Managing Pediatric Patients After Hurricanes

Managing Pediatric Patients After Hurricanes: Perspectives from the 2004/2005 Hurricane Seasons ©Lou Romig MD 2006. Used with permission. 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. 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 Threats Injury Acute infections Chronic illness Lack of access to care Compromised caregivers Key Concept The changed environment is the biggest challenge to excellent medical care after a large disaster FEMA Photo Library FEMA Photo Library Environmental Constraints: Physical Temperature/exposure Sunburn, dehydration, heatrelated illness Sweating, dirt, topical chemicals Environmental Constraints: Physical Lack of clean water Dehydration Poor hygiene Limitations in wound care Environmental Constraints: Physical Lack of appropriate food Inadequate nutrition Inappropriate diet Environmental Constraints: Physical Lack of electricity Nebulizers, other medical equipment Refrigerators Light, ventilation Information deficit regarding hazards Environmental Constraints: Physical Hazardous environments Lacerations, punctures Falls Motor vehicle trauma Tool-related injuries Weapons Environmental Constraints: Physical Hazardous environments Chemical exposures Allergens Insects/animals Environmental Constraints: Social/Infrastructure Disruption of healthcare systems Primary medical care Specialty medical care Hospital-based care Home health care Third party payers Environmental Constraints: Social/Infrastructure Disruption of supply chains Pharmacies and other stores Durable medical goods and consumable supplies 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 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 Environmental Constraints: Emotional Fear Insecurity Guilt Helplessness/loss of control Anger Denial CONSTRAINTS ADAPTATIONS Common Pediatric Problems Pulmonary Gastrointestinal Infectious diseases Trauma Psychosocial Pulmonary FEMA Photo Library 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 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 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 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 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 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 FEMA Photo Library/Dave Gatley Gastrointestinal 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 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 Don’t forget about contaminated ice! FEMA Photo Library 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 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 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 GI: Adaptations Minimize infant formulaswitching. Use stool volume replacement techniques in cases of diarrhea Staff must be protected against food poisoning! 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 Infectious Diseases 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 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. 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. Infections: Problems Local pharmacies may not honor prescriptions by non-local federal responders 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 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 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 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 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 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 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 Trauma 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 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 Trauma: Problems Increased chance of: Tool-related injuries MVC due to unregulated intersections Flame and contact burns Firearm injuries Trauma: Problems Increased chance of: Carbon monoxide exposure Hydrocarbon and bleach ingestion/aspiration Ingestion of medications Drowning Intentional injury Trauma: 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 Trauma: Adaptations 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. Trauma: Adaptations 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: 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 Psychosocial Psychosocial: 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 Psychosocial: Problems 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 Psychosocial: Problems 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: 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?” Psychosocial: Adaptations 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 things mean a lot Psychosocial: Adaptations 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 Summary 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 Summary 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