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Lessons In Emergency Preparedness After Boston Bombings


This is TALK OF THE NATION. I'm Neal Conan in Washington. Three people died from the blast and shrapnel of the pressure-cooker bombs at the finish line of the Boston Marathon. Hundreds more were injured, many severely. But as bad as it was, it could have been much, much worse.

Remarkably, everyone who arrived alive at an emergency room that Patriot's Day is expected to survive. Everyone in Boston, from EMTs and bystanders to nurses and surgeons responded with courage and competence. Hospitals had trained for mass casualties, and there was an element of luck.

As we look at what went right in Boston, we want to hear from emergency hospital workers around the country. What are you ready for, and what scares you? 800-989-8255. Email us, talk@npr.org. You can also join the conversation on our website. That's at npr.org. Click on TALK OF THE NATION.

Later in the program, the merits of memorizing poetry. Caroline Kennedy joins us on her new collection. But we begin with Dr. Paul Biddinger, medical direct for the emergency department operations at Massachusetts General Hospital. He's with us today from member station WBUR, and nice to have you on TALK OF THE NATION.

PAUL BIDDINGER: Nice to be with you, thank you.

CONAN: Can you take us back to the day the bombs went off?

BIDDINGER: Sure. When the race was going on, I was actually working in one of the medical tents on the course, on something called Heartbreak Hill, which is usually one of the busier tents, and my pager went off with notification there'd been an explosion at the tent at the finish line. Initially there was a suggestion it was a manhole cover.

I was standing next to officials from Boston Emergency Medical Services, EMS, and from the Department of Public Health. And so we quickly compared notes and rapidly figured out that this was much more than a manhole cover explosion and that this was something quite serious. We secured our operations at the medical tent, and I went to the hospital, first arriving at the hospital a couple minutes after the very first patients had arrived in our emergency department.

CONAN: And what did it look like?

BIDDINGER: There were parts of it that looked like one of our drills. People were standing where they were supposed to stand, gowned up for trauma resuscitations. We had lots of resources mustered and lots of people ready to go, but it was also incredibly clear that this was nothing like an exercise. There were very active trauma resuscitations going with some very, very critically injured people, and the noise and the intensity and the voices made it quite obvious that this was something much more serious than the exercises we've conducted.

CONAN: Did you have to decide whether to call in extra people?

BIDDINGER: Somewhat. We were fortunate that the events happened right at about shift change, and so around 3:00 is when hospital shifts often change. We had the day shift. We made the decision to hold all of them in the emergency department, and we kept the evening shift, obviously, quite busy. There were a lot of responders from elsewhere in the hospital, and some folks did come from home, but it was really remarkable that given the staffing we had, we actually had capacity to take care of even more patients, had we been asked to do so.

CONAN: Yet you had six critically injured patients. They came in almost immediately, some with almost no pulse.

BIDDINGER: That's correct. Six patients arrived in very, very short order, and they arrived into an incredibly busy emergency department. Our department is like most across the country, which is we are very busy and very active. I have 49 beds in our emergency department, and we had more than 90 patients that were receiving care at the time we first heard notification of the bombings.

CONAN: So how did you prioritize? Triage, we all hear about it, but how did you prioritize?

BIDDINGER: Well, the first thing is to have good plans in place to be able to make room for the incoming patients. We've studied mass casualty quite a bit, and we knew that the first few patients would arrive very quickly. Indeed, the first patient came without notification, initially about nine minutes after we first heard anything about this event. So we had very little time to make room.

Nonetheless, what we had planned for is if something like this happened, we had to make a lot of room in our emergency department. So we had patients sent from the emergency department to the upstairs floors with incomplete medication evaluations. But the admitting services, our medical service, other providers, really took the lead and were an integral part of our response so that we could have 30 open rooms within about 20 minutes after initial notification, which is what we had.

CONAN: So preparation, training played a big part in this?

BIDDINGER: It's not possible to tell everyone what to do when you hear something like this. They have to know it. And the only way they're going to know it is they will have practiced it, because I can tell them about it in a lecture, but they'll forget it very quickly. So we practice again and again and again. And people did the right thing because of practice, and that's one of the most important things that influenced our response.

CONAN: Where did you go to get advice as to how to prepare?

BIDDINGER: We've done it in a number of ways. Certainly we review the literature. There's a lot that people are studying out there about this. But we did two really important things, I think, that helped us a lot. Back in 2005, we invited a group of Israeli physicians and others to come over. They lectured us about their experience with improvised explosive devices, with terrorism, and gave us a lot to think about.

But they actually watched one of our practice exercises and critiqued it. And so when we responded, what we actually did was we used an altered triage system, different than what we had planned for before their visit, that allowed us to get patients into the emergency department much faster.

As a city we've also done a lot, and we hosted a conference here in the city two successive years, in 2008 and 2009, with leaders from London, where they had the subway bombings back in 2005; Madrid, where they had train bombings; Mumbai, where they had a mass terror attack, and they shared their experiences of how hard it is to distribute patients equally among the hospitals, how hard it is to make room inside active emergency departments, how hard it is to communicate and get good what we call situational awareness or a picture of the actual events.

And as a city I think we've worked very hard to learn those lessons. All the hospitals in Massachusetts, especially in the Boston area with Boston Emergency Medical Services, have been practicing these plans. And I think, again, the fact that we've worked together and practiced together, not just as individual hospitals, really affected our response.

CONAN: And have you gone back? Have you had the time to go back now and critique what you did right and what you did wrong on Patriot's Day?

BIDDINGER: We're working on it. We've had a number of internal debriefings in the emergency department, at the hospital level, with the surgical services, with the anesthesia services. This is one of those things where lots of lessons you want to capture quickly. People's memory fades, or it changes over time. But it's also important to process this in a rigorous and structured way. And so we are starting just now to really analyze the data of what we did, when we did it, what we could do better.

I'm sure there are things that we're going to need to improve, but right now we're still collecting data as much as we can.

CONAN: Yet your performance there and every other emergency room in Boston seemed to have certainly lived up to expectations.

BIDDINGER: Well, as someone who has professionally lost sleep about this for the last decade or so, it was good to see that the system worked the way that all of us had intended, as we've designed it across the city and across our hospitals. It's a terrible, terrible event, and I think all of us would have been much happier never to have had to test the system in the first place.

But it was good validation to know that the systems we've been planning for actually were able to perform.

CONAN: We want to hear from those of you work in emergency rooms around the country. What crises are you ready for, and what keeps you up at night? 800-989-8255. Email us, talk@npr.org. And let's bring Richard Knox into the conversation, NPR science correspondent, who's been covering the aftermath of the bombings and joins us now from his office in Boston. Richard, nice to have you back on the program.

RICHARD KNOX, BYLINE: Yeah, thank you very much, Neal.

CONAN: And we heard an element of luck there, that this happened pretty much at shift change, so there was a double staff on hand to help deal with this flood of patients. But there were other elements of luck. You reported the other morning that yes, these bombs were very nasty, but at least they went off outdoors.

KNOX: They went off outdoors. They were low to the ground. I think one of the hallmarks of these injuries is that they were very predominately lower-extremity injuries, and unfortunately that caused I think 15 people to lose their limbs because the force of the explosion went out laterally. And unfortunately one effect of that was that the 18-year-old - excuse me, the eight-year-old boy that was nearby got killed, one of the three fatalities.

But, you know, remarkably, nobody else of those - other than those three who died at the scenes, did die out of this. I think that's really one of the amazing things. Nobody who got into the hospital subsequently died.

CONAN: And outdoors is important because the blast effect is reinforced if it's enclosed.

KNOX: Yes, I gather that, you know, there's a lot of - well, there's two things. One is that the blast wave will get - will bounce back from the enclosed walls and structures. And then secondly you get collapse of the building if the bomb is strong enough, and then you have people crushed by that and difficulty in extracting them from the debris. So it's - it was a good thing, I guess, that people were outside.

And also, you know, amazingly there was this big concentration of first responders right there because it was near the finish line of the marathon, which is a very well-organized medical team on, you know, ordinary years. I think they see - they're prepared to see about 1,000 patients...

CONAN: They're ready for dehydration, maybe a heart attack.

KNOX: But you know, the people who are there may not be ready for this in terms of their equipment, but they certainly are trained first responders.

CONAN: So that was an element of luck as well. Clearly, though, we cannot rely on that combination that was - well, preparedness, that's something you can prepare for. Obviously the training that Dr. Biddinger described, that's something anybody can do. But that it happened at the right time and to some degree in the right place and in a city that has, well, extraordinary capacity.

KNOX: Yes, I think it's also very lucky that - where this happened. The explosions happened without about a - roughly a mile of six major trauma centers, one for pediatrics and five for adults, about equidistant from the Brigham and Women's and the Mass General and Tufts Medical Center, Boston Medical Center, Children's Hospital, Beth Israel, Deaconess Medical Center.

So, you know, it was pretty quick that people got to the hospital. I think, you know, within about the same amount of time that we're having this conversation, 30 of the most critically injured patients were treated and transported to hospitals, and that's pretty remarkable.

CONAN: Dr. Biddinger, as you look back on that day, do you feel lucky?

BIDDINGER: It's always hard to choose the right words. When there was so much death and injury to say that you feel lucky just never sounds like the right word. I think we do feel fortunate that things were not worse. We feel fortunate for the resources that we had. There are indeed a number of very capable hospitals, trauma centers.

Children's Hospital is a pediatric trauma center, as Richard mentioned. There are others. My hospital also can take care of adult and pediatric trauma. We have great clinical capability in this city, no question. But it also comes from a lot of planning and a lot of practice that I think we were able to - that we were able to respond the way that we did.

We were - I'll gladly take every single factor that worked in our favor that day, and if it means that fewer people died and fewer people were injured, that's a very good thing.

CONAN: Dr. Paul Biddinger, chief of the division of emergency preparedness, at Massachusetts General Hospital; also with us, NPR's Dick Knox, one of our health police correspondents there in Boston. We want to hear from those of you who work in emergency rooms. What are you ready for? What worries you? 800-989-8255. Email us, talk@npr.org. Stay with us. I'm Neal Conan. It's the TALK OF THE NATION from NPR News.


CONAN: This is TALK OF THE NATION. I'm Neal Conan. As the weeks passed since the bombings in Boston, we've learned more about some of those injured at the marathon. Some like Jarrod Clowery, a carpenter from Stoneham, Massachusetts, has spoken with the media. The blast left him with second-degree burns on 10 percent of his body and nails, ball bearings and bits of his own jeans embedded in his skin.

He has been treated at Brigham and Women's Hospital and told reporters his memories of the blast keep him up at night. That also severely injured three of his friends. That said, Clowery also remembered with awe how efficiently the hospital's doctors and nurses worked in the chaotic aftermath. That kind of praise echoed from all corners since Patriots' Day.

If you work in emergency medicine, call and tell us what emergencies is your ER prepared for and which ones scare you, 800-989-8255. Email us, talk@npr.org. You can also join the conversation at our website. That's at npr.org. Click on TALK OF THE NATION. Our guests are Dr. Paul Biddinger and NPR's science correspondent Richard Knox. And let's see if we can get a caller in. This is Kelly(ph), Kelly on the line with us from Lakeview in Oregon.

KELLY: Hi, how are you?

CONAN: Good, thanks.

KELLY: Good. I'm calling because we are pretty rural, and I work on the ambulance out there, and we work pretty closely with hospital staff because it's just a small community. And we're - our hospital ER is trauma level four. And that's one of the lowest, if not the absolute lowest. And for a big mass-casualty incident, we would end up transporting people by air to far towns, Portland, Oregon; Medford, Oregon; Bend, or by ground transport. And that's just hours for people to get the definitive care that they need. So by then the golden hour is kind of long gone. So we're really out there on our own.

CONAN: And that's obviously pretty scary. The odds of something happening, though, are relatively low.

KELLY: Yeah, they are. You know, we actually train and prepare for mass casualty incidents. Sometimes we prepare for school bus incidents or like a traveler, tourist bus incident come through sometimes. We have a mill up there. So we do train and prepare for those kinds of things. The risks are low, but I would argue that they're also a little bit higher because, I mean, our resources are just so slim.

CONAN: Well Kelly, thanks very much, and keep up the training.

KELLY: OK, thanks.

CONAN: Dr. Biddinger, I know you talked about worrying about this for the last several years, and, well, then in some degree your worst nightmare comes true. You have many more resources there in Boston than most hospitals.

BIDDINGER: It's true, but I would point to the experience of Joplin, Missouri, where a hospital sustained a direct hit from a tornado, and though it was not a small hospital, it was a several-hundred-bed hospital, it was relatively more rural, certainly, than Boston. And their preparations were fantastic. They only had a few seconds' notice before the tornado hit their facility, but all of their staff had planned, had trained, knew what to do.

And they protected patients. They rapidly were able to evacuate the hospital, and as the caller noted, they were also constrained somewhat in available EMS and transport resources, yet they were able to provide a lot of good medical care after the event in the parking lots, other unusual places.

And this really was the result of remarkable training that, again, you don't have to be a big, urban hospital to be able to make a big difference if something terrible happens.

CONAN: And has this kind of training accelerated after 9/11?

BIDDINGER: It really did. There's a lot of good work that was done in hospital emergency preparedness before 9/11. Here in Boston we actually had an emergency planning committee of the hospitals that was active since the 1980s. But most hospitals really re-evaluated their emergency operations plans. Many hired new, fulltime emergency managers after 9/11, and I would say that a great amount of progress in the health sector for emergency preparedness has been made in the last 10 to 12 years.

CONAN: And you've talked about how you were consulting with, well, people from Israel, people from Mumbai, people from London. Will you now be offering your expertise to places like Joplin, Missouri?

BIDDINGER: Absolutely. I think it's incumbent on all of us that have been through something like this to learn all of the lessons we can and to be as open and transparent and honest about our response as we can. Already the surgeons, emergency physicians, others involved in the response are forming, actually, a data-sharing group so that we're able to publish this in a way that's bigger than any one institution, bigger than any one hospital. And hopefully we'll let others, who are going to adjust their plans, learn our lessons and improve their response from the things that we both did well but also that we could have done better.

CONAN: Here's an email that we have from Kathleen(ph) in Cleveland: Many years ago I was the radiation safety office at a small outside of Cleveland. We once conducted a mock disaster involving a radiation spill. The drill went well, but my heart sank when I found out about the nuclear power plants in Japan. There are some things no amount of planning can prepare for.

And Dick Knox, as you see those kinds of incidents, yes, there are things that you can train for and you must train for, but yeah, people can get overwhelmed, too.

KNOX: Sure, yes. I mean, there's an infinite possibility of things out there that can - bad things that can happen, and you never know which one is - you're going to have to be confronted with. But I mean, I think that there's been a lot of thought, as Dr. Biddinger - I'm sorry...


KNOX: I've heard it pronounced a couple of different ways - Dr. B has pointed out there's a lot of planning and thought put into some of the contingencies that might have to be faced. And, you know, with a nuclear power plant, that's - there's a finite number of things that one can plan for, evacuate from, you know, and be ready for.

So, you know, it's - it's daunting, but it seems to be doable to plan.

CONAN: Let's see if we can go to another caller. This is Cindy(ph), Cindy with us from Charlotte.

CINDY: Hello, yes. I'm a retired paramedic with nearly three decades of experience, and in Charlotte we have an international airport, two nuclear power plants, and we host one of the largest sporting events in the world with the Coca-Cola 600. And several years ago we conducted a large multi-agency drill for a sarin gas attack. And the local media blasted us for wasting taxpayer money to play.

So I really appreciate your doctor raising awareness for the need for agencies and hospitals to drill because apparently a lot in the general public are not aware of that.

CONAN: When you say blasted for playing, in other words you had people who were portraying victims, that sort of thing?

CINDY: Well yes, we had hundreds of people. We had multiple agencies. And I know at least one local radio station, the hosts were complaining about us wasting taxpayer money to go out there and play.

CONAN: Dr. Biddinger, can you give us some idea of, well, what kinds of resources you devote there at Mass General to training?

BIDDINGER: Well, I think this is an area where being a bigger hospital does help. We have dedicated a good portion of our own hospital funds to training and preparedness. And I think it - your caller's experiences is right on with many and actually is really unfortunate. A lot of hospitals rely on federal funding. There's a great program called the Hospital Preparedness Program offered through the assistant secretary for preparedness and response at the Department of Health and Human Services.

And they give money to hospitals and to health sector organizations to practice their preparedness. Like a lot of the preparedness money since 9/11, it's actually been decreasing from Congress. And I think that's a real shame. I think that we've built a tremendous capability in the health sector with those funds, with those lessons, with those exercises.

And the threats really are not going away. So it seems really challenging to ask people to continue to practice, to continue to maintain a state of readiness when you're taking away the funding that supports them being able to do so.

CINDY: Yes, well, the agencies that were involved in our drill were all governmental agencies: police, fire, and we have a government-based EMS system. So we were using taxpayer money because we are taxpayer-based. So - but it is imperative that we drill for these things because, as you say, you can't just tell somebody how to do this. You've got to know what to do.

CONAN: Cindy, thanks very much for the call.

CINDY: Thank you.

CONAN: Here's an email, this from Ruth(ph) in Lincoln City, Oregon: I've worked as a medical laboratory technologist for over 35 years in a community hospital, a busy level two trauma center and a small critical access hospital. In a mass casualty situation, my greatest fear is not having enough blood available for transfusion. Blood supplies are often critically low. Blood donors are always needed.

And Dick Knox, this is - from time to time you hear appeals from various places, particularly coming up on holiday weekends, that sort of thing.

KNOX: Yes, that's, you know, a chronic problem, and it gets worse, as you say, during holidays and things when people are not donating - at least the ones who do donate regularly aren't. Often when you have a mass casualty event like this, it's striking that people really do come forward, and there's sometimes even a surplus of blood.

Obviously you don't want to count on that, and then of course in rural situations, it's not going to be as effective as in a place like Boston. But, you know, I think that at least with these high-visibility mass events, you know, people do step to the plate.

I wondered - I was going to ask, if I may, Dr. Biddinger, your impression of the importance of the bystander response, the Good Samaritans out there. I mean, one of the striking things about this episode we've just been through is that there were a number of remarkable stories of people at the scene who had the presence of mind to apply compresses to staunch the bleeding which saved the life of an 18-year-old girl, who I've been following, to rip off their belts and apply tourniquets and, you know, do things like that that I wouldn't necessarily expect bystanders to do. How big a role did that play in our good outcomes here?

BIDDINGER: I think it likely played a very significant role. There's no question that stopping the bleeding from this type of injury saves lives. Interestingly, it's actually one of the most important lessons, in the civilian medical community, we've learned from the wars in Iraq and Afghanistan. And, actually, as a result of it, the Boston EMS ambulances carry tourniquets just like the military tourniquets on their ambulances. They were used at the finish line. I have no doubt they saved lives.

I have no real way to know just yet, though. It is one of the many things we're looking at, whether bystanders started applying tourniquets because it seemed right or because they watched the Boston EMTs and paramedics and other medical professionals at the finish line doing the same and simply used whatever they had available. Whatever the reason is that they knew to do it, it absolutely saved lives. And I think it is tremendous to say that it's not just the professional responders that saved lives that day.

It really was doctors and nurses standing at the finish line who were in every way unaffiliated with the formal part of the medical response, but everyone stepped up, and everyone played a role. And I think it speaks wonderfully not just of the Boston community, but those that were visiting from out of town and quickly jumped in to lend a hand.

CONAN: There was an interesting piece in The New Yorker by Dr. Atul Gawande at Brigham and Women's, a frequent writer for The New Yorker. I don't know if you had a chance to read it, but he said: In a way, we have lost the naivety and that sense of shock that we had at 9/11, and that we were - in some sad sense, maybe - but in a real and important sense, ready for this. Would you agree with that, Doctor?

BIDDINGER: It's surprising to me, when I talk to people about events like this, that they seem to have thought it through, even when they're not part of the professional response community. People wonder what direction they would run or how they would help or what their first priorities are. And I think that's probably right that we are a little less naive as a nation, and more people have thought if - wondered to themselves, if I'm in the middle of a crowd, what would I do? But I think it's wonderful to see how many people step in and help and save lives when something like this happens.

CONAN: Dr. Paul Biddinger, chief of division of emergency preparedness at Massachusetts General Hospital. Also with us, NPR science correspondent Richard Knox. You're listening to TALK OF THE NATION, from NPR News. And let's get Katherine on the line. She's joining us from San Francisco.

KATHERINE, BYLINE: Hi. I'm calling because I'm a nurse in both New York City and San Francisco. I work in intensive care, and I've really never been a part of any of these kind of preparations. And I worry if I'm pulled to the - moved to work in the E.R. during this kind of situation, that we aren't as prepared. We're not actually helping the team as much as we could. In your situations, were they trained in the whole hospital, or was it just the emergency part?

BIDDINGER: Well, I think that's a great question. We are certainly trying to get deeper and deeper into the hospital with every exercise we do. Again, my hospital is relatively large, about 20,000 employees, so we can't say we've gotten to everyone. In most situations, what we actually need people to do is do their own jobs as well as they can. And so our intensive care unit nurses, for example, took on extra assignments, took extra patients in so that of the existing patients in the emergency department who needed ICU care before the bomb went off, they rapidly took care of those patients in the ICU faster than they normally would have assumed care. And that was incredibly helpful in supporting our response.

Since the event, we certainly have been continuing discussions with our operating rooms, our intensive care units, our medical service and others to find ways to get them to participate in the exercises. Again, we've been very fortunate at my hospital that we have a lot of buy-in across the institution for people to practice these exercises, but it still can be hard. When the intensity of events like this passes, people don't really want to have their day jobs bothered by persistent exercised activities.

And I think it's just important to remember that not just one year from now, two years from now, five years from now, but we will be exercising across the hospital just in case, and hopefully people will continue to participate with us.

CONAN: And a critical word there: persistent. You can't just do this once or twice.

BIDDINGER: That's exactly right.

CONAN: Katherine, you think your intensive care unit would be ready for that kind of buy-in?

KATHERINE: I actually - I do. The intensive care unit I'm working in right now, they're very cohesive. They work together very well, and they're - everybody pitches in and helps a lot. I was just worried about, you know, if we were pulled and sent to the E.R., which happens sometimes. And so I would just a little concerned about not being as helpful as I possibly could.

CONAN: Katherine, thanks very much.

KATHERINE: Thank you.

CONAN: And let's see if we can go next to - this is Bill, and Bill's on the line with us from Cambridge, Massachusetts.

BILL: Hello.

CONAN: Hi, Bill.

BILL: Hi. I heard the comments earlier about the caller who was talking about the criticism they received for participating and planning exercises. The one thing I've learned from the exercises that I was involved in as a participant and as an organizer is that you get your best results when the players, the participants do not know the content of the exercise before they arrive.

CONAN: Oh, in other words, they don't know if, for example, it's a sarin gas attack.

BILL: Exactly. They don't know what challenges they will face. You get - you really waste some of your resources or your time if they have time to prepare in advance, because in most emergencies, particularly as we saw in Boston, no one really was preparing for that type of event. You really need to prepare for all types of events, and the planning should be a challenge. It shouldn't just present an opportunity to practice. It should be a problem-solving event.

CONAN: Dr. Biddinger?

BIDDINGER: Well, I think that's right. I think it's hard to plan exercises that are appropriately both test the system and make sure you know what you're capabilities are, but also don't break the system and undermine confidence. It's interesting. I heard a presentation just yesterday from a colleague of mine who was part of the New York Hospital evacuations after Superstorm Sandy. And she said that if someone had ever given her the scenario that they faced with loss of power, loss of generators, loss of light, loss of phone, everything they went through, and they had to evacuate the entire institution, she would have criticized the scenarios as over-the-top and too much.

And so I think we do have to be willing to push ourselves. We have to be willing to give scenarios that are challenging. But, again, it's the iterative. It's participating in this regularly that helps us most.

CONAN: Bill, thanks very much for the call.

BILL: Thank you.

CONAN: And, Dr. Biddinger, thanks very much for your time today.

BIDDINGER: My pleasure to join you. Thank you.

CONAN: Doctor Paul Biddinger of Massachusetts General Hospital. Our thanks, as well, to NPR's Richard Knox, with us from his office in Boston. Coming up next: Caroline Kennedy joins us with the poems we should learn by heart as children. It's the TALK OF THE NATION, from NPR News. Stay with us. Transcript provided by NPR, Copyright NPR.

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