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Ocular Blast Injuries in Mass-Casualty Incidents
Ocular Blast Injuries in Mass-Casualty Incidents The Marathon Bombing in Boston, Massachusetts, and the Fertilizer Plant Explosion in West, Texas Yoshihiro Yonekawa, MD,1,2,3,4,5 Henry D. Hacker, MD,6 Roy E. Lehman, MD,6 Casey J. Beal, MD,7 Peter B. Veldman, MD,1,4,5 Neil M. Vyas, MD,8 Ankoor S. Shah, MD, PhD,1,3,4,5 David Wu, MD, PhD,1,4,5 Dean Eliott, MD,1,4,5 Matthew F. Gardiner, MD,1,5 Mark C. Kuperwaser, MD,2 Robert H. Rosa, Jr., MD,6 Jean E. Ramsey, MD, MPH,8 Joan W. Miller, MD,1,4,5 Robert A. Mazzoli, MD,9,10 Mary G. Lawrence, MD,10 Jorge G. Arroyo, MD, MPH2 Purpose: To report the ocular injuries sustained by survivors of the April 15, 2013, Boston Marathon bombing and the April 17, 2013, fertilizer plant explosion in West, Texas. Design: Multicenter, cross-sectional, retrospective, comparative case series. Participants: Seventy-two eyes of 36 patients treated at 12 institutions were included in the study. Methods: Ocular and systemic trauma data were collected from medical records. Main Outcome Measures: Types and severity of ocular and systemic trauma and associations with mechanisms of injury. Results: In the Boston cohort, 164 of 264 casualties were transported to level 1 trauma centers, and 22 (13.4%) required ophthalmology consultations. In the West cohort, 218 of 263 total casualties were transported to participating centers, of which 14 (6.4%) required ophthalmology consultations. Boston had significantly shorter mean distances to treating facilities (1.6 miles vs. 53.6 miles; P ¼ 0.004). Overall, rigid eye shields were more likely not to have been provided than to have been provided on the scene (P<0.001). Isolated upper body and facial wounds were more common in West largely because of shattered windows (75.0% vs. 13.6%; P ¼ 0.001), resulting in more open-globe injuries (42.9% vs. 4.5%; P ¼ 0.008). Patients in Boston sustained more lower extremity injuries because of the ground-level bomb. Overall, 27.8% of consultations were called from emergency rooms, whereas the rest occurred afterward. Challenges in logistics and communications were identified. Conclusions: Ocular injuries are common and potentially blinding in mass-casualty incidents. Systemic and ocular polytrauma is the rule in terrorism, whereas isolated ocular injuries are more common in other calamities. Key lessons learned included educating the public to stay away from windows during disasters, promoting use of rigid eye shields by first responders, the importance of reliable communications, deepening the ophthalmology call algorithm, the significance of visual incapacitation resulting from loss of spectacles, improving the rate of early detection of ocular injuries in emergency departments, and integrating ophthalmology services into trauma teams as well as maintaining a voice in hospital-wide and community-based disaster planning. Ophthalmology 2014;:1e7 ª 2014 by the American Academy of Ophthalmology. Supplemental material is available at www.aaojournal.org.
On April 15, 2013, 2 improvised explosive devices (IEDs) were detonated 13 seconds apart at 2:49 PM near the Boylston Street finish line of the 117th Boston Marathon.1 Improvised explosive devices are homemade bombs created and detonated outside of conventional military use, commonly used in terrorist attacks and guerrilla warfare. Masscasualty incidents caused by IEDs are rare in the United States civilian setting. Two hundred sixty-four runners and spectators sustained injuries during the Boston bombing, and 3 died at the scene.2 The marathon was halted, medical tents were converted to mass-casualty triage units, and emergency medical services (EMS) transported the victims to nearby adult and pediatric trauma centers. 2014 by the American Academy of Ophthalmology Published by Elsevier Inc.
Two days later, on April 17 at 7:50 PM, an ammonium nitrate explosion at a fertilizer plant in West, Texas, injured 263 and killed 15 people.3 A fire preceded the explosion, which resulted in: (1) the most severe injuries occurring in the first responders who were attending the fire, resulting in incapacitation of the primary EMS teams; and (2) a preponderance of glass shard injuries to locals who were observing the fire from behind windows at the time of the explosion. Neighboring emergency services were mobilized and transported the victims to hospitals, but the closest healthcare facility was 25 miles away. The 2 mass-casualty tragedies occurred 52 hours apart and resulted in similar numbers of injuries, but with ISSN 0161-6420/14/$ - see front matter http://dx.doi.org/10.1016/j.ophtha.2014.04.004
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Ophthalmology Volume -, Number -, Month 2014 different mechanisms, geographic settings, and local medical response networks. The Boston Marathon bombing was an intentional, planned, and relatively low-energy explosion that took place in a densely populated urban center, but with numerous level 1 trauma centers within a 2-mile radius. The West incident was a high-energy, accidental open-field explosion in a relatively rural setting. Both blasts caused severe ocular injuries and provide valuable lessons for both ophthalmic and trauma communities in disaster readiness and response planning. As the ophthalmic consultants for the 2 tragic incidents, we report and discuss the ocular injuries sustained by the survivors and the insight gained by ophthalmologists involved in these events.
Methods This study was a multicenter, cross-sectional, retrospective, comparative case series of victims of the Boston Marathon bombing on April 15, 2013, and the West fertilizer plant explosion on April 17, 2013. For the Boston cohort, patients were identified from inpatient or emergency department consultation records at the Beth Israel Deaconess Medical Center, Boston Children’s Hospital, Boston Medical Center, Brigham and Women’s Hospital, Massachusetts General Hospital, and Massachusetts Eye and Ear Infirmary. Tufts Medical Center is not included in the study because ophthalmology consultations were not required, but the number of patients transported to Tufts is included in the denominator of total casualties. For the West cohort, patients were identified from consultation and billing records from Children’s Medical Center of Dallas, Hillcrest Baptist Medical Center, McLane Children’s Hospital, Parkland Hospital, Providence Health Center, and Scott & White Memorial Hospital. Excluded were ophthalmology consultations that occurred during the bombing or explosion for patients unrelated directly to the events. Also excluded were ocular injuries seen only by emergency department personnel without ophthalmology consultations. Distances between incident sites and hospitals were determined using Google Maps (www.maps.google. com; retrieved January 21, 2014). Data collection of demographics was kept to a minimum to assure the confidentiality of patient identification (for example, patients were reported as adult or pediatric with no specified age, gender, or ethnicity, and systemic injuries were recorded intentionally without laterality). Presenting visual acuity, provision of rigid eye shields, ocular injuries, treatment provided, and associated systemic injuries were noted. For the Boston cohort, we also noted whether the patients were runners or spectators, and for the West cohort, whether the patients were outdoors or indoors at the time of injury. Categorical variables were analyzed using the Fisher exact test, and the ManneWhitney U test was used to compare nonparametric continuous variables. The binomial test was used to test proportions. Statistical tests were 2-tailed and significance was defined as P<0.05. Statistical analysis was performed using Stata software version 9.0 (StataCorp, LP, College Station, TX). The institutional review boards of each institution approved the study, except for Providence Hospital, which opted to approve the study as part of a quality improvement initiative. This study complied with the Health Insurance Portability and Accountability Act of 1996 and conformed to the tenets of the Declaration of Helsinki.
Results Boston Marathon Bombing The distances from the first IED detonation site to the respective institutions are shown in Table 1. The 2 IEDs injured 264 people,2
2
Table 1. Distance from Mass Casualty Site to Treating Facilities Boston Marathon Bombing
Miles
Massachusetts Eye and 1.3 Ear Boston Medical Center 1.3 Massachusetts General 1.4 Hospital Beth Israel Medical 1.8 Center Boston Children’s 1.8 Hospital Brigham and Women’s 1.9 Hospital Mean (SD)* 1.6 (0.3)
West Fertilizer Plant Explosion Hillcrest Baptist Medical Center Providence Health Center Scott & White Memorial Hospital McLane Children’s Hospital Children’s Medical Center of Dallas Parkland Hospital Mean (SD)*
Miles 24.6 26.2 55.9 57.5 78.0 79.6 53.6 (24.0)
SD ¼ standard deviation. *P ¼ 0.004.
with 164 transported to surrounding level 1 trauma centers.1,2 Three victims did not survive the blasts and were pronounced dead on the scene.2 All patients transported to trauma centers survived, including 19 who were critically injured.4,5 Twenty-two patients (13.4%) required ophthalmology consultations that were requested from emergency rooms, during trauma or orthopaedic surgeries, or after surgery in intensive care units or inpatient floors. Twenty-one patients (95.5%) were spectators and 1 was a runner. No patients were provided with rigid eye shields at the point of injury. Fourteen (63.6%) consultations were requested from the operating room or intensive care units, during or immediately after lifesustaining interventions, whereas only 3 (13.6%) were requested from the emergency room (Table 2). Periocular injuries were seen in 19 patients (86.4%), conjunctival or corneal injuries were seen in 13 patients (59.1%), posterior segment injuries were seen in 3 patients (13.6%), and an open-globe injury was seen in 1 patient (4.5%; Fig 1, available at www.aaojournal.org). Lodged ocular or intracranial foreign bodies were found in 6 patients (27.3%). All ocular and systemic foreign bodies were shrapnel, such as BB pellets and nails. Of 20 patients with ocular injuries, 19 (95.0%) had bilateral injuries and 12 (60.0%) had ocular polytrauma (multiple ocular injuries). One hundred percent of patients had concomitant systemic injuries. Of note, 18 patients (81.8%) had lower limb injuries, of which 16 patients (72.7%) required surgical interventions. In comparison, head and neck or upper extremity injuries were found in 13 patients (59.1%), of which only 3 such cases occurred in isolation without lower extremity injuries. Burns involving the periocular region were found in 17 patients (77.3%), and tympanic membrane perforations were diagnosed in 11 patients (50.0%) during this acute setting.
West Fertilizer Plant Explosion The distances from the fertilizer plant to the respective treating institutions are listed in Table 1. A total of 263 injured patients were treated at local and regional hospitals; 45 were seen at Hill Regional and John Peter Smith Hospitals, which did not take part in the current study. There were 15 reported deaths.5 Of the 218 patients from the participating institutions, 14 (6.4%) required ophthalmology consultations and are summarized in Table 3. There were 17 other patients with presumed ocular injuries triaged and treated by emergency departments and coded as superficial corneal injuries who were excluded from our analysis. The ocular injury rate increased to 14.2% if these patients were included.
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Boston Marathon Bombing and Texas Explosion
Table 2. Ocular Injuries in the Boston Marathon Bombing Visual Acuity (Right Eye; Left Eye)
Patient No.
Adult or Pediatric?
Consultation Location
Fox Shield
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Adult Adult Adult Adult Adult Adult Adult Adult Adult Adult Adult Adult Adult Adult Adult Adult Adult
Floor ER OR OR OR OR OR ICU OR ICU ER ER Floor ICU Floor Floor ICU
No No No No No No No No No No No No No No No No No
20/20; 20/25 LP; 20/25 d d d d HM; 20/20 d 20/60; 20/40 20/20; 20/20 20/20; 20/20 20/20; 20/20 20/20; 20/20 20/30; 20/30 20/20; 20/20 20/20; 20/20 d
18 19 20 21
Pediatric Pediatric Pediatric Pediatric
ICU ICU ICU ICU
No No No No
20/25; 20/25 F&F d d
22
Pediatric
Floor
No
20/25; 20/30
Ocular Injuries
Systemic Injuries
SL both eyes, SCH/K abrasion left eye IOFB (z II)/VH/total RD right eye SL/chemosis both eyes SL/chemosis both eyes SL/chemosis both eyes SL/chemosis both eyes Orbital roof defect/sclopetaria/RD right eye SL/chemosis both eyes SL both eyes, conj lac/K lac/K FB right eye Lid erythema both eyes Normal exam both eyes SL both eyes SL both eyes, lid lac right eye Normal exam both eyes SL both eyes, subconj FB left eye Lid abrasions both eyes, VH right eye Lid abrasions/SL/chemosis both eyes, K abrasion right eye SL/PEE both eyes SL both eyes Lid edema/SL/chemosis/PEE both eyes SL both eyes, conj FB/chemosis/PEE both eyes SL/conj gunpower/SCH/K FB both eyes
Head/neck FB LE shrapnel UE FB, LE amp, compartment syndrome UE/LE open fx* TMP, LE open fx LE amp/open fx Intracranial FB/heme, LE open fx UE shrapnel, LE open fx TMP, LE open wounds* TMP, UE/LE FB TMP, LE open wounds TMP, UE/LE FB Facial FB, TMP, LE open wounds TMP, LE open wounds, sepsis Head wounds Abdominal FB TMP, UE wound, LE amp Pulmonary contusions, LE open wounds Open head wounds, ICH, TMP, LE FB TMP, abdominal burns, LE open wounds Ear lac, UE burns, diffuse FB, LE amp TMP, facial/UE FB
amp ¼ amputation; conj ¼ conjunctiva; ER ¼ emergency room; F&F ¼ fixes and follows; FB ¼ foreign body (all shrapnel); fx ¼ fracture; heme ¼ hemorrhage; HM ¼ hand movements; ICH ¼ intracranial hemorrhage; ICU ¼ intensive care unit; IOFB ¼ intraocular foreign body; K ¼ cornea; lac ¼ laceration; LE ¼ lower extremity; LP ¼ light perception; OR ¼ operating room; PEE ¼ punctate epithelial erosions; RD ¼ retinal detachment; SCH ¼ subconjunctival hemorrhage; SL ¼ singed lashes (all associated with facial burns); subconj ¼ subconjunctival; TMP ¼ tympanic membrane perforation; UE ¼ upper extremity; VH ¼ vitreous hemorrhage; z ¼ zone; d ¼ not available. *All open fractures and open wounds were associated with shrapnel.
Seven (50.0%) consultations were requested from emergency rooms. Seven (58.3%) of 12 patients with available data were inside at the time of the explosion. All of these patients sustained injuries from window glass shards and accounted for 5 (83.3%) of 6 patients with open-globe injuries. Rigid eye shields were provided for only 1 patient with available data (rigid eye shields more often were not provided in either cohort, than were provided [P<0.001]). Periocular injuries were seen in 9 (64.3%) of 14 patients, conjunctival or corneal injuries were seen in 7 (50.0%) of 14 patients, posterior segment injuries were seen in 5 (35.7%) of 14 patients, and open-globe injuries were seen in 6 (42.9%) of 14 patients (compared with 4.5% in the Boston cohort; P ¼ 0.008; Fig 1; available at www.aaojournal.org). Lodged ocular or periocular foreign bodies were found in 5 patients (35.7%). Bilateral injuries were seen in 8 patients (57.1%), and 8 patients (57.1%) had ocular polytrauma. Two patients had isolated ocular injuries, whereas the remaining 12 patients (85.7%) had nonocular injuries. Of nonocular injuries, lacerations or embedded foreign bodies were seen in 9 patients (64.3%), all of which were glass. Injuries limited to the head, neck, upper extremities, or abdomen without involvement of lower extremities were seen in 9 (75%) of 12 patients with nonocular injuries (compared with 13.6% in the Boston cohort; P ¼ 0.001). There were no cases of traumatic amputations or open fractures in the West ocular injury cohort.
Ophthalmic Operative Treatment In the Boston cohort, patient 2 underwent open-globe repair with pars plana vitrectomy (PPV), endoscopic removal of a large
intraocular BB pellet, and retinal detachment repair. Patient 7 underwent a negative globe exploration and subsequently 2 pars plana vitrectomies for repair of retinal detachment and proliferative vitreoretinopathy associated with sclopetaria (this patient is also part of a case series of sclopetaria-associated retinal detachments6). In the West cohort, patients 29, 30, 33, 34, 35, and 36 underwent repair of open-globe injury injuries, of which patients 33, 34 and 36 also had intraocular foreign bodies (all glass shards).
Discussion Ocular blast injuries are well documented from military experiences,7e10 but mass-casualty blasts are rare in the civilian setting in the United States. Victims of blast injuries often sustain multisystem polytrauma.11 Explosions result in instantaneous rise in air pressure surrounding the blast epicenter, causing primary blast injuries from the baric overpressure.12 Secondary blast injuries are caused by shrapnel and debris carried by the blast wind, which often dictates the types of injuries that are sustained.13 Tertiary injuries are those caused by being displaced by the blast wind, such as concussions and orthopedic injuries from hitting hard surfaces. Quaternary injuries are flash burns caused by heat produced by the explosion, and quinary effects are inhalation of toxins and components of the blast cloud (vaporized explosive residue, sand, dirt) that may have lingering effects. The most severe ocular
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Ophthalmology Volume -, Number -, Month 2014 Table 3. Ocular Injuries in the West Fertilizer Plant Explosion Patient No.
Adult or Pediatric?
23 24 25 26 27 28 29
Visual Acuity (Right Eye; Left Eye)
Location
Consultation Location
Fox Shield
Adult Pediatric Adult Adult Adult Adult Adult
Outside d Inside Outside d Outside Inside
Floor ER ER ER ER Floor ER
No No No No No d d
30
Adult
Outside
Floor
d
31 32
Adult Adult
Outside Inside
Floor Floor
No No
d 20/50; 20/100
33
Pediatric
Inside
OR
Yes
d
34
Pediatric
Inside
OR
35
Adult
Inside
ER
No
HM; CF
36
Adult
Inside
ER
No
d
d
20/20; 20/20 d d d d d 20/30; NLP d
d
Ocular Injuries K abrasion right eye Lid lacs right eye Brow lac left eye Conj dust/PEE left eye K abrasions both eyes Lid lacs both eyes Commotio retinae right eye, OGI left eye (z III) Periorbital FB/K abrasion right eye, OGI left eye (z I/II/III) Orbital floor fx left eye Brow lac/intraorbital radiopaque FB left eye Lid lacs/FBs both eyes, IOFB right eye (z II), OGI left eye (z I) Brow lacs both eyes, K abrasion left eye, IOFB left eye (z II) Lid lacs/OGI right eye (z I/II), lid lac/SCH/VH/OGI left eye (z I/II) Lid lacs/SCH/OGI right eye (z I) Lid lac/SCH/IOFB left eye (z I/II/III)
Systemic Injuries Facial/UE/LE lacs None UE abrasions and ecchymoses None LE FB Cervical fx, lung contusion Face/chest/abdominal lacs UE fx, neck/UE burns Facial/chest/UE/LE lacs, resp failure Facial/neck lacs Facial lacs, UE FB (glass)/lacs Open cranium fx, esophageal FB, facial/UE/LE lacs Facial lacs Facial lacs
CF ¼ counting fingers; conj ¼ conjunctiva; ER ¼ emergency room; FB ¼ foreign body; fx ¼ fracture; K ¼ cornea; HM ¼ hand movements; IOFB ¼ intraocular foreign body; lac(s) ¼ laceration(s); LE ¼ lower extremity; NLP ¼ no light perception; OGI ¼ open globe injury; OR ¼ operating room; PEE ¼ punctate epithelial erosions; resp ¼ respiratory; SCH ¼ subconjunctival hemorrhage; UE ¼ upper extremity; z ¼ zone; d ¼ not available.
injuries in Boston and West were caused by secondary injuries: shrapnel in Boston and shattered glass in West. Ocular injuries are common in mass-casualty incidents.13,14 In the Boston bombing, 13% of patients transferred to level 1 trauma centers had ocular involvement suspicious enough to warrant ophthalmology consultations. In the West cohort, 14% had ocular injuries triaged by emergency departments, and 6% were seen by ophthalmology teams. In the April 19, 1995, bombing of the Federal Office Building in Oklahoma, 55 (8%) of 684 injured survivors sustained ocular injuries.14 During the World Trade Center tragedy on September 11, 2001, in New York City, most victims directly affected by the collapsed buildings did not survive, but ocular injuries were the second most common injuries for which disaster relief personnel were treated (inhalation injuries were the most common). Keratitis secondary to smoke and chemicals, corneal abrasions, or foreign bodies were the leading causes.15,16
Point of Injury In Boston, BB pellets, nails, and other shrapnel were implanted in a pressure cooker IED. The bomb was placed at ground level, resulting in many lower extremity injuries. An open-globe injury was seen in 1 patient, but more would have occurred if the bombs had been situated in an elevated location. In West, the prominent secondary injuries were from window glass: Many victims were standing by their windows to observe the fertilizer plant fire when it abruptly exploded. Facial and upper body injuries were more common, which translated into higher rates of open-globe
4
injuries. Communities should be made aware that facing windows during disasters is potentially vision and life threatening. This was also seen in the Oklahoma bombing: A significant number the injuries were the result of shattered glass, and there was a high rate of open-globe injuries (22%): 60% of these patients were facing a window during the explosion. Historically, the Halifax Disaster of 1917 also had a similar mechanism: After a collision in the harbor, a munitions ship caught fire and while residents looked out their windows, the ship exploded and caused significant ocular injuries from shattered glass, resulting in 249 enucleations.17 Quaternary (thermal) injuries were more common in Boston. Injury patterns depend on the energy of the explosion and the distance from the epicenter; the explosion in Boston was smaller, but the bomb was detonated in the middle of a crowd, compared with the explosion in West that was larger, but approximately 150 m away from the closest residential buildings, where most victims were located. West experienced an open-field blast where relatively predictable Friedlander physics apply more than the confined urban canyon of Boston, where blast waves also reflect off surfaces causing phase adding and subtracting.
Prehospital Care Many factors contributed to the efficient and effective care provided in Boston: predeployed police and EMS personnel for a major event that decreased response times, cleared city streets for the marathon, bystanders who acted as first responders and assisted medical personnel effectively, 6 level 1 trauma centers within 2 miles of the bombing site, and an
Yonekawa et al
Boston Marathon Bombing and Texas Explosion
explosion that took place during hospital changes of shifts, resulting in personnel from 2 shifts being present and thus doubling the available medical personnel.5 Although there are no substantiating data, sunglasses worn by runners theoretically are protective against ocular injuries also. The West victims received prompt and expert care, but faced different challenges in the relatively rural setting. The explosion incapacitated the initial responders, which required the robust surrounding regional EMS services to be mobilized. The closest medical facility was 25 miles away, and some casualties required helicopter transportation for urgent evacuation. Some patients self-transported or were sent to the nearest medical care facility, which might not have had the proper capabilities for required treatment. For example, patient 33 had open-globe injuries that were repaired at the third hospital to which he or she was transferred. The use of rigid eye shields was alarmingly low in both cities. First responders should be aware of potential ocular injury scenarios in polytrauma patients, should be provided with readily available rigid eye shields, and should be mindful to use them in all suspected ocular trauma patients. The military has instituted this in a clinical practice guideline with better success, and this should be applied in the civilian sector as well (Mazzoli RA, et al. Use of rigid eye shields (Fox shields) at the point of injury in Afghanistan. Poster presented at: Military Health System Research Symposium, August 12e15, 2013; Fort Lauderdale).
Trauma Teams Ocular injuries are assessed during the advanced trauma life support secondary survey, which is usually performed in the emergency room. In Boston, many casualties had lifethreatening injuries and secondary surveys took place in the operating room for a number of patients. Nevertheless, ophthalmology consultations were requested from the emergency departments for only 14% of patients in Boston and for 50% of patients in West; the remaining 86% and 50% of consultations, respectively, occurred afterward. Of the 7 patients with open-globe injuries in both cohorts, 4 consultations were requested from emergency rooms, whereas 3 consultations occurred afterward, in the operating room or inpatient units. Eye injuries are part of the blast polytrauma complex, but may escape early detection compared with other life-threatening nonocular injuries. Life support obviously is the primary goal of trauma care, but ocular issues should be considered in overall preoperative planning. For example, some potential consequences include additional iatrogenic ocular trauma resulting from unawareness of an open globe during patient manipulation and transportation, inadvertent taping of an eye with an open-globe injury, and forgoing orbital cuts in the trauma pan-computed tomography scan. Time also is required to arrange transportable microscopes or transfer to an ophthalmic operating room.
Coordination and Communication We found that reliable communication methods are essential for coordinating care. Cellular networks were overwhelmed during the first few hours of the Boston explosion, such that
communication between our team members had to be made on landlines and via paging systems. Disaster-readiness organizations indicate that text messaging is also an effective means of communication when network traffic is high.18 Manpower can become an issue, especially where 1 ophthalmologist may be on call for multiple facilities or extended geographic regions. In Boston, ophthalmology residents across several institutions were mobilized strategically while coordinating with faculty to cover facilities with the most need. This went beyond the usual call algorithm. The emergency patients may have disrupted normal clinic and operating room flow, but the bombing took place on a holiday when there were no scheduled clinics or routine surgeries. In West, the operative cases also were divided among facilities, albeit across further distances. We recommend that a 2- or 3-tiered disaster plan be put in place for all ophthalmic practices to accommodate high-volume mass casualty incidents. The flow of care for polytrauma patients may be disrupted if there are not enough ophthalmologists integrated into the trauma team. Access to subspecialty ophthalmic expertise also is essential. Similar to the systemic polytrauma seen in patients with blast injuries, the eyes of such patients often also have ocular polytrauma. Each type of injury requires subspecialized attention. Of note, vitreoretinal surgeries were required in both Boston and West. We recommend that ophthalmic communities be aware of the inventory of specialized equipment in their home institutions, such as endoscopes for bypassing media opacities19 and foreign body forceps and magnets for intraocular foreign body removal.20 If immediate access to subspecialty services is not available, the military experience has shown that socalled damage control surgery is an effective approach, in which open globes are closed, stabilized, and prepared for transfer to collaborators at tertiary care centers.9,10
Preparations for the Future Basic provisions that eye centers take for granted may not be available during emergencies. Computed tomography imaging is routine for head and neck trauma, but ocular injuries must be identified during the secondary survey to assure that orbital cuts are included in the scans. Patients with polytrauma invariably are situated in general surgery operating rooms, and portable microscopes ideally are transported into the rooms. Patients also are on general surgery beds with limited space around the head for the ophthalmologist’s leg positioning. In such cases, patients either can be positioned as superiorly as possible or can be positioned backward with the head at the foot of the bed, where there is more leg space. The ophthalmologist also must be prepared to work with general surgery technicians and nurses who may have limited experience with ophthalmology cases. In Texas, eye-care providers have anecdotally indicated that many of their patients became visually incapacitated because of the loss of their spectacles from the impact of the blast. Survivors of the Tohoku earthquake in Japan21 and Hurricane Katrina22 also had similar experiences.
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Ophthalmology Volume -, Number -, Month 2014 Navigating a disaster-struck environment while visually impaired increases the risk of more serious but preventable physical injuries, particularly at night or if power and infrastructure are disrupted. We recommend that stocks of spectacles be available as early as possible during disaster relief efforts. In many cities, preparation for mass-causality incidents became a priority after 9/11. Because of this response, the Boston trauma centers were well prepared.2 West also had similar discussions after the fertilizer plant explosion.3 However, the number of ocular casualties is not considered or planned for routinely. Therefore, ophthalmologists must remain in the discussions and medical response planning moving forward, because ocular injuries are common and potentially blinding for survivors of civilian blast injuries. The limitations of this report include inherent biases in its retrospective cross-sectional design. The numbers of mild ocular injuries are unknown because of triaging of patients with less-severe injuries to community facilities and selftreatment. The data gathered is skewed toward inpatients with severe systemic and polytrauma injuries who had ocular manifestations beyond the capacity of primary teams. Data collection purposely was limited after discussion with institutional review boards to be more conservative than usual in protecting patient anonymity in light of high media coverage, so we do not present age, gender, ethnicity, or laterality of systemic injuries. The cross-sectional design did not allow presentation of follow-up data, which is important in these patients whose traumatized eyes are susceptible to both acute23 and chronic7 sequelae. Of note, seemingly benign ocular injuries such as corneal abrasions may be a bellwether of other occult ocular trauma with significant long-term implications, such as angle recession. Additional natural disasters, manmade calamities, and intentional and unintentional mass-casualty incidents undoubtedly will occur in the future. Many survivors of multisystem trauma will sustain blast-related ocular injuries, and ophthalmologists must be seamlessly integrated into regional trauma teams and their preparations.
References 1. Kotz D. Injury toll from Marathon bombs reduced to 264. Boston Globe. April 24, 2013. Available at: http://www. bostonglobe.com/lifestyle/health-wellness/2013/04/23/numberinjured-marathon-bombing-revised-downward/NRpaz5mmvGquP7KMA6XsIK/story.html. Accessed April 7, 2014. 2. FEMA. Lessons Learned Information Sharing. Boston Marathon bombings: hospital readiness and response. Available at: https://www.llis.dhs.gov/sites/default/files/Boston%20Marathon %20Bombings%20Hospital%20Readiness%20and%20Response. pdf. Accessed January 24, 2014. 3. Zuzek C. The night West blew up. Tex Med 2013;109:41–5. 4. Gebhardt MC. Guest editorial: Patriots’ Day at the Boston Marathon. Clin Orthop Relat Res 2013;471:2045–6. 5. United States Senate, Committee on Homeland Security and Government Affairs. One Hundred Thirteenth Congress, First Session. Lessons learned from the Boston Marathon
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bombings: preparing for and responding to the attack. July 10, 2013. Available at: https://www.hsdl.org/?view&did¼740471. Accessed January 24, 2014. Papakostas TD, Yonekawa Y, Wu D, et al. Retinal detachment associated with traumatic chorioretinal rupture (sclopetaria). Ophthalmic Surg Lasers Imaging Retina. In press. Cockerham GC, Rice TA, Hewes EH, et al. Closed-eye ocular injuries in the Iraq and Afghanistan wars. N Engl J Med 2011;364:2172–3. Thach AB, Johnson AJ, Carroll RB, et al. Severe eye injuries in the war in Iraq, 2003e2005. Ophthalmology 2008;115: 377–82. Colyer MH, Chun DW, Bower KS, et al. Perforating globe injuries during operation Iraqi Freedom. Ophthalmology 2008;115:2087–93. Weichel ED, Colyer MH, Ludlow SE, et al. Combat ocular trauma visual outcomes during operations Iraqi and Enduring Freedom. Ophthalmology 2008;115:2235–45. Thach AB. Eye injuries associated with terrorist bombings. In: Thach AB, ed. Ophthalmic Care of the Combat Casualty. Washington, DC: Office of the Surgeon General at TMM Publ.: 2003:421–9. Lounsbury DE, ed-in-chief. Textbooks of Military Medicine. Available at: http://www.cs.amedd.army.mil/borden/ Portlet.aspx?ID¼4503a58c-5b6c-43f9-afef-0adb36fcc635. Accessed April 7, 2014. Wolf SJ, Bebarta VS, Bonnett CJ, et al. Blast injuries. Lancet 2009;374:405–15. Morley MG, Nguyen JK, Heier JS, et al. Blast eye injuries: a review for first responders. Disaster Med Public Health Prep 2010;4:154–60. Mines M, Thach A, Mallonee S, et al. Ocular injuries sustained by survivors of the Oklahoma City bombing. Ophthalmology 2000;107:837–43. Injuries and illnesses among New York City Fire Department rescue workers after responding to the World Trade Center attacks. JAMA 2002;288:1581–4. Reprinted from MMWR Morb Mortal Wkly Rep 2002;51(Spec Issue):1e5. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm51SPa1. htm. Accessed April 7, 2014. Kurup SK, Que ET, Kauffmann Jokl DH. The World Trade Center disaster: a brief on-site report from Ground Zero. Arch Ophthalmol 2002;120:395–6. McAlister CN, Murray TJ, Lakosha H, Maxner CE. The Halifax disaster (1917): eye injuries and their care. Br J Ophthalmol 2007;91:832–5. Federal Emergency Management Agency. Ready. Get tech ready. Available at: http://www.ready.gov/get-tech-ready. Accessed February 15, 2014. Yonekawa Y, Papakostas TD, Marra KV, Arroyo JG. Endoscopic pars plana vitrectomy for the management of severe ocular trauma. Int Ophthalmol Clin 2013;53:139–48. Soheilian M, Abolhasani A, Ahmadieh H, et al. Management of magnetic intravitreal foreign bodies in 71 eyes. Ophthalmic Surg Lasers Imaging 2004;35:372–8. Tanaka Y, Yamato A, Yaji N, Yamato M. A simple stock of optical glasses for a catastrophic disaster: eyewear donations after the 2011 Pacific Coast Tohoku earthquake. Tohoku J Exp Med 2012;227:93–5. Ridenour ML, Cummings KJ, Sinclair JR, Bixler D. Displacement of the underserved: medical needs of Hurricane Katrina evacuees in West Virginia. J Health Care Poor Underserved 2007;18:369–81. Stryjewski TP, Andreoli CM, Eliott D. Retinal detachment after open globe injury. Ophthalmology 2014;121:327–33.
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Footnotes and Financial Disclosures Originally received: February 24, 2014. Final revision: March 31, 2014. Accepted: April 8, 2014. Available online: ---.
8
Department of Ophthalmology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts.
9
Manuscript no. 2014-295.
1 Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts. 2 Department of Ophthalmology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts. 3 Department of Ophthalmology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts. 4
Department of Ophthalmology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts.
5
Department of Ophthalmology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
6
Department of Ophthalmology, Scott & White Eye Institute, Texas A&M Health Science Center College of Medicine, Temple, Texas.
7
Department of Ophthalmology, University of Texas Southwestern Medical Center, Dallas, Texas.
Department of Defense and Veterans Administration Vision Center of Excellence, Bethesda, Maryland.
10
Department of Ophthalmology, Uniformed Services University of the Health Sciences, Bethesda, Maryland. Presented at: American Academy of Ophthalmology Annual Meeting, November 2013, New Orleans, Louisiana. Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article. Abbreviations and Acronyms: EMS ¼ emergency medical services; IED ¼ improvised explosive device. Correspondence: Jorge G. Arroyo, MD, MPH, Department of Ophthalmology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Shapiro Fifth Floor, Boston, MA 02215. E-mail: jarroyo@bidmc. harvard.edu.
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Ophthalmology Volume -, Number -, Month 2014
Figure 1. Pie charts showing types of ocular injuries sustained in (A) the Boston Marathon bombing and the (B) West fertilizer plant explosion. Patients with multiple injuries are listed for each injury type.
7.e1
On April 15, 2013, 2 improvised explosive devices (IEDs) were detonated 13 seconds apart at 2:49 PM near the Boylston Street finish line of the 117th Boston Marathon.1 Improvised explosive devices are homemade bombs created and detonated outside of conventional military use, commonly used in terrorist attacks and guerrilla warfare. Masscasualty incidents caused by IEDs are rare in the United States civilian setting. Two hundred sixty-four runners and spectators sustained injuries during the Boston bombing, and 3 died at the scene.2 The marathon was halted, medical tents were converted to mass-casualty triage units, and emergency medical services (EMS) transported the victims to nearby adult and pediatric trauma centers. 2014 by the American Academy of Ophthalmology Published by Elsevier Inc.
Two days later, on April 17 at 7:50 PM, an ammonium nitrate explosion at a fertilizer plant in West, Texas, injured 263 and killed 15 people.3 A fire preceded the explosion, which resulted in: (1) the most severe injuries occurring in the first responders who were attending the fire, resulting in incapacitation of the primary EMS teams; and (2) a preponderance of glass shard injuries to locals who were observing the fire from behind windows at the time of the explosion. Neighboring emergency services were mobilized and transported the victims to hospitals, but the closest healthcare facility was 25 miles away. The 2 mass-casualty tragedies occurred 52 hours apart and resulted in similar numbers of injuries, but with ISSN 0161-6420/14/$ - see front matter http://dx.doi.org/10.1016/j.ophtha.2014.04.004
1
Ophthalmology Volume -, Number -, Month 2014 different mechanisms, geographic settings, and local medical response networks. The Boston Marathon bombing was an intentional, planned, and relatively low-energy explosion that took place in a densely populated urban center, but with numerous level 1 trauma centers within a 2-mile radius. The West incident was a high-energy, accidental open-field explosion in a relatively rural setting. Both blasts caused severe ocular injuries and provide valuable lessons for both ophthalmic and trauma communities in disaster readiness and response planning. As the ophthalmic consultants for the 2 tragic incidents, we report and discuss the ocular injuries sustained by the survivors and the insight gained by ophthalmologists involved in these events.
Methods This study was a multicenter, cross-sectional, retrospective, comparative case series of victims of the Boston Marathon bombing on April 15, 2013, and the West fertilizer plant explosion on April 17, 2013. For the Boston cohort, patients were identified from inpatient or emergency department consultation records at the Beth Israel Deaconess Medical Center, Boston Children’s Hospital, Boston Medical Center, Brigham and Women’s Hospital, Massachusetts General Hospital, and Massachusetts Eye and Ear Infirmary. Tufts Medical Center is not included in the study because ophthalmology consultations were not required, but the number of patients transported to Tufts is included in the denominator of total casualties. For the West cohort, patients were identified from consultation and billing records from Children’s Medical Center of Dallas, Hillcrest Baptist Medical Center, McLane Children’s Hospital, Parkland Hospital, Providence Health Center, and Scott & White Memorial Hospital. Excluded were ophthalmology consultations that occurred during the bombing or explosion for patients unrelated directly to the events. Also excluded were ocular injuries seen only by emergency department personnel without ophthalmology consultations. Distances between incident sites and hospitals were determined using Google Maps (www.maps.google. com; retrieved January 21, 2014). Data collection of demographics was kept to a minimum to assure the confidentiality of patient identification (for example, patients were reported as adult or pediatric with no specified age, gender, or ethnicity, and systemic injuries were recorded intentionally without laterality). Presenting visual acuity, provision of rigid eye shields, ocular injuries, treatment provided, and associated systemic injuries were noted. For the Boston cohort, we also noted whether the patients were runners or spectators, and for the West cohort, whether the patients were outdoors or indoors at the time of injury. Categorical variables were analyzed using the Fisher exact test, and the ManneWhitney U test was used to compare nonparametric continuous variables. The binomial test was used to test proportions. Statistical tests were 2-tailed and significance was defined as P<0.05. Statistical analysis was performed using Stata software version 9.0 (StataCorp, LP, College Station, TX). The institutional review boards of each institution approved the study, except for Providence Hospital, which opted to approve the study as part of a quality improvement initiative. This study complied with the Health Insurance Portability and Accountability Act of 1996 and conformed to the tenets of the Declaration of Helsinki.
Results Boston Marathon Bombing The distances from the first IED detonation site to the respective institutions are shown in Table 1. The 2 IEDs injured 264 people,2
2
Table 1. Distance from Mass Casualty Site to Treating Facilities Boston Marathon Bombing
Miles
Massachusetts Eye and 1.3 Ear Boston Medical Center 1.3 Massachusetts General 1.4 Hospital Beth Israel Medical 1.8 Center Boston Children’s 1.8 Hospital Brigham and Women’s 1.9 Hospital Mean (SD)* 1.6 (0.3)
West Fertilizer Plant Explosion Hillcrest Baptist Medical Center Providence Health Center Scott & White Memorial Hospital McLane Children’s Hospital Children’s Medical Center of Dallas Parkland Hospital Mean (SD)*
Miles 24.6 26.2 55.9 57.5 78.0 79.6 53.6 (24.0)
SD ¼ standard deviation. *P ¼ 0.004.
with 164 transported to surrounding level 1 trauma centers.1,2 Three victims did not survive the blasts and were pronounced dead on the scene.2 All patients transported to trauma centers survived, including 19 who were critically injured.4,5 Twenty-two patients (13.4%) required ophthalmology consultations that were requested from emergency rooms, during trauma or orthopaedic surgeries, or after surgery in intensive care units or inpatient floors. Twenty-one patients (95.5%) were spectators and 1 was a runner. No patients were provided with rigid eye shields at the point of injury. Fourteen (63.6%) consultations were requested from the operating room or intensive care units, during or immediately after lifesustaining interventions, whereas only 3 (13.6%) were requested from the emergency room (Table 2). Periocular injuries were seen in 19 patients (86.4%), conjunctival or corneal injuries were seen in 13 patients (59.1%), posterior segment injuries were seen in 3 patients (13.6%), and an open-globe injury was seen in 1 patient (4.5%; Fig 1, available at www.aaojournal.org). Lodged ocular or intracranial foreign bodies were found in 6 patients (27.3%). All ocular and systemic foreign bodies were shrapnel, such as BB pellets and nails. Of 20 patients with ocular injuries, 19 (95.0%) had bilateral injuries and 12 (60.0%) had ocular polytrauma (multiple ocular injuries). One hundred percent of patients had concomitant systemic injuries. Of note, 18 patients (81.8%) had lower limb injuries, of which 16 patients (72.7%) required surgical interventions. In comparison, head and neck or upper extremity injuries were found in 13 patients (59.1%), of which only 3 such cases occurred in isolation without lower extremity injuries. Burns involving the periocular region were found in 17 patients (77.3%), and tympanic membrane perforations were diagnosed in 11 patients (50.0%) during this acute setting.
West Fertilizer Plant Explosion The distances from the fertilizer plant to the respective treating institutions are listed in Table 1. A total of 263 injured patients were treated at local and regional hospitals; 45 were seen at Hill Regional and John Peter Smith Hospitals, which did not take part in the current study. There were 15 reported deaths.5 Of the 218 patients from the participating institutions, 14 (6.4%) required ophthalmology consultations and are summarized in Table 3. There were 17 other patients with presumed ocular injuries triaged and treated by emergency departments and coded as superficial corneal injuries who were excluded from our analysis. The ocular injury rate increased to 14.2% if these patients were included.
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Table 2. Ocular Injuries in the Boston Marathon Bombing Visual Acuity (Right Eye; Left Eye)
Patient No.
Adult or Pediatric?
Consultation Location
Fox Shield
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Adult Adult Adult Adult Adult Adult Adult Adult Adult Adult Adult Adult Adult Adult Adult Adult Adult
Floor ER OR OR OR OR OR ICU OR ICU ER ER Floor ICU Floor Floor ICU
No No No No No No No No No No No No No No No No No
20/20; 20/25 LP; 20/25 d d d d HM; 20/20 d 20/60; 20/40 20/20; 20/20 20/20; 20/20 20/20; 20/20 20/20; 20/20 20/30; 20/30 20/20; 20/20 20/20; 20/20 d
18 19 20 21
Pediatric Pediatric Pediatric Pediatric
ICU ICU ICU ICU
No No No No
20/25; 20/25 F&F d d
22
Pediatric
Floor
No
20/25; 20/30
Ocular Injuries
Systemic Injuries
SL both eyes, SCH/K abrasion left eye IOFB (z II)/VH/total RD right eye SL/chemosis both eyes SL/chemosis both eyes SL/chemosis both eyes SL/chemosis both eyes Orbital roof defect/sclopetaria/RD right eye SL/chemosis both eyes SL both eyes, conj lac/K lac/K FB right eye Lid erythema both eyes Normal exam both eyes SL both eyes SL both eyes, lid lac right eye Normal exam both eyes SL both eyes, subconj FB left eye Lid abrasions both eyes, VH right eye Lid abrasions/SL/chemosis both eyes, K abrasion right eye SL/PEE both eyes SL both eyes Lid edema/SL/chemosis/PEE both eyes SL both eyes, conj FB/chemosis/PEE both eyes SL/conj gunpower/SCH/K FB both eyes
Head/neck FB LE shrapnel UE FB, LE amp, compartment syndrome UE/LE open fx* TMP, LE open fx LE amp/open fx Intracranial FB/heme, LE open fx UE shrapnel, LE open fx TMP, LE open wounds* TMP, UE/LE FB TMP, LE open wounds TMP, UE/LE FB Facial FB, TMP, LE open wounds TMP, LE open wounds, sepsis Head wounds Abdominal FB TMP, UE wound, LE amp Pulmonary contusions, LE open wounds Open head wounds, ICH, TMP, LE FB TMP, abdominal burns, LE open wounds Ear lac, UE burns, diffuse FB, LE amp TMP, facial/UE FB
amp ¼ amputation; conj ¼ conjunctiva; ER ¼ emergency room; F&F ¼ fixes and follows; FB ¼ foreign body (all shrapnel); fx ¼ fracture; heme ¼ hemorrhage; HM ¼ hand movements; ICH ¼ intracranial hemorrhage; ICU ¼ intensive care unit; IOFB ¼ intraocular foreign body; K ¼ cornea; lac ¼ laceration; LE ¼ lower extremity; LP ¼ light perception; OR ¼ operating room; PEE ¼ punctate epithelial erosions; RD ¼ retinal detachment; SCH ¼ subconjunctival hemorrhage; SL ¼ singed lashes (all associated with facial burns); subconj ¼ subconjunctival; TMP ¼ tympanic membrane perforation; UE ¼ upper extremity; VH ¼ vitreous hemorrhage; z ¼ zone; d ¼ not available. *All open fractures and open wounds were associated with shrapnel.
Seven (50.0%) consultations were requested from emergency rooms. Seven (58.3%) of 12 patients with available data were inside at the time of the explosion. All of these patients sustained injuries from window glass shards and accounted for 5 (83.3%) of 6 patients with open-globe injuries. Rigid eye shields were provided for only 1 patient with available data (rigid eye shields more often were not provided in either cohort, than were provided [P<0.001]). Periocular injuries were seen in 9 (64.3%) of 14 patients, conjunctival or corneal injuries were seen in 7 (50.0%) of 14 patients, posterior segment injuries were seen in 5 (35.7%) of 14 patients, and open-globe injuries were seen in 6 (42.9%) of 14 patients (compared with 4.5% in the Boston cohort; P ¼ 0.008; Fig 1; available at www.aaojournal.org). Lodged ocular or periocular foreign bodies were found in 5 patients (35.7%). Bilateral injuries were seen in 8 patients (57.1%), and 8 patients (57.1%) had ocular polytrauma. Two patients had isolated ocular injuries, whereas the remaining 12 patients (85.7%) had nonocular injuries. Of nonocular injuries, lacerations or embedded foreign bodies were seen in 9 patients (64.3%), all of which were glass. Injuries limited to the head, neck, upper extremities, or abdomen without involvement of lower extremities were seen in 9 (75%) of 12 patients with nonocular injuries (compared with 13.6% in the Boston cohort; P ¼ 0.001). There were no cases of traumatic amputations or open fractures in the West ocular injury cohort.
Ophthalmic Operative Treatment In the Boston cohort, patient 2 underwent open-globe repair with pars plana vitrectomy (PPV), endoscopic removal of a large
intraocular BB pellet, and retinal detachment repair. Patient 7 underwent a negative globe exploration and subsequently 2 pars plana vitrectomies for repair of retinal detachment and proliferative vitreoretinopathy associated with sclopetaria (this patient is also part of a case series of sclopetaria-associated retinal detachments6). In the West cohort, patients 29, 30, 33, 34, 35, and 36 underwent repair of open-globe injury injuries, of which patients 33, 34 and 36 also had intraocular foreign bodies (all glass shards).
Discussion Ocular blast injuries are well documented from military experiences,7e10 but mass-casualty blasts are rare in the civilian setting in the United States. Victims of blast injuries often sustain multisystem polytrauma.11 Explosions result in instantaneous rise in air pressure surrounding the blast epicenter, causing primary blast injuries from the baric overpressure.12 Secondary blast injuries are caused by shrapnel and debris carried by the blast wind, which often dictates the types of injuries that are sustained.13 Tertiary injuries are those caused by being displaced by the blast wind, such as concussions and orthopedic injuries from hitting hard surfaces. Quaternary injuries are flash burns caused by heat produced by the explosion, and quinary effects are inhalation of toxins and components of the blast cloud (vaporized explosive residue, sand, dirt) that may have lingering effects. The most severe ocular
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Ophthalmology Volume -, Number -, Month 2014 Table 3. Ocular Injuries in the West Fertilizer Plant Explosion Patient No.
Adult or Pediatric?
23 24 25 26 27 28 29
Visual Acuity (Right Eye; Left Eye)
Location
Consultation Location
Fox Shield
Adult Pediatric Adult Adult Adult Adult Adult
Outside d Inside Outside d Outside Inside
Floor ER ER ER ER Floor ER
No No No No No d d
30
Adult
Outside
Floor
d
31 32
Adult Adult
Outside Inside
Floor Floor
No No
d 20/50; 20/100
33
Pediatric
Inside
OR
Yes
d
34
Pediatric
Inside
OR
35
Adult
Inside
ER
No
HM; CF
36
Adult
Inside
ER
No
d
d
20/20; 20/20 d d d d d 20/30; NLP d
d
Ocular Injuries K abrasion right eye Lid lacs right eye Brow lac left eye Conj dust/PEE left eye K abrasions both eyes Lid lacs both eyes Commotio retinae right eye, OGI left eye (z III) Periorbital FB/K abrasion right eye, OGI left eye (z I/II/III) Orbital floor fx left eye Brow lac/intraorbital radiopaque FB left eye Lid lacs/FBs both eyes, IOFB right eye (z II), OGI left eye (z I) Brow lacs both eyes, K abrasion left eye, IOFB left eye (z II) Lid lacs/OGI right eye (z I/II), lid lac/SCH/VH/OGI left eye (z I/II) Lid lacs/SCH/OGI right eye (z I) Lid lac/SCH/IOFB left eye (z I/II/III)
Systemic Injuries Facial/UE/LE lacs None UE abrasions and ecchymoses None LE FB Cervical fx, lung contusion Face/chest/abdominal lacs UE fx, neck/UE burns Facial/chest/UE/LE lacs, resp failure Facial/neck lacs Facial lacs, UE FB (glass)/lacs Open cranium fx, esophageal FB, facial/UE/LE lacs Facial lacs Facial lacs
CF ¼ counting fingers; conj ¼ conjunctiva; ER ¼ emergency room; FB ¼ foreign body; fx ¼ fracture; K ¼ cornea; HM ¼ hand movements; IOFB ¼ intraocular foreign body; lac(s) ¼ laceration(s); LE ¼ lower extremity; NLP ¼ no light perception; OGI ¼ open globe injury; OR ¼ operating room; PEE ¼ punctate epithelial erosions; resp ¼ respiratory; SCH ¼ subconjunctival hemorrhage; UE ¼ upper extremity; z ¼ zone; d ¼ not available.
injuries in Boston and West were caused by secondary injuries: shrapnel in Boston and shattered glass in West. Ocular injuries are common in mass-casualty incidents.13,14 In the Boston bombing, 13% of patients transferred to level 1 trauma centers had ocular involvement suspicious enough to warrant ophthalmology consultations. In the West cohort, 14% had ocular injuries triaged by emergency departments, and 6% were seen by ophthalmology teams. In the April 19, 1995, bombing of the Federal Office Building in Oklahoma, 55 (8%) of 684 injured survivors sustained ocular injuries.14 During the World Trade Center tragedy on September 11, 2001, in New York City, most victims directly affected by the collapsed buildings did not survive, but ocular injuries were the second most common injuries for which disaster relief personnel were treated (inhalation injuries were the most common). Keratitis secondary to smoke and chemicals, corneal abrasions, or foreign bodies were the leading causes.15,16
Point of Injury In Boston, BB pellets, nails, and other shrapnel were implanted in a pressure cooker IED. The bomb was placed at ground level, resulting in many lower extremity injuries. An open-globe injury was seen in 1 patient, but more would have occurred if the bombs had been situated in an elevated location. In West, the prominent secondary injuries were from window glass: Many victims were standing by their windows to observe the fertilizer plant fire when it abruptly exploded. Facial and upper body injuries were more common, which translated into higher rates of open-globe
4
injuries. Communities should be made aware that facing windows during disasters is potentially vision and life threatening. This was also seen in the Oklahoma bombing: A significant number the injuries were the result of shattered glass, and there was a high rate of open-globe injuries (22%): 60% of these patients were facing a window during the explosion. Historically, the Halifax Disaster of 1917 also had a similar mechanism: After a collision in the harbor, a munitions ship caught fire and while residents looked out their windows, the ship exploded and caused significant ocular injuries from shattered glass, resulting in 249 enucleations.17 Quaternary (thermal) injuries were more common in Boston. Injury patterns depend on the energy of the explosion and the distance from the epicenter; the explosion in Boston was smaller, but the bomb was detonated in the middle of a crowd, compared with the explosion in West that was larger, but approximately 150 m away from the closest residential buildings, where most victims were located. West experienced an open-field blast where relatively predictable Friedlander physics apply more than the confined urban canyon of Boston, where blast waves also reflect off surfaces causing phase adding and subtracting.
Prehospital Care Many factors contributed to the efficient and effective care provided in Boston: predeployed police and EMS personnel for a major event that decreased response times, cleared city streets for the marathon, bystanders who acted as first responders and assisted medical personnel effectively, 6 level 1 trauma centers within 2 miles of the bombing site, and an
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Boston Marathon Bombing and Texas Explosion
explosion that took place during hospital changes of shifts, resulting in personnel from 2 shifts being present and thus doubling the available medical personnel.5 Although there are no substantiating data, sunglasses worn by runners theoretically are protective against ocular injuries also. The West victims received prompt and expert care, but faced different challenges in the relatively rural setting. The explosion incapacitated the initial responders, which required the robust surrounding regional EMS services to be mobilized. The closest medical facility was 25 miles away, and some casualties required helicopter transportation for urgent evacuation. Some patients self-transported or were sent to the nearest medical care facility, which might not have had the proper capabilities for required treatment. For example, patient 33 had open-globe injuries that were repaired at the third hospital to which he or she was transferred. The use of rigid eye shields was alarmingly low in both cities. First responders should be aware of potential ocular injury scenarios in polytrauma patients, should be provided with readily available rigid eye shields, and should be mindful to use them in all suspected ocular trauma patients. The military has instituted this in a clinical practice guideline with better success, and this should be applied in the civilian sector as well (Mazzoli RA, et al. Use of rigid eye shields (Fox shields) at the point of injury in Afghanistan. Poster presented at: Military Health System Research Symposium, August 12e15, 2013; Fort Lauderdale).
Trauma Teams Ocular injuries are assessed during the advanced trauma life support secondary survey, which is usually performed in the emergency room. In Boston, many casualties had lifethreatening injuries and secondary surveys took place in the operating room for a number of patients. Nevertheless, ophthalmology consultations were requested from the emergency departments for only 14% of patients in Boston and for 50% of patients in West; the remaining 86% and 50% of consultations, respectively, occurred afterward. Of the 7 patients with open-globe injuries in both cohorts, 4 consultations were requested from emergency rooms, whereas 3 consultations occurred afterward, in the operating room or inpatient units. Eye injuries are part of the blast polytrauma complex, but may escape early detection compared with other life-threatening nonocular injuries. Life support obviously is the primary goal of trauma care, but ocular issues should be considered in overall preoperative planning. For example, some potential consequences include additional iatrogenic ocular trauma resulting from unawareness of an open globe during patient manipulation and transportation, inadvertent taping of an eye with an open-globe injury, and forgoing orbital cuts in the trauma pan-computed tomography scan. Time also is required to arrange transportable microscopes or transfer to an ophthalmic operating room.
Coordination and Communication We found that reliable communication methods are essential for coordinating care. Cellular networks were overwhelmed during the first few hours of the Boston explosion, such that
communication between our team members had to be made on landlines and via paging systems. Disaster-readiness organizations indicate that text messaging is also an effective means of communication when network traffic is high.18 Manpower can become an issue, especially where 1 ophthalmologist may be on call for multiple facilities or extended geographic regions. In Boston, ophthalmology residents across several institutions were mobilized strategically while coordinating with faculty to cover facilities with the most need. This went beyond the usual call algorithm. The emergency patients may have disrupted normal clinic and operating room flow, but the bombing took place on a holiday when there were no scheduled clinics or routine surgeries. In West, the operative cases also were divided among facilities, albeit across further distances. We recommend that a 2- or 3-tiered disaster plan be put in place for all ophthalmic practices to accommodate high-volume mass casualty incidents. The flow of care for polytrauma patients may be disrupted if there are not enough ophthalmologists integrated into the trauma team. Access to subspecialty ophthalmic expertise also is essential. Similar to the systemic polytrauma seen in patients with blast injuries, the eyes of such patients often also have ocular polytrauma. Each type of injury requires subspecialized attention. Of note, vitreoretinal surgeries were required in both Boston and West. We recommend that ophthalmic communities be aware of the inventory of specialized equipment in their home institutions, such as endoscopes for bypassing media opacities19 and foreign body forceps and magnets for intraocular foreign body removal.20 If immediate access to subspecialty services is not available, the military experience has shown that socalled damage control surgery is an effective approach, in which open globes are closed, stabilized, and prepared for transfer to collaborators at tertiary care centers.9,10
Preparations for the Future Basic provisions that eye centers take for granted may not be available during emergencies. Computed tomography imaging is routine for head and neck trauma, but ocular injuries must be identified during the secondary survey to assure that orbital cuts are included in the scans. Patients with polytrauma invariably are situated in general surgery operating rooms, and portable microscopes ideally are transported into the rooms. Patients also are on general surgery beds with limited space around the head for the ophthalmologist’s leg positioning. In such cases, patients either can be positioned as superiorly as possible or can be positioned backward with the head at the foot of the bed, where there is more leg space. The ophthalmologist also must be prepared to work with general surgery technicians and nurses who may have limited experience with ophthalmology cases. In Texas, eye-care providers have anecdotally indicated that many of their patients became visually incapacitated because of the loss of their spectacles from the impact of the blast. Survivors of the Tohoku earthquake in Japan21 and Hurricane Katrina22 also had similar experiences.
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Ophthalmology Volume -, Number -, Month 2014 Navigating a disaster-struck environment while visually impaired increases the risk of more serious but preventable physical injuries, particularly at night or if power and infrastructure are disrupted. We recommend that stocks of spectacles be available as early as possible during disaster relief efforts. In many cities, preparation for mass-causality incidents became a priority after 9/11. Because of this response, the Boston trauma centers were well prepared.2 West also had similar discussions after the fertilizer plant explosion.3 However, the number of ocular casualties is not considered or planned for routinely. Therefore, ophthalmologists must remain in the discussions and medical response planning moving forward, because ocular injuries are common and potentially blinding for survivors of civilian blast injuries. The limitations of this report include inherent biases in its retrospective cross-sectional design. The numbers of mild ocular injuries are unknown because of triaging of patients with less-severe injuries to community facilities and selftreatment. The data gathered is skewed toward inpatients with severe systemic and polytrauma injuries who had ocular manifestations beyond the capacity of primary teams. Data collection purposely was limited after discussion with institutional review boards to be more conservative than usual in protecting patient anonymity in light of high media coverage, so we do not present age, gender, ethnicity, or laterality of systemic injuries. The cross-sectional design did not allow presentation of follow-up data, which is important in these patients whose traumatized eyes are susceptible to both acute23 and chronic7 sequelae. Of note, seemingly benign ocular injuries such as corneal abrasions may be a bellwether of other occult ocular trauma with significant long-term implications, such as angle recession. Additional natural disasters, manmade calamities, and intentional and unintentional mass-casualty incidents undoubtedly will occur in the future. Many survivors of multisystem trauma will sustain blast-related ocular injuries, and ophthalmologists must be seamlessly integrated into regional trauma teams and their preparations.
References 1. Kotz D. Injury toll from Marathon bombs reduced to 264. Boston Globe. April 24, 2013. Available at: http://www. bostonglobe.com/lifestyle/health-wellness/2013/04/23/numberinjured-marathon-bombing-revised-downward/NRpaz5mmvGquP7KMA6XsIK/story.html. Accessed April 7, 2014. 2. FEMA. Lessons Learned Information Sharing. Boston Marathon bombings: hospital readiness and response. Available at: https://www.llis.dhs.gov/sites/default/files/Boston%20Marathon %20Bombings%20Hospital%20Readiness%20and%20Response. pdf. Accessed January 24, 2014. 3. Zuzek C. The night West blew up. Tex Med 2013;109:41–5. 4. Gebhardt MC. Guest editorial: Patriots’ Day at the Boston Marathon. Clin Orthop Relat Res 2013;471:2045–6. 5. United States Senate, Committee on Homeland Security and Government Affairs. One Hundred Thirteenth Congress, First Session. Lessons learned from the Boston Marathon
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Yonekawa et al
Boston Marathon Bombing and Texas Explosion
Footnotes and Financial Disclosures Originally received: February 24, 2014. Final revision: March 31, 2014. Accepted: April 8, 2014. Available online: ---.
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Department of Ophthalmology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts.
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Manuscript no. 2014-295.
1 Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts. 2 Department of Ophthalmology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts. 3 Department of Ophthalmology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts. 4
Department of Ophthalmology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts.
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Department of Ophthalmology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
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Department of Ophthalmology, Scott & White Eye Institute, Texas A&M Health Science Center College of Medicine, Temple, Texas.
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Department of Ophthalmology, University of Texas Southwestern Medical Center, Dallas, Texas.
Department of Defense and Veterans Administration Vision Center of Excellence, Bethesda, Maryland.
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Department of Ophthalmology, Uniformed Services University of the Health Sciences, Bethesda, Maryland. Presented at: American Academy of Ophthalmology Annual Meeting, November 2013, New Orleans, Louisiana. Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article. Abbreviations and Acronyms: EMS ¼ emergency medical services; IED ¼ improvised explosive device. Correspondence: Jorge G. Arroyo, MD, MPH, Department of Ophthalmology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Shapiro Fifth Floor, Boston, MA 02215. E-mail: jarroyo@bidmc. harvard.edu.
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Ophthalmology Volume -, Number -, Month 2014
Figure 1. Pie charts showing types of ocular injuries sustained in (A) the Boston Marathon bombing and the (B) West fertilizer plant explosion. Patients with multiple injuries are listed for each injury type.
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