Everyone Worked in Tandem
CNN and "New York Times" on care of Boston Marathon bombing victims
April 17, 2013 -- Two major media press reports on the tragic bombing at the Boston Marathon illustrate the range of nursing portrayals in coverage of mass casualty events. Yesterday CNN posted a short piece on its website by Elizabeth Cohen, along with related video, that relied mainly on commentary from two experienced trauma nurses who were on the scene as part of the regular marathon health care contingent. The report reveals something of the nurses' expertise and the key role they played in caring for the wounded. However, the piece is careful not to suggest that nurses acted alone, referring repeatedly to the "team" of "doctors and nurses" who cared for victims. Granted, the headline is "Nurses relied on trauma experience to help bombing wounded," but the report makes clear that it was not just the nurses, and on the same web page there is a link to a video interview with a physician from a local hospital ("Doctor: we were ready for this") who describes the care for the patients who arrived there in some detail. So there is a little risk that the CNN audience will miss that it was a team endeavor. Less impressive is today's longer New York Times report by Gina Kolata, Jeré Longman, and Mary Pilon, which matches its headline--"Doctors Saved Lives, If Not Legs, in Boston"--with a comprehensive account of the victims' care that suggests physicians did or directed everything important. The report does include two references to "nurses" being present at the care settings, but it does not name or quote any. Instead, there are multiple quotes from six physicians and suggestions that physicians did pretty much everything, including tasks in which nurses were surely key players, such as preparing for marathon-related issues like dehydration. At one point, the report notes that a "medical team" left a hospital at 2 a.m. and returned at 6 a.m., checking patients at each point, as if nothing happened in the interim. But the article does take time to describe a surgeon's nap. We are aware of no other Times report that corrects the imbalance in this one. We do thank CNN for its coverage of the work of nurses in the aftermath of the attack.
The CNN piece gives the accounts of the two nurses, Stephen Segatore and Jim Asaiante, more or less in turn. First, the report notes that Segatore, "a nurse for 18 years" who "works in the intensive care unit at nearby Tufts Medical Center," had worked at a half-dozen past Boston Marathons. He reportedly thought this one was unlikely to be too difficult because of the cool weather, which would reduce the risk of heat stroke and dehydration, perhaps limiting health issues to muscle cramps and twisted ankles. These notes associate Segatore with the treatment of significant conditions, with no suggestion that he needs a physician to tell him what to do. But after the first explosion, "a team meant to tend to the achy and exhausted became a trauma team," with those like Segatore who had trauma experience "dash[ing] out [of the health care tent] in the direction of the noise."
The direct quotes from Segatore are more of his emotional reactions and general observations that a lay person might have, but the indirect quotes and information the reporter presents in her own voice include specific care information that is more helpful in conveying nursing skill. For example, Segatore initially notes that when he ran out of the tent he saw "people who were missing legs and part of their face and part of their abdomen," and while "my training prepared me for what to do…nothing can ever really prepare you for what you see." Later, he notes that "no one expects to work at the Boston Marathon and end up at a terrorist attack." He adds: "I've seen people die all over the world, but I've never been this upset or angry in my career," explaining that "this is the Boston Marathon. People come from all over the world and all of a sudden that world exploded on them."
However, Cohen includes more helpful specifics in her own words, apparently based on Segatore's account. She says that he was "one of a team of dozens of doctors and nurses" who had volunteered at the marathon.
They worked quickly to stop bleeding and start IVs so patients could get into ambulances and to hospital emergency rooms. They treated dozens of patients without proper supplies for severe trauma, such as dressings and pain medications. One of [Segatore's] first patients was a young woman, he thinks maybe 20 or 22 years old, whose abdomen was torn open. Her left leg was broken and facing the wrong way and she wasn't breathing. He and his colleagues did CPR on her and kept checking for a pulse, but there was none. They stopped when they realized it was futile. She became the first patient in their makeshift morgue.
The piece notes that Segatore and others tried to find some way to identify this victim, but could not. He concluded that she "was probably a student somewhere in Boston." Of course this is all very sad. But the material in the block quote is helpful to nursing because it links Segatore directly with skilled care, from CPR to IVs.
The report moves on to Jim Asaiante, "a nurse in the emergency room at the UMass Memorial Medical Center in Worcester" who was "working alongside Segatore in Tent A." The article notes that Asaiante did not run outside right after the explosion, because "as a veteran of the Iraq War, he's also had plenty of experience with explosions."
"I heard the first IED (improvised explosive device), and I know there's never one. The bad guys always set up two or three," said Asaiante, an Army captain who did an 18-month tour in Iraq in 2006 and 2007. Another victim was brought into the tent, a man with his calves and feet blown off and blood pumping out of his knees. Asaiante put a tourniquet on him, started an IV, and in 15 minutes the man, who was screaming in pain, was in an ambulance. After the second explosion, Asaiante ran out of the tent. "There was lots of bleeding, shrapnel, glass. It was mayhem," he said. "The injuries were very similar to Iraq."
Again, all of that is very sad. But at the same time, this account includes specifics about Asaiante's trauma experience, his military rank, and his work to help the wounded here, such as the tourniquet and the IV, that reveal a skilled health care professional and a leader.
The piece closes with remarks from both nurses about the high quality team care. Asaiante notes that the work of the physicians, nurses, and EMTs was "impeccable." Segatore agrees:
The most amazing thing was how everyone worked in tandem. They didn't even have to speak a word between each other. In 20 years of nursing, this was the most amazing two hours of nursing in my life.
Teamwork was not a big theme in the longer New York Times piece about the aftermath of the bombing, as exemplified by the headline, "Doctors Saved Lives, if Not Legs, in Boston." Instead, there were many quotes from six physicians that, along with the reporters' own text, focused on what physicians did and decided, giving a pretty clear impression that that was what mattered. In fairness, there is a passing reference to "nurses" being present at the bombing site, and another to "doctors, nurses and other medical professionals" being texted to come to one affected hospital. "An emergency medical technician outside the [health care tent at the race site] coordinated ambulance service to hospitals." And the report briefly quotes chaplain Julie Dunbar of Beth Israel Deaconess Hospital; she said some health workers were faced with "more trauma than most ever see in a lifetime, more sadness, more loss."
But consider the accounts of the physicians who dominate the piece. "Dr. Peter Burke, the trauma surgery chief at Boston Medical Center," notes that "as an orthopedic surgeon, we see patients" with mangled extremities, but not so many and not as a result of blast injuries. A long quote from "Dr. Tracey Dechert," another trauma surgeon from that hospital, takes readers into surgeon decision-making:
What we like to do is before we take off someone's leg -- it's extremely hard to make that decision -- is we often get two surgeons to agree. Am I right here? This can't be saved. So that way you feel better and know that you didn't take off someone's leg that you didn't have to take. All rooms had multiple surgeons so everyone could feel like we're doing what we need to be doing.
Of course this is newsworthy information, but it ignores key health personnel who were just as numerous and important in these clinical settings. Did the presence of "multiple surgeons" by itself enable "everyone" to feel like they were doing what was needed? Did all the surgeons have nursing licenses? Did they give all the anesthesia themselves? In many cases, nurses are also deeply involved in helping patients come to terms with their status and make decisions about whether or not amputation is the right choice for them, to the extent the patients are able.
The reporters' accounts, which seem to be based mostly on speaking with the named physicians, have a similar focus. Because of the high number of terrible leg injuries, "in an instant, doctors at hospitals throughout the city who had been preparing for ordinary marathon troubles -- dehydration or hypothermia -- now faced profound, life-changing decisions for runners and spectators of all ages." Even if the physicians alone made these decisions, did they alone prepare for dehydration and hypothermia? Nurses play central roles in treating those conditions.
When the piece shifts to the site of the blast, physician observations remain paramount. The blast killed "only three, which doctors say" was because it was low and mostly injured people's legs, rather than abdomens, chests, or heads. Really--only "doctors" say that? "And tourniquets stopped what could have been fatal bleeding in many." Despite the piece's note that "at least eight doctors and what seemed to be 20 or more nurses were stationed in the [health care] tent" at the site, we don't hear from any nurses. Instead, the piece quotes only a veteran emergency physician from Georgia, "Dr. Allan Panter," who was standing near the finish line, waiting for his wife to finish the race. The estimates about how many of each type of professional were there seem to have been based on Panter's account. The report notes that "assisted by others," Panter applied tourniquets to several victims, and that he "assisted others in wheeling in a female victim who died." Panter also explains that tourniquets, once out of favor, are now again seen to be useful in treating blast injuries, such as those caused by explosives in Iraq and Afghanistan.
The report returns to the Boston hospitals, noting that at those facilities "doctors had to carefully coordinate their response." (Evidently the nurses and others did not have to.) In addition, "each [physician] has a story of where they were when the bombs went off and how they rushed to help and how, in some cases, they somehow just missed being victims themselves." So evidently these backstories on "where they were and how they rushed" are more important than getting even one comment from a nurse about actually caring for the victims.
Perhaps the best of these telling details involves "Dr. Alok Gupta, who directed the surgical response at Beth Israel." Apparently Gupta often goes to watch the finish of the race, "but this year he was so tired that he took a nap." Unfortunately there do not seem to be any photographs of this nap; it may be that there was so much excitement surrounding it that no one had the presence of mind to take any. In any case, we get a lot more details about Gupta hearing sirens and helicopters, wondering why, getting a garbled cell phone call, and rushing to the hospital within five minutes. Gupta "and his colleagues" cleared the emergency department and ICU as best they could in preparation for the wounded, and he "directed a central command." It's pretty hard to believe nurses did not play a central role in all this triaging and stabilizing the wounded, stopping the bleeding, and organizing activities so that the most severely injured and most likely to survive would be treated first. And people were contacted:
"Surgeons were notified, emergency-room physicians were notified, operating-room personnel were notified, everyone was notified," [Gupta] said. Cellphone service in Boston was limited, so doctors, nurses and other medical professionals were contacted with text messages.
Pretty impressive how the nurses slipped in there! They can read text messages! Soon patients started to arrive, and "doctors described the situation as calm and efficient."
The report includes some information about the specific measures taken at the local hospitals, including how many victims went to the OR and the ICU. Some patients would need multiple surgeries. Physician Burke, from Boston Medical Center, explains that many of the injuries were so awful that the amputation decisions were "pretty straightforward -- they weren't going to be able to salvage these things." He says that "we all would like to salvage whatever extremities we can," but when there is so much damage, the limbs may not ultimately be saved even after enormous pain and other problems over the course of months, and an early amputation may be the better option. In addition, the report says, using a tactic of the U.S. military in Iraq,
doctors at Beth Israel used felt markers to write patients' vital signs and injuries on their chests -- safely away from the leg wounds -- so that if a patient's chart was misplaced during a transfer to surgery or intensive care, for example, there would be no question about what was found in the emergency room.
That sounds wise, but did only physicians record vital signs and injuries on the patients' chests in the ED? That seems unlikely.
The piece closes with observations from two more physicians. Beth Israel trauma surgeon "Dr. Michael Yaffe" describes the victims at his hospital. The report also notes, apparently based on his account, that the Beth Israel "medical team" went home at 2 a.m. and returned four hours later at 6 a.m., examining each patient before they left and when they returned, as if that is all that mattered. But surely something happened to those critical patients in the intervening four hours: a lot of life-saving nursing care. We doubt the patients suddenly got up and gave themselves expert care. Anyways, the article notes that "doctors said" trauma patients often "will not notice some of their injuries until the major injury is taken care of." Yaffe adds that for some badly injured runners, the bombing took away "the thing they loved." On the other hand, "Dr. George Velmahos, chief of trauma services at Massachusetts General Hospital," observes that some patients said that they "thought they would die as they saw the blood spilling out," so when they awoke later, "they said they felt extremely thankful, some even considering themselves lucky." He notes that it's "almost a paradox to see these patients without an extremity to wake up and feel lucky."
These comments, like many in the Times report, are certainly newsworthy. The problem is the apparent assumptions that only one category of health professionals has much of interest to say and that only one group did anything important to help the bombing victims. This is reflected most strikingly in the statements about "doctors" doing activities in which nurses were almost certainly involved, like preparing for patients with dehydration. But it's also evident in the omission of descriptions of other important care, like what happened at Beth Israel between 2 a.m. and 6 a.m. We know many nurses are reluctant to speak to the press, though not nurses like Segatore and Asaiante, who appeared on CNN. Regardless, reporters have an obligation to at least try to provide a balanced account of what happened. We do not know of any other Times report about the aftermath of the Boston Marathon bombing that provides that balance.
Of course we are aware of the longstanding social assumption that what "doctors say" and do is the beginning and the end of what matters in health care. But we always hope that press reports like these will convey more of the reality of health care--as CNN did here--and help us move toward a day when nursing and other health professions get the respect and resources they need.
See Elizabeth Cohen's "Nurses relied on trauma experience to help bombing wounded," which was posted on CNN's site on April 16, 2013.
See also "Doctors Saved Lives, if Not Legs, in Boston," by Gina Kolata, Jeré Longman, and Mary Pilon, which was posted on the New York Times site on April 16, 2013.