The Boston Bombing Review: What Went Right and Wrong?

The 2013 Boston Marathon bombing wasn’t as bad as it could have been, and for that the official after-action report credits quick-acting medical responders and a well-designed system that allowed successful treatment of large numbers of patients fast.

The 130-page analysis, developed by the Massachusetts Emergency Management Agency and other entities involved in the response and aftermath, recounts the day’s events and conducts a five-part capabilities analysis spanning all aspects of operations. The latter looks at preparedness, the initial response, the ongoing response, the apprehension of suspects and the recovery.

The medical response fares well under the scrutiny. While many people were seriously injured, the report notes, every patient who was transported a local hospital survived. “This can be directly attributed,” it concludes, “to the rapid triage, transport and treatment these patients received on scene and at hospitals.”

Medical personnel in tents near the finish line earned particular praise: “Medical personnel supporting Alpha Tent near the Finish Line immediately transitioned to a mass-casualty response,” the report says. “They established triage and treatment groups and designated the tent as a casualty collection point. All critically injured patients were transported to area hospitals within 50 minutes.”

What Went Right, Wrong

The report recognizes three key best practices that contributed to the successful response and identifies three areas in need of improvement. The good:

• Strong relationships and successful unified command—Top leaders and agency heads were familiar with each other, and their trust and rapport helped them collaborate successfully. This simplified critical steps like obtaining resources and coordinating communications.
• The all-hazards approach—The extensive medical system in place on Marathon Day—implemented by the Boston Athletic Association with a goal of minimizing transports and not overtaxing hospitals—provided capacity to triage and aid large numbers of patients quickly.
• Well-planned and organized reopening of Boylston Street—Residents and business owners had access to their properties within 18 hours after the city completed its cleanup and passed control over to the Boston OEM, which planned the reopening. The street was reopened to the public less than 36 hours after.

The bad:

• Lack of mutual aid coordination/management in Watertown—A “significant portion” of LEOs involved in the Watertown search self-deployed, and there was no command or management structure in place to handle incoming mutual aid personnel.
• Lack of weapons discipline—This was noted during both the April 19 firefight that preceded the death of Tamerlan Tsarnaev and the standoff with Dzhokhar Tsarnaev later that day.
• Lack of a joint information center—Personnel at the unified command center helped coordinate messages and host press conferences, but a JIC would have better handled media needs over the course of the event. Public messaging lost coordination once the UCC stood down. Some agencies used social media to disseminate information without coordinating or validating it, leading to misinformation.

Overall, the report concludes, the response was a great success, particularly from the medical end. It credits the emergency medical system, quick triage and transport of the severely injured, and good care at hospitals for the fact that no transported patient died.

Among the extra resources Boston EMS had at hand to contribute to that were more than 120 extra personnel and 13 additional ambulances. Providers worked the tents and along the course in foot teams and on bikes and carts.

 “The plan was built up over years of experience with this race,” says Boston EMS Chief James Hooley. “We’ve had to worry about extremes of weather and everything else. In 2012 it hit 87ºF, and in Boston alone we transported 84 people from the course and tents. So among the things that came out of 2012 was that we all decided we had to increase capacity. The hospitals ramped up even more than they had. Every year you make adjustments based on what you learn and hear about in other races. There was a lot of attention to capacity that put us in a good position that day.”

The Attack and Initial Response

The Tsarnaevs planted two IEDs that exploded 13 seconds and 180 yards apart. These killed three people and injured 264 more, including 16 who suffered traumatic amputations. Responders on scene identified the explosions as likely intentional but nonetheless rushed to help survivors. Law enforcement had an ad hoc UCC up within 40 minutes.

Lots of medical resources were clustered around the finish line, including predeployed air-monitoring devices to detect contamination from dirty bombs. The nearby Alpha medical tent had advanced medical technology and treatment capabilities geared to help runners on scene. When the bombs went off, there were 16 ambulances staged in Copley Square; Boston EMS requested more and had an additional 73, including from mutual aid partners, staged within minutes. Told to stand by until the location and scope of the incident were clear, EMS units remained staged outside the blast area.

The worst-injured received essentially “scoop and go” care, with tourniquets to stop bleeding and fast transport to hospitals. Ambulances were outgoing with patients within nine minutes of the first detonation. Some were loaded on Boylston Street, others through the Alpha tent. Constant PA messaging within the tent helped keep loading paths clear. Lesser-injured patients were triaged, prioritized and staged near the ambulance loading area; some went to hospitals in private vehicles. Police worked to keep surrounding roads clear.

The second blast site was up the street from the Alpha tent and hard to access among fleeing spectators, interlocking barricades and emergency vehicles. Nearby firefighters, police and spectators got there first; one critical patient was transported in a BPD patrol wagon. Boston EMS arrived within minutes, took over triage and care, and established a second loading area.

Loading officers at the Alpha tent and both blast sites worked with medical control to coordinate transports to receiving hospitals based on patient condition, special needs and hospital capacity. This prevented any hospital from becoming overloaded. Ambulances transported a total of 118 patients from the scene.

“Patient distribution turned out to be very important,” says Hooley. “Those 118 patients were spread over about nine hospitals; the idea was to not inundate the closest hospital. All the hospitals said afterward they’d had the capacity for a bit more.”

Hospitals were alerted and initiated their MCI plans quickly; one flaw, however, was that they were not notified that the air detectors had ruled out dirty bombs. This slowed their intake of patients. All ultimately decided against deconning, however, based on patient severity and the absence of specific information about contaminants.  

Ongoing Activities

Following the bombing, the report says, “The health and medical needs, both physical and emotional, of survivors, witnesses, responders and the community as a whole required substantial coordination.” Hospitals focused on medical care that for many patients was very complex, requiring surgeries, rehabilitation, physical therapy and treatment for secondary injuries. They also struggled to balance sharing information with respecting patients’ privacy. They ultimately developed a centralized list of patients maintained by the Boston Public Health Commission’s Medical Intelligence Center (MIC). The MIC idea came out of the 2004 Democratic National Convention as a way to help hospitals collaborate, coordinate and share resources.

Other entities tended to the mental health needs of the affected. So many providers wanted to help that the MIC had to take over requests and logistics. It took two days to streamline the process, but services became available. A federal mental health team dispatched through coordination with regional HHS staff arrived and got to work quickly, giving state and local entities time to get going.

Best Practices, Areas to Improve

With each of the report’s focus areas, authors list best practices and areas for improvement. One best practice in preparedness was the development of relationships and integrated planning with multijurisdictional exercises.

“You know you may have to rely on those people in the next town,” says Hooley. “A lot of EMS in the cities that border us is done by private companies that have 9-1-1 contracts. So when we do our training, we always try to include them, because we never know which community’s going to get to host the disaster.”

The swift determination of CBRN noninvolvement was a positive, and plans are to update hospitals earlier if it happens again. “It’s one thing to say, ‘Be careful, we have radiation,’” says Hooley, “but it’s just as important to give out a pertinent negative—that’s one thing you can take off the table. That was a good lesson learned.”

Best practices in the initial response included fast transition of the medical system to an MCI response; swift establishment of unified command and a UCC; use of Incident Command to control EMS resource deployment; patient distribution; and good communication to prevent emergency vehicles from blocking access.

One area to improve was what the report called a limited use of triage ribbons and tags.

“In some ways that’s fair,” says Hooley. “People did categorize colors. As we went back through the logs and tapes, they’d announce that when they’d call in. But in some cases tags weren’t applied. I don’t think anybody suffered any ill effects because of it. One of the doctors told me when they scanned the patients coming in, maybe 50% had MCI tags on. He said in the end, because they didn’t get that many patients, everybody who came in still got secondary triage by them, so it really wasn’t of so much consequence.” In a larger incident, however, where hospitals are forced to rely more on EMS triage determinations, that could become more important.

Beyond the report, the biggest lesson for Boston EMS really came down to networking. Its leaders have been studying MCI responses and culling lessons essentially since Oklahoma City. They’ve learned from leaders from London, Madrid, Israel and Pakistan. They’ve not missed a chance, in other words, to gather insight that could better their responses to major events.

“There’s value in talking to your counterparts in other places,” says Hooley. “You learn the shortcuts, you learn things like, ‘Hey, this was in our playbook and we had to completely disregard it—we thought it’d work, but it didn’t.’ That’s why people publish things like this report—so you can debate and discuss it. There’s a lot of value in talking about these things.”

Find the complete report at https://www.mass.gov/eopss/docs/mema/after-action-report-for-the-response-to-the-2013-boston-marathon-bombings.pdf.