Battlefield Lessons Save Lives, Limbs after Boston Marathon Explosions

by U.S. Medicine

May 6, 2013

Annette M. Boyle

SAN ANTONIO, TX – Ten years ago, many of the survivors of the Boston Marathon bombing with major lower body injuries would likely have spent the rest of their lives in a wheelchair. A new — and far more positive — set of expectations have been established, however, because of 12 years of experience with improvised explosive devices (IEDs) gained in Iraq and Afghanistan.

“A decade ago, it would have been very, very rare for someone with a leg amputation or severe leg injury to run routinely, let alone run a marathon. Now it’s not only possible, it’s commonplace,” said Col. James Ficke, MD, chairman, Department of Orthopaedics and Rehabilitation at San Antonio Military Medical Center and Orthopaedic consultant to the Army Surgeon General. “I recently had a patient who had lost his leg from the buttocks down finish a marathon in four hours and 30 minutes.”

Massachusetts National Guardsmen help local and state authorities maintain a security cordon after the bombing at the Boston Marathon in Boston last month. Military medicine and the lessons learned in Iraq and Afghanistan have had a major influence on how victims have been treated. U.S. Army photo by Cadet Matthew Feehan

Specific Steps Critical

Whether the patient is a soldier, an athlete or a bystander, restoring full function following a blast injury requires specific, sometimes counterintuitive, steps from the moment of injury forward. And, getting the steps right makes a difference. Through April 2013, Army Medical Command has amputated limbs on 1,590 warriors who served in Iraq and Afghanistan.

“We’ve seen six times that number — more than 20,000 — with significant limb injuries that we would consider limb salvage. These are injuries that would have resulted in amputations in previous wars,” Ficke told U.S. Medicine.

“The Boston bombing underscores that these kinds of explosions and injuries can happen anywhere at any time. Teaching the skills that save lives in these situations enables us all to live in preparation, not fear,” Ficke said. “A number of surgeons at Massachusetts General, Brigham and Women’s and other Boston hospitals have gained expertise through disaster response courses we’ve taught and are able to teach the skills to the doctors around them.”

Ficke noted that “in traffic accidents or gunshot wounds, you don’t see the same issues as you have with very high energy injuries,” The shock wave from a blast picks up rocks, dirt and other debris and blows it into people, contributing to a diffuse spread of contamination and wounds that can affect the head, lungs, overall circulation system and multiple limbs.

“The first step is for someone nearby to put on a tourniquet as soon as the injury occurs, Ficke pointed out. “That’s a change in treatment. We’ve learned in conflict that the tourniquet prevents people from bleeding to death and doesn’t worsen the injury.” Reports from Boston hospitals indicate that many patients arrived with crude tourniquets in place — some placed by off-duty medical personnel who were viewing the race.

Once arriving at the hospital, the patient then goes in for surgery or, more often now, surgeries. “People sometimes think that multiple surgeries mean that the surgeons didn’t get it right the first time. We’ve learned that if we can eliminate contamination and stabilize the injury and then bring a patient back 48 to 72 hours later, we can mitigate the extent of injury and save limbs that might initially appear to require amputation,” Ficke pointed out.

Moving Quickly After Surgery

After surgery, patients with amputations or severe limb injuries must start moving again quickly, according to David Cifu, MD, national director of Physical Medicine & Rehabilitation Program Office, Veterans Health Administration.

“As soon as they are hemodynamically stable, we get them to start using the limb as much as possible,” Cifu said

“We start with putting gentle pressure on the injured area, then moving the body above the injury, doing exercises in bed,” headed. “In two or three weeks, they should have a prosthetic device so that the injured limb feels something on it again; they can stand on it or start to use it. Within six weeks, they’re using a temporary artificial limb. It gets their mind off of the disability and onto the possibilities.”

That’s when the real work for the patient and the support team begins. “The single biggest challenge in battle or Boston is that the injured are people who were a few minutes earlier very healthy. They were athletes, people associated with fitness, who must deal with the cold hard fact that these are life-changing injuries,” Ficke noted.

Military medicine has learned from the conflicts of the past dozen years that restoring full function following severe injuries and amputations requires attention to the whole person, mind and body.

“In Boston, we’ve seen rapid response by psychological support teams. They’re concerned that acute stress reaction may become post-traumatic stress disorder,” Cifu said. “We know that the sooner you get survivors to talk through their images of events, provide a positive focus, teach them relaxation and sleep techniques, the better the outcomes.”

Physicians are focused on mental function, sleep and other disturbances for another reason as well. “Up to 20% of forces experienced concussions in conflict. We’re likely to find that similar numbers of survivors of the Boston bombs will suffer mild concussions or brain injury,” Cifu explained. While many will get better on their own, others may report trouble sleeping, headaches or confusion over the next three months or more.

“Blood and limb loss can take precedence over a ding to the head,” Cifu noted. “It took years for us to get ahead of this in the [Operation Enduring Freedom/Operation Iraqi Freedom] conflicts, but because of the awareness we’ve gained of traumatic brain injuries from blast injuries, physicians and counselors in Boston are now alert to the signs of this often silent issue.”

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