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This week marks the 11-year anniversary of the . On April 15, 2013, beginning at 2:49 p.m., packed with nails, ball bearings, and shards of metal exploded 13 seconds apart, just shy of the marathon's finish line. The race had been underway for several hours by the time of the explosions and a large crowd was gathered, cheering on runners as they approached. Three individuals in the vicinity were killed immediately, and an additional 264 were injured. Zero lives were lost among the transported to the city's five level 1 trauma centers -- a remarkable mortality rate.

Now, over a decade later, the medical response following the bombing is still hailed as one of the most efficient and effective disaster responses in U.S. history. The incident is widely cited in disaster preparedness manuals, and as the regional director of emergency management for 21 hospitals in California, this was the case study I used over and over to provide training and highlight the key elements of mass casualty response for healthcare workers enthusiastic about the field of disaster medicine.

It's worth pausing to remember the event and consider: what went right?

Planning and preparation: The success of the Boston response was not an accident; nor did it reflect random good luck. Rather, the response was due to a decades-long history of disaster preparedness planning and a well-rehearsed set of plans. The Boston Marathon is one of the world's oldest marathons and it's massive: in 2013, the event attracted and approximately 500,000 spectators. This was not an occasion that city officials took lightly.

After the terrorist events of 2001 in New York City, the Boston healthcare community regularly practiced large-scale disaster simulation and refined the city's mass casualty plans. Between 2002 and 2013, Boston took advantage of federal funding available for disaster preparedness efforts and received almost $370 million from the Department of Homeland Security to refine its preparedness. For the Boston Marathon, planning began months ahead of time.

Collaboration: Individuals present during the event describe an extraordinary level of cooperation among the many federal and city agencies involved in the immediate aftermath of the bombing. Termed "" by one Boston public health leader, there was a notable "unity of mission" amongst responders with "no ego and no blame." This degree of collaboration was attributed, in part, to relationships and partnerships established in advance during the planning sessions that preceded the marathon. To this day, when I teach the many learning lessons of the event, I highlight the importance of relationships and trust among colleagues.

Bystander participation: In the years since the bombing, the concept of "" has taken hold via the STOP THE BLEED program. This initiative is predicated on the idea that individuals at the site of an event can render life-saving treatment in the form of wound-packing and tourniquet placement. after the Boston Marathon explosions demonstrate bystanders using clothing to hold pressure on wounds, applying tourniquets, and clearing a path to facilitate rapid extrication of victims.

Coordination: The Boston Marathon is no stranger to injuries; it typically produces over 1,000 medical encounters in 6 hours. On the day of the event in 2013, approximately 200 healthcare personnel were staged at various points along the 26.2-mile route, and 45 ambulances were standing by. When the explosions occurred, the closest medical tent was immediately converted to a mass casualty collection point where EMS were able to triage victims, implement rapid life-saving interventions (such as tourniquet placement), and then load patients onto ambulances.

By prior design, EMS central dispatch immediately called in all available private ambulances and began a process of "leap-frogging," wherein casualties are distributed evenly and in alternating fashion to surrounding hospitals, thereby decreasing the risk that any one hospital will become overwhelmed. The first 30 critically wounded victims were all transported to hospitals within 18 minutes, and surrounding hospitals received . Brigham and Women's received 38 patients; Mass General received 37 patients, including five critically injured patients within 8 minutes of each other and four who required amputations. Boston Medical received 29 victims, and Beth Israel Deaconess received 24; Tufts treated 28.

Code triage: At the time of the blasts, the city's ORs were booked and most EDs were full. At every hospital, command centers activated their surge plans: ED patients were rapidly transported to inpatient floors (where their care was continued by inpatient teams) and pending OR cases were put on hold. Perioperative staff were mobilized, additional staff called to the ED, equipment trays were rushed from central supply to the ORs, and the blood bank was put on notice. When change of shift came, the day shift stayed.

There was some luck: The bombings occurred in a city home to . The bombs detonated outdoors, rather than inside, where the effects of a blast are generally magnified. The attacks occurred at the same time as the 3 p.m. change of shift at most hospitals.

In the words of Atul Gawande, "Hence the grim efficiency with which the city responded."

The Boston Marathon bombings served as a wake-up call for hospitals across the country and inspired many young physicians (including this one) to undergo training in disaster medicine.

Today, the incidence of mass casualty events in the U.S. is ever on the rise. Boston's response illustrates the importance of that leaves healthcare and public health organizations prepared for these rare but high-consequence events. It highlights the value of rigorous training, drills that include all specialties and departments of a hospital, cross-agency collaboration, and meticulous planning. In our current era of crowded EDs, burnout, limited bandwidth, and staffing shortages, the anniversary of the Boston Marathon explosions is a reminder that good disaster preparedness saves lives, and cost-saving via cutting corners does the opposite.

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