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Boston Marathon: Horror, heroism, and takeaways for hospitals

April 21, 2014

    Dan Diamond, Managing Editor

    Even a year later, it's hard to find words to accurately capture last spring's terrible events at the Boston Marathon.

    On the one hand, the day's horror is still fresh when looking at photos of wounded spectators or reading interviews with the surgeons who saved them. At the same time, there's already been so much coverage, and the Daily Briefing team discussed how best to sensitively cover the anniversary.

    Health care providers say there's an important message that resonates in the community—a message that still needs to get out. Through providers' focus and perseverance, and bystanders who bravely became first responders, many critically injured patients were saved.

    In the days after the marathon tragedy, doctors and hospital staff who lived through the week's events began to share their lessons: How they responded, why so many injured spectators survived the day, and what they hope providers will know to do differently. We captured some of those takeaways in articles for the Daily Briefing, and in several cases, spoke directly with participants.

    Drawing on those interviews and considerable secondary research (sources are here), here's how those days in Boston unfolded, in the words of the patients and providers who lived through it.

    Monday, April 15, 2013: Boston's Copley Square

    Table of contents
    • Copley Square
    • Tragedy at the finish line
    • Hospitals react
    • Unexpected logistics
    • Stabilizing patients
    • Coping with altered lives

    For some medical personnel, volunteering to work in the Marathon's medical tent is as much of a tradition as running the race is for some athletes. In the hours before the race began, staff gathered in the medical tent—which is by the finish line—to game plan for the day.

    Dr. Jeff Brown, Harvard Medical School psychologist working in the medical tent: The medical staff had a [morning] meeting. We talked about protocols. We spent a lot of time talking about weather, since the weather often is related to the types of problems we'll see.

    Dr. Martin Levine, family physician working in the medical tent: We were ready for people who have a sudden hypernatremia or cardio event that can be lethal.

    Dr. Jeff Brown, medical tent: The general feeling was that it was going to be a beautiful spring day and a pretty easy day for us working in the medical tent because it seemed so great for runners.

    Meanwhile, Boston's hospitals were bracing for an uptick in patients—but nothing out of the ordinary for race day.

    Kate Walsh, CEO, Boston Medical Center: It was a quasi-holiday. Every hospital emergency room gears up with additional staff, in case people run further than they were ready for, or spectators have problems in the heat. There's always more volume on [Marathon] Monday.

    2:49 p.m.: Tragedy at the finish line

    About four hours after the Marathon began for many non-elite runners, a pair of improvised explosive devices went off on Boylston Street, the first by the finish line of the race and another explosion 13 seconds later and about one-quarter mile away. Almost 300 people were injured by the explosions, mostly spectators watching the race.

    Dr. Jeff Brown, medical tent: I was talking with [a runner] who also had a lot of cramping. He was in pain and grimacing. And that's when we heard the explosion. I've heard cannons and fireworks at parades and other celebrations, but this was just different. The folks in the tent just knew.

    Jeff Bauman, spectator: And then I heard it. The explosion. Not like a bomb in a movie, not a big bang, but three pops, one after the other.

    Dr. Sushrut Jangi, medical tent: My ears were ringing, and then — a long pause. Everyone in the tent stopped and looked up. A dehydrated woman grabbed my wrist. 'What was that' she cried. 'Don't leave.' I didn't move. John Andersen, a medical coordinator, took the microphone. 'Everybody stay with your patients,' he said, 'and stay calm.'

    Jeff Bauman, spectator: It doesn’t get hazy after that. It gets very clear. The hospital psychiatrist later told me that my brain “lit up,” that at the moment the bomb went off my brain became hyper-alert, so that even though my memories are fragmented into hundreds of pieces, all the pieces are clear.

    After the explosion, volunteers in the medical tent began springing into action, even as dazed spectators tried to make sense of the horror that had just happened.

    Dr. Martin Levine, medical tent: About two dozen people [were] lying on the sidewalk. As a doctor, I look for abnormal symmetry, and I noticed immediately that people were lying in heaps, their legs either blown off, severely wounded or deformed completely.

    Jeff Bauman, spectator: I looked down. There was nothing below my knees. I was sitting in a chunky pool of blood—my blood—and my lower legs were gone.

    Dr. Sushrut Jangi, medical tent: I almost fled, thinking there might be more bombs nearby. There was an exit onto Dartmouth Street, where the crowds were swiftly moving away. But from within the tent I heard Andersen's voice, an echo of my own conscience: “All medical personnel stay with your patients.”

    John Odom, a spectator visiting from California, suffering massive injuries to his leg and brain trauma. Using a belt, his son-in-law applied a tourniquet and Odom's family begged him to stay awake as he bled out on Boylston Street.

    John Odom: I believed at that point in time that that was where I was going to die. Right there. And I was okay with that if that was my time to go.

    Meanwhile, providers in the medical tent—confronting the reality of the situation—were improvising with the materials they had. And physicians in the crowd—or running in the race—unexpectedly found themselves as first responders.

    Dr. Martin Levine, medical tent: We asked people for their belts. We took off the lanyards we used for credentials and tied them around people’s legs.

    Dr. Natalie Stavas, pediatric physician who was running in the marathon: The police started to barricade the road…I jumped over one of the barricades, and I sprinted toward Boylston Street. The police were yelling at me, saying 'Ma'am, you can't go, you can't go!' I outmaneuvered a few of them.

    Dr. John Cowin, an orthopedic surgeon visiting from Florida: Thirty years ago, I was in the air force in a MASH type unit. You train all the time for something like this in the service. When I crossed the street, I thought, This looks like a drill, but there was blood everywhere and people lying around, moaning. The first person I saw had his leg blown off mid-thigh.

    Dr. Natalie Stavas: When I arrived, I saw the carnage and thought, Oh my God, this can't be happening…[But] for the chaos, the people doing medical care knew what they were doing and were coming to people's aid very quickly. People were doing CPR, tourniqueting legs, applying pressure to wounds, and carrying victims away from the scene at superhuman speed.

    In the medical tent, the volunteers were moving rapidly to stabilize patients and get them to properly equipped facilities.

    Dr. Allen Panter, an emergency physician visiting from Georgia: All in all, it was a pretty controlled environment [in the medical tent]. I’ve seen a lot worse. They were without question ready—not ready for those type of injuries, but they were prepared.

    Dr. Jeff Brown, medical tent: The police wanted to get the tent emptied as quickly as possible. They wanted to sweep the medical tent. Terrorists target the vulnerable, and the medical tent was a vulnerable spot. People were wheeled in and were given a number based on the severity of their injury—1, 2, 3—and then were evacuated.

    Hospitals react to a day unlike any other

    As pagers began to blare and word spread, staff at nearby hospitals were startled into action. Unlike most mass casualty events and practice drills, hospital staff had almost no warning that a deluge of patients were incoming.

    Dr. Ron Medzon, emergency physician at Boston Medical Center: We have a disaster radio that goes off, and we’re supposed to get some sort of notification, but there was such chaos at the scene that all we really got was the notification that there had been an explosion. We just tried to get ready as fast as we could. We had no idea what was coming.

    Dr. Robert Osgood, ED chief at Tufts Medical Center: There was sort of this beat where everybody in the emergency department ... stopped for a second. [E]verybody looked at me and said, 'Is this another one of your crazy drills?' and the first thing I said was, 'No, this is not a drill. This is for real.'

    Deb Mulloy, OR nurse at Brigham & Women's: We just knew this was real…and a lot of people could be hurt.

    Dr. David King—an Army veteran—had finished the marathon about an hour before. On the way home in a cab, he started getting cryptic texts that there had been an explosion.

    Dr. David King, trauma surgeon at Massachusetts General Hospital: I dropped the family off and went straight to the hospital. I still had my bib on. I took a banana with me.

    All told, more than 180 injured people were triaged away from Copley Square. Thirty-one were initially taken to Brigham & Women's Hospital, 29 more were routed to Mass General, and dozens of others ended up at Boston Medical Center, Beth Israel Deaconess, Tufts Medical Cener, and a half-dozen other hospitals across the city.

    Click to expand the map.

    Boston hospitals respond to Marathon bombingsDr. Ron Medzon, emergency physician at Boston Medical Center: It was just one after another after another. Every single person had a limb-threatening injury, a life-threatening injury. And I think 20 people came in over 40 minutes, which is just incredible.

    Dr. Atul Gawande, a Brigham & Women's surgeon who wrote about the day for the New Yorker: One emergency physician told me he’d never heard so many ambulance sirens before in his life.

    Joseph Bellabona, nurse manager at Boston Medical Center: Patients were bloody and in shock physiologically and psychologically. [T]hey had multiple shrapnel wounds and were being treated as though they had just been removed from the front lines of a war zone in Bosnia, Iraq or Afghanistan; instead, unbelievably, they were coming from only a few miles away in Boston’s Copley Square.

    Dr. Ron Medzon: I got my patient stabilized and just started running from patient to patient to make sure that everyone else was also getting the attention they needed. And every single patient had at least two or three super-competent, compassionate people working on them.

    Dr. David King, trauma surgeon at  Massachusetts General Hospital: I arrived in a cab at the hospital within 30 seconds of the first patient. I looked at the first five patients coming in…[and] I recognized the pattern of injury—this multiple fragmentation, bilateral lower-extremity blast. The injury patterns were the same thing I’d seen in Iraq and Afghanistan.

    Dr. David Mooney, trauma director at Boston Children's Hospital: We found BBs inside of kids. We found nails that looked almost like carpet tacks, maybe a centimeter long that were sticking out of a kid’s body.

    Logistics, surprises prove challenging

    Dr. Eric Goralnick, medical director of emergency preparedness at Brigham & Women's Hospital: [The] influx of patients sort of overwhelmed our standard registration services. It was taking too long to get them into the computer.

    Kate Walsh, CEO at Boston Medical Center: Something we learned, given the scope of the tragedy. Having strong patient and family support was absolutely essential to managing the crowds.

    Some patients were brought in with incorrect or misleading personal information, such as one woman who was taken to Mass General with the handbag of a woman who had died at the scene.

    Dr. Alasdair Conn, chief of emergency medicine at Mass General: They looked roughly the same, and so, in the hurry of the moment, we said, 'Oh, she must be this person.' And that was incorrect.

    As a result, the deceased woman's family came to Mass General, expecting to find their loved one alive—but instead suffered a "devastating" surprise when they later learned that she was already gone, Conn regretfully remembers.

    At Tufts Medical Center, a bomb scare forced an evacuation of the emergency department in the middle of treating patients.

    Dr. Reuven Rabinovici, trauma chief at Tufts Medical Center: We had to roll all the patients out of the emergency room, in the middle of caring for these patients. Police came with bomb-sniffing dogs, and they pretty much locked the hospital down.

    As a result, the emergency department was forced to reconvene in the hospital lobby—and there's a lesson to be learned from the experience, Rabinovici says.

    Rabinovici You have to identify an alternative place which has a minimum amount of glass, of course, if there is an explosion, and make sure that the flow continues uninterrupted.

    Meanwhile, with cell phone service down, but legal restrictions like sharing patient information still in place, hospital staff wrestled with how to reconnect families that had been split up and routed to different facilities—especially because some media were representing themselves as family members of the victims.

    Kate Walsh, CEO at Boston Medical Center: I don't know how you suspend HIPAA, in the center of all of this media scrutiny, but it was really a challenge.

    In some cases, Walsh reached out to help patients find their loved ones by using her personal connections with other administrators.

    Stabilizing patients, coping with the emotional distress

    Altogther, 16 people injured in the Marathon explosions suffered amputations.

    Dr. George Velmahos, chief of trauma surgery at Massachusetts General Hospital: Almost all of them had such severe trauma in their lower extremity that it was beyond salvation...I would consider them almost automatic amputees. We just completed what the bomb had done.

    Joseph Blansfield, program manager for the trauma center at Boston Medical Center: Tourniquets are a difference maker. Tourniquets can save a life. They proved their value [at the Marathon].

    Dr. David King, trauma surgeon at Massachusetts General Hospital: [At 2 a.m.], I took a break from surgery. I had been operating all night and hadn’t had anything to eat or drink except for that banana since the race.

    Kate Walsh, CEO at Boston Medical Center: All the hospitals did extremely well. If it had happened anywhere else in the world, many, many more people would've died.

    Maureen Martinez, nurse at Massachusetts Eye and Ear: When I got home, it was my family that really told me what was going on. That’s when I allowed myself to cry.

    Almost immediately after receiving word of the bombing, leaders of local rehab programs began preparing for an influx of patients who would need new limbs and onging therapy.

    David Crandell, inpatient medical director for the amputee program at Spaulding Rehabilitation Hospital: We’re not first responders. We’re not even second responders. But we were going to need to respond in a way the other places didn’t.

    On Friday, Boston issued a citywide shelter-in-place after a chaotic shootout between the bombinb suspects and police.

    Kate Walsh, CEO at Boston Medical Center: The shelter-in-place was a much harder day [than the Marathon] for how you run a hospital. No one could come and no one could leave. People were literally sitting there doing nothing. I know from a trip for Israel, this is what they drill the most: People not being able to be in touch with their families. And we're going to drill on this moving forward.

    While some patients were promptly stabilized, John Odom was in critical condition for several days—at one point, his heart stopped from blood loss—and underwent 11 surgeries in one month. Eventually, he was transferred to Spaulding Rehabilitation Hospital.

    John Odom, patient at Spaulding Rehabiliation Hospital: I said 'my goals are to walk, to be able to dance with my wife and to play golf.' I had to learn how to go to the bathroom, brush my teeth, comb my hair.

    Patients and providers cope with altered lives, PTSD

    Erika Brannock, spectator and survivor: On February 5, I had my 18th surgery since Boston…It’s looking good. My surgeon’s really happy with how it’s healed, and I can start getting back up and walking again.

    As the living symbols of "Boston Strong," several survivors found themselves the center of media attention for months to come, invited to attend as the guests of honor at sporting events and other local events.

    Jeff Bauman, spectator and survivor: It was tough for me to do that stuff. The Bruins game was tough. The first one you know I did and I was in my chair and I waved the flag and I didn’t realize that it was going to be that intense. It was like as soon as you go out on the ice, it’s just so many people cheering, and I was a little scared and so I was like, oh that’s good, I’m kind of glad its over, that was too intense for me. … The second time, I had just gotten my prosthetics and I was standing and a lot of people wanted to see me stand and I understand but I was so nervous, I was like I don’t want to do it, I’m going to fall. I’m going to go out there and fall. And I was just really scared to do it. But my mom forced me to do it. She was like you gotta go out there you gotta show everyone you’re up and you’re standing and I was like okay, alright, I will, I will.

    One study led by Alicia Quesnel has followed 93 patients who suffered ear injuries in last year's bombing.

    Dr. Alicia Quesnel, an ear specialist at Mass Eye and Ear and Harvard Medical School: Unfortunately for many of them, even if the hearing has improved, the tinnitus [ringing in the ears] seems to be a persistent problem.

    Meanwhile, many providers—even a year later—find themselves still affected by the week's events, oftentimes in surprising ways.

    Dr. Pierre Rouzier, volunteer in the medical tent in 2013: [Now] I hear noises. I don’t want to flee, I want to see who needs help. 

    Dr. Ron Medzon, emergency physician at Boston Medical Center: It stays with me. It’s not on a day-to-day basis, but once in a while, especially the staff I worked with that day will start talking about it, and all of a sudden I feel this constriction in my throat. Tears kinda start to well up, and I realize that I’m certainly not over it.

    Sources: Daily Briefing interviews; Grush, Fox News, 4/18/13; Gawande, New Yorker, 4/17/13; CBS, "This Morning," 4/15/13; WBUR, 4/16/13; WBUR, 4/16/14; WBUR; 4/14/14; Kowalczyk, Boston Globe, 7/27/13; Smith, "Shots," NPR, 9/19/13; Runner's World, July 2013; Jangi, NEJM, 4/23/13; Kime, Army Times, 4/28/13; Montgomery et al.,Washington Post, 4/16/13; Vautour, Gazette/UMass, 4/18/14; Lazar et al.,Boston Globe, 4/15/13; Lazar and Schweitzer, Boston Globe, 4/14/14.

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