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 such situations in mind, Barron Frazier, M.D., a pediatric emergency medicine specialist 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 the needs of children are sometimes overlooked by those preparing a disaster response plan, yet pediatric representation is crucial 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 the gap, Frazier and his colleagues are providing both on-site trainings and off-site lectures to rural emergency and non-emergency pediatric providers across five southeastern states, with the aim of improving crisis readiness.
Field Triage Strategies
Mass casualties often require a shift in prioritization. In some cases, care for an individual patient may take a back seat when the focus is on doing the greatest good for the greatest number of people.
Frazier 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 each 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,” Frazier said.
Another demand for working in the field is knowing how to correctly apply 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 strategies for rural hospital providers to use as their resources permit.
Pediatric emergency physician Claci Ayers, M.D., was working in the Monroe Carell ED on March 27, 2023, when a former Covenant School student entered with guns and took the lives of three children and three adults.
“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,” she 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.”
She says the trauma response director stepped up immediately, serving as a central liaison, mobilizing teams of physicians, nurses, respiratory therapists and paramedics from room to room.
“We were managing an overfilled waiting room of parents on top of addressing the needs of children who were injured or in shock,” Ayers said. “One thing that was crucial on that day was crowd control. Parents were asking ‘Is my child here?’ When will I know? Where do I need to go next to find out?’
“I and some other team members took over the role of providing what information we had, but we also had the continual support from social workers, the wellness team at Vanderbilt and our chaplains.”
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.”
