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

4

!  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

9

!  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

17

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