To care for Boston Marathon bombing victims, Mass General activated a meticulous plan that put the entire hospital in disaster-response mode.
Marc Fucarile, Gavin and Jen Regan on the Boston Marathon Bombing
Marc Fucarile (top) was rushed to Mass General after his right leg was torn off below the knee in the Boston Marathon bombing. He is pictured with his fiancée, Jen Regan, and their son, Gavin.

After the Boston Marathon bombing, Marc Fucarile was rushed to Massachusetts General Hospital in the back of a police van. His right leg had been torn off below the knee and his left was badly mangled. “I fought to keep my eyes open,” Marc recalls. “I thought that if I shut them, I was dead.”

The 34-year-old roofer and some friends had been standing outside a Boylston Street eatery cheering runners headed for the finish line. The group started to flee after the first blast. The second lifted Marc off the sidewalk and threw him down burned, bleeding and riddled with shrapnel.

When the police van stopped outside the Sumner M. Redstone Mass General Emergency Department (ED), Marc told himself his survival was in the hands of the caregivers inside.

Hundreds of them were beginning to mobilize. Minutes earlier, city emergency dispatchers had advised Boston hospitals to expect casualties from the explosions. Details were still sparse but, for Mass General administrators already in the ED, the early arrival of patients like Marc seemed like a warning of what was ahead. They called a “Code Disaster,” activating a meticulous plan that put the entire hospital on a disaster-response footing.

Robert Seger on Boston Marathon Bombing
In the aftermath of Boston Marathon bombing, creating capacity in the Mass General Emergency Department became an immediate concern for Robert Seger, Mass General’s executive director of Emergency Services and Emergency Preparedness.

A Response Plan Relentlessly Tested

Staffers throughout the hospital knew what to do after the Boston Marathon bombing. Some doctors, nurses and technicians rushed to join or support colleagues already in the Mass General ED. Other hospital workers began readying extra gurneys, medical supplies and coolers full of bagged blood. Nurses and social workers mobilized to help families seeking information about loved ones. The Trustees Room in the historic Bulfinch Building was quickly transformed into a high-tech command center. There, Ann Prestipino, senior vice president, Surgical, Anesthesia Services, Emergency Services and Clinical Business Development, would preside as incident commander.

Although the disaster-response plan had been activated for smaller emergencies, such as blizzards, the enormity of the Boston Marathon bombing would test the skills and resilience of Mass General caregivers.

Although the disaster-response plan had been activated for smaller emergencies, such as blizzards, the enormity of the Boston Marathon bombing would test the skills and resilience of Mass General caregivers. The future of dozens of badly wounded patients and their traumatized families were on the line. Moreover, this attack occurred at one of Boston’s most storied events. The caregivers themselves were shaken. Some struggled to save lives that afternoon fearing that the next patient who came through the doors might be someone they knew.

Tragically, three people did die as a result of the Boston Marathon bombing. The toll might have been higher if medical personnel were not deployed along the marathon route for routine medical needs.

But none of the more than 260 men, women and children who arrived at Boston emergency rooms alive perished. “I am extremely proud of the Mass General staff and of the entire Boston medical community for responding so quickly and effectively,” says Peter Slavin, MD, Mass General’s president. Even so, he adds, that the initial challenges faced by Mass General caregivers were “unprecedented in our history.”

Indeed, in those chaotic first hours, the perpetrators were still at large and there were rumors of more hidden explosives. Of the 39 victims of the Boston Marathon bombing treated at Mass General, some of the most gravely wounded arrived in a terrible early rush. They suffered from traumatic amputations, severe blood loss, third-degree burns and compound factures.

Megann Prevatt, RN on Boston Marathon Bombing
Megann Prevatt, RN, could not quite believe what she was hearing when a radio brought word of the Boston Marathon bombing to the MGH Emergency Department.

Like Everything Went Silent

Megann Prevatt, RN, had been going nonstop since her shift in the ED began that morning. When the department’s disaster radio crackled to life with a terse advisory about the explosion, “it seemed like everything went silent for a minute,” she recalls. “It was like you couldn’t believe what you were hearing.”

Clad in blue scrubs, George Velmahos, MD, Mass General’s chief of Trauma Surgery, had just wrapped up a busy shift in the operating room. Looking out his office window, he told himself it was a beautiful day for his teenage son to be in town watching the marathon. Then his phones and pagers – two of each – went off. Running toward the elevators, Dr. Velmahos could already hear the sirens.

In the ED, Robert Seger, Mass General’s executive director of Emergency Services and Emergency Preparedness, conferred with colleagues. One necessity loomed large after the Boston Marathon bombing. “We needed to create capacity in our emergency department,” he says. “That was absolutely key.”

Monday afternoons are typically very busy in the Mass General ED. Its 47 beds are often full, with less serious patients being treated in chairs or waiting to be seen. At the time of the explosions, 97 patients were already being actively treated in the ED.

After Boston Marathon Bombing, Just One Empty Bed

When the Code Disaster was called, Alasdair Conn, MD, then Mass General’s chief of Emergency Services, glanced at a monitor in his office that displays a chart tracking the ebb and flow of ED patients. On it, empty ED beds show up in white. With an unknown number of ambulances bound for Mass General, he had a grand total of one.

Alasdair Conn, MD on Boston Marathon Bombing
Alasdair Conn, MD, Mass General‘s chief of Emergency Services at the time of the Boston Marathon bombing, was relieved and impressed by how quickly staff made room to treat incoming casualties.

Even so, when Dr. Conn walked into the ED a few minutes later, he was relieved and impressed by how rapidly staff members were implementing one critical element of Mass General’s response plan. Nurses and doctors were shifting the gurneys of patients who could safely be moved away from the ED’s acute care area to make room for incoming casualties. Other patients were being moved to inpatient floors without delay. Some doctors and nurses were taking their patients upstairs themselves instead of waiting for patient transport workers.

“Within a minute at the most, the entire thing got organized into a perfectly coordinated team of people who knew exactly what to do,” says Alberto Puig, MD, a clinical educator from the Department of Medicine, who along with other faculty helped to supervised a group of residents involved in assessing, treating and moving ED patients on the day of the Boston Marathon bombing.

Refined and relentlessly tested for more than a decade, the hospital’s emergency preparedness plan is designed to speed decision making and marshal resources so medical staff can concentrate on meeting a major medical emergency while continuing to provide for existing patients.

Do I Know Anybody There?

Along with procedures for creating space in the ED, the plan includes a system for instantaneously notifying key staff. There are guidelines for conducting large-scale decontaminations and establishing emergency triage stations outside on the ambulance ramps. The plan also details steps for maintaining clear communications. Indeed, to provide for the rapid installation of extra gear, one chart details the precise location of every electrical outlet in the Bulfinch Building’s Trustees Room, the designated incident command center.

In refining its plan, Mass General sought outside advice and engaged in broad collaboration. Israeli emergency physicians came to Mass General to describe their procedures for responding to bus bombings and other incidents. Mass General and other Boston hospitals coordinated with Boston Emergency Medical Services officials in preparing for disaster scenarios that included the detonation of a dirty bomb at Logan airport.

Mass General Magazine 2013-10-08: Dr. John Herman on Boston Marathon Bombing
“The first thing that everybody thought about was, ‘Do I know anybody there and are they okay?’ ” says John Herman, MD, associate chief of Psychiatry, who was in the MGH Emergency Department after the Boston Marathon bombing.

On Marathon Monday 2013, the plan’s successful execution depended upon Mass General staff being able to stay focused while coping with enormous emotional challenges. “The first thing that everybody thought about was, ‘Do I know anybody there and are they okay?’ ” says John Herman, MD, associate chief of Psychiatry, who was in the ED and headed up subsequent family and staff support efforts. “That is a really important piece of the story.”

For eight years, Audilia Rosa has worked in the ED changing sheets, sanitizing equipment and making certain treatment bays are totally clean and disinfected after every patient. Though stunned by the level of suffering she witnessed around her after the Boston Marathon bombing, Ms. Rosa was determined to keep going. “I had to do it,” she says. “We had to be ready.”

Focusing on What You Had to Do

Too busy to contact family or keep up with what was going on outside the hospital, Ms. Prevatt, the ED nurse, worried about the safety of loved ones. “You just really had to stop your mind, hope that everyone was okay and focus on what you had to do,” she explains.

But after the Boston Marathon bombing, it was sometimes tough. Covered in black soot and bleeding badly, Marc Fucarile was wheeled into the bay where Ms. Prevatt was on duty. Working elbow to elbow with colleagues, she inserted an IV line, just as she had done hundreds of times before. But it rattled her that this young man was about her age. He also had the same hair color and first name as her boyfriend. The ED team worked to keep Marc alive, starting blood transfusions and connecting him to a ventilator. Through it all, Ms. Prevatt kept reassuring the patient in a soft voice. When the time came to rush Marc to surgery, she was part of the transport team.

When Jen Regan ran up the driveway to Mass General’s main entrance that afternoon, she knew her fiancé, Marc Fucarile, was among the Boston Marathon bombing victims inside.

Dealing with the emotional and psychological impact of disaster is a core component of Mass General’s response plan. During those first hours after the Boston Marathon bombing, that effort focused on reconnecting victims and their loved ones.

Cell phone service had crashed so marathon spectators who were safe couldn’t let loved ones know. Local residents came to area hospitals in search of people they knew. Thousands from around the nation and the world phoned.

Mass General’s Blum Patient & Family Learning Center was transformed into an emergency family support center staffed by psychiatrists, nurses, social workers and clergy. Extra phones were installed to help cope with the demand for information. For families who came to MGH searching for loved ones, the center became a quiet place to wait for word. “Every day we try to meet the needs of people who need our help,” says Brian French, RN, the Blum Center’s director. “In this case, it was primarily information but it was also comfort.”

Patricia Mian, RN, a psychiatric clinical nurse, helped reunite victims with their loved ones after the Boston Marathon bombing.
Patricia Mian, RN, a psychiatric clinical nurse, helped reunite victims with their loved ones after the Boston Marathon bombing.

Get to Mass General

Throughout the afternoon, new and updated patient information was ferried to Blum from the ED by nurses and social workers. They began trying to gather basic identify information about the wounded as soon as they arrived. Wallets and cell phones provided clues. Veteran caregivers quietly asked ED patients who were conscious if there was anyone they wanted to be contacted. “My goal is to get the families in here as quickly as possible so that we can start working with them and do as much as we can for them,” says Patricia Mian, RN, a psychiatric clinical nurse who was part of that effort.

When Jen Regan ran up the driveway to Mass General’s main entrance that afternoon, she knew her fiancé, Marc Fucarile, was among the Boston Marathon bombing victims inside. When she had tried to call him earlier, a firefighter riding with Marc in the back of the paddy wagon had answered his phone. “He said I needed to get to Mass General,” she recalls.

By the time Jen and the Fucarile family gathered at Mass General, Marc was in surgery. After a time, Marc’s loved ones were escorted to the waiting area for the Blake Building’s 12th floor intensive care unit. Doctors and nurses kept them updated and, by now, the family knew Marc had lost a leg but they craved more details.

George Velmahos, MD on Boston Marathon Bombing
From the start, George Velmahos, MD, chief of Trauma Surgery, was in the thick of Mass General’s response to the Boston Marathon bombing.

The Need to Move Quickly

Dr. Velmahos had been in the thick of Mass General’s response from the start. Seeing the first victims wheeled into the ED, the trauma chief knew he needed to move quickly. One patient’s heart had stopped. Several had suffered lost limbs. Dr. Velmahos went from treatment bay to bay, assessing each patient’s needs and making certain colleagues were assigned to handle their surgeries. Somewhere along the way, he got word that his own son, a marathon spectator, was safe.

The surgeon would personally take care of Marc Fucarile. From his weak pulse and gray pallor, “I knew he was drifting to death’s door,” recalls Dr. Velmahos, an expert in traumatic bleeding.

In the operating room, the surgical team applied more powerful tourniquets and within 10 minutes, Dr. Velmahos had brought the major bleeding to a halt. The bomb had taken Marc’s right leg off just below the knee but, because the blast had also badly damaged much of the tissue that was left, Dr. Velmahos amputated a few inches more, aiming to avoid infection while leaving as much of the leg as possible to make it easier for Marc to eventually use a prosthesis.

With burns, lacerations and open fractures, Marc’s left leg was terribly damaged but the injuries were not immediately life threatening. Knowing that a double amputation would complicate Marc’s recovery, Dr. Velmahos decided not to remove the other limb. “We had to fight hard to save that leg,” says Dr. Velmahos, who assisted with several other bombing-related surgeries that afternoon.

Scared and with a Million Questions

After stopping at the Bulfinch Building that evening to brief hospital leaders on the surgery patients, Dr. Velmahos set off to meet with each of their families to update them.

When he arrived on Blake 12, Dr. Velmahos took Marc’s family into a quiet hallway. He made a point of delivering the good news first: Although Marc was not totally out of the woods, he would likely survive. For her part, Jen was struck by the time Dr. Velmahos spent explaining details. “We were so scared and we had a million questions,” she recalls. “Dr. Velmahos didn’t brush us off. He listened. He answered our questions, honestly but kindly. He was great.”

After surgery, Marc was brought to Blake 12 in a medically induced coma. His face was badly swollen, his skin was burned and his hair singed. Before the family was brought in to see him, Emily Erhardt, RN, an ICU nurse, carefully cleaned him up and arranged his blankets so that the full extent of his injuries would not be quite so starkly visible. Later, the nurse moved a recliner close to the bed and arranged some pillows and blankets so that Jen could spend the night. “If that had been my fiancé or my boyfriend in that bed,” Ms. Erhardt says, “I would have wanted someone to do the same thing.”

In the days after the Boston Marathon bombing, messages of thanks were sent to Mass General caregivers from around the world.
In the days after the Boston Marathon bombing, messages of thanks were sent to Mass General caregivers from around the world.

By then, the most medically intensive part of Mass General’s response to the Boston Marathon bombing was over although the days that followed were hardly routine. On the Thursday after the bombing, President Obama visited Mass General. The day after that, Mass General had to grapple with staffing issues after public transportation was shut down amid a manhunt for the bombing perpetrators.
Though the hospital’s response was broadly praised, Mass General leaders soon began reviewing the hospital’s plan in search of ways to better handle any future disaster. In many departments, staff members attended meetings to talk about their experiences, aiming to relieve stress.

For her part, Megann Prevatt, continued to be bothered by memories of Marc. About two weeks after the Boston Marathon bombing, she decided to do something she’d never done with a former ED patient before: She visited him at the hospital. Comforted by his warmth, she came away with a picture of Marc, Jen and Gavin, the couple’s 5-year-old son. “He signed the back of it, ‘You are our angel,’” Ms. Prevatt recalls.

“Except for when I had pain, I don’t think I ever cried in that hospital,” Marc Fucarile says. “I don’t think I would have made it if I had gone anywhere else.”

Day after day during Marc’s recovery, Jen was moved and comforted by the way Mass General nurses carefully explained every procedure they were undertaking. “It makes you feel better knowing why they are doing the things they are doing to the person you love,” says Jen, herself a nurse. “For me, that was huge.”

On July 24, 2013, Marc went home on crutches after 45 days at Mass General and another 55 days at Spaulding Rehabilitation Hospital. He has undergone more than 50 surgical procedures and on the web site, www.marcfucarile.com, his sister is raising funds to help cover future expenses.

For Marc, Mass General’s response to the Boston Marathon bombing was not about plans or procedures but people. He talks about the way Dr. Velmahos gave him his personal cell phone number and encouraged him to use it. And the wisecracks he traded with surgeon Jeremy Goverman, MD, the burn expert who handled several of his operations. And then there was Laura Lux, RN, an ICU nurse. She treated Jen and the Fucarile family as though they were all under her care and, while Marc was at Spaulding, once came to visit bearing a plate of her homemade chicken parmesan.

“Except for when I had pain, I don’t think I ever cried in that hospital,” Marc says. “I don’t think I would have made it if I had gone anywhere else. Surgically maybe but, mentally, I really don’t.”