Jan 29, 2015Prepared for the Worst
From veteran athletic trainers to students, the sports medicine team at the Boston Marathon responded heroically to the bombings on April 15. What preplanning enabled everyone to act with such calm efficiency? And what lessons can we learn about medical coordination from the tragic event?
By R.J. Anderson
R.J. Anderson is an Assistant Editor at Training & Conditioning. He can be reached at: [email protected].
As he has done on the third Monday in April for 35 years, Brian FitzGerald, LAT, ATC, was at the 2013 Boston Marathon finish line tending to exhausted and dehydrated runners. When the first explosion went off at 2:49 p.m., he immediately thought the worst. “That’s got to be a bomb,” FitzGerald said to himself.
After a second boom 12 seconds later, the Finish Line Coordinator/Athletic Trainer Coordinator for the Boston Marathon was sure he was hearing a violent detonation. As unthinkable as it seemed, two bombs had gone off in crowded spectator areas near the finish line at the Boston Marathon.
As smoke filled the air, pandemonium ensued and FitzGerald did what athletic trainers do when a situation turns difficult: He responded. Running toward the smoke a few yards away, FitzGerald, along with his team of white-jacketed, red-hat-wearing athletic trainers, quickly reached the area where the first of the two bombs had gone off. They tore down the fencing separating the viewing area from the racecourse and encountered what FitzGerald describes as “another world.”
“It was eerily quiet once I stepped over the fence. A fire alarm was the only real sound,” says FitzGerald, whose full-time job is Community Outreach Coordinator at Boston Children’s Hospital. “The smell of the smoke was powerful and everywhere I looked there was blood and severely injured people. Those of us who came upon that scene started trying to help the injured any way we could. We didn’t believe what we were seeing at that point.”
Finish Line Co-Captain Jon Dana, ATC, Director of Sports Medicine at the University of New Hampshire, arrived at the area the same time FitzGerald did. “Nothing in my career prepared me for what I saw when I got there,” says Dana. “When I stepped over that fence and looked at all that blood on the ground, I remember thinking, ‘This is going to be unbelievably difficult.’ But like all of the other people wearing white jackets [indicating they were medical providers], I knew I had to go in and help–it was my job and my duty as a medical professional.”
Dana says his focus immediately narrowed and the calm-amid-the-storm mentality that he’d developed during his three decades as an athletic trainer kicked in. “The stuff I saw was so far beyond what I’m experienced in dealing with, but when you’re in a situation like that, you don’t have time to think about the pain and suffering the same way as if you were an outside observer–you have to react and do what you can to help,” he says. “I’ve been an athletic trainer for a long time and I think how I reacted was more a function of my training than instinct.
“During an injury situation, the athletic trainer is the one with the calm head,” Dana continues. “That’s how all of us reacted in those moments at the marathon.”
As the athletic trainers and other medical personnel tended to the victims, applying pressure to bleeding wounds and using belts, T-shirts, and ID card lanyards to tie impromptu tourniquets, athletic training student volunteers who had been transporting tired and dehydrated runners with wheelchairs from the finish line just minutes earlier came rushing to the scene. They quickly used the wheelchairs to bring the severely injured to nearby ambulances and a finish line medical tent that had been transformed into a triage area.
“The kids reacted perfectly and I’m telling you we really needed those wheelchairs to get people to the tents and the ambulances as fast as possible,” FitzGerald says. “Those without wheelchairs helped where they could. I had one athletic training student from Bridgewater State University who is a Marine Corp veteran pick up a woman and carry her to the medical tent in his arms.”
There were 97 injured people who had to be evacuated from the first bombing site. Ambulances transported the victims to nine different area hospitals in a process that took just 22 minutes. Some were in emergency rooms in as little as eight to 10 minutes after the first explosion. “I was astonished when the Boston EMS Special Operations Captain told me we evacuated that many victims from the scene and out into ambulances in 22 minutes,” says FitzGerald. “He looked at me and replied, ‘That is because all your people ran in the right direction.'”
How did the sports medical team respond in such an efficient, orderly–and heroic–way? While FitzGerald says there is no specific training that could have prepared him and his colleagues for that day, he believes that the medical response plan and protocols in place were key in helping bring the victims to safety. The plan for rushing a heat-stroked runner to an on-site medical tent or hospital was applicable for evacuating a spectator with shrapnel damaged legs. And following the chain of command, as displayed by the athletic training students, was also crucial.
We talked to FitzGerald and Dana about the planning that goes into the medical response for the Boston Marathon and how athletic trainers fit into that picture. They also share their experiences from that difficult April afternoon and how they and others who were there are helping each other cope in the aftermath.
MORE THAN A RACE
Commemorating the first battles of the American Revolutionary War, Patriots’ Day is a state holiday in Massachusetts and a major source of pride for the people of Boston. Held the third Monday in April, schools and businesses close and the city comes together in celebration. Athletics play a big part in the day’s festivities with the Red Sox hosting a late-morning game and more than a half million people coming out to appreciate and participate in the city’s crown jewel–the Boston Marathon.
For many athletic trainers in the area, the marathon is also an opportunity to give back and re-connect with one another. Each year, 130 or so volunteer their time providing medical coverage for more than 27,000 runners. Working the marathon is a prestigious opportunity and volunteer slots fill quickly. Many, including FitzGerald, Dana, and long-time Boston Marathon Medical Coordinator Chris Troyanos, ATC, (who was under media blackout at the time of publication) have each provided over 30 years of service to the 116-year-old race.
As one of the largest single-day sporting events in the world, the marathon also provides elite-level learning opportunities for students in athletic training programs from around the country. This year between 70 and 80 athletic training students from 15 colleges and universities came to Boston to learn the ins and outs of covering a very large sporting event.
The majority of athletic trainers working the marathon are located on and behind the finish line. Their job is to observe the health condition of the runners who have just completed their 26.2-mile goal. Usually, that means identifying signs of hyponatremia, heat illness, and dehydration, then escorting afflicted runners to nearby medical tents, which are manned by physicians, nurses, physical therapists, and other athletic trainers. In addition to highly trained medical personnel, the two finish line tents contain each runner’s medical records, cooling tubs, IVs, cardiac testing equipment, and a host of other cutting-edge medical tools.
“I don’t think there’s anything like it in the world,” says FitzGerald of the event’s on-site medical facilities. “There are 15 to 20 sections in each tent. Each section has a physician, an athletic trainer, a physical therapist, a nurse, an IV nurse, and a medical records person who all work together to treat runners as they are brought in. Each tent also has an intensive care section as well as an area manned by Boston EMS.”
The person responsible for putting everything together is Troyanos, Head Athletic Trainer at Lasell College and Medical Coordinator for the Boston Athletic Association, which puts on the marathon. “Chris has been with the marathon for 36 years, the last 19 as the medical coordinator, and he works year-round to organize everything medical-related from the start to the finish,” says FitzGerald. “Since he’s taken over, the medical coverage has evolved immensely, adding things like ice water immersion and temperature recording techniques. Before that, we weren’t using all of the evidence-based protocols as we do now.
“And the education component that Chris has added is phenomenal,” continues FitzGerald. “He has put together a 43-page medical manual for the event that is updated every year. Chris is constantly sharing signs, symptoms, and treatment specifics of the conditions the medical volunteers could see during the event so that they’ll have an understanding of what they’ll be dealing with before race day arrives. Along with that, he creates a safety video that is e-mailed to all of the runners and volunteers.”
Coordinating coverage for a 26-mile stretch of road is no easy task. To create a larger blanket of medical oversight that extends beyond his volunteer work force, Troyanos works with officials from every town along the course, ensuring all of the various fire departments, ambulance services, and emergency responders are on the same page. “He also meets with all of the hospitals on the route and educates them on what they might see and what they should have on hand, such as an ice water immersion tub,” FitzGerald says. “Chris’s communication with all of these entities is the key to making the event’s coverage consistent from one town to another.”
Although there wasn’t a specific plan in place for dealing with a catastrophic mass trauma situation, FitzGerald says the chain of command was very clear. “We’re taught that it’s really Boston EMS’s responsibility in a catastrophic situation, such as a collapse in the stands or something of that nature,” he says. “They’re trained to handle those types of situations. We’re there to assist and be good Samaritans and do what we can, but when they arrive on the scene, it’s our job to move aside and let them do what they do.”
Dana says effective coordination of an event–no matter the size–comes down to the execution of a few key principles. “It requires organizing everything in your head, then projecting that to the people who facilitate your plan–the hospital emergency rooms, the EMS services, and other entities,” he says. “It’s also about getting them to buy into your system.”
“There needs to be foresight and an awareness of the logistical challenges of the area where the event is being hosted,” FitzGerald says. “You also need to think about the type of athletes you’re dealing with, common injuries to consider, and the assets you’ll need to have on hand should something happen. Then it comes down to asset management and delegating responsibilities to make sure you have everything covered.”
MARATHON MEN & WOMEN
With great on-site facilities and a detailed plan, the medical coverage of the Boston Marathon is recognized as top notch. But what makes it world class are the volunteers who comprise the medical staff. That is especially true of the athletic trainer contingent, which relies on both experience and familiarity to provide efficient care and leadership. “The marathon is a prestigious event and it’s not hard to get people to volunteer,” says Dana, who has done so since 1977 when he was an undergraduate at Northeastern University taking classes alongside Troyanos. “The New England athletic training community is a fairly small, close-knit group. When we have downtime before the race, it’s a nice opportunity to catch up with old friends, make new contacts, and hang out and tell stories. Then once the race starts, we do what we’re trained to do.”
Joining Dana, 26-year marathon veteran Larry Venis, MEd, ATC, Head Athletic Trainer at Boston University, works as a Finish Line Co-Captain under FitzGerald. Dana and Venis each have 25 athletic trainers and 10 athletic training students working for them. Dana points to volunteer retention along with the group’s interpersonal relationships as a big reason things run so smoothly at the finish line area.
“Because Chris, Brian, Larry, and I have been doing this for so long, there is an understanding among all of us about our roles and positioning during the race,” Dana says. “For Chris, that means he doesn’t have to worry about the finish line, which is one less thing he has to monitor during the race.
“That trickles down to each of our teams as well,” Dana adds. “This year I only had two or three athletic trainers who were doing this for the first time, two or three in their second year, and the rest had five, 10, 15, or 20 years of experience working the marathon.”
Although they don’t have the years of experience, athletic training students are also critical. In 2013, no group played a bigger role in marathon bombing victim evacuation than these athletic trainers of the future. That day, there were 20 students at the finish line operating wheelchairs under Dana and Venis and a few others shadowing certified athletic trainers. Meanwhile, 50 or so other students worked with the race sweep team, walking various parts of the course to cover everything happening between the start and the finish.
When the first bomb went off, like the athletic trainers they were following, the students made the critical decision to run toward the chaos, not away from it. “And there really wasn’t a whole lot of direction from the athletic trainers,” says FitzGerald. “The students just followed our lead and figured out that you put an injured person in the wheelchair and take them to the tent–the same as they would if it was an injured runner.
“Our student program has always been a big part of our success,” FitzGerald adds. “I get requests from new schools every year that want to get involved. For example, this was the first year for LSU and James Madison University. We want these kids to have the opportunity to come and be a part of the most prestigious race in the world.”
ROAD TO RECOVERY
Once all the victims had been transported to hospitals and the bomb site transformed into a crime scene, there was one more important thing to be done. FitzGerald turned his attention to making sure his team was okay. With everyone healthy and accounted for, the volunteers’ day was finished, but the gravity of the situation was just starting to sink in.
“It was so fresh and just looping through my mind continuously after I left the site,” says FitzGerald. “I kept wondering if there was more that I could have done and if we could have handled anything differently. I wish I could have done more and gotten to more people and helped them. I also knew there would be others who would have regrets and trouble processing.”
The next morning, FitzGerald woke up early. Back to work at Boston Children’s Hospital, he immediately called members of his team. “I didn’t e-mail them because I wanted to hear voices and connect with each person. I wanted to feel what they were saying and make sure they would have another person with them in the days that would follow,” he says. “I also talked to athletic training faculty leaders who were with their students on the way back to their campuses and made sure there were support networks set up for all of them.”
And there were. “Everybody at those institutions were wonderful in opening their arms up to those kids,” FitzGerald says. “They made sure there were people the students could talk to about the experience.”
Over the next few days, he and Troyanos followed up with each group of athletic training students. In one meeting they joined students from Boston University in a group Skype with those from LSU and the University of South Carolina. “They were happy to see us and we were happy to see them,” FitzGerald says. “Whenever we’ve met or talked with the students who were at this year’s marathon it’s been great. We’re bound with all of these people for life. We need to keep in touch and continue talking about what we’ve seen, how we’re feeling, and how we’ve been affected. I’ve come to realize how important it is to stay engaged, communicate, and not withdraw when things like this happen.”
That’s the exact advice Dana received from counselors at New Hampshire. “I was told the best way to deal with post traumatic stress disorder is to keep talking about what happened,” he says. “So that’s what I’ve done. Anytime anybody has asked a question, I answer it. Anytime it comes up, I discuss it, whether that person was there that day or not.
“I look at it as therapy,” Dana adds. “Talking about it with different people gives me various ways to look at the experience and I’m okay with that. That’s how I have to process it.”
Despite all of the challenges and despair created by bombings at the Boston Marathon, both Dana and FitzGerald acknowledge that it could have been much, much worse. “The bombers actually picked a spot where there was probably the highest concentration of medical personnel in Boston at any time of the year,” Dana says. “You could not have asked for a more prepared location with better medical staffing to handle that type of situation.”
“And all of the emergency room physicians told us the same thing,” says FitzGerald. “They said if we hadn’t gotten the victims to them as quickly as we did, there would have been a lot more deaths.”
And if there are any questions about whether the impact of the 2013 attacks will dissuade medical volunteers from returning next year, FitzGerald can quickly put those doubts to rest. “Every single athletic trainer I’ve spoken with told me to make sure his or her name is on the list for next year,” he says. “We’ll definitely be back bigger and stronger.”
Sidebar: New Awareness
In the aftermath of the Boston Marathon bombings, many administrators are re-visiting their event planning as it relates to security and trauma response. At the University of New Hampshire, Head Athletic Trainer Jon Dana, ATC, who was a Finish Line Co-Captain at the 2013 Boston Marathon, has already been part of such a discussion. Just months after the Boston bombings, Dana and other university officials met with a local police officer who also works with the U.S. Department of Homeland Security to talk about the university’s response during a mass trauma scene such as a bleacher collapse, bombing, or shooting.
Still, he’s not sure if there is anything more an athletic trainer can do to be ready for such situations. “I’m really not sure how you can prepare for the devastation we saw,” Dana says.
Brian FitzGerald, LAT, ATC, Athletic Trainer Coordinator for the Boston Marathon, agrees. “I think any training would entail awareness more than anything medical,” he says. “One good thing we have nowadays is more former military doctors and nurses who have been in war situations volunteering at these events. We had that at the marathon finish line and it was really an asset in treating the severely injured.