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

1. Managing Pediatric Patients After Hurricanes: Perspectives from the 2004/2005 Hurricane Seasons ©Lou Romig MD 2006. Used with permission.

2. Objectives • 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.

3. 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.

4. Universal Threats • Injury • Acute infections • Chronic illness • Lack of access to care • Compromised caregivers

5. Key Concept The changed environmentis the biggest challenge to excellent medical care after a large disaster FEMA Photo Library

6. FEMA Photo Library

7. Environmental Constraints:Physical • Temperature/exposure • Sunburn, dehydration, heat-related illness • Sweating, dirt, topical chemicals

8. Environmental Constraints:Physical • Lack of clean water • Dehydration • Poor hygiene • Limitations in wound care

9. Environmental Constraints:Physical • Lack of appropriate food • Inadequate nutrition • Inappropriate diet

10. Environmental Constraints:Physical • Lack of electricity • Nebulizers, other medical equipment • Refrigerators • Light, ventilation • Information deficit regarding hazards

11. Environmental Constraints:Physical • Hazardous environments • Lacerations, punctures • Falls • Motor vehicle trauma • Tool-related injuries • Weapons

12. Environmental Constraints:Physical • Hazardous environments • Chemical exposures • Allergens • Insects/animals

13. Environmental Constraints:Social/Infrastructure • Disruption of healthcare systems • Primary medical care • Specialty medical care • Hospital-based care • Home health care • Third party payers

14. Environmental Constraints:Social/Infrastructure • Disruption of supply chains • Pharmacies and other stores • Durable medical goods and consumable supplies

15. Environmental Constraints:Social/Infrastructure • 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

16. Environmental Constraints:Social/Infrastructure • Lack of security • Hesitancy to leave unsecured property to seek medical care • Lack of mobility • Loss of jobs and other financial support

17. Environmental Constraints:Emotional • Fear • Insecurity • Guilt • Helplessness/loss of control • Anger • Denial

18. CONSTRAINTS ADAPTATIONS

19. Common Pediatric Problems • Pulmonary • Gastrointestinal • Infectious diseases • Trauma • Psychosocial

20. Pulmonary FEMA Photo Library

21. Pulmonary: 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

22. Pulmonary: 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

23. Pulmonary: 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

24. Pulmonary: Adaptations • Outpatient treatment • Allow 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

25. Pulmonary: Adaptations DO NOT yield to the temptation to treat every febrile pediatric wheezer with antibiotics. Bacterial “bronchitis” is rare in children. FL5 DMAT Photo

26. Pulmonary: 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

27. Gastrointestinal FEMA Photo Library/Dave Gatley

28. GI: 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

29. GI: 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

30. Don’t forget about contaminated ice! FEMA Photo Library

31. GI: 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

32. GI: Adaptations • 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

33. GI: Adaptations • 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

34. GI: Adaptations • Minimize infant formula-switching. • Use stool volume replacement techniques in cases of diarrhea • Staff must be protected against food poisoning!

35. GI: Decisions • Admission decisions must include consideration of shelter status • Lower admission threshold if adequate outpatient management is doubtful • If in doubt, schedule patient rechecks

36. Infectious Diseases FEMA Photo Library

37. Infections: 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

38. Infections: Problems • 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.

39. Infections: Problems • 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.

40. Infections: Problems Local pharmacies may not honor prescriptions by non-local federal responders

41. Infections: 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

42. Infections: Adaptations • 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

43. Infections: Adaptations • Obtain and distribute information about pharmacies in operation • Inform local pharmacies about prescribing privileges for federal responders • Consider distribution of starter doses of medications

44. Infections: Adaptations • 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

45. Infections: Adaptations • 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

46. Infections: 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

47. Infections: 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

48. Trauma FL5 DMAT Photo

49. Trauma: 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

50. Trauma: Problems • 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