Prof Alan Cohen's presentation on healthcare services in Boston and relfections on the disucssions from Day 1, for the CLAHRC WM Scientific Advisory Group meeting, 10th June 2015, Birmingham, UK

1. Some Thoughts from Boston
and Reflections from Day 1
Alan Cohen
12/06/2015

2. The Winter of 2014 – 15
in Boston
• New record (#1) – 108.6 inches of snow
(most since records first kept in 1872)
• #2 – 107.6 inches (1995 – 96)
• #3 – 96.3 inches (1993 – 94)
• #5 – 86.6 inches (2004 – 05)
• #7 – 83.9 inches (1992 – 93)
• #8 – 81.0 inches (2010 – 11)

5. SOURCE: http://www.bostonglobe.com/metro/2015/02/03/new-website-lets-boston-residents-track-status-snow-plowing-their-street/DkcvnntnCN3YYkiqvZNU0N/story.html

6. SOURCE: http://www.bostonglobe.com/metro/2015/02/03/new-website-lets-boston-residents-track-status-snow-plowing-their-street/DkcvnntnCN3YYkiqvZNU0N/story.html

7. SOURCE: http://mashable.com/2015/02/07/boston-record-snowstorm/

9. The View from My Front Door

10. Hope Springs Eternal

11. The Boston Marathon
April 15, 2013

12. Recent Events
• The Trial of Dzhokhar Tsarnaev, accused
Marathon bomber
 In the first (“guilt”) phase, Tsarnaev was convicted
on all 30 counts of crimes for which he was charged
• 17 carried the death penalty
 Massachusetts does not have the death penalty,
but the trial was held in federal court (which does)
 In the second (“sentencing”) phase, Tsarnaev was
sentenced to death on all 17 counts
 Now awaiting appeal

13. April 15, 2013
• The Marathon
 >26,000 runners
 >500,000 spectators
• The Incident
 2:49 PM: 1st explosion
 2:50 PM: 2nd explosion (12 seconds later)
• Near the Finish Line
 17,000 had completed the run
 9,000 still running

14. v

18. "My first reaction was to
run toward the people.
There was so much
commotion and a lot of
people running away. I
was one of the first to help
people and God protected
me. It was horrific.“
-Carlos Arredondo
• He used part of his
clothing to make a
tourniquet to slow the
blood loss from the man's
severed artery.

19. The Immediate Aftermath:
Destruction and Carnage
• 3 people dead
• 264 people
injured
• The cause: 2
pressure-cooker
bombs placed
near the finish
line
SOURCE: http://www.cnn.com/2013/04/16/us/boston-marathon-victims-profiles/

20. Young Lives Lost
• Krystle Campbell, 29
• Lingzi Lu, 23, BU
graduate student
• Martin Richard, 8
SOURCE: http://www.cnn.com/2013/04/16/us/boston-marathon-victims-profiles/

21. Medical personnel manning the
runners’ first-aid tent swiftly
converted it into a mass-
casualty triage unit

22. Medical Tent A
• Care for the wounded began at the scene of the blasts
• Patients had severe eye damage, deep flesh wounds,
and ruptured internal organs
 Similar to trauma seen in serious car accidents
• The medical tent had been set up to treat running
injuries, e.g., dehydration, hypothermia, and cardiac
arrest
• But doctors improvised
 The critically wounded were triaged to the back of the tent
 Routine ailments were treated in the front

23. Reactions of Clinicians
SOURCE: https://www.llis.dhs.gov/sites/default/files/Boston%20Marathon%20Bombings%20Hospital%20Readiness%20and%20Response.pdf
“There were victims coming in with both
legs blown off. I had never seen anything
like that.”
- Dr. Sushrut Jangi, Internist at Beth Israel
Deaconess Medical Center
Dr. Richard Wolfe, Chief of the Emergency
Department at Beth Israel Deaconess, said
that in his 14 years at the hospital, “nothing
comes close” to what he witnessed.

24. Initial Response
SOURCE: https://delvalle.bphc.org/mod/page/view.php?id=610

25. Emergency medical teams
mobilized from around the city
and transferred the victims to 9
different hospitals in minutes,
despite the chaos.

26. Patient Transports in the First 60 Minutes
SOURCE: https://delvalle.bphc.org/mod/page/view.php?id=610

27. SOURCE: https://delvalle.bphc.org/mod/page/view.php?id=610

28. 166 Patients Treated
at Six Level 1 Trauma Centers
SOURCE: https://www.llis.dhs.gov/sites/default/files/Boston%20Marathon%20Bombings%20Hospital%20Readiness%20and%20Response.pdf, Mary Devine,
Presentation at Conference of Boston Teaching Hospitals; & http://www.bostonglobe.com/lifestyle/health-wellness/2013/04/15/boston-hospitals-treat-injured-
with-wounds-more-often-seen-war-zones/MczjJJkkdLvjzqR9MK407N/story.html
Hospital Patients
Massachusetts General Hospital 37
(4 ER amputations)
Brigham & Women’s Hospital 38
(20 ER surgeries)
Boston Medical Center 29
Beth Israel Deaconess Medical
Center
24
(17 ER surgeries)
Boston Children’s Hospital 10
(children ages 2-12)
Tufts Medical Center 28

29. Brigham and Women’s Hospital
• 38 victims received; 28 with significant injuries
• 3:00 pm: Change of nursing shift
 Immediately notified day shift to stay on
 No one wanted to leave, anyway
• 3:08 pm: 7 patients arrived nearly at once
 All required emergency surgery
• The rest followed, spaced by just one minute each
• 3:25 pm: 1st patient surgery
 A patient in shock, hemorrhaging profusely, with inadequate
breathing and a near-completely severed leg
• 20 underwent surgery that day
 Mostly vascular and orthopedic procedures

30. Why Boston Was Ready
“Boston's health care providers reacted the way they did
because they knew what they were supposed to do. Those
who did not were smart enough to follow the lead of those
who did. That's how a ‘ritualized’ disaster plan works.”
– Arthur Kellermann, Dean of the F. Edward Hébert School of Medicine at
the Uniformed Services University of the Health Sciences
“We all know each other. That connectivity is one
big piece of why things went so well.”
– Meg Femino, Director of Emergency Management at Beth Israel
Deaconess Medical Center

31. Why Boston Was Ready
SOURCE: BUSPH PH712 Boston Marathon Bombing Case Study, NEJM Perspective May 2013 “Be Prepared — The Boston Marathon and Mass-Casualty
Events” http://www.nejm.org/doi/full/10.1056/NEJMp1305480
“The fact that the response was so well
executed wasn’t an accident—it was a result of
years of planning and coordination.”
– Richard Serino, FEMA Deputy Administrator

32. Why Boston Was Ready
Planning and practice make the difference
1. Partnerships are key
2. Social media can be effective
3. Volunteers and spectators can contribute
4. Improved resource allocation and information
sharing
5. Respect for survivors and victims
6. Recovery is ongoing—especially mental
health
SOURCE: BUSPH PH712 Boston Marathon Bombing Case Study, NEJM Perspective May 2013 “Be Prepared — The Boston Marathon and Mass-Casualty
Events” http://www.nejm.org/doi/full/10.1056/NEJMp1305480

33. Medical Intelligence Center (MIC)
• 1 minute after the first explosion, an EMS staff member in a marathon
medical tent alerted the center
• Within 10 minutes, an alert was sent to all area hospitals
– EMS radio dispatches: “Explosion near Medical Tent A. EMS will be using red
wristbands for patients. Multiple casualties reported.”
SOURCE: http://www.bostonglobe.com/lifestyle/health-wellness/2013/05/23/medical-intelligence-center-key-player-marathon-bombing-response-marks-
anniversary/bVemZLR8CCvdBbIfKfGUkL/story.html
• Only one of its kind in the U.S.
• Based out of the Boston Public
Health Commission
 Operates with money from city,
state, and federal governments
 Operates on certain days
• Marathon
• New Year’s Eve
• July 4th
• Weather and other emergencies

34. Coordination by MIC
• 7:00 PM: MIC briefing reported that 110 patients were
known to be injured
 1 hospital experienced a shortage of amputation kits and was
looking for more
• 2 days after the bombings: Seaport World Trade Center
donated space for victims and families to meet privately
with law enforcement authorities
• >120 teams of grief counselors were deployed by MIC to
help 1,500 traumatized people
 Marathon volunteers, first responders, staff working in stores
in the Boylston Street area, and health care providers
treating victims
SOURCE: http://www.bostonglobe.com/lifestyle/health-wellness/2013/05/23/medical-intelligence-center-key-player-marathon-bombing-response-marks-
anniversary/bVemZLR8CCvdBbIfKfGUkL/story.html

35. SOURCE: https://delvalle.bphc.org/mod/page/view.php?id=610

36. SOURCE: https://delvalle.bphc.org/mod/page/view.php?id=610

37. What Saved Boston…
It Could Have Been Worse
• 6 Level 1 trauma centers within one mile
• Blasts occurred 10 minutes before the 3:00
pm shift change at area hospitals
 Double staff were available to help
• Emergency response preparedness
 2002: Operation Prometheus – a multi-day exercise that
simulated the explosion of a dirty bomb; over 50 agencies
and 10 hospitals participated
 2011: Operation Falcon II – a functional exercise that tested
hospital response plans and their ability to handle a surge
of patients
SOURCE: https://www.llis.dhs.gov/sites/default/files/Boston%20Marathon%20Bombings%20Hospital%20Readiness%20and%20Response.pdf

38. • Aid to Victims
 Established to help those most affected by the
bombings
 $61 million collected and distributed in 75 days to
230 victims and survivors
 100% of donations dispersed; no overhead expenses
 2014 – additional $18.5 million in gifts distributed
 200,000 individual donations from 50 states & 60 countries
 $1.5 million to establish One Fund Center in
Massachusetts General Hospital
SOURCE: https://secure.onefundboston.org/pages/about

39. The Boston Marathon
2013 - 2015
• 2013 Winner – Men’s Division
 Lelisa Desisa of Ethiopia – donated his medal to
the City of Boston
• 2014 Winner – Men’s Division
 Meb Keflezighi – first American man to win the
marathon since 1983
• 2015 Winner – Men’s Division
 Lelisa Desisa of Ethiopia – got to keep his medal
this time
SOURCE: https://www.llis.dhs.gov/sites/default/files/Boston%20Marathon%20Bombings%20Hospital%20Readiness%20and%20Response.pdf

41. Reflections from Day 1