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How did Mass General respond to this event, where they prepared? And what deficiencies or shortcomings did they encounter?

Boston Bombings: Response
to Disaster
MAUREEN HEMINGWAY, MHA, RN, CNOR; JOANNE FERGUSON, MSN, RN

ABSTRACT

Disasters disrupt everyone’s lives, and they can disrupt the flow and function of

an OR as well as affect personnel on a professional and personal level even

though perioperative departments and their personnel are used to caring for

trauma patients and coping with surprises. The Boston Marathon bombing was a

new experience for personnel at Massachusetts General Hospital, Boston. This

article discusses the incidents surrounding the bombing and how personnel at

this hospital met the challenge of caring for patients and the changes we made

after the experience to be better prepared in the event a response to a similar

incident is needed. AORN J 99 (February 2014) 277-288. ? AORN, Inc, 2014.
http://dx.doi.org/10.1016/j.aorn.2013.07.019

Key words: perioperative disaster care, OR triage, terrorist bombings, Boston

Marathon, shelter in care, city lockdown.

M
assachusetts General Hospital (MGH),

Boston, is a level I trauma teaching

hospital where patients receive care for

all surgical specialties. Personnel have the capacity

and ability to care for a large number of patients

with varying acuity levels. There are 907 beds and

61 functional ORs located on one campus. In 2005,

MGH received designation as a Magnet? hospital,
and, in 2008 and 2012, the American Nurses Cre-

dentialing Center renewed this designation. The

hospital’s perioperative nursing team cares for

approximately 36,000 patients per year and pro-

vides perioperative care, on average, for 150 pa-

tients per day. The ORs are located on three levels

across five different buildings. The OR personnel

comprise 235 RNs, 92 surgical technologists, 27

equipment technicians, 115 OR assistants, and 17

operations assistants.

The environment in the OR can change very

quickly during the course of any day. Perioperative

nurses who work in the OR are aware that the daily

schedule may be disrupted by unscheduled events,

such as the arrival of trauma patients, transplan-

tation recipients or donors, patients who need to

return to surgery, or equipment or facility failures.

When terrorist bombs exploded at the annual

Boston Marathon, the resources and disaster plans

at MGH were put to the test. This article discusses

the response of personnel and the outcome and

changes made as a result of this experience.

APRIL 15, 2013

It had been a typical “marathon Monday,” with an

atmosphere of excitement in the city that was felt in

the hospital and OR environment. The Boston

Marathon is a long-standing tradition for many

people who participate either as runners, volun-

teers, or bystanders.
1
Notably, this third Monday in

April is Patriot’s Day, a state holiday for many,

which coincides with the public school system’s

http://dx.doi.org/10.1016/j.aorn.2013.07.019

? AORN, Inc, 2014 February 2014 Vol 99 No 2 ? AORN Journal j 277

vacation week. However, it is one of the few state

holidays not observed at MGH.

This marathon Monday began no differently

than many others already past. The OR had pro-

cedures scheduled in 51 rooms that morning,

compared with the usual 61 rooms, and periopera-

tive leaders were projecting that there would be

fewer than 40 rooms running by 3 PM. That

morning, 135 nursing team members arrived for

the 7 AM shift, with more personnel scheduled to

arrive for the 11 AM and 3 PM shifts. The surgical

schedule included a variety of cardiac, vascular,

neurosurgical, and spinal fusion procedures, all

starting at 8 AM. In the early afternoon, the elite

marathon runners’ race results started filtering

in through people’s social media connections.

Although our ORs are mainly situated on one floor,

they do extend through multiple buildings (Figure 1),

and it has become necessary for personnel to

communicate by using cell phones with texting

capability. Operating room leadership personnel,

such as the resource nurse and the anesthesia staff

administrator, communicate with perioperative

personnel through hospital cell phones. Additionally,

in an effort to decrease overhead paging, employees

are allowed to carry personal cell phones; however,

these cell phones are not to be used in the presence of

patients, and they need to be kept in silent mode at all

Figure 1. Aerial photograph of the locations of the perioperative services department at Massachusetts General
Hospital.

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February 2014 Vol 99 No 2 HEMINGWAYdFERGUSON

times. At 2 PM, the evening resource nurse and the

OR nursing leader assessed the afternoon staffing

situation and reported that it looked good: patients

were being cared for on time and team members were

not anticipating the need to work overtime hours.

DISASTER DECLARATION AND RESPONSE

Just before 3 PM, the hospital environment

changed dramatically. Social media provided the

initial information that a bomb had exploded at the

Boston Marathon finish line. The first responders at

the finish line began to care for the casualties by

converting the runners’ medical tent to an emer-

gency triage unit. From there, members of the

Boston Emergency Medical Services (EMS) tri-

aged and transported patients to trauma centers

across the city. Initially, the MGH emergency

preparedness leadership team did not know the

number of patients nor the types of injuries to

expect. Overhead paging alerted OR leaders to

check at the control OR desk.

Massachusetts General Hospital uses an emer-

gency notification system (ENS) for critical com-

munications to varying levels of hospital leaders

when an emergency or a disaster is declared, which

is in accordance with the MGH Hospital Incident

Command System Pre-Marathon (Figure 2). At 3

PM, senior-level hospital leaders learned of the

terrorist events through the Boston EMS system

and the hospital leaders then used ENS to activate a

disaster declaration at 3:03 PM. The first MGH

patient arrived in the emergency department (ED)

at 3:04 PM, but this information was not immedi-

ately relayed to all perioperative administrative

leaders or clinical personnel. As a result of this

limited information, perioperative leaders and

team members relied primarily on information

from social media sites and newscasts. Periopera-

tive personnel began to prepare for the expected

influx of wounded patients based on their individ-

ual experiences caring for trauma patients. To

prepare for the expected influx of wounded pa-

tients, perioperative personnel immediately began

to assess perioperative staff resources and room

availability. At the same time, OR leaders required

all day-shift team members to remain on duty until

they could properly evaluate and understand the

situation.

Communication Compromised

The primary means of intradepartmental commu-

nication in the OR is by cell phone, either personal

or work assigned. Team members did not anticipate

that there would be issues with communication

technology as a result of the bombing; however,

law enforcement officials in the city of Boston

made a decision to shut down all cell phone towers,

which rendered all personnel cell phones inactive.

This decision was part of law enforcement’s

response to stop any further detonation of un-

known explosive devices and to ensure public

safety. The ability to communicate among

individual team members, however, became

compromised. In response, all MGH personnel

began to use landline telephones in each OR and

at the control desks, overhead paging, pager tech-

nology, and personal interactions.

Readiness to Respond

The emergency preparedness readiness team and

perioperative personnel referred to the MGH peri-

operative emergency preparedness plans to guide

initial assessment of their readiness to respond.

These plans guided personnel to take the follow-

ing actions:

n Determine the number of personnel available to

care for incoming patients as well as the patients

who were already undergoing scheduled pro-

cedures. Although team members were required

to stay on duty, they exhibited a mood of co-

operativeness, willingness, and understanding.

A sense of everyone wanting to help came

through loud and clear.

n Identify a list of all available nursing per-

sonnel, surgeons, anesthesia professionals,

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and nonclinical support (eg, OR nursing and

medical, materials management, central sterile

processing departments) by skills and roles.

n Determine the current status of OR availability.

The nursing management team members began

this assessment by reporting the number of ORs

with procedures currently in progress, the

number of patients who were waiting for an OR,

and the number of rooms in which perioperative

teams were close to finishing scheduled surgical

procedures. This was an essential part of the

assessment plan to communicate and maintain

patient flow from the ED. At 3 PM, 32 pro-

cedures were still in progress, which left 26

ORs available for incoming patients. With this

report, the OR leadership team determined that

Figure 2. Massachusetts General Hospital’s incident command system before and after the Boston Marathon
bombing. Adapted and printed with permission from Massachusetts General Hospital, Boston.

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February 2014 Vol 99 No 2 HEMINGWAYdFERGUSON

the number of empty ORs and the rooms

finishing were sufficient to care for the antici-

pated initial influx of patients.

n Prepare for a wide range of patients with trau-

matic injuries by obtaining and readying spe-

cialty supplies and instrumentation. Initially,

team leaders planned for the arrival of patients

with abdominal, cardiac, and neurologic in-

juries. Very quickly, however, team members

understood that many of the injuries would be to

patients’ lower limbs and would be similar to

war zone or blast injuries. Although MGH

personnel frequently care for trauma patients,

blast injuries are not routinely seen.

In the 20 minutes between initiation of the di-

saster code and arrival of the first surgical patient,

members of the perioperative administrative team

decided to continue the surgical procedures on

schedule and for waiting patients. In addition, after

assessing staff member availability and skill level,

perioperative nursing leaders determined that each

new trauma patient would be cared for by two RNs

and one surgical technician (ie, the usual staffing

model for trauma patients admitted to MGH) and

that the resources available at that time were suf-

ficient to staff in that manner.

Emergency Care

The ED personnel, in the MGH ED, began ad-

ministering emergency care to the severely trau-

matized patients, where they assessed patient

injuries and then transferred patients emergently to

the OR. Through landlines and verbal communi-

cation with the ED, OR team leaders learned

that the bombing patients arriving at MGH had

traumatic lower limb amputations and shrapnel

injuries.

At 3:24 PM, the first severely injured patient

arrived in the OR at MGH. Five more patients

arrived in the OR within the next 20 minutes.

Perioperative personnel were preparing for a sev-

enth patient when the trauma triage surgeon in the

ED reported that the individual did not require

emergent surgical care. Team members from the

materials management and central sterile pro-

cessing departments were key in coordinating

orthopedic and trauma instrumentation. These

resources were critical to the perioperative

workflow during this disaster response.

Because the bombing patients had sustained

massive injuries, additional surgical nurses were

needed to assist with patient identification, identify

and obtain blood products, count procedures, pro-

cure supplies that were not readily available, and

oversee postoperative patient care assignments. All

staff RNs, surgical technicians, surgeons, and

anesthesia professionals who were not currently

assigned to an OR were asked to check in with

the staffing resource coordinator by name and role

group (eg, nurse, anesthesia professional), accord-

ing to the hospital’s emergency preparedness pro-

tocol. This master list was helpful when dealing

with injuries that required specialized care (eg,

patients with vascular compromise who would need

intraoperative imaging technology). In retaining the

day shift staff, we had 180 nursing team members

available at 3:30 PM, compared with the 88 who

had been projected before the code disaster.

By 5 PM, the city was in chaos, and the uncer-

tainty of whether additional bombings might follow

contributed to a sense of unease. As the late after-

noon progressed, we received word through the

ED personnel that we did not have any additional

emergent surgical patients. The influx of surgical

patients to the OR subsided approximately 4:30 PM

but the conflicting reports that we were receiving

from multiple sources necessitated retaining per-

sonnel until we were sure that care had been pro-

vided for all trauma patients. Nursing leaders

assessed the evening staffing numbers at this time

and began to let people leave at 5:30 PM. Not

knowing whether there would be a further need

for staff members during the night, the leaders

wanted to ensure that staff members were rested

and available.

The day had transitioned from a celebration

of patriotic freedom and athleticism to a day of

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heartbreaking terror. Our clinicians stated that they

“just wanted to help,” and in the end, personnel at

MGH cared for a total of 32 patients, including the

seven emergent surgical patients. Of the seven

surgical patients who were admitted, all seven un-

derwent amputation procedures and returned to the

OR for additional procedures on subsequent days.

APRIL 19, 2013

Marathon Monday was an emotionally draining day

for many clinicians at MGH. Later that week,

however, on Friday, April 19, 2013, the city of

Boston went into lockdown status (ie, shelter in

place), an event that proved even more difficult

than responding to the bombings. That Friday

morning, after clinical team members and same-

day surgical patients had arrived at the hospital,

Massachusetts governor Deval Patrick issued an

order for regional lockdown to accommodate a

manhunt for the main suspect in the bombings,

which resulted in a shelter-in-place order for Bos-

ton and its surrounding communities.
2
The uncer-

tainty of the immediate future brought the day’s

surgical schedule to a halt. The perioperative

leadership team members’ immediate concerns

were as follows:

n Personnel and patient safetydPatients were

arriving at the hospital, surprisingly even during

the lockdown period, for their scheduled sur-

gical procedures, but patients who had been

treated could not be discharged because of the

shelter-in-place order. Additionally, members

of the night staff had to remain at the hospital.

Personnel concerns around child care and other

personal obligations became issues that needed

to be addressed. We addressed the need for our

night shift personnel to sleep by reserving call

rooms for them for the day. Those staff mem-

bers with child care issues, although few in

number, were more problematic. However,

most were able to have their neighbors and

extended family to step in to care for the

children.

n High occupancy ratedOur normally high

medical/surgical occupancy rate of 90% com-

bined with the shelter-in-place order affected

our ability to admit patients even as more

continued to arrive at the hospital for their

scheduled admissions.

n Future developmentsdThe potential for a large

number of mass casualties was a concern and

caused hospital and perioperative leaders to put

all elective surgical scheduled cases on hold.

n Management of a temporarily idle teamd

Because of the halted surgical procedures, the

clinical nurse managers and clinical nurse spe-

cialists decided to offer education sessions on a

variety of subjects, such as the new surgical

robot and cardiopulmonary resuscitation recer-

tification and training, to nursing team mem-

bers. This action helped to alleviate team

member anxiety by providing an opportunity to

focus on internal matters instead of the constant

stream of external information. Taking advan-

tage of this valuable and unexpected education

time proved beneficial to all.

The reason the shelter-in-place situation was

more difficult than the response to the bombings is

that caring for patients with traumatic injuries is

what personnel at MGH are trained to do. However,

to have patients and personnel waiting for the

surgical schedule to proceed was especially chal-

lenging because it put the hospital personnel in a

holding pattern that did not permit them to provide

care and was combined with the anxiety that

everyone was feeling related to the terrifying

situation in the communities surrounding Boston.

Perioperative leaders made the decision mid-

morning to allow surgeries to begin based on two

factors: patient acuity, and for same-day surgical

patients, the discharge destination. The patient’s

discharge destination was important because pa-

tients could not be released into any location within

a wide, geographic area of Boston. This affected

the perioperative team’s ability to start proce-

dures, because the admission process at MGH is

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February 2014 Vol 99 No 2 HEMINGWAYdFERGUSON

dependent on inpatients being discharged to ac-

commodate same-day admission patients who need

postoperative beds. Because of the shelter-in-place

order, hospital staff members were unable to dis-

charge patients, which meant that postoperative beds

were no longer available. Additionally, any team mem-

ber who had arrived at the hospital was not allowed

to leave until the shelter-in-place order was lifted.

During the morning, staff members had several

emergent cases that needed to be started regardless

of the outside situation. Proceeding with patients

who were very ill and undergoing surgically com-

plex procedures later in the day and without a full

off-shift of staff members proved very challenging.

For example, leaders made the decision to proceed

with a patient scheduled for a thoracoabdominal

aneurysm repair at 10 AM, and that surgery con-

tinued late into the evening. Many team members

did not arrive at the hospital for their scheduled

shift because of the lockdown, which in turn chal-

lenged the evening staffing plans. Personnel cared

for a total of 52 patients of the 147 patients who

were originally scheduled for surgical procedures.

Our perioperative preadmission colleagues accom-

modated the surgical patients who had arrived at

the hospital that day but did not undergo surgery

and could not leave.

By the time Governor Patrick lifted the shelter-in

place order around 6 PM, and the crisis had passed,

members of the day shift who had not been allowed

to leave had been at the hospital for their regularly

scheduled 10- to 12-hour shifts, and some of our

afternoon and evening shift team members still had

not been able to arrive to relieve them. Team

members who had put in a full shift had to fill in

and care for patients of those team members who

were prevented from arriving. Members of the

evening shift began to arrive soon after the shelter-

in-place order was lifted, and OR nursing leaders

were able to release other personnel. However,

personnel began to hear media reports of gunfire,

which raised everyone’s anxiety and stress, and

further complicated operational issues. It remained

problematic to allow team members or patients to

leave the hospital’s safe environment and venture

into a situation in which gunfire was heard and

everyone wondered where the next terrorist activ-

ity would occur. To help address those external

concerns and to be prepared, MGH perioperative

leaders decided to keep four OR teams and four

ORs ready as trauma rooms in case emergent care

was needed for any casualties.

Despite the anxiety felt by personnel, the eve-

ning progressed without additional terrorist attacks

or incidents. After MGH personnel learned that the

suspect had been captured, the four standby ORs

and teams were released. There were still surgical

patients to care for that evening, and, by 8 PM, two

surgical procedures were in progress and ORs were

being prepared for procedures the next day.

PROCESS FOR CHANGE

An important exercise that leaders and staff mem-

bers at MGH use quite regularly is the debriefing

session. When an incident occurs, whether it is

related to patient care or to technical, operational,

or interpersonal issues, perioperative leaders

schedule a team debrief so that all the details of the

incident may be presented and reviewed. Debrief-

ing has become a valuable forum for our multi-

disciplinary teams to develop a comprehensive

understanding of an incident. During debriefing

sessions, team members consider events that led to

the incident, issues that occurred during the inci-

dent, and lessons learned. They also identify op-

portunities for change in areas of practice, work

flows, and communication. From there, recom-

mendations are made for appropriate changes in

practice and policy.

Before the bombing victims had even left the OR

that Monday evening, a debriefing session was

scheduled for the perioperative leadership team.

Similarly, the evening of the lockdown that Friday,

the associate chief nurse and the medical director

invited the perioperative leadership team members

who had helped during the day to a debriefing

session the next morning, so we could begin to

understand our response challenges, limitations,

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and successes. At the debriefing, all the participants

dincluding the nursing director of operational

planning and environment of care, associate chief

nurse, clinical nurse specialists, nursing clinical

managers, and other perioperative leadership team

membersdspoke in detail about what went well

during the events and identified potential opportu-

nities for improvement.

Members of the perioperative leadership team

agreed to support the formation of a small task

force whose mission would be to review existing

MGH policies, procedures, and communication

technologies, and then to make recommendations

for developing a more robust perioperative disaster

response plan. Members of the task force included

the director of operational planning and environ-

ment of care, who served as the project manager

and facilitator; clinical nurse specialists; the asso-

ciate medical director of perioperative services

departments of anesthesia, critical care, and pain

medicine; and the environment of care project

manager, who meet weekly. At the time of publi-

cation of this article, this task force is still in effect.

The task force began by developing a project

charter (Figure 3). Project charters have become an

integral part of the perioperative leadership team’s

work during the past few years because these

documents are important to keep the work on

target. The charter identifies short- and long-term

goals, a timeline, and resources necessary to ensure

success. The task force began meeting within one

week of the Boston bombing events. The first

weekly meeting included time for team members to

reflect on their individual experiences. After that

initial meeting, members of the task force began

work to revise and develop additional perioperative

roles and the corresponding job action sheets. They

also have worked to consolidate all necessary

supplies, including binders with job action sheets

and emergency vests to identify leadership per-

sonnel during a disaster event, into an accessible,

centrally located cabinet.

LESSONS LEARNED

The Joint Commission requires all hospitals to have

an emergency preparedness plan in place, and the

plan must meet certain standards.
3
The MGH pre-

paredness plan meets all of The Joint Commission

standards, yet perioperative leaders found room for

improvement. One of the lessons that the periop-

erative leadership team learned was that using the

processes outlined in the MGH emergency pre-

paredness plan resulted in unexpected challenges.

Many aspects of the emergency preparedness

response to the bombings and to the patient care

and outcomes were excellent; however, through

debriefing and subsequent conversations, leaders

identified opportunities for improvement that

included emergency notification, staff member

identification, traffic control, communication, and

development of a new plan.

Emergency Notification

In emergencies, senior MGH leaders activate the

hospital ENS. On that Monday, they sent the initial

ENS only to the highest tier of leadership, and, for

the OR, that was our associate chief nurse and

executive medical director. They immediately

responded to the senior leaders and received an

update on the situation. However, the ENS sent by

senior leaders did not go to the clinical managers or

to the anesthesia staff administrator for the day.

Initially, cell phone alerts from news stations pro-

vided information to the front-line perioperative

personnel and leaders, which led to some confusion

about what to expect and how to plan. These un-

confirmed reports and rumors made it difficult for

personnel to manage the existing schedule and

patient flow. Planning for staffing, equipment,

supplies, and instrumentation for the expected

influx of trauma patients also was very challenging

to personnel who found it difficult to separate fact

from fiction in reports and coverage of the event.

During the response, nursing leaders decided to add

a perioperative nurse to act as a liaison between the

284 j AORN Journal

February 2014 Vol 99 No 2 HEMINGWAYdFERGUSON

ED and the OR to address communication chal-

lenges. This liaison role was invaluable to response

efforts and decisions about emergency care because

that nurse was able to discern the information that

perioperative nurses needed to care for specific

patients.

Figure 3. Massachusetts General Hospital’s project charter. Adapted and printed with permission from
Massachusetts General Hospital, Boston.

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Identifying Staff Members

Role identification was an issue for those per-

sonnel outside of the immediate central desk area.

As part of the MGH emergency preparedness

plan, leaders assign team members specific roles

to centralize operations and resources. But it was

difficult for perioperative team members to iden-

tify those individuals. For example, many well-

meaning individuals went about gathering sup-

plies without direction and without knowing for

which patient. These actions contributed to sup-

plies being depleted from central storage spaces.

One of the revisions to the emergency prepared-

ness plan has been to formalize resource coordi-

nator roles to manage the flow of supplies and

instruments rather than relying on individuals to

work independently.

Traffic Control

Traffic control for perioperative clinical and sup-

port personnel became a significant issue for the

team at the control desk who managed the OR

schedule and led the disaster response. There was

no doubt that everyone wanted to help the patients

and one another, but that desire to help and the

hovering around the central desk that ensued was

an ongoing challenge. Despite repeated appeals

from perioperative leaders that all personnel vacate

the desk area, individuals wanted to hear informa-

tion firsthand at that central location, and the area

became very noisy and crow