Tragedy... when faced directly and bravely, leaves humans not diminished, but ennobled.
—Sophocles1 497-406 BC
We Are Boston Strong. This is our mantra, days after 2 bombs explode, 12 seconds apart at the finish line of the 117th Boston Marathon. On a brilliant Patriots Day in our historic city, an 8-year-old boy and 2 young women are killed instantly. Over 260 spectators and runners were injured. Before the week is out, a police officer is killed and another critically injured. One suspect is dead, one is captured.
Thousands of people arrive in Boston each year, to run or cheer on the runners. It is an annual rite of spring in Boston as more than 23,000 people start the race in Hopkinton, Massachusetts. The field is filled with elite runners from all over the world. However, many run for charities, in honor of loved ones, or simply to achieve a personal best. Crowds line the route along the 26.2-mile race, cheering and offering water or first aid. Boston College, where I teach, marks the 21st mile where runners endure mile after mile of difficult terrain, famously called “heartbreak hill.” At the finish line, families and friends wait for their loved ones with flowers, blankets, relief, and pride. The crowds at the finish are up to 15 people deep.
Hundreds of volunteers pack the course and staff medical tents. Doctors, nurses, physical therapists, chiropractors, podiatrists, and massage therapists back up a fleet of fire and police officers to ensure safety and order. Hospitals staff up, anticipating extra patients with hypothermia, dehydration, and a multitude of injuries or illnesses that often accompany large crowds.
I have lived a lifetime in Boston; it is my home and home to everyone I love; I am blessed. I love Marathon day and have missed very few. This year, my friend Carol and I wanted to cheer on some friends, students running for BC, neighbors, and friends of friends. We enjoyed walking around Copley Square; we marveled at the spectacle at the finish line. It was a beautiful spring day. Unable to cross Boylston Street at the finish or at any point, we headed south to Arlington Street, west past the Public Gardens, and turned north on to Commonwealth Avenue, arriving at her son’s condo, at the 25.5-mile mark on the route. This is a great spot to watch the runners. My cell phone reported locations of runners I was following; some were to arrive at the 25-mile mark soon. Standing on the steps of this beautiful historic brownstone building, I watched as the crowd rolled into “Comm Ave” from Kenmore Square. Suddenly, I heard cannons to my left. Strange, I thought for a moment, did someone fire a cannon? Seconds later, another blast.... Maybe a food truck or electrical explosions, I thought, remembering the congestion and equipment we had passed. Officials in front of us stopped the race; we exchanged worried glances and a few words with some runners, one of them sporting a Boston State Police T-shirt. I’m a nurse, I told him. Stay close, he warned, it could be something....
At 2:20 PM, 2 bombs exploded at the finish line, 12 minutes apart. They were low-cost, improvised explosives, containing nails and small ball bearings. A domestic terrorist attack, or something else... the city moves into alert, there is potential for more explosions, helicopters fill the sky, ambulances and swat teams converge on the city, and the Boston medical community responds.
Care of the wounded begins at the scene. Medical personnel, volunteers, firefighters, and spectators run toward the explosion tearing off shirts and belts to fashion makeshift tourniquets and bandages. Victims have limbs blown off, shrapnel wounds, burns, gruesome fractures, head injuries, concussions, perforated eardrums, eye injuries, and internal injuries. The runners’ first aid tent was transformed into a mass casualty triage unit. Victims were rushed to more than 8 different hospitals; through a city that was clogged with frantic people, looking for loved ones, looking for safety. Cell phone service jammed, subways halted, buildings evacuated... the city locked down.
How Did Boston Hospitals Handle This Act of Domestic Terrorism, and Why Where They Ready?
Remarkably, it appears that every victim alive when rescuers reached them will survive.2 The work is an amazing tribute to the efforts of emergency care and disaster management.
Dr Atul Gawande2 tells us, it is practice... drills, preparation, and coordination of emergency care, orchestrated well because medical staffs were ready and rehearsed. In our post 911 world, we have prepared. At hospitals, clinicians considered the possibility of radiation or chemical contamination. The first responders braced for additional attacks, even at hospitals.
Over the past few years, we have witnessed shootings, natural disasters, and wars that have prepared many young practitioners and have caused us to question our level of preparedness. Gawande reminds us, disaster response has become an area of wide interest and study. Recently, Massachusetts General Hospital brought in Israeli physicians to help with disaster planning, and Brigham and Women’s hospital hosted a lecture after the Aurora shooting entitled, “Are We Ready?”2
In 2009, Rich Serino, then Boston’s EMS chief and now deputy administrator of the Federal Emergency Management Agency, hosted the first citywide “Tale of Our Cities” conference in Boston. More than 750 locals attended, learning lessons taught by doctors from India, Spain, Israel, Britain, and Pakistan who had managed the consequences of terrorist attacks. They explained the nature of the blast injuries they treated, the triage systems they used, and other lessons responders can use to save lives.3
In Boston that day, medical teams worked smoothly, doing what they do every day... but on a larger scale. A young man with severe burns on his hands and legs and a body shredded by shrapnel from the second explosion watched the doctors and nurses from his stretcher in the emergency room at Brigham and Women’s Hospital. “They’re moving seamlessly,” he recounted at a press conference “They know what each other’s thinking... I’ve never seen, in all these years in New England, Tom Brady put a drive together that is as good as what these people are doing.”4
On the streets of Boston, friends and strangers banned together to assist thousands of runners unable to get to the finish line. Sadly, many runners stopped on the course and had no way to reach loved ones at the finish line. Many were far from home, shivering, frightened, dehydrated, and in need of that medical tent only miles away. The local citizens and spectators of Boston cared for these runners and guided them to safety.
How Do We Move on as a Medical Community and How Do We Share What We Have Learned?
We must continue to ask ourselves the question... Are we ready? We must huddle with our colleagues, leadership teams, community first responders, and family members. Review the events of the past decade; consider the Boston bombings. Ask yourselves, what would you need to do differently? Can you transfer what you do each day into a large-scale operation in the face of chaos?
Discuss concerns often; question your practice every day.
Consider an emergency plan for your family and loved ones. How do we communicate when phone lines are overwhelmed? In Boston that day, some people used text messages, twitter, and e-mail. Many used apps such as “find my phone” to locate family members. Test your plan; communicate in many ways
Become informed about what types of information are best for children watching events unfold, those far from home, and families and friends of the medical workers who are actively responding.
Be vigilant, be hopeful.
Kathleen Ahern Gould, PhD, RN
William F. Connell School of Nursing
Chestnut Hill, Massachusetts