Like all Americans, we were horrified to hear of the terrorist act today at the finish line of the Boston Marathon. While reports are still coming in, there were at least two people killed and numerous people injured, some critically. This event hits home for us at InsideSurgery.com in several ways.
First, this writer, who is a trauma surgeon, attended the Boston Marathon last year as a spectator and managed to wangle a spot right at the finish line where the first bomb went off. Last year on Patriot’s Day as I made my way across the Boston common and toward the corner of Boylston and Ring Avenue I was amazed and a little intimidated by the crush of humanity on the streets of Boston. At the finish line, which I had to step on tip toe to see, the crowd that I stood in across the street from the viewing stands was 8-10 people deep, packed closely shoulder-to-shoulder.
It was a warm day and people were in shorts and t-shirts. After about thirty minutes, I left because of the heat, but as I made my way back to my apartment, the thought did cross my mind that it would be the perfect set up for some low life piece of vermin if they wanted to do some harm.
Second, Boston is a town with truly world class medical care. In fact, I have collaborated with many of the physicians in the emergency departments and surgery departments of the Massachusetts General Hospital (regularly ranked as the No. 1 or 2 top US hospital) and the Brigham and Women’s Hospital in their writing of a very successful textbook on Emergency Medicine. I know how good the ER and trauma doctors are in these institutions.
It was fortunate for America that the people who left this bomb did so at a spot that was literally yards away from the medical tent at the finish of the race. There were dozens of physicians and nurses in their tennis shoes and carrying their plastic IV starter boxes from the ERs of these top hospitals in that medical tent and by the news footage I have viewed, they immediately ran toward the explosions and were on the scene with field medical gear in seconds.
This no doubt saved countless lives. From news reports from the chief of Emergency Medicine at MGH, it appears that bombs were rather crude devices placed at the side walk level causing the blast wave to cause the most injury to lower extremities instead of internal organs.
Third, while serious and life-altering to the patient, traumatic amputations and severe complex (orthopedic, vascular, and soft tissue) Â injuries are survivable if prompt control of bleeding is obtained. The fact that so many big city ER personnel were on hand was critical to calmly and efficiently applying the tourniquets, packing the wounds, and effecting transport that saved lives.
The Boston city hospitals such as MGH and Boston City are all well-versed and highly experienced in serious trauma and have mass casualty systems that were immediately put into place. There were four major hospitals within two miles or so of the site of attacks, all of whom no doubt were placed immediately on a mass casualty basis. Boston Children’s Hospital where the injured children were taken is also a world-renowned hospital.
Once at the hospital, the more seriously injured patients would be transferred right off to the care of trauma surgeons, top-flight anesthesia teams and experienced, well-trained orthopedic surgeons and intensive care teams, with deep resources available to get patients through their injuries.
While the event was horrific, the wounds likely to be encountered will be well within the experience and areas of care of the trauma surgeons. Indeed, MGH trauma surgeon Dr. Peter Fagenholz has commented the wounds were “not otherworldly,” surgery speak for “we can handle it.” The teams will not be overwhelmed with the complexity or volume of care that will be required
Complex lower extremity injuries typically most urgently re-establishment of vascular supply to save threatened limbs which entails arterial repair or bypass. Also performed at the first surgery is washout of wounds, an initial debridement of devitalized tissue, Â and external fixation of the orthopedic injuries.
Patients with traumatic amputations will receive what is called a guillotine amputation to remove dead tissue. This is a temporary level of incision where the muscle and bone is left open with no attempt to fashion a skin closure.
Patients will also receive antibiotics and tetanus prophylaxis. Some patients with vascular ischemia will also receive fasciotomy to prevent muscle necrosis due to edema caused by ischemia.
Most people with this type of injury will also receive additional surgeries to debride tissue, washout wounds, revise guillotine amputations and close fasciotomies.
While the degree of the injury to the nation’s psyche is yet to be calculated, and as physicians and nurses pull ball bearings out of wounds and struggle to save shattered limbs, there is one small comfort on this tragic day that can be taken.
The human toll in lost lives and limbs will be much, much smaller than it would have been if it were not for the planning of the Boston Athletic Association, the excellence of the medical community in Boston, and the bravery and heroism of the physicians, nurses, and prehospital first responders on the scene.