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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-+.