The bombs went off, one after the other. There was the potential more would explode, or some other threat would come to pass. The EMS providers were prepared for athletes, and an occasional bystander injury. But special events with big crowds mean rescuers must be prepared for any type of emergency.
In Boston on April 15, the scene evolved within seconds from marathon medicine to bomb and blast injuries, and EMS responders performed in the midst of hundreds of cameras. They did so with the highest level of professionalism.
Big Events, Bigger Risks
All-hazards preparedness begins with assessment of the community and preparation of emergency response personnel. It means EMS organizations and their individual EMTs must be prepared for responding to mass-casualty events of any cause, and have triage, treatment and transportation plans in place for all contingencies. An all-hazards plan means everyone understands the basic steps of scene safety, triage, primary interventions and transportation.
Start with identification of high-risk major events and likely scenarios. As in Boston, many communities have large events for which EMS providers must be accountable. Common ones are fairs, festivals, and athletic, faith-based and entertainment events. Each of these events requires a large-event plan. Contained within that must be contingencies for weather, acts of violence and unplanned structural problems (e.g., bleacher collapse at an athletic event, accidental carbon monoxide release). All event plans should address an element of unknown risks, and specify how further levels of resources can be tapped. EMS providers are typically assigned duties for planned medical events. Those personnel must serve as the center point of an MCI response should the unexpected occur.
Preparation of Personnel
Emergency providers must have three elements of preparedness firmly in place.
- Caregivers must be a flexible resource. With all-hazards training, EMTs and others can be used to provide care for a wide variety of medical problems, even those that change quickly. Day-to-day management of emergency medical problems provides the basis for this flexibility.
- Emergency providers must be provided with appropriate personal protective equipment and trained in its use. The elements of PPE (masks, gloves, gowns, eye protection) may change over time and even during an incident, but all personnel must have those measures of protection available. In Boston, providers were equipped primarily to manage running injuries, heat illnesses and metabolic stress. But the boxes of gloves and sports dressings were quickly adaptable for the treatment of bomb and blast injuries.
- All providers must be trained in recognizing unsafe incident scenes as part of their general preparedness for work in the field. They must know when to back away if a scene is not safe, and be capable of working within the National Response Framework and an incident management system. Day-to-day use of Incident Command principles provides the basis of this skill. At the Boston Marathon finish line, a variety of medical providers already had vests in place that identified their places in the incident and medical management systems. The responsible individuals could quickly adapt the management structure to the bombing incident.
Provision of initial emergency care for multiple victims requires providers to recognize the event that’s occurred, and for someone to declare that operations have switched from routine to extranormal. This is easier to do when a bomb has detonated or thunderstorm winds have just collapsed a tent onto a big crowd.
Care must begin with the basic elements of triage. Rapid evaluation and a few primary interventions will minimize the loss of life among those closest to the event. EMS providers must be prepared to do this evaluation with no medical equipment; most medical triage systems (START, SALT and others) allow for that to occur with just a pair of gloves.