1. PDLS: Children as Victims of Terrorism: Risk Assessment & Response
Dr. Jim Courtney
Assistant Professor of Emergency Medicine

2. Objectives Identify why children can be specific targets of terrorism
Discuss the differences that may make children more susceptible to certain acts of terrorism
Discuss specific treatment modalities and/or dosing that are unique to children

3. Guiding Principles
The best approach to disaster preparedness is to plan for all pertinent hazards.

4. Don’t need separate disaster plans for kids
Guiding Principles
Don’t need separate disaster plans for kids
Do need to focus on their unique needs and the critical differences between children and adults

5. Pediatric Issues in Terrorism
Children at risk
Assessing your community’s risks
Community preparation issues
Family preparation issues
Psychological issues with children
Resources

6. “Collateral damage?”
FEMA Photo Library

7. Or intentional targets?
When Lee Malvo asked why he planned to attack children in schools and on buses, convicted sniper John Mohammed allegedly replied:
“For the sheer terror of it…
The worst thing you can do to people is to aim at their children”
(From AP story 5/30/06)

8. Children at Risk: Targets
Innocent, vulnerable population
Tend to gather in large groups, including daycare centers at places of business
Natural curiosity
May not be able to rescue themselves
Extreme emotional reaction by rescuers and public

9. Children at Risk: Vulnerabilities
Low to ground
Faster respiratory rates
Larger skin surface area to mass ratio
Vulnerable to fluid loss

10. Children at Risk: Vulnerabilities
More permeable blood-brain barrier
Many rapidly reproducing cells
Unable to escape (longer exposure)
Found in large groups (contagion)

11. Community Preparation
EMS/Fire
Incorporate children in all MCI drills and exercises
Knowledge of at-risk groups in the area
Knowledge of local hospital pediatric capabilities
Have appropriate protocols/aids for pediatric care

12. Community Preparation
Hospitals
Incorporate the needs of children and families into all aspects of disaster planning and preparedness
Acknowledge the likelihood of an unusual pediatric patient load in the disaster setting
Be aware of available pediatric resources

13. Community Preparation
All medical responders/receivers must be prepared to deal with:
Lack of familiarity with pediatric antidotes and treatments and lack of pediatric drug formulations
Unusual pediatric patient loads and acuities
Relative lack of local pediatric specialty resources due to overwhelming patient volume
Ethical dilemmas in resource-constrained environments

14. There may be proportionally…
MORE CHILRDEN THAN ADULTS THAT ARE SICK

15. And children may be…
SICKER
THAN THE ADULTS

17. December 3, 1984 – Bhopal, India

18. Union Carbide Plant
Shortly after midnight, ~ 100,000 lbs of toxic Methyl Isocyanate (MIC) was released from the Union Carbide Plant
500,000 people were exposed
Within 24 hours ~ 8,000 people died
Since the disaster ~ 25,000 deaths have been attributed to the gas release

22. Quote from survivor
‘When I saw the leaves on the trees curl and turn black and birds fall dead out of the sky, I knew that this was Death, come among us as foretold. My regret is that I survived.’

23. Methyl Isocyanate (MIC)
Intermediate in pesticide production
Potent irritant of eyes and lungs
Can cause permanent damage to lungs and eyes but not through cyanide toxicity
Other unknown chemicals were also released at the same time

26. Lasting Effects Union Carbide sold to Dow Chemicals in 2001
Site remains as it was in 1984
City of Bhopal still does not have clean drinking water
Incidence of various cancers and birth defects are significantly higher than surrounding areas

27. August 21, 1986

28. Lake Nyos, Cameroon

29. Inhalational Disaster
In the middle of the night the lake which sits on top of a dormant volcano crater belched up ~ 1.6 million tons of carbon dioxide gas
Since carbon dioxide is heavier than air, it rolled along the ground and into the surrounding valleys and killed ~ 1,700 people by asphyxiation

30. Lake Nyos
The gas released also contained significant amounts of sulfur and hydrogen
Survivors sustained skin and eye lesions and some have permanent pulmonary and eye problems

31. Lake Nyos
The cloud was reported to be ~ 150 feet thick and traveled at ~ MPH
The cloud stayed densely packed and was lethal for ~ 15 miles
No children within this radius survived
The level of the lake dropped by 3 feet
The cause is unknown, but is believed to have been a landslide on the lakeshore

32. Livestock & insects were killed as well

34. Lake Nyos
Only 3 lakes in the world are known to be supersaturated with carbon dixoide
All are located within Africa
However, before this disaster, no one knew that Lake Nyos was supersaturated with carbon dixoide

35. “Degassing” Lake Nyos

36. BIOLOGICAL AGENTS

38. Biological Agents
Typically the treatments are not something usually recommended for children
Ciprofloxacin or doxycycline for Anthrax
Smallpox vaccine for Smallpox
Contraindications become very relative in situations like that

43. *Bone Marrow Suppression/Death
Radiation Exposure
Amount
Source
Symptoms
1 rad
X-Ray
None
<50 rads
rads
H-Bomb
*Vomiting
>200 rads
*Hemorrhaging
> 450 rads
Chernobyl
*Bone Marrow Suppression/Death

44. Chernobyl Experience 134 workers were treated for radiation sickness
22 had > 400 rad exposure – 32% of those died
21 had > 600 rad exposure – 95% of those died
The larger problem is the risk of cancers, especially thyroid, leukemia and lung cancer

45. Erythema on a Chernobyl fireman on Day 17
Erythema on a Chernobyl fireman on Day 17. The patient was primarily exposed to beta radiation (aerosol particles with adsorbed beta emitting radioactive compounds)

46. Severe ulcerative & necrotic radiation burns in Chernobyl fireman on Day 40 after the accident
Despite very severe extended beta radiation burns, this Chernobyl fireman is alive in the end of 2001 afetr close to 50 plastic surgical operations.

47. Severity of Symptoms Nausea Coma Vomiting Diarrhea Seizures
None
Death
Nausea
Coma
Vomiting
Diarrhea
Seizures
Hypotension

51. Your Friends During A Radiation Exposure
Time, Distance & Shielding
The most important things you can do to protect yourself
Potassium Iodide (KI)
Fill your thyroid with iodine so that I131 won’t deposit there
Potassium helps to rid the body of Cesium137 faster
Goal is to have this in the hands of everyone within 2 hours of exposure

53. Treatment Protocols
Does your system have Chemical, Biological Radiological, Nuclear and Explosive (CBRNE) protocols?
Does it address the pediatric population?

54. Questions?