The perfect setting, perfect timing, perfect sizing, and perfect response. The City of Boston is and should be proud of its outstanding response to the dreaded “terrorist bombâ€.  Nothing said here should take away any of the well-deserved kudos for a response job well done. The alleged bombers appeared to have selected a perfect time to enter the target zone, at the time when all were focused on the first runners crossing the finish line and after the last security sweep of the area. They opted out of inflicting 2X the death and destruction by positioning themselves between the two IEDs (Homicide-Bombing) an indicator that they had bigger and better plans.

Atul Gawande’s April 17, 2013 article in The New Yorker was insightful and surfaced many of the issues we consider important, however, it is important for the trusting public understand the “artificiality†of the setting and realize that the event was atypical in many respects to what others have experienced around the world.

The bombers achieve their primary goal of a “terror effect†across the nation. The slaughter and maiming of innocents has a powerful effect on a population which has been spared such an event for a decade, if you exclude the “workplace violence†at Fort Hood in 2009.

Having said all that, it is unusual for terrorists to locate their destructive devices within yards of a pre-positioned site where an elaborate array of professional healthcare workers, aid stations and experienced emergency responders including National Guardsmen were within seconds of the victims. Add to that sophisticated emergency equipment and emergency transport vehicles, waiting in the wings.

Add to this the host of courageous individuals who ran toward the scene rather than away from it.  Many, by training, knew that there was a high probability that a secondary blast could be waiting for them.

Add in the fact that there were multiple Emergency Trauma Centers (some of the best in the world) within minutes of the blasts.

Add in the size of the casualty load, well within numbers where Mass Casualty Triage did not call for the terrible angst associated with making horrible decisions about who lives and who dies.

The author has been there and done that on three Continents.

The trusting public should not accept this event and its response as a measure of the nation’s Public Health and Healthcare Readiness.

Add in any number of variables to the Boston Bomb mix and the outcome would have been catastrophic:

A tandem attack on Hospitals receiving victims using any of the following to create a Terror Multiplier Effect (TME) –

• Additional Explosives (they had an additional ~10 IEDs ready)
• Release of Biological Agents (i.e., Anthrax)
• Release of Chemical Agents (i.e., Sarin Gas)
• Release of Radiological Materials (i.e., cesium chloride 137)
• Mumbai-like attack (i.e., small group armed with assault weapons killing at random)

Fortunately, we in the US have never had to deal with this kind of multiple threat scenario, even during the most horrendous disasters of the Twin Towers, Oklahoma City, 9/11, Katrina and Sandy. Among the worst case scenarios would be when the above strategy is employed during Terrorist Attacks or Natural Disasters.