By Brigid Duffy
The morning of April 15, 2013 started as a typical Marathon Monday for Dr. Tim Lepore. At age 68, Nantucket’s only surgeon laced up his trainers and made his way to the starting line of his 45th consecutive Boston Marathon.
By mid-morning, long after the elites’ dust had settled, Dr. Lepore joined the second and third waves of runners who crossed the starting line on Hopkinton Massachusetts’ Main Street. The air was a cool 50 degrees. The sky was overcast with an occasional spot of sunlight that added brilliance to the outstretched road ahead. All in all, it was idyllic conditions for Dr. Lepore and the 26,383 other entrants who set out to compete in the 117th Boston Marathon. Months of training had been logged, and it was time for a 26.2 mile party.
Dr. Lepore ran alongside his daughter, thankful and excited to be part of what he likened to Christmas morning. “I’m 68,” said Dr. Lepore. “I was never fast, I’m not any faster now, but it’s such a fun event. The crowd does basically everything except use cattle prods to get you going.”
Like every third Monday in April for the past 44 years, Dr. Lepore made his way east toward Boston proper, past Hopkinton, Ashland and Framingham; Quaint New England towns that might be described as, “sleepy,” 364 days of the year, but crackle with electricity on Marathon Monday.
Everything was going according to plan as Dr. Lepore and his daughter coiled through Natick and Wellesley and turned onto Commonwealth Avenue at mile 18 when he received a call from his son. There had been an explosion.
“Nobody else seemed to know it because things were going along smoothly,” Dr. Lepore said. “And then it became obvious something was going on because all the police vehicles took off.” By the time Dr. Lepore reached mile 19, just a mile and a half short of the infamous Heartbreak Hill, he and the remainder of the runners on the course were stopped. Their marathon was over. “Just like that, we were told, that’s it, we were done.” At that point, there was no way to know the extent of the terror that was happening just seven miles east.
In Copley Square, screams and moans cut through an eerie silence. Everywhere, runners and spectators with mangled extremities, pulverized muscles, abdominal wounds, ripped blood vessels, shattered bones and soft flesh filled with nails and ball bearings were taken up, one by one, and rushed to local hospitals. Medical tent volunteers who anticipated a day of treating dehydration, muscle cramps and hypothermia applied tourniquets to control catastrophic hemorrhaging before shuttling victims to ambulances. Just a few hundred feet away from the finish line of the world’s most prestigious running event, there was more trauma and bloodshed than most medical professionals would see in a lifetime.
As patients arrived in droves at Boston Medical Center, Beth Israel, Brigham and Women’s Hospital, and Massachusetts General, surgeons saw the same gruesome leg injuries again and again. The same decisions had to be made, with little time to ruminate: “Should we amputate on this one? What about this leg?”
But after a week of terror following the bombing, with most Americans—runners and non-runners alike—glued to their televisions, a glimmer of good news emerged from the tragedy. Of the more than 180 victims with injuries who made it to the hospital alive, all survived—a testimonial to fast care at the scene, on the way to hospitals, then in emergency and operating rooms (ORs). From an unprecedented horrific event in American history has emerged unprecedented success in the way that doctors, nurses and paramedics handled a surgical surge that is usually only seen on the battlefields in Iraq and Afghanistan.
Dr. Lepore, who felt a very personal loss both as a runner and a surgeon, said, “The loss was tremendous, and there are many life-changing injuries, but it could have been a lot worse. The tremendous response showed what each of those hospitals could do, and they all rose to the occasion.”
The surgical response preceding the bombings has given many examples of collaboration and efficiency that are useful to surgeons seeking to improve their practice.
The ability to effectively organize in what had the potential to be a chaotic scene came down to disaster preparedness plans, according to George Velhamos, MD, chief of the Division of Trauma, Emergency Surgery and Surgical Critical Care at the Massachusetts General Hospital. “If we want to make a change in survival,” Dr. Velhamos said, “preparedness for the unexpected is absolutely necessary.”
Preparedness for mass casualty events starts not with surgeons, but with the emergency medical teams and paramedics who are the first to aid and transport victims on the scene. One of the first directives that James Hooley, chief of Boston Emergency Medical Services (EMS), gave after the two bombs exploded near the finish line was for staff to alert hospitals of a potential mass casualty incident and to call for mutual aid. Eleven private ambulance services answered the call by immediately sending more than 40 ambulances to support Boston EMS to help transport the injured to local hospitals.
According to the Boston Public Health Commission, within three minutes of the bombings, all Boston hospitals were notified of the mass casualty incident, and within five minutes mutual aid ambulance partners were asked to assist in the response. Boylston Street was cleared of patients in 18 minutes, and 90 patients from the scene were transported to area hospitals in approximately 30 minutes.
Beyond the rapid response to the bombing, Dr. Velhamos noted that the initial triage in patients was what enabled surgeons to work in an orderly fashion as patients started to arrive.
“In the short time that we arrived to the ER, within that time, patients were already arriving. The hospital providers did an outstanding job with triaging patients according to their level of injury.” In many mass casualty events, the walking wounded are usually the first to flood nearby centers, not leaving enough space and resources to those who arrive later and are in greater need of care. But Dr. Velhamos siad that this was not the case after the bombing because the Boston EMS System communicated so efficiently.
As patients began to arrive at Mass General, Dr. Velhamos described the scene as, “orderly and not chaotic.” Many surgeons see mangled extremities on a regular basis, but very few deal with more than 20 at one time. But for the surgeons at Mass General and other area hospitals, April 15, 2013 was merely a day in which years of preparation were finally put to use.
“We’ve done disaster preparedness plans and simulation plans again and again, for many years,” said Dr. Velhamos. “We’ve practiced situations of mass casualty events, so when it happened, we knew what to do.”
Many surgeons credit the contributions of the American College of Surgeon’s Committee on Trauma in the success in the surgical response following the bombings. COT’s mission is to develop and implement meaningful programs for trauma care in local, national and international arenas, and to provide professional development and standards of care. “Without the COT,” Dr. Vehamos said, “we wouldn’t have trauma systems, we wouldn’t have trauma teams, centers, standard of codes of managing trauma patients, no policies or protocols. It is this exact system put together that allows us to practice at the level that we do.”
Although disaster preparedness plans are instrumental in creating the infrastructure necessary in dealing with mass casualty, Carl Hauser, MD, a surgeon in the Division of Trauma and Surgical Critical Care at Beth Israel Deaconess Medical Center explained it is up to individual hospitals to make those provisions work.
“In the fog of war,” said Dr. Hauser, “one size does not fit all; you have to adapt locally.” For the team at Beth Israel, adaptation meant designating local personnel with a strong knowledge of the hospitals’ resources as leaders. As one team examined patients as they were brought through the door, another team directed them to a specific OR, while another assigned a surgeon to individual victims in critical condition.
“You need to be able to rely on the education of local personnel who will be able to adapt and know the hospital well enough to work out the logistics of where these people will go,” said Dr. Hauser. “It’s a secondary layer of triage.”
Beyond figuring out logistics, it is crucial to rely on the most experienced staff to make the right call in individual cases, especially when it is not a matter of saving one limb, but of saving as many limbs as possible within a group, and there isn’t time for deliberation.
In the case of deciding to amputate a leg, for instance, it is standard protocol for a second surgeon to assent to the decision to amputate, but in situations of mass casualty, a second opinion is not always an option.
“Management by committee in these circumstances leads to excess morbidity in the group as a whole,” said Dr. Hauser. “If two to three teams debate if a limb is salvageable, you thereby lose the ability to take care of two or three other patients over time. It’s the nature of mass casualty situations. You make your best call and you go with it.”
Damage Control Surgery
Beyond the outstanding preparedness and fast-acting adaptation that all of the Boston area hospitals exemplified in the hours and days following the bombings was the implementation of damage control surgery—the single most important breakthrough in trauma care in the past 20 years.
The accumulated knowledge of treating blast injuries gained over a decade of war in Iraq and Afghanistan has lent an unexpected value to saving civilian lives in Boston. According to a 2011 study in the British Journal of Surgery, traumatized lower limbs has become the signature injury in the conflict in Afghanistan, and with an increase in lower leg injuries has come greater innovation in treating them. The multitude of lower leg injuries that victims in Boston suffered was an all- too-familiar sight for surgeons who had served in the military.
The principal of damage control surgery is to do just enough to stop hemorrhaging, control contamination and reduce fractures with the understanding that further surgeries will be performed when the patient is more stable. If a patient in critical condition is under anesthesia for too long, it often can do more harm than good. “It’s critical not to get too hung up on injuries that don’t affect life or functionality,” said Dr. Hauser. The idea is to do the least possible to keep the patient alive with reasonable function, and recognize that on day 2 or 3 that there will be more resources and more logistic capability. As Dr. Hauser noted, “there’s no use in clogging up the OR with doing things perfectly.”
When dealing with lower leg trauma, the single most important measure in damage control resuscitation is the implement of tourniquets in the pre-hospital environment. A 2012 study published in The Journal of Bone & Joint Surgery, reported that the most common cause of death from injuries in both Iraq and Afghanistan was bleeding out. Dr. Velmahos said, “It is an extremely simple yet underused tactic. Surgeons should work with their local EMS to ensure that tourniquets are provided in each ambulance.”
After a patient arrives on the scene, the next step is rapid amputation and ongoing, through cleaning of the wound, including removal of dead, damaged or infected tissue. It is a process that requires coordination between vascular surgeons who repair torn blood vessels, orthopedic surgeons who stabilizes the bone and plastic surgeons who clean the wound.
Determining functionality of the limb is paramount, as there is a very real risk for a patient dying while surgeons try to salvage nonfunctioning tissue. In other words, there is a big distinction between saving a leg and saving the function of a leg. “The worse thing is to put vessels, bone and muscle together, and still have a leg that cannot move. It becomes more of a burden to the patient, and they might fare much better with a prosthesis,” said Dr. Velhamos. In treating the blast victims, nearly all of the amputations performed were guillotine amputations, in which bleeding and contamination is controlled, but a surgeon does a follow-up procedure to close the stump in the following days. As Dr. Hauser put it, “In times of mass casualty, things don’t have to look pretty on day 1.”
Although for many patients the path to recovery will be long and arduous, with hospital visits, stiffness from torn muscles, scars from operations, and arthritic joints, Dr. Velhamos recalls the moment when patients woke up, having a memory of blood spilling out of their legs, and being told they would live. It was, bizarrely, a happy moment, and many have the stellar communication, efficiency and training of the staff of local Boston hospitals to thank.
But for what was an extraordinary event in the lives of many victims and their families was just another day on the job for Dr. Velhamos. “Trauma knows no boundaries,” he said. “It cuts across race, age and social status. As trauma surgeons, we see it everyday. We have seen it all.”