BOSTON — A good emergency preparedness plan, a robust medical support system and smart use of tourniquets helped healthcare providers save lives when bombs exploded at the Boston Marathon finish line last year, according to the keynote speaker at the 2014 National Association of Pediatric Nurse Practitioners Annual Conference.
Eleven months after two blasts from homemade pressure cooker bombs injured 281 people and killed three just a few street blocks away from the meeting, David P. Mooney, MD, MPH, director of the Trauma Center at Boston Children’s Hospital, recounted his experience and shared important lessons from the day with a packed audience.
“Crises happen all the time. It doesn’t have to be a dreadful event like a bombing, it can be as simple as the number of patients increasing to a volume beyond what you can handle or being in the emergency room when a child stops breathing,” Mooney said. “Crisis preparation is not a question of ‘if,’ but ‘when.’”
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Appropriate planning and practice, training and equipping personnel and assuring the availability of adequate resources are essential elements of being prepared, he emphasized.
In the case of the Boston Marathon bombings, the first 20 critically injured patients arrived at area hospitals within 18 minutes, and the last severely injured victims had been transported within 45 minutes of the first explosion. A third wave of less critically injured people arrived over the course of hours, but all patients admitted to the hospital survived.
The quick response and relative success in caring for the injured was made possible by a strong clinician presence in medical tents and ambulances established to treat dehydrated runners at the finish line, close proximity to five hospitals with level one trauma units and a split-second decision to clear important access roads on the part of a police field commander, Mooney explained.
Although hospital staff was well-versed in triage protocol – a Hospital Incident Command System and STAT mass casualty trauma activation page were instituted after the September 11, 2001 terrorist attacks – they were less prepared for the types of injuries they saw.
“Most clinicians are not taught much about pediatric blast injuries,” Mooney said. But he noted that victims benefited from the presence of military veterans in the crowd, who had knowledge of proper tourniquet use from battlefield experiences.
Blast injuries are not always the result of bombings, though. These types of injuries can also be caused by fireworks or industrial accidents, according to Mooney.
When dealing with blast injuries, clinicians should be prepared to treat both minor and major injuries and should keep in mind that injuries will fall into five categories:
- Primary blast injuries — tympanic membrane rupture; pulmonary problems such as diffuse lung disease; ocular issues, including corneal abrasions from dust and debris; and brain trauma from the initial blast, as well as countrecoup effect
- Secondary blast injuries — penetrations, lacerations and amputations
- Tertiary injuries — occur when victims are propelled against a fixed object, or debris falls causing blunt force trauma or crushing the victim
- Quaternary injuries — flash, partial and full thickness burns; pulmonary problems such as asthma or COPD exacerbations from inhaling toxic dust, smoke or fumes; and toxin exposure
- Quinary injuries — exposure to infections or radiation; acute, post-traumatic and chronic stress disorder
One often overlooked but important area of blast injury treatment and management is screening for infectious disease transmission, Mooney noted. He recalled treating a pediatric patient that had received a tourniquet at the bombing site for a limb injury due to what appeared to be an exposed bone. On closer examination, the bone was not the child’s, but a bone fragment from another injured in the explosion.
“It’s important to test for hepatitis B, hepatitis C and HIV in patients who have been exposed to other injured patients bodily fluids,” Mooney said.
Also, be aware of psychological issues that may arise emergency situations – about one-third of children admitted to the ED with an injury develop acute stress disorder, and about 50% of these children go on to develop post traumatic stress disorder (PTSD).
Encouraging children to find something positive to associate with the traumatic event can help them recover from acute stress disorder, Mooney advised. For example one pediatric patient was able to go onto the field and was announced as a survivor of the bombing before the national anthem at his favorite baseball team’s game.
“There are certain situations you will always live in fear of. It’s very important to identify what those situations are, prepare and train to respond,” Mooney said.
