Extensive disaster preparedness training, heroic and rapid actions by first responders and a bit of luck were responsible for the extraordinary high survival rate among the people injured in the April 15 Boston Marathon bombings, according to two physicians who supervised the emergency medical response of nearby Brigham and Women’s Hospital.
Writing online Tuesday in the Journal of the American Medical Assocation (JAMA), Dr. Ron Walls, the hospital’s chief of emergency services, and Dr. Michael Zinner, its chief of surgery, note that the three people who were killed by the explosive devices all died before reaching a hospital. The other 261 casualties, including those with horrifically severe injuries that resulted in amputations, survived.
Why were so many lives saved?
Extensive preparation
The credit, say Walls and Zinner, belongs to the “courageous and rapid response of bystanders and first responders, expert field triage, rapid transportation of injured persons, and the skills and coordination of the receiving hospital trauma teams.” But those actions were largely possible, they add, because of the extensive emergency preparedness training that Boston hospitals and emergency medical services underwent after the World Trade Center attacks in 2001 — training that was further refined after the Aurora, Colo., mass shootings in 2012.
“Analysis by the University of Colorado Health Sciences Center showed arrival of 23 critically injured patients in approximately the first hour. This was sobering,” write Walls and Zinner. “Although the Boston hospitals had prepared, trained, and drilled for mass casualty events, the challenge of receiving so many critically ill patients so rapidly at a single hospital had not been specifically addressed.”
In response to the Aurora event, Boston’s hospitals moved their emergency preparedness “to a higher level.” That proved prescient. Within the first hour after the Boston Marathon bombings, Brigham and Women’s Hospital received 23 patients — “a chilling parallel to the Aurora incident,” write Walls and Zinner. (The hospital received a total of 31 of the injured bombing victims.)
Fortunate location and time
Providence also played a key role in saving lives in Boston. As has been widely noted in the media, many first responders were already at the marathon’s finish line, attending to the runners.
“When the bombs exploded,” write Walls and Zinner, “the first order of response to a mass casualty incident — the deployment of large numbers of first responders and vehicles to establish a triage facility at the scene and to initiate incident command — was preexisting.”
In addition, five adult and three pediatric level I trauma centers, including Brigham and Women’s Hospital, were located within a very short distance of the finish line.
But the timing of the explosions also provide fortuitous in terms of saving lives, as Walls and Zinner explain:
The bombing occurred in the middle of the afternoon, very near the typical time that hospital personnel change shift. As a result, Brigham and Women’s Hospital, and undoubtedly others, had nearly double staffing. Patriots’ Day is a holiday in the Commonwealth of Massachusetts, so operating room schedules were light, allowing hospitals throughout the city to muster open and fully staffed operating rooms much more rapidly than would otherwise be the case. Brigham and Women’s Hospital was able to open 7 operating rooms within minutes of the initial alert.
The inpatient census was lower than a typical Monday, and inpatient and intensive care unit beds were readily available. This permitted extremely rapid relocation of emergency department patients, with ill patients moving into the hospital and less ill patients moving, with supporting staff, into the waiting areas. In addition, virtually every attending surgeon on the entire trauma surgery service was in the hospital, working on various activities. Within minutes of the alert, multiple trauma teams were deployed throughout the emergency department.
Key lessons
The experience of Boston's trauma centers in the aftermath of the April 15 bombings offers several early lessons, Walls and Zinner conclude.
“First, repeated drills in a coordinated effort work. This may be difficult in communities with limited resources or private practice clinicians, but is critical. Second, identification and tracking of victims is challenging in the chaos but must be rigorous. Third, the emotional effects on caregivers and bystanders during these extreme situations cannot be underestimated and preparations for this should be initiated.”
You can read the article by Walls and Zinner in full on the JAMA website.