Medical Aspects of Chemical Warfare (2008) - The Black Vault

Medical Aspects of Chemical Warfareset up pediatric-specific areas to address the specificneeds of children.Clinicians may also need to handle uncooperativeor nonverbal children. This becomes especially challengingwhen an IV line needs to be started. Placing aline in a child while in full protective equipment can bedifficult, and the unfamiliar presence of a clinician infull personal protective equipment can cause fear anddistress in a child. Children undergoing decontaminationwill benefit from a guardian to guide them throughthe process and reassure them. For those childrenwho present alone, a guardian should be appointedand a system for parental identification should be inplace. Hospitals need to plan for this extra resource; amodel may be based on the system developed by anIsraeli hospital that employs social workers to managedisaster patient and family needs, including psychologicaldistress. 106 Parents and children should not beseparated during a crisis, so plans should be made forthe decontamination and treatment of parent-childpairs. 105A variety of specially sized equipment, ranging frompediatric-sized emergency equipment to supplies forbasic needs (eg, formula and diapers), is needed toappropriately manage children. Because decontaminationoften includes disrobing, pediatric-sized clothingis needed, and toys are useful to divert children whenthey need to be observed for long periods of time.Preparing FOR a Chemical EventThe first step in preparing for a chemical event isunderstanding the chemical agents used for terrorismand knowing how to manage their toxicity. Preparednessassessments should identify deficits and be usedto forge partnerships among community members. 31For example, after its assessment exercise, the Universityof Maryland Medical Center decided to partnerwith the local fire department to coordinate water decontaminationoutside of the medical center entrance.Planning for an attack begins with developing localhealth resources because time to borrow resources fromnearby communities after an attack is limited. Becausemost children spend the majority of the day at school,community preparation for a threat should include thelocal educational system and focus on developing arapid evacuation plan and in-school shelters.Healthcare facilities responsible for treating pediatricvictims of a chemical or biological event may beeasily strained and overwhelmed. Alternative areas,such as auditoriums and arenas, are often needed totriage patients after a large-scale chemical or biologicalincident, and these areas need to be staffed with personnelwho know how to manage pediatric victims. 32First responders must be able to recognize pediatricsigns and symptoms from each chemical agent, correctlydon protective gear in the face of persistentagents, handle pediatric patients, and manage fielddecontamination. Adequate supplies of protectivegear must also be available. When planning decontaminationprocedures, pediatric vulnerabilities andchallenges need to be considered.Another key element to appropriate preparednessis the development of a pharmaceutical cacheof antidotes, antibiotics, and vaccines. Although theStrategic National Stockpile is now in place throughoutthe United States, it may be several hours beforesupplies can reach hospitals from this cache and bedivided among sites. Efforts have been made to includepediatric-ready medications, such as suspensions andsolutions, in the Strategic National Stockpile. Localpharmaceutical caches should also try to address pediatricneeds (Table 21-10).Pediatricians are uniquely trained to manage pediatriccasualties and to advocate for children so thattheir needs are addressed in emergency planning. 32,107Pediatricians can assist in educating first respondersso pediatric triage and management is appropriate.Patients and families are also critical advocates forchildren. Through grass-roots efforts, political interestcan be generated to address deficits and encouragecollaboration among groups to mobilize importantresources. Parents can also prepare for an event bydeveloping a family emergency plan (Exhibit 21-6).In addition to developing a family emergency plan,parents must recognize that children will be deeplypsychologically affected after an attack. 108,109 Terrorismcauses strong emotional responses that can easily leadto panic; media coverage of an event is often real-timeand frequently graphic, making fear inevitable. Becausepsychological and emotional impact is the predominantmorbidity of an attack, some hospitals haveincluded guidelines for managing serious psychologicaldistress under special disaster preparation plans.Children can be expected to be among both the directand the secondary psychological victims of a terroristevent. Somatic complaints, such as headaches andabdominal pain, may be common. Pediatric providerscan help families address the underlying psychologicalorigin of physical complaints. How children respond toa terrorist event depends on maturity, prior experience,preexisting mental health, and coping skills. Familysupport and community resources for stress managementalso play a strong role in helping pediatric victimscope. Children may demonstrate fear, manifesting as678