When a mass casualty occurs, requirements for a robust response can quickly overstress the standard infrastructure and capabilities of any health care system.
In urban areas, a crisis may pose challenges in coordinating an efficient response involving multiple hospitals. In rural communities, a handful of critically injured patients may quickly overtax the single ambulance service and emergency response team.
Yet, the threat of significant disaster is not going away. In Nashville over the past five years, the city has undergone a devastating tornado, a downtown bomb explosion, and a school shooting, all bringing a multitude of children through the double doors of Monroe Carell Jr. Children’s Hospital at Vanderbilt’s emergency department.
With situations like these in mind, Barron Frazier, M.D. and Claci Ayers, M.D., pediatric emergency medicine specialists at Monroe Carell, offered recommendations at the Pediatric Academic Societies conference in May 2024.
“Sadly, school shootings and other mass casualty incidents are becoming all too frequent,” Frazier said. “My colleagues and I started thinking about what circumstances made pediatricians feel uncomfortable, and this level of challenge likely tops the list.”
The Pediatrician’s Role
Frazier says that children are sometimes overlooked in preparing disaster response plans and funding allocations, driving a need for pediatric representation at all points in the disaster-response cycle.
“Many pediatricians say they do not feel adequately prepared to respond to and manage the myriad demands of a mass casualty, which requires a whole different skill set from what we do in the clinic,” he said. “Pediatric generalists and even emergency medicine specialists are short on the needed training.”
“Mass casualty incidents require a whole different skill set from what we do in clinic. Pediatric generalists and even emergency medicine specialists are short on the needed training.”
To address this gap, physicians and nurses within the Division of Emergency Medicine at Vanderbilt are providing both on-site trainings and off-site lectures to rural emergency and non-emergency healthcare providers, with the aim of improving their response readiness.
Field Triage Strategies
Mass casualties may require a shift in prioritization from the individual patient to a focus on doing the greatest good for the greatest number of people
Ayers explained that a disaster-based triage plan lays out a simple, realistic and easy-to-rehearse strategy to determine how best to deploy limited resources by assessing the state of casualties and determining the urgency and nature of a patient’s treatment needs.
“An example for use in the field is to simplify the triage to answering yes-or-no questions: Is the patient is walking? Do they have severe bleeding? Are they talking? Are they breathing well? Then you assign a color – green, yellow or red – to indicate the urgency,” Ayers said.
Another demand for working in the field is knowing the correct application of a tourniquet, as messaged through the Stop the Bleed Program sponsored by the American College of Surgeon.
“If someone is bleeding out, calling 911 is not going to save their life. But ironically, tourniquet training is given very little attention in physician training, which I think is a glaring omission,” he said.
Hospital Response
Level 1 trauma centers exist to handle catastrophic emergency situations and can offer exemplary strategies for rural hospital providers to use on the scale their resources permit.
A pediatric emergency physician who was working in the Monroe Carell ED on March 27, 2023, when the Covenant School shooter took the lives of three children and three adults described the scene.
“This hit us on a day when we were fully staffed, but we also called in other off-duty providers who quickly came to the hospital, and adult trauma staff also made themselves available,” the doctor said. “We didn’t know what to expect in terms of the severity of injuries and how many children would be coming in needing intensive treatment, and we also had our other patients who were there with emergencies.”
The trauma response team lead served as a central liaison, mobilizing teams of physicians, nurses, respiratory therapists and paramedics from room to room.
“Our team worked effectively to help treat and triage the patients that came in that day. Hospital leadership helped with support from multiple different aspects including waiting room management. Also our team was supported by social workers, chaplains, and the wellness team at Vanderbilt.”
Psychological Healing
Jeffrey Upperman, M.D., surgeon-in-chief at Monroe Carell Jr. Children’s Hospital at Vanderbilt, co-authored the National Academy of Medicine’s Pediatric Disaster Science Series. He is an advocate for developing a coordinated initiative around the impact of disasters on children, who are may be overlooked.
In a recent interview with Holly Fletcher, editorial director for VUMC News, Upperman noted that children “are hard to study, spanning from zero to 21 years of age, each bringing different dynamics to the table,” which contributes to the planning omission.
During and after traumatic events, children may display stress-response symptoms, including regression, separation anxiety, sleep disturbances, appetite change, loss of interest in friends or activities and mood swings. Frazier says the recovery process should involve immersing the child back into normal routines and activities, while giving them space to talk about the experience as they desire.
Although acute stress responses are normal, behaviors that linger beyond a few weeks can indicate repression. This possibility may need to be further evaluated.
“We need to make sure pediatricians provide these psychological resources, whether it’s through the EHR or built into our after-care summary,” Frazier said. “We pediatricians need to take ownership of this process and push for these tools to be integrated into our systems.”
