Abstract
It has been reported that 50% of the affected during natural or man-made disasters are children. They have unique vulnerabilities that require unique and specific management. It is therefore vital to understand the optimal management in pediatric emergencies, and to consider efforts regarding pediatric preparedness and response in humanitarian situations.
This chapter reviews the necessary means of pediatric care that must be included in medical relief delegations, and proposes a structure for a dedicated medical team, as well as necessary logistic and administrative considerations.
A triage algorithm is described, considering three key parameters: urgency, available resources, and the likelihood of saving a patient’s life. Ethical dilemmas posed by the above approach are discussed as well.
Lastly, the authors discuss the necessary collaboration between the pediatric team and the traumatology and obstetrics/gynecology departments, and describe the structure and function of a pediatric ward in a field hospital, based on experience from medical relief delegations deployed by the Israel Defense Forces (IDF) after natural disasters in Haiti and Nepal.
Introduction
Natural and human-made disasters – earthquakes, tornadoes, floods, hurricanes, wildfires, and drought, as well as wars, massacres and genocides – have been afflicting humankind since the dawn of time. Although recent advancements in science and big data analysis enable the prediction of some of these disasters[1], most of them remain unpredictable and challenging to combat.
In 2005–2015, a total of 3853 natural disasters occurred, affecting about 1.7 billion people, 85% of whom were in Asia[2]. Extreme climate events represent 80% of these disasters and, while most of these disasters occur in rather developed countries, the small share occurring in lower-income countries and impacting an already impoverished population are the ones bound to be most devastating.
Disasters occur suddenly. However, they tend to have a long tail of collateral events and damage[3], bringing patients to seek medical help long after the disaster occurred and rendering recovery (contrary to relief) from the disaster a long and difficult process, impacting the local health-care system, economy, and quality of life for years.
Therefore, careful coordination between international relief agencies and emergency medical responders is critical to manage disaster victims both immediately and on a long-term basis. In this context, multiple agencies at national and local levels, including nongovernmental organizations (NGOs) such as the Red Cross and Médecins Sans Frontières (MSF), and military medical corps, are deploying their personnel in areas of disasters with a defined set of priorities aimed at disaster relief for the general population.
It has been reported that 50% of the population affected during natural or human-made disasters are children[4]. Moreover, in low- and middle-income countries, which contribute to the largest share of disasters, children are most likely to suffer from malnutrition, communicable diseases (CDs), psychological illnesses, and family disruptions[5]. It is estimated that more than 200 million children are affected by disasters worldwide, disrupting their physical, socio-emotional, and cognitive abilities[6,7].
Children have unique vulnerabilities in such disasters or emergency situations, and require unique and specific management as they have limited communication skills and different physiological and psychological responses to stress. In this regard, it is vital to understand the optimal management in pediatric emergencies and to consider efforts regarding pediatric preparedness and response in humanitarian situations, including pediatric experts in all levels of disaster management[5].
This chapter aims at reviewing the necessary means of pediatric care that must be an integral part of any medical relief delegation in humanitarian situations, disasters, and mass-casualty events. A suitable structure of a dedicated medical team will be proposed, as well as necessary logistic considerations for medical teams that do not treat children on a day-to-day basis.
Field Hospitals Acting as Medical Relief Facilities
Military medical corps of armed forces around the world maintain airborne military field hospitals, which can be transported to different areas to treat soldiers during warfare and emergency. The Geneva convention (GC) has specified that military field hospitals must take care of the civilian population of the area to the maximum extent possible[8], and it has been agreed that military field hospitals are responsible for humanitarian civilian medical care where security risks exist for civilian health-care staff and where inadequate medical facilities are available. In times of peace, these hospitals are deployed in areas of disasters and mass-casualty events, together with humanitarian hospitals operated by NGOs and relief agencies.
To deal with a pediatric population during a disaster, most common causes of morbidity and mortality should be recognized. Common causes of pediatric morbidity and mortality include diarrheal diseases, infections, malnutrition, burns, trauma, and poisoning[9]. Various studies have suggested having pediatric surgical care in humanitarian settings, as pediatric surgical interventions account for more than a third of all surgeries[10]. Among these surgeries, trauma and burns are the most common.
In this regard, Edwards and colleagues have documented more noncombat pediatric trauma and illnesses as compared to those of combat-related injuries in the Iraq and Afghanistan wars[11]. In the Iraq and Afghanistan wars, pediatric admissions varied from 3% to 18% in military field hospitals, where thousands of sick, malnourished, and wounded children were treated[12]. Although the treatment outcome was satisfactory, it was a big challenge at all levels of military hospitals and health-care agencies.
In January 2010, a 7.0-magnitude earthquake struck Haiti, causing the death of an estimated 316 000 people, injuries to more than 300 000, and more than 1 million people were left homeless. Numerous relief agencies, military, and search-and-rescue teams rushed to deploy their staff in Haiti. Despite the 6000-mile distance, an Israeli field hospital was deployed in Port-au-Prince within three days and started accepting patients 89 hours after the disaster[13]. Among the patients treated, 24% were children aged 0–16, only 57% of whom suffered earthquake-related injuries – the others suffering from infectious diseases or being newborns delivered in the hospital[14].
Thus, a medical-relief hospital deployed in an area of mass-casualty disaster should include a dedicated pediatric team, consisting of pediatricians, pediatric surgeons, pediatric nurses, and medics. A pediatric division with a dedicated hospitalization ward and an emergency department should be clearly marked, yet despite the physical separation, it must be fully coordinated with the general emergency, intensive care, surgical, and obstetric facilities.
Triage and Emergency Treatment of Pediatric Patients
To follow instant and accurate assessment of pediatric patients during a natural or human-made disaster, having a reliable triage system is of prime importance. As the children are the most vulnerable population following the disaster, immediate response through a proper triage system plays a key role in offering in-time care.
Critical-care capacity in a disaster area may be even further limited than general health care. The lack of facilities and equipment creates a resource-poor situation, necessitating the need for a so-called “resource triage[15].” Our triage algorithm considers three key parameters: urgency, due to patient condition, available hospital resources, and the likelihood of saving a patient’s life.
Naturally, the above approach poses ethical dilemmas. In times of disaster, the principle of justice becomes dominant, and should be implemented per the utility principle: providing the greatest good for the greatest number possible[16]. An egalitarian distribution of resources, despite seeming more attractive and “fair,” may lead to waste of scarce resources on a hopeless patient, while these resources could have been used to save others. According to Schultz and colleagues, following an earthquake, it is feasible to treat only patients with more than 50% probability for survival[17], and this approach can be implemented in other mass-casualty disasters.
Nevertheless, every effort should be made to maximize the availability of critical-care facilities and equipment. Only when these efforts are exhausted to the maximum, should the resource be allocated to those likeliest to benefit from it[18]. However, in a field humanitarian setting, the chances of survival are often difficult to estimate. The entire situation, and the patient’s condition within it, should be looked on through a prism of uncertainty. Room should always be left for the unexpected, and decision-making according to a strict rule may deprive patients of a chance to survive that we might think they do not have – only to be proven wrong on the next day[15]. An individualized approach, combined with an ongoing assessment and discussion by the hospital’s ethical committee, is the recommended approach to triage and treatment of pediatric patients in critical condition.
Pediatric patients are usually accompanied by a caregiver or a family member, who may be helpful in translating, and feeding and bathing the patient. However, after disasters, some children are admitted to a hospital without the attendance of relatives, who may be lost, wounded, or deceased. In this case, the ethical committee of the hospital will have to decide on the necessary treatment without seeking the parents’ consent and considering the benefit of the patient. During hospitalization, these patients may be assisted by family members of other patients. Their discharge, however, should be coordinated with local or international relief organizations to secure treatment continuity[14].
Additional ethical dilemmas are posed by the lack of proper routine medical care. In areas where the overall access to medical care may be low or nonexistent, a humanitarian hospital is indeed a miracle; albeit, a short-term one. Thus, every treatment decision made within the hospital should take into account the ability of the patient to survive with the commonly available medical care. This led, for example, to a sparing, conservative approach to limb amputations following the Haiti earthquake. In this case, considering the poor rehabilitation situation in Haiti, amputations were performed only for nonviable limbs, while any salvageable limb was treated with debridement and subsequent follow-up procedures, leading to fast exhaustion of supplies, yet providing improved quality of life to the patients[19].
Orthopedic trauma is usually predominant in earthquake injuries[13,17,20,21], while in floods and droughts, infectious diseases predominate due to lack of access to clean water[2]. Inappropriate sanitary conditions, crowded camps, and contaminated water and food may result in gastrointestinal, skin, and respiratory infections. During the second week after the disaster, one should also expect a decrease in incidence of new trauma cases, and an increase in cases of infectious and chronic diseases. Lack of antibacterial medications may lead to exacerbation of infections, and thus a humanitarian-relief hospital should carry systemic antibiotics, including intravenous ones, as well as tetanus-toxoid vaccines.
Pediatric trauma patients must be classified on the basis of type and severity of injuries following triage protocol[5]. The Emergency Severity Index (ESI) is a reliable tool for pediatric triage[22]. Although ESI was first designed for an adult population, pediatric vital-sign criteria were added to it in 2000, making it applicable for all ages[23]. A large study by the pediatric ESI research consortium has found that ESI Version 4 is a reliable triage tool for the pediatric population[24]. The triage nurse and health-care providers must keep in mind the following key points while triaging the pediatric population:
1. Follow a standardized triage approach as described in Table 15.1.
2. Infants must be observed, auscultated, and touched to get the necessary information.
3. Approach children in a nonthreatening way to avoid stranger anxiety.
4. Allow children to have a trusted caregiver with them at all times. Thoroughly explain the procedure to the child’s caregiver and get his or her help in ascertaining the chief complaint and other information as children have limited communication abilities, or are too shy or frightened. Caregivers may also be helpful in holding the children and removing their clothing. However, many children arrive at the hospital without a caregiver or a family member, thus posing additional dilemmas when surgical treatment is necessary.
5. In neonates and young infants, the signs of severe illness – poor feeding, irritability, and hypothermia – may be subtle, and thus require special attention. Children have a relatively larger body surface area than adults, and thus are at a higher risk of heat and fluid loss. Neonates, in particular, have not developed an ability to thermoregulate, and thus they should not be kept undressed longer than absolutely necessary.
6. Offer immediate lifesaving intervention to a hypotensive child. Hypotension is a late marker of shock in children.
7. Get actual weight of all the children. The actual weight is important for medication dosage and the safe care of the child. If a child is critically ill and cannot be weighed, weight can be estimated, but should not be guessed.
| Steps | Titles | Comments |
|---|---|---|
| 1 | Appearance/breathing/circulation: quick assessment |
|
| 2 | ABCDEa | Assess airway patency, respiratory rate and quality for airway and breathing; assess heart rate, skin temperature, capillary refill time, and blood pressure for circulation; assess neurological status for disability; undress the patient to assess for injury or illness. |
| 3 | Patient history | Proper history of the patient should be obtained, especially regarding onset of chief complaint, immunization, allergies, medications, past health history, events prior to arrival, and diet. Most children arriving at a hospital in the first days after the disaster will suffer from trauma, and their physical state may limit the triage ability. In addition, some of the children arriving at the care facility will not be accompanied by adults: their family members may be missing or dead, or taking care of other siblings. This, especially in small children, may result in lack of communication, greatly jeopardizing the ability to assess the patient’s history. |
| 4 | Vital signs | The rigorous evidence or guidelines for vital signs measurement is still lacking. However, oxygen saturation must be assessed in all children. Blood-pressure measurement may depend on the triage nurse assessment. |
| 5 | Fever | Must assess fever in all children. Rate ESI level 2 to the children with 38°C. |
| 6 | Pain | Assess pain using a validated pediatric pain scale, or as part of PQRLSb. |
a ABCDE: airway/breathing/circulation/disability/exposure
b PQRLS: assessment of pain, quality, radiation, location, and severity
It is vital to act promptly to classify the patients immediately to respective triage levels to offer them definitive evaluation and management. ESI levels 1 and 2 include potentially unstable patients requiring urgent management[25].
ESI Level 1 includes high acuity patients or those who would die without urgent and intensive care. Available literature reports that triage nurses underutilize ESI level-1[26], except children who are intubated or in cardiac arrest. Assigning ESI level 1 acuity is based on the clinical condition of the patient, and the conditions included are respiratory or cardiac arrest, major head trauma with hypoventilation, active seizures, unresponsiveness, altered consciousness with petechial rashes, anaphylactic reactions, respiratory failure, shock, or sepsis with signs of hypoperfusion, flaccid baby, and hypoglycemia with altered conscience level.
ESI level 2 includes the patients who are potentially at high risk. Examples of conditions included in ESI level 2 are syncope, hemophilia with acute bleed, immune-compromised status with fever, febrile infant (< 28 days; > 38°C), hypothermic infant, moderate-to-severe croup, suicidality, seizures, meningitis, and moderate-to-severe lower airway obstruction.
There are three more levels of ESI: 3, 4, and 5. ESI level 3 includes stable patients and should be approached in 30 minutes. In ESI levels 4 and 5, the patients can be seen nonurgently (Table 15.2). Moreover, ESI levels in pediatric settings may differ from those for the adult population. For example, lacerations in adults are included in ESI level 4, while in pediatric settings they require sedation and thus are kept in ESI level 3. The following conditions may require sedation:
displaced fractures
complicated lacerations: facial, vermilion, or requiring multilayered closure
contaminated wounds requiring debridement or thorough wash
Table 15.2 ESI levels
Related posts:
Chapter 6 – Training and Accreditation
Chapter 3 – Definitions, Needs, Scenarios, Functional Concept, and Modes of Deployment
Chapter 11 – Auxiliary Medical Services in a Field Hospital
Chapter 7 – Personnel
Chapter 18 – Orthopedics in a Field Hospital
Chapter 25 – Infectious Diseases and Public Health in a Field Hospital
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