Mass Casualty Event Preparedness and Response: The Boston Marathon Experience Katerina Lin; Aaron Baggish, MD; Sophia Dyer, MD; Chris Troyanos, ATC; Pierre d’Hemecourt, MD; and Lyle J. Micheli MD TABLE OF CONTENTS Abstract…………………………………………………………………………………… 3 Introduction………………………………………………………………………………. 3 Methods…………………………………………………………………………………… 6 Results………………………………………………………………………………… 7 Discussion………………………………………………………………………………… 37 References………………………………………………………………………………… 39 LIST OF FIGURES Figure 1: Boston Marathon Medical Records 2012-4: Total Number of Patient Visits Figure 2: Boston Marathon Medical Records 2012-4: Sex Distribution Figure 3: Boston Marathon Medical Records 2012-4: Chief Complaints Figure 4: Boston Marathon Medical Records 2012-4: Physical Findings Figure 5: Boston Marathon Medical Records 2012-4: Orders Figure 6: Boston Marathon Medical Records 2012-4: Treatment Fluids Figure 7: Boston Marathon Medical Records 2012-4: Fluid/PO Type Figure 8: Boston Marathon Medical Records 2012-4: Plasma Sodium Levels Figure 9: Boston Marathon Medical Records 2012-4: Patient Diagnoses Figure 10: Boston Marathon Medical Records 2012-4: Patient Disposition at Time of Care ABBREVIATIONS Boston Athletic Association (BAA) Brigham and Women’s Hospital (BWH) Department of Public Health (DPH) Emergency Medical Services (EMS) Emergency Medical Technician (EMT) Incidence command systems (ICS) Massachusetts Emergency Management Agency (MEMA) 2 ABSTRACT The prestigious Boston Marathon is the oldest annual marathon and one of the largest in the world. Among the world’s six major marathons, the Boston Marathon is a planned mass casualty event, which is an occurrence that strains or overwhelms local health systems and resources. Preparation for such a greatly attended and large-scale mass casualty event like the Boston Marathon presents a daunting task. Four years of the Boston Marathon have demonstrated comprehensive and effective responses to unique challenges on the racecourse. This article provides a four-year exploration of the planning, response, and health outcomes for the 2012-15 Boston Marathons. By investigating the medical, security, and logistical preparations for the 2012-15 Boston Marathons, it examines specific lessons gleaned from these experiences. The 2012 race was characterized by extremely hot weather conditions. It required medical care for heat-related illnesses and coordination with medical facilities to combat the weather. The 2012 race prompted enhanced preparatory measures in 2013, and this helped brace Boston for the unexpected attack at the finish line during the 2013 race. The city’s response to the 2013 bombings was rapid and efficient. This was largely a result of extraordinary teamwork and the city’s long history of interdisciplinary training and collaborations among multiple sectors for crisis management. The 2013 attack fueled overwhelming interest, record participation, and revamped security for the 2014 race. Boston’s intensive medical and safety preparations in 2014 led to a successful response and low casualty rate. Mental health support services were important in responding to the 2013 tragedy and were included in preparations of the 2014 Marathon. The 2015 Marathon contrasted with the 2012 race when the city faced unusually cold and rainy conditions. Every year could bring drastically differing experiences that tested the capabilities of event coordinators. Overall, throughout the four Boston Marathon races, multidisciplinary partnerships among emergency, safety, and medical departments were necessary for organizing medical care for the race, ensuring that local health systems do not overload from the high influx of patients during the race, and protecting safety. Tremendous collaborations among local, regional, state, and federal institutions have proved instrumental in ensuring successful and efficient responses at the Boston Marathon. INTRODUCTION Marathon racing has recently experienced unprecedented popularity in America. US marathon participation reached record highs in 2013 [1], with 541,000 finishers and over 1,100 races nationwide [2]. The largest marathons in the US today produce over 30,000 finishers, and the US hosts five of the top ten largest marathons in the world [2]. US marathons have increased in size, with the number of marathons achieving over 1,000 finishers in one year increasing by 360% over the past 25 years [2]. The Boston Marathon, the seventh largest race in the US, is the world’s oldest annual marathon [3]. It draws over 35,000 runners [4] and is New England’s most widely viewed sporting event, drawing approximately one million spectators along the racecourse [5]. The media expose millions more people in over 200 countries to the race [3]. Every year, the massive turnout consistently produces over 1,000 medical encounters within a short span of six hours [6]. The large scale of the Boston Marathon and high demand for medical services make it one of the largest planned mass casualty events in the nation. A mass casualty event is an incident in which large numbers of people are injured or killed and require medical attention, thereby placing tremendous strain on local resources to provide health care [7]. Utmost 3 priority is placed on protecting the health of runners and injury prevention, as the sport engenders a high incidence of injury, ranging from 19% to as high as 79% [8]. In preparing for a mass casualty event like the Boston Marathon, medical, emergency, and security teams undertake comprehensive planning to ensure that they provide quality medical care and safety during race day. The planning process requires extensive coordination and integration of community, state, and federal agencies and hospitals. The Massachusetts Emergency Management Agency (MEMA) coordinates regulatory and health systems across Massachusetts cities and towns. It plans meetings for local, state, and federal agencies to debate responses to theoretical marathon disasters. The Boston Athletic Association (BAA) organizes the Boston Marathon and seeks to optimize public safety by building strong relationships and working closely with the fire department, the local and state police, the Department of Public Health (DPH), and MEMA. These groups collaborate to develop comprehensive policy and operational plans to guarantee that all members understand their roles and have necessary resources to respond efficiently and effectively. On the racecourse, staff members provide medical coverage at multiple locations. The Boston Marathon spans eight cities and three counties, and the entire course is lined on both sides with countless spectators [9]. At many locations, medical tents provide on-site medical care so that local hospitals’ emergency departments are not overwhelmed, and caregivers refer patients with serious medical conditions to hospitals. Medical care is provided at the start area, Course Medical tents, Emergency Medical Services (EMS) locations, medical sweep buses, near the finish line, medical tents, and after the finish line. The Boston Marathon medical team additionally covers the Athletes’ Village, Hopkinton Green, and medical sweep teams. The medical staff keeps detailed health records for those who receive medical care. The staff includes medical directors and medical coordinators, who oversee overall operations, as well as physicians, nurses, emergency medical system coordinators, and other medical professionals. Medical volunteers and support staff from organizations, including local hospitals, higher educational institutions, the American Red Cross, EMS community, amateur radio clubs, and current volunteer staff provide additional aid throughout the racecourse. There are thirty American Red Cross stations distributed along the course, with two at the Athletes’ Village, twenty-six on the racecourse, and two at the finish [3]. All these medical preparations take into account surge capacity, the number of volunteers compared to amount of EMS support available; weather fluctuations; point in the race; and course difficulty. Primary objectives of Boston Marathon medical care teams are to prevent injury, provide high quality medical treatment at all course medical locations, and avoid hospital overload and public safety threats. To achieve this, extensive medical supplies and equipment are necessary. Approximately 25 EKGs, 40 defibrillators, 150 blood pressure cuffs and stethoscopes, 80 thermometers, 500 bags of ice, 380 cots, 1500 blankets, 4000 Band-Aids, 26 oxygen tanks, 900 IVs, and 2000 bandages are prepared at the start and finish medical tents [3]. More medical supplies are required along the racecourse: over 30 boxes of gloves, 50 bottles of sunscreen, 1500 gauze sheets, 250 ice packs, 52 heat packs, and 150 pounds of petroleum jelly are required [3]. Before the race, the BAA coordinates with local hospitals to prepare medical coverage for the marathon. It ensures that health related regional, state, and federal agencies work together to develop and revise medical protocol for the coming race. The BAA disseminates a Marathon preparedness plan that ten partner hospitals modify and integrate into their own systems for marathon day [10]. Hospitals devise their own Boston marathon protocols that have been 4 developed and refined over years of experience. Newton-Wellesley Hospital, for instance, uses its own marathon preparation checklists and specifically ensures that medical translators are available at the hospital to accommodate the high numbers of foreign runners [10]. On