1/16/2014. Prehospital Response to the Marathon Bombings: Boston, MA. Boston EMS: Who we are. The 117 th Running of the Boston Marathon

Transcription

1 Prehospital Response to the Marathon Bombings: Boston, MA Adam Darnobid, MD Fellow in EMS Department of Emergency Medicine University of Massachusetts Medical School David Hirsch, MD, MPH, FACEP EMS Medical Director Capital Area of New Hampshire Concord Emergency Medical Associates Concord Hospital Ricky Kue, MD, MPH, FACEP Associate Medical Director Boston EMS, Police and Fire Departments Assistant Professor of Emergency Medicine Boston University School of Medicine 2014 NAEMSP ANNUAL MEETING, TUSCON, AZ The 117 th Running of the Boston Marathon Boston EMS: Who we are Municipal 3 rd service EMS and bureau of the Boston Public Health Commission Two tiered system: Basic Life Support (BLS) and Advanced Life Support (ALS) 111,074 incidents in CY2012 Over 138,000 responses Average >300 calls/day >81,000 transports 378 department members 358 uniformed staff 251 EMTs 58 Paramedics 1

2 117 th Boston Marathon Multi Day Event ICS Implemented Zone Concept 9 BLS / 4 ALS 11 Bicycles Medical Stations / Proceed Out Teams Dispatch Operations Coordination Centers: UCC, MEMA, MIC Finish Area Footprint Marathon Medical Operations Operations managed by BAA and ARC medical tents Surges require triage and management outside of tents Data regularly sent to field command staff, hospitals, and race physicians during event PURPOSE Reduce surge to area hospitals (and EMS) by managing runner related illnesses and conditions at the medical tents Medical Stay and play mentality Runners Max. Temp Incident Totals Transport Totals Hospital Totals Incidence Rate Transports (% of Incidents) , , % 3.18% , , % 4.15% , , % 11.05% 2

3 ICU Section Heat Teams CWI therapy based on Marine Corps Marathon Medical Section istat POC testing hyponatremia 12 Lead ECG with Cardiology Podiatry / Physical Therapy EMS Critical care treatment area Airway, nebs, ACLS, meds, etc. Transport staging area VOLUNTEERS 47 Medical doctors 110 Registered nurses 60 Massage therapists 65 Physical therapists 50 Medical records personnel 60 Athletic trainers 25 Non medical assistants 5 Chiropractors TOOLS OF THE TRADE 7,200 Band Aids 3,000 Ice bags 400 IV bags of saline 314 Rolls of medical tape 200 Cots 46 Rectal thermometers 15 Massage tables (Source: Runner s World) 9:22AM Wheel Chair Participants Start Race 9:32 AM Elite Women Start Race 10:00 AM General Start (3 waves) 11:59 AM Female Winner Crosses Finish Line 12:10 AM Male Winner Crosses Finish Line 2:30 3PM Largest wave of amateur runners cross finish line 3

4 Another typical Marathon Monday Perfect marathon weather: 50s and dry. Marathon Maladies: Hypohydration Muscle Cramps, Blisters Heat Exhaustion/Stroke Hypothermia Hyponatremia Patient Tracking 523 Patients Seen 193 Active, 330 Discharged 8 Transports (some non marathon related) David Hirsch, MD, MPH, FACEP Marathon Video Insert video clip here The Initial Scene 4

5 5

6 Transport from Scene Some directly transported from scene Some taken to Medical Tent A Blast scene cleared of patients within 18 minutes 6

7 Pressure Cooker Bombs 101 Inexpensive way to create an effective IED with easily available compounds Contained system allows energy to build before release, increasing effect Components: Vessel, gun powder, detonator, shrapnel 7

8 Explosives Low Order subsonic explosion lack over pressurization wave e.g.: gun powder, petroleum based High Order supersonic explosion Creates a blast/over pressure wave e.g.: ammonium nitrate fuel oil (ANFO), TNT, dynamite, plastic Lessons Learned: Scene Response Scene safety Secondary device awareness Personal protective equipment Pre hospital vs. In hospital responders Equipment Tourniquets Triage Tags Litters Scene Safety Secondary (or tertiary ) device awareness Commonly taught, but not commonly encountered in US Law enforcement possessed higher awareness; communicated to EMS Created an urgency to clear scene (18 minutes) PPE Gloves and a polo shirt? Helmet and ballistic vest? Full turnout gear? 8

9 Responders at the Scene Pre hospital vs. In hospital Responders Different levels of training and awareness Different equipment Different mindset and priorities Equipment: X A B C s Combat Application Tourniquet (C A T) SOFT Tw Tourniquet 9

10 Equipment: Triage Tag Systems Equipment: Rapid Extrication/Transport 10

11 Return to the Medical Tent: Where was I osweep Bus Triage Physician olocated in the back of Medical Tent A oapproximately 100 yards from Boylston Street Adam Darnobid, MD The Community of the Medical Tent A Microcosm of the event Medical specialties ranging from endocrinology to cardiac surgery, emergency medicine to psychiatry Nurses, trainers, transporters, communications, registration, medical records, supply section, security and police. EMS and transport It s how we interact everyday, it s who we need to succeed. It s our team Medical Tent A Patient Flow Patient flow from the front of the tent to the back with patients of increasing acuity EMS resources stationed at the back of the tent Plan to transport all ill runners from the field to the back of the tent for medical evaluation if needed 11

12 Medical Tent A Patient Egress With Boston EMS at the St James St Exit with a natural entrance and exit, it made a logical natural patient flow As the event became acute, the exit away from the bombing site allowed a consistent flow of patients. There was natural bottle neck at the distal end of the tent allowing for further patient stratification The Knowledge Enough knowledge to know: Initially sports and marathon medicine were out of my comfort zone. As things changed, It became much more of what I knew The Knowledge Trauma paradigm Bleeding out Hypothermia IVF vs. Blood 12

13 The Knowledge Bleeding control Tourniquets Tactical experience The Knowledge Prehospital triage SMART/START The meaning of Black tag The Skills Its touches on every specialty Improvise It s the skills from being in the ED, from the Prehospital environment, its engrained 13

14 The Skills You have the skills and the knowledge, now you just need to do it Intersection of EMS and the Physician A unique setting where not every (or any) doctor could have performed Communication and the exchange of information needs to happen in a unique fashion This isn t the emergency department or hospital setting. Its prehospital medicine in its own environment with its own challenges The EMS Response: Chance favors the prepared mind Louis Pasteur Ricky Kue, MD, MPH, FACEP 14

15 MBHSR MCI PHASE DESIGNATIONS Phase 1 1 to 10 potential victims Phase 2 11 to 30 potential victims Phase 3 31 to 50 potential victims Phase 4 50 to 200 potential victims Phase 5 Greater than 200 potential victims Phase 6 Incident or Event Requiring Sustained EMS Operations (longer than twenty four hours) TRIAGE START Triage SALT Medical Tent A A Medical Director s Perspective Re defined the purpose of our forward medical asset and its role No longer definitive care, now a CCP Rapid clearance of victims to next available ambulance Trauma czar triage The basics: X A B C s 15

16 Training Urban Shield (2011, 2012) MBTA Green Line Crash (Nov. 2012) Flu Public Health Emergency (Jan. 2013) Tour Bus Crash (Feb. 2013) Nemo Blizzard (Feb. 2013) TCCC Training Time saves lives Early tourniquet use Hemostatic dressings Provider independence and autonomy under austere conditions EMS Staging Area 16

17 Patient Distribution 118 Patients via EMS Communications Field Operations BAMA CMED (+ EMS Physician) 800MHz Radios HAM (Amateur) Systems WebEOC (Boston, DPH, MEMA) HHAN Alerts (DPH, COBTH, MEMA) Cell Failure Impact Fast Moving Information Rumor Control 17

18 Hospital Distribution and Inter facility Communication Boston EMS Dispatch Operations Boston Area Ambulance Mutual Aid Network (BAMA) Central Medical Emergency Direction (CMED) Disaster Radio Network Consortium of Boston Teaching Hospitals (COBTH)* MIC Operations ESF 8 MACC MA DPH, HHS, COBTH, American Red Cross Situational Awareness SitBriefs (22 Total) Patient Tracking Operational Planning Hospital coordination Family reunification Human Services Coordination Victim Assistance Mental Health Demobilization & Transition Planning MIC: Medical Intelligence Center 18

19 Situational Awareness Hospital Operations ED Surge Transfer & Admit ED Patients Expedited Discharge Code Help Floor Clearance Staffing PPE Trauma Kits BMC Amputation Kit & Blood Requests Facilitated using ICS 10 Hospital Responses Blood filled by RI Blood Center via Mass. State Police Prepped Mobile Decontamination Units 19

20 And then, the longest day Sean Collier 26 Y/O Richard Donohue Jr. 33 Y/O Thank you 20