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The key to saving more lives in a mass violence incident

Good communication and pre-planning: What the Boston Marathon bombing taught us


Relationships, prior planning, and the fact that operating in an all-hazards incident team or EOC was second nature to the responders is an important level of readiness to attain.

Photo/Associate Press

Protests, riots, civil disorder and terrorism all tax and task first responder agencies. Whether it’s in the planning, preparation or participation stages, or the rapid deployment to an unscheduled, unplanned event, we in EMS are front and center.

In recent memory, we have witnessed every type of event from 9/11 through the Boston Marathon bombing, to active shooters and many others, sadly too numerous to mention. In some of these events, we were deployed, ready and prepared, hoping that all would be OK. In others, we had to run into the storm.

One of the key issues in the aftermath of any event is to conduct a detailed after-action review (AAR) – as well as an immediate team debrief and wellness check – to identify the issues we wish to single out and, if necessary, work on to ensure the next event runs a little smoother. Identifying lessons from an event is a key activity on the way to ensuring that we learn by absorbing what happened, and exercise and drill the scenario to ensure our future actions are well-rehearsed and further contribute to lifesaving.

The major lesson identified from any mass casualty incident caused by extreme and focused violence of bad actors is communication. The stress of the situation, the “fog of war,” and the lack of interoperable comms systems all add to the initially confusing scene and delay the ability to gather and form a common operating picture that then leads to organization and order.

The AAR on the World Trade Center attack on 9/11 highlighted communication failures and lack of interoperability as major lessons. To effectively deal with the outcome of violence, our drills, tactics, techniques and procedures must be understood and rehearsed. Planning must consider every possible twist and turn, and protocols must be developed to deal with them. The key to 911 response and life-saving therefore sits in the plan, or if there is no plan, at least the muscle memory that comes from training and exercise.

Lessons identified: The Boston Marathon bombing

On Apr. 15, 2013, Dzhokhar and Tamerlan Tsarnaev set off two explosives near the finish line of the Boston Marathon. The explosions resulted in three fatalities and over 250 injured. The AAR commended the high levels of preparedness and the strong and collaborative response effort from many agencies. The level of preparation and preparedness section noted that “safety planning exercises and the robust medical support at the marathon helped to minimize casualties/damages.” The report went on to note that “medical services performed especially well in the response effort, as they were able to coordinate the appropriate services for victims, families of victims and survivors.” The ability to keep the public informed about the closure of facilities and services is also touted as one of the response effort’s strengths.

A pre-planned MCI

Boston EMS Superintendent of Field Operations Joe O’Hare served as commander of dispatch operations in 2013. He told me that in terms of planning for such an event, “we always looked at the marathon the same as we looked at the 4th of July and other large scale events, a kind of MCI that we never actually thought would happen.” Nevertheless, planning and cooperation played a large part in the response to the attack.

Boston EMS’ training approach to dealing with large scale events begins at the new hire academy and is carried on through annual refresher training. O’Hare explained that everyone gets trained right from the academy in MCIs, and they continue to train every year. Nine months out of the year, they have mandatory training and run it 24 hours a day across a three-schedule calendar. The consistent approach to training ensures that every member of the staff is comfortable with such large-scale operations.

MCI partner capabilities

A major issue and finding with many MCIs is that communication often becomes the first casualty. The levels of planning and training in Boston ensured that this was not the case. O’Hare observes, “knowing your counterparts is a major requirement for good disaster response. That only comes through exercise and planning before the day.”

In addition to maintaining good public safety relations planning, long-standing systems with local hospitals aided reception and treatment on the day of the bombing. “We have multiple level one adult trauma centers, two adult to pediatric level one trauma centers, and a burn center,” O’Hare reported. “We have a preplan that we update pretty regularly for MCI. So, we reach out to all the hospitals within the city and then some, just outside the city that we will occasionally transport to. And we look to them to provide us their 24-hour-a-day capability, no matter what it is.”

Because of this level of understanding, the system level was understood, and a division and diversion of patients were able to be achieved with relative ease. Communication occurred at all levels as a result.

Lessons Identified

The after-action report, as it relates to EMS operations, supports O’Hare’s sentiments on prior preparation, planning and liaison. A key ingredient to any joint public safety response event is liaison and familiarity. Senior commanders should not meet for the first time on the day of the event. From an EMS perspective, this aspect was a success and should be emulated. The AAR noted key points, the question being – can you say the same of your command team, EOC or all-hazards incident management team?

  • Strong relationships and successful unified command. Strong relationships created and maintained by key leaders were paramount to ensuring commanders, agency heads and political leaders came together quickly to form unified command and facilitate collaborative decision-making after the bombings in Boston and during the manhunt in Watertown. Key leaders had the necessary trust and rapport that allowed for unified command to make effective, collaborative decisions, execute mission-tasking, maintain situational awareness, and coordinate public messaging.
  • All-hazards medical system for marathon day. The all-hazards medical system in place on marathon day ensured that the capabilities and capacity to quickly triage and transport the injured from the scene of the incident were immediately available. An enhanced, all-hazards medical system was put in place with the intent of taking pressure off the area hospital system by minimizing the number of patients who needed to be transported to hospitals. On the day of the bombings, medical personnel supporting the alpha medical tent near the finish line immediately transitioned to a mass casualty response. 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., every patient who was transported to area hospitals survived.

Level of readiness

Overall, the response to the Boston Marathon bombings must be considered a great success. Although many patients sustained grave injuries, every patient who was transported to an area hospital survived – a credit to the emergency medical system, the swift triage and transport of the most critical patients, and the care they received at area hospitals.

Relationships, prior planning, and the fact that operating in an all-hazards incident team or EOC was second nature to the responders is an important level of readiness to attain. The high levels of communication aided command and control, and without that, any event or operation is guaranteed a poor outcome. This is one lesson we must learn and takeaway.

The key to saving more lives in a mass violence incident: EMS One-Stop With Rob Lawrence

Listen below for an audio version of this article and a bonus guest as Rob is joined by Boston EMS Superintendent of Field Operations Joe O’Hare to discuss mass violence response.

This article was originally posted Nov. 11, 2020. It has been updated.

Rob Lawrence has been a leader in civilian and military EMS for over a quarter of a century. He is currently the director of strategic implementation for PRO EMS and its educational arm, Prodigy EMS, in Cambridge, Massachusetts, and part-time executive director of the California Ambulance Association.

He previously served as the chief operating officer of the Richmond Ambulance Authority (Virginia), which won both state and national EMS Agency of the Year awards during his 10-year tenure. Additionally, he served as COO for Paramedics Plus in Alameda County, California.

Prior to emigrating to the U.S. in 2008, Rob served as the COO for the East of England Ambulance Service in Suffolk County, England, and as the executive director of operations and service development for the East Anglian Ambulance NHS Trust. Rob is a former Army officer and graduate of the UK’s Royal Military Academy Sandhurst and served worldwide in a 20-year military career encompassing many prehospital and evacuation leadership roles.

Rob is a board member of the Academy of International Mobile Healthcare Integration (AIMHI) as well as chair of the American Ambulance Association’s State Association Forum. He writes and podcasts for EMS1 and is a member of the EMS1 Editorial Advisory Board. Connect with him on Twitter.