April 18, 2013 Liz Borkowski, MPH 0Comment

The New Yorker’s News Desk blog features an excellent piece by Atul Gawande called “Why Boston’s Hospitals Were Ready.” It’s a riveting read about how emergency medical teams, the city’s emergency command center, and hospital staff all responded immediately and with admirable coordination to the needs of those injured in the bomb blast at the Boston Marathon:

The explosions took place at 2:50 P.M., twelve seconds apart. Medical personnel manning the runners’ first-aid tent swiftly converted it into a mass-casualty triage unit. Emergency medical teams mobilized en masse from around the city, resuscitated the injured, and somehow dispersed them to eight different hospitals in minutes, despite chaos and snarled traffic.

My hospital, the Brigham and Women’s Hospital, received thirty-one victims, twenty-eight of them with significant injuries. Seven arrived nearly at once, starting at 3:08 P.M. All required emergency surgery. The first to go to surgery—a patient in shock, hemorrhaging profusely, with inadequate breathing and a near-completely severed leg—was resuscitated and on an operating table by 3:25 P.M., just thirty-five minutes after the blast. The rest followed, one after the other, spaced by just minutes. Twelve patients in all would undergo surgery—mostly vascular and orthopedic procedures—before the evening was done.

This kind of orchestration happened all across the city. Massachusetts General Hospital also received thirty-one victims—at least four of whom required amputations. Boston Medical Center received twenty-three victims. Beth Israel Deaconess Medical Center handled twenty-one. Boston Children’s Hospital took in seven children, ages two to twelve. One emergency physician told me he’d never heard so many ambulance sirens before in his life.

There’s a way such events are supposed to work. Each hospital has an incident commander who coördinates the clearing of emergency bays and hospital beds to open capacity, the mobilization of clinical staff and medical equipment for treatment, and communication with the city’s emergency command center.

In a mass-casualty event like this one, no single hospital can handle all the victims. In a Washington Post piece by David Montgomery, Mary Beth Sheridan, and Lenny Bernstein, Texas Trauma Institute chief John B. Holcomb congratulates Boston’s responders for not overloading a single hospital with wounded patients. Matching victim needs to hospital capacity requires a well prepared incident command and Emergency Medical Services systems.

In recent years, emergency planning has increasingly emphasized the importance of building “healthcare coalitions” — formal collaborations between hospitals, public health departments, emergency management and response agencies, and other healthcare providers in a geographic area. Coalition members work together to prepare for and respond to public health emergencies, which can include disease outbreaks and natural disasters as well as mass-trauma events like explosions (terror-related or not), fires, and major vehicle crashes.

Planning within an organization and with external partners requires a constant investment of time and money. (“Emergency management is like dishes or laundry — it’s never done,” explained  National Association of Community Health Centers Director of Emergency Management Mollie Melbourne at the organization’s recent Policy & Issues conference). EMS systems, hospitals, other healthcare providers, police, health departments, and emergency management agencies have to dedicate money to preparedness planning every year. Federal grant programs — most notably HHS’s Hospital Preparedness Program and CDC’s Public Health Emergency Preparedness program — also provide funding for states to invest in community preparedness efforts.

Overall, prepardness has improved a great deal since the 9/11 and anthrax attacks of 2001 . But, as Trust for America’s Health warned in its 10th annual Ready or Not? Protecting  the Public from Diseases, Disasters, and Bioterrorism report, “there continue to be persistent gaps in the country’s ability to respond to health emergencies, ranging from bioterrorist threats to serious disease outbreaks to extreme weather events.” Funding increases that followed the 2001 attacks have not been sustained, and many federal, state, and local agencies are seeing budget freezes or cuts. TFAH explains:

[Federal legislation freezing public health preparedness funding at FY 2011 levels] would not provide sufficient resources to modernize public health systems and ensure we are prepared in the event of an emergency. TFAH recommends restoring PHEP and HPP funding to FY 03 levels. Over the last several years, public health preparedness funding has declined considerably—contributing to the loss of more than 45,700 state and local public health jobs. Many of these workers were trained in public health preparedness, emergency response, biosurveillance and epidemiology. We must fund public health preparedness with the same level of commitment as we have made to other national security priorities.

In addition to the horrific events in Boston, the past week has seen an attempted ricin attack through the mail and a massive explosion at a Texas fertilizer plant. The emergency responders, healthcare workers, marathon runners, bystanders, and community members who responded heroically to save lives and help their neighbors deserve our thanks and praise. Such heroism does the most good when it’s coupled with well-prepared organizations that have worked together on emergency planning. We may not know where or in what form the next disaster will strike, but we know disasters are coming. Let’s make sure we’re ready.

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