At the annual Boston Marathon in April, the nation was reminded of the tragedy that struck four years ago in 2013 when two bombs detonated near the finish line, killing three people and injuring several hundred more. Thanks to the quick action and skill of Boston’s area hospitals, however, many lives and limbs were saved.
The lesson, said the academic medical centers involved in the emergency response: Prepare early, practice often. In fact, Massachusetts General Hospital (MGH) had been reviewing its emergency plans to ensure the best protocols were in place since Sept. 11, 2001, said Paul Biddinger, MD, director of the MGH Center for Disaster Medicine and vice chair for emergency preparedness.
MGH first received an alert about an explosion at the marathon over its disaster radio network, Biddinger said. Initially, there was little information about the incident or its seriousness. Nine minutes later, the first of 39 victims arrived at the hospital. At the time, 97 patients were being treated in the hospital’s 49-bed emergency department.
“We had plans in place to make capacity available within minutes,” he said. “When [the first victim] arrived and then two more people arrived in the back of transport vehicle, we had treatment rooms to take care of them. The surgical staff, the emergency staff, [and] the OR staff all mobilized incredibly quickly, and we sent six people to the operating room within the first half hour.”
“As we’ve seen, these events absolutely can happen, and they are not necessarily going to be next to the big trauma center. Every hospital, no matter how big or where [it is], needs to take this planning seriously. The consequences for not being prepared are enormous.”
Paul Biddinger, MD
Massachusetts General Hospital
The emergency response plans MGH had in place grew from a reassessment of the hospital’s readiness that included visits by a group of Israeli consultants who shared their experience with staff about urban bombings and observed the hospital’s emergency drills.
“There were lots of different elements in our plans that they told us were unrealistic,” Biddinger said. “[They explained] that events unfolded a lot faster than we thought, that details were much murkier, and that trying to wait until we were convinced that we knew the right answers would leave us unable to respond well.”
This feedback led to MGH restructuring its emergency response plans and investing significant time and effort into training exercises, Biddinger said. The improved preparation proved instrumental in the hospital’s response to the Boston Marathon bombing on April 15, 2013.
Staff at Brigham and Women’s Hospital (BWH) had been similarly trained, said Eric Goralnick, MD, medical director of emergency preparedness at the hospital and an assistant professor of emergency medicine at Harvard Medical School. They had participated in emergency exercises and drills in collaboration with fire, law enforcement, and public health officials from across the city and state.
BWH received 40 bombing victims that day, 19 of whom arrived in the first half hour. Nine patients required emergency surgery, Goralnick said.
“Ultimately, we believe that the drills and exercises and, in particular, the relationships that we [had] built with fire, EMS, law enforcement, and various departments across the city built a level of trust that was incredibly helpful for us as we cared for patients,” he said. “Overall, there were approximately 280 patients cared for at more than 24 hospitals in the Boston metropolitan area and every patient that made it to the hospital lived.”
The tragedy in Aurora
When the first shooting victim arrived by private car at the University of Colorado Hospital (UCH) emergency department, the staff was not yet aware that a mass shooting had just unfolded at a nearby Aurora movie theater.
The loud and violent scenes from the midnight showing of the movie The Dark Knight Rises masked the sounds of erupting gunfire, and patrons initially assumed the shooting was a prank or publicity stunt, said Richard Zane, MD, chair of emergency medicine at the University of Colorado School of Medicine. The chaos and confusion led to delayed calls for help and stymied communication by first responders.
But a quick-thinking UCH physician who gathered information from the first incoming patient, made the decision to activate the hospital’s disaster protocol, Zane said. As a result, staff saved priceless time and swiftly mobilized to care for the 22 additional shooting victims who flooded the hospital in the next hour.
“Based on that one patient, she decided to activate our disaster response system,” Zane said. “That was remarkable foresight. We had a lot of these types of decisions where [staff] had leadership moments that saved lives.”
Strong leadership combined with regular preparation before the shooting contributed to the hospital’s efficient response to the July 20, 2012, Aurora movie theater shooting, Zane said. Of the 23 patients the hospital received—many of whom had critical injuries and the type of wounds sustained in combat—all patients sent to UCH survived.
“We have seen an increase in the overall preparedness of our institutions to deal with emergencies including weather, violence on campus, and other unplanned events,” said John E. Prescott, MD, AAMC chief academic officer. “These are experiences that leaders at medical schools, hospitals, and universities have all taken into consideration.”
Expect the unexpected
Even with a comprehensive disaster plan, not every emergency need can be anticipated.
During the aftermath of the Aurora movie theater shooting for example, UCH struggled with security concerns due to the number of hospital visitors and callers inquiring about patients.
“The biggest challenges were those of security, meaning understanding who was friend or foe,” Zane said. “Having the ability to identify people who were asking questions because they were worried about a loved one or people who were asking questions because they were from the press was very difficult.”
Patient tracking and identification were obstacles during the Boston bombing. The city had an electronic tracking system during the marathon with data about marathon participants, but as the number of bombing victims rose, responders stopped using the time-consuming system so they could attend to critical patients more quickly, Biddinger said.
“We basically didn’t have good data and so we had lots of families and friends coming to the hospital asking where their loved ones were, and if we didn’t have their loved one at Mass General, early on we didn’t have a way to check and see if they were at the other Boston hospitals,” he said.
“Probably the single most important lesson that we learned and we’ve promulgated, has been that no matter how much you think you can anticipate the emotional toll [dealing with a disaster] takes on your staff and institution, you can’t overprepare for that.”
Richard Zane, MD
University of Colorado School of Medicine
As Hurricane Matthew loomed in 2016, staff in Florida Hospital’s central region, which includes nine hospitals in Orange, Osceola, and Seminole counties, faced the challenge of preparing new staff, some of whom had no experience with hurricanes, said Rick Sanchez, director of system safety for Florida Hospital. “This prompted a much larger need for reeducating staff on what to do regarding severe weather preparation,” he said. “There were several people that were promoted into leadership positions [who] ... must now direct implementation of our policies and procedures, where in the past they may have been waiting for someone else to give the order to execute.”
Lessons learned, policies changed
Debriefings are crucial after a disaster to enable leadership to break down what worked, what was lacking, and which policies need to be changed, experts say.
Brigham and Women’s Hospital conducted a series of debriefings, including a qualitative and quantitative review after the marathon bombing. “The quantitative review included triage, injury patterns, and surgical interventions across each level one trauma center,” Goralnick said. “The qualitative review was focused on key themes that emerged around leadership and management of these type of injuries.”
The analysis led to policy and protocol changes at the hospital and stronger teamwork among partners. For example, BWH has revamped its naming convention for unidentified patients and the way that staff perform triage and identify patients for care during a disaster.
At the University of Colorado Hospital, debriefings raised awareness of the deep emotional impact the theater shooting had on hospital employees. “Probably the single most important lesson that we learned and we’ve promulgated, has been that no matter how much you think you can anticipate the emotional toll [dealing with a disaster] takes on your staff and institution, you can’t overprepare for that,” Zane said. “[Staff] witnessed military types of injuries and assault to life that will [linger with them] forever.”
Since then, UHC has bolstered and improved the variety of social and support resources available to staff, he said.
Incorporating lessons learned into emergency preparedness plans is key, Biddinger stressed. “As we’ve seen, these events absolutely can happen, and they are not necessarily going to be next to the big trauma center. Every hospital, no matter how big or where [it is], needs to take this planning seriously. The consequences for not being prepared are enormous.”