EDITORIAL
The Danger of Complacency − Readiness and Preparedness = Effective Outcomes Kobi Peleg, PhD, MPH
I
t seems that most of the experts agree that the Boston health care system dealt with the Boston Marathon mass casualty incident (MCI) with a high level of effectiveness.1–4 The fact is more pronounced when taking into consideration that this was the first time in the last decade that Boston’s health care system has had to deal with a real terror MCI. The questions are as follows: How did they succeed in being so effective? Was this a coincidence? If not, how can we promise that every city or area will be prepared like Boston? Boston has a great history of preparedness for MCI. The Cocoanut Grove was the place to be in 1942. On November 28, 1942, at 10:15 PM, “a fireball of flame and toxic gas raced across the room toward the stairs.” A total of 490 dead and 166 injuries resulted from the MCI event. It is significant to note that even in 1942, Boston was prepared for MCI in advance. Two weeks before the huge fire in the Cocoanut Grove club in Boston, “In an interesting twist of fate, area hospitals had practiced a disaster drill the week before the fire.”5 Terror MCI is a situation that happens once in a while, usually, in another location such as Oklahoma, Madrid, New York, London, Boston, Bali, and other sites. It occurs once in a while, out of the blue, and so it is not easy to keep the whole system prepared 24/7 for an extended period of time for a situation that may or may not eventuate. This entails high costs, lots of attention, and resources such as, time, energy, space, manpower, equipment, and more from very busy personnel. To be ready, prepared, and effective, we have to carefully study the lessons learnt from the experience of others who have encountered terror MCI.6 They contain relevant lessons on the system and developed training and practices within the system accordingly. Oscar Wilde said, “Experience is one thing you can’t get for nothing.” So, what were the reasons for the success of the Boston health care system in this event? Boston was known to be one of the cities in which the health care system works very tirelessly to be prepared for such situations even before the Boston Marathon bombing. They organized international conferences to share experience and knowledge, workshops, setting up MCI system and Standard Operating Procedures, training sessions, tabletop exercises, and drills on MCIs and made a collaborative agreement with the CDC on this issue. The cooperative efforts have resulted in principles such as national standards for triage at the scene and other fundamentals.3 The outcomes were the results of conscientious efforts to be effective and involved deep thinking and intensive training. Undoubtedly, it is frustrating to prepare for something that does not happen and may never happen in your city, but Boston is a good example of how important it is to prepare and how many lives can be saved if the professional response is carried out correctly. In this case, none of the injured died in the hospitals.7 When we study the lessons learnt and are setting your system on the basis of the evidence gained from the experience of others, it seems simple and obvious, but actually it is not; we cannot take a system from one country and perform a cut and paste application to our system; no health care systems are identical. Hence, we are unable to build the same response system in any 2 countries. It can sometimes be similar but not identical. Even if the bottlenecks are the same in different countries, the way to deal with this issue may vitiate between a range of systems. Each system requires specific adjustments according to its structure. It seems that Boston realized this and correctly implemented the appropriate insights. MCI is a very complicated situation, which needs to be acted upon and huge numbers of decisions need to be made in uncertain situations, in a very short time, with a lot of agencies who interact in this situation, and when the information you need now to make the right decision is very limited and is changing every moment. This is the reason that it is so important to invest in education,
From the National Center for Trauma and Emergency Medicine Research, The Gertner Institute for Health Policy and Epidemiology, Tel-hashomer, Israel; and Disaster Medicine Department, School of Public Health, Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel. Disclosure: The authors declare no conflicts of interest. Reprints: Kobi Peleg, PhD, MPH, National Center for Trauma and Emergency Medicine Research, The Gertner Institute for Health Policy and Epidemiology, Tel-hashomer, Israel 52621, Israel. E-mail: [email protected]/[email protected]. C 2014 by Lippincott Williams & Wilkins Copyright ISSN: 0003-4932/14/26006-0967 DOI: 10.1097/SLA.0000000000000987
Annals of Surgery r Volume 260, Number 6, December 2014
www.annalsofsurgery.com | 967
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Annals of Surgery r Volume 260, Number 6, December 2014
Peleg
practice and training, and full drills for preparedness for MCIs. Boston did it and the outcomes proved that they were right.1,7 The importance of the article by Gates and his colleagues is by reason of the data they publish, enabling us to understand some relevant evidence-based lessons: What worked well in the Boston system and what we can improve.3 Most articles published on the Boston bombing presented details from different viewpoints elaborating on what worked well in dealing with the MCI1–4,6 including some aspects of the special conditions that accrued in this specific MCI. Some important issues surface from the article by Gates and his colleagues,7 which allow us to examine the principles conceived over time that have become part of the system. Following the data in the article, it may be necessary to reexamine certain issues in the system: for instance, on the subject of MCI casualties distribution, most articles dealing with MCI systems define that patients should be distributed between several trauma centers. It is essential that the severe casualties should be distributed between several trauma centers so that each trauma center will maintain its ability to provide optimal care. The distribution of severe casualties is much more important than the distribution of the total number of casualties.8 Theoretically, 16 severe casualties that could be distributed effectively to 5 or 6 trauma centers will leave us with around 3 severe casualties in every trauma center. In this MCI, only 4 trauma centers received severe casualties and 1 of the 4 received only 1 severe casualty.7 In MCI, the ability to provide optimal care to each casualty is much higher if the trauma center receives less severe casualties. The outcomes show us that there was no mortality in the trauma centers in the Boston bombing. Does this reflect on the number of casualties distributed to each of the trauma centers or perhaps, the special situation of double shifts at the hospitals during this event or other possibilities that could make the difference in outcomes? This is something to think about. A coordinated computerized system, which includes real time data from all the trauma centers in the specific area on the available critical resources, such as beds of intensive care unit, operating rooms, and beds of emergency department, can optimize the distribution of casualties, referring the right casualty to the appropriate trauma center. Another point to think about is triage at the scene for transportation priorities. Two severe casualties were transferred to the trauma centers by police cars and not by ambulance. The total number of severe casualties was 16, and a lot of ambulances were at the site within a short time after the event because of the marathon. One more point for consideration is the fact that all the systems currently dealing with MCIs all over the world use color tags of severity that include 4 to 5 colors. There is no doubt that colored severity tags make sense. However, the problem is that this works well in
968 | www.annalsofsurgery.com
drills, but not in real MCIs situations. In fact, most debriefings show that MDs and the paramedics do not use these tags effectively in real MCIs. The Gates article mentions that only 1 of 127 injured arrived at the trauma centers with an MCI tag, tags were not applied in 23 cases (18%), and in 103 cases the situation was unknown. In relation to the 103 unknown tag application, it means that the hospital staff did not record it, bringing us to 2 options: Most injuries arrived without tags or they arrived with tags but the hospital staff did not think that this helped or was important for them. Perhaps we have to reconsider the real needs and why the EMTs are not using the tags enough in real MCIs. Maybe we should use only 2 colors as some emergency medical services currently implement: urgent (red) and no urgent (green), thereby keeping it simple and “stupid.” To summarize, there is no substitute for the fact that intensive, systematic, and comprehensive preparedness for emergency situations is a “must,” even in the hope that this predicament will never eventuate. The manner in which the Boston health system coped with the Boston Marathon MCI is evidence-based proof, beyond any doubt, that such preparedness and readiness for MCIs is essential. Learning from the experience of others and integrating the relevant insights into the local system, as was the case in Boston, had an overwhelming impact. Each member of the health sector has a role of responsibility to prepare his/her field. Do not say, “It won’t happen to me”—take an example of how this has worked well in Boston and apply it to your system accordingly.
REFERENCES 1. Biddinger PD, Baggish A, Harrington L, et al. Be prepared—the Boston Marathon and mass-casualty events. New Eng J Med. 2013;368:1958–1960. 2. Jangi S. Under the medical tent at the Boston Marathon. New Eng J Med. 2013;368:1953–1955. 3. Schwartz RB, Sattin RW, Hunt RC. Medical response to bombings: the application of lessons learned to a tragedy. Disaster Med Public Health Prep. 2013;7:114–115. 4. Kellermann A, Peleg K. Lessons from Boston. N Engl J Med. 2013;368:1956– 1957. 5. The Boston Fire Historical Society. The Coconut Grove Fire. November 28, 1942. Available at: http://www.bostonfirehistory.org/firestory11281942.html. Accessed July 20, 2014. 6. Gawande A. Why Boston’s hospitals were ready. The New Yorker. http:// www.newyorker.com/online/blogs/newsdesk/2013/04/why-bostons-hospitalswere-ready.html?mobify=0. Accessed August 2, 2014. 7. Gates J, Arabian S, Biddinger P, et al. The initial response to the Boston Marathon bombing: lessons learned to prepare for the next disaster. Ann Surg. 2014;260:964–970. 8. Peleg K, Kellermann AL. Enhancing hospital surge capacity for mass casualty events. JAMA. 2009;302:565–567.
C 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
The Danger of Complacency − Readiness and Preparedness = Effective Outcomes Kobi Peleg, PhD, MPH
I
t seems that most of the experts agree that the Boston health care system dealt with the Boston Marathon mass casualty incident (MCI) with a high level of effectiveness.1–4 The fact is more pronounced when taking into consideration that this was the first time in the last decade that Boston’s health care system has had to deal with a real terror MCI. The questions are as follows: How did they succeed in being so effective? Was this a coincidence? If not, how can we promise that every city or area will be prepared like Boston? Boston has a great history of preparedness for MCI. The Cocoanut Grove was the place to be in 1942. On November 28, 1942, at 10:15 PM, “a fireball of flame and toxic gas raced across the room toward the stairs.” A total of 490 dead and 166 injuries resulted from the MCI event. It is significant to note that even in 1942, Boston was prepared for MCI in advance. Two weeks before the huge fire in the Cocoanut Grove club in Boston, “In an interesting twist of fate, area hospitals had practiced a disaster drill the week before the fire.”5 Terror MCI is a situation that happens once in a while, usually, in another location such as Oklahoma, Madrid, New York, London, Boston, Bali, and other sites. It occurs once in a while, out of the blue, and so it is not easy to keep the whole system prepared 24/7 for an extended period of time for a situation that may or may not eventuate. This entails high costs, lots of attention, and resources such as, time, energy, space, manpower, equipment, and more from very busy personnel. To be ready, prepared, and effective, we have to carefully study the lessons learnt from the experience of others who have encountered terror MCI.6 They contain relevant lessons on the system and developed training and practices within the system accordingly. Oscar Wilde said, “Experience is one thing you can’t get for nothing.” So, what were the reasons for the success of the Boston health care system in this event? Boston was known to be one of the cities in which the health care system works very tirelessly to be prepared for such situations even before the Boston Marathon bombing. They organized international conferences to share experience and knowledge, workshops, setting up MCI system and Standard Operating Procedures, training sessions, tabletop exercises, and drills on MCIs and made a collaborative agreement with the CDC on this issue. The cooperative efforts have resulted in principles such as national standards for triage at the scene and other fundamentals.3 The outcomes were the results of conscientious efforts to be effective and involved deep thinking and intensive training. Undoubtedly, it is frustrating to prepare for something that does not happen and may never happen in your city, but Boston is a good example of how important it is to prepare and how many lives can be saved if the professional response is carried out correctly. In this case, none of the injured died in the hospitals.7 When we study the lessons learnt and are setting your system on the basis of the evidence gained from the experience of others, it seems simple and obvious, but actually it is not; we cannot take a system from one country and perform a cut and paste application to our system; no health care systems are identical. Hence, we are unable to build the same response system in any 2 countries. It can sometimes be similar but not identical. Even if the bottlenecks are the same in different countries, the way to deal with this issue may vitiate between a range of systems. Each system requires specific adjustments according to its structure. It seems that Boston realized this and correctly implemented the appropriate insights. MCI is a very complicated situation, which needs to be acted upon and huge numbers of decisions need to be made in uncertain situations, in a very short time, with a lot of agencies who interact in this situation, and when the information you need now to make the right decision is very limited and is changing every moment. This is the reason that it is so important to invest in education,
From the National Center for Trauma and Emergency Medicine Research, The Gertner Institute for Health Policy and Epidemiology, Tel-hashomer, Israel; and Disaster Medicine Department, School of Public Health, Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel. Disclosure: The authors declare no conflicts of interest. Reprints: Kobi Peleg, PhD, MPH, National Center for Trauma and Emergency Medicine Research, The Gertner Institute for Health Policy and Epidemiology, Tel-hashomer, Israel 52621, Israel. E-mail: [email protected]/[email protected]. C 2014 by Lippincott Williams & Wilkins Copyright ISSN: 0003-4932/14/26006-0967 DOI: 10.1097/SLA.0000000000000987
Annals of Surgery r Volume 260, Number 6, December 2014
www.annalsofsurgery.com | 967
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Annals of Surgery r Volume 260, Number 6, December 2014
Peleg
practice and training, and full drills for preparedness for MCIs. Boston did it and the outcomes proved that they were right.1,7 The importance of the article by Gates and his colleagues is by reason of the data they publish, enabling us to understand some relevant evidence-based lessons: What worked well in the Boston system and what we can improve.3 Most articles published on the Boston bombing presented details from different viewpoints elaborating on what worked well in dealing with the MCI1–4,6 including some aspects of the special conditions that accrued in this specific MCI. Some important issues surface from the article by Gates and his colleagues,7 which allow us to examine the principles conceived over time that have become part of the system. Following the data in the article, it may be necessary to reexamine certain issues in the system: for instance, on the subject of MCI casualties distribution, most articles dealing with MCI systems define that patients should be distributed between several trauma centers. It is essential that the severe casualties should be distributed between several trauma centers so that each trauma center will maintain its ability to provide optimal care. The distribution of severe casualties is much more important than the distribution of the total number of casualties.8 Theoretically, 16 severe casualties that could be distributed effectively to 5 or 6 trauma centers will leave us with around 3 severe casualties in every trauma center. In this MCI, only 4 trauma centers received severe casualties and 1 of the 4 received only 1 severe casualty.7 In MCI, the ability to provide optimal care to each casualty is much higher if the trauma center receives less severe casualties. The outcomes show us that there was no mortality in the trauma centers in the Boston bombing. Does this reflect on the number of casualties distributed to each of the trauma centers or perhaps, the special situation of double shifts at the hospitals during this event or other possibilities that could make the difference in outcomes? This is something to think about. A coordinated computerized system, which includes real time data from all the trauma centers in the specific area on the available critical resources, such as beds of intensive care unit, operating rooms, and beds of emergency department, can optimize the distribution of casualties, referring the right casualty to the appropriate trauma center. Another point to think about is triage at the scene for transportation priorities. Two severe casualties were transferred to the trauma centers by police cars and not by ambulance. The total number of severe casualties was 16, and a lot of ambulances were at the site within a short time after the event because of the marathon. One more point for consideration is the fact that all the systems currently dealing with MCIs all over the world use color tags of severity that include 4 to 5 colors. There is no doubt that colored severity tags make sense. However, the problem is that this works well in
968 | www.annalsofsurgery.com
drills, but not in real MCIs situations. In fact, most debriefings show that MDs and the paramedics do not use these tags effectively in real MCIs. The Gates article mentions that only 1 of 127 injured arrived at the trauma centers with an MCI tag, tags were not applied in 23 cases (18%), and in 103 cases the situation was unknown. In relation to the 103 unknown tag application, it means that the hospital staff did not record it, bringing us to 2 options: Most injuries arrived without tags or they arrived with tags but the hospital staff did not think that this helped or was important for them. Perhaps we have to reconsider the real needs and why the EMTs are not using the tags enough in real MCIs. Maybe we should use only 2 colors as some emergency medical services currently implement: urgent (red) and no urgent (green), thereby keeping it simple and “stupid.” To summarize, there is no substitute for the fact that intensive, systematic, and comprehensive preparedness for emergency situations is a “must,” even in the hope that this predicament will never eventuate. The manner in which the Boston health system coped with the Boston Marathon MCI is evidence-based proof, beyond any doubt, that such preparedness and readiness for MCIs is essential. Learning from the experience of others and integrating the relevant insights into the local system, as was the case in Boston, had an overwhelming impact. Each member of the health sector has a role of responsibility to prepare his/her field. Do not say, “It won’t happen to me”—take an example of how this has worked well in Boston and apply it to your system accordingly.
REFERENCES 1. Biddinger PD, Baggish A, Harrington L, et al. Be prepared—the Boston Marathon and mass-casualty events. New Eng J Med. 2013;368:1958–1960. 2. Jangi S. Under the medical tent at the Boston Marathon. New Eng J Med. 2013;368:1953–1955. 3. Schwartz RB, Sattin RW, Hunt RC. Medical response to bombings: the application of lessons learned to a tragedy. Disaster Med Public Health Prep. 2013;7:114–115. 4. Kellermann A, Peleg K. Lessons from Boston. N Engl J Med. 2013;368:1956– 1957. 5. The Boston Fire Historical Society. The Coconut Grove Fire. November 28, 1942. Available at: http://www.bostonfirehistory.org/firestory11281942.html. Accessed July 20, 2014. 6. Gawande A. Why Boston’s hospitals were ready. The New Yorker. http:// www.newyorker.com/online/blogs/newsdesk/2013/04/why-bostons-hospitalswere-ready.html?mobify=0. Accessed August 2, 2014. 7. Gates J, Arabian S, Biddinger P, et al. The initial response to the Boston Marathon bombing: lessons learned to prepare for the next disaster. Ann Surg. 2014;260:964–970. 8. Peleg K, Kellermann AL. Enhancing hospital surge capacity for mass casualty events. JAMA. 2009;302:565–567.
C 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
