The 2013 Boston Marathon Bombings Lessons Learned from a Resource-Rich Urban Battlefield Presented at the 41 st Convention of the American Society of Plastic Surgical Nurses Boston, Massachusetts October 17, 2015
Acknowledgements The Boston Trauma Consortium BETH ISRAEL DEACONESS MEDICAL CENTER BOSTON CHILDREN S HOSPITAL BOSTON MEDICAL CENTER BRIGHAM & WOMEN S HOSPITAL MASSACHUSETTS GENERAL HOSPITAL TUFTS NEW ENGLAND MEDICAL CENTER Collaborative effort to amass reliable, city-wide data 2
Context The Context Annual road race held in Greater Boston Finish line in downtown Held on Patriot s Day (civic holiday) Estimated 500,000 spectators annually, most along race course Approximately 27,000 registered runners in 2013 3
The Event The Event 117 th Boston Marathon 4/15/13 Two IEDs detonated just shy of finish line at 2:50pm Devices concealed in backpacks deposited on sidewalk abutting race course High density of spectators at both detonation sites 4
Victim Demographics Victim Demographics Patient Demographics (Patients Treated on 4/15/13) Total Number of Patients 127 Patient Age 15 and Older 92.1% (N=117) Under 15 7.9% (N=10) Country of Origin United States 75.6% (N=96) Outside the United States 3.2% (N=4) Unknown 21.2% (N=27) Role in the Event Spectator 74.0% (N=94) Runner 2.4% (N=3) EMS 0.8% (N=1) Police 4.7% (N=6) Other 3.1% (N=4) Unknown 15.0% (N=19) Location E Code Road / Sidewalk 79.5% (N=101) Public Building 3.2% (N=4) Unspecified Place 16.5% (N=21) Other 0.8% (N=1) 5
On-Site Response On-Site Response Lifesaving care provided by numerous bystanders Medical tent located in close proximity to blast sites with multiple highly trained personnel Timely activation of city-wide EMS disaster response 6
On-Site Response On-Site Response Pre-Hospital Care (Patients Treated on 4/15/13) Signs of Exsanguinating Extremity Wounds Yes 24.4% (N=31) No 75.6% (N=96) Tourniquet(s) Applied if Exsanguinating Wounds (100% to Lower Extremities) Yes 83.9% (N=26) No 16.1% (N=5) Was a disaster tag applied? Yes 0.8% (N=1) No 18.1% (N=23) Unknown 81.1% (N=103) 7
City-Wide Triage City-Wide Triage 281 total injured 3 declared on scene 151 treated at six level 1 trauma centers located within 2 miles of blast sites Remainder treated at nine local secondary acuity hospitals 8
City-Wide Triage Patient Mode of Transportation to Hospital (Total n = 151) 81 28 14 2 2 Ambulance Walk-in Police Other Vehicle Unknown 9
Distribution of Patients Distribution of Patients by Institution (Total n = 151) 40 20 28 32 23 8 A B C D E F 10
Emergency Department Management Emergency Department Statistics Patient Stats Upon Arrival in ED (Patients Treated on 4/15/13) Blood Pressure, range 50/30 to 210/100 Heart Rate, average 92 Heart Rate, range 52 to 137 Glasgow Coma Scale (GCS) Less than or equal to 8 0% (N=0) 9 to 14 2.4% (N=3) 15 70.9% (N=90) Undocumented 26.8% (N=34) 11
Emergency Department Management Emergency Department Interventions ED Interventions (Patients Treated on 4/15/13) Interventions Emergency airway 9.5% (N=12) Central access 0.8% (N=1) PIV access 30.7% (N=39) IO access 0.8% (N=1) Crystalloids 30.7% (N=39) Colloids 1.6% (N=2) C-collar 3.9% (N=5) Analgesia 32.3% (N=41) Splint 3.2% (N=4) Other 18.9% (N=24) Radiologic Studies CXR 50.4% (N=64) FAST 18.1% (N=23) Pelvis 22.8% (N=29) CT scan 25.2% (N=32) Transfusion Administered? Yes 11.8% (N=15) No 88.2% (N=112) Type of Transfusion Packed cells 11.8% (N=15) Plasma 3.2% (N=4) Platelets 1.6% (N=2) 12
Nature of Injuries Nature of Injuries Preponderance of lower extremity injuries due to ground level location of devices High fragmentation burden due to dispersal of pressure cooker containers and internal projectiles Rudimentary device design resulted limited blast radius Fairly localized thermal radius Heavy contamination of wounds due to recruitment of street-level dust, garbage, etc. Human debris additional source of fragmentation injury 13
Distribution of Injuries Distribution of Injuries Face: 76 Head & Neck: 23 Chest: 9 Abdomen: 9 Extremities/Pelvis: 140 14
Initial Operative Management Initial Operative Management (Total n=54) 6 (11%) 3 (6%) 45 (83%) Direct to OR ICU then OR Ward then OR 15
Initial Operative Management Number of Patients 15:00 15:15 15:30 15:45 16:00 16:15 16:30 16:45 17:00 17:15 17:30 17:45 18:00 18:15 18:30 18:45 19:00 19:15 19:30 19:45 20:00 20:15 20:30 20:45 21:00 21:15 21:30 21:45 22:00 130 120 110 100 90 80 70 60 50 40 30 20 10 0 Operative Management Relative to ED Arrival Patients into the ED Patients into the OR Time 16
Operative Management Operative Needs TRIAGE DEBRIDEMENT FIXATION COVERAGE Standard principles of operative management 17
Institutional Example Number of Patients Hospital Course and Discharge Status Inpatient Phase (Patients Treated on 4/15/13) Patients Who Required Additional Surgery after Admission ICU LOS, average ICU LOS, range Patients Who Experienced Complications Hospital LOS, average Hospital LOS, range 33 30 72.0% (N=54) 5.06 days 1 to 22 days 5.3% (N=4) 10.68 days 1 to 49 days 11 1 Rehab Home Home with Services Skilled Nursing Facility Zero percent mortality among patients who made it to hospital alive 18
Lessons Learned Lessons Learned REAFFIRMATION OF PRIOR BATTLEFIELD EXPERIENCE & NEW INSIGHTS BASED ON SPECIAL CIRCUMSTANCES Important given unfortunate likelihood of similar events in urban areas in the future 19
Lessons Learned Applicable Principles from Prior Battlefield Experience Timely tourniquet control (HABC philosophy) Scoop and run policy for initial patient management High-altitude patient triage Rapid operative management Stage closure of wounds Infection prophylaxis and crosscontamination 20
Lessons Learned Blast Injury Components COMPONENT CAUSATIVE AGENT CHARACTERISTIC INJURY MARATHON EXPERIENCE Primary Pressure wave Tympanic membrane Pulmonary Globe Hollow viscera +++ TM Secondary Device and biological fragmentation Penetrating injuries +++ LE +++ Human to human Tertiary Blast wind Structure collapse Minimal Quaternary Burning components and toxic exposure Inhalation injuries Thermal injuries Minimal 21
Lessons Learned 22
Lessons Learned Special Circumstances Civic holiday with ample OR capacity and staffing Close proximity of several major academic medical centers Well educated populace On site medical infrastructure Effective, coordinated city-wide EMS system Full breadth and depth of medical expertise Unique opportunity to learn from experience in resource-rich environment 23
Lower Extremity Injuries Distribution of Injuries by Number of Patients (Total n = 151) Lower Extremity Injuries, 49, 32% Other Injuries, 102, 68% 24
Lower Extremity Injuries Management of Lower Extremity Injuries by Limb (Total n=60) Amputation, 12, 20% Limb Salvage, 48, 80% 25
Institutional Amputation Rates Institutional Amputation Rate for Injured Lower Extremities 33% 22% 18% 17% B E F D Mean Age % Male Mean ISS Mean MESS No. Services 39.3 55% 13.80 6.67 1.67 37.1 18% 10.55 4.56 2.33 34.5 44% 19.50 5.00 1.73 37.3 44% 11.89 6.83 2.92 Note: Differences in amputation rates do not demonstrate statistical significance 26
Collaboration Hypothesis Hypothesis: Impact of Collaboration in Acute Management VASCULAR SURGERY PLASTIC SURGERY ORTHOPEDIC SURGERY TRAUMA SURGERY 27
Role of Plastic Surgery 28
Role of Plastic Surgery 29
Role of Plastic Surgery 30
Role of Plastic Surgery 31
Role of Plastic Surgery 32
Political Caveat One Fund Cash Distributions A total of 6 eligible claimants each received $2,195,000. This category includes loss of life and those who sustained double amputations of limbs or permanent brain damage as a result of the Marathon tragedy. A total of 14 eligible claimants each received $1,195,000. This category includes those who sustained amputation of a limb as a result of the Marathon tragedy. A total of 69 eligible claimants each received between $125,000 and $948,300, as detailed in the list below. This category includes those who were physically injured and hospitalized for one or more nights due to physical injuries resulting from the Marathon tragedy. They received payments determined by length of hospital stay: 10 eligible claimants received $948,300 for 32 or more overnights 5 eligible claimants received $735,000 for 24-31 overnights 5 eligible claimants received $580,000 for 16-23 overnights 15 eligible claimants received $480,000 for 8-15 overnights 16 eligible claimants received $275,000 for 3-7 overnights 18 eligible claimants received $125,000 for 1-2 overnights 33
Conclusions The 2013 Boston Marathon bombing experience offers several opportunities for lessons learned Many of these lessons reference prior experience from battlefield injuries in war theaters and terrorist events Some are based on special circumstances and relate to capabilities present only in a resource-rich environment 34
Thank You 35