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Hospitals size up the lessons of Marathon attacks

Chief among concerns: accurately identifying patients amid chaos

A victim of the Boston Marathon bombing was rushed to Boston Medical Center.

Pat Greenhouse/Globe Staff

A victim of the Boston Marathon bombing was rushed to Boston Medical Center.

Boston’s trauma centers have been widely praised for saving dozens of Marathon bombing victims, treating one person after another who arrived at their doors with limbs torn off or mangled, some patients having lost most of their blood.

The day’s utter chaos made missteps inevitable, but in the months since, the hospitals have found lessons to be learned from the moments of confusion and occasional miscommunication.

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Boston’s six major trauma centers, which treated the most seriously injured bombing victims, have already made some changes for handling mass emergencies and are continuing to review their performance for ways to strengthen the city’s already sophisticated trauma system and share their lessons with hospitals nationwide — so they’re prepared for the next time.

In particular, the bombings brought forward a problem that has vexed trauma hospitals for years: the identification of victims.

Within minutes of the April 15 bombing, many patients arrived unconscious and without purses, wallets, or family members to identify them. An ambulance brought one woman to Massachusetts General Hospital with a handbag, but it wasn’t hers. It belonged to her best friend, who was killed on Boylston Street. Before the mixup was noticed, the family of the dead woman was told she was in a hospital bed.

There were challenges keeping patients straight at Brigham and Women’s Hospital, too. Staff assigned unidentified victims six-digit numbers, but they were confusing, and doctors and nurses had to continually double-check that imaging test results and medications were going to the correct patient. There were no mix-ups, said Dr. Eric Goralnick, medical director of emergency preparedness, but “we had some near misses.’’

Relatives and friends crowded waiting rooms, desperately searching for loved ones and pleading for any shred of information about their conditions. It didn’t help that siblings and spouses had been separated and that wounded parents and children, too, had been rushed to different hospitals.

A mother at Boston Medical Center, where her daughter-in-law was being treated, anxiously searched for her son. “The mother was very upset,” recalled Rebecca Blair, executive director of patient experience. “She was desperate.” Eventually, hospital president Kate Walsh called over to Beth Israel Deaconess Medical Center and located the son.

The hospitals plan to publish a joint analysis of the medical response. They will present some findings at the American College of Surgeons meeting in October in Washington, D.C.

“Every hospital in Boston will go back over every minute and communication,’’ said Dr. Ron Walls, chairman of emergency medicine at the Brigham.

So far they have also learned that they must use social media more effectively as an early warning system, because minutes matter in preparing trauma teams and operating rooms. Harvard researchers recently found that tweets mentioning the explosions began to appear six minutes before public health authorities sent alerts to emergency departments.

Hospital leaders also said they need to better organize and deploy the hundreds of hospital employees who show up to help in a crisis — and who contributed to congestion in emergency rooms on Marathon Monday.

The trauma centers are developing strategies to more accurately identify patients and reunite them with families faster — challenges that have plagued hospitals in other cities during disasters such as Hurricane Katrina. Atyia Martin, director of Boston’s Office of Public Health Preparedness, said the city is working with hospitals to standardize the reporting of patient identities to a central office that works to reunite victims with families. Hospitals did not all provide the same information and some lagged in reporting on April 15, she said.

Dr. Carl Schultz, research director at the Center for Disaster Medical Sciences at UC Irvine School of Medicine in California, said it is not surprising that Boston hospitals had trouble identifying patients and reuniting them with their families. “No one has solved that problem,’’ he said. But Schultz, who is co-editor of a textbook on disaster medicine, added, “Overall, things went very well in Boston.’’ Not a single patient died after reaching a hospital, though three spectators died at the race.

The identification error at Mass. General occurred during the intense rush to save lives after the first bomb exploded near the finish line at 2:50 p.m.

Hospital staff were alerted to the bombings when a physician at the scene sent a tweet. The message was picked up by an anesthesiologist, who suggested that his boss pause elective surgery, said Dr. Alasdair Conn, chief of emergency medicine at Mass. General. Patients began arriving by car, police van, and ambulance to a full emergency department at 3:04 p.m.

The first six victims were wheeled to emergency surgery; only one had been identified. One woman “was on the verge of death,’’ Conn said. “She had no blood pressure; she had lost all of her blood and was very critical. An extra couple of minutes and she wouldn’t have survived. She was lucky.’’

It was in this atmosphere that Karen Rand arrived by ambulance. She was given a patient number and whisked to an operating room. The pocketbook that arrived with her was put in a bag labeled with the same number, said Robert Seger, executive director of emergency services and emergency preparedness. Emergency room staff looked through it, searching for her identity, and found a purse with a driver’s license inside. It had the name Krystle Campbell.

Rand was no longer in the ER, so she could not be compared with the photo. And even if she could have been, the trauma victims had lost so much blood, they did not look like themselves, Seger said. “It was all very, very fast,’’ he said.

The information about this particular patient somehow made its way to the Campbell family, Seger said. The family didn’t discover the mistaken identity until they hurried into Rand’s room near sunrise on Tuesday. It was “an awful mistake,” Conn said.

A group of Mass. General caregivers and administrators now are debating how to prevent identification errors in the future. Should the hospital require two separate sources of identification, as does Beth Israel Deaconess Medical Center? How much energy should staff put into identifying patients in the initial minutes of a crisis?

“What is the priority?’’ asked Brenda Whelan, an intensive care nurse who has long worked with the Federal Emergency Management Agency. “We have to save the patient first, then work on IDing them. That causes stress to families.”

While no other hospitals reported misidentifying anyone, “reconnecting patients to families was really challenging throughout the city,’’ said Dr. Andy Ulrich, executive vice chairman of emergency medicine at Boston Medical Center.

Many matches occurred haphazardly.

At Boston Medical Center, a nurse in the emergency room handed Sheryl Katzanek, director of patient advocacy, a Post-it note with the name of an injured man and his wife’s name and race number. “She said, ‘Find her,’ ’’ Katzanek recalled.

Hospital spokeswoman Maria Ober said it is improving its communications system so that information about patients in disasters gets shared “in real time” with the hospital’s family reunification center.

At the Brigham, the first patient came in at 3:08 p.m., followed by 18 more in the first 30 minutes. “That influx of patients sort of overwhelmed our standard registration services,’’ Goralnick said. “It was taking too long to get them into the computer.’’

To expedite patients’ care, everyone was assigned a six-digit number, a strategy that ended up creating its own headaches. “The staff looked at the computer and saw a screen of six-digit numbers,’’ he said. The Brigham has eliminated those numbers and now identifies anonymous patients using states, colors, or the military alphabet.

Beth Israel Deaconess, which cared for the two suspected bombers as well as some of the victims, is also examining its public safety procedures.

On Friday, April 19, amid a manhunt for bombing suspect Dzhokhar Tsarnaev, “we pushed ambulances away from the building and had them searched,’’ said Meg Femino, Beth Israel Deaconess’s director of emergency management, because of concerns that the uncaptured suspect might arrive by ambulance and be armed and dangerous.

Earlier that week, the hospital had been searching ambulances, but did so close to the building. In the future, the hospital would make those searches further away from the building immediately after any attack, she said.

Trauma doctors said Boston was fortunate that the bombs exploded at an event where dozens of medical and public safety personnel already were stationed, and at an hour when shifts changed at the hospitals, nearly doubling the number of medical staff on site. But next time might be different, said Walls, of the Brigham. “We are analyzing every step now,” he said, “and trying to eliminate the element of luck.’’

Liz Kowalczyk can be reached at kowalczyk@globe.com.
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