[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.]
By Gina Kolata, Jeré Longman and Mary Pilon
 |
Eric Thayer for The New York Times
A vigil at the Boston Common, near the site of the
bomb blasts
at the Boston Marathon finish. More Photos »
|
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.”
Jess Bidgood and Richard A. Oppel Jr.
contributed reporting.