AOAV: all our reportsImprovised Explosive Devices2013 Boston Marathon Bombings report

Blood on the Streets of Boston: Medical care and financial support

This report is part of AOAV’s research on the bombing at the Boston Marathon in 2013. The full report, ‘Blood on the Streets of Boston’, can be read here. The main findings and summary can be seen here. The report considered the mental health support offered to survivors and witnesses, for more on this see here, as well as the services that were offered, see here. As part of the report it AOAV also researched the health impacts the bombing had – here. It was also important to consider the ‘Victims’ Voices’, from those who survived the attack. To read these please go here, here, and here.

Response to the 2013 Boston Marathon bombings

Immediate Medical Care

Police, the Emergency Medical Services (EMS), and civilian bystanders rushed to help those who had been injured.

The medical care given at the scene was minimal. Those who first attended to the injured could instantly see that many needed to be taken to hospital. The ‘scoop and run’ method employed by the emergency services was supplemented with hemorrhage control. Tourniquets, formal and informal, were used, as were methods such as applying direct pressure and elevating bleeding injuries.

The rapid extrication of victims resulted in very few medical interventions between the scene and hospitals. The scene was cleared of critical victims within 18 minutes of the bombings; all other victims were transported within 45 minutes. In total, 25 hospitals in and around Boston treated individuals suffering from injuries sustained in the bombings. The first injured victim arrived at Brigham and Women’s Hospital, Dr. Eric Goralnick told AOAV, at 3.06pm, 17 minutes after the bombings. The first patient went into the operating room 28 minutes after that. Brigham and Women’s Hospital treated 40 victims of the bombing, nine of whom underwent surgery that day.

Hospitals in Boston prepare extensively for mass casualty incidents. The disaster plan employed by Brigham and Women’s Hospital worked extremely quickly in order to identify and build capacity within the emergency and operating rooms. Existing surgeries were finished and all future surgeries were delayed or cancelled. Residents, physicians, psychiatrists and internal medicine personnel signed patients out of the emergency department, moving them to other areas of the hospital and creating space for bombing victims.

The medical care given to victims once they reached the hospital was, by all accounts, exceptional.

Nobody who arrived alive at any of the hospitals subsequently died. Medical caregivers were fortunate in a number of factors:

  • There were six level 1 trauma centers within two miles of the blast;
  • The bombings occurred in an area almost equidistant between these hospitals, and no one hospital was overwhelmed since patients were distributed evenly;
  • The bombings occurred at 2.49pm, and shift change at each of the main hospitals was scheduled for 3pm. Each hospital therefore had double the number of staff they would ordinarily have;
  • The bombings occurred at the Marathon: 
Emergency services, medical personnel and medical equipment were on site already; 
Roads were already closed, allowing rapid extrication of those who were injured.
  • Hospitals had members of staff with experience treating victims of IED explosions in conflict zones, and had extensive experience treating the types of injuries caused by bombs. Due to the recent US involvement in conflicts involving IED use, there is an increased aware- ness of how to treat such injuries. Surgeons had previously treated these injuries in active conflict zones;
  • The bombs detonated outdoors, causing
no structural collapse. The injured were not trapped under debris and rubble, meaning that rapid evacuation of casualties was possible and roads were not blocked.
  • There had also been a number of emergency incidents in the months prior to the bombing where the hospitals’ emergency plans were tested, due principally to the high levels of snow fall during
the winter. The hospitals had been well tested in a number of their emergency procedures prior to the bombing.

The rapid extrication of those injured and the subsequent medical care saved lives. The preparation done by the Boston hospitals, as demonstrated in the below case study, can be seen as an example of best practice in emergency preparedness for such an attack. The actions of first responders and care providers in Boston demonstrate the need for cities to extensively prepare for mass casualty incidents, and the key role such preparation plays in saving lives.

Security Response

The Marathon route winds through seven different communities, so police forces from multiple jurisdictions are responsible for ensuring it runs smoothly. In Boston itself, the Boston Police Department (BPD) is responsible for crowd control, road closures, and coordinating access to businesses along the route, as well as providing ordinary police services in the city. Extensive preparations are made each year for the policing of the Marathon.

Sergeant Mike McCarthy of the BPD told AOAV that as soon as the bombs were detonated, the police immediately responded to victims, helping those who were injured. The police administered emergency health care, taking some of those most injured to hospital in the back of police vans. They then transformed into crime scene preservation mode, clearing the area, securing the streets, and beginning the collection of evidence. All materials salvaged and removed from survivors’ bodies once they arrived at hospital were preserved as evidence.

Wider Security Impact

Security at the 2014 Marathon was notably heightened as a result of the bombings. Staffing levels were increased, and the BPD changed how they policed the event as a whole.

There were “significantly” more officers on patrol, although many were undercover, Sergeant McCarthy told AOAV. Technology was more fully utilized, with the entire route being surveyed by remote cameras. More explosive ordnance disposal (EOD) assets were used, including an increase

in staffing in the bomb unit, the purchasing of EOD equipment, and the use of bomb dogs. On Boylston Street itself crowd control was thought out more thoroughly, with a series of checkpoints and bag checks being established to limit the number of people permitted into each section of the street. This allowed police officers to move freely along the street, and decreased crowding on the sidewalk. The BPD told AOAV that the cost of policing the 2014 Marathon was $1,145,541.01.

The increase in security both helped and hindered survivors who had chosen to attend the 2014 marathon. An area was cordoned off for survivors who wanted to watch the race, however some survivors could not reach the safe area because of checkpoints further away. Lori van Dam, Executive Director of the One Fund, said: “Did that make anyone safer? Probably not. But I think it made people feel better that it was out there and the police department were completely justified in doing all of those things…it’s a human natural response.”

Stringent security measures have been implemented at other events such as the 4th July fireworks. Chris Strang, a lawyer AOAV spoke with about his role in assisting survivors of the bombings, said that the security at the 4th July 2013 fireworks was extensive. No bottles or backpacks were permitted, and security was carrying out bag checks.

Financial Assistance

The Victim Compensation Fund

Neither the Federal government nor the State created a victim compensation fund for those affected by the bombings. However, Massachusetts has a Victims of Crime Compensation Fund (VCF),25 which is administered through the Attorney General’s Office (AGO). Through the VCF, the State can provide financial assistance to eligible victims of violent crime, which includes those who were affected by the Marathon bombings.

Through the AGO, the State can provide financial assistance to eligible victims for costs such as medical care, mental health counselling, and lost wages. This Fund can assist with expenses of up to $25,000 per victim per crime, or up to $50,000 for victims suffering from ‘catastrophic injuries.’

Lisa Solecki, former Chief of the Victim/Witness Services for the AGO, told AOAV that many victims of the bombings qualified for the upper cap of $50,000.

The definition of a victim for these purposes is broad: Individuals who suffer personal physical or psychological injury or death as a direct result of a crime committed against them, are able to apply for compensation from the VCF. AOAV spoke to Manya Chylinski, who suffered from emotional problems after witnessing the attacks. She was unable to work in the immediate aftermath of the bombings, and the VCF paid her compensation for lost wages.

The VCF has also been used to supplement the financial support provided by charities to those who were physically injured. The One Fund, which was set up in the aftermath of the bombings, gave Ellen Sexton-Rogers, who was initially treated as an outpatient, $20,500. She told AOAV that the nature of her injuries, which have prevented her from returning to work since the bombings, are categorized as ‘catastrophic’ by the VCF. She is therefore able to apply for up to $50,000 in financial support. The VCF is currently reimbursing Ellen for the cost of her lost wages, supplementing the relatively small amount of money she was given by the One Fund.

When Ellen spoke to AOAV she had claimed $28,000 from the VCF, and it is likely that she will continue to claim reimbursement for lost wages until she hits the cap of $50,000. She told AOAV that she has no idea how she will survive once her expenses reach $50,000, as she will be unable then to pay for her mortgage, bills and other expenses.

The One Fund

There was an almost instant outpouring of generosity from the general public towards those who had been injured in the bombings. Hours after the attack, Boston’s Mayor Menino and State Governor Patrick decided to establish the One Fund, a charity to which donations could be made to help those affected by the bombings.

The One Fund was established as a separate
s. 501(c)(3) organisation, and by 7pm the day after the bombings there was a place where donations could be made.

John Hancock, a financial corporation in Boston, made the first major donation of $1million. Lori van Dam, Executive Director of the One Fund, told AOAV that its success was partly due to this first donation. The One Fund received at least eight additional $1million donations within the first couple of weeks of its establishment.

Kenneth Feinberg, a lawyer who had previously administered the 9/11 Compensation Fund, was brought in to determine how to divide the donations. It was decided the One Fund would only be available to the four families of those killed in the bombings and the subsequent manhunt, and those physically injured in the bombings.

Two public meetings were held to discuss the distribution of the money, and ultimately it was decided by the One Fund that the funds would be split based on the categorization of victims and their injuries into four groups. The awards were not means tested. Survivors were not informed of their awards until the distribution was actually made.

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The first division of funds to the survivors of the bombings, and the families of those who were killed.

The first distribution money was provided to survivors in June 2013, two months after the bombings.

Some who did not realise the severity of their injuries went home on the night of the 15th, only to realise that they needed hospital treatment in the days after the bombings. These individuals only received $8,000, regardless of the nature of their injuries and their subsequent hospital treatment.

Lori van Dam spoke of the frustration felt by these people, “some of them should have been admitted to hospital but went home for one reason or another – kids at home who were terrified or something like that. I’m a 19 year old and my parents are out of state and I just wanted to go home – that was a $117,000 decision.”

It could be argued that the One Fund should 
have taken more account of individual injuries, as opposed to hospital overnights. However, the One Fund was keen to distribute money as quickly as possible, and considering individuals’ circumstances and injuries would have delayed their payment.

The survivor community was not wholly satisfied with their categorization in the first distribution. Some were frustrated with how clean cut the categories had been. Particularly amongst those who had undergone amputations, survivors felt that the long-term implications of their injuries would vary massively and that the distribution of funds should have taken this into account. This was due to the difference in lifetime care whether an above or below the knee amputation had been performed, and the cost of lifetime care depending on age.

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The second distribution of funds to the survivors of the bombing and the families of those who were killed.

It was thought that the One Fund would close after the first distribution, however it has remained active. A needs assessment was done in order to determine how best to spend donations after the first distribution. A panel of medical experts was also convened to provide advice to the One Fund about the longer-term nature of the injuries sustained. The second distribution took into account things such as whether the amputation was above or below the knee, the nature of limb injuries, the age of the amputee, and the number of surgeries the applicant had undergone since 15 June 2013.

On 2 September 2014, the One Fund announced they were distributing a further $18,459,327 to survivors and victims’ families, and $1.5million to establish the One Fund Center. This money was provided to survivors in September 2014, and is intended to be the last cash payment they receive from the One Fund.

It was decided that any money donated subsequent to the second distribution would go to the provision of services. The One Fund learned lessons as time went on, adapting its objectives to the different stages of support required. It was recognized that future funds would be best spent on services, as they will support larger numbers of survivors more comprehensively than lump monetary funds. This willingness to adapt should be viewed as a positive aspect of the assistance provided by the One Fund.

The One Fund’s Definition of Survivor

The principal criticism of the One Fund was
with its definition of ‘survivor.’ This definition
 was narrow and only covered those who were physically injured in the attacks. “If you were just suffering from PTSD and no physical injuries, we couldn’t include you in the One Fund,” Lori told AOAV. This was the case in the initial distribution, and remained so in the second distribution; “we did not add anyone to the group for purely mental health issues.” Survivors and those in the wider community felt that this was an important gap.

The same is true for those who suffered from a Traumatic Brain Injury (TBI), such as Ellen Sexton- Rogers and Joanna Leigh, both of whom were diagnosed with such after the Marathon bombings. Ellen was given a total of $20,500 from the One Fund as an outpatient survivor of the bombing, a figure she is unhappy with.

When AOAV spoke to Joanna, she had been given $8,000 in the initial distribution, but was still waiting for money from the second distribution, and had not been informed of how much money she would receive. Both of these survivors felt that they should have been included in Category A in the initial distribution, as individuals who had suffered permanent brain damage. They were
not and both are now facing significant financial difficulty due to their injuries. Ellen is living on dis- ability allowance, and Joanna Leigh is thousands of dollars in debt, which they told AOAV is due to an inability to work because of their TBIs.

The Massachusetts Bar Association represented those who suffered from a TBI and were unhappy with their treatment by the One Fund. Advocates Paul White and Susan Baronoff told AOAV that the award given to those with “traumatic brain type” injuries were given a “completely inadequate award for someone with that serious an injury.”

It meant that they were left with limited means to receive financial support, a gap which was not remedied or filled by a public health system response.

Lori van Dam is intensely aware of the feelings of people such as Ellen and Joanna, and the opinions of people who think that the way in which the One Fund distributed the money was unfair.

Providing the context for the decisions for the approach of the One Fund, van Dam said, reporting the comments of a medical ethicist; “you have to take fair off the table because these people have experienced the most unfair thing that will ever happen to them and to try to rebalance that is impossible. We can talk about objective, we can talk about explainable, we can talk about understandable – and that is what we have tried to do.” She also emphasized the fact that the One Fund is not an insurance company, and that they had to find some kind of objective criteria in determining how to split the money.

From the perspective of the One Fund, the most appropriate way to assist those with mental health and psychological harms, and those with traumatic brain injuries, is through the provision of services. Any further donations will go to services to help the One Fund community, and the wider Boston community, and a research study on tinnitus.

The vast majority of financial support available to survivors of the bombing was not provided by the State or the government, but by the One Fund. Without the One Fund, those significantly injured could have faced significant financial hardship. The $25,000, or $50,000, available through the State would not have covered the costs faced by those with severe physical injuries and amputations. The State, although not explicitly, relied on the One Fund to provide such support. Reliance on charitable organisations is not sustainable. The State and government should have provisions in place to more securely financially support victims of such attacks.

Two of the four physically injured victims AOAV spoke with thought that the state should have provided more financial support for them instead of relying on charitable donations.

To read the whole report, please click here.