Because the United States is planning to invade Iraq, Saddam may fire missiles at us in Israel. Conventional warheads were bad enough in 1991, but now they may be unconventional. Anthrax? Takes a few days to develop symptoms, we'll have an ID before the patients arrive. Smallpox? A bit tougher, but at least part of the population was immunized in the past. The scenario we're planning for is chemical warfare. Up to 25% of patients may be pediatric if an unconventional warhead hits.
The pediatric critically injured station is to be located in the covered parking garage, midway between the children's hospital and the adult ED. It will be manned in two shifts; one headed by my colleague, a pediatric anesthesiologist, and the other by me, a pediatric emergency physician. We have about 8 assisting physicians and 12 nurses per shift with secretarial and support staff. I know if the missiles fall I'll be at the hospital—my husband is a college professor, classes will be cancelled so he'll be home with the kids, and my nanny has already announced she will move in with us for as long as I am on duty. Will the others show? Will they leave their husbands and children at home, with the missiles falling, and treat someone else's kids?
First, the patients will be triaged and the apneic ones intubated. Then they'll be decontaminated and washed. The plan is to give lots of atropine, toxogonin, and fluid resuscitation. Midazolam or valium if they're seizing. What if it's not enough? We decide to prepare our own kit with adrenaline, bicarbonate, pentothal. Pediatric endotrachael tubes in case there aren't enough; 25 and 22G intravenous catheters—there never are enough. Lots of code cards. Mass casualty situation protocols say we shouldn't attempt to treat the “unsalvageable,” but I know we'll probably try anyway. We review with the nurses how to assess vital signs, cyanosis, central and peripheral pulses, and capillary refill. We won't have any monitoring equipment, not even a pulse oximeter.
My colleague and I sit across from each other, trying out worst case scenarios. “If the kid is in full arrest, should we give adrenaline or just declare him dead and push him aside? How are we going to keep intravenous lines in a wet, diaphoretic, hypothermic child (this is February, March)? Should we just go for what can be given intramuscularly and skip an intravenous line altogether?” I post my question to a list on the Internet and get lots of good suggestions, especially from paramedics. Some suggestions on how to secure endotracheal tubes as well. A few people include political commentary, but I'm too exhausted to respond.
I stock the house with water, canned milk, snacks, chocolate, crayons, books, CDs. I tape the doors and windows in our bedroom against chemical attack, and every night before going to bed I take in the laptop (CNN on the Internet), spare mattresses, blankets, a bucket (can't use the bathroom during an attack), and everyone's gas mask. My children have lots of questions, but I can't really explain why the rockets might fall on us when the United States attacks Iraq. They model their gas masks and get photographed, and we try to pretend it's Purim (a holiday when children dress up). Then I tell them that Mommy will have to be at the hospital when the rockets fall.
My husband and I discuss options endlessly. Perhaps he should take the children to his mother's house in the south of Israel where there were no rocket attacks in the previous war. We all have dual citizenship; perhaps he should take them to my family in the United States. In the end, we decide to keep them at home, so that when I do come home we will be together. I lay awake many nights wondering what I will do if my children, or my friend's children, come through my station.
The missiles never fell, and eventually we put away our gas masks, ate all the snacks, and untaped the doors and windows. The chemical warfare file sits on my bookshelf with the remainder of my administrative files. Advance preparation for the unthinkable.
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