- Email: [email protected]
Responding to the Boston Marathon Bombing: The Unheralded Role of Graduate Medical Education
EDITORIAL
Responding to the Boston Marathon Bombing: The Unheralded Role of Graduate Medical Education Thomas C. Tsai, MD, Douglas S. Smink, MD Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts Before the tragic events that unfolded on April 15, 2013, much of the political and medical news coverage was on the White House’s budget for fiscal year 2014, which included a proposed reduction of graduate medical education funding of $11 billion over the next 10 years.1 At risk were both the direct subsidies from the Medicare program to fund the training of residents as well as the indirect subsidies to academic medical centers. Underscoring the debate over funding for graduate medical education were more nuanced discussions in both the popular press as well as the academic medical literature on resident duty hours and errors,2 the financial health of academic medical centers,3 and the closing of residency programs across the country.4 But on April 15, all of that discussion faded away. At 2:50 PM, 2 bombs exploded at the finish line of Boston Marathon, killing 3 individuals and injuring more than 170 others. Marathon Day in Boston is also Patriot’s Day, a statewide holiday, and most of those injured were spectators and family members cheering on loved ones. Patients were dispersed to trauma centers throughout Boston. Brigham and Women’s Hospital received 39 casualties overall, 31 in the immediate aftermath of the bombing, and 23 in the first hour, the “golden hour” of trauma. Despite the grievous injuries—penetrating wounds from shrapnel and traumatic extremity amputations—all the patients who made it to Brigham and Women’s Hospital and the 4 other Level I trauma centers in Boston survived. There has been a wave of discussion examining why the survival rate was so high.5,6 Much of the focus has been on the close proximity of trauma centers to the bombing site; the emergency preparedness of our emergency rooms and trauma surgery teams in a post-9/11, post-Aurora, post-Newtown world; the number of on-site medical personnel at the finish line; and the coordination of the first responders. All those factors were in play and contributed to the truly remarkable response of the Boston hospitals to this unprecedented event. There is a complementary and untold story to the Boston response, however. On April 15, as the Brigham and Correspondence: Inquiries to Thomas C. Tsai, Department of Surgery, Brigham and Women’s Hospital, 75 Francis Street, Boston, Massachusetts 02115; e-mail: [email protected]
Women’s Hospital was flooded with 31 trauma patients, surgery residents from all of the surgical services at the Brigham descended on the emergency room. All told, over 20 general surgery residents arrived to help, not to mention a number of residents from orthopedic and plastic surgery. The residents came from other services, affiliated hospitals, and even the research laboratories. For 2 hours in the emergency room that day, all the residents viewed themselves as part of the trauma surgery team providing care. There was no talk of work hours or whose responsibility it was to put in orders or write the admission note; there was only a sense of duty and camaraderie. The scene was hectic, but not chaotic. One senior resident organized all the surgical residents into teams led by either an attending surgeon or a chief resident. Senior surgical and emergency medicine residents oversaw the management of the trauma patients in each of the 3 pods in the emergency department. A team of interns compiled a database of patients and organized lists of laboratory tests and imaging studies to follow-up. Chief residents triaged the house officers in the operating rooms to ensure that each operative case was appropriately staffed, but not inundated with curious onlookers. All the while, medicine residents freed up examination rooms by expediting admissions for the nontrauma patients in the emergency department. Despite the unexpected nature of the event, all the patients were appropriately triaged and evaluated following the standard Advanced Trauma Life Support algorithm. And although the emphasis on prehospital and emergency room preparedness had readied the emergency room staff, mass casualty drills often stop once a patient becomes an inpatient. At Brigham and Women’s hospital, all of the admitted patients either became the primary responsibility of the trauma team or required active trauma consultation. As we at our hospital and the rest of the medical profession reflected on the lessons learned, our residents faced the long-term challenge of healing the deep emotional and physical trauma of the Boston Marathon bombing victims. The Boston Marathon provides a clear and present example of the intangible value of graduate medical
Journal of Surgical Education & 2013 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2013.06.001
555
education. This complementary story, however, is not about Brigham and Women’s Hospital or Boston’s many academic teaching hospitals, but rather about the type of training that general surgery residents receive. Through Advanced Trauma Life Support certification, all surgical residents know how to appropriately assess, triage, and treat patients with traumatic injuries. As simulation has become increasingly important in the training of surgical residents, surgery residents have had the opportunity to practice and hone their clinical and leadership skills in a controlled environment. At the Neil and Elise Wallace STRATUS Center for Medical Simulation at Brigham and Women’s Hospital, our residents refine their technical procedural skills, their clinical decision making in code situations, and just as importantly, their behavioral and nontechnical skills in simulated trauma scenarios with real-time feedback. This training in communication, leadership, and crisis management, although not designed for a mass casualty scenario, translated into the superb triage of both patients and personnel by the senior surgical residents. Although not typically a part of the surgery residency curriculum, additional training in mass casualty simulation may further augment the skill set of today's residents and tomorrow’s surgeons. But ultimately, the best training surgery residents have is perhaps the system and culture of surgical residency itself. Every day, surgical chief residents juggle complex tasks— running a busy inpatient clinical service; communicating to patients as well as multiple attending surgeons; and assuring that the wards, outpatient clinics, and operating rooms are all appropriately staffed and covered by junior residents. Although these management and leadership skills are not specified as core competencies of a surgical resident, they are important professional skills that form over 5 years of clinical training. Most importantly, the response to the Boston Marathon bombing highlights the sense of responsibility and commitment that general surgery residency training instills in its trainees. The surgical residents were effective that day
556
because they cared. These were not their patients for the next hour or shift, but their patients for the entire hospital course. These were their patients to round on each day; their patients to change painful dressings every morning; their patients with whom to conduct family meetings; and their patients to guide through the acceptance of lifechanging injuries. In 1959, Francis Moore wrote in Metabolic Care of the Surgical Patient, “The fundamental act of medical care is assumption of responsibility.”7 Half a century later, those words are just as true for the residents taking care of the victims of the Boston Marathon as for the victims of Cocoanut Grove.
REFERENCES 1. Budget of the United States Government. Fiscal year
2014. U.S. Government printing office; 2013 Accessed 15.05.13. 2. Sen S, Kranzler HR, Didwania AK, et al. Effects of the
2011 duty hour reforms on interns and their patients: a prospective longitudinal cohort study. J Am Med Assoc Intern Med. 2013;173:657-662. 3. Slavin PL. Commentary: health care reform and the
finances of academic medical centers. Acad Med. 2011;86:1076-1078.
4. Bernstein N. Trainees in Radiology and Other Special-
ties See Dream Jobs Disappearing. New York: New York Times; 2013. 5. Gawande A. Why Boston’s Hospitals Were Ready. New
Yorker. New York: Conde Nast; 2013. 6. Walls RM, Zinner MJ. The Boston marathon response:
why did it work so well? J Am Med Assoc. 2013:1-2. 7. Moore FD. Metabolic Care of the Surgical Patient.
Philadelphia: Saunders; 1959.
Journal of Surgical Education Volume 70/Number 5 September/October 2013
Responding to the Boston Marathon Bombing: The Unheralded Role of Graduate Medical Education Thomas C. Tsai, MD, Douglas S. Smink, MD Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts Before the tragic events that unfolded on April 15, 2013, much of the political and medical news coverage was on the White House’s budget for fiscal year 2014, which included a proposed reduction of graduate medical education funding of $11 billion over the next 10 years.1 At risk were both the direct subsidies from the Medicare program to fund the training of residents as well as the indirect subsidies to academic medical centers. Underscoring the debate over funding for graduate medical education were more nuanced discussions in both the popular press as well as the academic medical literature on resident duty hours and errors,2 the financial health of academic medical centers,3 and the closing of residency programs across the country.4 But on April 15, all of that discussion faded away. At 2:50 PM, 2 bombs exploded at the finish line of Boston Marathon, killing 3 individuals and injuring more than 170 others. Marathon Day in Boston is also Patriot’s Day, a statewide holiday, and most of those injured were spectators and family members cheering on loved ones. Patients were dispersed to trauma centers throughout Boston. Brigham and Women’s Hospital received 39 casualties overall, 31 in the immediate aftermath of the bombing, and 23 in the first hour, the “golden hour” of trauma. Despite the grievous injuries—penetrating wounds from shrapnel and traumatic extremity amputations—all the patients who made it to Brigham and Women’s Hospital and the 4 other Level I trauma centers in Boston survived. There has been a wave of discussion examining why the survival rate was so high.5,6 Much of the focus has been on the close proximity of trauma centers to the bombing site; the emergency preparedness of our emergency rooms and trauma surgery teams in a post-9/11, post-Aurora, post-Newtown world; the number of on-site medical personnel at the finish line; and the coordination of the first responders. All those factors were in play and contributed to the truly remarkable response of the Boston hospitals to this unprecedented event. There is a complementary and untold story to the Boston response, however. On April 15, as the Brigham and Correspondence: Inquiries to Thomas C. Tsai, Department of Surgery, Brigham and Women’s Hospital, 75 Francis Street, Boston, Massachusetts 02115; e-mail: [email protected]
Women’s Hospital was flooded with 31 trauma patients, surgery residents from all of the surgical services at the Brigham descended on the emergency room. All told, over 20 general surgery residents arrived to help, not to mention a number of residents from orthopedic and plastic surgery. The residents came from other services, affiliated hospitals, and even the research laboratories. For 2 hours in the emergency room that day, all the residents viewed themselves as part of the trauma surgery team providing care. There was no talk of work hours or whose responsibility it was to put in orders or write the admission note; there was only a sense of duty and camaraderie. The scene was hectic, but not chaotic. One senior resident organized all the surgical residents into teams led by either an attending surgeon or a chief resident. Senior surgical and emergency medicine residents oversaw the management of the trauma patients in each of the 3 pods in the emergency department. A team of interns compiled a database of patients and organized lists of laboratory tests and imaging studies to follow-up. Chief residents triaged the house officers in the operating rooms to ensure that each operative case was appropriately staffed, but not inundated with curious onlookers. All the while, medicine residents freed up examination rooms by expediting admissions for the nontrauma patients in the emergency department. Despite the unexpected nature of the event, all the patients were appropriately triaged and evaluated following the standard Advanced Trauma Life Support algorithm. And although the emphasis on prehospital and emergency room preparedness had readied the emergency room staff, mass casualty drills often stop once a patient becomes an inpatient. At Brigham and Women’s hospital, all of the admitted patients either became the primary responsibility of the trauma team or required active trauma consultation. As we at our hospital and the rest of the medical profession reflected on the lessons learned, our residents faced the long-term challenge of healing the deep emotional and physical trauma of the Boston Marathon bombing victims. The Boston Marathon provides a clear and present example of the intangible value of graduate medical
Journal of Surgical Education & 2013 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2013.06.001
555
education. This complementary story, however, is not about Brigham and Women’s Hospital or Boston’s many academic teaching hospitals, but rather about the type of training that general surgery residents receive. Through Advanced Trauma Life Support certification, all surgical residents know how to appropriately assess, triage, and treat patients with traumatic injuries. As simulation has become increasingly important in the training of surgical residents, surgery residents have had the opportunity to practice and hone their clinical and leadership skills in a controlled environment. At the Neil and Elise Wallace STRATUS Center for Medical Simulation at Brigham and Women’s Hospital, our residents refine their technical procedural skills, their clinical decision making in code situations, and just as importantly, their behavioral and nontechnical skills in simulated trauma scenarios with real-time feedback. This training in communication, leadership, and crisis management, although not designed for a mass casualty scenario, translated into the superb triage of both patients and personnel by the senior surgical residents. Although not typically a part of the surgery residency curriculum, additional training in mass casualty simulation may further augment the skill set of today's residents and tomorrow’s surgeons. But ultimately, the best training surgery residents have is perhaps the system and culture of surgical residency itself. Every day, surgical chief residents juggle complex tasks— running a busy inpatient clinical service; communicating to patients as well as multiple attending surgeons; and assuring that the wards, outpatient clinics, and operating rooms are all appropriately staffed and covered by junior residents. Although these management and leadership skills are not specified as core competencies of a surgical resident, they are important professional skills that form over 5 years of clinical training. Most importantly, the response to the Boston Marathon bombing highlights the sense of responsibility and commitment that general surgery residency training instills in its trainees. The surgical residents were effective that day
556
because they cared. These were not their patients for the next hour or shift, but their patients for the entire hospital course. These were their patients to round on each day; their patients to change painful dressings every morning; their patients with whom to conduct family meetings; and their patients to guide through the acceptance of lifechanging injuries. In 1959, Francis Moore wrote in Metabolic Care of the Surgical Patient, “The fundamental act of medical care is assumption of responsibility.”7 Half a century later, those words are just as true for the residents taking care of the victims of the Boston Marathon as for the victims of Cocoanut Grove.
REFERENCES 1. Budget of the United States Government. Fiscal year
2014. U.S. Government printing office; 2013 Accessed 15.05.13. 2. Sen S, Kranzler HR, Didwania AK, et al. Effects of the
2011 duty hour reforms on interns and their patients: a prospective longitudinal cohort study. J Am Med Assoc Intern Med. 2013;173:657-662. 3. Slavin PL. Commentary: health care reform and the
finances of academic medical centers. Acad Med. 2011;86:1076-1078.
4. Bernstein N. Trainees in Radiology and Other Special-
ties See Dream Jobs Disappearing. New York: New York Times; 2013. 5. Gawande A. Why Boston’s Hospitals Were Ready. New
Yorker. New York: Conde Nast; 2013. 6. Walls RM, Zinner MJ. The Boston marathon response:
why did it work so well? J Am Med Assoc. 2013:1-2. 7. Moore FD. Metabolic Care of the Surgical Patient.
Philadelphia: Saunders; 1959.
Journal of Surgical Education Volume 70/Number 5 September/October 2013