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  • Radiology Gives Front-line Aid to Boston Bombing Victims

    July 01, 2013

    Immediately after the Boston bombing, emergency radiology played a frontline role as hundreds of injured patients began pouring into emergency departments across the city.

    Laura Avery, M.D.
    James A. Brink, M.D.
    Tatiana Rocha, M.D.
    Jonathan Kruskal, M.D., Ph.D.
    Stephen Brown, M.D.

    Within minutes of the Boston Marathon bombings, healthcare personnel in more than a dozen area hospitals faced a harrowing scene of badly burned bodies, damaged limbs and dangerous shrapnel wounds. In those critical first minutes and the days following, emergency radiology played a frontline role as hundreds of injured patients began pouring into emergency departments (EDs) across Boston.

    Just a few miles from the bombing site, Massachusetts General Hospital (MGH) was one of the facilities that treated victims that day. Laura Avery, M.D., was heading the hospital’s Emergency Radiology Division on the afternoon of April 15—Patriot’s Day and the date the Boston Marathon is held every year—when she got the news.

    “We were already having a busy day,” she recalled. “And strangely, my husband, who works in finance in the city, called me with the news first. Then we found out from the ED that there had been a page reporting mass casualties.”

    The first order of business, Dr. Avery said, was to clear the ED of as many patients as possible before victims started arriving. Fortunately, a number of fourth-year residents quickly showed up at the ED after watching the marathon. “It was pretty impressive to see how quickly we were able to clear out the ED in order to make space for new patients,” she said.

    The Emergency Radiology Division immediately put staff on alert, blocked off CT scanners, and made sure that technologists were ready with all of the department’s most up-to-date portable imaging units. “Everything pretty much worked as planned,” Dr. Avery said. “All of these resources were immediately available.”

    The hospital treated 31 bombing victims, several of whom were taken to an operating room upon arrival. A number of patients received full-body CT scans. Since the radiologists and trauma surgeons were both present during CT scans, communication of the findings was immediate and a course of action could be determined on the spot.

    So many personnel responded to the trauma call that part of Dr. Avery’s job involved ensuring that each staff member contributed in the best way possible. “There were a lot of people there who wanted to help, so the challenge was to manage the situation by giving as many people as possible the chance to help while avoiding the chaos of overstaffing,” she said.

    James Brink, M.D., radiologist-in-chief at MGH, called the radiology department’s response to the emergency “prompt and efficient” and Dr. Avery said she believed she performed her duties well, particularly as they related to radiology services and allocating manpower.

    However, she admitted that she was personally shaken by the emergency since she lives in Boston with her husband and children, and she wasn’t entirely sure where her children were at the time of the bombings (she later learned they were safe with their nanny). And since so many people who work at MGH were running in the marathon, watching it, or lived in close proximity, “this was definitely an event that touched all of us personally.”

    Boston Hospitals Handle High Volume of Scanning

    The response at Brigham and Women’s Hospital (BWH) was similar to that at Massachusetts General, according to Tatiana Rocha, M.D., the attending emergency radiologist at BWH that afternoon. She helped ensure that the ED was cleared of as many patients as possible before bombing victims began arriving, that three CT scanners were held exclusively for trauma cases with an emergency radiology fellow stationed at each, and that other imaging modalities such as ultrasound and portable X-ray units were available in quantity as well.

    Dealing with the bombing victims who came in “wasn’t much different from our trauma routine,” Dr. Rocha said. “The difference was the volume of imaging.” There were two residents and three fellows in the hospital with Dr. Rocha when the bombing victims began arriving, and three additional emergency radiologists were rapidly mobilized to join the effort.

    When the initial trauma call came in at Beth Israel Deaconess Medical Center, radiology personnel responded according to the hospital’s emergency preparedness plan, said Jonathan Kruskal, M.D., Ph.D., chief of radiology. But, he said there was an “eerie” calm for about 15 minutes or so after that initial call as the ED waited for the first victims to start arriving.

    “And then, suddenly, the ambulances started coming,” Dr. Kruskal said. “And because there are so many hospitals in the area—Beth Israel Deaconess is located in Boston’s Longwood Medical and Academic Area—you just heard sirens for a solid half hour.”

    More than 20 bombing victims—including seven critically injured patients—were sent to Beth Israel Deaconess, creating an all hands on deck situation, he said. Technologists, residents and faculty who had been taking in the annual Red Sox Patriot’s Day game, watching the marathon, and, in some cases, even running the marathon, headed for the hospital to help.

    “Everything was incredibly efficient,” Dr. Kruskal said. “The equipment worked beautifully. I couldn’t be prouder of our imaging staff and it’s my sense that’s how all the radiology departments around town feel.”

    At Boston Children’s Hospital, the bombing prompted clinicians from various specialties to report for unscheduled duty. “The ED and trauma teams were clearly well prepared for handling such crises and demonstrated amazing leadership,” according to Stephen Brown, M.D., the radiologist who was on call at Boston Children’s Hospital that day and who serves as the radiology department liaison to the ED.

    Calling them “heroes,” Dr. Brown recalls how the radiology technologists interacted directly with the acutely injured patients and their family members.

    “Seeing terrible injuries is unfortunately not uncommon, particularly for front-line radiography and CT technologists, but these terrible injuries were different,” Dr. Brown said. “We viewed multiple radiographs of patients showing scattered and embedded ball bearings and nails, and it was surreal. Despite this awful reality, I will never forget how calmly, professionally and competently our radiology team managed their tasks.”

    Hospitals to Reexamine Communications Protocol

    One consequence of the day’s events, Dr. Kruskal said, was that it confirmed to him how invaluable digital radiography (DR) systems are. “Our managers were saying how thankful they were for DR, because it gave immediate images to the ED doctors to act on and triage patients,” he said. “That’s an important message.”

    The emergency also demonstrated the importance of enforcing Health Insurance Portability and Accountability Act (HIPAA) rules and other regulations, Dr. Kruskal said. “We wanted to make sure our faculty was very aware of who, and who not, to speak to,” about patients, he said, particularly later in the week when the surviving bombing suspect, Dzhokhar Tsarnaev, was brought to the hospital for treatment.

    X-ray of a Boston Marathon bomb victim and subsequent amputee
    BBs are revealed on the X-ray of a Boston Marathon bomb victim and subsequent amputee at Massachusetts General Hospital. Photo by Bill Greene/The Boston Globe via Getty Images
    Staff in the Emergency Department at Massachusetts General Hospital
    Emergency radiology played a frontline role at more than a dozen area hospitals the day of the Boston bombing. Above: Staff in the Emergency Department at Massachusetts General Hospital, which treated 31 bombing victims, wait for patients and news updates during the afternoon of the bombing. Image courtesy of Massachusetts General Hospital
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