Medical professionals treating the victims of the Boston Marathon bombings have one advantage over first responders at the Oklahoma City bombing: the accumulated knowledge of treating blast injuries gained over a decade of war in Iraq and Afghanistan.
Thanks to quick action after the blasts, new damage control surgery protocols, aggressive treatment to prevent secondary infections and advances in prosthetics, many Boston bombing survivors will be facing a life of mobility and near-normalcy that wouldn’t have been likely 15 years ago.
The improvised explosive devices (IEDs) used at the Boston Marathon on April 15, which claimed three lives, seriously injured dozens—mostly with lower body injuries. “These patients are probably going to be treated in a way that benefits from the experience we’ve gained from the wars,” says Odette Harris, associate chief of staff of polytrauma at the Veterans Affairs Palo Alto Health Care System in California. “The resulting amputations and orthopedic injuries would be similar to what our polytrauma department would have experienced. It’s important to make that link and reassure people that these individuals have incredible resiliency, and the outcomes that are possible are extraordinary, given the extent of the injuries.”
In fact, a 2008 study co-authored by Colonel Todd Rasmussen, deputy commander of U.S. Army Institute of Surgical Research at Fort Sam Houston in San Antonio, described the surgical response in the first 72 hours after three IEDs exploded in Iraq for the purpose of conveying lessons applicable in civilian settings. “The Boston hospitals got a surgical surge that almost mirrors in volume the individual incidents that we outlined in Iraq in 2008,” Rasmussen says. “An unexpected value in return for civilians' investment in combat casualty care research is that nearly all of the life-saving lessons, knowledge and products that come from that investment translate right into the civilian trauma care system. Undoubtedly, elements of damage-control resuscitation and damage-control surgery as it pertains to mangled extremities, abdominal wounds and head injuries have been used extensively in the medical centers in Boston over the past number of days.”
According to a 2011 study in the British Journal of Surgery, amputation of traumatized lower limbs “has become the signature injury of the conflict in Afghanistan.” Amputations among U.S. soldiers more than doubled from 2009 to 2010 therein, and double-amputations tripled. This increase in injuries meant an increase in knowledge, experience and innovation in treating them. “In the face of adversity, that’s when the greatest innovations come out,” says Pawan Galhotra, the program director for the Polytrauma System of Care at VA Palo Alto. “We’ve had to be very creative in management of individuals with multiple limb loss.”
How IED injuries are different
Blasts from grenades and mines are nothing new in war, but IEDs differ both in terms of injury patterns and in the long-term risks of infection from their improvised design. Galhotra describes two basic injury patterns from “mounted” and “dismounted” IEDs. Mounted IEDs are those embedded in the sand or road that a vehicle rolls over, primarily leading to traumatic brain injury. Dismounted IEDs are those that detonate when a soldier is on foot, and are the ones more likely to cause multiple limb loss, head injury and other complications, such as burns, internal organ damage, spinal cord injuries and genital or urinary injuries.
An important lesson from treating dismounted IED injuries, Galhotra says, has been immediate prevention of severe blood loss, a point echoed in a study last year in The Journal of Bone & Joint Surgery. British researchers reviewed lessons learned from injuries in Iraq and Afghanistan and noted that the most common cause of death was bleeding out. They described a 2005 protocol change in treating battlefield trauma that prioritized the control of catastrophic hemorrhage over “airway, breathing and circulation,” which had previously taken priority.
“This immediate phase of care used to be relatively neglected as medics and bystanders focused on calling for help and transportation,” Rasmussen says. “However, the military has shown that a certain percentage of patients who have the potential to survive will die if not tended to immediately.” That rapid response includes sitting conscious patients up so they can maintain open airways and breathing, using small needles to release the pressurize around a collapsed lung, use of topical agents and dressings to stop bleeding and, especially, widespread use of tourniquets to step excessive bleeding, such as the Combat Application Tourniquet developed during the wars.
Both the British study and a 2012 study from researchers at Walter Reed National Military Medical Center noted the “universal acceptance and use of tourniquets” as crucial to reducing mortality. According to U.S. army combat medic Caleb Causey, all soldiers are issued tourniquets at deployment, but many U.S. cities’ emergency services are still behind the times in tourniquet use. “First responders and anybody in public safety, whether law enforcement, fire department, or EMS, should have medical direction to use tourniquets and have tourniquets readily available,” says Causey, who now operates Lone Star Medics in Arlington, Texas. “In civilians we’re not usually seeing the same injuries we’re seeing in Iraq and Afghanistan, but bleeding is bleeding, and you’ll lose the whole patient if they bleed out.”
A 2008 study in the Journal of Emergency Medical Services discussed the effective use of tourniquets at Boston Medical Center and in the unofficial guidelines of Boston EMS, although it’s unclear how many first responders had tourniquets on hand during the marathon. Regardless, stopping the bleeding is just the first step in the acute treatment phase.
The next step, Galhotra and other trauma experts note, is rapid amputation and ongoing, thorough cleaning of the wound, including removal of dead, damaged or infected tissue, which is essential to preventing infection, a hallmark of IED injuries because the bombs are often literally dirty. The bomb-makers, he says, will “put anything they can find into the device, such as rusted old bolts, to contaminate the contents of the bomb, and whatever goes off of that gets embedded into tissue, causing long-term risk of infections.” The IEDs in Boston were “six-liter pressure cookers, filled with nails and small ball bearings, like buckshot,” the Boston Globe reported–exactly the kind of dirty bomb ingredients that can lead to additional or higher amputations if an infection spreads. Galhotra says it wasn’t unusual for a soldier to make it all the way back to the U.S. with a below-knee amputation, only to have more amputated because of an infection.
But equally important to these surgical interventions is not overdoing it, once the initial immediate amputations have occurred, at the cost of the patient’s well-being, Rasmussen says. That is where new protocols in damage control surgery have come in. “Damage-control surgery refers to doing just enough to stop hemorrhage, control contamination and reduce fractures with the anticipation of coming back to do further operations when the patient is more stable," Rasmussen says. "If you have a patient under an anesthetic for too long, it can be detrimental, and we realized we were pursuing perfection during 16 to 18 hours of operation at the expense of the patient's overall physiology and well-being." Now, patients receive "abbreviated operating" that allows for better improvement in their overall physiology, with ongoing resuscitation and subsequent operations over several days and weeks. Resuscitation involves replacing the appropriate amounts and types of fluids patients require when they have lost a lot of blood and are in shock. Rasmussen noted another study in JAMA Surgery last year outlining military research into certain medications and ratios of blood components that have benefited civilian trauma care.
Once the amputations and infection risk have passed, though, the real work for patients begins, and so does the remarkable innovation coming from battlefield medicine. “In terms of the long-term prognosis, we’ve come a long way in terms of technological advances and manufacturing of limbs and prosthetics,” Galhotra says. Instead of previous single-hinge-point knees, for example, he describes relatively new “microprocessor knees,” which have motors that can act on the different types of loading the knee sustains while walking, thereby “normalizing” the gait. “Before, if someone had come to us with both above-knee amputations, the prognosis for that individual was very bleak, because it takes very high energy for that person to walk, given that they would have two prosthetic limbs with hinges they had to mechanically control by shifting their body weight,” Galhotra says. “Now with the advancement in the knee joints, those people can walk for longer periods of time and possibly keep out of a wheelchair long-term.”
Another innovation has been construction of “exoskeletons” of sorts for those who lose part of their pelvis. Galhotra described a 20-year-old soldier who lost his right hip joint and the left half of his pelvis. “You’re not left with a lot to work with,” he says of such a situations: a person missing a pelvis cannot even sit down without tipping over. In the past the soldier likely would not have walked again. “Today, that individual is up and walking with bilateral prosthesis, but it took a lot of innovation,” Galhotra says. “It’s those kind of catastrophic injuries that led to the innovation, know-how and problem-solving to get these individuals back to being able to function in society.”
In the process of developing better prosthesis, Galhotra says that physical therapists have also learned the importance of preventing complications arising from reduced mobility throughout the recovery phase. “Old medicine used to say ‘rest is best and let it heal,’” he says. “New medicine says you need the rest and recovery, but just long enough to be able to accept the prosthesis.” Prolonging rest can decondition the body in terms of cardiovascular health and can risk letting the muscles shorten, making it painful and difficult to straighten the joint. “It’s sort of a battle between comfort and maintaining function,” Galhotra says.
Despite the advances, researchers still have much to learn to improve treatment. The Walter Reed paper noted that advances in bone-regeneration technologies have hit a ceiling, but promising avenues remain in finding improved methods of nerve reconstruction.
Even if that technology becomes a reality, however, patients will need one thing most of all: time.” The recovery phase is unfortunately very long-term,” Galhotra says. “Individuals with these injuries survive and have excellent outcomes—they can go back to playing basketball and participating in fulfilling life activities, whether it be returning to work or family life—but it takes a long time to get there.”