Words by Nicholas Wood
A mass casualty incident [MCI] requires a rapid and decisive response; however, in the context of complex, coordinated terrorist attacks, this creates a challenging and dangerous environment for emergency responders (1,2). In order to respond safely and effectively, prior planning in disaster and MCI management need to be undertaken by emergency responders’ services (1). The goal of this review is to describe and compare the responses to two separate MCIs, looking at similarities, differences, successes and major issues, with a focus on emergency medical services [EMS].
Description of Mass-Casualty Incidents
The 2013 Boston Marathon Bombings and the 2005 London Bombings are similar in the method of attack, using improvised explosive devices (3,4). However, the two MCIs are vastly different in their setting, the response and the capabilities of emergency responders.
On 15 April 2013, during the annual Boston Marathon a bomb was detonated near the finish line at 14:29 hrs followed by a second bomb 13 seconds later. The attack immediately claimed three lives and injured over 260 people, with 16 people suffering traumatic amputations (5).
On 7 July 2005, four bombs were detonated in the centre of London, three in the London Underground system and one on a double-decker bus. The attack claimed 56 lives, including four suicide bombers as well as injuring more than 700 people (6).
Both London and Boston posed several hazards to emergency responders due to the unknown potential for biohazard from the make-up of the bombs as well as the imminent threat of further attacks (5,6). The location of each attack required emergency responders to assess each scene for further hazards and risks and to take into account the surrounding area of the blasts, including damage to structures (7,8).
Identifying and comparing the specific differences in the emergency response
The chaos and difficulty around managing a MCI is evident when looking at the Boston and London bombings. However, there are marked differences in the emergency responses. Boston was unique, in that there was already a large presence of EMS, police, fire personal and available ambulances (8). The ‘Alpha Medical Tent’ also provided enhanced medical capabilities to the Boston Marathon (5). The Tent was approximately 90 metres from the finish line and immediately after the attack was converted into a triage, treatment and transport area for ambulances (9). In direct contrast, the London bombings were at four separate public transport areas, with each bombing becoming a separate incident (6). In London 4 significant responses were required and the deployment of ambulances and resources (See Figure 2).
Establishing early pre-notifications is important to allow receiving hospitals to enact their MCI plans in a timely fashion. After the two bombs were detonated in Boston, there was an immediate response by the Boston EMS and other agencies in alerting all levels of emergency responders to the MCI, including surrounding hospitals (5,10). Pre-notification of several Level 1 Trauma receiving hospitals was credited to the early activation of their MCI plans. Similarly, in London the London Ambulance Service [LAS] Emergency Planning Manager contacted the Central Ambulance Control in order to alert the London receiving hospitals to enact their MCI plans (See Figure 2).
The initial ambulances at Boston were supported by nine private EMS companies who responded to the EMS request for assistance (See Figure 1). In contrast, the initial response at London required EMS and other agencies to mobilise a large number of resources to multiple locations (6). Each of the four major sites were declared a major incident; however, the timing and communication between agencies was suboptimal with different services declaring major incident at different times, unaware of other agencies doing so already (6). A major incident can be declared by any of the emergency services, with this considered on behalf of police, fire and ambulance services (6). Eventually a London-wide major incident was declared at 09:23 hrs by the Gold Coordinating Group who were responsible for the strategic co-ordination response in London (6,7).
London has a detailed disaster response plan that is developed and organised by the London Emergency Services Liaison Panel. The structure uses a three-tier system with the following levels: Gold (strategic), Silver (tactical), and Bronze (operational) format for a major incident (7). The Gold Coordinating Group is chaired by the Metropolitan Police Service and includes senior delegates from other emergency services and authorities that would be involved in a major incident (7). The key role of the Gold (Strategic) is responsible for activating major incident response plans from surround hospitals and health systems. The plan also requires a medical officer on scene to provide Silver (tactical) management from a medical perspective. The London Helicopter Emergency Medical Service [HEMS] provided these medical officers to fulfill the role of medical commanders, which was further supported by on-call volunteers from the London Medical Commander pool (7). Within this framework bronze (operational) is a representative from each emergency service who is charged with operational implementation of the tactics set out by Silver (6).
Figure 1. Figure 1. EMS Response: 16 April 2013 Boston Marathon bombings - Adapted from the Policing Institute (5). Abbreviations: MCI, Mass Casualty Incident; EMS, Emergency Medical Service
Figure 2. EMS Initial Response Times: 7 July 2005 London bombings - Adapted from the Greater London Authority (6). Abbreviations: LAS, London Ambulance Service; MCI, Mass Casualty Incident
Critically analysing the response of emergency services to the incidents
Significant differences in the response times?
Boston was unique in the availability of ambulances and EMS as well as other medically trained personnel. Within 10 minutes of the two explosions, the first critical casualty had been transported to hospital (See Figure 1). The median time from explosion to hospital for an injured patient was 11 minutes with a range of 5-53 minutes (8). Within the first 18 minutes of the attack, EMS transported 30 critical patients to hospital with the remaining critical casualties transferred within 45 minutes (11). The EMS response at Boston was almost immediate due to a vast range of prior resources and planning resulting in the positive outcome for the vast majority of casualties (5).
At Boston the almost immediate transfer of critical casualties and low fatality rate has been attributed to the available resources (12). However, it is also important to note that the last casualty was not transferred until 20:50 hrs (See Figure 1). Why this is important is because it highlights the need for appropriate triage and use of resources. After a MCI hospitals need to prepare for a potential surge of patients and other members of the community (13). Therefore, by coordinating which casualties require urgent transfer and those who can be treated on scene, hospital surge capacity can be assisted. Boston was able to treat casualties on scene due to the Alpha Medical Tent and abundance of health professionals present.
Looking at the initial response of the EMS at London, shows a spread of arrival times ranging from 10-30 minutes (See Figure 2). There was a lack of communication in declaring a major incident between various emergency services, highlighting some key issues around interdisciplinary emergency services communication (6). Any emergency service can declare a major incident on behalf of all emergency services; however, each service did not seem aware of other services declaring a major incident (6). The key reason for declaring a major incident is to alert all services from police, fire and ambulance to mobilise units and initiate major incident processes within all the services (6). These issues also translated to further difficulties with various managers using mobile phones to communicate between the Gold–silver–bronze command structure (6).
In comparison to Boston, London was significantly slower in the transport of critical casualties to hospital (See Figure 1 & Figure 2). At London, 27 critical casualties were cleared from the scenes every 2 hours, however; almost all sites cleared within 3 hours of the initial explosions (7). A key reason for this was the spread of attacks, with three bombs being detonated at different sites in the space of a few minutes, and a fourth 54 minutes later (6). Whilst this created challenges, the use of the Gold–silver–bronze command structure allowed for emergency service resources to be managed by using a clear command structure (7). The result was that paramedics were able to be redeployed to incidents that needed it, further resources sent, and surrounding hospital made aware of incoming casualties (6). Whilst initially slower to transfer critical patients, it is clear that the organisation and clearing of sites was completed quickly and efficiently. In contrast to Boston, London moved quickly to clear the sites in order to redeploy resources, and to remove casualties from further danger of attacks.
What were the differences in the emergency services in the two areas (type, response capabilities)?
Boston was fortunate in that resources were available almost immediately after the attacks (9). The Alpha Medical Tent was staffed with 200 medical professionals including physicians, nurses and paramedics (11,12). Boston Police and National Guardsman were also present and able to assist the medical professionals using basic first aid and makeshift tourniquets (11,12). The Boston Trauma Center Chiefs’ Collaborative noted that the presence of both Boston Police and National Guardsman to be an important factor, with many having military experience in applying tourniquets (12). Additionally, the Boston Athletic Association had three disaster medical teams staffed by physicians and nurses able to provide a higher-level care to participants (11). The triage among hospitals was conducted by a central team within the Boston EMS Command Centre in order to distribute the casualties between the various adult and paediatric Level 1 Trauma Centres within the Boston area (5).
In contrast to Boston, the Royal London Hospital was the only ‘Grade 1 Trauma Centre’ in London (13). However, it is important to note that the Royal London Hospital is linked with the London HEMS service. London HEMS took several actions to support the LAS in providing advanced practice physicians and paramedics (13). These teams were dispatched with a combination of paramedics and physicians via fast response cars in order to gain access to each of the four sites as quickly as possible. The use of helicopters was also essential in dropping off teams of physicians and paramedics (6,13). The London HEMS teams not only have an increased scope of practice as physicians, but the paramedics that work within this service are highly skilled and experienced (13).
A particular point in which the London HEMS assisted is the team leading, scene management and role as Medical Commanders who provide tactical support to the Silver commanders and Gold Coordinating Group (6,7). As part of the London major incident plan Medical Commanders are required to provide a medical perspective of the situations on scene (7). Whilst resources needed to be deployed at London, the capability of the London HEMS and specialised teams within the LAS provided the skills and experience to manage the difficulties experienced at the four London sites (13). Central Ambulance Control also mobilised small fast response physician teams to perform scene management, extraction of casualties and undertake care of seriously injured casualties (14). The LAS deployed a total of 100 ambulances consisting of over 250 medical professionals to the four sites (15). The addition of the London HEMS was integral at London, bolstering the capabilities of the LAS through advanced skills and scope of practice, whilst also providing essential team leading and scene management roles (13).
It is difficult to compare a like for like disaster particularly in the context of complex, coordinated terrorist attacks. Boston and London have several differences, however as mentioned above the Boston Marathon was a planned event and EMS resources were prepared and available. Comparing the response of EMS at Boston and London bombings is important as it provides learning points for future practice to see how EMS can improve the response to targeted attacks on events, or attacks that are carried out in everyday situations.
Did the emergency services have detailed disaster response plans? Were these plans followed?
Each year the Boston Athletic Association, Boston EMS, and the Boston health care community plan for the occurrence of an MCI (8). The plan outlines key operational points including first aid locations, medical tents, weather and communications information (11). However, a review of the Boston bombings noted issues with law enforcement redirecting and confounding EMS. Research found that some hospitals received higher volumes of critical patients, with one centre receiving six critical from two ambulances at once (12). Another key issue highlighted at Boston was the dependency of emergency services on cell phone communication (12). During the event, cell phone use was impacted by both an increase in calls and the Boston Police shutting down the cell phone network in fear of further attacks (5).
London also has a detailed disaster response plan that is developed and organised by the London Emergency Services Liaison Panel. The structure uses a three-tier system with the following levels: Gold (strategic), Silver (tactical), and Bronze (operational) format for a major incident (6,7). At London, Medical Commanders were provided by the London HEMS service in order to provide strategic support to the Gold Coordinating Group during the major incident Gold London-wide status (7). As with the Boston issues around communication adversely impacted emergency providers, operational teams and EMS communication (15). The issues arose from the reliance on cell phones by emergency responders and issues with inter agency radio communication (6).
The London and Boston bombings whilst similar are seven years apart and are not a like for like comparison. However, several significant learning points to improve future practice can be gained from the critical analysis of these two incidents. The benefits of early pre-notification to receiving hospitals is clear, as this is critical in enacting MCI protocols and plans. Surge capacity is a key factor in how hospitals manage MCIs, and the earlier operating theatres and beds can be made available the better flow through the emergency department will be. Communication with hospitals is also vital to establish which patients should be transported where, in order to not simply move a disaster from an area to the ED.
The Boston marathon bombings demonstrate how high-risk events that have detailed and comprehensive plans with adequate resources are able to respond competently and quickly to the event of an incident. The prior assembling of medical teams, the Alpha Medical Tent and access to ambulances on site for transfer demonstrated some key takeaways for MCI preparation. The London bombings and the use of the Gold–silver–bronze command framework provides an example of how a clear and structured MCI plan can assist emergency services and hospitals to smoothly swing into dealing with a MCIs.
The issues around communication and the use of mobile phones and their networks by emergency services was highlighted in both Boston and London. The use of radios is standard practice across EMS and other services, however particularly with the advances in technology and versatility of smart phones, hence there is an argument to provide EMS and other services in the field with access to mobile phones that can operate separate to public mobile networks. Particularly when using something such as the Gold–silver–bronze command framework which requires commanders at each level to be able to communicate quickly and easily.
Comparing and critically analysing the response of EMS to similar but different MCI provides key learning points for future practice. Preparation and a clear structured framework are critical to facilitate the best outcomes and to continue to develop and improve best practice.
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