From the Editor: Could Looming Healthcare Changes Affect Disaster Readiness?

  The tragic events of April 15 in Boston provided us all a too-common reminder: We’re not really safe. Not today. Not tomorrow. Not any time soon. Threats of terrorist attack can no longer be considered anything other than imminent. Will a changing healthcare system be able to clinically and financially support at least the illusion of safety and readiness to respond moving forward? Statistics compiled by the Global Terrorism Database show overall occurrence of such acts on US soil is down since the 1970s (especially since 9/11), due in part to improved security. Yet, the number of injuries reported as a result of the marathon bombings ranks among the highest in recent US history for similar incidents (surpassed in the past 20 years only by the 1993 World Trade Center attack and the 1995 Oklahoma City bombing). Although we can take some comfort in knowing our collective awareness remains at a peak, the reality is that we’re not really any more safe. Despite fewer acts of terrorism and the awe-inspiring heroism by people who risked their lives to aid the injured in Boston, the increased sophistication of weapons during recent attacks brings into question our ability to be protected. Thankfully, first-responders and other medical, police, and emergency personnel in Boston curtailed the death toll and the extent of injuries by providing care at the scene and getting patients to multiple Level I trauma centers. And all involved have my utmost praise and respect. But, I can’t help wondering how much of this was the result of good triumphing over evil and confirmation of the true readiness of our healthcare system, and how much was the benefit of logistical luck. Yes, trauma centers spend countless hours participating in disaster drills and preparing for crisis, but would more deaths have occurred if the alleged perpetrators planned differently? (And this is not an attempt to boast that only “a few” deaths resulted from this attack. Even one would have been too many.)   Commensurate with the race, medical and safety staff were on-site and in heightened emergency-response mode due to the number of people in the city, particularly the runners. Typical marathon emergency plans for hospitals and on-site caregivers anticipate cases of dehydration, muscle injuries, and, on a more emergent level, heart attacks. Plans aren’t inherently established to predict the off chance of treating crush and blast injuries that rival those suffered during military combat. With the race in mind, Boston-area hospitals were better positioned to handle more than 170 emergency department visits. But what if this was just an otherwise crowded day in the city? True, fewer people would presumably have been at risk, but would the carnage have been greater? It seems the suspects targeted not necessarily Boston, but the “free-living” US — striking on Patriots’ Day in a city that hosts one of our country’s most anticipated sporting events on a day that acknowledges the anniversary of two poignant American Revolutionary War battles. Was the planning by the accused actually convenient for the trauma centers?   Regardless, could looming changes to healthcare for 2014 affect disaster or hospitals’ planning and readiness for an annual event? What about the possible financial trickle down of Medicare budget cuts now or in the future? Will more US hospitals close EDs? According to the CDC, trauma centers reduce the risk of patient death by 25 percent. Among those that remain open, that is. This is not a suggestion that Boston is in danger of seeing doors close at any of its centers; it’s just another potentiality for a country that may not be as safe as it could be. Recent data from the American Hospital Association show 339 trauma centers shut down from 1990-2005 while EDs overall closed at a rate of 11%. Many of Boston’s bombing survivors face extensive rehab and wound care. Their ability to recover and afford optimal treatment will come down to many factors not limited to age, access to services, and insurance coverage. For many, the struggle to recuperate will continue long after the admirable life-saving efforts of all those providing care and assistance that day. When “next time” strikes, here’s hoping the impacted healthcare practitioners and other providers are sufficiently positioned to help.