THE BOSTON MARATHON BOMBING
David R. King, MD, FACS
Boston has the most robust medical infra-structure per capita of any large city on the planet. This fact,
by itself, allowed the city’s five Level I trauma centers to adequately respond to the terrorist bombings
on Patriot’s Day in 2013. The patients were distributed across each of the trauma centers (and in some
cases even non-trauma center hospitals) in such a way that no one institution was overwhelmed. This
allowed the event to be viewed as a “symmetrical” mass casualty event. Additionally, the bombings
occurred on a city holiday where, except for the marathon course, the streets were clear with without
traffic. This allowed for the facilitation of rapid transport from the scene to the hospitals. The event
occurred at approximately change-of-shift for many nursing resources. This allowed for staff to be
effectively and instantaneously doubled without the delay of mobilizing additional personnel from
home. These circumstances, among others, led to successful management of this incident.
Once casualties arrived at the hospitals, the emergency departments were cleared of all patients, with
all centers exercising their surge capacity. Surgeons took a forward and aggressive posture with respect
to tourniquet placement and rapid movement of casualties to the operating rooms. Once there, a
damage control approach was liberally exercised in order to clear the rooms for additional patients and
additional waves of patients. Procedures were abbreviated and patients moved to the ICU quickly.
After each patient’s index operation and stabilization, trauma teams met together to carefully go over
all radiologic studies, need for additional studies, and careful secondary and tertiary surveys were
performed. Importantly, dozens of missed injuries were identified that were missed during initial
hemorrhage and contamination control.
The Boston Marathon bombings recently brought home a hard-learned lesson from the battlefield (1):
the desperate need for civilian prehospital tourniquets. As a cause of death on the battlefield, extracavitary extremity hemorrhage has largely been eliminated as a major contributor to preventable
exsanguination (2) due to the ubiquitous presence and early, aggressive use of prehospital tourniquets
(3-6). There were 66 patients with extremity injuries and only 25 had a tourniquet placed, of which only
one purpose-made tourniquets were identified (all others were improvised). It is clear that improvised
tourniquets rarely work (3, 6) and that future efforts need to be directed at equipping prehospital
providers with purpose-made tourniquets and providing the training and sustainment for their proper
application.
Pertinent Bibliography
1. Peev MP, Naraghi L, Chang Y, Demoya M, Fagenholz P, Yeh D, Velmahos G, King DR. Real-time
sample entropy predicts life-saving interventions after the Boston Marathon bombing. J Crit
Care. 2013 Dec;28(6):1109
2. Eastridge BJ, Mabry RL, Seguin P, Cantrell J, Tops T, Uribe P, Mallett O, Zubko T, Oetjen-Gerdes L,
Rasmussen TE, Butler FK, Kotwal RS, Holcomb JB, Wade C, Champion H, Lawnick M, Moores L,
Blackbourne LH. Death on the battlefield (2001-2011): implications for the future of combat
casualty care. J Trauma Acute Care Surg. 2012 Dec;73(6 Suppl 5):S431-7.
3. Beekley AC, Sebesta JA, Blackbourne LH, Herbert GS, Kauvar DS, Baer DG, Walters TJ, Mullenix
PS, Holcomb JB; 31st Combat Support Hospital Research Group. Prehospital tourniquet use in
Operation Iraqi Freedom: effect on hemorrhage control and outcomes. J Trauma. 2008 Feb;64(2
Suppl):S28-37.
4. Kragh JF Jr, Littrel ML, Jones JA, Walters TJ, Baer DG, Wade CE, Holcomb JB. Battle casualty
survival with emergency tourniquet use to stop limb bleeding. J Emerg Med. 2011
Dec;41(6):590-7.
5. Lairet JR, Bebarta VS, Burns CJ, Lairet KF, Rasmussen TE, Renz EM, King BT, Fernandez W,
Gerhardt R, Butler F, DuBose J, Cestero R, Salinas J, Torres P, Minnick J, Blackbourne LH.
Prehospital interventions performed in a combat zone: a prospective multicenter study of 1,003
combat wounded. J Trauma Acute Care Surg. 2012 Aug;73(2 Suppl 1):S38-42.
6. King DR, van der Wilden G, Kragh JF Jr, Blackbourne LH. Forward assessment of 79 prehospital
battlefield tourniquets used in the current war. J Spec Oper Med. 2012 Winter;12(4):33-8.