Pediatric Disaster Management

If for no other reason than its many powerful tornadoes, you’d expect Oklahoma to have developed a fairly advanced trauma care system. And it has—though more recently than you might surmise.

Pediatric surgeon David Tuggle, MD, was a key player in growing those capabilities in the state’s capital and extending them to a population that’s often vulnerable and underserved in major mass-casualty incidents: children. Now at Dell Children’s Hospital in Austin, TX, Tuggle is a featured speaker at the World Trauma Symposium and EMS World Expo, coming this November 9–13 in Nashville. Dr. Tuggle's presentations are being sponsored by the American Academy of Pediatrics.

At the WTS on Nov. 10, Tuggle will speak on pediatric disaster management and last-resort airway management for kids. The next day at Expo, he’ll address prehospital management of children in MCIs. In this advance Q&A he previews those talks and discusses key aspects of aiding kids when trouble strikes.

How did you become interested in pediatric and pediatric MCI issues?

Well, I’m a pediatric surgeon, and when I moved to Oklahoma, we were required to take care of injured kids by default—there was nobody else to do it. The system in Oklahoma then, which was great for practicing pediatric surgery, wasn’t all that great for taking care of all the complex stuff that goes around managing injured children. We needed to do better, and so I started working with injury prevention and teaching Advanced Trauma Life Support courses to physicians. But there was no trauma center in Oklahoma City, and there was no trauma system, really.

So then in 1995 the Oklahoma City bombing occurred, and we got a whole bunch of kids all at once. So I at least had to organize my hospital to take care of them, but the adult piece was still not well developed. So after Oklahoma City the governor recognized the trauma system in Oklahoma wasn’t as well developed as it could be and had a task force come up with recommendations to improve it.

That was 1997, and some of those got implemented, but one of the big pieces that didn’t was that there wasn’t a lead trauma hospital in Oklahoma City. Smaller cities near us had Level 1 trauma centers—Wichita had two Level 1s, Tulsa had a Level 2, and Oklahoma City’s bigger than both of them, and we had nothing.

So we still hadn’t fixed that, and in 1999 we had a tornado that killed 46 people and injured 700, of which there were 65 kids, and we ended up taking care of most of it. So that got people to dust off the governor’s task force recommendations, and with those my department chair and I were able to convince the dean and CEO of the hospital to make a Level 1 trauma center. It took two mass-casualty events to propel us through the political and financial aspects of it. It took a year, and I was the designated trauma medical director.

It took us a year to get organized, and our trauma center went live on July 1, 2000. You have to have a year’s worth of data to get through the process of being verified as a Level 1 trauma center, so we got our year’s worth of data and were verified in Nov. 2001. So we went from nothing, with no organization whatsoever, to a Level 1 trauma center in about 17, 18 months.

Now there are 8 full-time trauma surgeons there. But since that time, there have also been two more F5 tornadoes in Oklahoma City, the last of which was May 2013. So because of that, the system is very well developed. It was much easier to take care of all those injured adults and children, and probably there were some injury-prevention efforts that also went on because of the development of the trauma system in central Oklahoma.

What else will go into the Expo presentations?

I’m also going to discuss things that are unique about taking care of injured pediatric patients, not just in mass casualties but day to day. For instance, we’ll talk about post-traumatic stress disorder, we’ll talk about family reunification, we’ll talk about some of the physiology you have to think about when you’re managing injured kids with respect to biological, nuclear and chemical attacks. Hopefully we’ll never have any of those, but you have to think about them.

A recent EMS World article noted that only around 13% of EMS departments have pediatric MCI plans. How would you evaluate EMS systems’ preparedness for major pediatric events?

That number sounds accurate. I’m a senior site reviewer for the American College of Surgeons’ verification process, where we go in and look at hospitals and see how they’re prepared. I’d say EMS is generally OK in its ability to resuscitate children. In my day job, where I’m the associate trauma medical director at Dell, we have an extremely robust relationship with our EMS department, but even now there are things we can do and educational pieces we need to continue to work on with our EMS partners.

It’s one of those things you can’t have too much of. Because you transport 80% adults and 20% kids, you have much less familiarity with children compared to taking care of adults.

What about hospitals? Have they become more prepared for pediatric surges?

The larger hospitals generally have adapted the EDAP (Emergency Department Approved for Pediatrics) minimum emergency department equipment for children. Usually critical-access hospitals are more likely to not have everything that’s needed for kids compared to urban environments, where a lot more children come through. I’d say more rurally located hospitals are the ones that are challenged in having all the necessary equipment for all the sizes they need.

What are the key physiological differences for kids?

What you need to remember is that the range of normal vital signs in the pediatric population changes by category. For instance, from 0–2, the heart rate is going to be 80 or 100 to 140 in normal patients.

In our locale we had a 3-year-old patient who was transported with a heart rate of 53. That’s not adequate for a child, because they don’t have the contractility of the heart to increase stroke volume to maintain cardiac output. They need a faster heart rate. So the challenge is remembering, getting out your Broselow tape or putting your thumb up to the baby and going, ‘What’s a normal heart rate, what’s a normal blood pressure for a child this size?’ And then, if they don’t meet what you recall being a normal heart rate or blood pressure, you need to step up your resuscitation efforts.

This child with the heart rate of 53 probably needed CPR and didn’t get it. So even though we talk to our EMS partners all the time, there’s still some of those things people have to remember up front.

What are the key elements in a family reunification plan?

The physicians and nurses can’t also be providing the standards needed for family reunification. These are really chaplain programs, social work programs, Child Life programs. People we partner with are going to be much more appropriate for helping with family reunification. Clearly, physicians and nurses have a piece of that too, but if you have 60 or 80 kids from an elementary school that just sustained an F5 tornado like we did last May, the parents are frantic, and you have to match up the child with the parent. And a lot of times, we don’t wear dog tags. So finding that child and then making sure they go with the right adult provider is critical.

There are only about 15 states that require family reunification plans for schools and day care centers. All the other states have no clue about how they want to go through the process of reunifying children with their families. That’s an area where we’re really behind.

For registration or more information on EMS World Expo, see https://emsworldexpo.com. For the World Trauma Symposium, see https://worldtraumasymposium.com.