On the morning of April 15, 2013, more than 23 000 athletes gathered in Hopkinton, Massachusetts, and began the 26.2-mile course of the Boston Marathon.1, 2 Less than 6 hours after the start of the race, as runners continued to cross the finish line, 2 explosions, 12 seconds apart, sent shrapnel and debris through the crowd of families, friends, spectators, and runners gathered to cheer on those finishing the race.3
As first responders and on-site medical personnel scrambled to attend to the wounded, Boston emergency medical services (EMS) coordinated triage and transport to receiving hospitals that worked to confirm information and prepared to receive multiple survivors. In the hours that followed the explosions, first responders including EMS, police, fire, physicians, nurses, and bystanders would provide immediate assistance to survivors who would be transported to area hospitals, with the total number of injured ultimately rising to 264.Reference Kotz4 Numerous survivors, many in critical condition, required emergent surgery.
Debriefings of both prehospital and in-hospital responses to the bombings have provided lessons learned to improve existing mass casualty processes. This brief report provides an overview of the medical response to the bombings through a review of the timeline of the event including initial response in the field, EMS transport and patient distribution to area hospitals, and emergency department (ED) and trauma team response on receiving patients. On duty at Brigham and Women's Hospital (BWH) at the time of the event—as attending emergency physicians (S.M. D. and S.R.K.) and Medical Director of Emergency Preparedness (E.G.)—we also provide a detailed account of the experience in the BWH ED, including lessons learned from the response and opportunities for strengthening mass casualty response further.
The Event and Overview of Prehospital Response
The Boston Marathon is the oldest annual marathon in the world.5 The race attracts more than 20 000 competitors each year and many more spectators and supporters. The 26.2-mile route finishes in downtown Boston on Boylston Street (between Dartmouth and Exeter streets), a busy shopping thoroughfare that borders Copley Square and the Boston Public Library. On marathon day, the area around the finish line could reasonably be expected to hold hundreds to thousands of spectators and supporters of the runners. The race begins at 9 am, with various waves of competitors beginning at different times. The elite group of runners starts at 10 am, and the first of the finishers completes the course in just over 2 hours. By 2:50 pm, the estimated time of the first explosion, approximately 17 000 runners had completed the race.6 The area around the finish line remained congested with spectators and runners cheering for those finishing the race.
At 2:50 pm, an explosive device detonated in a crowd of spectators on the north side of Boylston Street, less than 100 meters from the finish line. Twelve seconds later, a second bomb detonated nearby, also on the north side of Boylston Street. Following the explosions the scene was chaotic; hundreds of victims sustained injuries that ranged from instant fatalities to amputations to minor blast injuries.Reference Kellerman and Peleg7 While not instantly fatal, traumatic amputations placed survivors at substantial risk of critical hemorrhage. Both explosions occurred within 2 blocks of the medical tent.Reference Lazar, Johnson and Wen8 Medical personnel from the tent joined scores of EMS personnel to stabilize and mobilize patients. This on-site first aid station became a temporary stabilizing site for many blast victims.Reference Biddinger, Baggish and Harrington9 While ongoing review of the response continued, early reports indicated that within 18 minutes of the explosions, ambulances had transported all seriously injured patients from the site to local hospitals.Reference McConville10 Furthermore, a review of the volume of patients received by area hospitals demonstrated successful efforts by EMS to distribute patients evenly to area medical facilities.
Brigham and Women's Hospital Emergency Department Response
At the BWH emergency department (ED), the first notification of the bombings came at 2:50 pm through the Boston Fire and EMS radio frequency. At 2: 54 pm, Central Medical Emergency Direction (CMED) reported 2 explosions at the marathon. A BWH physician near the scene at the medical tent also called the ED to provide advanced notification that the department should expect to receive multiple injured patients. While these reports provided very limited information (2 explosions at the finish line, multiple serious casualties), preparations were immediately begun to clear the ED for the arrival of multiple casualties.
As subsequent reports confirmed a mass casualty event in downtown Boston, attending physicians and charge nurses rapidly coordinated efforts to move ED patients to inpatient units or to expedite discharges. Code Amber—the hospital-wide disaster response—was activated by leadership of the hospital incident command. Physicians on inpatient teams who happened to be in the ED were alerted to the pending arrival of multiple patients from a mass casualty event. These physicians played a key role in expediting patient transfer to inpatient units, including coordinating directly with the admitting department to assign inpatient beds, a task usually the responsibility of the ED attending physician.
Several ED psychiatric patients requiring inpatient treatment had been receiving care in the ED observation unit pending transfer. For these patients the psychiatry service coordinated the expedited disposition of 8 patients from the ED; 4 patients were admitted to the inpatient surge pod and 4 were transferred to McLean Psychiatric Hospital. As ED patients were rapidly transferred to inpatient units, an overhead page announced, “multiple trauma patients, 2 minutes” followed by “multiple trauma patients now arriving.”
The BWH ED is a 55-bed unit divided into 3 acute patient care areas (Alpha, Bravo, and Charlie pods), each with about 14 beds plus an observation unit of 10 beds. At 3 pm, a total of 5 attending physicians were present in the BWH ED owing to a period of overlap between the outgoing day shift and incoming evening shift. Because attending emergency physicians from the day shift stayed late to help, the ED was maximally staffed with physicians during the rush of patients from the bombing site. Similarly, nurse, resident, and physician assistant staffing also would normally be preparing around 3 pm for a busy afternoon and evening. In general, on a typical Monday afternoon between 3 and 5 pm, BWH ED has 6 attending physicians, 9 residents, 6 physician assistants, 24 nurses, and 12 emergency service assistants on shift. In addition to those staff members, at least 8 ED clinicians and many more clinicians from other specialties spontaneously arrived in the ED to help. The ED staff roster immediately after the bombings was more than adequate to handle the number of patients received.
The BWH ED received 31 patients in the first hours after the bombings. Incoming patients were triaged so that the most severely injured patients went to the Alpha pod, which contained the trauma bays. Patients with less severe injuries were distributed between the Bravo and Charlie pods. Between 3:08 and 4:38 pm, a total of 26 patients were received, 19 of whom arrived within the first 30 minutes. Conditions ranged from stable to critical, and the patients ranged in age from 3 to 62 years. The senior attending physician in the Alpha pod organized trauma and emergency staff into trauma teams and assigned them to specific patient rooms, with the directive to evaluate and remain with the patient triaged to their rooms. Soon after, 8 additional ED physicians who had been performing nonclinical duties at the hospital arrived in the ED to provide additional clinical support, triage, and medical direction. The medical director acted as media liaison in cooperation with the hospital's public communications officer. Two physicians began caring for patients in the observation unit—typically staffed primarily by a physician assistant—and a third ED attending physician reported to the Bravo pod to reinforce the 2 attending physicians who were now receiving multiple patients.
Injuries were consistent with the reported mechanism of bomb blast and included traumatic amputations, open fractures, burns, and intracranial and intra-abdominal injuries due to projectiles. Trauma surgery, orthopedic surgery, and plastic surgery teams began patient evaluation in the Alpha pod and rapidly moved through the Bravo and Charlie pods. These surgical teams received reports from ED teams and helped conduct rapid trauma evaluations. Senior anesthesiologists and operating room (OR) nurse leadership coordinated with surgical services, led by trauma surgery, to prepare OR resources to receive priority patients. Additional OR resources were readied to receive stabilized patients requiring urgent surgery. As patients were stabilized, they were transferred immediately to the OR or to inpatient surgical units. Elective cases were put on hold. A total of 9 patients were identified for emergency surgery and were taken to the OR soon after arrival, aided by a direct-to-OR process coordinated by the lead anesthesiologist who was stationed in the ED and a nursing director in the OR.
Once the influx of patients had finished, trauma teams and surgical personnel remained present in the ED, anticipating the possible arrival of additional patients. Unconfirmed reports of additional events including a fire at the John F. Kennedy Library (later confirmed to be unrelated to the bombings) added to the confusion about ongoing security concerns in the city. During this time, the ED remained staffed with additional personnel, and 5 ED trauma teams awaited the arrival of additional patients. As it became evident that no other injured patients would be received from the bombings and no additional security events had been reported, ED staff patterns were reconfigured under the direction of ED leadership to standard levels, and non-ED personnel were redeployed within the hospital. Under the guidance of the hospital-wide incident command, Code Amber status was deactivated after approximately 4 hours.
Rapid efforts were made to ensure psychosocial needs of patients and providers were considered in both real time and after the event. Debriefings have been coordinated throughout various departments and continue currently as lessons learned are identified and an after-action summary is prepared. The BWH Employee Assistance Program and Peer Support Team made a concerted effort to reach out to staff members involved in the response. Employee Assistance Program staff members were present at each debriefing session to offer support and services. The Peer Support Team also contacted each responding emergency medicine staff member individually by phone to offer personalized support.
Immediate Insights and Lessons Learned
BWH conducted phased debriefings starting with initial hotwashes (ie, debriefings immediately following the event), to provide all participants an opportunity to give feedback on the strengths and weaknesses of the event response. At the time of this writing, BWH has begun a lessons-learned phase to further identify and solve issues identified by the hotwashes. These debriefings will serve as the basis for institutional and departmental after-action reports.
Preparation and practice was integral to our successful response. Since 2005, BWH has activated its emergency operations plan 78 times for both exercises and real-world events. The BWH Emergency Preparedness Team has also participated in 623 minor events, communications tests, or exercises that were at a level not requiring a hospital-wide activation. These drills established and refined current procedures and policies to ensure role clarity, authority, and accountability for hospital personnel during this mass casualty response. During the hotwashes, several staff members commented that their actions on April 15, 2013, were informed and improved by their participation in previous exercises. Initial discussions noted rapid clearing of the ED, direct-to-OR transports, and interdisciplinary team responses as key successes.
At the height of the ED response, 2 actions on the part of ED attending physicians were found to be particularly helpful. First, clear and rapid organization of ED staff and arriving trauma surgeons, orthopedic surgeons, and anesthesiologists into room-specific trauma teams helped to decrease confusion and overcrowding in the ED, particularly in the Alpha pod. As room-specific trauma teams were organized, available ED room numbers were given to the triage physician so that he would know where to send arriving critical patients. The order of rooms to be used was communicated to both the triage physicians and the room-specific trauma teams so that all teams would know when they were next to receive a patient.
Second, room-specific trauma teams were regularly informed with situation updates as information became available via radio reports and from EMS responders arriving from the scene of the bombings. The ED attending physician in the Alpha pod updated each room-specific trauma team every 5 to 15 minutes during the response to keep teams informed of anticipated arrivals and the expected time of the response stand-down. Both actions helped to create order, decrease confusion, and prevent responding clinicians from drifting away from their response-ready positions.
Finally, when the reports of the explosions were received, the ED attending physician in the Alpha pod and the hospital disaster personnel considered the possibility of a radiation emergency. While no reports of chemical or radiation contamination from EMS had occurred, ED personnel performed limited screening for evidence of radioactive contamination among the first patients to arrive to the ED. This experience highlights the challenge of determining the need for screening arriving patients for evidence of radioactive or chemical contamination after a presumed terrorist attack.
Areas for Further Improvements and Research
As described, the ongoing review of the BWH ED response to the event highlights both successes and opportunities for improving existing processes. Opportunities for improvement that have been identified include (1) how extra medical staff who present to assist in patient care may be best used, (2) how intradepartmental communication may be improved, and (3) how future departmental training can be enhanced based on lessons learned from this experience.
A large number of providers from various specialties presented to the ED and offered to provide additional assistance. These providers were asked to report to the ED waiting room. This coordination of personnel helped control volume of personnel present in the ED and allowed for more cohesive coordination of care. Furthermore, in the event of an influx of patients with minor injuries, this reserve group of providers could be activated to provide direct patient care.
As described, the ED is divided into 3 acute care areas and an observation unit. While these pods are near one another within the department, the central location of the observation unit creates a distinct architectural separation among the 3 acute care pods, limiting direct communication among providers of individual pods. This physical layout of the ED into 3 discrete pods plus an observation unit creates a physical barrier that prevents both direct visualization and direct communication among pods.
Postevent debriefings have identified communication among pods after such an event as one area in which ED response could benefit from improvement. One proposed solution has been to assign a pod leader to each individual pod and an additional provider to coordinate patient care among all of the pods. The individual pod leaders would not be engaged in direct patient care. Rather these pod leaders would coordinate patient care within the pod and communicate with the physician assigned to coordinate care among all pods to prioritize resource utilization and coordinate patient disposition from the ED. Ongoing debriefing and discussion will further explore opportunities to strengthen this aspect of the ED functioning in mass casualty response.
While some providers have credited previous training exercises with improving readiness for the response, review of the ED experience also informs areas of potential improvement of training activities. Future drills could include such topics as emergency ED documentation systems, unaccompanied pediatric patients, and management of a high volume of spontaneously arriving medical personnel. Finally, drills should include all personnel in the ED, as nonmedical personnel including administrative support and housekeeping staff carry out functions that are integral to efficient operations of the department.
Conclusion
Initial reflections on the medical response to the 2013 Boston Marathon bombings have revealed a well-coordinated and well-executed prehospital and in-hospital emergency and trauma service response that did not compromise the standard of patient care for victims of the blasts. In particular, the Boston EMS response proved highly efficient in time to patient transport and equitable distribution of patients among the city's trauma centers. It is reasonable to conclude that prehospital efforts contributed in large part to the success of the hospitals’ ability to manage patient care and allowed for an efficient use of the city's robust medical infrastructure. At the BWH ED, multiple lessons have been learned in the response to this tragedy, although ongoing debriefings and reviews of the response are expected to yield more lessons.
Successes include rapid assessment and stabilization of all patients received, rapid mobilization of both human and medical resources, and adaptation of multiple medical services, including non-trauma teams to coordinate patient care and prepare the ED to receive a large number of patients. Among the opportunities for improvement are an enhanced ED disaster command structure, overcoming communication limitations of an ED organized into a multipod configuration, development of a durable, noncomputer-based documentation and communication system adaptable to a variety of uses, and augmented training exercises to incorporate lessons learned from this event.
A number of factors converged to create a cohesive response by the Boston Medical Community.Reference Kellerman and Peleg7 In preparation for the marathon, Boston EMS resources were deployed in close proximity to the medical tent, which was near the site of the bombings. Also, the bombings occurred on a weekday when hospital personnel and resources were readily mobilized. At the BWH ED, patients arrived at a time when both incoming and outgoing personnel were present. Moreover, previous preparation contributed to provider preparedness for a mass casualty event.
A continued critical focus on the medical response to the 2013 Boston marathon tragedy will allow providers and administrators to strengthen existing processes, rendering individuals and the medical system better prepared to serve patients affected by such events.
