the local level? What does your city or village have in place?  What does your town have in place? What does your community have in place? And many times, if you asked even your daycare provider, what's their disaster plan?  So if there was an environmental disaster that was sweeping in, how are they going to communicate with you and how are you going to get a hold of your child?  More importantly, how many of you are healthcare providers in the room? Almost all of you. So if that's the case, where do you think you'll be?  You'll be tied in to the healthcare system where they're going to probably say, we need you and we need everybody who's going to be here.  So how and what systems do you have in place for your own families? Now IOM did a really nice report where they actually took a whole group of stakeholders  looking at disaster and they really wanted to talk about what are the gaps for managing preparedness response recovery.  And they have a really nice summary that certainly if you have interest in this or if you're  part of your healthcare organization's administration, you might want to take a look at this to see some of their recommendations. Keep getting that wrong.  As far as family disaster resources, there's a whole compendium of them. Many different agencies and particularly the American Academy has put a lot of time and  effort into providing materials for both pediatricians, for the public at large, for disaster strategies as well as plans. The CDC has them, FEMA has them, of course.  The World Health Organization has a wonderful downloadable PDF for those of you who are not U.S. based and they have some really nice information within them.  The Red Cross as well and then of course United Nations. So just some of the basics and these may seem really simple to all of us, but how many of you have them in place?  So after I kind of went through all these different websites and I started reading and started trying to find some research literature where there wasn't, I started thinking about  how come, you know, am I actually adhering to any of these things within my family? And I realized I'm a total failure.  I have not actually enacted many of these things that we kind of just take for granted are going to work if there is a disaster.  So making the plan, yeah, we taught our kids, okay, if something were to happen, here's kind of what we think our plan is going to be. Building a kit, no, not so much.  No, we don't have that radio that runs off of a crank or whatever they encourage you to have. And then to be informed, so what applications do you have on your phone?  Well, we have a lot of applications on our phones, right? I mean, most of our phone numbers are on our phones. Well, guess what?  If telecom goes down, we're going to be in a real jam. And so some of the things that they encourage families to do and this is something that,  you know, whether you're working in the critical care unit or whether you're working, you know,  in the community, these are informations that are important for you which, you know, as a healthcare provider may actually help your family have less stress should there be a  disaster. And I think the important pieces on this slide are really being able to figure out what the emergency plan is and then who are you going to call for help.  And I was talking to a group of colleagues and I said, how many of you have designated outside individuals for your families to be the contact person should there be a natural  disaster in your community? Well, nobody had done that. They all picked like their spouse or their sister or brother or somebody immediate within that same geographic area.  Well, that's going to be a problem if your family gets divided and there is a natural disaster. The second thing too is, is there a call tree?  So if the first person is also impacted by that natural disaster, who's the next person that you're going to be contacting?  And that's the same also for having any kind of meeting spot. Is there a primary meeting spot or a secondary meeting spot?  And I think as Dr. Borgman pointed out, when we had these mass casualty disasters in the school systems, where did all the parents go?  They're all trying to flock into these school areas where all of our emergency response personnel are trying to secure that area.  And so where are you going to try to meet your child and how are you going to be able to communicate with them, particularly if they're asking them to leave their cell phones  wherever they're at? And then the other thing that came up in conversation, and I saw this in several of the articles I was reading, is the safe word.  So how many of you have young children and have taught them a safe word? So there's a family, yeah, great. So there's a family safe word.  So that's some stranger who says that they're a family member or somebody been sent to pick them up would be somebody they would trust to go with.  So many families will have safe words. And if you know the safe word, then that's a safe person to go with. Well, in a mass casualty disaster, that could be problematic.  Because yes, you want your children to be safe, but there may be complete strangers taking these children into locations of safety.  And if they need to have a safe word and operationalize that for the child, it can be very catastrophic for them. Okay, communication. Here's the thing.  We all rely on our cell phones, but telecommunication companies, you know, they've done everything  they can possibly do in order to keep our telecommunication open when there is a natural disaster. But many times, their lines are affected.  And so, you know, one of the keys are we still need a paper and pencil, and we still need a way to document contact information. This is true within hospital settings as well.  Because if you're running on backup generators, you're going to use those generators for all life support, and you're not going to use it.  You're going to power down things that you're not going to need access to. And so, some of the things that we, you know, need to be really conscientious about is,  you know, this is kind of getting back to how much can you do using computer systems? How much can you do without a computer system?  There's some really nice family emergency and communication plans that you can see on this slide. And then also, of course, having some kind of meeting.  This applies to within your hospital as well. Do you have not just disaster drills for the staff, but does the actual administration have good disaster relationships with the  community? I wanted to share this because I went through some of the telecommunication information, and this is really what they strongly encourage. And I don't know how many  of you are aware of this. But really, not to use the calling feature of your phone, but rather to text because it uses less bandwidth. Additionally, if you send a text and you  don't think it's gone through, wait 10 minutes. Because the delivery time is slower, but it  usually will go through. And so they say if you constantly re-text your text, you're actually  eating up more bandwidth time, and then others can't get their messaging through. And then  also figuring out alternatives to cell phone communication if there are no telecom available.  Who do you trust in a local disaster for your child or for your community? Do you have photos  of your children? And why that's important is when we talk about reunification, and we'll  talk about what the healthcare system organization needs to have, having a photo of your child  can be immensely helpful. And if your phone, if it's on your phone, that's great. If your phone is charged but there's no power and your phone's running out, do you have another  physical picture of your child? And also, do you know where their whereabouts are? The next thing is your contact information. So who else can be seeing your child? And then  following up within, and this is for healthcare organizations as well as you as an individual, what are the plans for all of the places that your children are in contact with or  where the children of the community are in contact with? So can I tell you whether Duke University understands what Wake County, where my child goes to school's disaster plan is?  Yes, they have an understanding of what that school will do if there is a natural disaster or if we have something that would require our hospital to be an emergency site.  Okay, reunification. Now it gets really tricky because there's a lot of really great information  but this can be very difficult to actually carry out. And I don't think at this point anybody can tell us like the perfect system. And there is really no data on how well different  models of reunification, gosh, I can't just say that word tonight, work. So one of the things that I think gets really complicated is where is everybody and can they get to  one location? Well oftentimes you may be able to have one family member meet up with the child, but if that child is injured, that child will go to any number of the area hospitals  and are you aware of where that child is going? FEMA has some really nice post-disaster reunification  of children, a nationwide approach. They have some great information there both for hospitals as well as for families. And then there are a number of other resources that families  can use but also hospitals can use. So I'm going to make sure that I just stress this prevention of reunification with the child predator. There's some information around  that, but again, you know, we teach our children to be safe. We have to also teach our children to trust that somebody is going to take them to safety if they need to go to safety.  So for healthcare organizations, one of the things that, at least for the United States, when there is a natural disaster or a mass casualty disaster, there is a waiver for HIPAA  to disseminate certain protected health information. And why that's important is because, you know,  all of our organizations are HIPAA bound. There are some pre-authorization steps that need to be put in place. So that's something if you're an administration or you work with  a healthcare organization, you should have some idea of whether those are in place so that you can get a transfer of information. Additionally, you should have some pre-approved  protocols around patient information exchange. Additionally, disaster and family unification  plans, do you have those in place within your healthcare organization and what do they look like? Do you have the staff who are trained around that? I can tell you that I've never  been in a training for family reunification being in the pediatric ICU. I have no idea what Duke would expect me to do. I think they would tell me I have to go do my job, but  if I was set in an environment where they said, okay, you're in charge of getting all these kids back to their families, I'd say, I have no idea what our plan is. So do you  know what your plan is and do you have one in your organization? Also remember that the personnel are going to be needed for clinical areas. Who are going to be those to interface  with the families in the emergency response system to help get families reconnected? So who are those individuals and do they understand what their job is? And then also, what are  the psych mental health service supports? Because oftentimes children are not always injured, but they are very scared and they also have a lot of just the psychosocial and  emotional responses to being disconnected from people who they trust to be safe. The organization itself needs to adapt for the staff because when there's a natural disaster  or there's a mass casualty, those people who are caring for others may also need to know that their families are safe and they may need to leave their organizations in order  to make that happen. The next thing is, what about security? And Dr. Borgman touched on  that a bit. Yeah, this gets to be really challenging because who's going to be chaperoning people  to the places they need to be and how many security personnel are there? Mass disasters  create an immense amount of anxiety, but they also create a lot of chaos for families and not everybody has great coping skills. So do you have trained personnel who can help  individuals get to where they need to be, get people sorted out, but also keep the environment as calm as possible? The biggest thing that helps for healthcare organizations, if you  can go ahead and get a picture of the person coming in the door. So if it's a child coming  in the door, get a picture. Many people put a whiteboard, they'll be able to get a photograph and they'll stick it on the board. Even if you cannot get a photo, it's helpful to get  their eye color, get their hair color, get their height, their weight, and their general description. Are they Caucasian? Are they African American? Because that's how some  of the calls will start coming through. Can they tell you their age? Can they tell you their name? If they can't, then can you at least get some description of them? The other  thing too is be prepared. You're going to have, let's say a daycare brings all their kids in to your local area because you're safe. Do you have enough diapers? Do you have  enough formula? Do you have enough space to keep these pretty healthy children in your emergency location until they're reunited with their families or moved to another destination?  And there's some really nice information here from the family reunification following a disaster site. So last, patient tracking. And I think Dr. Upperman might talk a little  bit more about this, but there are some patient tracking and identification tools that you can use within your emergency departments and within your healthcare organizations.  These are just a couple, but I will tell you that, you know, if you're really challenged with electronics at the time because you don't have power, these may not be as efficient.  So just keep that in mind. The other thing too, remember to have locations for individuals  who are healthy and well, but are just being relocated versus those that are truly injured.  And then can you designate a reunification center, either within your healthcare organization or within your campus area? These are some resources for you. Got some references for  you. And thank you for your time. Thank you, Karen. Our final speaker is Jeffrey Upperman, who is professor and chair of the  Department of Pediatric Surgery at the Monroe Corral Junior Children's Hospital at Vanderbilt University Medical Center. Dr. Upperman will be speaking to us today about education in  a pediatric mass critical care event. Good morning. How y'all doing? Well, wait a second now. I'm supposed to bring this home.  My voice is bad. I am coughing. I feel horrible. And this is the good morning that I get. Good  morning. Thank you. The reality is, are you vaccinated? All right. All right. I'm a disaster  cynic. I think all this stuff they just talked about is a bunch of crap, but I love them. All right. We're going to get started. Ken Tegmeyer. Ken's talking right now. He's my  We put this out in chest about six or seven years ago, an educational approach to mass critical care.  So disclosure, I belong to a lot of groups. I'm a retired military U.S. Army reservist.  I'm a member of American Red Cross Scientific Advisory Council. I don't represent anybody except me, Arthur  Maryland's child. And I will speak my mind and hopefully we get into an interesting dialogue. And I don't take up too much time. Just in time education. That's what really happens.  You're here, but you won't be there when it jumps off. All right. Just remember that you're not going to be there.  Matter of fact, if it's jumping off right now and near E.D., you're critical. You're here. Right. And do they know what you know right now? No, they don't. Or they forgot.  That's the reality. So what can we do? Where do we pick to educate? We love that recovery phase. Dr. Ruth Rice just talked about that.  There's a lot of observations, but it's not put well together.  And I'm going to talk a little bit about some strategies some folks are talking about. But, you know, three quarters of this cycle.  We have an opportunity to do all this prep learning, but do we really use it? And even during the response,  during these infectious diseases, because of the time course, we actually do learn and we do it in a very interesting way.  But I'm often surprised at some of the missteps that happened the previous one that we don't apply to this one.  And yada, yada, yada. You heard about it. So there's a framework that I put together when presenting to the Institute of Medicine a few years back.  And I just draw your attention to the kinetics of the disaster. Y'all know this. It makes sense. And matter of fact, Dave, when I went back to L.A.,  I just realized that I had to realize that the earth did shake there because I'm in Nashville now.  I'm putting all kinds of fancy stuff on my shelves now. It's great. I don't have to worry about it shaking off, I don't think.  But, you know, it's wonderful. Now, they did say we have tornadoes, but I got 16 minutes to figure it out. OK, so in this viral thing, I was on service last week, so I'm hurting.  So it hits you in a different time course. So your ability to educate should probably reflect that.  But in all of those models, just-in-time learning really is something that happens, shows up, and we need to figure it out.  OK, what's the problem? Well, the problem is all things low. How many people from Florida?  OK, for the people not from Florida, do you ever wonder how they're watching CNN for the entire week and then like two days before they're all jammed on the highway and you're like, first of all, you live there.  You know the drill. Matter of fact, why are you even living there during the time that it's about to hit?  And we all sit there like, man, this is crazy. Why? And then before you know it, and then they put a microphone in front of dude and he's like, yeah, I tried to get out.  Dude, you knew a week ago to get out. We don't learn nothing. All right. Earthquake. Why do you live there? Exactly. I left. OK.  Why do you live on the side of a hill with all this like hay and dry stuff, knowing it doesn't rain and it's going to burn?  Why do you live there? I like the view. All right. So all problems are local. When they hit you, you deal with it.  I guess we're resilient. The world is smaller. We just saw a picture of China.  We've been hearing about China for the last week. We didn't even know where we were. Matter of fact, when they first said Wu-Tang, I said Wu-Tang, what happened?  I mean, how are they involved? I mean, how are these brothers involved with a virus? I mean, come on.  They said, no, it's Wu-Tang. OK, OK. But it's much smaller. I mean, I can find out what's going on in central China right now.  I just pick up my little phone and be like, oh, interesting. So we're getting a lot of noise from that. The timing we've heard about and the resources, it depends.  So now that Dr. Ruda writes, I sit in the C-suite and I hear these conversations and now I understand why my boss has always said not today.  No, not really. Let's try it next budget cycle. That's me now. I am the parent now. I tell people, no, I love it.  It's fun. But, you know, the resources are scarce. How do we all know?  Not we all, but those who take care of kids every single day, tell an adult hospital facility that has 10 beds, you need to be ready.  And they're looking at you like, for what? You know, they're not going to come to us. Yes, they will.  But they look at a budget and it's like, what am I planning for? So it's the resources are scarce.  They're already running close to budget and there's no contribution margin in being prepared for a disaster.  All right. So what's the training dilemma? I think this is, man, dude, I've got to turn on the watch. I know that. But, you know, I've got to stay on time. It's business as usual.  You can't go into these facilities and say you need to be ready for DEF CON 10. I mean, Army guy comes in. It's just like, yeah, you need to be ready. Like, when is he leaving?  Does he know we're in budget now? I mean, we're really trying to figure out, you know, we can allocate.  We have no time for it. Yeah. They nod their head. Yeah. Next. And it's always going to be the other guy's problem. Right.  They're going to come to their hospital, not my hospital. And I can do my thing. And anyway, I don't tweet. So who cares that Twitter knew 10 minutes before it hit my door?  Who cares? I don't have time for that. So nobody really wants to learn. Nobody wants to learn just in time. He's leaving. I'm about to save his life. He's out of here.  So we wish the world, as it relates to those who want to help, were like the lieutenant colonel's world.  He can walk in a room like this. If he had said good morning, first of all, you would have been standing up.  You'd have been looking at him. You'd have been all like, yeah. What do our teams look like? Hey, guys. Hey, did you wash your hands? You know, squeeze in, squeeze out.  Yeah. Next. And we're trying to train about life saving stuff in an environment where team and training means so many different things.  So many different things. And we care. We're in health care. We actually care. All right. So that is a huge challenge. So here we go. Here's the cynic in me.  Everybody recognize him? Raise your hand if you don't recognize him. All right. So this side of the room would clearly be safe. You all are going to get it.  All right. So Thomas Eric Duncan. He is a driver in Liberia. For whatever reasons that I got to get out of Liberia, it was the Ebola.  So he gets the airport. They say, hey, have you been exposed? No, no, no, not me. Not the kid.  All right. Get on the plane. He gets on a plane. He goes check out the people in Dallas. He's hanging out. Little kids running around. All of a sudden he gets sick.  You know how that story plays out. Right. But what if this party played out? What if he had decided as a driver that he could actually take her to school?  This is a stock photo. This ain't real, but imagine. And he shows up at the school and he said, oh, oh, you're your uncle's from Africa.  Yeah. Uncle, come on in my kindergarten class. Tell them about Africa. Right.  You're hearing about Africa. Four days later, she said that kindergarten class, nobody knows the difference. And each one touch one loved one. Here you go.  And we know the rest of the story as related to our people. Right. Our people who are trained to dawn and doff the isolation equipment expertly.  Somebody you signed off on them. You signed off on them and you say you're ready to go. They were focused, ready to go take care of this. And they got it. They got Ebola. All right.  They were trained to do it. Now, I was in some meetings, CDC and others, and they were talking about, well, the parents really want to be with their child, three year old child and all this.  I'm looking at him. I'm like, so wait a second. We had nurses in Dallas who were trained to dawn and doff.  They take care of people all the time and they know how to do all this stuff.  And we're going to train a family member to put on this stuff and go in and be with. I said they ain't never coming out that room.  If it happened in my house, they ain't coming out that room. They're in there for the long haul.  How many people have those isolation to go on the floors and they got all these yellow gowns and stuff and you walk in a yellow gowns and mom sitting on a bed just laying all over that Mercer.  Just run that Mercer all up in it. And so I pulled a nurse. I said, so is she quarantined in this room?  Oh, what are you talking about? Well, you know, she's about to go downstairs a subway and touch everything, right?  Well, we don't want to be. So why am I spending 25 percent, 25 percent a visit?  You get it. Lessons learned, really. So, you know, little kids coming to E.D., it's in our neighborhood.  We start washing them down. Y'all going to do it. You ready to do it. Do you even know where this is in your hospital?  You ready to start doing this? Spraying kids down to come in with flu. Quarter million people have been hospitalized this cycle.  Right. Ninety two kids did. And we worry about Wu Tang. OK, the real stuff that always happens is really happening right now.  Right now. So how are we going to respond? So I try to figure it out.  Look, if there's any educational thing you put in disaster and all this other stuff, you got over almost 700 million hits.  Can we talk about that? I mean, there's a lot of noise out there, not a lot of substance.  So this lessons learned paradigm at the end of the day, it's like my guy Alan Iverson once said, and he is a philosopher.  I truly believe this. So so check this out. So so people have found ways to get promoted.  Yours included saying over the last generation, there's been a proliferation of papers, lesson learned type papers that are out there.  And we don't learn anything, but we find opportunities to write about what we didn't learn because our earthquake that devastated our community was different than the one five years ago, five years ago.  And so my point being that if we want to get serious about it, we need to figure out how to do it in real time.  And also stay away from this nonsense about we're too busy to understand what we're doing.  We figure it out in some cases and not in all. We need to be disciplined. So how many people have never heard of Alan Iverson? Raise your hand.  I'm going to pick somebody. OK, so a basketball player, young guy, probably arguably one of the best point guards ever to play the game.  You only buck sixty five go up in there with seven footers and he would go in there and get all beat up and score, et cetera.  Alan Iverson at a press conference after a game, a reporter says, do you think your performance tonight was a reflection of your attitude as relates to practicing?  Your coach seems to say that you're not really focused. And so his classic line was practice. We're talking about practice.  I mean, come on. I mean, so his point was they just finished a game and it was game time decision.  What did he do in the game? How did he perform? I mean, and he probably had some ridiculous number of points.  And they're talking about practice. And so the concept of how we perform during the real events, we need to take some of that to heart by this great American philosopher.  I asked the question. We had a disaster exercise and we had our normal emergency visits going on.  And I said, you know, how good was documentation? And, you know, the answer to this. No, they didn't document well during the drill.  They did. They missed things. They were just running. They weren't practicing. So, you know, they're Iversons.  They believe in Iversonism. They will do it right when they have to practice.  So let's talk a little bit about just-in-time education. Well, I think there's some things that we need to take advantage that we have.  Just-in-time research is something we need to turn on and get done.  We're going to have these things. We might as well use these experiments of nature, these observations of disaster, and have smart people looking, observing, figuring things out.  We need to do some modeling. I'm going to show you a little bit of that. And we need to do what kids do. Kids play games.  All right. Here's my good friend, Perrin Cobb, who is on the right. Perrin is brilliant. You all know him from these settings.  Perrin, basically, he's the master network in science. And he put together this network called the Resilience Intelligence Network with a simple concept.  Why don't all these groups of groups of people who are studying these various things come together to share some key insights, et cetera, as we're facing all these crises?  So he looks at flu season and sees it. Can we communicate about resources that are available? Some of you may be involved in some of that work.  It's smart because if the Wu-Tang thing kicks off, we're going to need to really understand what we're learning in different corners of the universe in a very rapid way.  We need to understand those things. I've taken some of this data and group. Eric Barthel is one of our previous fellows.  And we threw some natural observations into some mathematical models to figure it out.  And here's an observation regarding Dr. Ruta Rice's summary. So the blue is the number of patients that are coming to a center. It's dropping to nil over time.  You see the admissions in red go up. And then you look at this green line, and that is what we all know.  That three-year-old, even though they are negative for whatever the problem is or whatever the situation is, those of you working in children's hospitals, that three-year-old with no parent is not going anywhere.  Where are you going to put them? Now, I showed this model or one of these things looking at these behaviors, and folks are like, I don't get it.  All right, let me try it again. A three-year-old does not get released, even if he says, really, I'm Uncle Bobo. No, we don't know you. You do not get to take this child with you.  That's what we do as a children's hospital. That's what we do as child health experts.  So when we talk about education, there's this thing. This is a setting that's advanced. You guys are learning some things.  We can mass market it. We can be reproducible. The just-in-time stuff we need to be smart about. We need to look at how it's going to be less interactive. Maybe it's on a game.  So here's some guidances. This is a paradigm we've used in a former life.  Basically, we've created some games so that people like myself who have attention deficit are playing games.  Or we think about some telecoaching. You'll see all of this at a later point, but really Google this.  And here's some resources. Go online. There's a ton of stuff during this time period. Now, in terms of the next, go to the next slide, please. See if it works.  As my voice is on the last rope. What I was going to briefly show you is the fact that we decided to get real creative with this stuff.  I think what we do every day is a kinetic sport. I'm a visual as well as a kinetic learner.  And I thought it was extremely important that when we were training people about how to respond, I thought it did not come down to the individual issues that they were facing, whether it was threat A, B, or C.  It's how we work together. So we had an exercise. We called it a disaster Olympics. And what we wanted people to do is to communicate. We taught people how to lead.  And we had people do some very simplistic, even silly stuff, but it was the type of thing that we had so that teams would come together and learn how to work together.  So in conclusion, I would say, one, be a part of a learning network, whether it's a disaster coalition or it's other groups within your community to understand how things work.  Understand what your processes are internally. And last of all, stay innovative. If it works in your neighborhood, do it. Thank you all for your time and attention.  So we have a couple of minutes for questions, and please direct your questions at any of the three speakers or a general question, and they can choose who's going to answer.  Microphones are there and there.  Dave Bliss from Children's Hospital. I just mainly have to come up to Raz, Jeff, but all kidding aside.  I've been thinking about this a lot, and Jeff worked in our region for quite a while, and I've inherited his work.  And something that I've given some thought to but don't know how to solve is we are currently siloed in terms of resources, which is to say the child or the patient has to come to the hospital or to the care location to get care.  But in areas where you may not be able to reach the hospital, so California is a great example, an earthquake could disable all transport mechanisms, all communication mechanisms.  It seems that there's a place for moving caregivers to the patients or sort of inverting that relationship.  Do you guys have any thoughts about the flow of personnel as opposed to patients and turning locations not necessarily into the destination but the patients into the destination?  Dave, thanks for that question. It really depends on what the threat is.  I mean, if you basically have structural integrity issues, then nobody's really moving around that environment unless they're military and they have special equipment to sort of safely get people around.  But you bring up an interesting point. I was playing around with the whole robot piece because I basically said I don't want infectious disease anywhere near the emergency room because there are experts.  They should understand how to take it. We need to have them sequestered away so that they're bringing the intelligence to the environment but not being threatened by that environment.  And there are other examples of that that clearly my colleagues can speak to.  Yeah, I was going to mention, so I was teaching the FCCS Resource Limited course as a pre-course, and one of our people taking the course was actually from Half Moon Bay area of California.  And she's part of the Medical Reserve Corps that's recently resurrected. It kind of lost funding. It was going strong for a while. It lost funding.  But now with the recent campfire stuff and that kind of thing, there's this new interest in creating this volunteer Medical Reserve Corps type force, so to speak, because of, say, when fires or that kind of thing hits.  There's providers there who are isolated, but they kind of need to fend for themselves. And so potentially that might be a model for doing just what you described.  Go ahead.  Hi, Christian from NYU Langone. Just a question on medication access during times of disaster preparedness. How do you guys deal specifically with controlled substances like narcotics?  Meaning, I mean, same way we do every day. I mean, we're not doing anything different. I mean, the reality is, if you were dealing with structural damage and those things that led to a mass casualty, you would treat those patients in front of you.  I think the discharge paradigm as it relates to children, I don't see us sending kids out with scripts of anything. So I think you will do business as you do usually. If it's about the security of your stockpile, then it may come down to your security plan and locking up your hospital and having a more controlled access.  This is not a question, but a comment to the previous gentleman. In Texas, I don't know if you're a part of GTAC, but when we were part of GTAC, we devised a plan to identify fragile children that would be out there.  So you all work in PQ. So, you know, all those kids that have chronic events that they don't have the best resources at hand. So when you don't have a snowstorm that you know is going to hit in 24 hours, or when you have a hurricane that you know is going to come in, fire would actually be deployed.  And, you know, would it find out all these children, bring them up, you know, that they would need specific resources to actually to a safe environment. And several cities have actually adopted that. Dallas being the first one, if I remember correctly. But so those systems are in place.  Another comment, you know, we think about providers, healthcare providers, you know, doctors, nurses, saving lives. But actually administrators save lives too. And I'm just going to comment on one of the examples.  You know, I happen to be in one of the mass casualty events in El Paso for the last year. And it was a quick thinking of an actual administrator that was able to deploy from all the different hospitals lab trays.  Between five minutes, there were all these lab trays, you know, that needed for surgical trays actually be brought up into the, because you can have surgeons, they don't have surgeons too, you know, but you can have everything you want. But if you need to open up a belly to explore it, you know, I guess you can use the last one, you know, as a last resource.  You know, but actually they have mobilization of all these resources on a quick thinking from an administrative perspective. Because we wouldn't know, you know, who to call.  Thank you for your comments. We have gone over time. I'm sorry.  So we're going to wrap this up now. And the panelists will be up here to discuss this further with anybody that would like to continue. Thank you all very much. Thank you very much.

Video Summary

The video transcript discusses various aspects of responding to mass disasters involving children. The first speaker, Dr. Matthew Borgman, talks about pediatric triage in mass critical care events. He discusses the frequency of children being involved in mass casualty events and reviews various triage algorithms that can be used to determine the severity of a child's injuries and prioritize their treatment. Dr. Borgman also highlights the importance of resources and preparation for such events.<br /><br />The second speaker, Dr. Karen Reuter-Rice, focuses on the issue of keeping families together during a disaster. She emphasizes the need for communication strategies and techniques to ensure that families can be quickly reunited following a mass disaster. Dr. Reuter-Rice discusses the challenges faced in terms of communication and reunification and suggests strategies such as creating emergency plans, having designated contact persons, and using photos and other identifying information to aid in the reunification process.<br /><br />The final speaker, Dr. Jeffrey Upperman, addresses the topic of education in a pediatric mass critical care event. He highlights the importance of just-in-time education and the need for ongoing learning and training in emergency situations. Dr. Upperman also discusses the role of technology in education, the importance of teamwork, and the need for innovative approaches to training and preparing for mass disasters.<br /><br />Overall, the transcript highlights the key challenges and considerations involved in responding to mass disasters that involve children, including triage, communication, reunification, and education. The speakers provide insights and recommendations for addressing these challenges and improving the response to such events.

Asset Subtitle

Pediatrics, Crisis Management, 2020

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2020 Critical Care Congress held February 16-19, 2020, in Orlando, Florida, USA.

Learning Objectives

Explore the tools available for triage and their limitations in a pediatric mass casualty event
Discuss techniques and priorities of keeping families together and, if they must be separated, how to ensure that they reunite in a timely fashion
Formulate communication strategies for separated families, particularly when the parents may also be injured and neither party is able to communicate
Delineate just-in-time educational strategies for adult providers for optimizing pediatric outcomes in mass casualty events

Pediatric Triage in a Mass Critical Care Event

Matthew A. Borgman

Keeping the Family Together During a Disaster

Karin Reuter-Rice

Education in a Pediatric Mass Critical Care Event

Jeffrey S. Upperman

Meta Tag

Content Type Presentation

Knowledge Area Pediatrics

Knowledge Area Crisis Management

Knowledge Level Foundational

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Membership Level Professional

Membership Level Associate

Tag Resource Allocation

Tag Communication

Tag Education

Year 2020

Keywords

mass disasters

children

pediatric triage

triage algorithms

communication strategies

family reunification

emergency plans

education in mass critical care

technology in education

improving disaster response

	Society of Critical Care Medicine 500 Midway Drive Mount Prospect, IL 60056 USA Phone: +1 847 827-6888 Fax: +1 847 439-7226 Email: support@sccm.org	Contact Us About SCCM Newsroom Advertising & Sponsorship DONATE	MySCCM LearnICU Patients & Families Surviving Sepsis Campaign Critical Care Societies Collaborative	GET OUR NEWSLETTER
© Society of Critical Care Medicine. All rights reserved. \| Privacy Statement \| Terms & Conditions The Society of Critical Care Medicine, SCCM, and Critical Care Congress are registered trademarks of the Society of Critical Care Medicine.