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Order amidst chaos

Thursday October 10, 2013
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When the city of Boston was shut down four days after the marathon bombings because the suspects were on the loose, trauma centers caring for the victims had already updated their response plans based on lessons learned on that horrific day.

“By Friday, the day of the shelter-in-place [emergency procedure], we had already instituted some hospital-wide changes,” said Joanne L. Ferguson, RN, MSN, director, operational planning and environment of care for perioperative services at Massachusetts General Hospital.

For example, she said, when the hospital’s emergency notification system was triggered on the day of the bombing only the top perioperative administrators received the alert. On Friday, the day of the lock down, the alert went out to almost everybody.

Not long after the first bomb sent shrapnel flying into marathoners and spectators at 2:50 p.m. on April 15, the city’s top trauma hospitals triggered well-rehearsed disaster plans. Shrapnel from the bombs caused severe lower limb injuries, including numerous amputations. The victims were sent to eight Boston hospitals. “All of the things we learned came together on that day,” said Brigham and Women’s Hospital’s Brenda McKonly, RN, MSN, OR nursing director. “As bad as that day was, we all knew what we had to do and we did it. We had our first patient in the OR at 3:36.”


Charlotte Guglielmi, RN
What can we do better?

For the most part, hospital disaster plans unfolded as intended and trauma and surgical teams were so well-trained and prepared that not one bombing victim died after they reached ED doors, even though the injuries from the homemade bombs were like those seen in Iraq or Afghanistan, not in a U.S. city. “One of the key lessons of that day is that the city was incredibly well-prepared for the tragedy we encountered,” said Charlotte Guglielmi, RN, BSN, MA, CNOR, a perioperative nurse specialist at Beth Israel Deaconess Medical Center and the former president of the Association of periOperative Registered Nurses.

Yet not everything went as planned in the chaos of the disaster. Perhaps the most publicized mistake was the misidentification of a patient. The next day, hospitals citywide began debriefing staff and discussing what they could do better should such an event occur again. Lessons learned still are being reexamined and disaster plans fine-tuned. “We formed work groups to really look at the emergency preparedness plan, to make sure it covered everything that needed to be covered, that it is user friendly and that training is ongoing,” Ferguson said.

OR nurses interviewed from MGH, Brigham and Women’s and Beth Israel Deaconess shared common areas of improvement that are being implemented in their respective perioperative settings following the bombing.


Maureen Hemingway, RN
Communication is crucial

Improving communications and ensuring that disaster response roles and leadership are clearly defined are some of the most important lessons cited by the OR nurse leaders. “You can’t communicate enough with people,” said Maureen Hemingway, RN, a clinical nurse specialist for perioperative services at MGH.

MGH has ORs in five different buildings on three different floors. Each area has its own control desk that needed to effectively communicate with the other OR units during a disaster, for example while fielding calls or coordinating schedules and staffing. OR staff eager to help congregated around the perioperative central desk, raising the noise level and making it difficult for the staff working with the victims, Hemingway said. “We had to tell people to go somewhere else,” she said. “We needed someone to handle traffic.”

Nurses and physicians also lost cell phone communication when phone towers were shut down because of fears there were other bombs yet to be detonated by cell phones. MGH became dependent on the overhead paging system and beepers, Ferguson said.

Social media: Help or hindrance?

Another lesson learned was the influence of social media during a disaster. Texts from home, media alerts and other forms of social media notified hospital personnel about the bombing before traditional means of communication. “We received a lot of information from a variety of sources and not just through the means we had in the past,” McKonly said. “We were getting information faster through our cell phones than our Code Amber [alert system]. We had never talked about it before, but we talked about it a lot afterward.”

Whether social media enhanced the disaster response by the instant, but not always accurate, flow of information still is being discussed by communication and disaster experts. The lesson, McKonly said, is not to be afraid of social media and new technology but to take that information and use it to help validate what is occurring during the disaster.

Defining new roles during a disaster

The hospitals discovered that clearly defining roles during the disaster must be a priority to ensure perioperative teams work quickly and efficiently and that no time is lost duplicating efforts or wondering who is doing what. Although specific roles are defined in disaster plans, not all the roles were clearly and easily understood. The hospitals also found they needed some new roles, such as traffic controller, and someone to log and track the names and contact information of OR personnel who would be available to help, if necessary.

“We rewrote job descriptions so they are now clear and succinct,” said Ferguson. “The hospital wanted to make sure that if a disaster occurred at night, the night shift personnel would understand the roles. They need to be able to read the job title, the brief role description and assign someone to it. It’s almost in a checklist like format now.”

Brigham and Women’s McKonly agreed. “We learned you need to be very clear about who is acting in what role. The staff needs strong and easily identified leadership roles.”

Tweaking roles, processes

MGH adopted a process from the Brigham and Women’s disaster plan and now has a room with prepositioned supplies, such as binders with the information needed for each role designated in perioperative services and a vest to be worn by each person.

McKonly said Brigham and Women’s central processing personnel recommended that in future disasters some specialized OR supplies and instrumentation, such as external fixators, be located in one central area outside the operating suites so they could be readily dispatched in order of priority of need, she said. Many of the nurses were calling for the same equipment or instrument sets to have in their rooms. “This way, they could be located immediately when actually needed,” she said.

Leadership at Beth Israel Deaconess let the nurses who were in charge when the bombing occurred and initially took control of the disaster continue in that role. “Leadership removed obstacles instead of taking over,” said Barbara DiTullio, RN, BSN, MA, nurse manager of the ORs.

At Brigham and Women’s, simple paper bags became emblematic of the importance of collecting each patient’s clothing and personal belongings for law enforcement personnel including the FBI, ATF and Boston and state police. Although OR nurses have collected bullets from patients in the past, preserving other types of forensic evidence for a federal investigation “was new for us,” McKonly said.

That was especially true for the OR staff at Beth Israel Deaconess. The lockdown of the city was triggered after a police shootout with the bombing suspects in nearby Watertown. The suspects, one who was dead on arrival and the other wounded, were brought to Beth Israel Deaconess. “At first we didn’t know if the patients coming in were all victims or were possibly the perpetrators,” Guglielmi said. “All of their belongings had to be managed securely in a way that was different from normal operations.”

When the staff learned that they were caring for a bombing suspect, “it was difficult for the staff charged with working with him,” DiTullio said.

The most enduring lesson learned by Beth Israel Deaconess is remembering that after everything is done and the last patient is discharged, it is time to care for and support the staff. There is no one-size-fits-all way to assist employees, said DiTullio. “Everybody responds differently and is at different stages of recovery,” she said.

For example, some employees appreciated opportunities to meet with social workers and others did not. “We are now almost six months out, and we are still asking what do we need to do for our staff,” Guglielmi said. “Many of them are recovering from what for them was an unthinkable event.”


Janet Boivin, RN, BSN, BA, is a freelance writer. Post a comment below or email specialty@nurse.com.