Managing Pediatric Patients After Hurricanes: Perspectives from the 2004/2005 Hurricane Seasons...

Managing Pediatric Patients After Managing Pediatric Patients After Hurricanes: Perspectives from the Hurricanes: Perspectives from the

2004/2005 Hurricane Seasons2004/2005 Hurricane Seasons

©Lou Romig MD 2006. Used with permission.

http://www.fl5dmat.com/2004_Charley/Photos/133-3315_IMG.jpg

ObjectivesObjectives

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 ThreatsUniversal Threats

Injury

Acute infections

Chronic illness

Lack of access to care

Compromised caregivers

Key ConceptKey Concept

The changed environment is the biggest challenge

to excellent medical care after a

large disaster

FEMA Photo Library

FEMA Photo Library

http://www.photolibrary.fema.gov/photolibrary/photodetails.do?id=10744



Environmental Constraints:Environmental Constraints:PhysicalPhysical

Temperature/exposure

Sunburn, dehydration, heat-related illness

Sweating, dirt, topical chemicals


Lack of clean water

Dehydration

Poor hygiene

Limitations in wound care


Lack of appropriate food

Inadequate nutrition

Inappropriate diet

Environmental Constraints:Environmental Constraints:Physical Physical

Lack of electricity

Nebulizers, other medical equipment

Refrigerators

Light, ventilation

Information deficit regarding hazards


Hazardous environments

Lacerations, punctures

Falls

Motor vehicle trauma

Tool-related injuries

Weapons


Hazardous environments

Chemical exposures

Allergens

Insects/animals

Environmental Constraints:Environmental Constraints:Social/InfrastructureSocial/Infrastructure

Disruption of healthcare systems

Primary medical care

Specialty medical care

Hospital-based care

Home health care

Third party payers


Disruption of supply chains

Pharmacies and other stores

Durable medical goods and consumable supplies


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


Lack of security

Hesitancy to leave unsecured property to seek medical care

Lack of mobility

Loss of jobs and other financial support

Environmental Constraints:Environmental Constraints:EmotionalEmotional

Fear

Insecurity

Guilt

Helplessness/loss of control

Anger

Denial

CONSTRAINTS

ADAPTATIONS

Common Pediatric ProblemsCommon Pediatric Problems

Pulmonary

Gastrointestinal

Infectious diseases

Trauma

Psychosocial

PulmonaryPulmonary

FEMA Photo Library

Pulmonary: ProblemsPulmonary: 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: ProblemsPulmonary: 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: AdaptationsPulmonary: 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


Outpatient treatmentAllow 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


DO NOT yield to the temptation to treat every febrile pediatric wheezer with antibiotics.

Bacterial “bronchitis” is rare

in children. FL5 DMAT Photo

Pulmonary: DecisionsPulmonary: 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

GastrointestinalGastrointestinal

FEMA Photo Library/Dave Gatley

GI: ProblemsGI: 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: ProblemsGI: 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 Don’t forget aboutaboutcontaminatedcontaminatedice!ice!

FEMA Photo Library

GI: AdaptationsGI: 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


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


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


Minimize infant formula-switching.

Use stool volume replacement techniques in cases of diarrhea

Staff must be protected against food poisoning!

GI: DecisionsGI: 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 DiseasesInfectious Diseases

FEMA Photo Library

Infections: ProblemsInfections: 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


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.


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.


Local pharmacies may not honor prescriptions by non-local federal

responders

Infections: AdaptationsInfections: 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


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


Obtain and distribute information about pharmacies in operation

Inform local pharmacies about prescribing privileges for federal responders

Consider distribution of starter doses of medications


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


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: DecisionsInfections: 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: DecisionsInfections: 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

TraumaTrauma

FL5 DMAT Photo

Trauma: ProblemsTrauma: 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


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


Increased chance of:

Tool-related injuries

MVC due to unregulated intersections

Flame and contact burns

Firearm injuries


Increased chance of:

Carbon monoxide exposure

Hydrocarbon and bleach ingestion/aspiration

Ingestion of medications

Drowning

Intentional injury

Trauma: AdaptationsTrauma: 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


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.


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: DecisionsTrauma: 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

PsychosocialPsychosocial

FEMA Photo Library

Psychosocial: ProblemsPsychosocial: 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


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


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: AdaptationsPsychosocial: 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?”


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 Little things things

mean a lotmean a lot

FL5 DMAT Photo


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

SummarySummary

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

SummarySummary

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

Managing Pediatric Patients After Hurricanes: Perspectives from the 2004/2005 Hurricane Seasons...

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