Nightmare of Reality: Part II

Like any act of terrorism, terrorist events targeting children are not new. As far back as biblical times it is documented that children have been targeted for political reasons. As a past example in 1838 proves, a pioneer camp along the Blaukaans River in South Africa was attacked by a band of Zulus, killing 185 children.

More recently, in 1974, three "guerillas" from the Popular Front for the Liberation of Palestine attacked a bus carrying Israeli women, killing two and injuring six. They went on to Ma'alot village where they occupied a school. After failed negotiations, a firefight ensued that resulted with 26 people dead and 70 injured, many of them students. Over the years since, there have been numerous events in Israel and the Middle East that have targeted children, whether intentional or not.

In Baghdad, Iraq, a suicide car bomber detonated next to a U.S. Military vehicle that was surrounded by Iraqi children, killing at least 7 children. Prior to that, in 2004 insurgents attacked U.S. troops as they handed out candy to Iraqi children in West Baghdad resulting in the deaths of 35 children. These events are being carried out by insurgents on their own soil and killing their own children. This begs the question of, "How safe are our children on our own soil?" Although the variable may seem that a state of war exists in Iraq, experience has shown us how quickly a state of war can be brought upon us here in the United States.

The largest and most devastating event against children occurred in Beslan, North Ossetia, Russia. 186 children were murdered along with over 150 adults after Chechen terrorists commandeered a school on September 1, 2004. After a three-day siege, explosions were heard inside the building. As Russian forces responded, gunfire erupted and children were intentionally killed by the terrorists while trying to escape. As one can draw many parallels to a small town like Beslan, or for that matter, any small town in the United States, I will continue to refer to the event throughout this series. I often wonder how a smaller town or city in the United States would respond if placed in the same situation. In fact, the final scenario for this series will be based on a similar situation.

In April of 2006, two major school shooting plots were uncovered in the United States. In Riverton, Kansas, five teenagers were arrested in a school shooting plot. Numerous weapons have been discovered in the case and the plot was discussed on a website that is frequented by people across the world. The arrests were made on the anniversary of the shooting at Columbine High School. Riverton, Kansas has a population of approximately 600 people. In the same week, in North Pole, Alaska, 14 miles outside of Fairbanks, six students were arrested on charges of plotting to take over the North Pole Middle School and kill students and faculty. The plot, uncovered by a parent, has been assumed to be credible. North Pole, Alaska has a population of 1600 people. Columbine High School in Littleton, Colorado is one of the most publicized school shootings in the United States. On April 20, 1999 two students began a shooting rampage that ended with 12 dead and another 24 wounded.

Terrorist events targeting children have a larger place in our history than we would like to admit. In fact, it has appeared, until recently, that we as responders have had a problem in the recognition of that fact. This failure to recognize, or, listen intently to those who have recognized, has led to today's' deficiency, or lack of proficiency in this arena.

In 2003, The Mailman School of Public Health at Columbia University in New York City held a national consensus conference1. This conference was designed to take a close look at the level of preparedness in the hospital and prehospital arena. The conference included representatives from federal, local government, professional agencies as well as non-governmental agencies. Their recommendations as well as some interesting observations were published (the link is below).

One of the items presented was the result of a poll that identified the following;

• 78% of all respondents felt that pediatric issues were minimally addressed at their level or organization
• 98% felt that there were ongoing pediatric needs that were not being met
• 66% felt that in attempt to meet these needs, other essential services were suffering reductions
• 78% felt that they were unprepared at that time to respond effectively to a terrorist event involving children.
• 90% felt that there was no information being filtered down to the general public.

The argument can be made that this data is three years old and pediatric preparedness is better now. Well if it is, please email me and tell me how.

As I stated in the introductory article, I recently did a presentation on terrorist events involving children and specifically asked the group their thoughts on the level of preparedness in their hometowns. The response was interestingly quite similar to those numbers above.

The collective response was: "We are not ready."

After the release of the first part of this series, I was contacted by many people who stated that they would read this series with great interest, as their department or squad was taking on the pediatric preparedness effort in greater detail. Many contacts stated that to this day, they have no additional training or equipment to increase their confidence in their preparedness level.

A common statement among EMS providers is that even on a regular basis, pediatric calls are too few to develop a comfort zone. This limited amount of pediatric calls results in many EMS providers not having a solid experience level with pediatric calls. This process is amplified when responding to pediatric mass casualty incidents. Pediatric MCI calls are extremely rare. In many cases of an MCI, EMS providers may encounter some pediatric patients, but not an entire patient group. Even experienced paramedics and EMTs will readily admit that they have not achieved that "comfort zone" while managing pediatric patients. This is evidenced by the "scoop and run" response that continues in many services today.

In responding to a pediatric call, the EMS professional must have a good solid foundation of knowledge to work with. The recognition of the physiological and pathophysiological differences between children and adults alone is essential to good quality field assessment and treatment. In pediatric trauma, recognition of inadequate perfusion (aka "shock" for you old timers) is a key element in the survival of the child. As pediatric patients tend to initially compensate well, assessment can often be trickier than it sounds in the book. Multiply the situation by 15 or 20 or even 100 and you have an overwhelming task in front of you.

When we look at preparedness, we tend to only think about how much equipment and training we need (how fast can you put on that HAZMAT suit). Seldom do we consider the emotional impact that any major event would have on us. This emotional impact exists with any incident, but surges in incidents that involve children.

Remember your first peds call??

Preparedness is as much about emotional resources as it is about training and equipment.

In preparing for the next article in this series, and to assist you in developing a stronger knowledge base for your own program, I am providing links to several resources available on the web for EMS providers to gather information. This information will help providers assist their EMS services in beginning, or completing the task of preparing to treat America's children in times of disaster. Some of these documents originate from the experiences of the medical community in Israel. The Israeli experience in terrorist response, including terrorist attacks involving children, is invaluable, however unfortunate that it must exist at all.

I invite you to visit the links below and continue building your foundations. This is your homework assignment for our continuance on this journey. I will be referring you to additional articles and guidelines as we move forward to protect the future of our children.

The next article in this series will cover special needs of children in disaster, existing professional training recommendations and building partnerships.

Resources:

• Columbia University Mailman School of Public Health: Pediatric Preparedness for Disasters and Terrorism; A National Consensus Conference
  Outlines recommendations for emergency and prehospital care, equipment, training and drills.
• Jumpstart Pediatric Multiple Casualty Incident Triage
  Lou E. Romig MD, FAAP, FACEP
  A collection of valuable information on pediatric events. Includes a pediatric specific triage process tailored to consider the physiological differences in the pediatric population.
• Triage Principles in Multiple Casualty Situations Involving Children; The Israeli Experience Meirav Mor, M.D. and Yehezkel Waisman, MD
  Department of Emergency Medicine, Schneider Childrens Medical Center of Israel Petah Tiqva, and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
  A study that approaches physiological differences in children and examines alternate triage methods.
• The Impact of Terrorism on Children: A Two-Year Experience Yehezkel Waisman, MD; Limor Ahronson-Daniel, PhD; Meirav Mor, MD; Lisa Amir, MD, MPH; Kobi Peleg, PhD, MPH
  Prehospital and Disaster Medicine, Vol 18, No.3
  A study of 41 Mass Casualty events that produced injuries in 160 children.

1. Columbia University Mailman School of Public Health
Pediatric Preparedness for Disasters and Terrorism
A National Consensus Conference
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Greg Santa Maria is the Manager of Pre-Hospital Care and Emergency Preparedness at Sioux Valley Hospital USD Medical Center, Sioux Falls, SD. He can be contacted at SANTAMAG@siouxvalley.org.

Mr. Santa Maria started his career as a Volunteer Firefighter / EMT with the Massapequa Fire Department in Massapequa, New York. He served with the fire fepartment for 12 years and held the rank of Captain of Engine Company 4.

In 1990, Mr. Santa Maria attended the Paramedic Training Program at St. Vincent's Hospital in Manhattan. Upon graduation, he served as a full time paramedic in the City of New York working predominately in the boroughs of Queens and in Lower Manhattan.

In 1996, Mr. Santa Maria was appointed as the Paramedic Program Director at St. Vincent's Manhattan Hospital. During his tenure, he trained and graduated over 300 paramedics into the New York City EMS 911 System. He also served concurrently as ambulance department supervisor and emergency preparedness / decontamination coordinator at St. Vincent's. Mr. Santa Maria received a distinguished service award for his participation in the response to the terrorist attacks on the World Trade Center, September 11, 2001.

Mr. Santa Maria served as the Greater New York Hospital Association Paramedic Representative to the Regional Emergency Medical Advisory Committee of New York City where he worked on protocol development and training subcommittees.

He is a Nationally Registered EMT-Paramedic and is currently certified as a paramedic in South Dakota and in New York State. He is also an Instructor Coordinator and remains active in EMS training.

He has authored several EMS related review books, participated in numerous television, print and radio broadcasts and has spoken nationally on issues of preparedness and disaster response.