Thursday, April 25, 2013

Imagining the Unimaginable

The terrorists who struck among crowds massed at the Boston Marathon finish line seemed intent on inflicting maximum harm, and the harm done was heartbreaking. But did the location of the explosions actually help to minimize fatalities?

The explosions occurred in close proximity to medical facilities and staff on hand for the runners, many of whom where themselves medical professionals, and response to those injured was immediate. Extraordinary medical care was just blocks away at Massachusetts General Hospital, Boston Medical Center, Tufts Medical Centerl, Beth Israel Deaconess Medical Center and Brigham and Women’s Hospital.

Two other factors were preparation and imagination. To a remarkable degree, Boston’s emergency physicians, surgeons, nurses and others were ready for the staggering demands of the tragedy. While such violence may seem unimaginable, imagining it was crucial to the response.

As reported by Bloomberg News, lessons learned since 9/11, and revisited annually in the years since, prepared Boston’s medical professionals and institutions for this tragedy. Boston isn’t alone in this; since 9/11, cities across the country have prepared as never before not only for acts of terrorism, but for other catastrophic events and pandemics.

The impetus for such preparation is easy to find. Just in the days since the Boston bombings, Canadian officials arrested two men allegedly plotting to derail a New York-Montreal train, Texans dealt with the deadly explosion at a fertilizer plant, and the Nature mapped outbreaks of the H7N9 avian flu in China.

According to the science journal, “One map supplied to Nature by the researchers shows, they note, that eastern China — the epicentre of the current H7N9 outbreaks — is one of the world's busiest hubs for airline traffic. A quarter of the global population outside of China lives within two hours of an airport with a direct flight from the outbreak regions, and 70% if a single connecting flight is included, the researchers explain.” 

As the Bloomberg story recounts, medical professionals train annually in disaster response: “The drills, now standard in most major U.S. cities, cover everything from plane crashes to natural disasters and dirty bombs, medical officials said. Each of the hospitals sends a team of 10 to 20 doctors and staff to the yearly drills ... The teams are then asked to respond to each scenario and the responses are discussed in depth by the entire group. ... This helps create the area-wide plans that kick in when an actual emergency occurs.”

Community Voices in Medical Ethics, which sponsors this blog, got a rare insight into this process of imagining disaster when we consulted with the Massachusetts Department of Public Health in imagining how to engage the public on what are known as Crisis Standards of Care. These are the standards put into practice during a catastrophe, natural or otherwise, that overwhelms available medical care, and so changes the rules of care we’ve come to expect.

In urgently caring for victims of the Marathon bombing, patients scheduled for surgery had to wait until those in more urgent need were operated on. So imagine the decision-making challenge for medical carers in the event of a tragedy of even greater proportions.

When there are not enough ventilators to go around, who gets one? When vaccines are in short supply during a pandemic, who goes to the head of the line? When there aren’t enough surgeons to meet the demand, or enough blood, who waits? Once first responders have been taken care of, who gets priority? How are fairness and ethics applied in such cases?

Some of the questions are just about impossible to answer, but to avoid them means not being ready the next time -- and unnecessarily adding the burdensome pressure of moral distress to an already beleaguered care team. And Bostonians have gotten a profound lesson in the benefits of imagination and preparedness.

According to Community Voices co-founder Carol Powers, one of the lessons of the Boston tragedy will be an emphasis on the emotional health of the care providers. She heard from a Brigham and Women's staff member about the emotional devastation for members of the care team determining which limbs could be reattached, and removing shrapnel and ball bearings from humans.

 “All the drills in the world don’t really get completely to the emotional toll,” she said. “The fact is that they shifted into gear and all procedures were laudatory and will be studied for a long time. But also studied will be the emotional fallout.”

The most compelling insight I’ve found into the emotional cost of care that day came from the blogger Nurse Bridgid.

“We have run disaster drill training extensively, city-wide, and hospital-wide, so we all know our roles,” she wrote, “but what I walked into, I could never have been prepared for.”

Hers is an astounding account of care expertly delivered amid unthinkable chaos, and when all the injured had been cared for, she left the hospital and stepped into a wild scene of federal and local police and tearful, anxious family members yearning for news.

“I was sobbing, and the FBI agent soothed me saying it was OK, this happens, and they will call me ... as I was walked out by one of the officers through the line of SWAT officers and sobbing family members of victims, all pleading me and begging me for information about their loved ones, telling me what they are wearing, and staring into the eyes of a young mother who asked if I remembered seeing her sons, and if they both still had their legs, I felt my whole body start to shut down. I couldn’t take it. I hadn’t cried, I hadn’t eaten or had anything to drink in hours, and I started shaking, as I got to the front of the Medical Center, I looked at the officer and said, I am going to vomit now, and he just put his hand on my back, turned away, I leaned over and vomited on the sidewalk. He told me I did a good thing today, and I walked to my car, called my mom to let her know I was OK, and cried my eyes out.”

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