Eric Goralnick

The initial response to the Boston marathon bombing: lessons learned to prepare for the next disaster.

Objective:We discuss the strengths of the medical response to the Boston Marathon bombings that led to the excellent outcomes. Potential shortcomings were recognized, and lessons learned will provide a foundation for further improvements applicable to all institutions. Background:Multiple casualty incidents from natural or man-made incidents remain a constant global threat. Adequate preparation and the appropriate alignment of resources with immediate needs remain the key to optimal outcomes. Methods:A collaborative effort among Bostons trauma centers (2 level I adult, 3 combined level I adult/pediatric, 1 freestanding level I pediatric) examined the details and outcomes of the initial response. Each center entered its respective data into a central database (REDCap), and the data were analyzed to determine various prehospital and early in-hospital clinical and logistical parameters that collectively define the citywide medical response to the terrorist attack. Results:A total of 281 people were injured, and 127 patients received care at the participating trauma centers on that day. There were 3 (1%) immediate fatalities at the scene and no in-hospital mortality. A majority of the patients admitted (66.6%) suffered lower extremity soft tissue and bony injuries, and 31 had evidence for exsanguinating hemorrhage, with field tourniquets in place in 26 patients. Of the 75 patients admitted, 54 underwent urgent surgical intervention and 12 (22%) underwent amputation of a lower extremity. Conclusions:Adequate preparation, rapid logistical response, short transport times, immediate access to operating rooms, methodical multidisciplinary care delivery, and good fortune contributed to excellent outcomes.

The Boston Marathon Bombing: After-Action Review of the Brigham and Women’s Hospital Emergency Radiology Response

PURPOSE To analyze imaging utilization and emergency radiology process turnaround times in response to the April 15, 2013, Boston Marathon bombing in order to identify opportunities for improvement in the Brigham and Womens Hospital (BWH) emergency operations plan. MATERIALS AND METHODS Institutional review board approval was obtained with waivers of informed consent. Patient demographics, injuries, and outcomes were gathered, along with measures of emergency department (ED) imaging utilization and turnaround times, which were compared with operations from the preceding year by using the Wilcoxon rank sum test. Multivariate linear regression was used to assess contributors to examination cancellations. RESULTS Forty patients presented to BWH after the bombing; 16 were admitted and 24 were discharged home. There were no fatalities. Ten patients required emergent surgery. Blast injury types included 13 (33%) primary, 20 (51%) secondary, three (8%) tertiary, and 19 (49%) quaternary. Thirty-one patients (78%) underwent imaging in the ED; 57 radiographic examinations in 30 patients and 16 computed tomographic (CT) examinations in seven patients. Sixty-two radiographic and 14 CT orders were cancelled. Median time from blast to patient arrival was 97 minutes (interquartile range [IQR], 43-139 minutes), patient arrival to ED examination order, 24 minutes (IQR, 12-50 minutes), order to examination completion, 49 minutes (IQR, 26-70 minutes), and examination completion to available dictated text report, 75 minutes (IQR, 19-147 minutes). Examination completion turnaround times were significantly increased for radiography (52 minutes [IQR, 26-73 minutes] vs annual median, 31 minutes [IQR, 19-48 minutes]; P = .001) and decreased for CT (37 minutes [IQR, 26-50 minutes] vs annual median, 72 minutes [IQR, 40-129 minutes]; P = .001). There were no significant differences in report availability turnaround time (75 minutes [IQR, 19-147 minutes] vs annual median, 74 minutes [IQR, 35-127 minutes]; P = .34). CONCLUSION The surge in imaging utilization after the Boston Marathon bombing stressed emergency radiology operations. Process analysis enabled identification of successes and opportunities for improvement in ongoing emergency operations planning.

We fight like we train.

In recent years, Brigham and Womens Hospital has activated its emergency response team for many drills that taught staff familiarity, comfort, trust, and routines during a disaster. After the Boston Marathon bombing, when the hospital treated 39 survivors, routines saved lives.

The Boston Marathon Bombings Mass Casualty Incident: One Emergency Department’s Information Systems Challenges and Opportunities

Emergency department (ED) information systems are designed to support efficient and safe emergency care. These same systems often play a critical role in disasters to facilitate real-time situation awareness, information management, and communication. In this article, we describe one EDs experiences with ED information systems during the April 2013 Boston Marathon bombings. During postevent debriefings, staff shared that our ED information systems and workflow did not optimally support this incident; we found challenges with our unidentified patient naming convention, real-time situational awareness of patient location, and documentation of assessments, orders, and procedures. As a result, before our next mass gathering event, we changed our unidentified patient naming convention to more clearly distinguish multiple, simultaneous, unidentified patients. We also made changes to the disaster registration workflow and enhanced roles and responsibilities for updating electronic systems. Health systems should conduct disaster drills using their ED information systems to identify inefficiencies before an actual incident. ED information systems may require enhancements to better support disasters. Newer technologies, such as radiofrequency identification, could further improve disaster information management and communication but require careful evaluation and implementation into daily ED workflow.

Radiologic Features of Injuries From the Boston Marathon Bombing at Three Hospitals

OBJECTIVE The aim of this study is to describe the radiologic imaging findings of primary, secondary, tertiary, and quaternary blast injuries in patients injured in the Boston Marathon bombing on April 15, 2013. MATERIALS AND METHODS A total of 43 patients presenting to three acute care hospitals and undergoing radiologic investigation within 7 hours of the time of the bombing on April 15, 2013, were included in this study. The radiographic and CT features of these patients were evaluated for imaging findings consistent with primary, secondary, tertiary, and quaternary blast injury. RESULTS There were no pulmonary or gastrointestinal manifestations of the primary blast wave on imaging. Secondary blast injuries identified on imaging included a total of 189 shrapnel fragments identified in 32 of the 43 patients. The shrapnel was identified most often in the soft tissues of the leg (36.5%), thigh (31.2%), and pelvis (13.2%). Imaging identified 125 ball bearings, 10 nails, one screw, 44 metal fragments, and nine other (gravel, glass, etc.) foreign bodies. CONCLUSION Injuries from the Boston Marathon bombing were predominantly from the secondary blast wave and resulted in traumatic injuries predominantly of the lower extremities. The most common shrapnel found on radiologic evaluation was the ball bearing.

Terrorist Bombings: Foreign Bodies from the Boston Marathon Bombing

On April 15, 2013, 2 improvised explosive devices detonated at the 117th Boston Marathon, killing 3 people and injuring 264 others. In this article, the foreign bodies and injuries that presented at 2 of the responding level 1 trauma hospitals in Boston-Brigham and Women׳s Hospital and Massachusetts General Hospital--are reviewed with a broader discussion of blast injuries and imaging strategies.

Leadership During the Boston Marathon Bombings: A Qualitative After-Action Review.

OBJECTIVE On April 15, 2013, two improvised explosive devices (IEDs) exploded at the Boston Marathon and 264 patients were treated at 26 hospitals in the aftermath. Despite the extent of injuries sustained by victims, there was no subsequent mortality for those treated in hospitals. Leadership decisions and actions in major trauma centers were a critical factor in this response. METHODS The objective of this investigation was to describe and characterize organizational dynamics and leadership themes immediately after the bombings by utilizing a novel structured sequential qualitative approach consisting of a focus group followed by subsequent detailed interviews and combined expert analysis. RESULTS Across physician leaders representing 7 hospitals, several leadership and management themes emerged from our analysis: communications and volunteer surges, flexibility, the challenge of technology, and command versus collaboration. CONCLUSIONS Disasters provide a distinctive context in which to study the robustness and resilience of response systems. Therefore, in the aftermath of a large-scale crisis, every effort should be invested in forming a coalition and collecting critical lessons so they can be shared and incorporated into best practices and preparations. Novel communication strategies, flexible leadership structures, and improved information systems will be necessary to reduce morbidity and mortality during future events.

Sign Me Up: Rules of the Road for Humanitarian Volunteers During the Ebola Outbreak

The current Ebola outbreak is the worst global public health emergency of our generation, and our global health care community must and will rise to serve those affected. Aid organizations participating in the Ebola response must carefully plan to carry out their responsibility to ensure the health, safety, and security of their responders. At the same time, individual health care workers and their employers must evaluate the ability of an aid organization to protect its workers in the complex environment of this unheralded Ebola outbreak. We present a minimum set of operational standards developed by a consortium of Boston-based hospitals that a professional organization should have in place to ensure the health, safety, and security of its staff in response to the Ebola virus disease outbreak.

Effectiveness of Instructional Interventions for Hemorrhage Control Readiness for Laypersons in the Public Access and Tourniquet Training Study (PATTS): A Randomized Clinical Trial

Importance Several national initiatives have emerged to empower laypersons to act as immediate responders to reduce preventable deaths from uncontrolled bleeding. Point-of-care instructional interventions have been developed in response to the scalability challenges associated with in-person training. However, to our knowledge, their effectiveness for hemorrhage control has not been established. Objective To evaluate the effectiveness of different instructional point-of-care interventions and in-person training for hemorrhage control compared with no intervention and assess skill retention 3 to 9 months after hemorrhage control training. Design, Setting, and Participants This randomized clinical trial of 465 laypersons was conducted at a professional sports stadium in Massachusetts with capacity for 66 000 people and assessed correct tourniquet application by using different point-of-care interventions (audio kits and flashcards) and a Bleeding Control Basic (B-Con) course. Non-B-Con arms received B-Con training after initial testing (conducted from April 2017 to August 2017). Retesting for 303 participants (65%) was performed 3 to 9 months after training (October 2017 to January 2018) to evaluate B-Con retention. A logistic regression for demographic associations was performed for retention testing. Interventions Participants were randomized into 4 arms: instructional flashcards, audio kits with embedded flashcards, B-Con, and control. All participants received B-Con training to later assess retention. Main Outcomes and Measures Correct tourniquet application in a simulated scenario. Results Of the 465 participants, 189 (40.7%) were women and the mean (SD) age was 46.3 (16.1) years. For correct tourniquet application, B-Con (88% correct application [n = 122]; P < .001) was superior to control (n = 104 [16%]) while instructional flashcards (n = 117 [19.6%]) and audio kit (n = 122 [23%]) groups were not. More than half of participants in point-of-care arms did not use the educational prompts as intended. Of 303 participants (65%) who were assessed 3 to 9 months after undergoing B-Con training, 165 (54.5%) could correctly apply a tourniquet. Over this period, there was no further skill decay in the adjusted model that treated time as either linear (odds ratio [OR], 0.98; 95% CI, 0.95-1.03) or quadratic (OR, 1.00; 95% CI, 1.00-1.00). The only demographic that was associated with correct application at retention was age; adults aged 18 to 35 years (n = 58; OR, 2.39; 95% CI, 1.21-4.72) and aged 35 to 55 years (n = 107; OR, 1.77; 95% CI, 1.04-3.02) were more likely to be efficacious than those older than 55 years (n = 138). Conclusions and Relevance In-person hemorrhage control training for laypersons is currently the most efficacious means of enabling bystanders to act to control hemorrhage. Laypersons can successfully perform tourniquet application after undergoing a 1-hour course. However, only 54.5% retain this skill after 3 to 9 months, suggesting that investigating refresher training or improved point-of-care instructions is critical. Trial Registration ClinicalTrials.gov Identifier: NCT03479112

An active shooter in our hospital

On Jan 20, 2015, at about 11 am, a gunman deliberately shot and killed a gifted young cardiac surgeon in our hospital. Michael Davidson, aged 44, director of endovascular cardiac surgery at Brigham and Women’s Hospital (Boston, MA, USA), was shot twice by the assailant, who then turned his weapon on himself, with similarly fatal consequences. In the immediacy of the moment, several staff members, without knowing whether the shooter was still at large, tended to their stricken colleague and transported him rapidly to the emergency department, while others systematically secured themselves and patients in various rooms—doors closed and locked, furniture moved to barricade. It is impossible to know whether lives were saved by the responses of our staff in the area, but the tenet of our active shooter preparation was singular— we cannot ever fully prevent such occurrences, but we can, and must, prepare for them. Mass shootings in Aurora, CO, Newtown, CT, Washington DC Navy Yard, Los Angeles International Airport, and more recently the Charlie Hedbo shootings in Paris, have shown the potential of a so-called active shooter to inflict devastating loss of life. The United States Department of Homeland Security (DHS) defines an active shooter as “an individual actively engaged in killing or attempting to kill people in a confi ned and populated area.” Active shooter is a specifi c term used by law enforcement to describe a shooting in progress where law enforcement personnel and bystanders have the potential to affect the outcome of the event. The random, violent and short-lived nature of these events makes management by public safety responders a challenge. Hospital shootings are rare, but health-care personnel are more at risk of violent acts than most of them suspect. From 2000 to 2011, there were 154 hospital-related shootings in the USA, 60% of which were inside the hospital and the remainder on hospital grounds. Shootings happened in 40 US states, with 235 people injured or killed. Active shooter events are even rarer; only four such events occurred at health-care facilities between 2000 and 2013. Of those four events, two shooters committed suicide at the scene, paralleling our event. At Brigham and Women’s Hospital, our focus has shifted to recovery, supporting the grieving, and aiding the healing process that allows those affected by the events to begin to navigate the path to a new normal. A hospital is a place of healing, sanctuary, and comfort, both for those who seek care and those who provide it. A place of healing must welcome its community openly with warmth, but must also promise safety and security. Our after-action review of the shooting, designed to examine individual and collective responses and identify opportunities for improvement, is well underway. But, in preparing for the future, we will leave no stone unturned. We have commissioned a nationally regarded security firm to help us to design the best solution to the irreconcilable conflict between ensuring accessibility for our community and preventing a person or object capable of inflicting violence from entering. We cannot, with certainty, prevent, but we can certainly anticipate and prepare.