Birju Rao
Chicago, Illinois, United States 

Sometimes, what seems like a miracle is actually a product of history.

I

It was the dead of night on a chilly April 18, 1775, in the large town of Arlington, MA. A muffled shout and a distant sound of hooves startled the sleepy village watchmen. The beating hooves drew nearer, and a light from a rapidly approaching lamp illuminated the silhouette of a man on horseback. Now awake with heightened senses, the watchmen finally understood the rider’s frantic shouts. Quickly, they ran up to the bell tower and sounded the alarm. As the village folk awoke, the rider’s message spread throughout the town: “The British are coming, the British are coming!” The horseman who delivered the message rode on and alerted several key cities and went on to play an iconic role in the American Revolution. His name was Paul Revere.

II

Around nine in the morning on April 15, 2013, the shot of pistol fire marked the beginning of the 106^th annual Boston Marathon. At 2:49 pm EST, two IEDs were detonated near the finish line. In the blasts and in their aftermath, 262 people were injured and 14 required amputations, all coordinating around twenty-seven local hospitals. The Boston Marathon Bombing was perhaps the most devastating attack on American soil since 9/11. Almost immediately, first responders arrived at the scene to stop the race, evacuate spectators, and triage the wounded. Within the first thirty minutes, the message of the crisis had spread throughout most the city. Within a few hours, the whole world was watching as Boston mobilized to deal with this disaster.

III

Paul Revere is most well-known for his midnight ride alerting America of an impending British invasion. But Revere also played an instrumental role in developing America’s medical emergency preparedness infrastructure—these early underpinnings laid the groundwork that gave Boston the ability to react to the deadly marathon bombings.

After winning the war for its independence, a tired, cold and hungry confederation looked towards a tottering government to direct the colossal project of setting up the infrastructure of a new country. And so began the great American Experiment.

Within the next several years, a variety of public works projects popped up throughout the thirteen states and with them came accidents. From building bridges to boats, many able-bodied men were involved in some form of construction project. Naturally, with more construction came more construction related accidents. Arms would get crushed, legs would break, or skulls would get fractured. In these sorts of traumatic injuries, time was of the essence if lives were to be saved. The existing medical system did not cater well for these emergencies. When workers were injured, friends and co-workers would do their best to try to control the bleeding. By the time the local physician was found, alerted, and arrived at the scene it was already too late. This posed a real problem. In an era when physicians would make house calls, hospitals were seen more as prisons where the quarantined and mentally ill were locked up to keep the healthy safe.
All this changed when several physicians banded together to push for a change from a concierge system of medicine to a hospital-based system—the first great American health care reform. However, like any reformation, there were many obstacles along the way. One was the high cost of overhead that hospital-based care posed compared to care that took place at the patient’s home. This was perhaps one of the biggest hurdles that restricted the establishment of many hospitals. In addition, the popular belief championed by French intellectual, Montesquieu, was that hospitals were essentially places were the poor and homeless feigned sickness to get free lodging and food.¹ Finally, most patients preferred to be treated at their own homes, surrounded by their loved ones. Though some hospitals did exist, they were usually the offspring of Christianity and provided care for people who had no friends or family to care for them—the destitute. All these obstacles conspired to corrupt the common sense of legislators, and as a result, the group of physicians struggled to procure public funding for their project. This is when Paul Revere, now a successful entrepreneur and political advisor, stepped up to be an early financer of one of the first modern hospitals in America: “Boston Infirmary.”²

IV

As the world watched in horror at the tragedies that unfolded in Boston, an age-old emergency preparedness system that had its roots in Paul Revere’s venture sprang into action. It was this very system that, through the years, was meticulously refined to respond to a crisis such as this. There were two explosions that took place at 14:50, twelve seconds apart. Within seconds, first responders were at the scene and medical personnel transformed the runner’s first aid tent into a triage bay. At 15:08 the first victims started rolling into the seven major trauma hospitals in Boston (one of them being Tufts Medical Center) and by 15:25 trauma surgeons had them in the operating rooms. Like well a choreographed dance, no one had to be told what to do and where to be. As a result, of the more than one hundred seventy that were wounded, everyone that was alive when rescuers reached them survived.³ This was neither serendipity nor a miracle. The success was a result of years of building upon a system that was originally set in motion by Boston Infirmary.

V

Public records and hospital documents⁴ demonstrated that Boston Infirmary’s goal to operate independent of charity would be accomplished by stabilizing patients as quickly as possible to return them to their primary care provider—an idea that was revolutionary during that time. The hospital’s strategy for financial independence helped them spearhead innovation in emergency medical care.

Reacting to the need of trauma care, Boston Infirmary institutionalized the concept of the hospital as a place where emergency care could be centralized. Trauma victims would be brought to the hospital where physicians would treat wounds and stabilize the patient and send the patient home where a local physician would tend to her. In addition, the hospital became one of the first to hire ancillary staff known as “dispensary nurses” to respond to medical emergencies. These nurses were responsible for triage and crisis response, in addition to general patient care.

As the years passed, the Boston Dispensary served as a model for the six other trauma centers that emerged in Boston. All the while, Boston Dispensary continued to make iterative improvements in emergency medical care ranging from the universal use of the stethoscope to hygiene control.⁵ In the 1960s, it formally became a training ground for young, budding physicians when it merged with the Floating Hospital for Children and Pratt Diagnostic Clinic, and eventually became known as Tufts Medical Center.

VI

On April 15, 2013, two explosives went off during the Boston Marathon. When the world expected Boston to react with chaos and confusion, it responded with equipoise and efficiently. What happened that day was a tragedy, but things could have been much worse. Of course, the cultural legacy of 9/11 and the adoption of smart policies and protocols played a role in emergency preparedness, but too often those pioneers who helped clear the a path towards the future are forgotten. It was no coincidence that one of the first modern hospitals with an emergency response framework was down the street from the marathon. The framework that made the success of Boston possible was laid down by the inception of Boston Dispensary, and who better to fund the venture than Paul Revere, a man who knew a thing or two about mobilizing forces during an emergency.

References

1. History of Boston Dispensary
2. Revolutionary Care Then and Now: A History of Tufts-New England Medical Center Founded in 1796
3. History Education, Boston Marathon Bombings. 2014. http://www.history.com/topics/boston-marathon-bombings
4. Centennial Report of the Boston Dispensary Front Cover Boston Dispensary,
5. Robert Willard Greenleaf Riverdale Press, 1898 – Hospitals – 64 pages
6. Hoyt, Edwin Palmer. The Improper Bostonian: Dr. Oliver Wendell Holmes. New York: Morrow, 1979. ISBN 0-688-03429-2.