Boston Marathon Bombings Force Reevaluation of Emergency Radiology Procedures

A review of an emergency radiology response to the US Boston Marathon bombings emphasizes the vital role medical imaging plays in emergency circumstances and ways in which radiology departments can optimize their preparedness for mass casualty incidents.

The study’s findings were published online July 2014 in the journal Radiology. “It’s important to analyze our response to events like the Boston Marathon bombing to identify opportunities for improvement in our institutional emergency operations plan,” said senior author Aaron Sodickson MD, PhD, emergency radiology director at Brigham and Women’s Hospital (Boston, MA, USA).

Lead researcher John Brunner, MD, was an emergency radiology fellow working in the Brigham and Women’s emergency department on April 15, 2013, when two bombs exploded near the finish line of the Boston Marathon. As a level 1 trauma center, the hospital received 40 of the wounded patients, most within hours of the bombing. “Imaging is one of the best ways to decide who needs attention most quickly,” Dr. Brunner said. “The use of shrapnel-laden explosive devices resulted in extensive shrapnel injuries that required evaluation with X-ray and computed tomography, or CT.”

Of the 40 patients who arrived in the emergency department for care, 31 patients (78%) underwent imaging, including 57 X-rays performed on 30 patients and 16 CT scans of 7 patients. More personnel were rapidly mobilized, including attending radiologists, radiology fellows, and residents, and X-ray and CT technologists. Moreover, the typical emergency radiology imaging equipment (two portable x-ray machines and two fixed digital X-ray units, an ultrasound unit and a CT scanner) were supplemented with additional imaging units from elsewhere in the hospital, including two additional CT scanners and additional portable X-ray units.

The researchers studied the emergency radiology response by comparing turnaround times--or the amount of time taken to perform exams and to interpret the findings--from routine emergency radiology operations with those during the mass casualty event. CT exam turnaround time averaged 37 minutes during the mass casualty event, substantially lower than the yearly median of 72 minutes during routine operations. The researchers said the fast turnaround was likely the result of having access to three CT scanners and stationing a radiologist at each. “By having a radiologist stationed at each CT scanner, we could provide real-time protocols and preliminary interpretations of crucial results to help our trauma teams,” Dr. Brunner said.

By contrast, the researchers found the X-ray turnaround time (median, 52 minutes) was longer than during regular operations (31 minutes), in all probability due to a logjam created by the use of traditional radiography portable X-ray systems relying on a single X-ray plate readout device. To eliminate this technical logjam, these portable X-ray units have since been replaced by digital radiography equipment with wireless image transfer to enable faster scan completion and image availability. “Imaging plays a vital role in all emergent situations, from everyday emergency department visits and trauma to mass casualty events,” Dr. Sodickson said. “The surge in imaging utilization following the Boston Marathon bombing stressed emergency radiology operations but overall, things went smoothly in terms of patient care.”

The hospital’s system for naming unidentified patients during the mass casualty event contributed to a large number of duplication of imaging orders and has since been revamped. The new system, which includes a grouping of a unique color, gender, and numeral (e.g., Crimson Male 12345) should lessen confusion that accompanied the arrival of multiple patients following the Boston Marathon bombings.

“Hospitals need to have emergency operations plans in place, and emergency radiology is a crucial component of that preparedness,” Dr. Sodickson said. “When an event occurs, it is important to direct a critical eye to the plan’s operation in order to refine it for the future.”

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Brigham and Women’s Hospital