September 1, 2015 — On the afternoon of April 13, 2013, after two bombs exploded at the Boston Marathon, scores of severely injured people were rushed to hospitals across the city. Although three people died at the scene and many had life-threatening injuries, everyone who was transported to a hospital lived.
How was it that so many people were able to survive?
A new study outlines some of the challenges that arose in Boston hospitals in the wake of the bombing, as well as successes. One of the key reasons why so many lives were saved, the researchers found, was the high level of flexibility and autonomous decision-making among physician leaders.
The study involved experts from the National Preparedness Leadership Initiative (NPLI)—a joint venture of the Harvard T.H. Chan School of Public Health’s Division of Policy Translation and Leadership Development and the Harvard Kennedy School’s Center for Public Leadership—and colleagues from Boston hospitals and several Israeli institutions. Since the bombing, NPLI—which focuses on equipping leaders for crises—has been studying the tragedy, hoping to draw useful lessons.
“We study crises and we teach leaders for times of crises,” said Leonard Marcus, lecturer on public health practice at Harvard Chan School, co-director of NPLI, and a study author. “This was one of many events we follow. The difference here was that this was in our own backyard.”
For the new study, the researchers gathered information from a focus group of trauma and emergency medicine physician leaders from several Boston hospitals, and from subsequent detailed interviews with some of the participants. Their goal was to analyze the role of organizational dynamics and leadership in the bombing’s aftermath.
Bugs in the system
Asked to choose the number one bottleneck during the crisis from a list of several options, 100% of the focus group members picked the same answer: information systems.
“There were challenges around registering and identifying patients and ordering medications, fluids, and blood for these patients,” said lead author Eric Goralnick, medical director of emergency preparedness and assistant professor of emergency medicine at Brigham and Women’s Hospital (BWH), and a faculty associate at NPLI.
Part of the challenge was the sheer number of injured streaming into hospitals. BWH, for example, treated roughly 40 bombing victims, and it took time to enter each person into the system. Hospital personnel also struggled with naming unidentified patients. Although all hospitals have conventions for giving patients placeholder names like “John Doe,” it was confusing with dozens of unknown patients showing up all at once. At BWH, emergency room workers used strings of numbers to identify patients, but that strategy was problematic.
“If you have only one John Doe in the emergency room, everyone knows who it is,” said Barry Dorn, lecturer on public health practice at Harvard Chan School, NPLI faculty member, and a study author. “But when you have many, it’s easy to confuse them by transposing a number.”
To offset this sort of problem, BWH presented its findings to federal emergency preparedness officials on the possibility of establishing national naming conventions, Goralnick said.
Thinking on their feet
To handle other issues that emerged in the bombing’s aftermath—such as overflowing emergency departments—physician leaders encouraged flexibility and autonomous decision-making.
In some cases, resident physicians helped clear crowded emergency rooms by signing patients out and moving them to inpatient wards much more rapidly than would normally occur.
When communication proved a problem because of spotty cell phone service in Boston following the bombing, hospital staff employed workarounds such as increased face-to-face communication, runners, radios, and social media.
Such “on-the-fly” solutions went a long way toward achieving the overall goal of saving as many lives as possible. “We found that there was extraordinary leadership among emergency and trauma clinicians,” said Marcus.
Widening the lens
In addition to their study of the Boston medical community’s disaster response after the Marathon bombing, NPLI experts have also examined how agencies and sectors throughout Boston worked together during the emergency. In those studies, they found similar examples of flexibility and cooperation—among city, state, and federal agencies, and police and other emergency departments.
“We wanted to know what leaders were thinking, what they were doing, and how they were working together, because there was an extraordinary outcome in the wake of the bombing: Coordination and collaboration that was smoother and more seamless than we’ve seen in other events,” said Eric McNulty, the NPLI’s director of research and professional programs. Such coordination, according to the NPLI experts, is an example of “swarm intelligence,” a phenomenon in which many individuals all work intelligently toward a particular goal—even if no one is giving specific direction.
The researchers discovered five principles of swarm intelligence that applied to leadership during the Boston Marathon bombings response, including unity of effort (all were intent on saving lives); generosity of spirit; everyone focused on his or her own job and helped others succeed in theirs; no ego and no blame; and a foundation of strong relationships. Of greatest significance, there was no one leader who was in charge of the overall operation. Nevertheless, those involved were able to establish order—even without central control—in coordinating a complex array of decisions and actions over the 102 hours between the bombings and capture of the suspects.
The NPLI team has studied the leadership response for many disasters across the country—including the H1N1 outbreak in 2009, the 2010 Deepwater Horizon oil spill, and Hurricane Sandy in 2012. It has helped that some of the leaders involved in these crises have gone through NPLI training and have been happy to share the lessons they’d learned with the NPLI team, Marcus said.
Whether emergency responders handle large-scale crises successfully or not, it’s important to explore their aftermath fully to collect critical lessons for the future, according to the NPLI team. The new study’s insights—showcasing how leaders got their jobs done in the difficult hours and days following the Marathon bombing—suggest that flexible leadership and creative solutions could be key to saving lives in future crises.
photo: Aaron Tang/Wikimedia Commons