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EMS News in Focus
by Arthur Hsieh

5 triage lessons learned from the Boston Marathon Bombing

At the NAEMSP annual conference, emergency medicine physicians shared the value of ‘worst-case scenario’ planning

By Arthur Hsieh

At the 117th running of the Boston Marathon, EMS and other on-scene medical professionals were prepared to handle the usual influx of runner and bystander injuries that come from an athletic mass event. But for the physicians who were part of the medical team that day, the double bombing that occurred at just past 3 that afternoon in April dramatically changed not just the tenor of the event itself, but also how patients were evaluated and treated immediately after the incident began.

Such was the message of the opening presentation at the National Association of EMS Physicians’ annual conference held in Tucson, Arizona, January 16-18, 2014. Drs. Adam Darnobid, Ricky C. Kue and David J. Hirsch spoke to the challenges and success the medical teams experienced during the hour it took to evaluate, initiate austere care, and transport 118 patients to area trauma centers and hospitals. Several themes appeared during the presentation that EMS providers and organizations should consider when preparing for their own worst-case scenario.

1. Being overly prepared is good.

In 2012, the medical teams saw a dramatic rise in the number of patients they managed — over 2,100 medical incidents were recorded, with 11 percent transported to area hospitals. This was attributed to unusually warm conditions during the marathon. As a result the medical team increased surge capacity for 2013, in both staff and supplies. This may have been influential in the immediate, full response to the bombings.

2. Triage occurs at many levels.

When the bombs detonated, Dr. Hirsch stepped outside of his post within the forward medical tent to see what was happening. Within moments he and other medical responders realized there had been a bombing and that help was urgently needed.

As he arrived at the scene itself, multiple critically injured victims were lying where they were cut down by the blast, with numerous amputations and massive soft tissue injuries. The available number of tourniquets was rapidly exhausted, and shirts, belts, surgical tubing and other devices were rapidly deployed to stem the massive bleeding.

Dr. Hirsch noted that the formal scene triage was difficult, especially when nearly all of the patients were immediate reds. Most of the green patients had already fled the scene, and there were essentially no delayed patients. Another problem with triage was that the triage tags were difficult to slide in and out of their plastic sleeves; more often than not, the tags ended up on the ground, separated from their victims.

Most of the actual triage occurred at the medical tent, which turned into a casualty collection point. Once the victims arrived there, they were more thoroughly evaluated so that the most critical of the critical patients were transported first.

3. The potential of secondary devices is real.

Nearly all of the patients at the first bombing scene had been either transported or moved to the medical tent within 18 minutes. The alacrity wasn’t just because of the extent of injuries — medical personnel had been notified by on-scene law enforcement that there was a real possibility of another device.

That additional pressure influenced the rapid evacuation of the victims, using everything from gurneys to wheelchairs to hand carries. Even within the medical tent, the presence of a secondary threat hung over the team as they worked to have the victims removed.

4. Coordination and communications are key.

There were many resources immediately available at the blast scene — perhaps too many. Coordinating the number of medical personnel was a major challenge. There was also a loss of cell phone communications as the local towers were overwhelmed. However, the mutual aid radio system remained functional, as did the main Boston EMS communications net. Hospitals were notified within the first few minutes of incoming casualties, and 68 ambulances were moving to the staging area within 15 minutes of the blast. That proved essential in getting critically injured patients to trauma care.

5. The priority of trauma is the movement of the patient to definitive care.

One of the challenges the physicians faced was getting other, nonemergency physicians to realize that the patients required immediate transportation to a trauma center. The level of care at the medical tents was simply not sufficient to manage the injury level, remarked Dr. Darnobid. There were moments of tension between the medical staff and the EMS personnel, and it became apparent that the medical tent was not a point of care for the blast victims, but a point of collection and distribution. Once the team made the transition, patients were rapidly transferred out of the treatment area.

What’s your worst-case scenario? Is your organization prepared for such an emergency? Please discuss in the comments section.

About the author

EMS1 Editorial Advisor Art Hsieh, MA, NREMT-P currently teaches at the Public Safety Training Center, Santa Rosa Junior College in the Emergency Care Program. Since 1982, Art has worked as a line medic and chief officer in the private, third service and fire-based EMS. He has directed both primary and EMS continuing education programs. Art is a textbook author, has presented at conferences nationwide, and continues to provide patient care at an EMS service in Northern California. Contact Art at
The comments below are member-generated and do not necessarily reflect the opinions of or its staff. If you cannot see comments, try disabling privacy and ad blocking plugins in your browser. All comments must comply with our Member Commenting Policy.
Brenton Lee Dulak Brenton Lee Dulak Monday, January 20, 2014 8:08:08 AM AKA Everything that an experienced Military Medic already knows. Next thing you know they will be saying "Hm, maybe tourniquets are not such a bad idea when used properly." The EMS system is dying because it is not changing and adapting, as medicine is. Get with the times and dump the antiquated BS.
Kelsea Lewis Kelsea Lewis Monday, January 20, 2014 10:57:35 AM Learned from the Boston bombing? I remember all of this from PHTLS
Brenton Lee Dulak Brenton Lee Dulak Monday, January 20, 2014 10:59:16 AM Change is slow and painful in the field, meanwhile patients suffer and die.
Aaron Lawrence Aaron Lawrence Monday, January 20, 2014 5:34:46 PM I'm conflicted. It's good info and I'm glad people are taking notice and pushing it out, but it annoys me that this information is written as if its new and groundbreaking, and we get a blurb at the end with a bunch of acronyms telling us how qualified and intellectual the author is. Really?? The kids coming straight out of Ft. Sam know this because it was well taught and reinforced. I agree, get with the times.
Ed McCarthy Ed McCarthy Thursday, January 23, 2014 8:48:00 AM I don't know why this article is worded the way it is. Boston EMS trains for this kind of mass-casualty event constantly. Crews paid attention to trainings that took lessons from Iraq and Afghanistan. One of our docs was deployed there, and stressed tourniquet use. Those that hadn't yet been issued CAT tourniquets made several of their own, and used them to great effect on scene after the blasts. With over 90 critical trauma patients, NO PERSON EVACUATED FROM THE SCENE SUCCUMBED TO THEIR INJURIES as a result of Boston EMS-led pre-hospital care. According to EMS Chief of Department James Hooley, over ninety victims were triaged within moments, and categorized by severity, largely at the tent. The most seriously hurt were transported to receiving hospitals within fifteen minutes of the blasts. By the time 30 minutes had elapsed, ALL of the injured from the blast zones were assigned hospitals, and were en-route to definitive care - a miraculous feat. The "Credit Pie" has many slices to pass out: Boston EMS communications (The Turret) who coordinated the hospital assignments, and EMS resources, Forward thinking physicians plugged into EMS, Special Operations who saw to the planning / preparations for the event, volunteers, and others. There is no dust on Boston EMS.

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