NEW YORK When it happened during the Boston Marathon, they were ready.
With emergency teams already on hand because of the race, the citys emergency rooms went into auto-mode, said Mark Pearlmutter, chief of emergency medicine at St. Elizabeths Hospital in Boston. Within minutes after the bombs went off, the wounded were parceled into five major trauma centers that took those with the worst injuries. Several other community centers handled the rest.
A key reason the triage went smoothly is the citys program of training drills that date to the aftermath of the Sept. 11 terrorism attacks, doctors said.
We had protocols, policies and work flows 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.
LOOKS ARE DECEIVING
A mass trauma like the Boston explosions, which killed three, including an 8 year-old boy, and injured more than 175, isnt 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 citys hospitals and trauma centers regularly practice 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 in a telephone interview.
Stephanie Kayden, a physician in the department of emergency medicine at Brigham & Womens 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.
SCAN FOR HOLES
Brigham & Womens emergency department treated 31 patients Tuesday, five of whom were still critically injured as of Tuesday afternoon, Kayden said.
John McManus, a retired colonel and Army trauma physician who served two tours in Iraq and ran the militarys Baghdad combat support hospital, said doctors 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.
Injuries inside the body can develop slowly. 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. 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.
3 TYPES OF INJURIES
Most of the wounded in Boston suffered damage to their lower extremities, George Velmahos, chief of trauma surgery at Massachusetts General Hospital, said Tuesday in a news briefing. That has led doctors to think the bomb must have been detonated from the ground up, Velmahos said.
Medical personnel were treating three primary groups of injuries: internal bleeding, those sustained when falling or thrown to the ground from the bombs 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 about the 20th mile on the marathon course. There he was caring for runners who were struggling with dehydration, heatstroke and other 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 hadnt 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.
PAIN AND PTSD
Bostons hospitals have been preparing intensively for something like this since 9/11, Biddinger said in a telephone interview. In a disaster, hospitals will cancel unnecessary operations on other patients even before the new patients arrive, and clear beds to handle the wounded.
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 center for the Navys 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 have to worry about patients pain. McManus, the Army trauma physician, said doctors in Iraq learned that controlling how patients feel was a key component in whether they developed symptoms of post-traumatic stress later.
Medical personnel also have a role in collecting evidence for the criminal investigation, Demetriades said.
Every piece of debris removed from a patients body will be saved, as will burnt 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.