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Lessons from Boston Arthur L The NEW ENGLAND JOURNAL of MEDICINE Perspective Lessons from Boston Arthur L. Kellermann, M.D., M.P.H., and Kobi Peleg, Ph.D., M.P.H. t 2:50 p.m. on April 15, nearly 3 hours after • Because it was race day — in- the first runner completed the Boston Mara- deed, a state holiday — it is A likely that the city’s operating thon, two blasts ripped through the crowd that rooms and other clinical ser- was gathered along the approach to the finish line, vices were running at less than full capacity. killing 3 people and injuring more [disaster] plan to accommodate.”1 • The attack happened shortly be- than 260. Within moments, the Praise for Boston’s rapid and ef- fore the 3 p.m. change of shift crowd’s initial panic was replaced fective response is richly deserved. at area hospitals. As a result, a by purposeful action, as bystand- Clearly, lives were saved. But be- full complement of administra- ers ran to, rather than from, the fore memories fade, we should tive staff and two shifts of horror to help the injured. Law- analyze the event for the lessons health care providers were on enforcement and emergency med- it offers. Although a formal after- site at each facility. ical services (EMS) personnel action report will take time, • The bombs were detonated in swiftly converged on the scene. enough is known for us to offer a city that is home to seven Within minutes, ambulances be- some initial observations. trauma centers and multiple gan transporting the most criti- First, the remarkably low mor- world-class hospitals (see map cally injured to nearby hospitals. tality rate of the attack — 1% in the Supplementary Appendix, Once victims reached Boston’s — was attributable in part to available with the full text of hospitals, the story continued in excellent care and in part to six this article at NEJM.org). Boston the same vein. Noted Harvard factors that favored the rescuers: EMS personnel wisely distrib- surgeon and author Atul Gawande • The bombing occurred at a ma- uted casualties among the described how quickly they ar- jor event where large numbers area’s trauma centers, so each rived and how “everything hap- of police, security, and EMS per- one received a manageable pened too fast for any ritualized sonnel were already deployed. number. n engl j med nejm.org 1 The New England Journal of Medicine Downloaded from nejm.org by JAMES KAHAN on April 25, 2013. For personal use only. No other uses without permission. Copyright © 2013 Massachusetts Medical Society. All rights reserved. PERSPECTIVE Lessons from Boston • The bombers detonated their relatively low-yield devices out- of-doors. A bombing inside a closed space (e.g., a building, bus, or train) produces more primary blast injuries (e.g., blast lung) and fatalities, because surrounding walls concentrate blast waves.2 The absence of structural collapse facilitated the swift extrication of victims. • Although most health care pro- viders in the United States have never treated a bombing vic- tim, lessons learned by mili- tary surgeons, emergency phy- sicians, and nurses in Iraq and Boston Marathon, April 15, 2013. Afghanistan are progressively percolating through the trau- trol bleeding. Other bystanders tals treat disaster preparedness ma care community. Moreover, pulled racecourse barriers aside as an afterthought. We would be hundreds of Boston’s prehos- to facilitate access to the victims wise to emulate Israel’s doctrine, pital and hospital-based re- and their rapid extrication to which emphasizes the impor- sponders had already learned area trauma centers. Bystanders tance of national coordination, the basics of blast-injury care and runners with medical train- standard operating procedures, and the operational challenges ing started triaging victims. These constant attention to surge capac- their city could face. In 2009, courageous civilians were the true ity, the avoidance of emergency- Rich Serino, then Boston’s EMS first responders. department overcrowding, the dis- chief and now deputy adminis- Third, the seemingly sponta- tribution of casualties according trator of the Federal Emergency neous actions Gawande describes to type and severity, and the fre- Management Agency, hosted didn’t happen by chance. The quent conducting of rigorous the first citywide “Tale of Our goal of a well-crafted disaster drills.4 Because Boston followed Cities” conference in Boston, plan is to provide a framework many of these principles, it mount- at which doctors from India, for preconsidered action. Experi- ed an effective response. Our Spain, Israel, Britain, and ence has shown that such a goal must be to ensure that every Pakistan who had managed framework is necessary to en- U.S. city can do the same.5 the consequences of terrorist sure a well-coordinated response Finally, Boston’s response il- attacks explained the nature of to a sudden mass-casualty event. lustrates the value of adopting a the blast injuries they treated, Boston’s health care providers broad-based approach to disaster the triage systems they used, reacted the way they did because preparedness. In the early years and other lessons responders they knew what they were sup- after 9/11 and the anthrax attacks can use to save lives. More than posed to do. Those who did not that followed, federal prepared- 750 locals attended.3 were smart enough to follow the ness efforts were too narrowly Second, photographs taken lead of those who did. That’s how focused on bioterrorism and weap- shortly after the bombings vivid- a “ritualized” disaster plan works. ons of mass destruction. More ly depict the vital role bystanders What is not clear is whether recently, agencies have embraced play in the initial response to other U.S. cities, if faced with a a more flexible, all-hazards ap- mass-casualty incidents (see photo). challenge of similar magnitude, proach, as exemplified by the Na- Instead of fleeing the scene, would have done as well. In con- tional Health Security Strategy runners tore off their shirts and trast to Israel, a country that has first published by the Depart- either used them as tourniquets ample experience with terrorist ment of Health and Human Ser- or applied direct pressure to con- bombings, too many U.S. hospi- vices (DHHS) in 2009,5 the De- 2 n engl j med nejm.org The New England Journal of Medicine Downloaded from nejm.org by JAMES KAHAN on April 25, 2013. For personal use only. No other uses without permission. Copyright © 2013 Massachusetts Medical Society. All rights reserved. PERSPECTIVE Lessons from Boston partment of Homeland Security’s merate what went well; we must Disaster Medicine Department, Tel Aviv Quadrennial Homeland Security understand why. Otherwise, some University, Tel Aviv, Israel (K.P.). Review published in 2010, and a citizens and health care profes- This article was published on April 24, 2013, monograph from the Centers for sionals may erroneously conclude at NEJM.org. Disease Control and Prevention that it doesn’t matter if emergen- 1. Gawande A. Why Boston’s hospitals were ready. The New Yorker. April 17, 2013 entitled “In a Moment’s Notice: cy departments are crowded and (http://www.newyorker.com/online/blogs/ Surge Capacity for Terrorist if disaster plans and rigorous newsdesk/2013/04/why-bostons-hospitals Bombings” (released 2007, updat- drills are lacking, because their -were-ready.html?mobify=0). 2. Golan R, Soffer D, Givon A. The ins and ed 2010). hospital’s medical staff will sim- outs of terrorist bus explosions: injury pro- The best way hospitals can pre- ply “rise to the occasion.” That’s files of on-board explosions versus explo- pare is to base their response on a a risky bet. The Red Sox benefit- sions occurring adjacent to a bus. Injury 2013 March 11 (Epub ahead of print). strong foundation of daily health ted from some lucky breaks in 3. Smith JF. Doctors share expertise on 4 care delivery. The $347 million the 2007 World Series, but their handling terror attacks. The Boston Globe. in federal funding allocated to victory was largely due to prepa- June 15, 2009 (http://www.boston.com/news/ world/worldly_boston/2009/06/doctors_ the DHHS’s National Healthcare ration, teamwork, and execution. share_expertise_on_han.html). Preparedness Program cannot, by The same was true when the city 4. Peleg K, Kellermann AL. Enhancing hospi- itself, transform our $2.8-trillion- of Boston was attacked on April tal surge capacity for mass casualty events. JAMA 2009;302:565-7. per-year health care industry; the 15. The rest of us should take that 5. The National Health Security Strategy of economics don’t work. Therefore, lesson to heart. the United States of America. Washington, DC: it is vital that hospitals weave Disclosure forms provided by the au- Department of Health and Human Services, thors are available with the full text of this 2012 (http://www.phe.gov/Preparedness/ the threads of preparedness into article at NEJM.org. planning/authority/nhss/ip/Documents/ their daily routine. nhss-ip.pdf). From the RAND Corporation, Arlington, VA As we reflect on Boston’s re- (A.L.K.); and the National Center for Trau- DOI: 10.1056/NEJMp1305304 sponse, it’s not enough to enu- ma and Emergency Medicine Research, Copyright © 2013 Massachusetts Medical Society. n engl j med nejm.org 3 The New England Journal of Medicine Downloaded from nejm.org by JAMES KAHAN on April 25, 2013. For personal use only. No other uses without permission. Copyright © 2013 Massachusetts Medical Society. All rights reserved. .
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