In the second year of the Preparedness Summit Podcast series, take a deeper dive into the subject of preparedness with some of the most fascinating Summit speakers. Michael Frogel, Co-Principal Investigator for the New York City Pediatric Disaster Coalition shares his experience planning for a pediatric mass casualty event after the failed bombing attempt on Times Square in 2010. Download the full podcast here.

You’re here at the Preparedness Summit to talk about the attempted attack on Times Square, had the bomb actually detonated, what would be your role?

We have a Pediatric Disaster Coalition and our main goal is to prepare New York City for a potential mass causality event involving very large numbers of children. Unfortunately, if this bomb had gone off, or fortunately that it didn’t, we would have had a catastrophic situation with hundreds if not thousands of injured children. This bomb was placed right across from a theater where the Lion King was playing. There are usually 1,000 kids in that theater and 500 adults. If you look at the Oklahoma City Bombing, which had a similar bomb, it completely destroyed that building. The bomb was in such close proximity to the building so you can imagine 500 parents and 1,000 kids in an event that would have brought the entire building down.

What are some of the questions that a hospital needs to consider before preparing for such a mass causality event? What needs to be in place and how do you address the need for psychological counseling?

We spent a lot of time thinking about this actually, and in this type of event it wouldn’t be one hospital. The entire city would have to respond. In 2010, there were only about 220 pediatric critical care beds in all of New York City. Our first lesson learned was to develop more critical care beds and we’ve been working on that now for seven years. We’ve almost doubled the capacity of critical care beds. We probably need three or four times that. It’s very difficult, but it’s very essential. You have to be able to move patients from the point of the incident to the appropriate places, match resources to needs, and have the right kind of transport. We’ve been working very hard on a pediatric disaster plan with the Fire Department and we’ve worked out special plans for pediatric victims.

They would be brought to Tier 1 and Tier 2 hospitals to give them the appropriate care. Tier 1 hospitals are pediatric intensive care hospitals and Tier 2 are pediatric capable hospitals. We’ve completed twelve full-scale exercises in New York to look at a potential catastrophic event. We’re almost ready, we hope, to roll out our pediatric disaster plan, which is for primary and second day transport. We’ve also trained over 100 healthcare providers in a pediatric critical care course so they would be able to help the pediatric intensive care unit physicians and be force multipliers because there aren’t enough critical care docs to take care of all these kids. It’s kind of multifactorial – you have to go from the point of impact, and you have to train the first responders. We’ve changed their triage protocols. We have primary transport, secondary transport, pediatric surge capabilities and capacities that have been developed to respond to an event like this. We’ve also learned a lot during our exercises. Lessons learned have been able to change our plans and make them better.

Building on how emergency rooms can respond to an event of this magnitude in a major metropolitan area, there are a lot of attendees at the Preparedness Summit who are from rural health departments. What are some lessons they can apply to smaller, less populated areas?

The majority of kids in this country are not cared for in pediatric emergency departments or hospitals. Probably 80 to 85 percent go to hospitals without those capabilities. Every emergency department we believe needs a pediatric champion. There is something called Emergency Medical Services for Children, which is a wonderful organization that works to provide medical services for kids. They’ve developed a domains plan that tells you all the different things you need to think about to take care of pediatric mass casualty events. We hope that every hospital gets the right space, staff, and stuff to be able to care for kids. We also think it’s important they become involved in coalitions that can build communities together and offer regional responses. At the very least, they need to be able to stabilize the kids and perhaps act as a triage hospital until the cavalry can come and help.

It sounds like this involves a lot of partnerships. Are they both public and private partnerships?

Well coalitions actually are somewhat ill-defined. Many coalitions do many things. We just started a National Pediatric Disaster Coalition. We hope many coalitions around the country to join us. One of the first things we’re trying to do is to set up what we hope are standards or capabilities that coalitions should have, working in concert with the adult parts of the coalitions. We can’t do it alone. Pediatrics represents 25 percent of the population, but pediatric coalitions should be within the framework of an overall coalition, using all the resources. There’s something called ESF #8 capabilities that involve security, poison control, and mental health. We think it’s very important that there be coordination so people aren’t working in silos. We often have problem with silos. We need to get everyone together, with the funding issues and lack of resources available, we need to go to the private sectors, we need to use government sectors, foundations, hospitals, children’s hospitals, NGOs, etc.

Although it was a failed attempt, was this a true wakeup call for you and your staff? Had you already started laying groundwork to prepare for such an attack?

We actually started our coalition in 2008 and had already started working on this. We’ve done studies and large numbers of exercises to test everything. The attempted bombing did push us obviously even harder. We hope that by the end of next year, we will have plans in place for all of the 25 or so pediatric intensive care unit capable hospitals in New York City and we’re also going to be developing plans for 16 non-pediatric intensive care hospitals this coming year. We try to include all of the different hospitals and try to make sure that the city is prepared as it can be.

You began this plan in 2008. After the attempted bombing in 2010, did you discover any gaps in the plan?

Of course. Just thinking about the episode brings home what capabilities we still need. It’s not as simple as saying you have “X” number of rooms, you need to have the ventilators, you need to have the staff, you need to have the people who are able to care for the patients. You may have to change the rules. You may not have one nurse per intensive care patient. Hopefully it will be sufficient care. It might not be optimal care. We learned from this almost real event and all of our exercises.