Attention To The Boston Marathon

Attention to the Boston Marathon

Introduction

It is April 2013, the month in which the anniversary of the Lexiston and Concord battles of 1775 is commemorated, which mark the beginning of the war for the independence of the United States. As usual in the state of Massachusetts, the third Monday of the month is a holiday, and by tradition, it is the day the Boston Marathon is celebrated. This edition was carried out on April 15, 2013, being the 177 version of the race, making it the oldest in the world in its kind. For this event, around 23 were registered.000 participants in the different categories. Being such a prestigious career, not all fans can participate. 

Around 80% of the runners have complied with minimum times in previous marathons to classify and have the right to run it, evidencing the high level of the athletes present . Besides, more than 500.000 spectators accompanied the race throughout their tour. Unfortunately, on April 15, 2013, it will be a difficult date to forget for the world. But not for the sports results obtained, but by the terrorist facts presented during the event.

Developing

On April 15, 2013, around 9:30 in the morning, Boston Marathon begins. Elite female athletes were the first group to start. Around 10:00 in the morning the elite male athletes accompanied by the first series of thousands of runners started their career. Around 10:20 and 10:40 in the morning, the rest of the career participants were released.

The first to reach the goal in the women’s group was Rita Jeptooo, a broker originally from Kenya, today winner of 3 Boston marathons, and owner of the test record in 2014. For that edition it was crowned with a time of 2:26:25. 

On the men’s side the winner was Lelisa Desisa, from Ethiopia, with a time of 2:10:22. At approximately 2:50 in the afternoon, with more than 5600 career participants, two explosives were detonated near the finish line, separated from each other for about 50 to 100 meters away, with an approximate interval of 815 seconds. What was a sunny afternoon of family sports activity became a scene of chaos, destruction and blood. Some data give an idea of the background of the terrorist act. In 2011, there are reports that ensure that Russia’s intelligence and security service gave information to the FBI of Tamerlan Tsarnaev, a radical follower of Islam, who was based in Cambridge, Massachusett with her family with her family. 

However, in the first investigations there was no link of the subject with a terrorist group. During 2012 the Russian authorities report that Tsarnaev entered their country, where he performs different procedures, including the filing of a passport that was never collected. It continues under state surveillance for a few months, until it returns to the United States at the end of 2012. In the first months of 2013, the Cultural Center of the Islamic Society of Boston (The Islaty of Boston Cultural Center) mentions that Tsarnaev participated in two explosions during the celebration of some important dates, which were accepted at the time by the groupMuslim. Until that date there were no clear data from the association with terrorist groups, much less was known about its future participation in this terrorist act.

The first investigations of the authorities after the attack identify the type of explosives used. They indicate that they were artisanal artifacts, containing pellets and nails inside. Only two explosions were confirmed, despite the suspicion of other artifacts yet without detonating. Given the magnitude of the facts, more than a thousand people of local and state order were involved in the investigation. In the early hours thousands of photos and videos from security cameras or other media were analyzed near the area where the events occurred. From this first analysis, two male suspects were detected, however, so far their identity was not known. The role of the community was fundamental in trying to identify them. 

On April 18, a transcendental event occurred in the research process. At nightfall, Sean Collier, a police officer from the Massachusetts Technological Institute was killed when he was shot inside his vehicle, in the Cambridge school. This time the actors were identified. These were the Tsarnaev brothers: Tamerlan, 26 years old and 19 -year -old Dzhokhar. After the murder, the brothers stole a truck near the place, taking the driver host. In the early hours of the next day, a dispute was given between the brothers and the authorities. After shooting and explosions, Tamerlan is seriously injured and dies in a nearby hospital.  At that time it was already known that the Tsarnaev brothers were the authors of the explosions during the race. After the clashes with the authorities, and taking into account that Dzhokhar was still free, maximum security in the city was declared, the schools were closed and no one could leave their homes. In the afternoon a local inhabitant found in his boat a young man injured, who would be Dzhokhar Tsarnaev. 

When the authorities arrived in custody, and found in the boat a note in which he explained the reason for the terrorist act, the explosions during the race were as a protest to the United States wars in Muslim countries. The younger brother declared innocent. However, in 2015 the Court declared him guilty for 30 crimes against him. Dzhokhar Tsarnaev is sentenced to death penalty. He currently keeps Custody in the maximum security prison Florence-High in Colorado. What happened to the attention of the injured? Were Boston hospitals prepared to attend mass victims? Before September 11, 2001, the United States spared the consequences of different terrorist acts that to date occurred in other countries. 

After perhaps the worst terrorist attack in the United States in their history, the Americans would be more familiar with these acts, even with the effects of artisanal bombs used in countries such as Iraq, Israel and Afghanistan. In this sense, the Boston Medical Emergency Service (Boston Emergency Medical Services) and the Boston Health Community (Boston Health Care Community) were prepared for years for the care of events with mass victims. For the race a temporary medical care store was installed on the finish line in order to serve up to 2.500 runners. The store includes paramedics, doctors, nurses, physiotherapeutas and other personnel trained to handle injuries due to high temperatures and overcourse during the difficult race. Emergency service personnel were strategically located next to the store with transport capacity of 200 to 250 runners if additional attention in hospitals in the area is necessary. 

The city of Boston, with around 630.000 inhabitants, was the only one trained with 5 trauma centers level I for adult care and 4 trauma centers specialized in pediatric care. Not only was the infrastructure necessary for the attention of multiple victims. This is accompanied by hospital management to make resources available to the case. Each hospital had an incident commander, in charge of coordinating the output of previously hospitalized patients to release beds and open the capacity, in addition to the mobilization of personnel and equipment necessary for care. These commanders were in permanent contact with the Central Emergency Command of the city, synchronizing the entire answer.

This terrorist act left three dead people: Martin Richard with 8 years of age, a student at the House Charter school in Boston;Krystle Campbell, 29 years old;and Lingzi Lu, originally from China, graduated from Boston University. In addition, a total of 281 injured that were treated in 26 nearby hospitals. Of the total injured, 154 patients were treated in different hospitals at level I or required attention days later, while 127 required care in trauma hospitals level I previously mentioned during the day of the terrorist act of patients treated in trauma centers level I, 117 were over 15 years old and 10 minors. Most were originally from the United States;95 were spectators, 6 police, 3 runners and another 23 unknown occupation. They were initially attended by police and the staff arranged in the store. 118 of these patients were immediately evacuated by the severity of trauma and the eminent threat of new explosions. The team preparation allowed the average transfer time from the explosion to the hospital of 11 minutes. 31 patients presented exanginating traum.

In total, 31 patients were admitted to the Brigham and Women’s Hospital, the Massachusetts General Hospital also received 31 patients, Boston Medical Center with 23 victims, Beth Israel Deaconess Medical Center 21 patients, and Boston Children’s Hospital attended 10 pediatric patients, among others (other (18). Patients severely traumatized, determined with a score of the insult severity score (ISS) greater than or equal to 16, were distributed equally in the different trauma centers level I of the city. However, a more specific analysis revealed that there was a hospital attending 6 patients severely traumatized, located close to another that did not attend to any. It is concluded that the distribution could have been more equitable, impacting even more on the reduction of victims’ morbidity.

The increase in the ability of hospitals thanks to the release of patients forces to improve the system of classification of patients in emergencies. All hospitals services were notified of the need for a rapid triage in the emergency room, having the necessary resources. The most experienced trauma surgeon in the hospital would be in charge of leading the triage process, identifying those patients who might require surgical management, communicating with other surgical subspecialties, anesthesia and surgery rooms. 41% of the patients received in trauma centers level I were discharged after the initial evaluation in the Emergency Department. The rest of the patients were admitted for additional assessment and treatment. Due to the severity of trauma or direct airway injury, 12 (9.5%) patients required emerging air control with orotracheal intubation. 

In addition, 15 (11.8%) patients required transfusion of blood components. During the attention, no surgical handling of the airway or thoracostomy was required, given the infrequency of injuries that these interventions needed. The absence of immobilization with skeletal traction or the need fasciotomy is attributed to a short time between the admission of patients and the entry to the surgery room of those who required it (45 minutes on average). Likewise, most injuries were presented with soft tissue commitment and did not require compartment decompression. Regarding diagnostic aid, in total 67 (52%) patients were performed thorax radiography as an annex to the initial evaluation, 29 (23%) Pelvis radiography patients, 23 (18%) FAST patients (abdominal focused ultrasound inTrauma), and 32 (25%) tomography. 

The average stay time in the emergency department before your disposal to other services was 106 minutes. Of the 75 patients admitted to hospitals, 45 (60%) were taken directly to the operating room, 11 (15%) to Intensive Care Unit (ICU), and 19 (25%) to observation. The majority of patients who required surgical management were transferred to intensive care for post -surgical assessment. Despite the high need for resources in ICU, the previous coordination allowed the release of beds and the disposition of the necessary personnel.

The majority of patients in surgery required care for trauma and orthopedics surgery. Other specialties such as vascular surgery and neurosurgery also contributed in surgical care. The group includes plastic surgery, which had a fundamental role in the reconstructive process of patients in later days. 24 patients required foreign body extraction (nails and pellets contained in handmade bombs). In just 2 of them the procedure was performed by neurosurgery. Of the 75 admitted patients, 49 (65%) required surgical intervention due to lower limbs injuries. Of these patients 12 were taken to lower limb amputation. The majority of patients undergoing surgical intervention required a total of 3 to 5 procedures during hospitalization. The average time of stay at ICU was 4 days, and total hospital stay of 8.5 days.

conclusion

The low mortality and complications presented in the terrorist act were thanks to several factors. First, the management and organization of a complete emergency care system and the preventive actions they took in the event were fundamental. Without a doubt, it was the factor that most influenced the results obtained. This is added the preparation and training of care personnel, not only doctors and residents, but also nursing staff, firefighters, prehospital care, physiotherapists, etc. 

On the other hand, the trauma mechanism and the lesions presented by explosives compared to other events described in other parts of the world was lower. This terrorist act leaves many teachings, especially in the medical care of the victims, and the role of a good preventive program. As Atul Gawande, surgeon who participated in attention: we have learned, and we have aware. This is not a reason for celebration or satisfaction. That we have reached this state of existence is a great sadness. But it’s our great fortune.