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Published On Mar 25, 2016

Policy

In the Event of Disaster, Children First

Children are the most vulnerable during a disaster. So why isn’t the emergency response system better at helping them?

Super Storm Sandy, Hurricane Katrina, 9/11—the toll of these kinds of events on adults is tragic enough. But children tend to be even harder hit during a disaster. They have thinner skin and breathe more air per pound of body weight, which makes them more vulnerable to radiation, for example, or biological and chemical agents that may float around in a disaster’s aftermath. Children are more prone to dehydration, too. And the mental scars that such events inflict tend to run deep. Six months after the 9/11 attacks, 27% of public school children in New York City had experienced at least one psychiatric disorder—post-traumatic stress disorder, major depression, panic attacks, agoraphobia—and the numbers were similar in New Orleans three years after Hurricane Katrina.

That storm, in 2005, brought the vulnerability of the young into sharp focus. In the aftermath, hospitals weren’t equipped to handle the onslaught of pediatric cases. Evacuations were disorganized, which meant that children were stranded or separated from their families for weeks. The safety of children simply hadn’t been a priority. In fact, nationwide less than one cent of every $10 that states received in federal emergency preparedness grants between 2004 and 2012 was spent on ensuring children’s safety. So Congress responded by creating the National Commission on Children and Disasters in 2007, which in 2010 issued 81 recommendations on ways the nation can better protect kids during calamities.

Having the right tools and resources was at the top of the list. According to a report by the Centers for Disease Control and Prevention, in 2006 only 7.2% of hospital emergency departments had all the supplies to care for children that had been recommended by The Department of Health and Human Services (HHS) Emergency Medical Services for Children. And only 19% of emergency rooms had pediatric trauma services. Children, as badly as they fare during disasters, don’t otherwise turn up in most ERs very often. Sixty-nine percent of ERs see fewer than 14 kids a day, and 39% treat fewer than five kids each day. In contrast, children’s hospitals, which account for only 2% of all hospitals, see an average of 118 kids a day in their ERs, according to the National Emergency Medical Services for Children Data Analysis Resource Center. In a disaster, hurt and sick kids are likely to surge into the more numerous and available adult ERs, where kid-size ventilators, endotracheal tubes and other gear may be lacking.

And without the experience of treating dozens of kids every day, many ER physicians might not know proper medication dosages for children or when to offer liquid formulations, which are easier for children to take. “Critically ill or injured children aren’t a common occurrence, and as with any other group, it takes practice to be good at treating them,” says Steven Krug, head of pediatric emergency medicine at Lurie Children's Hospital in Chicago and chair of the American Academy of Pediatrics' disaster preparedness advisory council.

Two simple hospital policies could address those shortcomings, Krug says. First, hospitals could include kids in mock disaster drills to help prepare physicians for the challenges that pediatric disaster victims present. And second, they could designate a physician or nurse skilled in pediatric emergency care to ensure that the ER is always prepared and equipped with the right medications and supplies. Yet a 2015 survey of more than 80% of the nation's hospitals showed that most had been slow to adopt such policies. Only 47% had disaster plans for children, and fewer than half of the hospitals had a physician coordinating pediatric emergency care. 

If individual hospitals can’t deliver, perhaps ad-hoc coalitions of hospitals can. As of 2012, HHS’s Office of the Assistant Secretary for Preparedness and Response (ASPR) began to award grants exclusively to groups of hospitals, most of them newly formed, that agreed to collaborate during an emergency. "Hospitals don't normally share their patient census or what medicines they have in stock,” says Melissa Harvey, director of the Division of National Healthcare Preparedness Programs under ASPR. “But that's exactly the information that is required in a crisis. We also require each coalition—and there are now around 500—to focus on pediatric needs and to support pediatric emergency planning.” 

The Los Angeles County coalition, for example, has grouped many of its independent regional hospitals into six tiers to improve care. In an emergency, kids will be transported to the hospital that can best accommodate their severity of illness or injury, and each hospital can plan for the type of emergency it will see.

But even when hospitals can treat all of the affected children, the psychological fallout of a disaster hits them especially hard.  "When you’re a child, you don't go back to the way you were before the disaster," says David Schonfeld, a developmental-behavioral pediatrician and professor of practice, social work and pediatrics at the University of Southern California. Schonfeld has consulted with schools and communities after some of the biggest recent disasters—Katrina, Sandy, tornados, earthquakes and the school shootings at Newtown, Conn.,, and Aurora, Colo. The best solution, Schonfeld says, is to enroll more than the medical community in the healing. Teachers and school social workers—not just pediatricians, nurses and psychologists—need to be trained to help children grieve and recover. "We have to build the capacity of schools to deal with the loss and trauma in the lives of kids, including those that happen to kids every day," he says.

Disaster planning tends to become a priority when it’s too late. As of 2015, only 21% of the recommendations set out by the National Commission on Children and Disasters had been fully met, and in 2012 only 19 states had dedicated funds to preparing for kids’ needs in a disaster. And while a 2010 study found that 14% of kids were exposed to a disaster in their lifetime, that number is quite likely to increase. 

“Natural disasters are happening at greater frequency," Krug says. "We are clearly better prepared today than we were a decade ago. But we’re nowhere near where we need to be in taking care of kids in an emergency. People care dearly about kids. We simply must do better."  

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