Julia E Gunn
! State holiday ! Historical
reenactments ◦ Battle of Lexington
and Concord ◦ Paul Revere’s ride
! Red Sox Game ◦ Late morning start
! Boston Marathon
! First run in 1897 ! Organizer: Boston
Athletic Association (BAA)
! 15 runners with 10 completing the 24.5 mile race
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! Eight cities/towns: from Hopkinton to Boston’s Copley Square
! 2013: 26,839 official runners plus ‘bandits’
! 500,000 plus specators ! World class runners, wheel
chair racers and local favorites (Hoyts)
! Draw large crowds ! Require additional resources ! Maintain day to day operations ! Partnerships and collaborations are critical ! Standardize – “working together” ! Bring the right people to the table ! Work with event organizers ! Security plans matter ! Unified incident command structure ! Risk communication coordination
! Main event and other related events (nesting) ! Dates, duration, and location ! Weather and environmental factors ! Expected public attention or political
importance ! Number and characteristics of participants ! Incident command structure (who’s in charge) ! Prior experience ! Other medical services (DMAT teams; field
services)
! Weather: Heat vs Cold ! Injuries ! Dehydration ! Emergency health care ! Communicable diseases
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! 24 Medical Stations along the course
! 16 First aid stations ! Two large medical
tents at the Finish ! Staff: Volunteer
nurses, doctors, EMTs, paramedics and others
! Boston EMS ◦ Logistical support ◦ First responders ◦ Transportation
! Coordinated system which integrates the requirements of pre-hospital, hospital, public health and emergency management
! Real-time person or equipment location and movement
! Uses barcodes, hand scanners, and a web application
! Uses ◦ Mass Casualty Incident ◦ Mass dispensing clinics ◦ Evacuation and sheltering
! Six level 1 trauma centers ! Pediatric and adult ! Specialty care – burns, rehabilitation ! Well practiced surge plans – including prior marathons, July 4th and other special events
! Long history of collaborative planning among hospitals, BPHC, EMS, COBTH, MA DPH
! Unseasonably steamy, reaching 89 degrees Fahrenheit by 12:30 p.m
! Warning: “if you are not highly fit or if you have any underlying medical conditions (for example-cardiac disease, pulmonary disease or any of a number of medical problems), you should NOT run this race. Inexperienced marathoners should not run”
! Opportunity to defer entry until the 2013 race ! Trained 400 runners and spectators in CPR
Total Runners requiring Medical Services: over 2,100
Finish Area Medical Stations: 1,560 persons • A Medical Tent: 895 persons • B Medical Tent: 665 persons
Marathon-Related EMS Transports in Boston: 100 persons
Hospitals: 202 persons (includes EMS transports)
Runners Max. Temp
Total “patients” Transports Hospital Visits*
2010 22,540 61 1,320 42 68 2011 21,554 61 1,324 55 87 2012 22,426 89 2,181 241 260
*Transports + Other means of arrival
! Hyposmolality and/or hyponatremia (Sodium deficiency)
! Volume depletion(Dehydration, depletion of volume of plasma or extracellular fluid, Hypovolemia)
! Renal impairment ! Rhodomyolysis ! Hyperthermia – Temp 105 ! EKG changes
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21
BPHC: Lawlor Medical Intelligence Center
Time of arrival Injury 3:04:00 PM AMPUTATION
3:05:00 PM KNEE INJ 3:15:00 PM AMPUTATION
3:17:00 PM L HAND INJ 3:20:00 PM AMPUTATION
3:22:00 PM AMPUTATION
3:23:00 PM SHRAPNEL/FOOT
3:27:00 PM AMPUTATION
◦ All 9 acute care hospitals in Boston report information for each emergency department (ED) visit ◦ Information transmitted includes:
! Age, gender, and race/ethnicity ! Zip code of primary residence ! Chief complaint ! Primary discharge ICD-9 when available ! Unique patient identifier (HIPAA-compliant) ◦ Syndrome counts are stratified by hospital, neighborhood,
age and gender ◦ Reviewed daily by BPHC epidemiologist for parameters
indicative of a cluster or clinically significant event ◦ Operational since July, 2004
! Marathon Blast Syndrome = Event or Explosion or Trauma or Burns or Hearing
! Anxiety ! PTSD ! Suicidal Ideation ! Alcohol ! Injuries without a cause (MVA, Falls) ! Lacerations without a cause (MVA, Falls) ! Fractures and dislocations without a cause (MVA,
Falls ! Other = All other visits
! Event ◦ Runner, marathon, BAA
! Explosion ◦ Disaster, Bomb, Explosion, MCI
! Trauma ◦ Trauma, Amp (n=6)
! Burns ! Hearing
0 200 400 600 800
1000 1200 1400 1600 1800
4/8 4/9 4/10 4/11 4/12 4/13 4/14 4/15 4/16 4/17 4/18 4/19 4/20 4/21 4/22 4/23 4/24 4/25 4/26 4/27 4/28
Num
ber o
f Vis
its
Days
Boston Emergency Department Visits: April 7- April 27, 2013
0 10 20 30 40 50 60 70 80 90
100
4/8 4/9 4/10 4/11 4/12 4/13 4/14 4/15 4/16 4/17 4/18 4/19 4/20 4/21 4/22 4/23 4/24 4/25 4/26 4/27 4/28
%
Days
Boston Emergency Department Other Syndrome Visits: April 7-April 27, 2013
0
2
4
6
8
10
4/8 4/9 4/10 4/11 4/12 4/13 4/14 4/15 4/16 4/17 4/18 4/19 4/20 4/21 4/22 4/23 4/24 4/25 4/26 4/27 4/28
%
Days
Date Event Explosion Trauma Burns Hearing 4/7/2013 0 0 2 6 0 4/8/2013 0 0 0 3 0 4/9/2013 0 0 2 1 1 4/10/2013 0 0 2 2 0 4/11/2013 0 0 10 4 0 4/12/2013 0 0 4 3 2 4/13/2013 0 0 2 4 2 4/14/2013 0 1 6 8 1 4/15/2013 24 60 31 17 13 4/16/2013 1 4 4 1 2 4/17/2013 0 0 3 3 0 4/18/2013 0 0 1 6 0 4/19/2013 0 1 2 1 1 4/20/2013 0 3 1 5 1 4/21/2013 0 0 6 5 3 4/22/2013 0 0 8 1 1 4/23/2013 0 1 3 1 1 4/24/2013 0 0 4 3 0 4/25/2013 0 0 0 6 0 4/26/2013 0 1 4 3 2 4/27/2013 0 0 4 5 2
! Below and above the knee amputations ! Severe blood loss ! 2nd and 3rd degree burns ! Poly-trauma: Open fractures, open wounds,
lacerations, embedded shrapnel with tissue injury
! Closed fractures with contusions, sprains and strains
! Head injuries, post-concussion syndrome ! Hearing loss with tympanic membrane injury ! Acute anxiety
! Biological ! Blood borne
pathogens ! Chemical ! Radiologic ! Other explosive
devices ! Other trauma ◦ Over 5,000 runners
were on the course at 2:49pm
! Boston: MIC: BPHC & BEMS ◦ Monitored BEMS, advised
Boston hospitals about incoming patients
◦ Central point for collection of patient information
! Massachusetts: DOC: DPH ◦ Ongoing communication
with partners ◦ Communication with
surrounding states for transfer of patients who would otherwise have gone into Boston
! Family reunification ! Mental health support ! Blood supply delivery ! Requests for amputation & vascular kits ! Volunteers and employee checks ! Runner assistance ◦ Relocation ◦ Travel assistance ◦ Medications
Boston Public Health Commission • American Red Cross • FBI Victim Assistance • Massachusetts Office of Victim Assistance • U.S. Attorney’s Office • U.S. Health and Human Services • Boston
Police Department Victim Assistance • Public Safety Details: Boston Police, Boston EMS, State Police
BPHC: Lawlor Medical Intelligence Center
! Prior experience ! Onsite medical personnel and
equipment ! Bystanders immediately assisted the
injured ! Holiday and roads were closed for the
event ! Deep health care infrastructure ! Boston EMS – tourniquet protocols ! Additional resources: National guard,
operations centers, monitoring systems
! Survivors: Over 260 ! Deaths: 3 ! Majority treated at
Boston acute care hospitals
! Focus of high value data ! Information flow starts in the field ! Health care business processes change in surge
situations ◦ “Direct admissions” ◦ Redirection of emergency department patients ◦ Varies by site ◦ Little is known
! Long term emotional health monitoring is essential ◦ More work is needed
! Protected health information: DUA’s ! Disrupted wireless communication ! Increased communication regarding chemical
and radiologic monitoring: Negative results are important
! Outbreaks and communicable diseases: ◦ Maybe identified later ◦ Systems for notification and coordinated follow-up
! Event related non-critical syndromes monitoring may be helpful
! No one blast syndrome does it all ◦ Type of blast defines the injuries ! Boston pressure cooker bomb with shrapnel vs Texas
fertilizer plant ◦ Non-specific chief complaints have limited utility ◦ Context matters (Marathon vs MVA)
! Flexibility and rapid deployment of syndromes is critical ! Limited experience with chemical and radiologic syndromic
surveillance ! Metadata: Trauma levels and Specialty care (Burns)
Peter Burke: Chief of trauma services – Boston Medical Center Bostonia 2013
! Estimated 10,000 additional runners ! Increased security requirements ! More monitor systems ! Expanded field medical services ◦ Start: Medical teams for last minute needs ◦ On-course: Medical aid stations at 26 locations ◦ Disaster Management Administrative Teams (DMAT) ◦ Medical buses ◦ Finish Line tents ◦ Massage therapy ◦ Mental health support
Atyia Martin: Director Public Health Preparedness James Hooley, Chief Boston EMS