Once a year, Boston hospitals work together to prepare for the unthinkable. When it happened during the Boston Marathon, they were ready.
With emergency teams already on hand because of the race, the city's emergency rooms "went into auto-mode," said Mark Pearlmutter, chief of emergency medicine at St. Elizabeth's Hospital in Boston. Within minutes after the bombs went off, the wounded were parcelled into five major trauma centres that took those with the worst injuries. Several other community centres handled the rest.
A key reason the triage went smoothly is the city's program of training drills that date to the aftermath of the Sept. 11 terrorism attacks, doctors said.
"We had protocols, policies and workflows in place to do the best job possible," Pearlmutter said.
The drills, now standard in most major U.S. cities, cover everything from plane crashes to natural disasters and dirty bombs, medical officials said. Each of the hospitals sends a team of 10 to 20 doctors and staff to the yearly drills, Pearlmutter said in a telephone interview. The teams are then asked to respond to each scenario and the responses are discussed in depth by the entire group, he said.
This helps create the area-wide plans that kick in when an actual emergency occurs.
A mass trauma such as the Boston explosions, which killed three, including an eight-year-old boy, and injured more than 175, isn't much different from a bomb blast scene in a war zone, doctors said.
The first step is to quickly determine which patients are most in danger of dying, no easy task in a bombing when hundreds of victims are covered in blood, some with life-threatening internal injuries and others with little more than superficial cuts.
The city's hospitals and trauma centres regularly practise for just this sort of event, running drills on a mass-casualty disaster, said Boston Medical Center trauma surgeon Tracey Dechert.
"After 9/11, people took it up a notch," Dechert said.
Stephanie Kayden, an attending physician in the department of emergency medicine at Brigham & Women's Hospital in Boston, said the biggest problem with blast injuries "is they can look a lot less severe than they actually are. The liver is just a hunk of fleshy material," she said. "Although you may not see any damage on the outside, the liver itself can be broken into pieces and bleeding profusely."
John McManus, a retired colonel and U.S. Army trauma physician who served two tours in Iraq and ran the military's Baghdad combat support hospital, said doctors first use tourniquets and anti-bleeding drugs to stop obvious bleeds before looking for harder-to-see effects.
"How do you deal with a person with a bunch of holes in them? You basically scan them head to toe," he said.
And injuries inside the body can develop slowly, the doctors said. A patient scanned with a CT machine may show little internal fluid at first, then over half an hour develop a life-threatening problem as blood pressure drops and cells are deprived of oxygen. Burns can be insidious as well -- the inside of the mouth and throat may take time to show damage, then the tissue swells and cuts off breathing.
Most of the wounded in Boston suffered damage to their lower extremities, George Velmahos, chief of trauma surgery at Massachusetts General Hospital, said.
Medical personnel were treating three primary groups of injuries: internal bleeding, those sustained when falling or thrown to the ground from the bomb's shock wave and embedded debris from the bomb as well as flying glass, he said.
During the race, Paul Biddinger, medical director for emergency preparedness at Massachusetts General, was at a medical tent on Heartbreak Hill, located at about the 20th mile on the marathon course. There he was caring for runners who were struggling with dehydration, heatstroke and other medical issues that typically occur during marathon races.
Biddinger was called when the bombings occurred and arrived at the emergency room about the same time as the first patients appeared.
"We can clearly point to a couple of people who went to the operating room first -- truly, minutes mattered," he said in a telephone interview. "If this hadn't gone smoothly -- from the marathon itself, to the transport, to the care in the hospital -- had not every single step been perfect, they would have died.
''Overall, I would like to think we saved limbs and lives, but there is no question that we have a couple of people that lived because the system worked the way it did,'' he said.
Boston's hospitals "have been preparing intensively for something like this since 9/11,'' Biddinger said. ''We listened to their experiences, the pitfalls and the learnings, and that played an enormous role in how our response unfolded.''
In a disaster setting, hospitals will begin cancelling any unnecessary operations on other patients even before the new patients arrive, and clearing beds to handle the wounded.
The vast majority of life- and limb-threatening injuries in this bombing came from shrapnel and debris, Biddinger said.
While a wound from flying debris and bomb material "can be superficial, it can be very deep," said Demetrios Demetriades, director of trauma services at the Los Angeles County-University of Southern California Healthcare Network, which serves as the training centre for the U.S. Navy's trauma-care physicians.
''The closer you are to the explosion, the higher the possibility of amputation," he said "This is the most common type of injury you see from war."
Doctors also have to worry about a patient's pain. McManus, the U.S. Army trauma physician, said doctors in Iraq learned controlling how patients feel was a key component in whether they developed symptoms of post-traumatic stress disorder later.
"We want to have people adequately controlled," he said. "We don't want to just give people low doses and say, 'Do you feel OK?' We want them pain-free."
Medical personnel also have a role in collecting evidence for the criminal investigation, Demetriades said. Every piece of debris removed from a patient's body will be saved, as will burned and torn clothes. "Everything removed from the victim needs to be preserved," he said. Criminal investigators can use it to look for traces of explosive, or try to figure out how the bomb was made.
At Boston Medical Center, Dechert, the trauma surgeon, said they had seen 23 patients from the blast -- and amputated limbs from five. "I still think it hasn't hit us really," she said.
Across Boston, the mood at hospitals is similar.
"We're proud we were able to limit the injury and illness, but it was a tragic event," Biddinger said. "Everyone is going through sorrow and loss. It was a great system response, but it's hard to celebrate given the reason for what went on."
-- Bloomberg News