Many centers unprepared for pediatric mass casualties

In 2010, the National Commission on Children and Disasters issued a nearly 200-page report on the unique vulnerabilities faced by children in crisis situations. Finding that only about 25 percent of emergency responders had the equipment and supplies needed to treat children in an emergency, the commission concluded that "children were more often an afterthought than a priority" in the country's disaster planning.

A follow-up report in 2015 by Save the Children said little had changed. The national commission made 81 recommendations to improve the medical and psychological help children receive during disasters., Five years later, only 21 percent of those recommendations had been fully implemented, half had been partially implemented, and more than a quarter hadn't been met at all.

Terri A. Elsbernd, R.N., pediatric trauma coordinator at Mayo Clinic's Level I Pediatric Trauma Center in Rochester, Minnesota, says one recommendation that hasn't received enough attention — or action — is making children's needs a priority in disaster training and equipment purchases.

"Most of the mass casualty incidents in the last 10 years, including the Sandy Hook shootings and the 2011 tornado in Joplin, Missouri, have been heavily weighted toward young children. Although many hospitals are devoting increased attention to disaster preparedness, very little is pediatric specific. Yet these days, the possibility of children being involved in a mass emergency is very real, so trauma centers have to think carefully about how they will handle a surge of young patients," she says.

That's why Mayo Clinic has incorporated pediatric-specific drills into its disaster preparedness training.

"In the past, for every mass casualty incident drill, we would have 10 adults and one or two children," Elsbernd explains. "But most centers can easily handle one or two children. A few weeks ago, we wrote a hypothetical scenario in which a car crashed into a child care center, injuring one adult and critically injuring six children, ranging from infants to toddlers. We had one pediatric surgeon on call and six children needing to go to the OR.

"In this case, we had to triage between adult and pediatric surgeons; in other situations, we might need to send some of those children to other hospitals. If you don't drill or think or talk about it, you won't have a plan when you actually have to do it. You have to stress your system to see where the weaknesses are."

Although drills are often in the morning, Elsbernd staged this one in the early evening, when some of the more than 12 million kids in child care in the U.S. are waiting to be picked up, and emergency departments (EDs) are typically at peak census.

"Evening is a very vulnerable time because the ED is busiest at night, yet a lot of people have already gone home. If you run drills only at 10:00 in the morning, then you aren't really stressing your system," Elsbernd says.

Making children a priority

Although children can be more physically resilient than adults in some ways, they are more vulnerable in others. They are more seriously affected by blood loss and dehydration, and are more likely to lose body heat.

In almost all cases, children require different medications, dosages and delivery systems than adults, and they need blood pressure cuffs, urinary catheters and respiration equipment that fit them. Yet studies and experience show that many emergency departments don't stock the drugs and equipment needed to treat critically injured children or providers can't find what they need.

"You have to think about specialty populations; this is not one size fits all," Elsbernd says. "Maybe you don't have enough pediatric equipment for a mass casualty situation. Where will you get more if you need it?"

What's more, she says even the most experienced adult providers can feel uncomfortable treating children because they have so little experience with pediatric patients.

"Adult providers are fine with a 10-year-old, but they may have some anxiety about treating a 10-month-old because there are so many additional factors to consider. Again, child care is a good example. Say it's 6:00 p.m., and there are one or two adults caring for six children. The kids are unharmed, but both adults are unresponsive. How do you notify the parents? How do you get the children to the right place or person? Where do you start?"

Elsbernd suggests having a plan for family reunification to ensure children aren't released to the wrong person or a noncustodial parent. "These are all things that have to be thought about ahead of time," she points out.

She also says it's not uncommon for providers to question the need for this level of disaster preparedness. But she notes that anyone involved in a real disaster always says, "I will never doubt the impact of simulation drills. If we hadn't drilled as if it were the real incident, it would not have gone as well as it did."

For more information

Agency for Healthcare Research and Quality. National Commission on Children and Disasters 2010 Report to the President and Congress.