ddsOne year on from the terrorist attack at the Boston Marathon Dr Dave Sloggett looks at the lessons emerging from the immediate response of bystanders and emergency services professionals to the incident:

Ten minutes before 3 o’clock in the afternoon on 15 April 2013 a 78 year-old pensioner, called Bill Iffing, was ten yards away from the end of the Boston Marathon when he was blown over by the blast wave from the first of two bombs that detonated that day. The second was to go off 13 seconds later approximately 200 yards further up the course. Both bombs detonated in the crowds watching the end of the marathon. The initial scenes at both sites were ones of carnage with people laying around with blood pouring form their wounds and some suffering the loss of limbs.

One of the iconic pictures taken that day shows Bill Iffing being knocked over by the force of the blast. He later observed “my legs just gave way”. It was Bill Iffing’s third Boston Marathon. Lying dazed on the floor the images from that day show that quickly a steward in a yellow jacket picks up Mr Iffing and he turns running and partly staggering the last ten yards to the end of the marathon. Even an attack by terrorists was not going to stop him completing the journey he had set out on 4 hours, 3 minutes and 47 seconds before.

It was the day of the 117th running of the Boston Marathon and it will be one that no one involved will ever forget. Terrorist had unexpectedly come to the streets of Boston. The attack killed three and injured a further two hundred and sixty four, one hundred and eighteen of which had received serious injuries requiring their prompt evacuation to hospital.

Further reading: Boston uncut

The reaction of the steward who helped Mr Iffing to his feet was mirrored by many other stewards, bystanders, medical volunteers and members of the emergency services. In the first few critical minutes they quickly set about their task of trying to help people survive their injuries. Two people were beyond help and quickly succumbed to their injuries. A third died later. But as the result of their actions over 140 people are alive today.

Self-Organising Teams
The images taken at the scene shows how the initial response arose from what can be termed ‘self-organising teams’. Bystanders and medical volunteers who had survived the initial bombing stayed with those who were injured and tried to administer some form of initial treatment for their wounds.

Many of those caught up in the blast were suffering from the kind of soft tissue injuries that are typically experienced by people in close proximity to a bomb blast. To treat the initial injuries bystanders ripped off their shirts and created improvised tourniquets, although it was subsequently noted that this supply did quickly become exhausted.

These prompt actions taken by people in the immediate vicinity without doubt saved many lives. Others began to administer CPR to those who had stopped breathing. The twenty Ambulances located at the finishing line were quickly stripped of their medical supplies.

Further reading: Boston - A new terror lite model?

Around them other members of the emergency services cleared crown control barriers in order to help the evacuation process. Quickly a sense of organisation emerged at the scene as the emergency services personnel mobilised their resources and implemented their crisis response plans.

For those bystanders and medical volunteers providing this initial response a collective sense of responsibility to help the victims quickly arises. Psychologists studying this phenomenon refer to this as a collective sense of identity that rapidly emerges were everyone involved is a victim. Some are just far more seriously injured than others. This is one of the reasons why ‘self-organising teams’ quickly emerge. It is an effect that has been noted at other major incidents around the world, such as the attacks on the railway system in Spain in March 2004 and London Underground in July 2005.

The Central Role of the Medical Tent
One facility that was to play a crucial part in the response was the medical tent that was located around 100 yards from the end of the marathon. Its location was well known to many of those that became involved in the initial response to the incident. It became the de-facto casualty collection point.

This was crucial in assuring a fast response by those who became involved in the evacuation. It was the obvious first port-of-call for those that needed to be evacuated from the initial blast sites. There the medical teams were able to stabilise the patients and then start to make arrangements for their evacuation to local hospitals.

Until the point when the first bomb exploded the medical team had seen the usual run-of-the-mill patients checking into to be given some medical assistance at the end of a marathon. Within seconds of the first bomb exploded few in the tent failed to appreciate the scale of what was about to unfold.

Further reading: Boston & Woolwich - we were warned

That was quickly confirmed when an announcement was made inside the tent that they were to “prepare to receive a large number of casualties”. Within a matter of minutes those first patients began arriving. Many of them arrived in wheelchairs and gurneys that had been left at the finish line to provide help for runners who may have needed medical assistance as they complete the marathon. Some patients were hand carried to the medical tent. This prompt response ensured that all of the casualties with major injuries from the first blast location had arrived in the medical tent within eighteen minutes of the initial detonation.

One of the reasons for the speed of the evacuation was the concern that additional bombs, referred to as secondary devices, may be present to target the emergency response teams. There were even real concerns that the medical tent itself could be a target.

Past lessons learnt
This initial response also benefited from the lessons that had been learnt from the 2012 marathon that had been run on a very warm day. It had resulted in over 2,000 medical incidents occur, with nearly 250 having to be transferred to hospital for further treatment. As a direct result of this additional resources were made available for the 2013 event. They were to prove critical in helping deal with the scale of the casualties that unfolded during the attack.

Almost instinctively, thanks to many previous exercises and well documented procedures, the Mass Casualty Incident (MCI) procedures started to be implemented. Arrangements were put in place to secure the crime scene and ensure the evacuation of the most critically injured patients to local hospitals was started. The speed with which these procedures were implemented is a tribute to the preparations that had been taken in the wake of a number of major spree shooting events in the United States.

At this point the training that many Boston hospitals had routinely undertaken for dealing with an MCI proved its worth. The procedures allowed the hospitals involved to manage the arrival of the casualties and avoid the kind of problems that an unexpected surge of people with life-threatening injuries could have created.

Six category one trauma centres in Boston received one hundred and sixty four patients. Thirty-eight were evacuated to Brigham and Women’s Hospital and thirty seven to Massachusetts General Hospital (MGH). Boston Children’s Hospital received eight casualties. In total between forty five and fifty ambulances were involved in the response out of a total of sixty eight that had been mobilised to the staging area within fifteen minutes of the blasts occurring.

At the receiving hospitals the emergency teams cleared the Emergency Department, started to prepare operating theatres and pre-positioned trauma teams to conduct another level of triage as patients arrived. Radiotherapy departments were also placed on alert. At MGH the decision was taken to suspend routine CT scans and also place mobile imaging units on standby. All of this worked smoothly. That is a tribute to the regular exercises that had been held in the area involving imaginary incidents that had far higher casualty counts and even involved a Chemical, Biological, Radiological and Nuclear (CBRN) response.

Real resilience
The low fatality count at this incident is a mark of the speed of the immediate response involving medical volunteers and untrained bystanders at the scene. Their improvisation saved many lives. But other factors also played a critical part. The close proximity of the medical tent was critical. It ensured that those with grievous injuries did receive prompt medical care.

The efficiency with which the MCI procedures were enacted also enabled the designated receiving hospitals to arrange for the smooth handling of the patients once they arrived. This reaffirms (if it is really needed) the benefits of routine exercises and especially those that involve dealing with large-scale events. It is only they that really test the resilience of any operational response planning.