September 1, 2025

During September, we will address pediatric considerations in disasters and mass casualty incidents.  

First, the definition of disasters: any disruptive event that causes trauma or loss to a community, creating overwhelming needs that cannot be met by available resources. They are mostly unpredictable and generally cannot be prevented, vary by size and location of the event, and can cause overwhelming effects on a community’s response. Disasters pose a significant local impact but may often also have county, state, or regional impact. Planning and partnering ahead make a difference in children’s health and their psychological outcomes. Ensuring that children’s needs are not neglected in planning, response, and recovery efforts is vital. Pre-hospital providers have a critical role to play in disaster management, which will be discussed in the coming weeks. A critical aspect of planning is to identify those children at the highest risk. For example, communities may face additional challenges protecting children during emergencies because of economic, geographic, or racial/ethnic disparities.  

Types of Disasters 

Natural Disasters include floods, hurricanes, tsunamis, storms, tornadoes, and wildfires. 

Man-Made Disasters include bioterrorism, terrorist events, school shootings, structural failure, or a hazardous material spill.  

Infectious Disease Outbreaks, Emerging Infections, or Pandemics include, but are not limited to, outbreaks of new and unknown diseases, known diseases that spread quickly, coronavirus infections, and diseases that are persistent and hard to control. 

It is important to remember that children differ from adults in physiology, developing organ systems, behavior, emotional and developmental understanding of and response to traumatic events, and dependence on others for basic needs. The American Academy of Pediatrics released a policy statement emphasizing the need to include children in disaster planning, seen below:

Ensuring the Health of Children in Disasters

DISASTER PREPAREDNESS ADVISORY COUNCIL; COMMITTEE ON PEDIATRIC EMERGENCY MEDICINE

This Policy Statement was reaffirmed April 2021.

Infants, children, adolescents, and young adults have unique physical, mental, behavioral, developmental, communication, therapeutic, and social needs that must be addressed and met in all aspects of disaster preparedness, response, and recovery. Pediatricians, including primary care pediatricians, pediatric medical subspecialists, and pediatric surgical specialists, have key roles to play in preparing and treating families in cases of disasters. Pediatricians should attend to the continuity of practice operations to provide services in time of need and stay abreast of disaster and public health developments to be active participants in community planning efforts. Federal, state, tribal, local, and regional institutions and agencies that serve children should collaborate with pediatricians to ensure the health and well-being of children in disasters.

Next week, expect to read the reasons why children are more vulnerable during disasters. In the coming weeks, we will also discuss mass casualty incidents, planning for disasters, triage, and the roles of prehospital providers in disasters.  

Until then, stay safe and have a great week,

Regina A. Yaskey, MD

September 8, 2025

Last month, Shaun Kibler provided all of us with an excellent lecture on Active Shooter/Hostile Event Response (ASHER), along with Massive Hemorrhage, Airway, Respiration, Circulation, Head/Hypothermia, or MARCH, and a review and discussion of warm Rescue Task Force (RTF) maneuvers. We reiterated that for casualty stabilization, we must:

1. Stop the bleeding

2. Keep them breathing

3. Get them leaving

With all of this in mind, we separated the victims into 3 classes:  

1. Walking or minimally injured, no tapping and pointing them in the direction you want them to self-extricate.  

2. Dead or expectant, receive a zebra black and white tapping to avoid reevaluation.  

3. All others who should be tapped orange.  

We told the departments to get the red, yellow, and green tape out of the RTF bags because we want all departments to comply with this active shooter preparation. We also stressed NO tagging in the warm zone. This should only be done in the cold zone casualty collection point (CCP). First pass, sifting and sorting, second pass, and reassessment were all part of this dynamic active shooter training. 

This month, we have the talented Dr. Yaskey writing for us, who delivered a great lecture on pediatric mass casualty and how pediatric patients are unique in a mass casualty event, whether they are in a flood, fire, or other disastrous event. She described proper preparation, proper pediatric equipment preparation, mitigation, response, and recovery.

Immediately, our medical directors and instructors received many questions. Many were taken by the prior months’ use of the simplification of MARCH, and using common sense. I personally am not asking our providers to count respirations during a mass casualty event and will continue to use the MARCH program. The other question was the tapping. We discussed this at the medical director and instructor meeting today. All felt that the RTF bags needed to limit tapping to orange and zebra. The trauma bags used for mass casualty events that aren’t considered dynamic dangerous events should continue to use the standard colors: red for immediate, yellow for delayed, green for minimal, black or zebra for deceased or expectant. The focus is still on common sense and recognizing who needs to go now, who can wait, and who can extract themselves from any emergency environment. 

I’m sure more questions will arise, and we trust our providers to use common sense and get the right patient to the right place at the right time for the right care. We will also maintain a team approach to these mass casualty incidents and welcome any further discussion on these topics.  

Sincerely,

Don Spaner, MD

September 15, 2025

This week, we'll be discussing the reasons children are more vulnerable in disasters and the importance of prehospital pediatric readiness. Remember that children are not little adults; they differ from adults in physiology, developing organ systems, behavior, emotional and developmental understanding of, and response to traumatic events, and dependence on others for basic needs. 

Children are vulnerable in disasters for many reasons:

• They lack self-preservation skills, so they are at risk of running towards dangerous situations without fear for what lies ahead.

• They have limited verbal and motor skills, limiting their ability to escape dangerous situations. This also adds difficulty when trying to express their symptoms or complaints.

• Their dependence on caretakers can lead to separation anxiety and the young ones who are unable to care for themselves.

• They lack coping skills, which can lead to increased susceptibility to post-traumatic stress disorder and other psychological disturbances.  

All EMS agencies and medical institutions need to be prepared for an influx of pediatric injuries and casualties in a disaster. Less than 50% of all U.S. hospitals had written disaster policies that addressed issues specific to the care of children (according to a 2014 webinar from the Emergency Medical Services (EMSC) for Children National Resource Center for Pediatric Readiness).

In October 2022, the American Academy of Pediatrics in a joint policy statement with other national organizations, outlined the essential elements for pediatric readiness in EMS systems. This statement identified key areas critical for EMS systems to be prepared for pediatric emergencies: Physician Oversight, Personnel, Policies and Guidelines, Equipment and Medications, and Performance Improvement.  

• Include pediatric considerations in EMS planning (dispatch, protocol, operations, physician oversight). 

• Have pediatric-specific equipment and supplies available. 

• Collaborate with medical professionals who have significant experience or expertise in pediatric emergency care, public health, and family advocates. 

• Develop processes for delivering comprehensive, ongoing pediatric-specific education.  

• Implement practices to reduce pediatric-specific medication errors.  

• Develop, maintain, and enforce policies for the safe transport of children in emergency vehicles.  

• Promote overall patient and family-centered care, which includes using lay terms to communicate with patients and families. 

• Consider using resources compiled by the EMSC program when implementing recommendations.  

Next week, we will delve more into prehospital pediatric readiness and discuss the prehospital provider’s role(s) in disasters. 

Until then, thank you for all your hard work.

Stay safe and be well,

Regina Yaskey, MD

September 22, 2025

Good morning. This week, we will be discussing mass casualty incidents and the role(s) of the prehospital providers in disasters.  

A mass casualty incident (MCI) is an event that generates more patients than available resources needed to care for them. They cause an enormous impact on EMS systems; therefore, mutual aid agreements should be in place to provide backup for jurisdictions stripped of their local resources. It is important to note that a well-organized MCI plan with community involvement can have positive effects on disaster response. EMS systems may not have pediatrics-specific plans or general plans that adequately account for pediatric requirements. Only 248 out of 1,808 prehospital EMS surveyed had any specific plans for the care of children.1 The most effective plans are those that closely match an agency’s daily activities. It is essential to include pediatric hospitalists, nurses, and other pediatric specialists in the development of EMS pre-disaster planning. 

There are three levels of MCI:  

• Highest level MCI: 

• This level usually involves activating the state’s disaster plan. Sometimes requests for federal assistance might be necessary. 

• Moderate Level MCI: 

• This level requires multi-jurisdictional medical mutual aid. 

• Lower-Level MCI: 

• This level is used when local medical resources are available, adequate, and regional backup resources may be put on alert.  

EMS is a vital resource in pre-disaster preparedness and response. Prehospital providers play a crucial role in the disaster process. They might be called before a disaster to assist in evacuating hospitals, nursing homes, and other specific skilled care facilities, performing search and rescue, providing medical care, and distributing information to the public. 

Assist in your communities by maintaining a presence in community disaster preparedness meetings and activities. It is vital that you understand your community’s incident command system (ICS), when and how it is activated, and what your role is at a disaster event.

• Pre-plan responses to schools or buildings in your community, and become familiar with the various rooms, sports fields, and layout of the school campus.

• Know which agency takes the lead in evacuation, and, if going into an incident, when medical treatment is deemed safe.

• Be aware of any children with special healthcare needs and necessary accommodations that may be needed. Identify a process for transport tracking, with someone available on scene and at the receiving facility to assist in patient destination verification.

• Maintain adequate pediatric supplies and know who to call and where to get additional supplies and equipment in the event of a disaster.  

Next week, we will discuss the phases of disaster response, overall response strategy, and pediatric response considerations.  

Until then, continue the hard work and stay safe,

Regina Yaskey, MD

Source:

1. Shirm S, Liggin R, Dick R, Graham J. Prehospital Preparedness for Pediatric Mass Casualty Events. Pediatrics. 2007; 1200 120(4);e756-e761. [Pubmed 17908733]

September 29, 2025

Good morning. This is our final week discussing Pediatric Considerations in Disasters and Mass Casualty Incidents.  

Let’s start by going over the recommendations that emerged when the National Association of State EMS Officials (NASEMSO) met to discuss children’s needs in EMS. This was an interdisciplinary working group trying to improve pediatric patient care through the commitment to education by all EMS practitioners. They emphasized that medical science and technology are constantly improving; therefore, clinical competency requires lifelong commitment by the practitioner, the EMS agency, the EMS medical director, and the regulatory body to ensure that EMS practitioners remain proficient to provide safe, effective, and high-quality patient care. They also stressed that children of all ages, circumstances, and needs should receive appropriate assessment and care from EMS personnel consistent with their scope of practice and local protocols. This is best accomplished through: 

• Effective entry-level and continuing education for EMS and online medical control personnel. 

• Valid and reliable competency measurement tools. 

• Model evidence-based guidelines that serve as a foundation for EMS care across states and jurisdictions. 

The group also identified several current barriers to effective pediatric EMS education. These include: 

• Uncertainty as to how many instructors know how to design lesson plans and educational strategies that fully address the needed depth and breadth of pediatric instruction. 

• Educator time may be very limited for curriculum development, especially if it involves sophisticated simulations and/or AV aids. 

• Most programs have not allocated sufficient time to pediatric-related didactic content, labs, or clinical experiences. 

EMS Programs often rely heavily on instructor-centered teaching methods and do not gain the benefit of simulations (high fidelity or low tech) or contact with “real” children. 

Now, let us talk a little bit more about disaster medicine.  

The Phases of Disaster Response

1. Activation Phase: The initiation of Incident Command System (ICS) and scene assessment 

2. Implementation Phase: Includes search and rescue, victim triage, initial stabilization, transport of the injured, management of scene hazards, and victims.  

3. Recovery Phase: Occurs at the time of scene withdrawal, with return to normal operations and post-incident debriefing.  

The goal in a disaster response is to do the best for the most victims, and these actions allow optimal organization of the response. Remember that you cannot help if you become ill or injured. Scene safety is of the utmost importance. Before entering any scene, ensure that it has been cleared by the appropriate authorities (e.g., law enforcement, fire, HazMat). Refrain from rushing to the scene until it is declared safe. Use appropriate safety gear and PPE on every call when there is the potential that the rescuer may encounter contaminated patients.  

Pediatric Response Considerations: 

1. Staging 

2. Triage 

3. Treatment 

4. Transport 

Planning 

Response vehicles should have pediatric supplies, including a range of pediatric airway equipment, pediatric sized cervical collars, IO needles and catheters, methods to control hypothermia. 

Having a system in place for patient tracking and reunification is essential.  

Staging 

Occurs when ambulances and personnel arrive on the scene of a recognized disaster. 

EMS should meet in an assigned location and await instructions from the staging officer.  

Providers assigned to staging must remain close to their ambulances and equipment.  

Pediatric specialty equipment should be identified by the staging officer.  

Triage 

The process of prioritizing patients based on the severity of their injuries and the available resources.  

The goal is to make a daunting task manageable.  

The pediatric population can be challenging (non-verbal, frightened, some are non-ambulatory) 

Treatment 

JumpSTART triage is the tool used to prioritize treatment for pediatric patients.  

• Ages 1-8 years are usually chosen. Children less than one year of age are less likely to be ambulatory. The pertinent pediatric physiology (specifically, the airway) approaches that of adults by approximately eight years of age. The current recommendation is: 

• 
  

If a victim appears to be a child, use JumpSTART. 

If a victim appears to be a young adult, use START. 

Decontamination 

Decontamination is the physical process of removing or neutralizing potentially harmful substances from patients, personal equipment, and supplies. It should be performed whenever an individual is actually or potentially contaminated with a hazardous substance. It is essential to strive to keep families together throughout the process. Kids are more at risk for hypothermia (ensure you use warm water, have pediatric sized clothing and blankets). 

*Please remember to conduct a secondary triage (after treatment area) to see if triage status has changed.  

Reunification 

Reunification should occur as quickly as possible. Unless strictly contraindicated because of medical needs, children should not be separated from their families or loved ones. Children need to be tracked with protocols and provisions for temporary care. The ability to understand where patients, victims, or clients are at any point during an emergency is important, from the time emergency response agencies take ownership of an individual through definitive medical care. These structures require significant work and diligence. Many departments still rely on paper methods of tracking, usually implemented within an EMS branch or triage, treatment, or transportation group. Visibility of patient whereabouts for providers, incident commanders across the incident, and the hospital staff is nonexistent with this method. Long-term documentation of patient tracking is also problematic with paper-based solutions. Other solutions currently in practice involve a triage card, with or without peelable barcodes attached, affixed to the patient, usually around the wrist. These triage cards can be difficult to keep with the patient, depending on the environment; blood, sweat, or other fluids can significantly decrease the capability of these cards. In other cases, duplicate tags may be printed, or the tag may detach from the patient. 

Essential Elements of Reunification Plans should include: 

• Leadership and staff role, incorporated into Emergency Operations Plan (EOP) and Hospital Incident Command System (HICS). 

• Registration and tracking of unaccompanied children. 

• Questions to ask to help with identification of children. 

• Identifying your Hospital Reunification Center. 

• Identifying your Pediatric Safe Space. 

• How you will share pertinent information with hospitals, families, public health and responders. 

Thank you for the opportunity to share this information with you.

Have a wonderful rest of the year and stay safe out there,

Regina Yaskey, MD