The Boston Marathon Response
Authors: Ron M Walls, Michael J Zinner
Journal: JAMA (2013)

ON MONDAY, APRIL 15, 2013, BOSTON EMERgency medical services and other agencies transported scores of casualties to local hospitals within 90 minutes of the 2 explosions at 2:50 PM near the Boylston Street finish line of the 117th Boston Marathon. Brigham and Women’s Hospital received 39 casualties overall, 31 on Monday, and 23 of these in the first hour. Many of these patients had severe injuries, including penetrating head and neck injuries and exsanguinating orthopedic blast injuries. Other trauma centers in the area received similar patients in similar numbers. Overall, only 3 people were killed by these explosive devices, and all 3 died before reaching the hospital. Not one patient who arrived at a hospital subsequently died. How did this happen? This astoundingly high survival rate, despite the nature and severity of the injuries, is a tribute to the courageous and rapid response of bystanders and first responders, expert field triage, rapid transportation of injured persons, and the skills and coordination of the receiving hospital trauma teams. It is also, however, the product of a confluence of deliberate actions stretching back to September 11, 2001, augmented by a series of providential but not random events. Consider first the deliberate actions. On Friday, November 8, 2002, about 14 months after the World Trade Center attacks, the city of Boston, Boston emergency medical services, and the 14 hospitals of the Conference of Boston Teaching Hospitals cooperated on a large-scale disaster drill dubbed Operation Prometheus, which simulated explosion of a dirty bomb on an inbound airliner. Brigham and Women’s Hospital received 72 simulated patients, including 12 requiring decontamination. The hospitals and local agencies continued to work to refine the response. For example, from 2006 to 2012, Brigham and Women’s Hospital conducted or participated in 73 separate exercises, events, and disaster activations. In addition, the hospital conducted tests on communications systems, power backup, and internal procedures, in all a total of 623 separate exercises. In 2010, Operation Falcon, coordinated by Metro Boston Homeland Security, tested system-wide response to a mass casualty bombing, complementing previous exercises in 2007 and 2008. Through these exercises, sparked in part by the events of September 2001, the city and the hospitals within it increasingly were prepared to coordinate and provide care for a large number of injured persons. The second deliberate action occurred on July 20, 2012, when James Holmes killed 12 people and injured 58 others in a multiplex cinema in Aurora, Colorado. Analysis by the University of Colorado Health Sciences Center showed arrival of 23 critically injured patients in approximately the first hour. This was sobering. Although the Boston hospitals had prepared, trained, and drilled for mass casualty events, the challenge of receiving so many critically ill patients so rapidly at a single hospital had not been specifically addressed. The third deliberate action was a direct consequence of the second. Brigham and Women’s Hospital worked with disaster preparedness leaders to analyze the University of Colorado timeline and the nature of the injuries to determine whether staff could optimally respond to an event of similar proportions. This led to a presentation to the Board of Trustees entitled “Are We Ready?” In the course of this review, the need to perform additional incident command training, particularly for senior leaders, was identified, and efforts were initiated to move preparedness to a higher level. The fourth deliberate action occurred over the last 2 years. With the mutual desire to improve communication and team performance, trauma surgery and emergency medicine, along with emergency nursing, worked together to provide team training for trauma team members in the hospital’s medical simulation center. This training would prove invaluable when multiple trauma teams had to be assembled at once. Together, these actions were waypoints along the path to readiness. No amount of preparedness, however, is truly sufficient to address the enormous number of casualties produced by the improvised explosive devices that were detonated on April 15. It was here that providence played a key role. A series of related and unrelated circumstances created an environment that would tremendously enhance emergency response from the scene of the bombing all the way into area emergency departments, operating rooms, and intensive care