Pediatric Issues in Terrorism

© Lou Romig MD, 2006. Used with permission.

http://lordoftheflies.org/img/beslan01.htm

Guiding Principles

Assuring excellence of pediatric emergency care on a daily basis is the best preparedness for pediatric disaster care.

Preamble

Preparing for the involvement of children as victims of a terrorist attack is little different than preparing for any other kind of multicasualty disaster.

Guiding Principles

The best approach to disaster preparedness is to plan for all pertinent hazards.

Guiding Principles

We don’t need separate disaster plans for kids but we do need to focus on their unique needs and

critical

differences when it comes to preparing for any kind of disaster, including terrorist attacks.

Guiding Principles

We must all be responsible for our own preparedness and that of our loved ones.

Pediatric Issues in Terrorism

      Children at risk Assessing your community’s risks Community preparation issues Family preparation issues Psychological issues with children Resources

“Collateral damage?”

Or intentional targets?

When Lee Malvo asked why he planned to attack children in schools and on buses, convicted sniper John Mohammed allegedly replied:

“For the sheer terror of it – the worst thing you can do to people is aim at their children.”

(From AP story 5/30/06)

Children at Risk: Targets

     Innocent, vulnerable population Tend to gather in large groups, including daycare centers at places of business Natural curiosity May not be able to rescue themselves Extreme emotional reaction by rescuers and public

Children at Risk: Vulnerabilities

 Low to ground  Faster respiratory rates  Larger skin surface area to mass ratio  Vulnerable to fluid loss

Children at Risk: Vulnerabilities

 More permeable blood-brain barrier  Many rapidly reproducing cells  Unable to escape (longer exposure)  Found in large groups (contagion)

Is your community at risk?

Is your community at risk?

      Major trade, banking or retail centers Historic landmarks Military installations Colleges/schools Manufacturing plants Chemical storage centers

Is your community at risk?

      Government buildings Major sports, entertainment, and convention venues and events Technological research centers Airports, other transportation centers Religious centers Hospitals

Are there children near your community’s at-risk sites?

Community Preparation

Local emergency management    Assess pediatric venues at risk Assist local medical services and agencies in preparing for the needs of children and families Involve local child and family advocate agencies in emergency planning

Community Preparation

Local emergency management  Community education addressing children’s issues  Pediatric aspects of shelter management  CERT programs  Working knowledge of state and federal response resources

Community Preparation

Schools and Child Care  Disaster plans and exercises including initial scene assessment, rescue and triage  Awareness of risk factors in area  Education for teachers, administrators, parents and children  Reunification/ shelter in place/ evacuation planning

Community Preparation

EMS/Fire  Work to be able to take good care of kids on a daily basis  Training  Equipment  Quality management

Community Preparation

EMS/Fire  Incorporate children in all MCI drills and exercises  Knowledge of at-risk groups in the area  Knowledge of local hospital pediatric capabilities  Have appropriate protocols/aids for pediatric WMD/WME care

Community Preparation

Hospitals  Work to be able to take good care of kids on a daily basis  Training  Equipment  Quality management

Community Preparation

Hospitals  Incorporate the needs of children and families into all aspects of disaster planning and preparedness   Acknowledge the likelihood of an unusual pediatric patient load in the disaster setting Be aware of available pediatric resources

Community Preparation

Hospitals  Incorporate children and families in all disaster exercises  Work within hospital networks to identify pediatric resources that might be tapped in cases of unusual pediatric load  Prepare for public concerns

Community Preparation

All medical responders/receivers must be prepared to deal with:   Pediatric and adult multicasualty triage Decontamination issues      Children who are unable to self decontaminate Risk of hypothermia Post-decon clothing for infants and children Keeping family members together Children’s fear of “monsters” garbed in protective equipment

Community Preparation

All medical responders/receivers must be prepared to deal with:  Lack of familiarity with pediatric antidotes and treatments and lack of pediatric drug formulations  Unusual pediatric patient loads and acuities  Relative lack of local pediatric specialty resources due to overwhelming patient volume  Ethical dilemmas in resource-constrained environments

Family Preparation Issues

FEMA Photo Library

Family Preparedness for Terrorism

The best family preparedness plan focuses on

all

pertinent hazards. The possibility of being affected by a terrorist attack should be acknowledged and addressed the same as any other hazard but not emphasized.

The concept of terrorism is now a part of our culture. Children must have a context into which to place information about terrorism.

Children Need to Know

 If a parent has a potentially hazardous occupation, children need to know  Discuss

why

parent takes the risk  Talk about general risks to safety; limit details  Stress safety measures taken; allow children to become familiar with protective equipment

Children Need to Know

 What to do if they find an unidentified package or substance  How to find safe places and exits  Not to be scared of rescuers  What potentially dangerous areas are located near home and/or school

Family Prep: Reunification

 Everyone needs to carry ID and an emergency contact number  Keep current photos of all family members in a secure place  Family members should have a general idea of where others in family are  Appoint one family member to keep track of family travelers

Family Prep: Reunification

   Plan on who will pick up children from school, etc if necessary in an emergency Be familiar with school disaster plans (early pick-up, shelter in place, pre planned evacuation sites) Plan family rendezvous points   Physical Central communications point

Family Prep: Talking about Terrorism

Terrorism is now a part of our culture. Children need to learn about terrorism the same way they learn about other aspects of the world’s cultures, history and current events.

Talking about Terrorism

 <5 yrs of age   Children in this age group have little concept of the future and will not understand discussion of something that

might

happen.

Be honest about your emotions if an attack does occur. Tell child that people were hurt but that he/she and the family are safe and that you’ll feel better after awhile.

Talking about Terrorism

 5-9 yrs of age   Discuss terrorism when child shows curiosity because of exposure at school or in the media.

Ask the child what they’ve heard about terrorism. Correct misinformation and misunderstanding.

 Emphasize the emotions of terrorism rather than the politics.

Talking about Terrorism

 5-9 yrs of age  Emphasize that many people are working hard to keep all of us safe.

 Discuss who to blame and who not to blame.

 Discuss things the child can do to stay safe from all kinds of hazards.

Talking about Terrorism

 9 yrs and older  Can begin to discuss “politics”, including why people and countries may disagree  Talk in general about the different things terrorists might use as weapons   Emphasize that it is very unlikely that anyone in the family will be involved in a terrorist incident Caution children about rumors

Psychology in the Aftermath

FEMA Photo Library

Immediately After An Incident

    Allow children to watch media but limit exposure and be present to discuss and handle children's reactions.

Reassure younger children that they didn’t cause an event to happen.

Assure children that an event is not happening again just because they see pictures over and over on TV.

Set aside a time for family discussion.

Immediately After An Incident

   Explain in concrete terms what happened and answer questions truthfully.

If possible, reassure children that their loved ones are safe.

If a family member’s status is unknown, tell children why and what is being done to find out.

Immediately After An Incident

   Children pick up on adults’ emotions. Don’t hide emotions but try to keep them under control.

Tell children that it’s OK for them to be feeling sad, angry, or numb and that not everyone will be feeling the same way at the same time.

Maintain family routines.

FEMA Photo Library

Expect and respect fear for family members in public service positions

As Time Goes On

     Supervise media exposure Expect a greater need for physical reassurance Encourage talking and emotional expression Emphasize tolerance and unity Turn thoughts toward recovery



As Time Goes On

Common psychological reactions:  Regressive behaviors  Sleep disturbances  Fatigue  Unusual expressions of anger  Changes in appetite  Mood swings  Lack of ability to experience pleasure  Substance abuse

    

As Time Goes On

Seek professional assistance if children have:    New behaviors that consistently interfere with activities of daily life Suicidal thoughts Depression Aggressive behavior Flashbacks Substance abuse Chronic physical symptoms

As Time Goes On

Allow children to participate in memorials and help in relief efforts FEMA Photo Library

As Time Goes On

Introduce a family ritual to honor victims and responders, especially if loved ones and acquaintances were involved.

FEMA Photo Library

Summary

  The best preparation for emergency medical response to children as victims of terrorism is to be able to take excellent care of kids every day.

An all-hazards approach to planning at all levels is probably the most efficient.

Summary

  Individuals and families must plan for the

possibility

(not affected by terrorism.

probability

) that they will be directly or indirectly Terrorism should be discussed with children in appropriate terms.

Help!

    Children and families are well represented on many federal and national planning committees. Watch for consensus statements and recommendations.

Broselow/Luten CWIK Response project Increasing availability of pediatric drug delivery systems such as Meridian Medical’s Atropen ® autoinjectors National Disaster Medical System includes two specialty pediatric teams.

Some Useful Resources

 International Critical Incident Stress Foundation @ www.icisf.org

 EMS-C National Resource Center @ www.ems-c.org

 American Academy of Pediatrics @ www.aap.org

 FEMA @ www.fema.gov

(includes FEMA for Kids)

Some Useful Resources

    Centers for Disease Control @ www.cdc.gov

Pediatric Preparedness for Disasters and Terrorism: A National Consensus Conference @ http://www.bt.cdc.gov/children/index.asp

JumpSTART Pediatric MCI Triage @ www.jumpstarttriage.com

Chemical Warfare involving Kids (CWIK) @ http://www.cwikresponse.com