Guest editorial: Patriots' Day at the Boston Marathon.

A disaster code appeared on my pager at approximately 3 pm on April 15, 2013. I stopped editing papers and turned on the news to find images of two devastating explosions near the finish line at the Boston Marathon. I headed to Beth Israel Deaconess Medical Center. When I arrived, I encountered scenes I had never witnessed before and hope to never see again. The emergency room was at once chaotic and organized. Emergency staff wheeled patients with leg tourniquets into trauma bays. Some already had sustained traumatic amputations. The many staff present followed the direction of the triage “conductor” who led a symphony of emergency care. Initially, we only had one junior orthopaedic resident and one nontrauma attending on site. Within minutes, numerous volunteer orthopaedic faculty and residents arrived. In less than an hour, we had five patients in the operating room, most of whom had orthopaedic injuries. In addition to those with traumatic amputations, there were others with extensive soft tissue injuries that required debridement and fasciotomies. Most of the bombing victims at our hospital had leg wounds, but we treated some major hand and upper extremity injuries as well. I scrubbed in to help on one of the debridements, then debriefed in our Command Center. I observed a different orchestra at the Command Center. Senior vice presidents and members of the administrative team, including representatives from the emergency department, operating room, anesthesia, surgery and orthopaedics all had gathered. The “conductors” were, at various times, our chief executive officer, senior vice president of nursing, and the leader of the disaster response team. This impressive unit considered everything. Moments after the call came in, the Command Center set up a HazMat tent to screen the incoming patients for radiation and other hazardous materials; fortunately, there were none. Leaders from the nursing staff ensured a fully staffed hospital with ample amounts of intensive care unit beds and recovery rooms for the bombing victims. The Command Center’s communication team stayed in constant contact with the police, Boston’s Emergency Center and hospital staff. Social service and psychiatry teams communicated with families of the victims and media personnel. Nutrition services offered plenty of snacks, water, soft drinks and pizzas for the staff throughout the hospital and the families waiting for information. The first blast occurred at 2:50 pm. Stretchers and emergency medical teams ran toward the victims within a minute of the first explosion. The first patients hit our emergency department at 3:01 pm. The emergency teams at Boylston Street cleared the injured victims and got them to one of the five Level 1 Trauma Centers within about 20 minutes. All of the victims taken from the scene of the bombings survived, an astounding tribute to first responders and to our staff, of whom I am most proud. It also involved some prepared luck. Ambulances, emergency medical team personnel and physicians were on the scene, expecting to treat marathon injuries and dehydration. We have five trauma centers in Boston, so no one hospital was overwhelmed. Prior mock drills helped the staff prepare and coordinate cohesively. When the orchestra needed to play, it performed beautifully. By 3:45 pm, the initial victims were in surgery, less than an hour after the blast. We learned other lessons as the days unfolded. Attending to the emotional responses of the residents, faculty, staff, patients, and their families became top priorities. It was a difficult week emotionally — at times bringing back emotions reminiscent of September 11, the Haiti earthquake, Sandy Hook, and even the assassination of President John F. Kennedy. We experienced these events and real time, and our whole country (and world) watched them unfold live. Our hospital staff got to know the victims well, as some required several trips to the operating room. One can only imagine the horrors that the victims and their loved ones faced. Some families had loved ones in more than one hospital. Some could not easily communicate by phone due to hearing loss from the blast. We had to find ways to add these additional procedures to operating rooms already filled with scheduled elective surgery. Our anesthesia and nursing teams gave us extra rooms so the victims were not added to the end of a long day. Suspect #1 arrived, and died at the hospital. Along with the entire city, our hospital was locked down as the police and FBI searched for the second suspect. A terrorist, “armed and dangerous,” lurked somewhere in our city. When police captured Suspect #2 alive, he was brought to our hospital and treated for injuries under heavy law enforcement and FBI guard. Many victims were still being treated for their injuries. All staff handled this with professionalism, compassion and expertise. After 6 days, Suspect #2 left our facility, in government custody. The immediate drama is over, but in many ways it is just beginning. These events will take time to digest. Boston will never be the same. Our hospital will never be the same. Many of the patients have been discharged, but are just beginning their rehabilitation. I was impressed by the response of volunteers at the scene, gratified by the physicians and nurses at the hospital who volunteered their time to help, and especially proud of our trauma team, our residents, and our nontrauma faculty. We also can learn from what went well and what could have been done differently. Cell phones went down initially, just after the bombing. We need improved communication and triage trees to call appropriate personnel when needed. We were fortunate that the hospital was fully staffed, and the emergency medical teams were already at the scene; we benefitted a bit from timing – it was a change of shift, so we had plenty of personnel at the hospital. We were fortunate that there were many patriots who rose to the occasion on April 15 and the ensuing days following the bombing. I learned about leadership by observation and personal experience. We have some healing to do, but we are strong — Boston Strong.