Trying to Prepare for the Unthinkable

Lisa R. Rhodes
March 31, 2003

Dr. Michael Shannon, acting chief of emergency medicine and co-chair of the Biodefense Committee at Children's Hospital Boston.No one wants to think about it—but fortunately, doctors, emergency responders and staff at children's hospitals are thinking about it anyway: how can we best prepare for a domestic terror attack causing numerous casualties among our children?

While current federal, state, and local disaster preparedness plans do not address the special needs of children, the professionals who provide medical care to children are taking steps to prepare to provide first-rate care for children in such an event.

Children's health care experts say it is a big job. "There are ongoing chronic problems and little resources in the public health system to do the work that needs to be done," says Dr. Irwin Redlener, president and co-founder of the Children's Health Fund, with regard to how equipped we are as a nation to protect our children. "It's a mixed bag."

Dr. Michael Shannon, acting chief of Emergency Medicine and co-chair of the Biodefense Committee at Children's Hospital Boston, the largest pediatric medical center in the country, says that since September 11, 2001, health care professionals and medical facilities have come to grips with the possibility of a new kind of health threat—a biological, chemical, radiological or other form of terrorist attack affecting large numbers of children.

"I would say that there's a recognition that we have not thought about it and have not prepared for it," says Dr. Shannon. "We've had to move in a rather speedy fashion to make adjustments so that children are properly cared for."

Not Just "Little Adults"
According to Dr. Joseph Wright, associate professor of pediatrics and emergency medicine at Children's National Medical Center in Washington, D.C., this planning must take into account the fact that children are not "little adults." Children respond differently to all kinds of trauma, for reasons related both to their size and their developmental stage.

To give one example, children breathe faster than adults. As a result, they take in a larger amount of air, relative to their body size, than adults. If that air is contaminated with biological or chemical agents, the risk to kids is somewhat elevated.

Then there are developmental issues. A child's ability to full understand the realities of an attack, and then to move quickly to escape harm, is not equal to that of an adult. Even adolescents, says Wright, are more likely than adults to become confused in a high-stress situation.

Children's Hospitals Leading the Way
These considerations are a top priority for the estimated 250 children's hospitals across the country. Experts say most children's hospitals are prepared to handle young patients in many different kinds of an emergency, but that preparing for mass casualties presents different challenges.

Children's Hospital Boston and Children's National Medical Center are generally considered among the top children's hospitals. Because of their prestige, medical expertise, and highly-regarded pediatric emergency medical response teams, these two facilities are good examples of what steps children's hospitals can take to prepare for a terrorist attack.

"September 11th made it clear that you almost have to be creative in your thinking of what could possibly happen and how to respond," says Dr. Wright.

At Children's Hospital Boston, the Biodefense Committee has been working for more than two years to develop policies and procedures for how to manage large numbers of patients and how to best utilize medical and administrative staff and hospital resources during an attack.

Interestingly, one key element of the plan is making sure the hospital has stockpiles of critical drugs to protect adult personnel—to safeguard the ability of doctors, nurses and staff to care for patients. For example, Dr. Shannon says the hospital is stockpiling antibiotics to protect employees against biological agents such as anthrax. Smallpox vaccine is also on hand. "Our priority is taking care of children, but we also have to take care of our personnel so they are able and feel safe to care for children," says Dr. Shannon.

The hospital has also created a physical plan to convert non-emergency sites, such as its radiology unit, into emergency sites to provide proper care for critical patients. Dr. Shannon says additional equipment has been ordered to transport infectious and critical patients throughout the hospital. This includes negative pressure transport systems—beds on wheels contained within isolation units. Alternative care sites have also been identified in the event there are too many patients to handle in the hospital itself.

Children's National Medical Center in Washington has developed a Code Purple disaster plan that includes detailed procedures for a hospital "lockdown." Dr. Wright says a lockdown would be necessary if a biological or chemical attack were to make it dangerous for anyone to enter or leave the building. In such an event, the hospital is preparing to sustain itself for 72 hours. The hospital's air handler system, which regulates the air inside the hospital, will be adjusted to keep contaminated air out and recirculate air within the facility. Dr. Wright says the hospital has stockpiled medicine, equipment, and food to accommodate staff and patients.

Staff members who operate the hospital's Emergency Communication and Information Center (ECIC) have also undergone additional training to handle communications during a disaster. The ECIC is staffed by paramedic communication specialists and emergency medicine attending physicians. It provides the hospital's primary internal communications system and its link to other hospitals in the Washington-metro area, as well as to police, fire, and emergency medical services.

Both Dr. Shannon and Dr. Wright say their facilities must also be prepared to care of adults. Parents, other family members, and guardians are likely to rush injured children to children's hospitals, but they may also need emergency care. As a result, both hospitals have ordered medical supplies and equipment specifically for adults.

In case children or adults need to be decontaminated, both hospitals have a decontamination facility—complete with male and female showers and containment vessels to hold contaminated water—that can be set up outside. Personal protective gear is also available at both hospitals for staff to wear while treating contaminated patients.

Training and drills on matters ranging from how to assemble one's personal protective gear, to how to decontaminate an infant, and to whom and where to report during the crisis, are mandatory for all employees at both hospitals.

Preparing Pediatricians and Emergency Workers
The American Academy of Pediatrics has established a Task Force on Terrorism to "make sure all children's needs are addressed in all efforts to prepare and protect the nation," says Dr. Joseph Hagan, chair of the task force.

The AAP is working to educate and train pediatricians and first responders (paramedics, emergency medical technicians, and emergency medical service workers) to help them respond to a lethal attack. Experts say most pediatricians do not know how to recognize the signs of a biological, chemical, and radiological agents, and many first responders do not have the expertise or equipment to properly treat children.

In addition to giving pediatricians information about biological, chemical, and radiological agents, the AAP is also providing suggestions on how to help parents and children deal with the threat of bioterrorism on its Web site.

In cooperation with the Emergency Medical Services for Children (EMSC), the AAP also provides pediatric emergency care training for first responders through its Pediatric Education for Prehospital Professionals (PEPP) program. The program's new curriculum, scheduled for released in the summer of 2004, will include information on bioterrorism and disaster management. The organization also provides guidelines on what kind of equipment—such as child-size blood pressure cuffs, resuscitation boards, and surgical airway kits—first responders should carry to care for critically injured children.

Establishing Standards for Kids
A critical part of patient care might be giving antibiotics and antidotes to children who have been exposed to biological and chemical agents. But children's health care experts say there are no uniform national standards on the best pediatric medications for such exposures, or the best dosages for kids. Dr. Shannon and Dr. Wright say their hospitals have developed their own pediatric protocols using the best scientific data available for adults, as well as the expertise of their staff trained in toxicology, emergency medicine and infectious diseases.

The Children's Health Fund and the Children's Hospital at Montefiore in New York City sponsored a three-day conference in February, 2003 for children's health experts and government officials to come to a general agreement about the best pediatric protocols for exposure to biological and chemical agents such as anthrax, botulism, and Sarin gas.

Conference recommendations will be published in an executive summary titled "Pediatric Preparedness for Disaster Terrorism: A National Consensus," scheduled for release in April, 2003.

Dr. Redlener says the recommendations are preliminary, but that they will help health care professionals to make the best possible medical decisions under extreme conditions. The report is being distributed to federal, state, and local agencies, hospitals, medical professional societies, and first response agencies, such as the police, firefighters, and emergency medical services.



Lisa R. Rhodes is a freelance writer living in Maryland.