BOSTON — So many patients arrived at once, with variations of the same gruesome leg injuries. Shattered bones, shredded tissue, nails burrowed deep beneath the flesh. The decision had to be made, over and over, with little time to deliberate. Should this leg be amputated? What about this one?
"As an orthopedic surgeon, we see patients like this, with mangled extremities, but we don't see 16 of them at the same time, and we don't see patients from blast injuries," Dr. Peter Burke, the trauma surgery chief at Boston Medical Center, said.
The toll from the bombs Monday at the Boston Marathon, which killed at least three and injured more than 170, will long be felt by anyone involved with the city's iconic sporting event. For the victims, the physical legacy could be an especially cruel one for a group that was involved in the marathon: severe leg trauma and amputations.
"What we like to do is before we take off someone's leg — it's extremely hard to make that decision — is we often get two surgeons to agree," Dr. Tracey Dechert, a trauma surgeon at Boston Medical, said. "Am I right here? This can't be saved. So that way you feel better and know that you didn't take off someone's leg that you didn't have to take. All rooms had multiple surgeons so everyone could feel like we're doing what we need to be doing."
The widespread leg trauma was a result of bombs that seemed to deliver their most vicious blows within two feet off the ground. In an instant, doctors at hospitals throughout the city who had been preparing for ordinary marathon troubles — dehydration or hypothermia — now faced profound, life-changing decisions for runners and spectators of all ages.
Some victims arrived two to an ambulance, some with huge holes in their legs where skin and fat and muscle were ripped away by the bomb and with ball bearings or nails from the bombs embedded in their flesh. Others had severed arteries in their legs or multiple breaks in the bones of their legs and feet. The shock wave from the blast destroyed blood vessels, skin, muscle and fat. And at least nine patients — five at Boston Medical Center, three at Beth Israel Deaconess Hospital and one at Brigham and Women's Hospital — had legs or feet so mangled they would need to be amputated.
Some of the attendant medical professionals, said Julie Dunbar, a chaplain at Beth Israel, were faced with "more trauma than most ever see in a lifetime, more sadness, more loss."
There were only three fatalities, which doctors say was because the blast, low to the ground, mostly injured people's legs and feet instead of their abdomens, chests or heads. And tourniquets stopped what could have been fatal bleeding in many.
Dr. Allan Panter, 57, an emergency-room physician from Gainesville, Ga., was standing 10 yards from the blast near the finish line, waiting for his wife, Theresa, to complete her 16th Boston Marathon. Assisted by others, he said he used gauze wraps to apply tourniquets to several victims, including a man who appeared to be in his late 20s who lost both of his lower legs in the blast. He said he saw another six or seven victims with belts tied around their wounded legs.
Tourniquets, once discouraged because they were thought to cause damage to injuries, have returned to favor and have been used to treat wounds inflicted by explosive devices in the wars in Iraq and Afghanistan, Dr. Panter said.
"With blast injuries to the lower extremities that we're getting in the Middle East, you bleed out," he said. Tourniquets "can help save lives. I don't know if they helped in this situation, but it sure couldn't hurt."
While there was some initial chaos in a medical tent near the finish line, and some screaming and moaning by victims, it was generally an orderly scene, Dr. Panter said. He assisted others in wheeling in a female victim who died, he said. He described 20 to 30 cots in the tent with IV bags that had been intended for dehydrated runners.
At least eight doctors and what seemed to be 20 or more nurses were stationed in the tent. A man with a microphone stood in the center of the tent to coordinate medical care. Arriving victims were assessed and categorized as 1 for critical, 2 for intermediate, 3 for "can wait" and "black tag" for anyone who appeared to be dead, Dr. Panter said. An emergency medical technician outside the tent coordinated ambulance service to hospitals.
"All in all, it was a pretty controlled environment," said Dr. Panter, who has been an emergency-room physician for 30 years. "I've seen a lot worse. They were without question ready — not ready for those type of injuries, but they were prepared."
Once victims were transported to Boston's hospitals, doctors had to carefully coordinate their response. Each has a story of where they were when the bombs went off and how they rushed to help and how, in some cases, they somehow just missed being victims themselves.
Dr. Alok Gupta, who directed the surgical response at Beth Israel, said he often goes to the finish line of the marathon to watch the race. But this year he was so tired that he took a nap. Then he heard ambulance sirens and helicopters outside his home in Back Bay, near the marathon finish. He was just beginning to wonder why the sirens had not dissipated and why the helicopters were hovering when his cellphone rang.
"The call was broken up," he said. "All I heard was 'mass casualty.' " And "we need you," he said.
He was out of the house in less than a minute and at the hospital five minutes later. Then he and his colleagues set to work. They cleared the emergency room, sending home those who could leave and sending others to beds elsewhere in the building. They cleared intensive care, sending patients to other areas of the hospital. Dr. Gupta directed a central command.
"Surgeons were notified, emergency-room physicians were notified, operating-room personnel were notified, everyone was notified," he said. Cellphone service in Boston had been limited to prevent terrorists from using cellphones to detonate any more bombs, so doctors, nurses and other medical professionals were contacted with text messages.
About 10 minutes later, patients began to arrive. Each was put in a room and assessed. Doctors described the situation as calm and efficient.
Seven patients at Beth Israel went directly to the operating room for emergency surgery to stabilize them, stopping bleeding for example. Five went to intensive care. At Brigham and Women's Hospital, six patients went to the operating room and nine to intensive care.
"I think a lot of these injuries are so devastating, it was pretty straightforward — they weren't going to be able to salvage these things," said Dr. Burke of Boston Medical Center. "We all would like to salvage whatever extremities we can, but one thing we've learned in trauma is when you get too much damage, you can create too much hassle, so you may get the amputation but it may be a year down the line. Ten operations, failed operations, addictions to narcotics for the chronic pains, all these kinds of things." An early amputation, Dr. Burke added, can mean a quicker return to a normal life.
Borrowing a tactic used by the military in Iraq, doctors at Beth Israel used felt markers to write patients' vital signs and injuries on their chests — safely away from the leg wounds — so that if a patient's chart was misplaced during a transfer to surgery or intensive care, for example, there would be no question about what was found in the emergency room.
Those who needed surgery would often need more than one operation on subsequent days. Those with huge blast wounds that ripped out skin and muscle would need plastic surgery. Those with severed arteries would need surgery, too.
Most of the injured taken to Beth Israel were no older than 50, said Dr. Michael Yaffe, a trauma surgeon at the hospital. A few were runners, but most were spectators who had prime viewing positions near the finish line.
At about 2 a.m. on Tuesday, the Beth Israel medical team left for home, to return again at 6. They examined each patient before they left and again when they returned. Often, in trauma, the doctors said, patients will not notice some of their injuries until the major injury is taken care of.
The Boston Marathon is so special, a day to celebrate athleticism and the thrill of the sport. For those runners who trained for months and now can be facing months or years or rehabilitation, and the end of their running days, the bombs took away "the thing they loved," Dr. Yaffe said.
In the moments after the explosions, some patients recalled that they "thought they would die as they saw the blood spilling out," said Dr. George Velmahos, chief of trauma services at Massachusetts General Hospital. When they awoke Tuesday and realized they were still alive, they said they felt extremely thankful, some even considering themselves lucky, Dr. Velmahos said.
"It's almost a paradox," he said, "to see these patients without an extremity to wake up and feel lucky."
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