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Boston Marathon Bombing Yields Lessons for Hospitals

April 17, 2014

As researchers begin to analyze data on the injuries, surgeries, and outcomes collected on those wounded in the 2013 bombings, the medical director for emergency preparedness at one Boston hospital says he expects to "learn from this event for a lifetime."

Cheryl Clark is on vacation.


David King, MD,
Trauma Surgeon at Mass General

A year after the two bombs went off near the finish line of the Boston Marathon, killing three and injuring scores, the city is making final preparations for the 2014 marathon on Monday, April 21.

First responders and healthcare workers in particular have learned a number of lessons from the events of April 15, 2013. For example, since the bombing, Boston hospitals have changed the way they receive unidentified trauma patients in the emergency department. Members of the city's police force are now equipped with military-quality tourniquets.

More lessons, perhaps further-reaching, will come as researchers begin to analyze data on the injuries, surgeries, and outcomes for each of the more than 240 people injured.

Much has been said of the fact that the blast took place in a neighborhood literally surrounded by trauma centers. Within 22 minutes, ambulances had transported 24 victims to Beth Israel Deaconess, 29 to the Brigham and 28 to Tufts Medical Center. Boston Children's Hospital took eight.

You won't find an equivalent cluster of well-equipped hospitals anywhere on the planet, says Mass General trauma surgeon David King, MD,. The trick now is to draw lessons from how this unique, elite health delivery ecosystem performed under intense pressure.

King had just finished running the race and was headed home with his family when he started getting text messages about the blast. He turned around and went to work. There, Mass General Hospital emergency department workers were coping with a surge of 37 people injured in what is technically known as an MCI, a mass casualty incident.

'How Can We Do It Better?'
Now King is part of a consortium of the city's five trauma centers that has been studying the response. The data and the research emerging from it are part of the effort to use the lessons of the marathon to improve trauma care.  

"This is asking ourselves: How did we do? How can we do it better?" King says.

Unlike many of his Boston peers, King had experience with mass casualties before the Marathon bombing. As a Lt. Col. in the U.S. Army, he was stationed at a combat outpost in Afghanistan when a truck bomb went off outside the gates on the tenth anniversary of 9/11.

His experiences here and overseas where 75 percent of all injuries were caused by explosions— have made King a huge promoter of the tourniquet. The bystanders at the finish line did their best with t-shirts, belts, and other makeshift tourniquets, he said. But, it takes a medical-quality device to stop arterial hemorrhaging and prevent blood loss that can make a leg wound fatal.

In a report on the marathon bombing, the Federal Emergency Management Agency noted that the use of tourniquets had fallen out of favor. They may do more damage than good by cutting off circulation to healthy tissue. However, the FEMA report noted, the successful treatment of battlefield injuries in Iraq demonstrated the value of tourniquets.


Eric Goralnick, MD
Medical Director for
Emergency Preparedness
at Brigham and Women's Hospital

"We have extensive science on this from the past twelve years of war," King said.  

EHR Shortcomings
King and others think one of the major problems during the initial response to the blast was the inability of some hospitals' electronic health records systems to keep up with the surge of severely injured patients. It just took too long to register them, he said. At one point, King looked down and saw that he was writing patient notes on his scrubs with a Sharprie.

Eric Goralnick, MD, agrees. He's the medical director for emergency preparedness at the Brigham and Women's Hospital and, like King, a military veteran. A graduate of the U.S. Naval Academy, he served from 1995 to 2002.

"The No. 1 bottleneck was the information system," he said. By that, he means the electronic medical records, virtual tracking board, and the numeric naming conventions they had been using at the hospital to identify patients.

For example, when unidentified patients arrive at the ED, they are assigned numbers. With so many on race day, it was easy to confuse patients with a single keystroke, Goralnick said. Now, they are assigned an M or F for male and female and a state or city name, and a color.

"We would love to think about how we can optimize electronic health systems so they can function during an MCI," Dr. Eric Goralnick said. "The goal is to have reliable system that you can rely on every day."

In the meantime, they plan to use paper records with wristbands and presigned orders to respond to the next mass casualty event.

At BIDMC, the EHR system—which was designed in house and already uses a text-based naming system—worked more efficiently. The hospital's ED dashboard was written by emergency physicians. Patient can be "micro-registered" in a few seconds by any nurse by entering a name, date of birth and gender, according to Dr. Larry Nathanson, ED's director of emergency medical informatics.

Registration staff follows up to gather the rest of the data. For patients who are too critical even for this, there are dozens of binders with patient information pre-registered as "EU CRITICAL, ADAM", "EU CRITICAL, BRAD", "EU CRITICAL, CHARLIE", etc. Nathanson writes in an email. "We just grab a binder and start treating the patient with zero delay."

Beyond the ED, staff tackled a different issue—the parade of specialists who marched through patients' rooms every day. Instead of separate visits from the vascular surgeon, orthopedist, plastic surgeons and social worker, the hospitals formed teams that did rounds as a group.

Ultimately, Boston hospitals did well because those who responded knew what they were doing. Boston surgeon Atul Gawande wrote in The New Yorker that he was "struck by how ready and almost rehearsed they were for this event. A decade earlier, nothing approaching their level of collaboration and efficiency would have occurred."

'The Equivalent of 1,000 Drills'
In fact, they were rehearsed. In its report on the response, FEMA pointed to 2002 an exercise meant to simulate the explosion of a dirty bomb on an incoming airplane that involved over 50 agencies and 10 hospitals. In 2011, another exercise tested the ability of hospitals to handle a surge of patients from an explosion and building collapse.

"Members of the hospital staff were familiar with their roles and responsibilities because of the training and exercises they had previously conducted," according to the FEMA report. "Additionally, hospitals developed plans with first responders, ambulance services, and law enforcement to successfully coordinate a hospital response during an MCI."

Goralnick agrees that preparation and collaboration made a huge difference. But he said that, in terms of lessons learned, the Boston Marathon bombing was the equivalent of 1,000 drills: "We're going to learn from this event for a lifetime."

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