Emergency Response: Pre- and Post-9/11

Robert Glatter, MD; Paul D. Biddinger, MD


September 09, 2016

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9/11—15 Years Later

Robert Glatter, MD: 9/11 is a day that is seared in our nation's memory. The sheer amount of death and destruction was unprecedented in previous attacks on our homeland. Because there were so few survivors of 9/11, there were not as many lessons learned about mass casualty incident management from the tragedy itself. In recognition of the 15th anniversary of 9/11, I would like to welcome back Dr Paul Biddinger, who joined me several months ago to discuss important lessons learned from the Boston Marathon bombings in April of 2013.

Dr Biddinger is chief of emergency preparedness in the Department of Emergency Medicine at Massachusetts General Hospital in Boston, an associate professor of emergency medicine at Harvard Medical School, and a senior fellow in emergency preparedness at Harvard School of Public Health. He's a nationally recognized expert in disaster medicine and emergency preparedness. Welcome, Dr Biddinger.

Paul D. Biddinger, MD: Thank you.

Dr Glatter: My pleasure. I wanted to start by getting your comments on 9/11 as a turning point in mass-casualty incident planning, and the event that crystallized this transformation.

Dr Biddinger: 9/11 was really the wake-up call for so many in the US healthcare system that their overall emergency planning efforts weren't what they should be. There is a lot of data out there that notes that many emergency plans weren't based on looking at the reality of how events really unfolded, didn't expect patients to present as quickly as they can, and planned for access to more information than is typically available when you look at real emergency events. The thing that I think was most important about 9/11 is that is spurred hospitals to completely overhaul their emergency management, their communications, their situational-awareness systems. Although it's been a long process, I think most hospitals in the United States are in much, much better shape than they were 15 years ago.

Dr Glatter: In terms of preparedness, it's often said that being overly prepared is good. I think that was something that came out of this tragedy. Now, we potentially go a step further than we need to. Would you agree with this concept as part of mass-casualty planning?

Dr Biddinger: I think that's right. None of us knows what we're going to be asked to face, but we have to have emergency management systems that can ramp up very quickly, and sometimes to a scale that we hadn't thought was really possible. At my hospital, our emergency management systems that have helped us respond to potential outbreaks, such as SARS and MERS; or actual outbreaks, such as the 2009 H1N1 pandemic; or things like the nearly 9 feet of snow we had a couple of winters ago here in Boston, are the exact same systems that helped us respond very effectively to the Boston Marathon bombing. It's about coordination and the best use of assets in a very chaotic situation. One of the most important things that we can do is have these emergency systems in place so that we are overprepared and can be nimble when the event actually occurs. We don't know exactly what it is that we're going to face, but we do know that we'll face some sort of emergency almost every year.

Lessons for First Responders

Dr Glatter: Going back to the Boston Marathon bombings, certainly transporting patients to definitive care was something that emerged during this event, as first-aid tents weren't clearly prepared to handle some of the serious types of injuries that presented, including amputations, patients with open fractures, and so forth. Can you comment on the role—the "scoop and run" mantra—of care, along with tourniquet application, that should be done at the scene?

One of the most important things we saw demonstrated in the Boston Marathon bombing was that there wasn't an excess amount of care delivered in the field.

Dr Biddinger: Tourniquets absolutely are lifesaving, although I would caution that really it is proper tourniquets that work—those that are wide enough and have a windlass, which is the stick that you need to twist to provide proper amounts of pressure. Improvised tourniquets often don't work and may actually harm the patient. But you're exactly right that hemorrhage control is absolutely essential. One of the most important things we saw demonstrated in the Boston Marathon bombing was that there wasn't an excess amount of care delivered in the field. Boston Emergency Medical Services (EMS) and the other first responders in the tents and at the finish line did an amazing job of identifying those patients who were most likely to bleed out immediately. Rather than overresuscitating in a space that, exactly as you point out, doesn't have a blood product resuscitation or operating room capability, EMS got the injured patients quickly to a destination that does have these facilities, which were the acute-care hospitals.

The basics of supporting the ABCs [airway, breathing, circulation] and hemorrhage control with real purpose-designed tourniquets are the right things to do in the field. Probably not much more should be done. That even includes starting an intravenous line, which is not really a value-added step in the field. As long as you have sufficient transport resources, ambulances or other vehicles, to safely get people to an acute-care hospital destination, transports should be priority over aggressive field intervention once the basic ABCs and hemorrhage control have been taken care of.

Preparing for a Secondary Device

Dr Glatter: The other issue, always, is the real potential of a secondary device. That's something that was thought to be at least possible when people were being transported on scene. Obviously, you were there. Was that something that was, in your mind, a real potential?

Dr Biddinger: Absolutely. Again, I'll give credit to Boston EMS. There's some radio traffic, which was made public, of senior EMS commanders advising their workers to be alert for their safety. There's really been quite a shift in thinking in EMS from, say, 15, 20 years ago, when EMS was always told to stay away from a potentially unsafe scene. Now, I think, we are in a transitional period, though not at a definitive conclusion yet about what is the best course of action to protect both victims and responders. But we should give EMS and other first responders, fire and police, the tools to be able to make the best decision and use their own personal judgment about whether they want to go into a scene to extract the victim, to potentially save lives, recognizing that scenes will be unsafe. We have absolutely seen the evolving terror threat around the globe that those that want to do us harm may put secondary, tertiary, other devices in the areas where first responders will congregate.

I give enormous credit to the heroism of the first responders in Boston and now to those in Paris, in Brussels, and in other places around the world. These are events where scenes may be unsafe but lives are absolutely saved when, in a rational and thoughtful way, EMS responders go extricate the victims, don't try to linger on scene, but get the patients to definitive care. That saves lives, because victims don't bleed out while they're waiting for the scene to be safe.

The Role of Technology

Dr Glatter: Exactly. And to get back to the role of coordination and communication, we later learned in Boston that the cell phone towers were overwhelmed but the mutual-aid radio system remained functional, as did the Boston EMS communications network. Going forward, are there any advances in technology that you see on the horizon that would be useful in future mass-casualty events?

One of the other important things that we have evolved to in our system is an understanding of what information is not available and the idea that that is okay.

Dr Biddinger: I think there are. In most systems, we still have access to other multimodal communications technologies, such as the Health and Homeland Alert Network, which can send text messages, pages, and emails simultaneously. One or more of those systems may be up and running even if the others are impaired. Our city and state health authorities are able to use those, and many hospitals have similar systems. My own network here within Partners HealthCare has a similar system. In addition to working on the technology, we've refined the types of information that we share. For example, our public safety authorities know that hospitals are very interested in whether there may or may not be hazardous materials at a mass-casualty incident scene, in order to know whether we have to do decontamination. So that is on their list as part of the information they have to push out (in addition to information that an incident has occurred and a rough idea of how big it is) so that we don't have to call them to ask.

One of the other important things that we have evolved to in our system is an understanding of what information is not available and the idea that that is okay. We don't expect anything like a full ambulance report on the radio when we're being brought critical patients from a mass-casualty incident. Boston EMS will tell us, "One red, three yellow"—that's the full extent of the report, which gives us just a number and a triage category of the patients. We ramp up systems so that we're fine with that. It is unrealistic to expect more information, and if your systems account for that fact, if you're ready to react no matter what happens, it ends up being better for the patient, and you're not disappointed or waiting too long for information that just will never come.

Key Lessons Learned

Dr Glatter: Are there any other take-home points from your personal experience that you want to share with emergency physicians and critical care specialists?

Dr Biddinger: A couple of things. One is that we've seen, unfortunately, with Orlando, with other events in this country, that a mass-casualty event, whether it's a mass shooting or something else, can happen anywhere. Whether you're in a trauma center or in a community facility, your facility has to have a tested and broadly based mass-casualty protocol that is more than just saying that you're going to call in extra staff. These events unfold in a matter of minutes and become overwhelming. All of us have to be prepared, because, although for any one of us the events are pretty unlikely, they are going to happen to someone, and we don't want lives to be lost because of a lack of preparation.

Second, I think that we are really having some continued challenges in this country in looking at how we would respond if there were to be a hazardous-materials release associated with a mass-casualty event. It's been a long time since 9/11, when hospitals first put money into personal protection for chemical and radiologic hazards, and I think that a lot of that equipment, a lot of that training, has atrophied. Although, again, I think that this kind of event is very unlikely, it's certainly possible, and it would be a tragedy to have patients or healthcare workers suffer injury because of the lack of those preparations.

I think most everybody who's involved in preparedness is aware that you're never going to be as good as you hopefully are next year, and that this year, hopefully you're better than last.

Dr Glatter: Absolutely. How often does your own emergency department (ED) conduct drills in order to have people remain sharp and polished and make sure the process works?

Dr Biddinger: We have found in our ED that we can conduct several drills a month that are very brief, minimally disruptive, no-notice, that ask people how they would turn on the emergency response system. We present our senior nurses, physicians, and administrative leaders with a brief fictional scenario. We ask them, who do they call? What do they do? How do they organize triage? How do they make room in the ED to care for incoming patients? After about 15 or 20 minutes, we stop the exercise and they go back to delivering clinical care. Any busy ED in this country obviously can't make much more time than that available, but we've found that it's incredibly helpful for keeping people sharp with the plans that they need to know.

More robustly, we do between three and four full mass-casualty, full-scale exercises each year. We find that those are really important, both for educating staff and continually improving those areas where we are not quite as sharp as we want to be. I think most everybody who's involved in preparedness is aware that you're never going to be as good as you hopefully are next year, and that this year, hopefully you're better than last. Preparedness is not a state of being; it's just a progression to try to improve every year.

After-Hours Response

Dr Glatter: What about mass-casualty incidents that occur after hours, late at night? That's always an issue. Certainly, what happened at the Pulse nightclub occurred very early in the morning. The ability to ramp up staff was really a concern. Any thoughts about that type of drill or that preparation in the early hours?

Dr Biddinger: I think there are a couple of things that can be done. Certainly, it is very important to have very efficient computerized staff notification systems that prioritize the staff that are most important initially: ED, operating room, surgical staff. Those are the ones that are going to save lives first. Make sure that you have the nurses, doctors, technicians, and administrative staff that are essential to get the patients who are bleeding out into definitive care. That's really important.

Second is figuring out who lives close by and helping those people know how they would get to the hospital. Time really does matter, and although where staff are located can be somewhat arbitrary, it is an important variable. Where you live can make the difference in being part of a successful response.

The last thing I would say is, again, that a mass-casualty protocol should be much more robust than simply planning for the ED staff to call in nurses and doctors. The operating room must do the same. With the structured use of your minimum complement of staff who are onsite in the overnight hours or on the weekends, when you know you're thin, you still can make an awful lot of good use of people who are present and who may be underappreciated resources. It is also important to work with sister hospitals in your community and your EMS providers, because not every patient in such a situation has to be at the trauma center. The critical patients have to be in a setting that can control hemorrhage definitively as quickly as possible.

It is a community-wide planning effort to make the best use of surgeons, operating rooms, blood-bank supplies, and ED resuscitation capabilities. That's how we're going to save lives across communities.

Dr Glatter: Thank you. I really appreciate your input, which has been invaluable.


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