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.