Rich Serino had spent all day on April 15, 2013, at the finish
line of the Boston Marathon, monitoring it as deputy
administrator for the Federal Emergency Management Agency. He’d
just left to speak at a class at Harvard’s Kennedy School of
Government when he got the news that there’d been a bombing at
the finish line, with two homemade explosives ripping through the
crowds of bystanders. He raced back to the scene along with
Juliette Kayyem, a senior lecturer on national security and CNN
commentator whose class he was attending.
This past week, Serino, now a Distinguished Visiting Fellow at
Harvard’s National Preparedness Leadership Initiative (NPLI), and
Kayyem participated in a panel discussion at Harvard T.H. Chan
School of Public Health that focused on lessons learned in the
wake of the tragedy. Other panelists included S. Atyia Martin,
who was director of the Boston Public Health Commission’s Office
of Public Health Preparedness at the time; Eric McNulty,
associate director of NPLI; and Leonard Marcus, founding
co-director of NPLI. “It is incumbent upon us to reflect on the
lessons that can be learned from such shocking events so that the
learning serves to save lives, support responders, and
potentially even prevent such events in the future,” said Marcus,
who moderated the panel.
In an instant, an explosion or blast can wreck havoc; producing
numerous casualties with complex, technically challenging
injuries not commonly seen after natural disasters such as floods
To address this issue, Centers for Disease Control and Prevention
(CDC), in collaboration with partners from the Terrorism Injuries
Information, Dissemination and Exchange (TIIDE) Project, as well
as other experts in the field, have developed fact sheets for
health care providers that provide detailed information on the
treatment of blast injuries.
The fact sheet addresses background, clinical presentation,
diagnostic evaluation, management and disposition of blast injury
Minutes after a terrorist attack killed three at the finish line
of the Boston Marathon, doctors and nurses at the city’s
hospitals faced severed limbs, burned bodies, shrapnel buried in
For Boston doctors, the challenge presented by last week’s
bombing was unprecedented — but they were prepared.
Many of the city’s hospitals have doctors with actual battlefield
experience. Others have trauma experience from deployments on
humanitarian missions, like the one that followed the Haitian
earthquake, and have learned from presentations by veterans of
other terror attacks like the one at a movie theater in
But they have benefited as well from the expertise developed by
Israeli physicians over decades of treating victims of terrorist
attacks — expertise that Israel has shared with scores of
doctors and hospitals around the world. Eight years ago, four
Israeli doctors and a staff of nurses spent two days at
Massachusetts General Hospital teaching hospital staff the
methods pioneered in Israel.
Bright sunlight filtered through the awnings of the medical tent
pitched in Copley Square, where I joined the many medical
professionals caring for people who’d fallen ill from their
26.2-mile run. Some volunteers had been staffing the medical tent
for years — one nurse had worked at the Boston Marathon more than
Suddenly, there was a loud, sickening blast. My ears were
ringing, and then — a long pause. Everyone in the tent stopped
and looked up. A dehydrated woman grabbed my wrist. “What was
that?” she cried. “Don’t leave.” I didn’t move. John Andersen, a
medical coordinator, took the microphone. “Everybody stay with
your patients,” he said, “and stay calm.” Then we smelled smoke —
a dense stench of sulfur — and heard a second explosion, farther
off but no less frightening. Despite the patient’s plea, I walked
out the back of the tent and saw a crowd running from a cloud of
smoke billowing around the finish line. “There are bombs,” a
woman whispered. My hands began to shake.
The bombs at the Boston Marathon were designed to maim and kill,
and they did. Three people died within the first moments of the
blast. More than 170 people were injured.
Medical personnel manning the runners’ first-aid tent swiftly
converted it into a mass-casualty triage unit. Emergency medical
teams mobilized en masse from around the city, resuscitated the
injured, and somehow dispersed them to eight different hospitals
in minutes, despite chaos and snarled traffic.
Brigham and Women’s Hospital received thirty-one victims,
twenty-eight of them with significant injuries. Seven arrived
nearly at once, and all required emergency surgery. The
first to go to surgery was on an operating table by 3:25 P.M.,
just thirty-five minutes after the blast. Twelve patients in all
would undergo surgery—mostly vascular and orthopedic procedures.
This kind of orchestration happened all across the city.
Massachusetts General Hospital also received thirty-one
victims—at least four of whom required amputations.
There’s a way such events are supposed to work. Each hospital has
an incident commander who coordinates the clearing of emergency
bays and hospital beds to open capacity, the mobilization of
clinical staff and medical equipment for treatment, and
communication with the city’s emergency command center.
A decade earlier, nothing approaching this level of collaboration
and efficiency would have occurred. We have replaced our pre-9/11
naïveté with post-9/11 sobriety. When ball bearings and
nails were found in the wounds of the victims, everyone
understood the bombs had been packed with them as projectiles. At
every hospital, clinicians considered the possibility of chemical
or radiation contamination, a second wave of attacks, or a direct
attack on a hospital.
What prepared us? Ten years of war have brought details of
attacks like these to our towns through news, images, and the
soldiers who saw and encountered them. Almost every hospital has
a surgeon or nurse or medic with battlefield experience,
sometimes several. Many also had trauma personnel who deployed to
Haiti after the earthquake, Banda Aceh after the tsunami, and
elsewhere. Disaster response has become an area of wide interest
A city whose hospitals and physicians are renowned for research
and cutting-edge surgical innovations faced a starkly different
challenge Monday, treating scores of injuries more commonly found
in a war zone.
Patients arrived at Boston hospitals with limbs blown off,
shrapnel wounds, burns, gruesome fractures, and perforated
eardrums from the shock wave of two explosions near the Boston
Marathon finish line shortly before 3 p.m.
“For many, many people in emergency medicine who are practicing
domestically and not in the military, these are
once-in-a-lifetime events,” said Dr. Ron Walls, chairman of the
Department of Emergency Medicine at Brigham and Women’s Hospital.
Runners and spectators alike were rushed to hospitals, where
doctors said that the injuries individually were not
extraordinary, but that the volume was unprecedented.
At least eight hospitals in the Boston area treated more than 140
victims of the Boston Marathon explosions yesterday, which have
left three people dead and many more critically
The scope of injuries from the explosion resembled those of a war
zone, according to a Boston Globe report, startling many medical
providers who are not accustomed to such trauma. The severe
injuries and influx of patients left the area’s hospitals
mobilizing disaster plans and reinforcing emergency departments
with extra staff and security.
The California State Threat Assessment System is an all hazards
Information Sharing partnership of Federal, State and Local law
enforcement agencies throughout California. The System connects
Suspicious Activity Reporting and incidents that may have a
possible Terrorism or Homeland Security nexus with law
enforcement statewide through a network of interconnected
Regional Threat Assessment Centers (RTACs) in San Diego, Los
Angeles, San Francisco, and Sacramento.
These Regional Centers are directly connected to the FBI and the
U.S. Department of Homeland Security, and provide regional
analysis and assessment of events, including patterns and trends,
to deter, detect and prevent terrorism in California.
Additionally, the State Threat Assessment Center (STAC), also in
Sacramento, is a partnership of the California Highway Patrol and
the Governor’s Office of Homeland Security, whose focus is
statewide analysis of incidents, trends and patterns to help
identify larger threats and protect key and critical
Suspicious Activity Reporting (SAR) programs such as “If You See
Something, Say Something” are active across the country and help
communities deter crime, violent incidents, and in some cases
prevent terrorism. The idea is simple, but for first
responders/receivers there are particular activities to look for
depending on your sector.
This training module can easily be added to any in-house training
for new employees or yearly refresher training for established
personnel. The new training
module joins others disciplines such as public safety
telecommunications, fire/EMS, emergency management, maritime, and
more. Those completing the training successfully can print a
All hospitals should know what suspicious activity is and how it
should be reported. All hospitals should also know which threat
assessment center they fall under and maintain contact
This Information Bulletin contains information gained from
federal, state and local public safety sources with expertise in
explosives and response to explosives incidents. As with any
public safety issue, local agencies must determine local policies
and procedures. Note that a subsequent Information Bulletin will
be issued, to include information for use when responding to a
suspected bomber, if the call is received prior to an actual