The Role of the Pediatric Orthopaedic Surgeon in Disaster Response

For many years, the United States was relatively spared from disasters compared with other nations around the world. More recently; however, the American medical community has gained expertise and improved its preparation in caring for the victims of disasters including the World Trade Center and Pentagon bombing in September of 2001, the Oklahoma City bombing in 2005, and Hurricane Katrina in 2005.1 Most recently, in 2013, the efficient and coordinated medical and surgical disaster response to the Boston Marathon bombing by Boston physicians, nurses, police, fire fighters, emergency medical technicians, the Boston Athletic Association, and area hospitals saved countless lives.2 Disasters occur at the local, regional, and national levels. Disasters require a collaborative response by civilian and governmental agencies. Advanced preparation is needed to coordinate medical and surgical care, food, water, shelter, sanitation, hygiene, refugee oversight, communication, medical record keeping, patient evacuation, and safety.3 It is important to plan and prepare for any form of disaster that may occur including terrorist attacks, floods, hurricanes, and earthquakes, biological, nuclear, or chemical events. Sometimes overlooked systems during a disaster response effort include communication, triage procedures, heating, air conditioning, refrigeration, electricity, medical records, radiology services, pharmacy services, orthopaedic industry, security, and even a morgue. Disaster preparedness is enhanced by disaster education, a database of credentialed responders, and communication between medical/surgical groups including the American Academy of Orthopaedic Surgeons (AAOS), the Pediatric Orthopaedic Society of North America (POSNA), the Orthopaedic Trauma Association (OTA), the Society of Military Orthopaedic Surgeons (SOMOS), the American Academy of Pediatrics (AAP), and the United States military.4 In a disaster setting, supplies, surgeons, and time all become precious commodities. The standard goal of providing the greatest good to each individual patient may change to providing the greatest good for the greatest number of patients.5 Many surgeons feel unprepared for disaster management.6 Hopefully this brief article will provide practical value and information that will help the pediatric orthopaedic surgeon to become better prepared and safely involved in disaster relief efforts in the future. LOCAL DISASTER PREPARATION AND RESPONSE At the local level, a coordinated disaster response requires training and education at hospitals, fire departments, emergency medical services, public health departments, police departments, and media outlets. Pediatric orthopaedic surgeons should become familiar with their hospital’s emergency response protocols. These protocols include notification and alert systems, response actions, logistics, physician assignments, casualty flow, and recovery steps.7 Preparation, practice, and performance are imperative for successful disaster care at the local level. In addition, hospitals are required to perform drills as a component of their emergency management plan according to regulations set by the Joint Commission on Accreditation of Healthcare Organizations.8 The use of drills to train employees and test aspects of hospital response has proven valuable. Several types of hospital drills have been used, including computer simulation, tabletop exercises, and operationalized drills involving specific victim scenario. Details involving specific drills to improve disaster planning and care can be found at http://www.ahrq.gov under public health preparedness archive/evaluation of hospital disaster drills. In addition, pediatric disaster preparedness involves the home.9 For example, every family should have its own disaster plan including a plan for communication in the event of separation, a supply of nonperishable food, 1 L of water per family member for at least 3 days, a battery-operated radio and cell phone charger, spare batteries, and cash.5 Additional information for families in your practice can be found at http://www.ready.gov. NATIONAL AND INTERNATIONAL DISASTER PREPARATION AND RESPONSE The AAP Disaster Preparedness Web site is http://www.aap.org/disasters. This AAP Web site contains valuable information about disaster preparedness and response focused on the unique needs of children. Although children are among the most vulnerable patients during a disaster, there are deficiencies in the preparedness plans of many emergency medical services in the United States for pediatric care in the event of a disaster.10 A complete pediatric disaster plan includes: appropriate personnel and equipment, disaster-specific and venue-specific training, and family preparedness.9 Pediatric orthopaedic surgeons can play a critical a role in advocating for the inclusion of children in disaster planning. The AAP Web site includes information about: equipment and medicine, physiological vulnerabilities, developmental dependencies, social and behavioral needs, key resources, education and training updates, strategic partnerships, collaborative guidelines with the CDC, AAP policy statements, bereavement information, and resources for families. The POSNA Trauma and Prevention committee oversees disaster preparedness and response for POSNA members. The POSNA Trauma and Prevention committee hosted a Disaster Response Symposium May 2, 2013 at the POSNA meeting in Toronto. In addition, the POSNA Children’s Orthopaedics in Underdeveloped Regions (COUR) committee was very involved in the Haiti earthquake disaster relief efforts in 2010 and would be involved in any future international disaster efforts. The AAOS has a detailed disaster preparedness and response program. The Web site is: http://aaos.org/member/humanitarianprograms/disasterprep/disaster_prep_resp.asp. This Web site is filled with valuable information about disaster preparation, plans, training, nongovernmental organizations (NGOs) involved in disaster relief, United States government disaster response, and credentialing programs. At the national level, the United States government’s response to disasters is coordinated by the National Disaster Medical System (NDMS). The NDMS was established in 1987 as a partnership between public and private agencies to provide emergency medical services in times of crisis. In 2003, Disaster Medical Assistance Teams (DMATs) were established—teams of volunteer medical professionals and support staff located at various sites throughout the United States. The role of the NDMS has grown to include international medical assistance teams deployed at the direction of the State Department and the Office of Emergency Preparedness. The OTA has been instrumental in getting orthopaedic trauma surgeons included in International Medical Surgical Response Teams (IMSuRT).11 For example, in 2010, within 24 hours of the Haiti earthquake, the NDMS mobilized 3 international medical-surgical response teams and 5 US DMATs. These teams were made up of volunteer physicians, orthopaedic surgeons, nurses, emergency medical technicians, pharmacists, and other medical specialists. In addition, >30 ships from the Navy, Coast Guard, Military Sealift Command, and the Maritime Administration also responded. More than 300 centers were established to distribute millions of meals and bottles of water and tons of medical supplies. The Navy also sent the USNS Comfort and augmented the Naval Hospital in Guantanamo Bay, Cuba with 225 medical personnel including orthopaedic surgeons. The Comfort provided 40 intensive care beds and 450 ward beds. Many of the patients presented with open and infected long bone fractures and crush injuries. Phenomenal teamwork ensued between military and civilian physicians providing care to disaster victims.3 In 2011, SOMOS in collaboration with the AAOS, OTA and POSNA developed a Disaster Response Course (DRC) to help prepare orthopaedic surgeons for the unique patient care requirements presented by the austere environments of disaster. The course has been given biannually since 2011. POSNA members can become “credentialed” in disaster preparation and management by attending this SOMOS directed continuing medical education course. Physicians can seek more information for the next course at phone: 1-800-626-6726 or Web site: http://www7.aaos.org/education/courses/course_detail.aspx?ProductId=25128 or email: [email protected]. DRC attendees receive important training needed for personal and team preparation to effectively handle the physical, emotional, ethical, and care management skills for treating the injured in areas affected by catastrophic events. Day one is a lecture format and is followed by day 2—a half day in the cadaveric skills laboratory. The learning objectives for this CME course include: Discuss personal and team preparation for deploying as a member of a disaster response team. Describe injuries commonly encountered in the disaster environment. Identify the challenges of caring for victims of disaster in the austere environment. Identify cultural and ethical considerations in caring for victims of disaster. In addition, the AAOS now provides a pathway for surgeons to become disaster response trained and credentialed with recommendations for medical, disability, and liability protection for volunteers. The AAOS plan defines 3 types of volunteer disaster responders. Type I—orthopaedic trauma–trained surge responders designated for immediate deployment. Type II—acute phase responders deployed in the aftermath of a disaster. Type III—responders deployed during the reconstruction and maintenance phase of a disaster12 (Table 1).TABLE 1: AAOS Disaster Responder ClassificationTwo credentialing pathways are offered. Pathway 1 is for civilian physician volunteers providing services through an NGO, such as Health Volunteers Overseas, the American Red Cross, or Surgical Implant Generation Network (SIGN). Credentialing pathway 2 is as a temporary government employee through a branch of the US Military. The federal credentialing process is more complex and can be pursued through the Department of Defense or Health and Human Services NDMS. Most pediatric orthopaedic surgeons are likely to choose to train and certify as type II or III responders via credentialing pathway 1.12 Attending the DRC is the required component of the pathway for AAOS members to become disaster response trained and selectively identified in the AAOS Disaster Responder Database. Once certified by the hands-on CME DRC, the orthopaedic surgeon becomes an AAOS-Registered Disaster Responder and can then be called upon to help at future disasters. After the first 2 DRC CME programs, 70 attendees, including many pediatric orthopaedic surgeons, registered for the responder database. As a registered responder, a pediatric orthopaedic surgeon can connect efficiently with volunteer organizations to volunteer rapidly when disaster strikes in the future. In addition, pediatric orthopaedic surgeons volunteering for a disaster relief effort should contact their malpractice carrier to be certain that coverage is provided in the United States and abroad. Volunteers should also check their medical, disability, and life insurance policy carriers for coverage in these situations. Most states offer limited licenses for short notice volunteer care if the physician is licensed and in good standing in another state. Medical liability in overseas settings can be minimized by participating in the relief effort with an NGO which often provide malpractice coverage to the volunteer. Finally, SOMOS offers a Disaster Preparedness and Trauma Care Toolbox that provides basic educational tools and resources to help educate nonmilitary orthopaedic surgeons in the areas of disaster preparedness and trauma care. The Toolbox includes a journal devoted to disaster preparedness, an online textbook that includes the SOMOS Combat and Disaster Related Trauma Course, a quarterly newsletter, and a blog. More information can be found at SOMOS.org. SUMMARY Preparation, planning, rehearsal, and research are needed to significantly reduce the consequences of natural and man-made disasters. Appropriate disaster response can enhance peace in areas of the world by providing humanitarian aid and support.3 It is vital that volunteer surgeon responders to a disaster have some training in disaster management and the principles of providing care in an austere environment.13 Uncoordinated, unrequested, and unexpected care can do more harm than good. Most importantly, volunteers going overseas should be affiliated with established NGOs or the United States Military that are efficient and experienced in providing health care in disaster situations.14 Disaster education for civilian physicians and a database of credentialed specialists who can be called on in the event of a disaster is vital and is now provided by the AAOS. Pediatric orthopaedic surgeons will be valuable members and often times leaders of multidisciplinary teams needed to succeed in disaster management in the future. Getting credentialed using the currently available AAOS pathways and becoming a member of the AAOS database is the first step for any pediatric orthopaedic surgeon interested in becoming an effective disaster responder.

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