Marathon Monday starts early with registration for runners and a briefing for thousands of volunteers. Because of last year’s record heat and humidity, race planners and volunteers put in extra time to make sure everybody was ready for the possibility of excessive heat. The Boston Athletic Association (BAA) works to ensure every runner gets world-class health care at all times.

That day, I worked in a new role as the Bus Triage Physician. School buses pick up runners unable to complete the race and deliver them to the end. There is an occasional sick runner, and the goal is to get the right resources to the right patient. As I arrived at Medical Tent A, I met my team – another physician, two nurses, a registration person, and a direct line of communication with the EMS.

As the day started, we had a chance to ready cots and organize resources. The goal was to be ready as the elite runners and wheelchair racers crossed the finish line. Runners began to cross, and the tent came to life. Teams of nurses, athletic trainers, doctors, and massage volunteers rushed to help each runner. People with orthopedic injuries and various ailments came to us. We started to hit our stride. The ICU section scooped up the sick patients as Boston EMS readily transported seriously ill people with ease, and communication with all aspects of the marathon course was up and running.

‘At the time of writing this, almost 2 weeks later, I’ve had trouble getting back to normal. Vivid memories, graphic dreams, and symptoms I’d never experienced before in my life.’

And then, everything changed.

Waiting for an inbound bus of runners, I was making small talk with some of the Boston PD who helped at the finish line. We heard a blast, and I remember saying, “Why is there a cannon?” The police were immediately on edge, then another blast. I vividly recall the lapel microphone of the police officer in front of me raining with static and screams. I immediately ran back into the tent. As I entered, there was just enough time to see one of my colleagues rushing to his backpack. He stood up and started putting on tactical body armor.

The pace in the tent rapidly picked up, and I recalled thinking, “Uh oh.” We moved tables and arranged equipment as best we could for the unknown coming shortly. We didn’t know what happened, but we knew it was bad.

Then patients started to arrive. I remember the first two clearly. They came immediately to the back of the tent, and at the time, they were the sickest. Both had lower extremity wounds and started receiving treatment.

There was commotion at the front of the tent, and I can only recall people saying, “Clear the aisle!” as a stretcher came down the middle of the tent carrying an injured person with bilateral lower extremity traumatic amputations. Blood, flesh, bone, and screams are still in my memory every time I close my eyes. I remember yelling to get an ambulance ready and “Get him out of here!” As the EMS officer at the end of the tent asked, “Where should he go?” I said, “Anywhere but here, just go.” We had a few waiting ambulances ready for runners and the extremity amputee was loaded and sent off to a hospital.

Then a continuous flow of injured patients came into the tent. Young people with lower extremity wounds in every degree of severity just kept coming. Trying to categorize the sickest patients in my head quickly became futile. Soon we had the back of the tent full of the most critically ill patients I have ever seen. Patients with gray limbs and patients who were gray themselves.

Pools of blood rapidly accumulated on the ground, and medical volunteers were frantically trying to do what they could.

Our IV nurses rushed to start lines as we had lots of normal saline ready to give from the earlier marathon preparation. It may not have been ideal, but it was something.

Tourniquets became the most valuable medical item. The available commercial ones were rapidly used. Then, we had to improvise … belts, shirts, and rubber tubing. I looked up, and a stretcher came down the tent with rescuers doing CPR. It was distantly reminiscent of codes I have seen in the field and in the hospital, with some differences. There was more passion, more drive, more force than I had ever seen in a code before. When they stopped CPR, I saw the weight of the universe come down on those rescuers. The situation became even more challenging with a fatality.

EMS was getting all available resources to us, and in groups of two, three, and four patients rapidly leaving the tent. A system was developed out of necessity whereby crews would leave their stretcher on one side of the tent and went to the bedside of the next sickest patient, rapidly moving people to definitive care. A triage system by consensus and yelling was established at the onset and proved to be helpful in getting patients to their destinations.

As things continued, triage tags came out, and areas of the tent were designated for acuity with signs. Patients were arriving with triage designations written on their foreheads with marker. At the same time, less acute patients were lining up for transport. Overall, things were quickly getting organized. The medical tent was transformed from a high-performing sports medicine facility to an organized trauma repository managing injuries that I could not conceptualize prior to that day.

As the response progressed, we were afforded even more ambulances and were moving patients quicker. Then the influx of patients stopped almost as soon as it started. Fire, police, EMS, and volunteers had an amazing effort in bringing the patients to the tent amazingly fast.

A split second of change, or so it seemed, was now winding down almost as fast. We weren’t sure what to do next. We watched patients leave. Fear, uncertainty, and concern crept in. In the tent, all we knew was that two bombs exploded. Were there more? Were the police outside the tent? Was there a fire? What was going on in the rest of the nation or the world? All we knew was for the recent past we focused on every casualty coming through, blind to the bigger events just outside the thin white canvas walls.

When things started to wind down, people were dismissed through a newly created side door in the tent. As I walked out, a police officer said, “there will be a controlled detonation” and my heart stopped, and sure enough there was another explosion as we were walking out. It took away the fragile calm and forced us into the reality around us.

There was only one way to walk, from the tent and toward the Boston Commons. EMS, police, and fire were still actively running around outside the tent. It was abundantly clear this was still a dynamic situation. As we headed east, police and fire continued toward Copley Square. There was a large influx of manpower in such a brief time. Barricades were being moved, and streets were being closed.

As we headed out, the Medical Director for the BAA said, “There are still runners out there,” and he quickly made a plan to rendezvous in the Commons.

As we wandered through empty streets of Boston, punctuated only by the occasional piercing wail of sirens, we arrived at the Commons. There, a group of medical providers stood, waiting. The occasional text from a close friend in a medical tent on the race course was reassuring. There were at least areas west of the site still functioning. One of our friends reached into his bag and produced some tin foil wrapped goodness, homemade fruit bars. He had worked for years in the tent and noted at around 4 p.m., people get quite hungry after working all day.

It was 4. We had not eaten since 10, but no one was hungry. The realization of, “Now what?” crept in slowly. One at time we all started to realize that we were standing in a public park and didn’t know where to go next. My original plan was to have a nice dinner and get picked up in town. Roads were closed, trains were stopped, and the parking garage where my two closest coworkers parked was now a crime scene.

We made our way to a restaurant. We didn’t know where we were going, but just walked in a direction. Before we knew it we were seated and for a while we just stared at menus, each other, and blankly out the window. The staff was thankfully patient with us, and we eventually ordered. Each of us proceeded to push food around with our forks taking the occasional bite. We knew we should eat, but we just weren’t hungry.

I am grateful for my colleague’s family. She was able to text and call loved ones with accessible cars.

Not long after, I was on my way home, and it was done. I hadn’t even begun to absorb what had happened that day. My legs were sore, my mind was racing, and I was exhausted. I slept that night, not well, but slept. At the time, I didn’t know the hard part was just starting.

At the time of writing this, almost 2 weeks later, I’ve had trouble getting back to normal. Vivid memories, graphic dreams, and symptoms I’d never experienced before in my life. I can recall ambulance sirens startling me. Getting groceries became a challenge, and working clinically was now mystifying. Thankfully, my coworkers came to my side. As soon as it was over, people reached out to me from my department. Sharing experience from people who’ve been to Haiti, or worked through Sandy and Katrina helped.

The marathon is staffed by a diverse group of clinical professionals from all over New England. That afternoon, as per normal, all of the medical volunteers went home from Maine to New York.

All of the sudden people had to go back to their home institutions, which now had to absorb all of their staff with this terrible event fresh in their minds. There are hundreds of lessons to be learned, and it would take years to discuss them all, but some things stick out in my mind at this moment.

The Marathon was ready for an emergency, staffing with physicians and other professionals. They were ready for a different type of challenge, but having such a concentration of resources saved lives.

As an emergency physician, I was uniquely able to assist, to see patients, and to make quick decisions. To stratify a number of patients who were triaged 1’s and 2’s, into subsets of injury severity. The other emergency physicians knew the system; they knew ICS and understood triage. A Trauma primary and secondary survey was indoctrinated into us and was ultimately valuable. I greatly appreciate having my family practice, internal medicine, surgical, cardiology, and other specialists there, but a subset of skills was critical at those moments.

Tourniquets saved lives. Ingenuity in bleeding control and homeostasis allowed the victims to survive to the hospital. I know I have had academic discussions about their clinical and prehospital use prior to this event. They turned out to be, in reality, much more elegant.

The Boston hospitals were ready and willing that day. To have such a concentration of high quality institutions in one area made a difference. All patients got the care they needed and in very timely fashion.

The setup of the tent allowed a natural exit with ambulances standing by. There was a direct line from the entrance to EMS at the back. The ambulances then had access to a number of major Boston thoroughfares. The importance of the ability to move patients rapidly to definitive care cannot be overstated. Although the footprint of the tent may not have been intentional, it made a tremendous difference.

In a time of such tragedy, I had the chance to witness terrible effects of human malice. At the same time, hundreds of volunteers stood up and took it upon themselves to rush to the aid of patients.

People rallied and delivered excellent trauma care even when it was well out of their scope of practice. In less than an hour, all of the wounded were gone. It was miraculous, and that positive is what keeps me going day in and day out.

Dr. Darnobid is an EMS Fellow and emergency physician at the University of Massachusetts Memorial Hospital in Worcester..