Mitchel B Harris
Michael J Weaver
For most Americans, April 15 is generally remembered as the ominous day of the year that taxes are due. However, for nearly 27,000 runners representing 77 nations, and more than half a million fans, friends and family members, April 15, 2013 will be a day they will never forget. The Boston Marathon is the oldest continuous running marathon in America, first run in 1897. It is generally considered the most prestigious annual running event that is open to the public, once qualifications are met. Prior to its 117th consecutive running, it had not been generally viewed as a target for a "terrorist attack". However, on April 15, 2013, two misguided brothers placed explosive filled backpacks with remote detonator switches within yards of each other and the finish line of the Boston Marathon.The following paragraphs will highlight the extraordinary efforts put forth by the medical community of Boston and, in particular, many members of the OTA.
Boston is well known as a highly resourced and sophisticated academic medical community. It has 6 Academic Medical Centers (AMC's: BIDMC,BMC,BWH,CHB, MGH and Tufts) each with an American College of Surgeon's certified level one trauma center. This is despite a metro population of only 636,000, and a greater metro area population of 4.5 million. Each of these
medical centers provides cradle-to-grave medical services to their respective local communities and function as New England's regional referral centers. Additionally, a few of these centers function as tertiary and quaternary centers for patients throughout the US and internationally. Within each of these AMC's is a trauma program and embedded within these trauma programs are 12-15 OTA members (active and associate, not including resident members) whose role during the events surrounding the Marathon Bombing deserves acknowledgement from our professional organization.
April 15, 2013 was also Patriot's Day. Patriots Day is a civic holiday celebrated in Massachusetts and Maine, acknowledging the onset of the American Revolution. It generally marks the start of a weeklong school break in the New England states as well as the running of the Boston Marathon. The Red Sox also schedule an early season home game, so as you can imagine, Boston is packed with runners, baseball fans and associated family and friends. As is the practice with all trauma centers, during vacation weeks or academic conference times, travel and call schedules must be juggled to maintain appropriate coverage. This April break was no exception, with three of the five orthopedic trauma service chiefs scheduled away with family related activities (college visits and Disney world). Case in point, I was just beginning my daughter's campus tour of Vanderbilt University when I received notification of the bombing.
The race begins in Hopkinton, Mass, a town of 13,500. Most out-of-state runners reserve hotel rooms in the city and take advantage of a well-rehearsed bus shuttle system to bring them out to the starting line for the 9 AM start. The finish line is located in downtown Boston, between the Prudential Building (home of major sponsor- John Hancock) and the Boston Public Library in
Copley Square. The race starts with the mobility impaired and wheelchair racers followed by the elite runners and ultimately the thousands of runners who have either earned their runners’ bibs via qualifying times or are among the many who are sponsored runners for charities throughout the US.
The Boston Athletic Association's Medical Team, the Mass Department of Public Health, the Mass Emergency Management Association, the Boston Police Department, the city's EMS leaders, and the 6 AMC's ED and Trauma Services, meticulously prepare for this event annually. Unbeknownst to me prior to putting this essay together, this group of individuals and committees have prepared for the possibility of a terrorist event for the past 5 years. Their preparation includes table-top planning exercises and simulated terrorist induced scenarios in addition to their standard 5-6 meetings per year for the event. This incredible level of preparation along with the unprecedented heat wave during both the 2004 and 2012 races leading to > 250 participants requiring medical care, had the medical community prepared and on alert.
At 2:49 on April 15, 2013, the first of two bombs was detonated within a block of the finish line. Scarcely 20 seconds later the second bomb was detonated and a full city-wide mass casualty alert was initiated. (The following data was accrued through the efforts of each AMC and their research and public health staff.) 151 people were triaged to 1 of the 6 designated trauma centers. Tufts Medical Center was quickly removed from the triage list after an additional bomb threat was made on their campus. As the bombs were placed at ground level the vast majority of patients sustained isolated, though often devastating, and lower extremity injuries. Tourniquets and belts were liberally applied to scores of individuals to control bleeding and stabilize injuries. There were 3 immediate deaths at the scene of the bombing. Remarkably, no additional deaths have been associated with the bombing events aside from the shooting death of the MIT security guard during the aftermath and chase of the perpetrators.
The medical tent was quickly and efficiently converted into a triage station. Numerous first responder bystanders grabbed the injured and initiated civilian transport to the local trauma centers as well. Within 15 minutes of the first explosion, patients were being brought into the operating rooms to complete amputations at Boston Medical Center and Mass General Hospital. On average, it took 17 minutes from the time of the bombing until the first wave of critically injured patients arrived at the EDs of the participating hospitals. The triage effectively distributed the injured such that most hospitals received between 10-40 seriously injured patients. From 3 PM until midnight, the collaborative effort of the Boston hospitals committed 36 operating rooms to those 50 victims requiring emergency surgery. There were 12 amputations on the first day, and subsequently only an additional 3. By the time I returned from Nashville to BWH, around 10:30PM, the last round of surgeries were nearly completed there as well as at BID, BMC and MGH.
At each location, the OTA members quickly assumed leadership roles and responsibility for both ED triage and organizing operative teams. At BMC, former OTA president, Paul Tornetta and Bill Creevy performed both front line triage and emergency surgery; at BID- Paul Appleton served as the principle orthopedic traumatologist organizing the efforts of the trauma service; at BWH- Michael Weaver worked with the trauma, vascular and plastic surgeons to assign each of the injured to an operating team that integrated all four services throughout their care; at MGH-
Malcolm Smith ,David Lhowe and John Kwon were the OTA members participating in some of the earliest life saving amputations from the events; while at Tufts, both Chuck Cassidy and Scott Ryan provided urgent care for their victims. Over the ensuing 48 hours, all of the trauma centers returned to their full orthopedic trauma staffing, gaining further operative support from Ken Rodriquez at BID, George Dyer at BWH and Mark Vrahas at MGH. During this time the patient load from the bombing increased significantly. Of the 281 injured, 50 victims required emergency surgery during the initial 24 hours whereas many others required surgeries though neither life nor limb threatening. At each of the hospitals, in addition to the OTA members involved, many of the orthopedic faculty participated in the early debridements and placement of temporizing external fixations.
Over the past several months, many of the bombing victims have significantly recovered, while those who underwent amputation and those with reconstructed mangled extremities continue to receive ongoing treatment. Many of the lessons we learned from the LEAP studies, from our trauma fellowship training, as well as years of providing care for trauma victims were invaluable during the response.
Take home lessons:
Be prepared. One of the most important factors in managing a mass casualty situation in the civilian setting is to quickly and effectively organize a treatment team. No single surgeon or isolated clinical service can optimally care for the multiply injured patients. This may require close collaborations with providers who are not typically involved in trauma care. Therefore, it is essential to be well acquainted with personnel in the ED and ICU’s, in addition to members of the general, vascular and plastic surgery services prior to such an event. This existing
relationship will go a long way towards improved collaborations during times of stress. If at all possible, participate in your institution’s disaster planning so that when an event occurs, valuable time can be saved and treatment teams can be efficiently created to provide optimal, efficient, appropriate and safe care.
Stay organized. The volume of patients and uncertainty encountered during a mass casualty event can be daunting. As you can imagine the emergency room can be chaotic with dozens of patients arriving in a short period. Patients’ identity is often unknown or unclear and mis-identification can be a problem. It is important to have a clear and simple way of identifying multiple unknown patients as medical record numbers can be cumbersome and confusing. Maintain a simple list with patient names or other identifier, medical record number, injuries, pertinent medical information and any allergies if known that can be easily shared among the treatment team. We found that those most experienced in orthopaedic trauma care were best utilized in the emergency room; performing triage and prioritizing patient care pathways. Meanwhile, other orthopedic faculty performed the majority of the initial debridements and external fixation. After the event it is important to continue to circle back and have multidisciplinary rounds or meetings to continue to coordinate patient care through the sub-acute treatment phase.
Be conservative. In the heat of the moment injuries often look worse than they are. In this case, we were fortunate that the bombs utilized gunpowder and not a more potent explosive. In the recent Middle East military conflict, the improvised explosive devices (IEDs) were made with military grade explosives causing devastating injuries with extensive soft tissue trauma and
contamination. While many of the injuries treated following the marathon bombing were associated with bone loss and neurovascular injury, many of these were able to be salvaged. We focused on early debridement and boney stabilization with follow-up re-assessment by a coordinated team of vascular and plastic surgery as needed. Patients were brought back to the operating room early and often for serial wound debridements prior to definitive fixation with early flap coverage as indicated.
Have access to the right equipment. The unique medical environment of Boston with six level 1 trauma centers within a 5 mile radius allowed for a massive response to this event. At one point there were 36 operating rooms active across the city dedicated to the care of the injured bombing victims. The majority of initial cases were completion amputations, wound debridements and external fixation placement. Despite distributing the patients across the city, orthopaedic equipment, especially external fixator sets were in short supply. We had situations where the necessary pins, bars and camps were taken from one room, flash sterilized and used in another room. It would have been more beneficial to have opened one set in a centralized area and distributed the pieces to each room as needed to be sterilized and used.
The medical response to the Boston Marathon bombing was nothing short of extraordinary. The OTA should be proud of its members and their role in this mass casualty event.