Four Level I trauma centers lie within a mile of the Boston Marathon finish line. Thirty minutes after the Patriots' Day bombings, all four were treating dozens of seriously injured people. Eventually, 26 hospitals cared for more than 200 patients wounded in the blast.
The response of Boston's hospitals and emergency medical services has been hailed as the gold standard for handling a mass casualty incident (MCI). But most communities don't have Boston's financial and medical advantages or strong, decades-old regional partnerships. Is it realistic to expect towns with fewer resources to respond the same way?
Eric M. Weller, program manager of Emergency Medical Services at South Central College in Mankato, Minn., says hospitals and communities can respond effectively and decisively in a crisis — but only as far as available resources allow.
"A disaster is when a situation or event outstrips or overwhelms the current resources," he explains. "So the definition of an MCI is obviously different at a 25-bed critical access hospital whose daily census is three or five than it is at Saint Marys (one of Mayo Clinic's hospitals in Rochester, Minn.), where there are 30 to 50 patients in the ED at any one time. A 25-bed hospital can treat, triage and transfer two critically injured patients, but five or six critical patients would likely overwhelm any disaster plan," he says.
Boston had some luck on race day. Hospitals were on heightened alert because of the marathon, first responders and medical tents were at the scene, and several surgeons in nearby trauma centers had firsthand experience with blast wounds. But Weller stresses that luck can't be factored into preparedness planning.
"In a small community hospital, if a serious event happens at 11 a.m. on a weekday there are more people around. But incidents typically happen nights, weekends and holidays, when there is low staffing. So in disaster planning, you always have to account for the worst-case scenario. You learn to look ahead, to recognize early on when there is the potential to outstrip local resources and respond to that," he explains. "You don't want to be 30, 60 or 90 minutes into an incident and suddenly realize you're overwhelmed."
Weller adds that the only way to learn the emergency capabilities of any facility — large or small — is through drills and exercises. The Joint Commission requires all hospitals to conduct two preparedness drills a year, one with community partners, such as Emergency Medical Services (EMS). Many big centers conduct far more; last year, Beth Israel Deaconess in Boston undertook 12 drills, one lasting five days.
Weller says the importance of such exercises can't be overestimated.
"The key is to press the system to break, to think beyond normal circumstances. The Joint Commission says you have to stress the system on all levels. Some people think it's just the ED that participates, but it's a hospitalwide response," he says. "Everyone has a role in disaster response — maintenance, housekeeping, dietary workers. A cook may be asked to guard a door because there aren't enough security people. Or the hospital may not even have a security staff. This is especially true in small community hospitals where people may already be performing five different jobs."
After a drill, an improvement plan is drawn up that lists both successes and opportunities for improvement. Challenging areas are then retested the next time around.
What hospitals prepare for is influenced, in part, by the day's news. School shootings are a widely discussed topic, not just because they are increasingly common, but also because children in general present special challenges.
"They're not just little adults; they have unique needs that nonpediatric centers may not be able to accommodate, including child-size equipment and drug dosages," Weller notes. "Plus, dealing with a badly injured child is always especially stressful on providers. Most are used to dealing with adults on a day-to-day basis and may feel uncomfortable dealing with kids."
Tornado preparedness is another critical issue, and the devastating tornados this season prompted a region-wide discussion.
"We brought in all the hospitals and talked about how we would set up medical resources in our own communities after a similar catastrophic incident," Weller says.
Most experts agree that hospitals and health care systems are better prepared to handle emergencies now than they were 10 years ago. But cuts in federal funding may stall future progress and prevent hospitals from conducting rigorous preparedness training.
Weller says, "Emergency preparedness isn't something you learn in school. The need to train and retrain providers on this topic is a continual process."