Mass casualty incidents (MCI’s) happen everywhere and challenge resources, whether in established trauma centers or remote general medicine facilities. UCSF pediatric emergency specialists and pediatric trauma surgeon, Chris Newton, MD, FACS, FAAP, explore how to develop a mass casualty plan that accounts for how children will be affected. This webinar offers both guidance and online tools for ensuring the best possible care for kids in tragic yet increasingly common events such as fires, earthquakes, and shootings.
Hi everyone. Welcome to this episode of our limited series on Children's emergencies called Send or mend. The title of our show comes from a conference our department hosted this last fall and refers to the question of how you decide to send a child to the emergency room or try to mend the medical emergency yourself. I'm dr Sunny tat a pediatric emergency doctor. I work at the Children's Emergency department at U. C. S. F. In SAn Francisco and at SAn Francisco General Hospital. My co host is under Narula. I'm in there. I'm the pediatric emergency outreach nurse educator. I also work at Benny at Children's Hospital in SAn Francisco and SAN Francisco General Hospital. This webinar series is meant to be a practical and interdisciplinary approach to emergency medical care for Children. We're going to invite regional national experts in the field to have a conversation focusing on the challenges related to the gray areas of medicine. Under this past year alone, we've seen a number of mass casualties happen around the country. To me sometimes feels like these events are happening with increasing frequency as providers in hospitals and clinics specializing care for Children. I thought would be important to learn a little bit about our role in a mass casualty today. Our guest is Dr Chris Newton, who's a pediatric trauma surgeon at many of Children's in Oakland. He's also the pediatric director of peri operative services at Children's Hospital of Oakland and also leads the Western Regional Alliance for Pediatric Emergency Management. A federally supported collaborative too expand and integrate pediatric specific disaster preparedness and response capabilities. This network connects to other regional and national efforts to drive improvements for Children affected by disasters throughout the US. Moving forward, we're going to use the term M. C. I. To mean mass casualty incident, which is a term we might hear on the news but M. C. S. Aren't just shootings and terrorist events. We get em Ci alerts at san Francisco general more than anyone would probably think bus or train accidents, large scale toxic exposures like tear gas and fires might be M. C. Is depending on the number of people involved and just because you're not at a trauma center, it doesn't mean that patients from an M. C. I won't arrive at your doorstep. N. C. I. S include many things we never hear about yet. The impact. A lot of people in the health systems have to be ready. Dr Newman, thank you for joining us to share your expertise today. Thank you. I'm thrilled to be here and happy to answer any questions. I love how you set this up, defining exactly what we're talking about with EMC's and and kind of what that means and I'll applaud and echo what you said these happen anywhere and they happen in all sorts of flavors. Chris mass casualty is a term tossed around a lot. Can you tell us what an EMC is and what it means to you as a pediatric trauma surgeon from a definition standpoint and EMC would be classified as anything that can exceed your capabilities. Now, what that means is different for every hospital. So if you're a trump center that runs three or four trauma rooms at a time and you have enough surgeons and anesthesiologists at O. R. Is to be able to meet three or 42 at a time. That kind of defines your ceiling. If you get six Children all at once and they all need the O. R. At the same time, you now have to decide which one waits and which one goes or you have to decide, do we need to move this child or adult to a different hospital when you reach those decision points? That's an EMC are what are some of the most likely? M. C. A. Events that could happen in our area and what makes our areas susceptible for these type of events. So northern California is particularly known for earthquakes obviously and yes this happens on a regular basis and it's always at the top of everyone's fear list over the past several years. Active shooter events also are happening everywhere around the country and we are not immune to that. That is that is something that we worry about here fires in California have also been increasing and causing a lot of problems every year and almost predictably every year we know there's going to be some challenges and it's going to overwhelm the system. Since these can overwhelm the system, as you just mentioned with a number of patients who come at once. Triaging I imagine is super critical. Sure. And er triage we assess each patient for how sick they are or how many resources are involved to help meet their needs. How is N. C. I triage different from er triage from a conceptual standpoint. It boils down to are you capable of meeting the current standards with resources you have on a day to day basis. E. R. May get very busy some days are worse than others. And on those normal days every kid is getting checked in and seen per kind of the normal routine. The situations we are talking about occur when it's clear you're not going to be able to meet your daily standard. But the bottom line is the triaging and EMC means some child is going to have to wait where some child is going to have to not get the normal standard of care or transferred to another hospital. This makes everybody very uncomfortable, understandably. This is not what we want to see happen. So a lot of the preparedness efforts in a system is to try to do the best we can recognize where you're going to have problems. Get the kids, you know, the very best care even if you're stretched and he's the anxiety that everybody's going to have about making tough decisions. And how does this triage differ from a for Children versus adults preparing for a disaster is a very standardized thing. It happens all over the country in every hospital. There's emergency managers in every hospital system. Those plans for adults generally are good for kids. There's a lot of things that overlap Message one is the normal adult plans are good plans. Don't deviate too much from them, but then you begin to think about what makes you know, any population special whether it's pediatric or a nick you or a nursery or an L. And G. Unit, There's some special needs that are not transferable that you have to pay attention to. We often talk and planning about space staff and stuff. So for kids, if you begin to think about stuff and staff, you quickly appreciate the core of the problem, the younger you get in the smaller uh child that you're treating unique different equipment and you need access to it and you need enough of it to treat a bunch of kids all at once. Tertiary pediatric hospitals may have that stuff like Oakland, but that's not necessarily true of every hospital staffing question comes into breath of experience. And how often do you see kids every day whether you're a nurse or a doctor, whether you're an E. R. Or a surgeon or a radiologist looking at films universally if you're not used to seeing a five year old and all of a sudden you are forced to multiple times in a stressful situation. It's not easy. Now we talk about also in triage kind of a standard four tiered method when there's bunches of patients in a parking lot on gurneys, you go around to each one and you label them they need immediate care or minimal care or can be delayed or expect they're gonna they're not gonna make. And you classify the patients into each of those categories when you begin to think about kids. Those categories are pretty tough and we still preach the same categories. But let's be honest it's not easy to say that a child is expectant and not going to make it. That's not a call anyone wants to make and it's not easy to see something that needs to be delayed, but it's a child. And how do you delay and how do you move when you've got a child that's entered in and parents that are there, this puts us a special challenge on the triage. The other special challenges. Kids can't talk. And while I said very frequently they come with parents. Sometimes it's the other extreme and they're by themselves and they don't know their phone number, they don't know their address and you don't know where their parents are and now you have to figure out are they okay and put them in. One of the category boxes becomes an impossible task. There's a couple of tools that have been developed for this to try to help. One of them is called the salt triage tool. Let me paraphrase it. Head, heart and lungs. Even in a child who can't talk you can at the doorway look in and then 10 seconds appreciate is their head okay? Are they breathing? And are they perf using or bleeding? And this kind of triangle for kids is kind of an example of one of the tools to help get them in the right box chris I think you're referring to the walk wave and still. What does that mean? That's not it's not typically how we think about triage in the E. R. But I think this is a really important concept. If you take apart each of those statements that you that you said you can quickly imagine how in a chaotic situation those things helps you make a quick decision whether it's a child or an adult. If they are walking on their own and moving around and talking and waving, they're probably in good shape, at least for the moment. Doesn't mean they don't have a problem, but okay, that gives you some comfort. If they are unable to even wave and are laying on the ground, this is the head part of that head, heart, lungs, they've got a problem. You need to prioritize getting over to find out what the problem is. You know, these are great, just chamonix to try to make the obvious simple so that you can remember it. Yeah, that's great. I think I remember from my own training in emergency medicine, they would say in a disaster, anybody who is sick, walk over here and then you immediately say those people are okay and go to the people who didn't move. You know, it's not a bad trick. The curve ball is kids are either attached to an adult, it's two for the price of one. You may say everyone who's okay, walk over here and mom picks up her child and walks over there. She may be fine, but the child may be may not or the opposite extreme. You have a child by themselves, they don't understand you, they don't know what you're talking about. There's no caregiver, you've got a problem. You know, now that you've convinced us that being unprepared for an M. C. I. Is a disaster itself waiting to happen. How should we as providers, both in hospitals and clinics kind of begin to prepare? What are some general principles of forming an M. C. I. Plan? It all seems kind of overwhelming otherwise. It is overwhelming. And and let me answer that in multiple different facets. Every hospital around has an emergency manager and a plan for the hospital. You may not know it exists, but it does. And there should be a system. When some event happens, there's a team that it's activated that comes together to make decisions at a high level. Ultimately they implement what your hospital plan is. That plant means you need a place to receive patients and you need a way to triage them is you got to figure out is the surgeon gonna be out doing triage? Whereas the surgeon tied up in the O. R. Is the E. R. Doc doing all of this triage. Do you need people who aren't used to touching patients to start doing a job? Maybe you're chaplains become child life helpers start taking blood pressures planning for how do those re distributions and those volunteer pools report into the hospital and how do they push out to where they're supposed to be? This is part of all the things you write down beforehand. I've done it for lots of hospitals. It's it's not easy. There's challenges at every facility and you have to think out, you know in advance. What can our place do and what are the bottlenecks? Where do we not have resources? Do we have only one CT scan? How many O. R. S. Can we run it once? How do patients leave the hospital? If I have a flood of patients coming in, how do I empty out beds upstairs? And how do I transfer patients out that I need to get out of the hospital to take care of the marginals. It's all great questions and they're different at every facility. Well, chris why aren't disasters just left to the trauma centers that we have set up in the region? That's what they're there for, right. Yeah. And generally speaking, the trauma centers, whether you're an adult trauma center for pediatric trauma center, you're generally pretty well equipped to be able to flex, meaning if there's a surge we can stretch pretty far before we are overwhelmed. However, there's a few important key points. Eventually even your trauma center is going to get overwhelmed no matter how well equipped or how good you are, how big your building is, there does come a point where you can't handle it, you need help. Problem two is all these great trauma centers that we have, whether it's SAn Francisco General or highlander Oakland or stanford Davis happened to be real close to fault lines. You know, it's not a minor worry to think what happens if your trauma center that is the foundation of your plan can no longer function. The other important part of your question however is things happen everywhere. Things don't just happen in Oakland and san Francisco will happen all over northern California and and you can look at the tubs fires and see how this impacted all levels of hospitals throughout all of northern California and these aren't trauma centers. We've now learned their protocols to help not just the fires but also the hospitals and the evacuation of people and the coordination of patients. And there's a system in California that integrates between that system and each of the hospitals. If those fire commanders are seeing the fire come near the hospital and near the city, they begin to make a you know a proclamation, you need to evacuate your hospital. This has happened, it's now happened a couple of times. Moving an entire hospital to a different hospital is unbelievable event. We now have several ddos around northern California that now have a lot of experience with. This is a different kind of M. C. I also needs planning. Also needs some preparation of who you're going to call and how you're going to coordinate that and how you prioritize which patient goes to goes to which place. This is interesting twists that we've learned. Of course you have a fire, you're going to have burned patients. But the ripple effects of evacuating a hospital, we're not having resources were having air quality that impacts every asthma patient throughout northern California. Those ripple effects are quite dramatic. And how should we think about Children differently when it comes to preparing for mass casualties? As is true with many things situations change and get more complicated when Children involved right in your system and in your hospital thinking about the stuff that you have and the space for kids and the staff and the experience. So the space staff and stuff. And it needs to be pediatric specific number two, preparing two for the price of one. This means in a disaster, parents don't want to be separated from their child wherever it's possible. Keeping them together is valuable. You need an adult hospital. If the mom is the one that really needs most of the care that can also check out the kid or vice versa and then the final one is is the other extreme kids that have been separated from their caregiver. And uh, you got to do the best. You can. You have no way to get a history. You have no way to figure out what to do. At some point. Your medical concerns are over. And now you get the final challenge. How do you reunite a child with their family in the middle of chaos? You can't talk to the child, They can't respond and you don't know how to find their family when it's a facility that doesn't see a lot of Children. What can generally leads do to help them feel more prepared for taking care of M. C. S. That are pediatric related. There's a few things that I would offer may be the best philosophy out there to answer this question is what do you do every day and every day, Every day care, everyday preparedness for kids gets into the MSC and and pediatric E. R. Readiness programs. So these are national programs. They are federally funded and set up in each state and each county. They provide guides and tool kits for E. R. S. And list. Uh, This is the equipment that you need advice on. This is the list of training that your staff should get. There is a national Pedes ready assessment. This is focused not on the Children's hospitals. This is on every hospital. It should help you determined where do we have gaps in that we can fill? It's a great program. There's no downside. Everybody should be doing. And you know, and it will help you do the day to day care. That it just becomes so important when the system gets overwhelmed. Maybe one of the most important parts of that. E. M. S. C. P. S Ready program is the encouragement of every hospital to have someone designated. That is a Pedes care Champion. And this is usually a nursing manager who, who is designated as the go to person to help figure out do we have the right stuff? Do we have the right training? Can we do more? Do we know who our partners are? How do we transfer out if we need to, who do we call for help? All these great questions and getting that champion in place is maybe one of the most crucial things you can do in your facility to get prepared. Now we in Oakland we participate in this by doing what I think is great. We have a team that goes out to each individual local hospital around us to help, you know, to help the nursing managers and go through the list and help do this. An on site survey of, you know, are you guys ready? My group has participated very heavily in the tool kids and checklists that are now online. If you go to the website, there is a whole list of tools that you can that you can download. You know, we helped with updating a lot of those tools and they're great chris you've worked on something called the stop the bleed campaigns, tell us a little bit about what stop the bleed is and why these community outreach efforts and drills are so important. Stop the bleed is a national program that got rolled out from the American College of surgeons. You know, it sprung from this concept of a lesson learned from military experience in Iraq and Afghanistan historically, tourniquets to control bleeding. We were a little wary of in trauma. They have downsides and you leave them on too long and okay, that puts a limit risk or, or nerves at risk And that's especially true in kids 10, 15 years of military experience in in Iraq and and you quickly have a ton of data showing that stopping bleeding with tourniquets saves lives. So the trauma community began a campaign to teach anyone and everyone who is capable of how to put on a tourniquet because it's simple. This campaign has been very very successful nationally. They have taught in schools and community events and teachers and you know how do you do a tourniquet in a child? Most trauma centers us included have a team that does the training and so we will go out to various events schools community events whatever and teach teach civilians community. How do you how do you put on a tourniquet? I will also advocate that if you are a doctor or a nurse working in a hospital and uh and you don't know how to put on a tourniquet but your teacher does. Yeah that's not good. We need to stack people hear about M. C. I. S. All the time but I don't know that. People think about kids involvements in M. C. I. S. In a lot of these M. C. S. We hear about both nationally and maybe the ones we don't hear about our kids involved in them at all. It's a good perspective and you're bringing up kind of the statistics of impact. And it also raises another interesting question of the acuity and how long this lasts. If you look at all the events over the last 1020 years and you can list them whether it's the active shooter events, you know the Newtown shooting or or the hurricanes uh or the fires or whatever it may be. And you look at the people who were injured, You would think that kids should represent about 25% of the injured Because kids are roughly 25% of the population. It's really interesting if you look through all of the events and look at the numbers those who are impacted in all these the kids are kind of Disproportionately affected here. The number of kids in most of those is much more than 25%. Now there's exceptions. You know, the Las Vegas shooting as an example didn't have a wealth of kids. Kids generally don't go to country music concerts so they were spared. But okay, you go down the list and you quickly appreciate that in many or most of these events, kids are vulnerable, especially with things like hurricanes and fires and earthquakes. And part of that vulnerability is not just the acute event. It's what happens for the 2-4 weeks after the event. What happens when the kids by themselves and their caregiver is gone and there's no food and the water supply is contaminated and you can go on and on and you quickly appreciate that a child in that environment is at risk and needs help. And that's a moment where we can help there. There's an opportunity to prevent that problem. Today, we talked to Dr Chris Newton, who's one of our pediatric trauma surgeons at Children's Hospital Oakland about disaster management specific to pediatrics. He walked us through the National Emergency Medical Services for Children and also highlighted resources extend to both Children, families and community hospitals to help us all feel at least a little bit better prepared for this worst case scenario. So join us next time as we keep asking that essential question of when to send and when to mend. Yeah, Yeah, yeah.