What started as a typical “Marathon Monday” in Boston, MA, quickly turned into a rigorous test of the city’s disaster preparedness when two bombs exploded at approximately 2:50 pm April 15 near the finish line of the 117th running of the storied footrace. The explosions sent pellets, small BBs, headless nails, and other pieces of shrapnel flying upwards, ripping through the lower extremities of runners and spectators.*† Within seconds, Boylston Street looked like a bloody battlefield.
Three people died at the scene, but the patients‡ who were transported to the city’s six American College of Surgeons (ACS)-verified Level I trauma centers and multiple emergency departments (EDs) all survived. The surgeons who treated many of the most severely wounded patients that day attribute this positive outcome to several factors: a remarkable level of dedication and cooperation among the city’s emergency care providers, their past experiences, careful preparation, the indomitable spirit of the victims, and, frankly, a little luck. They also say that this incident provided some valuable lessons in how to better handle these situations in the future.
Getting word, marshaling resources
Like most Americans, the surgeons who provided life-sustaining care to the victims were shocked when they first learned of the marathon bombing. George Velmahos, MD, FACS, chief of trauma surgery at Massachusetts General Hospital, was just finishing 32 hours on call. “I was planning to wrap up the day when I received notification that there was a mass-casualty event. Initially, I thought it would be a big car crash or something, but the second phone call immediately followed, and that’s when I learned it was a bombing event. I ran into the emergency room [ER], and within minutes I heard the sirens of the ambulances arriving.”
The thought that it was a terrorist attack “didn’t even connect,” Dr. Velmahos said. “I mean Boston was the last place in the world anyone would have thought something like that could happen—a peaceful city, an intellectual city, a civilized city. Even when they said ‘bombing,’ I was thinking a gas tank explosion or something. It never occurred to me that it was a terrorist attack until I arrived in the emergency room, and a few minutes later, people with blown-off legs and the police arrived.”
Like Dr. Velmahos, Jonathan D. Gates, MD, FACS, medical director of trauma services, department of trauma, burns, and surgical critical care at Brigham and Women’s Hospital, was completing some paperwork when he learned of the incident. He received a phone call from the Brigham’s trauma manager, a spectator at the race. She reported that an explosion had occurred near the finish line. That phone call was followed by another from an orthopaedic trauma surgeon who also had heard of the bombing. “We agreed that we would make our way to the emergency department to find out what was going on,” Dr. Gates explained. “When we got up there, there were actually three or four patients who had already been brought in. We did a quick read on our resources, and having just been in the office minutes before, I was able to have a pretty good sense of who we had available in terms of trauma personnel. I went back to the office and said, ‘All hands on deck. It’s time to bring everybody up.’”
David P. Mooney, MD, MPH, FACS, director, trauma program, department of surgery, Boston Children’s Hospital, was on call when his wife phoned to inform him of the bombing. “So I thought I’d walk down to the emergency room and see what going on. When I got to the ER, our emergency alert radios started going off, indicating that patients were coming our way. We had no idea what was going on, just that there was a bombing and an as yet unknown number of kids heading our way,” Dr. Mooney said. “We started to organize into our teams, and then in about 10 or 15 minutes patients started to arrive.”
“My secretary, whose desk is just outside my office, was listening to coverage of the marathon on the radio, and all of the sudden I heard her exclaim, ‘Oh my God. There’s been an explosion,’” said William Mackey, MD, FACS, chair, department of surgery, Tufts Medical Center. “It was just a few minutes later that we got EMS [emergency medical services ] notification of a mass-casualty event, so our trauma team was mobilized. By the time we got our first casualties, which was probably 20–30 minutes after the first explosion, we had three trauma teams and four or five orthopaedic teams in the ER waiting.”
Carl J. Hauser, MD, FACS, a trauma surgeon, division of trauma and surgical critical care, the Roberta and Stephen R. Weiner Department of Surgery, Beth Israel Deaconess Medical Center, learned of the explosions first via text message and then through a hospital alert. He then walked to the trauma center and started assembling the necessary resources. “In the case of this particular event, which happened in broad daylight with so many people watching, a lot of the things we normally would have to assemble self-assembled because the entire medical community all throughout the city all knew almost instantaneously. They were coming in the door faster than we were calling them.”
Much to his frustration, Peter A. Burke, MD, FACS, chief of trauma services, Boston Medical Center, was dealing with an entirely different set of problems. He was in Nevada at a meeting of the Surgical Infection Society when he learned what was happening back in Boston. “I went to the concierge and said, ‘I really have to get back to Boston.’ They were able to get me on a flight in about an hour-and-a-half. I got back to the hospital at about midnight, and I was able to help with a couple of operations and for the duration of our efforts. I wasn’t here for the initial incident, but our team did a great job,” Dr. Burke said.
As the trauma teams were assembling, EMS, police, and bystanders were cutting through the chaos surrounding them at the scene of the bombing. The surgeons who treated the bombing patients agreed that the first responders should be commended for getting patients to the trauma centers expeditiously and for providing life-sustaining emergency care.
According to Dr. Gates, “They had the first patient here at the Brigham I would say about 12 or 15 minutes after the bombs went off. That rapid transport of patients to definitive care made a tremendous difference in the patient survival rate.”
Furthermore, EMS took measures to ensure that patients were evenly distributed across the city’s six (five adult, one pediatric) Level I trauma centers. “There was remarkable equanimity in the way that the EMTs spread the patients out,” Dr. Hauser said. “Although we got a lot of patients all at once and had to use a lot of resources all at once, we weren’t really overwhelmed.”
Dr. Burke agreed, noting, “In a way, we never had to go to true mass-casualty procedures where you find yourself having to triage people and say, ‘Well, we’ve run out of resources. I can’t help this patient so I’m going to triage him to comfort care.’ Everyone got what they needed, and that’s why, in my opinion, nobody died except for the people who were killed at the scene.”
Dr. Burke added, “Another thing that went well was the early use of tourniquets by first responders and by civilians, and that, with extremity injuries, was lifesaving in many respects.”
The patients arrived at the hospitals in waves. The first surge came within minutes of the explosions and included the most severely injured people—the ones with mangled limbs, severed arteries, and so on. The second ripple came within the first hour or so, followed about half an hour later by the less severely injured. By the time the patients reached the hospitals, the trauma teams were fully assembled and ready to start delivering care.
“We treated 32 patients of whom 12 were more severely injured, and eight of them went immediately to the operating room,” Dr. Velmahos said. The most commonly performed operations at Mass General that day were amputations, wound management and damage-control procedures, shrapnel extractions, laparotomy, and orthopaedic operations to treat fractures. “There were other injuries, such as eardrum rupture, that we left to manage on another day,” added Dr. Velmahos.
The Brigham and Women’s Hospital received 35 patients on the day of the bombing; 15 of them were bodily injured, and 10 went directly to the OR for management of their injuries. Two amputations were completed, but most patients had major open wounds combined with bone and vascular injuries or just bone and soft tissue injuries, Dr. Gates said.
Boston Medical Center evaluated 28 patients and admitted 19, of whom 16 underwent operations within the first eight hours or so. “Most patients had soft tissues injuries to the lower extremities. We did seven amputations on five patients,” Dr. Burke said. Surgeons also performed three vascular procedures and operated on one abdominal injury.
Children’s treated a total of 10 patients—nine children and one parent, Dr. Mooney said. “Three of the kids were immediately admitted to the [intensive care unit]. The other kids had shrapnel injuries that we were able to treat in the ER. One kid had a laceration on his scalp, and that was just closed,” explained Dr. Mooney. “We had two kids with pretty bad injuries to their legs that were sent right upstairs to the OR. Both had tourniquets on when they arrived at the hospital.”
The 18 cases seen at Tufts included blast injuries with open fractures, shrapnel wounds, and soft tissue injuries between the knee and the ankle. “There was a very significant knee injury where the knee was totally blown out, and that was just a wash out with an external fixator application,” Dr. Mackey said. No amputations were performed at Tufts.
On the other hand, of the 21 patients Beth Israel received, “we had three people within the first three minutes who clearly were not going to have limb survival. They had injuries that we would call ‘mangled extremities’ where the chances of successfully saving them were extremely remote,” Dr. Hauser said.
All of the surgeons at institutions where amputations were performed said they had no alternative. “Amputations were done on patients with legs that were already 75 percent or 90 percent severed by the bomb, so we didn’t do much more than complete the work that the bomb had done,” Dr. Velmahos said. “There was no question about amputating these legs. They were hanging by a thread.”
Many patients, including those who had amputations or partial amputations, underwent multiple operations. According to Dr. Burke, staging of procedures is a technique that originated with military surgeons who are all-too familiar with blast injuries. “You do what we call ‘damage-control’ operations initially, where you just take care of the immediate threat to life, and then develop a plan to bring these patients back to do staged operations,” Dr. Burke explained. “A key concept of damage control is one of prioritizing time, with the initial focus being on the physiology and not the anatomy.”
The surgeons emphasized that their past experiences in treating patients with advanced trauma were of enormous help in delivering the care that these patients needed.
“Unfortunately, the gruesomeness and the gore of this situation were no different than what we see on a daily basis because trauma is trauma, and car crashes, falls from heights, terrible gunshot wounds produce the same type of gruesome injuries,” said Dr. Velmahos. “Before Boston, I worked in one of the largest trauma centers in the United States in Los Angeles, CA, and before that at one of the largest trauma centers in the world in South Africa. Back then, a typical Saturday night seemed like a mass-casualty event because of the tremendous volume of patients we were receiving.”
Dr. Hauser has been a trauma surgeon for nearly 30 years. “I was in Newark when 9/11 went down. I’ve seen a lot of Saturday nights in L.A. County and places like that where we’d see a lot of injuries all at once. This was about what you expect and what you prepare for,” he said.
“Every day in our ER we see 30 to 40 injured kids, and that day turned out to be a slow day because once the bombing happened, no one left their house,” Dr. Mooney said, noting that the morning of the attack, a young man had run through a plate glass window in his house and nearly cut off his arm.
Dr. Mooney added that involvement in efforts to assist the victims of the 2010 earthquake in Haiti provided him with experience that was helpful in this situation. “I’m on one of the DMATs [Disaster Medical Assistance Teams], and I deployed to Haiti. I was on one of the first U.S. teams to arrive after the earthquake, and we saw a lot of really awful injuries down there. They’d come in big numbers and then there’d be sort of a pause. There was a little bit of a correlation with that,” he said.
Dr. Gates also was involved in Haiti relief initiatives. “Our group at the Brigham was located at the university hospital in Haiti, and at that time, we had over 1,000 patients at the hospital at one time,” Dr. Gates said. “There we didn’t have the resources or teams that we had available here. We realized in Haiti that it’s very important to get down to basics. Haiti was more amputations, wound care, stabilization, and evacuation, and I found in this situation, too, it was very important to make sure we were following the same standards for all patients.”
All of the surgeons emphasized that every successful operation performed that day was carried out by teams of dedicated health care professionals and said they were impressed with how quickly and determinedly the hospital staff responded to this dangerous and emotionally jarring event.
Dr. Hauser said that when he was preparing for the arrival of the patients, he called the OR supervisor to check on the availability of surgical resources and personnel. “The OR supervisor said they had nursing, anesthesia, tech staff pouring in. They all heard about it, and they wanted to know when they would get someone to operate on,” he said. “When they heard about it, they all poured in, so we were able to get patients into eight or 10 operating rooms in no time flat.”
“We had a remarkable number of hospital employees hear about the bombings and just come in.” Dr. Mooney said. “I had seven of my surgeon colleagues here. We just had so much help from people who literally had to walk the last few blocks to the hospital because [the police] had shut down streets around the hospital. When we told them we needed them, they helped, and when we told them we didn’t need them, they got out of the way,” Dr. Mooney said.
“[At Boston Medical Center] all the surgeons from multiple specialties came to help. All the residents who were off-duty came in. So, there was a great availability of people to help, and we used all of them. We used plastic surgeons to help with acute trauma cases. We used orthopaedic surgeons, vascular surgeons—all of them were intimately involved in the immediate surgical response. It was really a group effort, and it really went quite well,” Dr. Burke said.
“I think [this situation] reinforces again that the best care we deliver is clearly as a team and that includes the pre-hospital element, which was critical in this situation, to the emergency department, to every one of the surgical services,” added Dr. Gates. “It truly was a hospital-wide effort.”
The surgeons involved in this incident were impressed not only with their colleagues’ performance and dedication, but also with their patients’ determination and strength.
“I took care of the parent of a kid that was injured. I was removing shrapnel from his leg, and he’s just a guy—a regular guy—and refused any pain medicine because he didn’t want his head to be clouded at all so that he could be there for his kid. He just didn’t care [about his own pain] as long as he could take care of his child. I was very moved by that—what he was willing to put himself through for his child,” Dr. Mooney, who is a father as well, said.
Other patients were resolute that their injuries were just a temporary setback. “The kind of people that participate in a marathon or that go to cheer on people in a marathon are pretty high-spirited, and boy, I don’t think they anticipated what they were in for, but they recovered well,” Dr. Mackey observed. “These are otherwise mostly young, healthy, energetic people who were just determined that this wasn’t going to slow them down. We had one woman with a lower-leg injury who said, ‘You know, I’m going to run the marathon next year just to show ‘em.’”
“The patients and their families remained as defiant and as optimistic as the rest of Boston’s population was,” Dr. Velmahos added. “These patients woke up from general anesthesia only to realize that a leg was missing or that they were on the brink of death and had survived. It was amazing to see how quickly they regained their optimism and their love for life and started planning for the future rather than whining and feeling sorry for themselves. I call them the true heroes.”
To encourage the patients on the road to what was likely to be a long and painful recovery, several public figures paid them a visit. During his visit to Mass General, President Barack Obama thanked the trauma team and “went into each room of each patient and spent meaningful time with each patient, and, in a very humble and truthful way, he related to the patients,” Dr. Velmahos said.
Visits from celebrities and professional athletes proved to have a positive effect on the patients. “The reality is that famous people are special in people’s eyes for whatever reason, and when they came to see the patients, those patients felt special, too, and that was good for people. It was good for the patients. It was good for the staff to feel like they were a little bit special,” Dr. Burke said. “And, so, they made this very difficult situation a little bit easier.”
Members of the U.S. military who have undergone amputations due to wartime injuries also visited the patients, showing them that there is life after the loss of a limb. “It was inspiring and did so much good for patients,” Dr. Burke added.
Planning and “providence”
The fact that so many patients survived captured the attention of health care professionals and health care policymakers throughout the nation, and, indeed, around the world, all wanting to know how Boston was able to accomplish this feat.
“This astoundingly high survival rate, despite the nature and severity of the injuries, is a tribute to the courageous and rapid response of bystanders and first responders, expert field triage, rapid transportation of injured persons, and the skills and coordination of the receiving hospital trauma team. It is also, however, the product of a confluence of deliberate actions stretching back to September 11, 2001, augmented by a series of providential but not random events,” wrote ACS Regent Michael J. Zinner, MD, FACS, chair, department of surgery, and Ron M. Walls, MD, chair, department of emergency medicine, Brigham and Women’s Hospital, in a Journal of the American Medical Association blog.§
Approximately 14 months after 9/11, the city of Boston, local EMS providers, and the 14 institutions that comprise the Conference of Boston Teaching Hospitals participated in a large-scale disaster drill called Operation Prometheus, which simulated the explosion of a dirty bomb on an inbound airplane, according to Drs. Zinner and Walls.
Since then, Boston-area trauma centers have been refining their plan for handling mass-casualty events. “For example, from 2006 to 2012, Brigham and Women’s Hospital conducted or participated in 73 separate exercises, events, and disaster activations,” wrote Drs. Zinner and Walls. “In 2010, Operation Falcon, coordinated by Metro Boston Homeland Security, tested system-wide response to a mass casualty bombing, complementing previous exercises in 2007 and 2008.”
Boston hospitals also took note of how the University of Colorado Health Sciences Center managed the arrival of 23 critically injured patients within approximately one hour of the mass shooting of 70 moviegoers on July 20, 2012, in Aurora, CO.
“Although the Boston hospitals had prepared, trained, and drilled for mass-casualty events, the challenge of receiving so many critically ill patients so rapidly at a single hospital had not been specifically addressed,” wrote Drs. Zinner and Walls. To ensure that Boston hospitals would be ready for an onslaught of patients in the event of a mass-casualty event, “additional incident command training, particularly for senior leaders, was identified, and efforts were initiated to move preparedness to a higher level.”§
In addition, over the last two years, trauma surgery, emergency medicine, and emergency nursing staff at area hospitals have worked together to provide team training for trauma team members using simulated disaster situations. These combined actions—the drills, the analysis of other mass-casualty events, the team training—“were waypoints along the path to readiness,” according to Drs. Zinner and Walls.
The plan that emerged from all of these initiatives “involves multiple levels, and we have practiced it incessantly, and this is exactly why when the real deal happened, we were totally prepared to do the right thing. We really saved a lot of lives because we were prepared—because the pre-hospital system was prepared, because EMS personnel were prepared, because the trauma teams were prepared and responded immediately, the operating room, the ICUs, the orthopaedic teams—everyone was prepared,” Dr. Velmahos said.
The surgeons at other Boston-area trauma centers concurred. “I really think that the drilling, the training, the practice, the whole crisis management control system that Boston hospitals have put in place for these kind of events works terrifically well, and out of the chaos of the moment, when 12 or 14 patients arrive in your emergency room with injuries really of unknown severity and have to be cared for within a matter of minutes, organization and practice really do make a difference,” Dr. Mackey said.
Based on what the hospital staff learned during the drills, “we were able to assemble what were essentially full-service teams for each of the badly injured patients,” Dr. Gates said. “So the emergency department would be working on the patients who were perhaps not badly injured and then we would have an emergency department individual—resident or staff—who would be an airway person. We’d have a general trauma surgeon with them and an orthopaedic surgeon, as well as a complement of residents to take care of each patient. So essentially we were able to take care of each patient as we would on a normal day of taking care of trauma patients.”
Several surgeons noted that ACS programs provided the foundation for much of the city’s disaster planning. “I cannot underscore enough that in these preparations a major role has been played by the Committee on Trauma (COT) of the American College of Surgeons,” Dr. Velmahos said. “We all talked about the hospitals. We all talked about the trauma teams. But we tended to forget that the reason why trauma centers exist, the reason why trauma teams are assembled, the reason why we have verification of Level I, II, and III for trauma centers, the reason why we have guidelines, and the reason why we perform so well in trauma is because the Committee on Trauma of the ACS has created all of these systems. So I think a lot of the credit should go to the COT.”
Dr. Hauser also believes that this incident demonstrates the value of the College’s trauma center verification and educational programs. “Most governments use ACS verification as their benchmarks, and especially in areas where there are not these kinds of dedicated resources, it’s very important to have people in place who have the ability to use these well-tried-and-true methods of stabilizing patients and moving them on to other, higher levels of care,” he said.
Although preparation clearly was a deciding factor in the successful efforts carried out by these institutions, “we shouldn’t forget that within this tragedy, we got a little bit lucky because, if it had to happen, it happened in the optimal location, at the optimal time,” Dr. Velmahos said. First, the bombs were detonated near the finish line of the marathon where EMS has traditionally set up a fully staffed emergency care center for runners who might experience injury, dehydration, chest pains, or heat stroke. Ambulances are on standby to transport the more serious of these cases to area hospitals, and ERs increase their staffing to ensure that runners who are ill or injured can be treated promptly. Furthermore, Marathon Monday is also Patriots’ Day—a holiday in the Commonwealth of Massachusetts—so all of the hospitals are open, but their ORs tend to have a light schedule. In addition, the blasts occurred right at change of shift at most of the hospitals, so the day shift was still on-site, while the evening shift was starting to check in, and happened in the afternoon when the ORs tend to less full.
Furthermore, the bombs were only volatile enough to damage people’s legs, in most cases. “If these had been more powerful bombs that created trunk and head injuries, the situation would have been more challenging,” Dr. Mackey noted. “But, as tragic as the event was, we were very fortunate in terms of the readiness because it was Marathon Monday, because of the time of day it happened, because it was change of shift—all those things and the nature of the injuries conspired to create very good outcomes.”
In the aftermath of the bombings, Boston hospitals reviewed the situation and used it as an opportunity to think about what new initiatives might need to be put in place to ensure that they are prepared in the event of another mass-casualty incident.
First, they said a better means of tracking patients should be instituted. “In a lot of cases in this situation we had patients who were unidentified initially,” Dr. Gates said. As a result, hospitals had trouble getting them into the tracking system and monitoring their care.
Dr. Burke agreed, noting, “The usual systems of tracking patients and keeping them identified break down pretty quickly when you have an influx of critical patients simultaneously. Everyone has a disaster form that they use, and we need to perhaps make that a little more efficient.”
It is also important to track the “walking wounded,” Dr. Burke said. “I think it’s very important to recognize all of the patients who are injured, even those who might have minor injuries, to make sure they are still treated within the hospital’s care even after they are allowed to leave the hospital because their wounds aren’t serious.”
Likewise, patients’ families need to be able to find out where their loved ones have been taken. Dr. Burke said that the trauma community is working to develop a central area for identifying patients, which possibly would be run through EMS, so that patients’ families would have a single, reliable starting point in their search.
The trauma community also is evaluating what steps can be taken to ensure optimal outcomes when a mass-casualty event occurs under less favorable conditions than this one did. “The biggest thing we’ve talked about is what would have happened if this had happened on a Sunday evening or at 1:00 in the morning. How would our response have been different? What would we have done to make sure our response was adequate? As a result, we’ve developed a much more robust telephone tree to notify people—to get people in that are necessary—to get our disaster response really sort of revved up,” Dr. Mackey said.
Dr. Hauser also suggested that the use of tourniquets be further evaluated. “There were clearly situations here where the tourniquets did help and there were situations where either they didn’t work or made things worse. We need to get that data out and figure out why they worked or didn’t work in that patient with that kind of injury in that location,” he said.
Finally, surgeons expressed concern with respect to the long-term psychological effects of this incident on victims and their families. “Patients and their families need a lot of support through an experience like [this], and the thing to remember is that they’re going to keep needing it,” Dr. Burke said. “Now that all of the dust has settled and everyone who was admitted to a hospital has survived, patients and their families have to try to figure out how to deal with the consequences,” Dr. Burke said.
ACS Fellows quoted in this article
‡Initially estimated to be 140 patients, but now believed to be a total of more than 250, including those who came forward in the days following the attack.
*Kolata G, Longman J, Pilon M. Doctors saved lives, if not legs, in Boston. The New York Times. April 16, 2013. Available at: www.nytimes.com/2013/04/17/us/physical-legacy-of-bomb-blasts-could-be-cruel-for-boston-marathon-victims.html?pagewanted=all&_r=0 . Accessed May 31, 2013.
†Conaboy C. Ball bearings, nails removed from marathon bombing patients. Boston Globe. April 16, 2013. Available at: www.bostonglobe.com/lifestyle/health-wellness/2013/04/16/boston-doctors-ball-bearings-nails-removed-from-patients-from-marathon/4SzxUrTHZcpzLSCcc7OobI/story.html. Accessed May 9, 2013.
§Walls RM, Zinner MJ. The Boston Marathon response: Why did it work so well? JAMA. April 30, 2013. Available at: http://jama.jamanetwork.com/article.aspx?articleid=1684255. Accessed April 30, 2013.