On 15 April 2013 at 14:29 hours, two improvised explosive devices (IED) exploded within 15 seconds of each other in Boston. The devices were constructed within common pressure cookers concealed within two separate backpacks and built using low grade explosives, metal shards, and common BBs to create a field of shrapnel upon detonation. The explosions occurred approximately 200 yards apart at the Boston Marathon finish line. The devices were placed on the ground behind the metal barriers that kept spectators out of the street where the runners were arriving at the finish line. At the time of the event only two thirds of the runners had crossed the finish line (Serino, 2013).
The event caused three deaths, including an 8-year-old boy, all of whom died before reaching the hospital. Boston EMS triaged and transported 90 of the 264 injured people. Of those, 30 were triaged as red and were transported within 18 minutes of the explosions. The balance was transported within the first 30 minutes. The most critically injured suffered traumatic amputations, penetrating chest, and neck and head wounds. Patients were distributed in a manner that enabled the hospital community to manage patients effectively without any delay in care. Patients requiring specialty care arrived at specialty facilities directly without being transported to intermediary facilities.
In the follow on to the event it became quickly apparent that Boston EMS, in collaboration with the health community had achieved, by any standard, an effective response. One determining factor was the survival of victims; in Boston no victims died who survived the initial blast. This success did not happen by chance. In the wake and review of the events it became apparent that the successful response during the Boston Marathon was the result of decades of preparedness. The recipe of a successful response is not a destination, but a journey that is continuously evolving and enabling a culture of collaboration that leads to a community that is ‘Boston Strong’.
This article will not dwell on the actual response events as other reports and articles have done that well. The intent is to discuss the underlying principles that led to a successful response by Boston EMS and the other parts of the community response system. As will be discussed, the whole community of Boston participated in not only the response that day, but was integral parts of the recipe that created such a successful response.
Foundation
The response to the 15 April, 2013 Marathon Bombing was not a fortunate event. Nor were the stars just perfectly aligned for a lucky response. In fact, the foundation of a successful response is built around several strategic factors evolved over a number of years that ultimately enable a community to respond to an unanticipated crisis effectively. These factors can be summarised as leadership, resource development, day-to-day operations, collaboration, planning and exercising. Over a number of years, Boston as a community, but Boston EMS specifically, evolved all of these strategic factors, but most significantly, provided the consistent leadership to enable the community to be prepared for the worst.
Leadership
Leadership is frequently discussed as an important ingredient in evolving effective emergency response organisations. Understanding that requirement and fostering its effects over a long period of time are not entirely common in our governmental structures. The leadership of the community, whether it is governmental, private sector or nongovernmental organisations must be engaged and participatory in a community's safety and health. In Boston, leadership came in the form of a longstanding mayor, a long-standing EMS chief, as well as long-standing senior officers, many of whom had grown up in Boston and fundamentally felt a responsibility for providing the best possible care to the citizens and visitors of Boston. Boston EMS began as part of the city-operated hospital and healthcare safety net, thereby inculcating a history of health care-focused practice within the department, not just public safety response. As the agency evolved, and as health care in the US changed, Boston EMS evolved and became part of the Boston Public Health Commission (rare structure in the US), the department's mission is ‘to protect, preserve, and promote the health and wellbeing of all Boston residents, particularly those who are most vulnerable’ Boston Health Commission, 2010). This fundamental day-to-day mission is a cornerstone in the foundation of preparedness by which one EMS agency has become a leader in community preparedness, not just for large-scale events, but every day.
In the mid-1990s the US became aware of the need to be better prepared for no-notice events, especially terrorism. The Murrah Federal Building explosion in April of 1995 brought a stark vision of the incredible violence that can be perpetrated when explosives are used in large quantities on an unsuspecting public. Leaders have the responsibility to identify risk to the citizenry and develop a process to mitigate the risk when possible, but equally important, prepare to manage the consequences of that risk and minimise impact to the community. The need to develop preparedness process for the unusual events, manmade or natural, became part of every large city's operational paradigm. Improving process, planning and resources within any governmental structure can take time. The political process by which the US operates is not quick and it frequently takes years to change policy and funding mechanisms to affect the underlying operational direction of an organisation. A unique environment within Boston was its consistency in leadership. Focused and sustained leadership at the highest political and operational levels is one of the key factors in moving a community's preparedness forward as it allows for long-term vision, allocation of resources and evolving collaboration to be become successful operational doctrine.
Long-term strategic planning can only be successful with consistent ‘champions’ who work over a long period of time to lay the foundation that enables community response systems. The successful event response is based upon a culture of preparedness principals that are applied each and every day.
Resource development
Inherent in any successful EMS agency is the need to be appropriately resourced. Although it is impractical for communities to be resourced at such a level that they can manage even the most unusual and catastrophic events, a community that recognises its requirements and implements a strategy that ensures adequate capacity within its capability will ultimately manage better than those who don’t. How communities determine that appropriate level of resources historical was both an exercise in managing large spreadsheets, but also the need to be politically adept in order to navigate the budgetary gauntlet of any large organisation. In years past, basic data elements around response times and call location would be used to identify ambulance posting locations or stations. Now we have the ability to make better determinations by incorporating the massive variables around traffic flow, time of day and hospital availability and resources. Using advance technology as Boston did, enables better communications, better situational awareness and ultimately leads to operational decision-making that improves patient outcome every day and especially during large-scale events. Former Chief Richard Serino of Boston EMS and recently retired Deputy FEMA Administrator is quoted as saying at Congressional hearing after the bombing that, ‘Both Massachusetts and Boston invested state, local and federal grant funds in systems that were critical during the response, including the stand-up of an Emergency Patient Tracking System, which is a secure, web-based application that facilitates incident management, family reunification, and overall patient accountability during emergency incidents. This system made a difference on April 15th, as it helped ensure that not a single hospital in the city was overwhelmed with patients in the aftermath of the bombings. In part because of the investment made in that system, and in no small part of the outstanding work of our first responders, patients were triaged and transported in an orderly manner to the appropriate hospital based on their needs’ (Serino, 2013: 51). EMS operations in large communities is a dynamic and data-laden environment that requires synergy of leadership, staffing, training, equipment and technology
Someone once said, ‘Strategy lacking resources is rhetoric.’ This statement connects, in no uncertain terms, the fiscal obligations of a community to support the response system, not just give it lip service. Boston EMS did not arrive on the day of the marathon explosions with all of the resources it needed by accident. The process of right resourcing was years in the making both through annual budgetary allotments, managing successfully the revenue recovery of the health insurance system, and aggressively pursuing methodologies to augment budgetary support through various grant systems made available in the post September 11 environment. Where many first responder systems around the country used Federal terrorism funds for equipment, Boston EMS invested in capability through rigorous training systems for not only EMS staff but also for hospital staffs and other first responders across the region. This sharing of resources across the response community was somewhat unique and has been cited as one of the reasons that events such as the marathon operate so well (Serino, 2013: 48). The city of Boston also made significant investment through its own financial system to grow Boston EMS, enabling a better resourced system.
Day-to-day operations
Over the years, Boston EMS worked to evolve a resource environment that enables success every day. It has been frequently noted that ‘if you can’t do it every day, you won’t be able to do it on disaster day.’ This operational dictum that ‘day-to-day’ success leads to success during disasters cannot be over stated. Metrics of day-today operations usually revolve around response time intervals and cardiac arrest data. Most would agree that neither have much to do with a disaster response. But as surrogates of day-to-day capacity and capability both of these discrete metrics offer visibility into a well-run EMS system. In the case of Boston EMS, they respond to all priority calls in less than 6 minutes (Boston Emergency Medical Services and Boston Public Health Commission, 2013) and have reported ventricular fibrillation cardiac arrest survival rate above 40% (Davis, 2005). Evaluation of this sort of data does not come easy or without resources. Fortunately, in this day and age, it can be accomplished quickly and efficiently via a strong technology system that supports the overall goals of an EMS system. Technology doesn’t fix our systems; it enables us to understand our systems and develop solutions to issues that inhibit our goals of high quality patient care, safety of our staff and the evolution of a resilient community.
A principle of successful day-to-day operations is the ongoing analysis which in real time operationalises information, situational awareness of the operational environment and analytical capability. Although these processes are inherent in a high-performing EMS system, it is difficult to build these capabilities into a poorly resourced system. In lesser resourced systems, each day brings challenges of staffing, vehicle acquisition, maintenance issues and public expectations. ‘In God we trust, everyone else brings data’ represents the new requirement in EMS that data drives decision making.
Many systems have varying data systems for use daily or for events, but few have created a specialised information system that operates during crisis or planned events as a regional health information hub. In Boston, the creation of the Stephen M. Lawlor Medical Intelligence Center in 2009 provided a physical location under which the healthcare community could convene an operational information and intelligence group during large events and crisis and also serves as the Boston Public Health Commission's operations centre (Boston Public Health Commission, 2013). This centre has become the centre for all medical information in Boston during special events and disasters. The room is populated with members of the public health and healthcare community and enables incredible medical information collaboration.
Collaboration
Post the Boston Marathon bombing much was written and expressed by Boston public safety officials about the collaborative environment that enabled an effective response. What has evolved in Boston is beyond an environment and really is a culture of collaboration. This culture has evolved during decades of collaborative support across the public safety agencies, the healthcare community and non-governmental organisations for the numerous planned events that occur annually in metropolitan Boston.
A catalyst that ‘jump-started’ the environment came in 2004 when Boston hosted the first political convention post September 11, 2001 and as such a significant concern was that it could be terrorist target. This event altered the current event planning process in Boston and evolved it to a regionalised collaborative effort not seen previously. Significant funding was received from Federal sources to support the safety and security of the event under the National Special Security Event designation. As part of the regional planning process micro grants were distributed across the region by the City of Boston to support the collaboration and response during the event. Nothing says collaboration like sharing a funding stream. This set a new standard in Boston and built incredible trust and cooperation among the metro Boston response community.
Collaboration became the operational requirement in Boston for each special event where there was a collective planning environment to support the needs of the event. A need to share the event became the standard thus enabling the culture of collaboration.
Planning and exercising
Planning for large events is a local process that must be led and supported. If the leadership of the community is not engaged and participating in the planning it will simply not be taken seriously by the participants or the community. Boston plans several large-scale events each year and have honed their processes over years of collaboration. Each year Boston uses the planned events as planned disasters under which they may exercise each relevant system. Boston EMS leads the medical component of the preparations and draws in the non-governmental community systems as partners in planning, preparedness and exercising. Whether it is the long-standing partnership with the Boston Athletic Association (operator of the Boston Marathon) or the local Red Cross chapter, the underlying principles are the same, bringing everyone to the table makes a better plan and enables a successful event
During the years since September 11, exercises have become a stable of validating planning processes across US cities. In Boston, federal dollars have supported 11 major disaster exercises geared toward large regional responses (Serino, 2013: 54). Other regional exercises have included senior level table tops to insure that the executives of the regional response organisations are familiar with each other and aren’t ‘exchanging business cards’ at the next event. Support for exercising is always a challenge for communities. They are time consuming from a planning and execution perspectives. Yet, they are the best way we have to enable engagement, validation and vetting of our planning process. Resources to operate successful exercises must continue to be made available within the community if a successful response to a large event is to be expected. Practice does make perfect, or in the difficult world of emergency response it at least makes a better response.
Conclusions
The Boston Marathon bombings of 2013 provide a unique perspective on the recipe required to manage a successful no notice event in a large urban area. Such a recipe must include extensive and pervasive leadership that is sustained and effective across the community for a long period of time; ability to resource day-to-day operations in a manner that promotes a healthy and safe community; and planning and exercising that is collaborative with a shared interest in successful responses. Replicating the Boston Strong experience is entirely possible as long as the fundamental leadership exists and a community is willing.
Conflict of interest: none declared