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Tuesday, August 27, 2013

Before Marathon Bombings, Aurora Helped Boston Prepare

Medical workers aid injured people at the finish line of the 2013 Boston Marathon following an explosion in Boston, Monday, April 15, 2013. (Charles Krupa/AP)

Medical workers aid injured people at the finish line of the 2013 Boston Marathon following an explosion in Boston, Monday, April 15, 2013. (Charles Krupa/AP)

Almost a year ago, Dr. Ron Walls, an emergency room doctor in Boston opened an email from Dr. Richard Zane, a colleague in Colorado.

It was about the mass shooting in Aurora, and it had links to 911 calls that night. In a movie theater, 12 people were shot and killed and 58 were injured by shooter, James Holmes.

In one hour, 23 patients arrived at the University of Colorado Hospital with injuries more common on battlefields than in emergency rooms.

The very first thought that I had was, “Oh my goodness, are we really ready for this?”
– Dr. Ron Walls

“After the dust had settled and we’d done lots of analysis, I thought, we need to share this, we need to show it to other people because they’re going to learn from this,” Zane told Here & Now.

That email provided lessons for Dr. Walls at Brigham and Women’s Hospital in Boston — in particular, the timeline of the 23 critically-injured patients arriving in rapid succession.

“It was a really dramatic effect to see so many critical patients arrive that fast,” Walls told Here & Now, noting that Brigham and Women’s had done more than 70 emergency preparedness drills in the previous six years. “I won’t say we were smug about it, but we really felt that we were ready. And what happened to me in the moment I looked at that 23-mark hour from the University of Colorado, the very first thought that I had was, ‘Oh my goodness, are we really ready for this?’”

About six months later, on April 15, Brigham and Women’s Hospital received the same number of critically-injured patients as the University of Colorado had — 23, in just one hour.

In addition to strategies for treating large numbers of critical patients, Zane also counseled Walls on providing support to the caregivers.

“We had to think very hard about how we put in place support services — not just the 23 patients who were severely injured, but also the psychological component of having seen things that one should never have to see,” Zane said of the Aurora shooting. “It affected the people who took care of these patients. It affected the people who lived with the people who took care of these patients. It will forever affect the community.”

Guest

Transcript

ROBIN YOUNG, HOST:

Well, we want to take a few minutes now to look at lessons learned on the front lines on the homefront. The six major trauma hospitals in the Boston area that handled hundreds of patients after the Boston bombing are preparing a report to deliver to the American College of Surgeons, in October. But for some of them, the learning curve began in Aurora, Colo. Let's explain.

For 14 years, Dr. Richard Zane was head of disaster preparedness at Boston's Brigham and Women's Hospital, working directly for Dr. Ron Walls. But by the Aurora movie theater shootings, July 2012, Dr. Zane had become chair of the Department of Emergency Medicine at the University of Colorado Hospital, in Denver. After those shootings, he sent emails to Dr. Walls with these 911 calls from that night.

(SOUNDBITE OF 911 CALLS)

UNIDENTIFIED DISPATCHER: Team 6, we've got another person outside shot in the leg, a female. I've got people running out of the theater that are shot - in Room 9...

YOUNG: Twelve people were shot and killed, 58 injured, by shooter James Holmes. And police will have to figure out what to do.

UNIDENTIFIED POLICE OFFICER #1: Metro 10, Lincoln 25. Do I have permission to start taking some of these victims via car? I've got a whole bunch of people shot out here and no rescue.

UNIDENTIFIED POLICE OFFICER #2: Yes. Load them up - get them in cars and get them out of here!

YOUNG: In one hour, 23 patients arrived at the University of Colorado Hospital. On April 15th, Dr. Walls received the same number at Brigham and Women's Hospital after the Boston bombings. What lessons did he learn from his former colleague? We want to ask them both today.

Dr. Richard Zane - again, chair of the Department of Emergency Medicine at the University of Colorado Hospital, in Denver, joins us. Welcome.

DR. RICHARD ZANE: Thank you for having me.

YOUNG: And we also have Dr. Ron Walls, the chair of the Department of Emergency Medicine at Boston's Brigham and Women's Hospital, in their studio at the hospital. Dr. Walls, welcome to you, as well.

DR. RON WALLS: Hello, Robin nice to be here.

YOUNG: Dr. Zane, what was your thinking when you sent those emails with those hard-to-listen-to 911 calls to Dr. Walls?

ZANE: When we had this experience - which is completely life-changing for everybody that possibly could ever be involved - after the dust had settled and we'd done lots of analysis, I thought, we need to share this; we need to show it to other people because they're going to learn from this. So I sent it to Ron.

YOUNG: What did you learn?

ZANE: I learned that the approach to emergency preparedness is generic, and there's a reason for it. And the reason is that you could never possibly think that 23 severely injured patients could come in one hour, suffering wounds only seen in war. We'd thought about how do you communicate with staff so that you can get staff to the emergency department or to the operating rooms.

How do we change the acuity of the emergency department so that patients who are not severely ill or injured can be moved to a different place, creating an alternative care site. All of those things had been planned and practiced before, just not in the very specific way for 23 severely injured patients.

YOUNG: I would imagine that would be the biggest concern. You think you're working on somebody who is the most seriously injured because how could it be worse, and then somebody worse comes in.

ZANE: Well, for patients who are injured with penetrating injuries like these, they come in in a certain way, and they change very rapidly. So we would have two or three patients who came in immediately, one who was critically ill and then one patient who had come in 20 minutes ago becomes critically ill, and then another three patients come in that are critically ill.

It just requires a way of leading a team to care for a group of people instead of one person caring for one person. There were some things that were just new, the rapidity with which these patients came. This was an incredible event. It affected the people who took care of these patients. It affected the people who lived with the people who took care of these patients.

It will forever affect the community, and we had to think very hard about how we put in place support services, not just the 23 patients who were severely injured but also the psychological component of having seen things that one should never have to see.

YOUNG: Yeah. So Ron Walls, you're back in Boston and you are getting these emails from your colleague. What are your thoughts when you're hearing these 911 calls?

WALLS: When I clicked on the links, there were two things embedded. One was the 911 calls, some of which you just played. But the other which was much more compelling to me was a timeline of the arrival of the patients at the moment they hit the emergency department.

What was much more compelling to me from the disaster preparedness standpoint was the number of marks on that timeline in the first hour. It was a really dramatic effect to see so many critical patients arrive that fast.

YOUNG: Well, but we know that here in Boston all of the major hospitals have all sorts of drills. Were you thinking, you know, if this were to happen, we'd be ready, or were you thinking we've got work to do?

WALLS: Well, I have to tell you that we have done a lot of drills. We did over 70 drills in a six-year period, big drills and important drills. And we really felt like we were ready. And I won't say we were smug about it, but we really felt that we were ready.

And what happened to me in the moment that I looked at that 23-mark hour from the University of Colorado, the very first thought I had was, oh, my goodness, are we really ready for this?

YOUNG: So what did you do?

WALLS: So I actually contacted Rich, and we started talking. Just fortuitously, we had planned a presentation on our disaster preparedness for our board committee that oversees it. And we had done a typical annual summary of the number of drills we had done and what our preparedness was and sort of what was new and just a sort of routine progress report.

And instead of that, I - I'd already seen that, but I called our disaster preparedness people in, and I said I want to tear this up and start all over, and I want to use the theme are we ready? And I showed them that slide, and I said I need to know that we can do this, and I'm not so sure we can do it now.

YOUNG: Again Dr. Ron Walls, chair of the Department of Emergency Medicine at Brigham and Women's Hospital in Boston. We're also been speaking with Dr. Richard Zane, who chairs the Department of Emergency Medicine at the University of Colorado Hospital in Denver. When we come back, more on how Dr. Walls responded to the realization that he was not prepared.

JEREMY HOBSON, HOST:

Meanwhile we're also keeping an eye on the massive wildfire in and around Yosemite National Park in California that continues to rage. Later on the show, we'll look at how they're trying to protect the ancient sequoia trees in the park.

And coming up on ALL THINGS CONSIDERED, the story of the Geronimo Hotshot firefighting team from San Carlos, Arizona, one of seven elite Native American firefighting crews in the West. That's coming up later on ALL THINGS CONSIDERED. Robin's conversation continues in a moment, HERE AND NOW.

(SOUNDBITE OF MUSIC)

YOUNG: It's HERE AND NOW. When the Boston bombings happened, staffers at some hospitals found out when doctors who happened to be working the finish line sent tweets. At Mass General, an anesthesiologist suggested stopping all elective surgery; a good move, it turns out.

The Boston Globe reports that Harvard researchers later concluded that tweets appeared six minutes before the public health authorities sent alerts to hospitals. And now, Boston hospitals are asking can they use social media more effectively as they prepare a report on what they learned after the bombings.

Most hospitals have long been thinking about disaster response, but as we've been hearing, Dr. Ron Walls of Boston's Brigham and Women's Hospital realized after the Aurora shootings that he was not prepared. He received emails from a former colleague, Dr. Richard Zane of the University of Colorado Hospital in Denver, who handled patients after the Aurora shooting.

We've been speaking with both, and Dr. Walls, you say one of your realizations after Aurora had to do with scope and scale. Tell us more.

WALLS: So to get ready for a disaster, you have to increase the scale and participate in drills to do that. What this showed me, this Colorado experience showed me, was that all of our city planning - and I actually went back and reviewed the plans - in all of our city planning, we had never drilled, either in our own drill or in a citywide drill, receiving more than about 12 to 14 patients in the first hour. And so I knew that we had to go up to another level of readiness.

YOUNG: Yeah. An other doctors, by the way, in this area had the same experience. The Boston Globe took a deep look at this, at how hospitals had prepared prior to the Boston bombings. And they spoke with the head of the emergency medicine at Mass General, a Dr. Kahn there, and they had their aha moment when an Israeli medical team visited their hospital.

They were told by this Israeli medical team you have to have an experienced doctor out at every ambulance that comes in the parking lot so that you can figure out who is the sickest. How would you change that idea of how do you assess the people as they come in.

ZANE: Well, firstly you have to get ready before they come in, and if you're talking about scope and scale and basically doubling or tripling it, even over what you were previously prepared for, one of the first issues is how do you identify people so that as they come through the door you have a unique identifier, and you don't mix patients up.

When we take care of a patient with a gunshot wound, we often don't know who people are, and they often can't speak to us, and they often have horrible injuries that are horrible to see. But it's scope and scale. You might get one or two of those people at a time, and you may have advanced notification from EMS of anywhere from one minute to 10 minutes that you're going to get those patients.

YOUNG: Well, and as people in this area know, there was a terrible mix-up at a very fine hospital, again Mass General, because one of the bombing victims came in, she had a handbag with her, but it wasn't hers. And so initially they thought someone had died who hadn't. It was just a terrible mix-up.

ZANE: That is not uncommon. We had a patient who was severely injured who was intubated in an ICU for days before he was identified, and that's simply one of the things that you have to prepare for when you're doing mass casualty care and that you're responding.

YOUNG: And that's again Dr. Zane there in Colorado. And Dr. Walls, you're saying that you tried to have a system that better figured out who was who.

WALLS: So you have to be able to pre-register patients before they arrive, and we realized we had to pre-register large numbers of them. So it wasn't a matter of having a few trauma packs ready. It was a matter of having a lot of trauma packs ready. It wasn't a matter of having a number of beds ready. It was having a large number of beds ready.

It was being able to triage large numbers of patients arriving in rapid succession, not just a significant number of seriously injured patients.

YOUNG: And Dr. Zane, I'm learning that it's not just about identifying people so that their family and kin know the status of their loved ones, but later on when you're delivering medication, I mean, this becomes critical.

ZANE: It becomes critical at every single level. So we have processes so that you can triage and register or keep track of multiple, multiple patients at one time. And then there has to be a system so that that system links to the normal system, and there's ways that family members can come and identify their patients, and they're sent to the right people in the right places.

And then if they're - if they've been at the institution before, we can know about their medical records, we can know about their allergies, and we know how to care for them.

YOUNG: Yeah, and Dr. Walls, this idea of prioritizing patients, I hear that one of the first patients came in, and the staff decided as bad as they look, we think it's going to be worse?

ZANE: Well that's a complicated thing is figuring out who is sort of the most ill. So what that allowed us to do was to create trauma teams throughout our emergency department. So we had multiple, multiple trauma teams, each one taking care of one patient, just like they would on an ordinary day. And the challenge was in communicating between and among those teams to make sure that we knew which patient was highest priority, which patient was second, both for things like CT scan and for things like the operating room.

YOUNG: Well, we know that hospitals here in Boston are doing an analysis of the response. There's going to be a presentation at the Americans College of Surgeons meeting in October in Washington. Ron Walls, what else do you want to tell - as Dr. Zane told you, what else do you now want to tell other hospitals?

WALLS: Well, this is like a lot of other areas of medicine. Nobody knows it all, and anyone who thinks they know it all is probably dangerous. And I'll tell you in addition to all the preparation we did and all the after-analysis we did, when we cleared sort of over the top of this Monday evening, I think it was probably 7:30 or 8, and we knew that we had stabilized all of the patients, there weren't going to be any more critically ill patients arriving, patients were in the OR, I called Rich at that moment and said to him, OK, we're over the top of this. What did you do wrong in the first 48 hours afterward? And he then counseled me a lot regarding response to staff, and I remember his specific counseling, which was: think of all of the intensive emotional support you need to provide your staff. Think of it in the most generous way possible, and then triple it, and you'll still be short.

YOUNG: Dr. Zane, how is your staff doing?

ZANE: You know, our staff are making steady progress. People grieve or respond in a very different way. So when we thought we'd had a handle on it, and the shootings in Connecticut happened, we had a lot of staff who began to grieve again and were very, very affected.

YOUNG: It's like it's a post-traumatic stress for the nurses and doctors, it sounds like you're saying.

ZANE: Well, it's post-traumatic stress for the nurses, for the doctors, for the executives, for the housekeepers, for the transport people. These people were exposed to things that they're not supposed to be exposed to. They're not supposed to be on the front lines of a war, and that's exactly what it looked like.

And every time there is something that happens, including the Boston bombing, they think again to their experience, and what we need to be prepared for, which we've instituted, is a way in which to respond to that type of need, no matter how long ago the Aurora shooting was and no matter what type of resources they need.

WALLS: One of the things that was remarkably healing that I would not have anticipated is that we got flags and banners and posters and cookies and chocolates from emergency departments and trauma centers all over the country. And that made our staff fell like they weren't alone. It made them feel like they were part of something good.

And so we've picked that up, too, and we've started reaching out to others, and we reached out to San Francisco General after the Asiana flight crash. So I think this, being part of a community so that you can learn from a community but also so you can support that community is really important.

YOUNG: That's Dr. Ron Walls, chair of the Department of Emergency Medicine at Boston's Brigham and Women's Hospital. Of course his hospital took in so many patients after the Boston bombing. Dr. Walls' colleague, Dr. Richard Zane, is the chair of the Department of Emergency Medicine at the University of Colorado Hospital in Denver. And of course they handled patients and victims of the Aurora shooting. Dr. Zane, Dr. Walls, thanks so much for speaking with us.

ZANE: Thank you.

WALLS: Thank you, Robin.

YOUNG: It's worth noting of the hundreds of patients who made it to Boston hospitals after the bombing, none died, remarkable. How about your town? Or maybe you're working on improving disaster response. What are you concerned about? Weigh in at hereandnow.org. We'd love to hear from you. Latest news is next, HERE AND NOW. Transcript provided by NPR, Copyright NPR.


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Robin Young and Jeremy Hobson host Here & Now, a live two-hour production of NPR and WBUR Boston.

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