‘Organized chaos': What hospitals can learn from Boston Marathon bombing response

At first, the 2013 Boston Marathon was going more smoothly for hospitals in and around downtown Boston compared to the prior year’s event, when a heat wave meant more runners needed medical attention. David Reisman, MHA, senior administrative director of emergency medicine at Massachusetts General Hospital, admitted he had begun to think it would be an easy day.

That changed just before 2:50 p.m., when two bombs exploded at the marathon’s finish line less than two miles away from Mass General, an attack which would leave three people dead and 264 injured, with more than a dozen losing limbs and others suffering second or third degree burns.

In his presentation at the 2018 American College of Healthcare Executives (ACHE) in Chicago, Reisman detailed how the hospital put in place its Mass Casualty Incident, or MCI, protocol which had been the subject of more than a hundred exercises and training sessions before the bombings. As he put it, the response is a “whole hospital problem” where everyone needed to know their role ahead of time, even if precise preparation for an unexpected tragedy would be impossible.

“The goal here is not to make a perfect, orchestra-like system where everything is calm and organized because that’s just not reasonable,” Reisman said. “Organized chaos is kind of where we want to be. If we’re looking at that level of response, then I’m pretty happy.”

The “organized” portion of the chaos came from advanced planning for a large event like the Boston Marathon. The 1,001-bed, 25,000-employee hospital is close to a number of places which could be targets for incidents which could overwhelm an emergency department. Mass General’s MCI protocol spelled out who could activate it, who would be in command, what simple tasks individual department heads and all personnel needed to carry out, down to how many stretchers and ventilators will be needed. All of this had been practiced in both small exercises and larger drills, though the scenarios there involved potential incidents like a plane crash at nearby Logan International Airport or a release of hazardous materials.

In the case of the marathon, the planning went beyond the Mass General campus. The hospital was involved in pre-event planning with other Level I trauma centers near the marathon route, coordination with the on-site emergency responders near the finish line and conference calls with the state’s public health department, all before the bombings took place.

The usual marathon-related patients had been coming into area hospitals that day when the bombs detonated just before 2:50 p.m. Five minutes later, the ED received the first word of the explosions, soon followed by reports of casualties. At 3:03 p.m., the MCI protocol and disaster plans were activated and a command center was set up in the hospital conference room. A minute later, the first patient arrived not in an ambulance, but in someone’s car, being the first of several people to have limbs amputated at Mass General that day.

Once the protocol is activated at any hospital, quick responses are essential. In this case, Mass General needed to immediately create capacity in its ED by clearing out existing patients. Within 90 minutes, ED dropped from 97 patients to 39.

“Our resource nurse and our admitting office, as part of our plan, immediately round the ED, either in person or looking at the bed board in the computer and make decisions about where those people are going to go,” he said. “Inpatient units come down, without taking pass off, and take patients up.”

Trauma teams led by attending physicians set up triage stations both in the waiting room and on the ramp of the ambulance bay and security had to be stationed everywhere, as there was concern the hospital and other “soft targets” could themselves be attacked and law enforcement needed facilities locked down as it sought out the bombers.

Within all of that “organized chaos” as the protocols went into effect were some strokes of luck, Reisman said. For one, the bombing happened minutes before a shift change, so the hospital essentially had double the usual staff on hand.

The first person within the hospital who was documented to have been notified of the bombings was working at the operating room (OR) control desk. Just based off a text message from a friend, he decided to temporarily hold several scheduled elective procedures from taking over some of the ORs, clearing space and resources for the six patients were taken into ORs for surgery within 30 minutes of their arrival at the hospital.

“That decision probably saved lives,” Reisman said.

Marathon planning also helped Mass General. Since the bombings occurred near the emergency medical services tents at the finish line, coordination with dispatching ambulances and patients was made easier. Mass General and nearby Brigham and Women’s Hospital received an identical number of patients (39), meaning no hospital was overwhelmed, something which Reisman said wouldn’t be expected in most of these kinds of incidents.  

Overall, Reisman said the hospital and the city as a whole performed “pretty well” in its medical response to the bombings, but mistakes were still made. It was only after the hospital started taking in patients that Reisman thought of the possibility of contamination, like some sort of biological attack. No information indicated that kind of threat, however, and Reisman said if they had played it cautiously and set up a decontamination tent outside the ED—which could’ve taken at least 30 minutes—patients may have died in the meantime.

The hospital’s biggest error, however, was misidentifying a patient. As reported by multiple media outlets after the attack, a woman named Karen Rand was mistaken for her friend, Krystle Campbell, because she had Campbell’s ID on her when she was brought to Mass General. The Campbell family was told she was in surgery when in fact she had been killed at the scene of the bombing, and the mistake was only discovered after Campbell’s parents came to see her.

Reisman called this situation “a nightmare” for both the family member and the staff member who made the error. Patient tracking and identification was mentioned among the topics requiring special attention in a MCI protocol and considering what happened with this patient, the hospital knew it needed to refine its processes.

“I’m a big believer in the fact that a plan is never really done,” Reisman said. “Patient registration and tracking was a huge issue for us. How you register these people when they’re coming in fast and furious and how you track them through the hospital is a big issue.”

Communication among the staff was also a problem. Partially thanks to the bombings occurring right before a shift change, there was an abundance of doctors and nurses available—so much so that Reisman said it had to shut out personnel who may not have been helpful in the ED. Rather than having physicians and nurses running from patient to patient, Mass General found it more efficient to bring patients to the clinicians.

Each MCI plan will be different and leaders need to know what will be difficult in their hospital when so many patients need immediate help. Creating a “playbook for patient distribution” in your community will help, Reisman said, mirroring the efficient distribution by EMS in Boston. Within your walls, pre-planning and training will be keys to a successful response when a mass casualty incident occurs.

As Reisman repeatedly emphasized, the hospital needs to act as a team when activating the MCI plan. This includes supporting the decision to activate it—even if it ends up being unnecessary—and helping staff members after operations return to some sense of normalcy. Reisman said while he felt fine the day of the bombings, but on the one-year anniversary of the event, he struggled.

“There are just triggers that you’re not expecting. What’s important is we recognize that in our staff and we make it OK not to be OK and we have systems to support them when they need it,” Reisman said.