Ideas and Opinions |

April 15, 2013 FREE

Anne M. Stack, MD
[+] Article, Author, and Disclosure Information

This article was published at www.annals.org on 28 May 2013.

From Boston Children's Hospital, Boston, Massachusetts.

Potential Conflicts of Interest: None disclosed. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M13-1049.

Requests for Single Reprints: Anne M. Stack, MD, Division of Emergency Medicine, Boston Children's Hospital, Boston, MA 02115; e-mail, anne.stack@childrens.harvard.edu.

Author Contributions: Conception and design: A.M. Stack.

Drafting of the article: A.M. Stack.

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

Final approval of the article: A.M. Stack.

Administrative, technical, or logistic support: A.M. Stack.

Ann Intern Med. 2013;159(2):146-147. doi:10.7326/0003-4819-159-2-201307160-00658
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April 15, 2013, was a glorious spring day in Massachusetts—Patriot's Day, a time for celebration of the birth of American independence. In Concord, where I live, that means a classic New England small-town parade with high school marching bands, balloons, and American flags, with the addition of troops of Minutemen, women and children in colonial garb, and the occasional Red Coat.

Knowing that I was scheduled to work the evening shift in the Boston Children's Hospital ED, I decided to start the day by taking a run around Concord to celebrate the beautiful crisp day; the Concordians who in 1775 kindled a revolution for freedom; and, of course, Marathon Monday. I ran past the parade to the Old North Bridge where the reenactment of the “shot heard round the world” was under way. I heard the boom of the cannons, never imagining that there would be a deadly boom near other runners in a few hours.

As I entered the ED for the start of my shift, I saw a strange look on the faces of colleagues. The C-Med radio had just cracked that we should stand by for a mass casualty event after reports of an explosion at the finish line of the Boston Marathon. What? I logged on to Twitter and immediately saw reports of severe injuries. One deep breath, and we were launched into disaster mode. We delegated a trauma code team leader and an overall ED team leader and arranged for a hospitalwide disaster response. Immediate needs were for rapid discharge of nonacute ED patients, fast transfer of planned admissions to the inpatient units, and care of noncritical patients arriving via car or on foot. Three trauma teams were rapidly assembled. Each consisted of an ED physician team leader, a pediatric surgeon, an airway doctor, bedside and recording nurses, residents and fellows, and clinical assistants. Pharmacists, radiology technicians, and administrators were also on site. We donned yellow precaution gowns, masks, and gloves, then affixed colored labels indicating our respective roles onto our gowns. I would be the ED team leader for the first injured child. I hushed the crowd of providers and asked them all to maintain order while we worked. By then, anesthesiologists, respiratory therapists, subspecialty surgeons, and others had started to arrive and were asked to wait in the hallway. We would call them as needed.

Before anything else could be said, the first patient arrived. The second came almost immediately afterward. The faces of the medics said it all. Even these consummate professionals were shaken. The lead medic looked at me as he transferred the first child, who we designated “Trauma A,” onto the ED stretcher, and said, “Tourniquet time 1500 hours.” I remember saying, “Tourniquet on what?” His eyes traveled to the left leg. I picked up the sheet and saw torn and bloody jeans, a yellow rubber band held tight with a Kelly clamp at the upper thigh. Below that was a knee and then flaps of skin and muscle. We dove into the Advanced Trauma Life Support algorithm for care (www.facs.org/trauma/atls/).

These children were grievously injured. Awake and wide-eyed, their hair was singed, soot covered their faces, they were burned in patches everywhere, there were innumerable penetrating wounds, and inside those wounds, I saw nails. A wave of disgust came over me. The explosions were planned—planned to inflict even more pain and suffering than a standard blast. But I had to let that go and focus on immediate care: distraction questions for the school-aged patient, IV morphine, IV antibiotics, tetanus status assessment, arranging for CBC, O-negative blood, x-rays, orthopedist examination, finding the parents, preparing for transfer to the operating room, all as we were irrigating and covering wounds.

The first wave of children was rapidly transferred to the operating room. The rooms were cleaned immediately as we prepared for the next group of casualties. By now the number of providers had swelled and a sea of yellow gowns was flowing through the ED. I directed a plastic surgeon to the operating room. The neurosurgeons could stand by. Critical care doctors and nurses from the inpatient units and off-duty ED physicians streamed in from near and far. We assembled 4 more trauma teams. And waited. There were reports of an explosion at the John F. Kennedy Library and more possible bombs. There could be overflow from neighboring Brigham and Women's Hospital. But no more critical patients arrived.

In January 2010, I traveled to Haiti to provide pediatric emergency care after the earthquake. Medical resources were lacking; an already fragile basic infrastructure had unraveled. When I returned, I spent several weeks deeply rattled and frustrated by such unnecessary death. After the marathon bombing, I waited for the same emotional blow, but as of this writing, it has not come. Upon reflection, I believe that although the experience of caring for the earthquake and then bombing casualties might be superficially the same, there was a fundamental difference. In Boston, unlike in Haiti, a horrific mass casualty event happened in a setting with hordes of trained first responders, good Samaritans, and professional health care providers right at the site, with ambulances at the ready and several world-class trauma centers minutes away. It was a state holiday, so the operating rooms and intensive care units were quiet. It was change of shift so we had twice the usual number of staff. Resources were unlimited and of the highest quality. We had trained for almost this exact scenario.

I am comforted by the knowledge that our team functioned superbly, each individual contributing expertise, professionalism, compassion, and teamwork far beyond what even I might have imagined. Despite the unfathomable tragedy, these children received and are receiving the highest quality care for their heinous injuries. They will have the best possible chances for good outcomes. That is hugely consoling. I am fortunate to have been able to be there. And my runs around Concord will never be the same.





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