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Conclusion: Perspectives on Mass Casualty Incident Management (Continued)

To develop a successful disaster response plan, the framework must be solid enough to be recognizable, strong enough to be resilient to the force of the disaster, and flexible enough to expand and contract as the need arises. The Incident Command System is such a system, and thus, essential to disaster mitigation strategies. However, to be successful, each and every member of the team and volunteer must be familiar and fluid with the concept and fluent with the language of the Incident Command System. It only takes one person to make something wrong for everyone else, so preparedness means everyone.

Part of the planning for a Mass Casualty Incident must be the ability to examine systems for weaknesses to modify them to withstand a particular challenge. The Hazard Vulnerability Analysis (HVA) and Threat and Hazard Identification and Risk Assessment (THIRA) Process provides such a took. At the same time, the related calculation of disaster capacity and capability, patient flow in hospitals and staffing levels provides the practical framework to predict responders' abilities and potential to provide sustained care.

The ability to predict the likelihood of a terrorist attack or a natural disaster is of tremendous value in assessing the resources that should be dedicated to this preparedness. The Target Risk Score (TRS), or Hazard Mapping, provides such a tool to encourage government agencies to make such dedicated commitments of funding resource, and respect. Knowledge of the types and variety of disaster scenarios allows for the planning for infrastructure, resource, and manpower to meet the challenges of each Mass Casualty Incident. From the scene management standpoint, a critical task analysis will aid in the proper deployment of resources.

Communication among the most important considerations during Mass Casualty Incidents. All obstacles can be overcome if there is a successful communication of the framework of a plan, the number and condition of the casualties, the resource needs, and the available manpower, supplies, and other resources to treat the casualties. The structures of the multiple and redundant communication systems must be developed long before the disaster occurs, however, the choices for unified communication can determine the success or failure of a plan.

During Mass Casualty Event, while the initial management may be circumscribed enough for local control, often the disaster, or the resulting cascade effects, will spiral beyond the scope of the local authorities. This situation is magnified when disaster involves WMDs, because multiple agencies, by definition, must be involved. These agencies will need coordination and oversight. Equally challenging is when as disaster impact on larger systems such as transportation or communication, requiring the input of multiple administrative bodies or organizations.

For all these reasons, and many more, the need for strong government oversight, at multiple levels, is clear. At the local level, multiagency input can create chaos. Few disasters as are restricted that they need only one type of rescue effort. More frequently, police, fire, EMS, local hospitals, and even the military can be involved. A unified command structure must be organized to coordinate the input of these various agencies.

Disasters rarely follow a predictable pattern for very long, and cascade effect will make the disaster response obsolete rapidly. The plans must be reviewed constantly. Hazard Vulnerability Analysis must be repeatedly performed, taking into account worst case scenario philosophy of disaster management. Such a philosophy is type of Murphy's Law of Disasters. If anything can go wrong, it will, and at the worst possible time. To that statement, it can be addressed that, with the situation as presented, what is the worst possible outcome. Use of this philosophy allows the plan to mutate to meet the changing needs of the Mass Casualty Incident response.

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n engl j med 368;21 nejm.org may 23, 20131958

Be Prepared — The Boston Marathon and Mass-Casualty Events Paul D. Biddinger, M.D., Aaron Baggish, M.D., Lori Harrington, M.D., M.P.H., Pierre d’Hemecourt, M.D., James Hooley, E.M.T.-P., Jerrilyn Jones, M.D., Ricky Kue, M.D., M.P.H., Chris Troyanos, A.T.C., and K. Sophia Dyer, M.D.

boston marathon and mass-casualty events

On April 15, two improvised explosive devices (IEDs) were

detonated in short succession near the finish line of the Bos­ ton Marathon, in the middle of a densely packed crowd of thou­ sands of runners, families, friends, and spectators. Three people were killed and 264 were injured,1 with more than 20 sustaining critical injuries. Yet in the face of these tragic and horrifying events, de­ spite catastrophic injuries not commonly seen in civilian medi­ cine and the fact that these were the first IEDs to cause mass inju­ ries in the United States, the over­ all medical response has generally been considered successful.2

Victims at the blast scene re­ ceived immediate, lifesaving aid. Crucial stabilization of trauma injuries was provided in the medi­ cal tent near the marathon fin­ ish line. Patients were rapidly triaged and loaded into ambu­ lances. Within 45 minutes, the last of the injured patients was transported from the scene. Each of the city’s major trauma cen­ ters received approximately equal numbers of critically injured vic­ tims. No one who was trans­ ported to a hospital died.

The fact that there was not more loss of life is attributable to more than just providence and the extraordinary skill and courage of the volunteer and pro­ fessional responders. As Keller­ mann and Peleg note in their Perspective article, the response was enabled by the medical com­ munity’s prior efforts to build and sustain emergency­prepared­ ness programs and, perhaps

most important, to practice its response in exercises and drills.

For more than a decade, emergency managers in Boston’s medical community, like those in other cities, have been refin­ ing plans for mass­casualty events. Every year, they review the liter­ ature to learn from others who have faced such events. For exam­ ple, in 2008 and 2009, Boston hosted two symposia, cospon­ sored by the Centers for Disease Control and Prevention and the Harvard School of Public Health, on planning for and responding to terrorist bombing incidents. Speakers from London, Madrid, Mumbai, and Israel shared their experiences in caring for over­ whelming numbers of patients after a mass attack and the les­ sons they had learned. The speak­ ers described common challeng­ es, such as navigating the chaos that follows an explosion and coordinating the sharing of in­ formation among responding agencies and institutions. They commented on difficulties in rap­ idly triaging patients and dis­ tributing the most severely in­ jured appropriately among area hospitals. And they stressed the operational challenges at receiv­ ing hospitals that are caused by very limited preparation time.

Boston’s emergency managers and medical leaders have used this knowledge when planning for special events such as the marathon. Because of the size and complexity of the Boston Mar­ athon, an event that each year typically produces more than 1000 medical encounters in less

than 6 hours, the Boston Athletic Association annually assembles a medical leadership team of sports, cardiovascular, and emergency medicine specialists and works with area public safety, emer­ gency management, hospital, and other officials to ensure that re­ sources are in place to handle the anticipated medical needs. Medical resources are staged in medical tents along the 26.2­ mile course and include physi­ cians, nurses, emergency medi­ cal technicians, paramedics, and other professionals.

The medical tents’ primary goals have been to provide prompt medical care to those who need it and to avoid overloading area emergency departments (EDs). Providers working in those tents have traditionally treated both minor illnesses and more serious clinical conditions such as myo­ cardial infarction, hyponatremia, and hyperthermia. Seriously ill patients are transported to area hospitals when necessary. Event planners and medical leaders have traditionally used the Bos­ ton Marathon as a “planned mass­casualty event” and have taken the opportunity to practice and test the disaster­response protocols and systems of all par­ ticipating public safety services — police, fire, emergency medi­ cal services (EMS), emergency operations, hospital disaster pre­ paredness, and state and federal partners.

When the IEDs went off, Med­ ical Tent A, located beyond the finish line, was rapidly trans­ formed from a site for delivering

n engl j med 368;21 nejm.org may 23, 2013

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1959

boston marathon and mass-casualty events

medical care for ill runners to a casualty collection point, as Jan­ gi describes in his Perspective article, where EMS personnel initiated triage, rapid treatment, and the loading of patients onto ambulances. Bystanders and vol­ unteer medical staff provided lifesaving treatments, including tourniquets to stem severe hem­ orrhage. One of the important medical lessons from military operations in Iraq and Afghani­ stan has been that early tourni­ quet use in those with blast in­ juries from IEDs dramatically reduces combat deaths from limb exsanguination.3 Although EMS personnel typically use tourniquets infrequently in civilians, Boston EMS has incorporated tourniquets and associated training into its hemorrhage­control protocol for years; more recently, it has be­ gun preparing for active­shooter mass­casualty incidents by adapt­ ing concepts from Tactical Com­ bat Casualty Care.

Immediately after the explo­ sions, Boston EMS also mobilized an extensive network of commu­ nications and other resources, calling in available private am­ bulances to supplement its own. At the Boston EMS Dispatch Op­ erations Center, a physician as­ sisted the loading officer with the distribution of the most crit­ ically ill, or “red­tagged,” patients. All ambulance transports were centrally coordinated through that center. The initial 30 red­ tagged patients were triaged, treated, and transported within 18 minutes after the explosions.

Boston’s hospitals have also learned from others’ experiences. In this era of overcrowded EDs and full hospitals, how does one rapidly create capacity to receive incoming patients? Other cities’ experiences have taught us that this problem must be addressed.

At the time of the blasts, the city’s hospital operating­room (OR) schedules were booked and most EDs were full. Massachu­ setts General Hospital (MGH) re­ ceived five critically injured pa­ tients in very rapid succession into a full ED, but after a brief period of evaluation and resusci­ tation, all five were sent to the OR, within approximately 8 min­ utes of one another. This was possible only because of preex­ isting plans that supported rapid transport of many patients who were being evaluated in the ED to inpatient f loors, where their evaluation and clinical care were continued by the inpatient hos­ pital teams, and because of plans to rapidly open multiple ORs by holding pending cases and mo­ bilizing OR personnel. In total, MGH received 31 patients in ap­ proximately 1 hour, but the hos­ pital could have accommodated even more injured victims if necessary. This response would not have been possible without prior institutional plans that an­ ticipated these needs. Just as ef­ fective trauma systems coordinate the response and contribution of myriad clinicians and special­ ists to effectively care for each patient, the hospitals’ emergency management systems had to ef­ fectively manage the response to the medical, emotional, social, and other needs of the victims.

The outcome of the medical response has been partially at­ tributed to an unusually high number of teaching hospitals and trauma centers4: Boston has 6 hospitals designated for either adult or pediatric trauma care, and all 10 of its hospitals have some affiliation with one of the three medical schools in the city. As Kellermann and Peleg indicate, other fortuitous facts also played a role — for example, the mara­

thon finish line is centrally locat­ ed, so the distances to many of the trauma centers were similar.

It’s important to recognize that the response in Boston gen­ erally followed a very carefully crafted and much­practiced set of plans and that those plans owe much to the lessons of others in the unfortunate frater­ nity of cities that have experi­ enced mass casualties from in­ tentional attacks. We believe that the speed and coordination of the response is partially attributable to reviewing other cities’ experi­ ences, adjusting our plans, and repeatedly training staff in imple­ menting those plans. In this con­ text, it seems especially unfortu­ nate that U.S. health departments, hospitals, and EMS are facing severe budget constraints, owing to cuts in federal funding that will undermine planning, train­ ing, and practice activities that have been so important in build­ ing health emergency prepared­ ness capabilities. Nonetheless, as we review our successes and fail­ ures in detail, we will endeavor, in turn, to share our findings with others.

It’s often said that disaster medicine is a team effort. But we must sustain our focus as a nation to examine experiences together, plan together, and train together if we are to truly say that we’re learning the lessons of others and improving our ability to respond.

Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.

From Massachusetts General Hospital and Harvard Medical School (P.D.B., A.B.); the Harvard School of Public Health (P.D.B.); Boston EMS, Police, and Fire (L.H., J.H., J.J., R.K., K.S.D.); Boston Medical Center and Boston University School of Medicine (L.H., J.J., R.K., K.S.D.); the Boston Athletic Association (A.B., P.H., C.T., K.S.D.); and the Boston Public Health Commission (J.H.) — all in Boston.

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n engl j med 368;21 nejm.org may 23, 20131960

This article was published on May 1, 2013, at NEJM.org.

1. Kotz D. After double checking records, injury toll from bombs reduced to 264. Bos- ton Globe. April 24, 2013:B3. 2. Gawande A. Why Boston’s hospitals were ready. The New Yorker. April 17, 2013 (http://

www.newyorker.com/online/blogs/newsdesk/ 2013/04/why-bostons-hospitals-were-ready .html?printable=true&currentPage=all#ixzz 2QwMjfM13). 3. Kragh JF Jr, Littrel ML, Jones JA, et al. Battle casualty survival with emergency tour- niquet use to stop limb bleeding. J Emerg Med 2011;41:590-7.

4. Cheney K. ‘Medical mecca’ Boston was equipped for mass trauma. POLITICO.com. April 18, 2013 (http://www.politico.com/ story/2013/04/boston-medical-mecca- equipped-for-mass-trauma-90228.html).

DOI: 10.1056/NEJMp1305480

Copyright © 2013 Massachusetts Medical Society.

boston marathon and mass-casualty events

We Fight Like We Train Eric Goralnick, M.D., and Jonathan Gates, M.D.

As we say in the U.S. Navy, “We train like we fight, and

we fight like we train.” In Bos­ ton, we do the same.

That was never more evident than at 2:50 p.m. on April 15, when two explosive devices abrupt­ ly shattered the 117th Boston Marathon. On Patriot’s Day, the day we commemorate the open­ ing battle of the Revolutionary War in Lexington and Concord, Boston was under attack.

Over the past 8 years, Brigham and Women’s Hospital (BWH) has activated the emergency re­ sponse team on 78 occasions. We have activated it for both real­ world events and drills based on a wide array of scenarios — chemical attacks, oil spills, train crashes, blizzards, and building evacuations. Eight times we prac­ ticed mass­casualty drills simu­ lating the human fallout from bombings, aircraft accidents, and “active shooters,” such as those at Sandy Hook, Connecticut, and Aurora, Colorado. These drills have been departmental, hospital­ wide, city wide, and statewide. They taught us familiarity, com­ fort, trust, and routines. On April 15, these routines saved lives.

At 8 a.m., in accordance with our annual Patriot’s Day protocol, our emergency management direc­ tor opened the hospital’s Emer­ gency Operations Center.

At 2:49 p.m., the nurse in

charge of Alpha Pod (one of four separate 14­bed pods, all within the larger emergency department [ED]) conducted a scan of our 55­bed ED. It was full: 47 patients in beds, 6 in the hallway, 6 in the waiting room, and 4 in the tri­ age area.

One floor below the ED, our perioperative nurse administrator reviewed his caseload: 30 of 42 operating rooms (ORs) were ac­ tive, with 8 more available for the 4 patients waiting in the pre­ operative area. An additional 15 elective cases remained on the schedule for that busy Monday.

At 2:50 p.m., reports of an ex­ plosion came over the Boston Fire and emergency medical services radio frequency.

At 2:54 p.m., the Central Med­ ical Emergency Direction Center hotline rang in Alpha Pod, re­ porting two explosions and in­ coming patients. The lead emer­ gency medicine (EM) physician in Alpha Pod, recalling her expe­ riences in Haiti after the 2010 earthquake and as incident com­ mander during a practice drill for responding to mass casualties from a bomb in March 2011, huddled with the nurse in charge of Alpha Pod and the emergency management director. This team quickly assessed the crowded de­ partment and prepared to receive victims; their first task was to clear the ED of current patients.

The Boston Public Health Commission’s Medical Informa­ tion Center called; BWH would be receiving 8 patients from the scene. The team initiated Code Amber, our hospital­wide disaster response.

A senior EM resident who had attended a disaster­management training session in October 2012 reminded the team to consider the possibility of a hazardous­ material (HAZMAT) threat.

As reports trickled in — that there was a fire at the John F. Kennedy Library across town, that other devices had been found — the emergency management director recalled the 2008 Mum­ bai attacks, in which a mass shooting was followed by an at­ tempted assault on the hospital where victims were sent. He di­ rected security to lock down the hospital and open the HAZMAT decontamination unit.

In Alpha Pod, the chief of the Division of Medical Psychiatry co­ ordinated the placement of 8 pa­ tients awaiting psychiatric beds by transferring them to our surge pod or to McLean Hospital in Belmont. He spoke with every psy­ chiatric patient, calmed one pa­ tient who believed the unfolding events were his own delusion, and collaborated with social workers to identify the psychosocial needs of patients and their families.

Teams of internal medicine

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