Lessons from Boston: Providing Trauma Care

    • April 26, 2013

On an otherwise quiet Monday afternoon, Jeremiah Schuur, MD, an emergency physician at Brigham and Women’s Hospital in Boston, was in his office catching up on work when a story on the Internet caught his eye. “I saw that there had been a bombing at the marathon,” he recalled. “We were only a few miles from the site, so I knew patients were on the way.”

Schuur, a Robert Wood Johnson Foundation (RWJF) Clinical Scholar (2005-2007), supported in part by the U.S. Department of Veterans Affairs, swiftly joined the small army of his colleagues converging on Brigham’s emergency room (ER) from all parts of the hospital. “In minutes there were nearly a hundred people there, in addition to the ER staff on duty. The nurses and physicians on the shift immediately began to organize us into trauma teams comprised of five or six—most often nurses, emergency physicians, trauma surgeons and orthopedists, making sure each team had at least one expert in intubating patients.”

About 30 badly injured patients arrived in the span of roughly 20 minutes." -Jeremiah Schuur, MD

Even before the wounded began to arrive, the staff also realized that they were short on beds. “We are a level I trauma center with significant capacity, but at 3 o’clock on a Monday afternoon most beds were full,” Schuur said. In moments, physicians, nurses and psychiatrists began clearing ER beds by safely moving existing patients to other parts of the hospital or preparing them for transfers to psychiatric care.

An ER on Overload

Schuur and the rest of Brigham’s greatly expanded trauma team were suddenly faced with a flood of severely wounded patients. He likened the scene to the night he spent working in the ER at Rhode Island Hospital when more than 63 severely burned patients arrived after the Station nightclub fire.

“About 30 badly injured patients arrived in the span of roughly 20 minutes,” he said of the Boston situation. “We see traumatic injuries, but usually only one or two at a time. The most serious cases were those directly in the line of the blast. They had traumatic wounds to the lower extremities, clearly caused by projectiles, the type of wounds seen in war.”

As the patient load increased at a furious rate, the staff was forced to switch to paper records. The electronic patient intake system could not handle the rapid flow of information. “It soon became clear that the computer system was not able to keep up with the pace of care,” Schuur recalled.

Crowding and computer hassles aside, Brigham and Women’s trauma team followed a carefully drawn disaster plan that created calm out of chaos in the span of a few hours.

Hitting the Wall

And then there was quiet: The sickest patients had been moved into the operating room, and the pressure of tending to the wounded while comforting their traumatized loved ones had ceased. Now reality set in.

“We are trained to deal with really sad situations and keep on moving,” Schuur said. “But when they told us no more patients were coming—very quickly, people were overcome with emotion. Boston is a small city and we found ourselves taking care of medical professionals along with runners. We also had staff at the marathon.”

Because providing the needed care filled every minute of that Monday afternoon and evening, Schuur added, “we had staff members who had worked while worrying about their own families. At our evening debriefing, people got together to talk about some of the patients we cared for and just how hard it was to see people who were so critically injured.”

How They Did It

“Overall our system worked very well,” said Schuur, who is director of quality, safety and performance for Brigham’s department of emergency medicine, but there are always important lessons that can be learned.

  • ER capacity was critical. “There is a great deal of discussion about whether ER’s are overused,” Schuur said, “but Boston was able to handle this because we have an incredibly robust ER system, not just in our hospital, but around the city. Events of this type really speak to the value of that investment. You never know when something like this is going to happen.”
  • Leadership created synergy. “It took extraordinary leadership skills for the on-duty ER staff to immediately organize us into the interdisciplinary care teams needed to take on this challenge and they accomplished it before the disaster resource teams even arrived in the ER,” Schuur said.
  • Training created the framework. “I cannot over-emphasize the importance of training for these situations,” Schuur advised. “Whether it’s city-wide disaster drills or mock codes, the work we did together was the key to preparing us for this event.”

While the immediate trauma of the day has passed, Schuur knows that the memory will stay with him and his colleagues for a very long time. He advises other caregivers who have experienced this type of crisis to “find a safe space to talk about what you have been through,” adding, “It has also been helpful to have incredible support from our professional community. It makes me proud to be a part of Brigham and Women’s Hospital.”


Related Websites

Read another perspective on the Boston Marathon bombings from RWJF Executive Nurse Fellow Carolyn Hayes.
Learn more about the RWJF Clinical Scholars program.
For an overview of RWJF scholar and fellow opportunities, visit www.RWJFLeaders.org.