Evan Gross

Public Health Preparedness II

Boston Marathon Bombings: Model Leadership Displayed During Blast Response

The Boston Marathon on April 15, 2013 was supposed to be a normal day for a marathon.

The goal was for everyone to finish the race, besides the ones who sustain running-related

injuries during the race. The event involved over 25,000 runners, who were in it to complete the

26.2-mile journey. In addition to that amount of runners, approximately 500,000 spectators lined

up to see the event, making it the second biggest sporting event in a single day, behind the

Superbowl (Nadworny, Davis, Miers, Howrigan, Broderick, Boyd & Dunster 2014). That day

changed drastically and the race ended early after pressure-cooker bombs went off at the finish

line, injuring 264, and killing three people (Yonekawa, Hacker, Lehman, Beal, Veldman, Vyas,

& Arroyo 2014). Preparedness plans resulted in the unanticipated benefit of responders working

together under emergency conditions to reduce bomb blast injuries and deaths through model

leadership during the response to the Boston Marathon Bombings. I will analyze how city of

Boston facilitated collaboration with internal and external emergency response partners prior to

the Boston Marathon Bombings, how responders solved problems under emergency conditions

following the bombings to reduce casualties, and the unresolved threats to physical and mental

health that remain in survivors of the bombings to this day. One of the major factors that affected

the entire incident was the preparedness of agencies in Boston prior to the marathon event.

The city of Boston facilitated collaboration with internal and external emergency

response partners prior to the Boston Marathon Bombings. Multiple drills performed following

9/11 helped prepare city first responders and hospital for mass-casualty events. Multi-agency

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coordination was essential during preparedness drills and the response to the bombings. On

Friday November 8, 2002, a large operation was performed called Operation Prometheus. This

involved the coordination of emergency responders and 14 hospital stakeholders in the Boston

Area, which simulated the release of a dirty bomb from an incoming airliner. A considerable

amount of patients had to be decontaminated, and Brigham and Women’s Hospital received

several patients. Additional drills executed in the following years involved Brigham and

Women’s Hospital, other Boston area hospitals, and first responders. In 2010, an exercise titled

“Operation Falcon,” was completed with the coordination of Metro Boston Homeland Security.

Operation Falcon tested the system-wide capacity of Boston medical response (Walls & Zinner

2013). As witnessed, the operations executed after 9/11 increased the city’s preparedness

capabilities by strengthening relationships among emergency response partners.

Beth Israel Deaconess Medical Center in Boston was another hospital that had prior

experience in hospital preparedness, which helped them handle the load of patients in the

aftermath of the bombings. Preparing for the worst-case scenarios is essential for hospital

preparedness, according to Meg Femino, who was the director of emergency management at the

hospital during the bomb blast response. Beth Israel had several drills regarding preparedness

prior to the bombings, and they started with a common plan. This plan involved tabletop

exercises, which involved stakeholders in the response to figure out how things should work.

Once this was completed, the more functional plan expanded until it developed to a full-scale

exercise. This strategy was used in a drill that simulated a structural collapse of Fenway Park

occurred, in which there were approximately 500 injured patients. Multiple areas of the hospital

were involved, including emergency department (ED) and operating room (OR) staff, which had

to prioritize patient care based off index cards that patients yielded describing the condition(s)

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they had (Knudson 2014). This exercise was one of several performed, and was one method that

increased Beth Israel’s preparedness for the Boston bombings. Another way hospitals were

prepared for the bombings was that they structured their Emergency Departments under Incident

Command Structure, and were carrying on their duties under that structure for a planned MCI

due to the planned increase in marathon patients. This involved delegated roles to emergency

department staff for a smoother response of all involved hospital workers (Nadworny et al.

2014). The plans between multiple agencies ensured a smooth response during the event

response. This planning among stakeholders was crucial, and bolstered the abilities of responders

to solve problems under emergency conditions.

Responders solved problems under emergency conditions following the bombings to

reduce casualties. The location of responders effected the time to treatment for victims. Although

the finish line was a good target for a terrorist attack due to the large amount of people, it also

included many medical professionals who were able to respond quickly. The medical tent

contained first responders, paramedics, nurses, doctors and other healthcare professionals for the

race. The tent was prepared for running injuries and illnesses, and in 2012, over 1500 runners

were sidelined during the race, with an additional 2000 runners requiring treatment in area

hospital, to give an idea of what these professionals were prepared for (Nadworny et al. 2014).

Although the tent was not expected to be used for a bombing response, due to it being within two

blocks of the bombings, it become a temporary location for stabilizing patients injured from the

bombings (D'Andrea, Goralnick, & Kayden 2013). Boston EMS organized triage and transport

following the bombings, in coordination with receiving hospitals (D'Andrea et al. 2013).

Through EMS experience, the critical time to get a trauma patient to the hospital is within

the “golden hour,” is preached. Although no specific study proved that one hour is the exemplary

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time for patient outcomes, trauma care and EMS development is based upon this principle. This

term was created by R. Adams Cowley, who a pioneer in trauma care system development

(Rogers, Rittenhouse, K., & Gross 2015). This approach was behind the courageous work by

EMS and healthcare providers on scene of the bombings, who ensured a quick triage and

transport of patients to appropriate hospitals. This quick action by Boston EMS resulted in the

transport of all critically injured patients from the scene to hospitals within 18 minutes following

the bombings. Due to the large amount of patients, Boston EMS determined that in order to get

all patients to definitive care in a timely manner, they needed additional resources. With the

assistance of other ambulance agencies, every remaining non-critical patient was transferred to

hospitals within 45 minutes (Nadworny et al. 2014). Almost all patients transported by EMS

came in to EDs with triage tags, which enabled the triage nurses in one of the hospitals to set up

outside the ED to assess patients easier than if they had no condition identification. This

enhanced the screening by the nurses having not only a verbal report, but also a triage tag with

patient condition identified to increase the speed of assessment of patients. This process enabled

nurses to send critical but stable patients to triage inside the ED, and critical and unstable

patients directly to the trauma bays (Nadworny et al. 2014). As evidenced, triage and transport

strategies were efficient under emergency conditions through pre-planned and practiced

procedures. Not only were all critical patients transported within that timeframe, but all who

were transported survived. The three people who killed were pronounced dead on the scene

(Walls & Zinner 2013). This may indicate that those patients had serious enough injuries that

they could not be saved. For the ones who could be salvaged, they had more benefits to being

bombing victims in Boston.

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The locations of the bombings helped reduce injury because of its proximity to important

hospitals. Due to the mechanism of injury being a bomb blast, many patients needed trauma care.

The race was in close proximity to five level-one adult trauma centers, and three level-one

pediatric trauma centers (Walls & Zinner 2013). Level-one trauma centers have the highest

capabilities in treating trauma patients due to 24/7 access of a trauma team and high volume of

patients that come in their doors. Patients have better outcomes in going to a trauma center as

compared to a local community hospital. With the mechanism of injury being a bomb blast,

many patients utilized trauma teams in these nearby trauma centers. Along with the close

distance, many streets were closed around the bombings due to the race, which enabled less

congestion in the responses by first responders (Yonekawa et al. 2014). Boston EMS also did an

outstanding job in distributing the injured patients throughout the several hospitals in Boston in

order for hospitals to be able to better handle patient loads (Kellermann & Peleg 2013).

Hospitals had a benefit to the timing of the event, which in combination of the benefits of

location of the bombing, led to better treatment. As evidence in Brigham and Women’s Hospital,

the event of the bombings was during a weekday, and gave an advantage of hospitals having

more staff on hand for the bombings. Not only that, but it happened during a change of shift

time, which provided the hospital with outgoing and incoming personal. The initial bombing

notification came in at 2:50pm, which was near the 3pm change of shift time. The outgoing

personal stayed to help, to bolster the staffing levels for the treatment of incoming bomb blast

patients (D'Andrea et al. 2013). Another factor that benefitted response was the marathon being

on a state holiday, which is usually when fewer patients were scheduled for routine care and

surgery (Kellermann & Peleg 2013). In addition, hospitals had a lower census from it being a

holiday, and physicians were in the hospital working on other projects (Walls & Zinner 2013).

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This gave them more freedom to respond to the influx of patients, because they did not have their

normal patient load to care for.

Hospital were prepared and performed exceptionally well with the amount of patients

they encountered by prioritizing processes during the aftermath of the bombings. One example of

excellent performance following the bombings was at Brigham and Women’s Hospital, which

initiated a Code Amber, the hospital’s disaster response alert. 31 patients were received within

the first hour following the bombings. Patients with minor conditions and needing psychiatric

care were cleared quickly from the ED to prepare for the influx of patients. They had three

sections of the emergency department: Alpha, Bravo, and Charlie. The less critical patients were

sent to the Bravo and Charlie units, while the more serious patients, including those needing

trauma care, were sent to the Alpha unit. Several trauma bays were set up in the Alpha Unit, with

individual trauma teams for each bay. These units stayed in the rooms to reduce confusion. More

professionals trickled in from other sections of the hospitals supplement workers in the ED. As

patients were assessed and stabilized, they were sent to the Operating Room or inpatient units in

order to clear up space in the ED, which was prepared for more patients due to the unknown

consequences following the bombing. These methods are a witness of how the emergency

department staff prioritized patient care in order to solve problems in a timely fashion while also

preparing for more patients. During the performance, and following the rendering of the medical

care, debriefing occurred to support the psychological health of providers. These fast acting

approaches helped improve flow of patients and supported providers with needed workers and

psychological support. (D’Andrea et al. 2013).

Multiple agencies collaborated for mental health care of people affected by the bombings.

This included local, state, and federal agencies to help in the immediate aftermath emergency

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mental health care, and the recovery period. The lead agencies for the mental health response

following the bombings were the Boston Office of Emergency Preparedness and the Boston

Public Health Commission (Beinecke 2014). Regarding first responders, the Boston Police

Department and Emergency Medical services were the first responders most involved. Both were

involved in all aspects of the marathon, and the bombings. Both were on scene of the marathon

prior to the race and the bombings, and had to respond to injuries from the bombings and events

that transpired afterwards. Boston EMS treated many of the patients in the bombings and was on

the front lines. Boston Fire Department’s role ended mostly on the evening of April 15, while the

police’s role continued in searching for the subjects. Not only were Boston police involved, but

multiple agencies in local jurisdictions were involved as well. Police were involved not only in

the pre-event and event, but were actively involved in the post event as well. Not only did they

respond to the bombings, but they also needed to search for the subjects involved, which added

to the various possible triggers for Post-Traumatic Stress Disorder (PTSD) and other mental

health issues. Mental health is another aspect of preparedness that Boston was prepared for prior

to the bombings.

A helpful resource that Massachusetts General Hospital had was its Department of

Psychiatric working in conjunction with its burn unit. General Hospital had an arrangement for

years in which it had a Burns and Trauma Psychiatry program within its Psychiatry program.

Residents and fellows would work under the director of the Burns and Trauma Psychiatry

program to help support the mental health needs of trauma and burn victims (Beinecke 2014).

Since this program had extensive experience with trauma and burn victims prior to the bombing

events, treatment to bombing victims was routine work, with the only difference being a larger

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than normal patient load. Although the event went smoothly, it left patients and responders with

visible and invisible injuries.

Unresolved threats to physical and mental health remain in survivors of the bombings to

this day. Many injuries resulting from the blast included visible and invisible injuries, with many

patients suffering from both. Secondary blasts injuries were the most common type of injury as

discovered in a study of three acute-care hospitals, with the most common injury location being

of the lower extremities, and ball bearings as the most common shrapnel found. Regarding injury

mechanism, the lower extremities were affected due to the bombs being places at ground level

(Yonekawa et al. 2014). The most common location of these injuries was the leg, thigh, and

pelvis areas. Primary injuries included rupturing of the tympanic membrane seen in over 10

patients. Other injuries from a result of the blast included fractures to back, facial bones, and

upper extremities. There were also several patients with burns resulting from the bomb blasts

(Singh, Goralnick, Velmahos, Biddinger, Gates, & Sodickson 2014). Another injury that affected

22 of the 264 total patients was ocular injuries, and required ophthalmologic care to repair

damage and improve or restore damage vision from the impact of shrapnel from the bombs

(Yonekawa et al. 2014). Although the physical injuries that you could see were a major issue, the

invisible injuries suffered by people were in greater numbers.

Many people were left with invisible injuries because of the blast. Most hospitals and

organizations employed psychological first aid immediately following the bombings. For

example, Birdham and Women’s Hospital, the consultation-liaison psychiatry department

provided immediate care in the emergency department, which included direct care and

consultation. In the immediate aftermath, the team worked to get patients with psychiatric issues

out of the emergency department and into beds for preparation to transfer to a hospital that had a

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psychiatric unit. This provided emergency department staff with more room for physically

injured patients. There were several conditions reported by first responders and hospital

employees through the chain of command in order to initiate appropriate treatment for the

populations. Patients and their families were affected as well, and psychiatric care was

incorporated into their treatment (Oser, Shah, & Gitlin, 2015). However, a week after bombings,

44 percent of adults and 35 percent of children had posttraumatic stress disorder symptoms

(PTSD) (Beinecke 2014). Veterans who had PTSD from previous experience reported

aggravated symptoms of the condition in weeks following the bombings (Kredlow & Otto 2015).

The most prevalent type of physical trauma following the bombings was otologic trauma

(Remenschneider, Brodsky, Heman-Ackah, Kujawa, Lee, Quesnel, & Vecchiotti 2014).

Massachusetts Eye and Ear Infirmary and Harvard Medical School found that close to 100

people were treated for hearing damage due from the bomb blast. This hearing damage included

hearing loss, tinnitus, and balance issues. In addition, people closer to the bomb blasts suffered

ruptured eardrums. Hearing damage is one of the greatest threats to health that remains for

victims of the bombings (Preidt 2014). Tinnitus is one of the more debilitating effects of hearing

damage because patients experience constant ringing in their ear(s), which has no current

effective treatment to reduce the ringing. Tinnitus afflicts several in the military as well, as it is

the number one disability of veterans. Noise exposure is the common cause between Boston

Bombing victims and military veterans. The Department of Veterans Affairs awards more than

$1 billion dollars annually for disability related to tinnitus and hearing loss, and these

populations of victims are increasing the urgency for an effective treatment (Remenschneider et

al. 2014).

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In an article from the Wall Street Journal, Dr. Daniel Lee, who is a professor of otology

and laryngology at Harvard Medical School, declared that Tinnitus specialists in the Boston Area

have been overwhelmed and many patients have been complaining of distress due to Tinnitus.

Philip Littlefield, director of otology and neurotology  at Tripler Army Medical Center in

Honolulu stated that the “bombs not only sprayed shrapnel, but generated tremendous noise,

likely above the level at which ear drums start to rupture” (Levitz 2014). The article goes on to

state that some victims had to change their normal lives routine due to hearing loss. Victims who

ran in the race included a 44-year-old doctor who now sees fewer patients in his office after

damaging his hearing, which slowed him down, and an amputee who lost her lower left leg, who

at 39, now needs to wear a hearing aid in order to hear (Levitz 2014). Although the injuries

sustained from the bombing will remain for most of the victims, it will also serve as a

remembrance for the courageousness displayed on April 15, 2013 by victims and responders

involved. The city of Boston, the United States, and the world has benefitted through lessons

learned from this terrible tragedy.

Preparedness plans resulted in the unanticipated benefit of responders working together

to reduce bomb blast injuries and deaths through model leadership during the response to the

Boston Marathon Bombings. I analyzed how city of Boston facilitated collaboration with internal

and external emergency response partners prior to the Boston Marathon Bombings, how

responders solved problems under emergency conditions following the bombings to reduce

casualties, and the unresolved threats to physical and mental health that remain in survivors of

the bombings to this day. Through the unfortunate happenings at the Boston Marathon, the

lessons learned are resources for future mass casualty events. Public health preparedness, and

medical treatment and research are improving as we speak from the lessons learned. This will

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help victims of the bombings, and prepare future marathons to be safer in which people can

finish the race they started.

Image obtained from http://bit.ly/1To5wHN

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Citations

Beinecke, R. H. (2014). Addressing the Mental Health Needs of Victims and Responders to

the Boston Marathon Bombings. International Journal Of Mental Health, 43(2), 17-34.

doi:10.2753/IMH0020-7411430202

D'Andrea, S., Goralnick, E., & Kayden, S. (2013). 2013 Boston Marathon bombings:

overview of an emergency department response to a mass casualty incident. Disaster

Medicine And Public Health Preparedness, 7(2), 118-121. doi:10.1017/dmp.2013.53

Kellermann, A. L., & Peleg, K. (2013). Lessons from Boston. The New England Journal Of

Medicine, 368(21), 1956-1957. doi:10.1056/NEJMp1305304

Knudson, L. (2014). Hospital preparedness for a mass casualty event. AORN Journal, 100(3),

C1-C10 1p. doi:10.1016/S0001-2092(14)00851-5

Kredlow, M. A., & Otto, M. W. (2015). INTERFERENCE WITH THE

RECONSOLIDATION OF TRAUMA-RELATED MEMORIES IN ADULTS. Depression

& Anxiety (1091-4269), 32(1), 32. doi:10.1002/da.22343

LEVITZ, J. (2014, July 24). Bombings Spur Closer Study of Ear Injuries. Wall Street

Journal - Eastern Edition. p. A3.

Nadworny, D., Davis, K., Miers, C., Howrigan, T., Broderick, E., Boyd, K., & Dunster, G.

(2014). Boston Strong—One Hospital’s Response to the 2013 Boston Marathon

Bombings. JEN: Journal Of Emergency Nursing, 40(5), 418-427 10p.

doi:10.1016/j.jen.2014.06.007

Oser, M., Shah, S., & Gitlin, D. (2015). Psychiatry Department Response to the Boston

Marathon Bombings Within a Level-1 Trauma Center. Harvard Review Of Psychiatry, 23(3),

195-200.

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Preidt, R. (2014, November 14). Boston Marathon Bombing's Legacy of Hearing

Damage. HealthDay Consumer News Service.

Remenschneider, A. )., Brodsky, J. )., Heman-Ackah, S. )., Kujawa, S. )., Lee, D. )., Quesnel,

A. )., & ... Vecchiotti, M. ). (2014). Otologic outcomes after blast injury: The Boston

Marathon experience. Otology And Neurotology, 35(10), 1825-1834.

Rogers, F., Rittenhouse, K., & Gross, B. (2015). The golden hour in trauma: Dogma or

medical folklore?. Injury-International Journal Of The Care Of The Injured, 46(4), 525-527.

Singh, A., Goralnick, E., Velmahos, G., Biddinger, P., Gates, J., & Sodickson, A. (2014).

Radiologic Features of Injuries From the Boston Marathon Bombing at Three

Hospitals. American Journal Of Roentgenology, 203(2), 235-239.

Walls, R. M., & Zinner, M. J. (2013). The Boston Marathon Response. JAMA: Journal Of

The American Medical Association, 309(23), 2441-2442. doi:10.1001/Jama.2013.5965

Yonekawa, Y., Hacker, H., Lehman, R., Beal, C., Veldman, P., Vyas, N., & ... Arroyo, J.

(2014). Ocular Blast Injuries in Mass-Casualty Incidents The Marathon Bombing in Boston,

Massachusetts, and the Fertilizer Plant Explosion in West, Texas.Ophthalmology, 121(9),

1670-+.

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