Learning from the Boston Marathon Bombing

Like many of you I watched over 40 thousand people run the London Marathon last weekend.  It was fascinating to see the mix of backgrounds and abilities all attempting the 26.2 mile run and all with their own personal reasons.  This reminded me the marathon in Boston a few years back where shocking events were to unfold and After Action Review (AAR) was to come into its own once again.

There were several AARs held after the marathon bombing on April 15th, 2013 and each of them provided profound insights into how the Boston healthcare system responded on this terrible day. 3 people died and 247 were injured, many with considerable limb damage yet incredibly no one who arrived at a Trauma Centre alive, subsequently died.

The first bomb went off at 2.50pm and casualties arrived at the first trauma centre at 3.09pm. Because the nursing shift changes at 3pm, there were sufficient staff available to put the Emergency Medical System Mass Casualty Incident (MCI) plan into action and clear Emergency Departments of other patients. The Boston marathon takes place on the local holiday called “Patriots day” when hospitals have less surgery scheduled so time to the Operating Room was impressively rapid and undoubtedly saved lives.  So “luck” clearly played a part in saving lives and whilst there may be no practical lessons to be learnt from this, perhaps there are some philosophical and moral ones which can be just as valuable in these circumstances.

The practical lessons learnt which have led to the updating of the MCI Plan include creating a “pooling room” for spare staff to be drawn on as required.  One of the trauma centers did this and it was an effective way to use the many staff arriving to volunteer along with that extra shift of staff.  The AARs facilitated the review of the triage processes for MCI events of this type as less than 50% of casualties arrived with mass-casualty triage tags. These tags help decide the level of urgency for medical attention and treatment. Uncertainty about additional explosives created a sense of urgency in loading people into ambulances so tags were not attached to the most seriously injured. However sufficient manpower in the hospitals did allow for effective triage once casualties arrived and the lesson is that field triage may not always be a realistic expectation and instead a universal and robust hospital-level triage protocol should be developed.

One of the simpler lessons learnt that perhaps has more in common with the type of lessons we learn for AARs in our own workplaces, was about tourniquets. The importance of these for saving lives that day in Boston has meant that it has now been recommended to be included in the national first aid curriculum. Something as simple as tourniquet training for first aiders is the type of lesson which we can all understand as a constructive outcome from an After Action Review. Without the the structured space of an AAR to think together would this level of clarity emerge about what is important to save future lives?  My experience suggests it’s not worth taking the risk.

I would like to applaud all those who called for, facilitated and participated these AARs as, not only did they generate incredibly valuable learning for future mass casualty incidents, they also provided a safe and supportive space during which people could reflect and try and make sense together of the significant human effort to do the very best on a difficult day.

Yet we shouldn’t only use AARs for exceptional events such as this.  The appetite to learn may not be as compelling in our more everyday workplaces but the value can be just as great. Unique emergencies provide lessons about behaviour under exceptional circumstances yet more routine events create multiple opportunities to learn how to do it better every single day.