BETHESDA, MD 19 April 2013—The people who arrived in the emergency department on April 15 had injuries unlike any Nancy Balch had seen in her 12 years as an emergency department pharmacist at Massachusetts General Hospital in Boston.
Their injuries were severe. At least one person had had a limb blown off.
"I've seen a lot, unfortunately," she said of her decade-plus in emergency care at the level 1 trauma center, "but nothing like this."
High volume, extensive injuries. By the end of Balch's regularly scheduled shift on Monday, the hospital had treated 29 people injured by the bombs that exploded near the finish line of the Boston Marathon.
People came to the emergency department the next day, too, Balch said. Some sought care because their hearing had not returned to normal. Others did not realize until Tuesday that they had a piece of metal stuck in them.
Shannon Manzi, at Boston Children's Hospital, has spent almost as much time in an emergency department as Balch has.
"I have not seen these types of injuries since I was in Haiti," said Manzi, who went there in 2010 immediately after the 7.0-magnitude earthquake.
But in Haiti, the patients had crush injuries, she said. On Monday, the patients at Boston Children's had blast injuries. Both types of injuries can sever limbs.
The children hit by the blasts, however, had injuries more extensive than what Manzi had seen after the earthquake.
On Monday, Boston Children's, a level 1 pediatric trauma center, received 10 patients from the blasts, the hospital has reported.
Manzi said she had just torn down the medical tent at mile 15 in the marathon when her pager alerted her to a "mass casualty" at the hospital.
The first 2 patients were in the emergency department when she arrived.
Good decisions, well-made plans. The bombs exploded about the same time as the overlap in day and evening shifts for emergency department pharmacists and pharmacy technicians, Manzi said.
On arrival, she assumed the role of managing pharmacist. Pharmacists with emergency department training who had been working upstairs in the hospital came downstairs to bring the total to six.
Manzi said emergency care personnel organized into four teams, each with two physicians, two nurses, one clinical assistant, one respiratory therapist, and one pharmacist. She remained available to manage resources, ensure everyone had what they needed, communicate with the main pharmacy, and step in when a pharmacist needed relief. The sixth pharmacist worked with the patients who were in the emergency department for reasons other than the bomb explosions.
Brigham and Women's Hospital, a level 1 trauma center next to Boston Children's, received 31 patients from the explosions, an emergency department physician told CNN on Monday night.
Nine of those patients underwent major surgery that day, he said.
Pharmacy services executive director William Churchill said his department's immediate goal was to ensure that the physicians and nurses in the emergency department would not have to leave a bedside to obtain a medication.
The pharmacy accomplished that goal by shifting resources to have six pharmacists in the emergency department in the initial hours after the explosions, he said.
One pharmacist was already in the emergency department for the evening shift. The day-shift emergency department pharmacist, Churchill said, stayed on, as did nearly all the staff.
And, "as luck would have it," he said, several members of the "emergency department pharmacy team" were already on duty in other areas of the hospital. The pharmacy deployed two to each of the main areas of the emergency department. In each twosome, one spoke with the nurses and physicians to determine what they needed and answer questions and the other pharmacist expedited medication delivery.
"We drill a lot with preparing for disasters and mass casualties," Churchill said.
In those types of emergencies, patients may need a medication before they have a medical record number or their name is known. Lacking that information, he said, personnel other than the pharmacists can have trouble obtaining a medication from an automated dispensing machine. So the pharmacy on Monday deployed pharmacists who could obtain medications quickly from automated technology, he said. Those pharmacists also facilitated the preparation and delivery of preoperative i.v. drug doses for the patients heading for surgery.
"One of the pharmacists said to me that it was her perception that . . . the nurses seemed to be relieved that the pharmacists were there as part of the team helping them," Churchill said.
All of this transpired while he was offsite.
John Fanikos, one of the pharmacy's senior directors, assumed the role of the pharmacy unit leader and went to the hospital's command center, Churchill said.
"We've actually drilled and practiced that with all of my senior directors," he said.
With Fanikos in the hospital's command center, Churchill said, two of the mid-level managers took roles in operating the pharmacy command center.
Contingencies. At Massachusetts General, interim chief pharmacy officer Erasmo "Ray" Mitrano made sure Balch had support in the emergency department—another pharmacist who could lend a hand and provide care to pediatric patients if any arrived.
Mitrano sent Lois Parker to the emergency department from the pediatric intensive care unit. He also had pharmacists elsewhere in the hospital remotely handle the workload that would have been Balch's on a normal day. This, he said, freed up Balch and Parker to focus on the patients injured by the bombs.
Parker said she stayed in the pediatric emergency department to be out of the way until her assistance was needed.
But no pediatric patients had arrived by 5:30 p.m., she said, when the hospital's incident command center sent a broadcast e-mail stating that staff coverage was adequate enough for the day shift to leave. She checked with Balch, who concurred that Parker could leave.
Parker said she felt "pretty prepared" for the situation in the emergency department. The hospital has conducted disaster drills on a regular basis, and she participated in a tabletop disaster drill that was specifically geared toward pediatrics.
Emotional support. The day after the bombs exploded, Manzi said, Boston Children's held a debriefing for emergency department personnel.
She said the hospital commonly holds a debriefing after a bad outcome. But the recent debriefing was held for another reason. The injuries on Monday were not the type seen every day, she said.
"When it's in your background and it's terrorism," Manzi said, "it's a different thing than when it was a very, very sad case of a motor vehicle accident or a shaken baby."
Churchill estimated that 50-some pharmacists were at "The Brigham" when the bombs exploded.
"People rolled up their sleeves and volunteered to stay and did whatever was necessary to get it done," he said. "I couldn't be more proud of that situation or my department."
Churchill, when interviewed two days after the bombing, said he continues to check on how his staff members are doing.
"Hopefully, everybody's going to do real well," he said.
Parker, who said she was not directly involved in caring for any of the injured, said the bombing hit particularly "close to home" because coworkers could have been among the injured.
"The Mass General has a fairly sizable team of people who run in the marathon, and they raise money for various programs at the hospital, including the pediatric oncology clinic," she said.
Word of the bombing reached Parker soon after she and others had determined through the marathon organizer's athlete tracking system that some of their colleagues were near the finish line.
Balch said she sees "awful accidents" all the time, yet what she saw April 15 was different.
"The thing that most struck me," she said, "is it was something that somebody did to people. . . . That's what makes it most horrific for me."
Three hours after the bombing, the Boston Police Department reported that three people had died.
Local hospitals had received 176 people by 7 a.m. Tuesday, the department later stated.