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Marathon Day at Massachusetts General FREE

Alasdair Conn, MD
[+] Article, Author, and Disclosure Information

This article was published at www.annals.org on 30 April 2013.

From Massachusetts General Hospital, Boston, Massachusetts.

Potential Conflicts of Interest: None disclosed. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M13-1008.

Requests for Single Reprints: Alasdair Conn, MD, Massachusetts General Hospital, 55 Fruit Street, Founders 114, Boston, MA 02114; e-mail, aconn@partners.org.

Author Contributions: Conception and design: A. Conn.

Drafting of the article: A. Conn.

Critical revision of the article for important intellectual content: A. Conn.

Final approval of the article: A. Conn.

Administrative, technical, or logistic support: A. Conn.

Ann Intern Med. 2013;159(2):143-144. doi:10.7326/0003-4819-159-2-201307160-00648
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We thought it would be a normal Marathon Monday at Massachusetts General Hospital (MGH). The Boston Marathon is always held on the third Monday in April and is a public holiday—Patriot's Day. All state offices are closed, together with many businesses; but for hospitals, it is a regular working day. The MGH normally expects to receive about 15 to 20 marathon runners with hyponatremia and dehydration, many more are treated at the medical tents along the route of the marathon. For many this is a day that Bostonians look forward to each year as the unofficial start of spring.

It was not to be. At 2:50 p.m., an explosion rocked the area near the finish line, closely followed 11 seconds later by a second blast. Two minutes later, Boston EMS initiated a hospital ringdown; they contacted all of the Boston hospitals requesting disaster capability. Our answer is always the same; we have immediate capacity for 10 critical patients, 20 seriously injured, and we can accept unlimited “walking wounded.” I was paged as soon as the radio call came in; at this time we had no idea of the potential number of injured patients or of their severity. I looked at the current ED census—we were full and had 1 open stretcher bay in the entire department.

The first patient arrived without entry notification at 3:04 p.m. by private vehicle; the patient was female and had sustained a traumatic amputation of one of her legs together with multiple other injuries. Two minutes later, a police van arrived with 2 additional patients—both also had traumatic lower extremity amputations, again there had been no time for entry notification. We activated our Hospital Incident Command System (HICS). Simultaneously, several hundred MGH staff received a phone call to their home and work, a message was also sent to their pagers, e-mail, and cell phone alerting them of the need to respond to disaster stations. The response from all staff was immediate and coordinated. Within minutes, the ED was vacated and rooms stocked in preparation for the arrival of further victims. Disaster packs, one for each expectant patient, were opened, enabling us to identify patient by prearranged medical record numbers. Preprinted wrist bands with the bar codes on them were attached to all disaster patients upon ED arrival. (We use scanned bar codes for patient identification.) Eight critical patients arrived to the hospital within 30 minutes of the explosion. Among the first was the patient who arrived pulseless; she had already exsanguinated. IVs were started; she was given 4 units of uncrossed blood and, with her blood pressure restored, was transferred immediately to the operating room. Over the next few minutes 5 other patients—3 with traumatic amputations—were also resuscitated and sent to the operating room; at that time we had positive identification on 1 of these 6 patients. More patients, albeit less severely injured, followed them to the operating room over the next 2 to 3 hours. The MGH treated 31 patients that day; several more arrived over the subsequent 24 to 48 hours.

Unfortunately, 3 patients died at the scene of the explosions; miraculously all of the patients who were transferred to hospitals survived. There will be further debriefings over the next few weeks—several factors undoubtedly contributed to this remarkable survival rate. At the scene, many first responders were immediately able to respond (despite the personal risk of further potential bomb blasts) and to control the hemorrhage from the multiple patients with lower extremity injuries. Stories abound of clothes being torn to make improvised tourniquets—this proved to be lifesaving. Staff in the medical tent close to the finish line changed their role from treating dehydration to controlling external hemorrhage and crystalloid resuscitation without missing a beat. Many ambulances were stationed near the finish line and could transport the most critically injured rapidly to the nearby hospitals. Boston EMS staff on scene performed an exemplary function in triaging the severely injured to the trauma centers, taking care not to overload the resources of any one hospital. Boston is fortunate to have a plethora of hospital resources—5 level 1 adult trauma centers and 3 level 1 pediatric trauma centers are within 3 miles of the finish line; all hospitals received critical patients in roughly equal numbers.

The timing of the explosions was also opportune; the incident occurred at the change of shift. The morning shift was completing the 7 a.m. to 3 p.m. shift; the 3 p.m. to 11 p.m. shift was already in house. On every unit in the hospital, the medical, nursing, and support staff stayed to assist however they could—it was as though there was immediate double coverage. It was a Monday; the hospital was relatively open and had not yet filled with the elective cases that tend to occur early in the week. Being a state holiday, the scheduled operating list was relatively light, but because it was a normal working day, the operating rooms were fully staffed; the operating rooms were also completing their operative schedules for the day. All of these factors contributed, but above all, it was the training and the repeated disaster drills that made the difference. Although we did not receive any patients from Ground Zero on that fateful day in September 2001, we realized that our hospital internal disaster plan was inadequate; we took the opportunity to thoroughly revise our response. We requested a consultation with Israeli emergency physicians—they let us know how they are able to respond to a bombing on a bus—they told us they experience this scenario every 6 weeks and are able to manage 70 to 80 patients arriving simultaneously. We worked with Boston EMS to hone our coordination and skills and performed numerous drills, often on a citywide basis. The simulated building collapse, the dirty bomb scenario at Logan airport, and the repetitive activation of the MGH disaster response system—yes—on nights and weekends all contributed to our learning and familiarity. This training and the iterative improvement in response by all involved made the difference on Marathon Monday. Our elected representatives who help fund these efforts have to be informed that this is money well-spent; this training made the difference and translated directly into lives saved.

Unfortunately, terrorism in today's world is a reality and even in the United States we now realize we are not immune. As a medical community we must be prepared to meet this challenge. In the ensuing months, I am sure we will be analyzing the Boston Marathon response in more detail and we will surely find that there are more lessons to be learned. However, as a medical professional working that day, I feel an enormous sense of pride in being a member of a team of health care providers—both prehospital and in-hospital—all of whom functioned in a rehearsed, choreographed, and coordinated response. At the end of the day, the system worked and lives were saved. I remain convinced that it was mostly this coordination of effort that contributed to the dramatic survival of the bombing victims. Or as one physician stated to an ad hoc debriefing about 48 hours after the event, “We all came together and worked as a team, and as a team we together saved lives.” It was truly a day to remember.





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