The Boston Marathon bombings: A post-event review of the robust emergency response

Lessons learned include the critical importance of hospital-wide drills, historical insight

Fortunately, terrorist attacks are not a common occurrence in America. But ever since the World Trade Center towers were struck down by extremists in September 2001 in New York City, hospitals around the country have been honing the way they drill so that they will not be caught off guard in the unlikely event that a terrorist act triggers mass casualties in their region.

By all accounts, such preparation paid off handsomely in Boston on April 15th when two bombs exploded near the finish line of the city’s annual marathon. Three people died and nearly 200 others were injured in the blasts, but observers note that the loss of life and limb would have been much greater had there not been such a quick and robust emergency response.

Indeed, Boston is well-equipped from a medical standpoint, with as many as five level I trauma facilities. And a number of medical personnel from these facilities were already working in tents at the site of the marathon to deal with marathon-related health issues, so immediate care was close at hand at the scene of the blasts. But it is also clear that while disaster response plans never work perfectly, all of the drilling that hospitals conduct for just such an event prepared the facilities to handle the incoming patient surge while also guarding the safety of patients and medical personnel. It is also notable that all this occurred in the midst of a threat that was not well understood for some time.

Hospital-wide response is crucial

Brigham and Women’s Hospital had three residents working in a medical tent at the marathon, so the ED got an early warning that two explosions had occurred and that staff should be prepared to receive patients. An official call from the Central Medical Emergency Direction Center came at 2:54 in the afternoon, explains Eric Goralnick, MD, medical director of Emergency Preparedness and associate clinical director of the Department of Emergency Medicine at the hospital.

At this point, the hospital’s incident commander and the other clinical leaders in charge issued a code Amber, which initiated a hospital-wide response. “Although our emergency center was already open [because of the marathon], the code Amber triggered a gathering of our command and general staff in the center and prompted a rapid decamping of the ED,” says Goralnick.

The code Amber was communicated via both cell phone and pager messages, as well as through the hospital’s overhead speaker system. It cued several different specialties from the upper floors of the hospital to make room for ED patients. “For example, internal medicine staff came down and identified patients who were admitted or in the midst of a workup, and they did a sign-out with the emergency medicine providers,” notes Goralnick. In some cases, resident physicians transported the patients upstairs themselves, and in other cases, patient transport services handled the transfers.

Many different departments retrieved patients in this way to clear the ED for the anticipated victims. “This was the sort of team effort that occurred. Everybody took their patients and got them out of there, so it all happened very rapidly,” says Goralnick. “Some of this was part of the process that we had drilled on, but some was spontaneous, and that is what we are trying to figure out now.”

For instance, to care for eight patients who were awaiting psychiatric beds, the head of the hospital’s psychiatry unit came down to the ED and arranged for four of these patients to be admitted to a surge pod that the hospital had opened to accommodate these patients, and he arranged for the other four patients to be transferred to another hospital. “That was very impromptu. He knew we had to clear the ED, and he found space for four of the patients upstairs, but there is no checklist for calling another facility to get this done,” says Goralnick. “There are many lessons to be learned from this experience.”

At the same time that the ED was being cleared, the code Amber triggered a halt to all elective surgeries that had not yet commenced. “We have a total of 42 operating rooms (OR), and 30 of them were active at the time, so staff continued with those operations, but they were aware that some of them might have to stop. That is part of the routine,” notes Goralnick.

The OR prepared to take care of patients in eight beds, and began forming a labor pool of all of the different types of staff that are used in the OR so that this pool could be quickly tapped as needed.

Within a half-hour of the code Amber being issued, the hospital received 19 of the 39 patients it would ultimately receive from the marathon bombings. “There was one traumatic amputation, and there were several individuals who had open fractures,” explains Goralnick. In addition, many of the patients had shrapnel embedded in their bodies, there were several different types of blast injuries, and there were multiple burn wounds.

“We did a rapid triage of these patients and determined which ones needed to go to the OR right away,” says Goralnick. “In the first wave of patients, six were identified. Overall, nine patients went to the OR based on injuries that were life-threatening.”

A leadership team consisting of an orthopedic specialist, a trauma surgeon, an ED manager, and an anesthesiologist took charge of balancing resources with availability, and the approach worked well, says Goralnick.

While the ED clinicians have certainly learned valuable lessons from colleagues who spent time in the military caring for soldiers with battle wounds, Goralnick says an experience that proved particularly beneficial for many of the staff was time spent volunteering in Haiti following the earthquake that occurred there in 2010. “We dealt with a lot of traumatic injuries there, so I think that was extremely beneficial,” he says. “A lot of the triaging techniques that we used there were implemented here at Brigham and Women’s.”

Lack of clarity heightens concern

One issue that has been a problem in other homicidal bomb attacks is that there are sometimes third, fourth, or fifth bombs that are set to go off targeting first responders, and the ED can be in the line of fire as well, notes Goralnick. “There was that sense of urgency, but there was also a lack of clarity,” he says. “We were worried about whether there were more bombs that were going to go off, and whether we were a potential target.”

To guard against such threats, the hospital went into lockdown mode, a move that puts established protocols in place for the hospital’s own security force to set up a perimeter around the hospital. “That force was augmented very quickly by local law enforcement,” observes Goralnick. “They were in the ED with the first patients, and they were collecting evidence on site throughout the ED.”

Already under extreme stress, the types of injuries ED staff confronted that day heightened the emotional toll on care providers. “To see patients coming in with traumatic amputations, active hemorrhaging, shrapnel and bones sticking out of the skin ... the impact on a provider is significant and shouldn’t be lost in this,” says Goralnick.

To deal with this aspect, administrators quickly assembled a team of psychiatrists, social workers, and peer counselors. “We were very aggressive about insuring that our staff had the resources, knew where to find the resources, and were able to meet the professionals who would provide those resources,” explains Goralnick, noting that within a day of the bombings, several open forums were held so that all the different types of staff who were involved with the emergency response, from housekeepers to clinicians and technicians, could be briefed about the help that was being made available.

“We also set up a wellness committee that met on a daily basis with representatives from several different services to get updates [on how staff were doing] across the various different subspecialties,” adds Goralnick. “That process continues, and I think it has been very beneficial for staff.”

Quick action proves pivotal

The biggest immediate challenge facing the ED at Massachusetts General Hospital (MGH) when it first got word of the bombings was the fact that it was already very crowded that day. “My ED has 49 beds, which is relatively large, but we had more than 90 patients who were active in the department at the time,” explains Paul Biddinger, MD, chief of the Division of Emergency Preparedness and medical director of Emergency Operations at MGH. “The time between first notification of the bombings and the first arrival of patients was incredibly short. It was nine minutes. And that is typical of events like this.”

To make room for incoming patients, leaders in the ED worked with hospital nursing directors and the admitting office to quickly identify available beds anywhere in the hospital so that the patients in the ED could be quickly transferred upstairs. “That worked even better than planned. What we found is that the nurses upstairs were not only willing to take patients, which was fantastic, but they actually, in many instances, came down and got the patients themselves,” notes Biddinger. “The benefit of that was two-fold. It got patients out of the ED without having to wait for transport resources, but also the nurses were able to get a face-to-face pass off so that they could hear [first-hand] what were the active issues and concerns for the patients when they took them out of the ED.”

Similarly, internal medicine staff came down to the ED and either held patients in the back of the ED until beds could be identified or promptly took the patients upstairs. “This kind of active pulling of patients out of the ED tends to be under-appreciated, but it is an important way to create capacity,” says Biddinger.

Any delay in these actions to make room for incoming patients would have left the ED without the capacity it needed to handle the surge, says Biddinger, noting that the hospital received 31 patients in the initial wave. “In an event like this, patients are going to present very quickly with very little warning and with severe injuries,” he stresses. “You have to be able to [activate] — not just the ED, but the whole hospital to muster the resources that the sickest patients will need early.”

As things turned out, even with the sudden surge of bombing victims, some of whom were critically injured, the ED at MGH could have accommodated two to three times as many patients as it received, notes Biddinger.

Recent history provides valuable insight

While MGH has never dealt with a terrorist bombing incident before, there were security protocols in place to deal with this type of threat. “We actually talked about and trained for the possibility of terrorists coming to the ED disguised as victims or as actual victims,” says Biddinger. “We have policies in place to check people as they are arriving.”

Further, in the hospital’s plans for hazardous materials, all items are routinely removed from patients and placed in a secured site until the hospital knows whether law enforcement wants to take charge of the items or not, explains Biddinger.

“One of the biggest reasons why our system worked well is because we practiced it a lot. I would say even in Boston most of the people who practiced these exercises didn’t think that we would really face this challenge,” observes Biddinger. “The reason we were able to make so many things that are relatively complex happen so quickly is because we had done it many times before.”

Biddinger emphasizes that it is important for hospital leaders to continually review the literature and to stay current on what happens during mass-casualty events around the world. “We have spent a lot of time in the last decade retooling our emergency plans, learning lessons from the London subway bombings [in 2005], the Madrid train bombings [in 2004], and the series of terrorist attacks that occurred across Mumbai, [India in 2008],” he says, noting that the rate of patient presentations, the types of injuries that occurred, and the interventions employed during these incidents were not consistent with some of the old-school assumptions about what emergency plans should include. “You have to try to make sure your plans reflect reality.”

Biddinger has no doubt that more lessons can be learned from the Boston bombings of 2013. “We are reviewing some of our data right now. Hopefully it will be helpful to others as we get a chance to publish from this event.”

Extra help requires management resources

Beth Israel Deaconess Medical Center (BIDMC) received a total of 24 patients from the bombings, according to Kirsten Boyd, RN, MHA, associate chief nurse for Ambulatory and Emergency Services. Like MGH and Brigham and Women’s, the hospital had to quickly clear the ED to make room for the surge of patients, but Boyd observes that one of the greatest challenges the staff faced was dealing with all of the hospital employees who were not scheduled to work that day, but after hearing about the incident through social media and news reports, they showed up to lend a hand.

“This required us to organize [the extra staff] in a separate area so that we would be able to pull out a nurse, a physician, or a tech, as needed, depending on what their roles were,” says Boyd. “We appointed one of our managers to be in charge of coordinating this group.”

Whenever a clinician, tech, or another type of hospital employee showed up to offer services, he or she would be placed in the employee break room and given a scrub top to wear, explains Boyd. “They would write on their backs ‘Nurse Judy’ or ‘Doctor Smith’ just so we could identify them,” she says. “Although many of these hospital employees were familiar faces, the majority of them did not work in the ED.”

Whenever the ED needed assistance with transporting a patient or with clinical care, administrators would then pull from this group, but it did create some additional operational challenges, says Boyd.

There is always the challenge of having too many or too few staff. Hospital disaster planners are careful to write policies that don’t discourage hospital personnel from responding spontaneously in major disasters, since formal communication systems are not timely enough or may be unavailable in disasters. But staff need to be prepared if a larger then needed group of personnel are onsite. Biddinger says that MGH faced a similar problem, with more people self-responding to the ED to help than the department actually needed. “Although we tried to manage it by creating teams of surgeons and emergency physicians and a couple of specialists that were posted outside of each empty room so that when patients came they could be matched up with a room and a team, we still had more [personnel] than we needed, and that ultimately ended up taking some management resources away from the ED,” he explains.

Biddinger says this is one area where the hospital can make improvements going forward. “We are continuing to work on ways to manage the specialists and the early responders that we need. We certainly don’t want to end up in a situation where we don’t have enough trauma surgeons, vascular surgeons, or others, but self-responding before we know what we need also detracts from the response a little bit, so we are definitely working on this,” he says.

Communications are challenging

One of Boyd’s roles at BIDMC during the crisis was to serve as a liaison between the clinical staff and anything happening operationally outside of the department. “We were able to secure the environment and enable our clinicians to focus on patient care,” she says.

This became particularly important a few days after the bombings when the prime suspect was apprehended and brought to BIDMC for care. The hospital’s corporate communications department took charge of fielding all media inquiries while hospital social workers focused on meeting the needs of families who had loved ones being treated for injuries sustained in the bombings.

The teamwork between the different hospital departments at BIDMC was key to the hospital’s success in dealing with the crisis, says Boyd. She emphasizes that the response worked well because it had been well practiced. “We are very focused on clinicians, emergency physicians, and emergency nurses and technicians, but there are so many other layers in the hospital to include in these drills,” she says. “Have focused drills that really encompass all areas of the hospital,” she advises colleagues. “I think that is really a key take-away.”

Goralnick agrees with this advice, but he would add that it is important to pay particular attention to how your organization is going to handle communications during any mass-casualty event. “Actually walk through the drill and insure that there is a route of clear communication throughout,” he says, noting that different organizations face different types of communications challenges.

Also, insure that all individuals who are identified as players in the Hospital Incident Command structure use identifying elements (hats, vests, or signs) so that they can be identified from across a busy, loud, crowded ED, advises Goralnick. “This way you will have clear, established leaders and point-persons that staff can go to when there is staff confusion,” he says.

Goralnick further advises colleagues who are fine-turning their emergency plans to include procedures for streamlining their chain of command. “The whole purpose of a Hospital Incident Command structure is to go from a matrix organization — an organization that is very diffuse and has many senior leaders — and to streamline it into the format of an incident commander and general staff,” he says. “Insure that the individuals placed in those roles have the accountability and the authority to execute what needs to be done in a short amount of time.”

Finally, whenever emergency plans have been executed, it is critical to go back and pin-point where changes could improve the emergency response the next time it is required. “Identify an action plan to follow up on those areas — not just with changes to your emergency operations plan, but with actual drills as well,” says Goralnick.

Sources

Paul Biddinger, MD, Chief, Division of Emergency Preparedness, and Medical Director, Emergency Department Operations, Massachusetts General Hospital, Boston, MA. Phone: 617-724-3122.

• Eileen Bohannon, BSN, CEN, Director, Emergency Services, Providence Health Center, Waco, TX. E-mail: ebohanno@phn-waco.org.

• Kirsten Boyd, RN, MHA, Associate Chief Nurse for Ambulatory and Emergency Services, Beth Israel Deaconess Medical Center, Boston, MA. E-mail: kboyd2@bidmc.harvard.edu.

• Eric Goralnick, MD, Medical Director of Emergency Preparedness, and Associate Clinical Director, Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, MA. E-mail: egoralnick@partners.org.