Can you tell us about your research in pediatric mass casualty incidents (MCI)? How did you develop an interest in pediatric mass casualty? Was there a particular patient experience that you had?
I haven’t had a personal experience with it, necessarily—we’ve certainly had some overwhelming car accidents, but nothing to the level that I would call a true pediatric mass casualty incident. These are always tragic events, and especially after Sandy Hook, it became clear that kids could make up a sizable portion if not the entirety of the victim population of an MCI.
We’ve done a lot of work in the PEM [pediatric emergency medicine] community on general community hospitals being ready to see a lot of kids in general. I work with an organization called COPEM [Committee on Pediatric Emergency Medicine] that looks at our pediatric receiving hospitals and makes sure they’re up to standard in terms of delivering pediatric care and having the appropriate supplies. And that’s just for a single routine pediatric patient. So the thought of how a group of very traumatized pediatric patients simultaneously is going to be handled is something we discuss a lot.
I also work with a research consortium of pediatric emergency medicine physicians in Los Angeles who have an interest in EMS, and we’re talking about the different tools for taking care of these kids, even just for triaging. They’re not uniformly standardized or well-studied and validated, and we figured that this would be a great first step: to look at some of these tools and see which triage tools would be useful in the clutch—when you can hardly even remember your own name because it’s such a nerve-wracking situation—which tools are easy to remember, and easy to apply to a pediatric population with good validity. That’s how we started looking into MCI: how we could take those triage tools and make them usable for EMS providers and general emergency medicine providers.
Are any of these tools built into local policies yet, or are you still in the early phases of identifying them?
There are about five or six different tools for pediatric triage, and a lot of international groups have a difficult time because different tools are accepted in different countries. So if you have a group like Doctors Without Borders, that works with providers from very different areas, and you’re responding to a mass casualty incident with other volunteer providers from other countries, you may be using completely different triage tools. Some of them are arduous and take a long time to use, and some of them have relatively poor validity when looking at whether or not we’re sending the right people to the hospital at the right rate.
In America, we tend to use JumpSTART, which is a permutation of the START [Simple Triage and Rapid Treatment] system that we use for adult MCI. More work still needs to be done in refining these and making sure that they are picking out the kids that we need to be picking out for immediate care.
How do these events affect patients over time, in terms of post-traumatic stress? Does this tie into your research into pediatric mental health?
I’m not doing specific PTSD research, but we do see PTSD from the trauma of everyday life, especially where I work in Los Angeles in Boyle Heights. We see a large Department of Child and Family Services population, and those kids clearly have undergone a fair amount of trauma throughout the course of their lives. So we definitely see the effects of PTSD, or, as it may be more appropriately described, an ongoing trauma situation. It’s hard to say post-traumatic stress for a lot of these kids, because they’re still undergoing more daily trauma than many of us can relate to.
But in terms of following a MCI, absolutely—even a single incident like that is going to cause a fair amount of trauma. And when you look at kids who have sustained even a concussion, without being part of a mass casualty incident, one of the reasons for prolonged symptoms, mostly headaches, is the anxiety from post-traumatic stress disorder. So it’s something to consider with any trauma. And then when you throw on top of that that they might have seen friends and family traumatized, they might have seen friends and family die, that is a huge issue that needs to be dealt with for kids who have been in that type of a situation.
Acutely, in the emergency department, we are focused more on stabilizing the medical conditions than treating the post-traumatic stress disorder, but sometimes that’s difficult as well. If a child is on the younger side, is a little bit injured, and has been separated from their family and witnessed something traumatic, sometimes it’s difficult to find out exactly how injured they are and where their injuries are if they’re quite hysterical. Just the other day, we had a routine trauma come in, and her dad was with her, but she was crying and crying so much that when I called for her to go to the floor and they asked what her Glasgow Coma Scale was, and I had to tell them, “It’s either 14 or 15—she looks fine, but she’s crying so much that I don’t know if she’s confused or not!” Can you imagine if Dad hadn’t been there, or if she’d witnessed a great deal of trauma? That could have been something even more profound and persistent.
Do you have any thoughts on psychosocial components of child abuse specifically, outside of other types of trauma? What broader systems changes could be made so that the responsibility doesn’t fall only on individual physicians and providers?
That’s a tough question, and if I had a good answer for you, I would hope that I would leave medicine and get into a political career that would enable me to see that forward! I do think that in general, from what I’ve seen in all of these fields—child abuse, parenting, mental health—we don’t really create the resources to help everybody early enough.
It seems to me that we’re largely operating a failure-based system. If I come into my ED today and I say that I’m not suicidal, but I’m really depressed and I need help, I will probably be given a number that will require me to call multiple times, wait on hold, and maybe if I’m lucky, I could possibly get an appointment maybe three months from now. Whereas if I come in and I say I’ve been here seven times saying I’m depressed, but I haven’t really gotten any follow-up, any medication, and now I’m suicidal, all of a sudden I’m placed on a 72 hour hold, locked up in a facility, being treated left, right, and center… and then I get released to the situation that I was in before. So we wait for a crisis to occur, then we put a lot of time and resources, financially and emotionally, into dealing with the crisis situation, and then as soon as it’s stabilized, we let it fall back.
It’s the same with child abuse. If I have a parent who comes in who is clearly doesn’t have the coping mechanisms and the social skills for parenting, and the way they’re dealing with their child is very immature and problematic but not anywhere near the level of child abuse, what am I going to do? I can talk to them a little bit as an individual provider, if I happen to have the time to do so, but there’s rarely a useful and cost-effective parenting class I can just send them to. There are not a lot of resources in that situation, so you basically just wait until finally the parent loses it, hits the kid, and then suddenly everyone is involved, and it’s very expensive in terms of emotions and finances and time. And I think this is how we operate a lot in our society.
My child has some learning disorders. He’s very smart, but has dyslexia. I’m trying to get him some support through the school, but am told by the school that I can’t get him any support until he’s pretty much failing. Rather than just spending an hour a week making sure that my kid is caught up with his peers, which is inexpensive in terms of time and money, you would rather wait until he completely fails out of school, needs intense catch-up therapy, intense educational therapy, and will probably need mental health therapy at that point, because he’s now just failed out of elementary school? That’s the most horrible thing ever- crushing to children and fiscally inexplicable. And this is kind of how we deal with many of these difficult situations involving children.
I don’t know how to reassign the resources that we have available to us to deal with all of the kids who are already being abused, all of the mental health patients who are already on holds for suicidality and then also support this at-risk population. Clearly, there are some people who, even with all the support in the world, are going to progress to that next level. But I am also sure that a large chunk of these people who, if they had support, if they had parenting classes, if they had someone come in and tell the husband, “Hey, you can’t treat your wife like that, that’s actually abuse and that’s why she’s acting out on the child” and teach him how to act differently—if we have those kinds of resources available—I think we might be able to avoid some end-stage tragedies.
I see a lot of patients where I think, “I wish that I could have met you two years ago, and had the resources to change the course of your severe depression or your decision to hurt your child.”
I hate to say it, but I think whatever the solution is, at least part of it will involve making a business case for more preventive care and definitively showing that you could save a lot of money with it.
Even if you could say you’re going to budget it and allocate this much money to it, it’s still a difficult situation. There are so many barriers to address.
See Part 1 of our interview with Dr. Claudius here.