The bombs that tore through the finish-line of the Boston Marathon caused carnage seldom seen anywhere but a war zone.
As doctors now treat the injuries from shrapnel, shock and burns, they are following protocols developed and perfected on the battlefields of Iraq and Afghanistan, doctors here said.
“What you are seeing here is basically a combat injury. These are military-grade injuries, things you see from anti-personnel mines,” said Dr. Ahamed Mohaideen, an orthopedic surgeon who treats children at Palms West Medical Center in Loxahatchee and St. Mary’s Medical Center in West Palm Beach.
By Wednesday afternoon, 70 people remained hospitalized from Monday’s attack, 24 of them in critical condition, according to the Boston Globe. Three people were killed in the attack, more than 170 injured.
It’s a scene not unfamiliar to Dr. Robert Borrego, the trauma medical director for St. Mary’s, who served a tour as a combat surgeon in Iraq. Blast injuries are so complex and pervasive, he said, health care workers must start with the most life-threatening issues and work backwards.
Breathing comes first.
“No matter how hurt you are, the first thing we look at is your airways. Then the circulation. Once we know we have heart, lungs, then we deal with the extremities. Stop the bleeding. Fix the fractures,” Borrego said.
The bombs were packed with nails and pellets, timed to explode four hours after the start of the race, to inflict maximum carnage, authorities said.
If there is a bright side, it’s that the victims are being cared for in some of the nation’s best hospitals, said Dr. Ernest Shwayri, chief of surgery at the U.S. Department of Veterans Affairs West Palm Beach Medical Center. That there were paramedics on hand for the runners may have saved lives, he added.
“Immediate care is extremely important,” he said.
Blast injuries reveal themselves over a matter of hours and sometimes days. There are four patterns of injuries, doctors said. An exam of the ear drum is often the quickest indicator of the severity of injury, Shwayri said.
“The first organ that is going to be affected is the ear drum. Once it is injured you have to have a complete detailed examination,” Shwayri said.
The shockwave explosion itself often does the most unseen damage. Depending on the force, and where the person stood in relation to it, the wave doesn’t just ruptures eardrums, it can hemorrhage eyes and internal organs including lungs, spleen and colon. There can be brain damage or bleeding. There are often burns.
The second pattern of injuries comes from shrapnel, flying bullet-like debris, creating gunshot type wounds. Doctors in Boston reported seeing some patients with 20 or 30 metal pellets embedded in patients’ legs.
Third, there can be crush injuries to muscle and bone. Severe crush injuries can require amputation, because the nerves and blood supply to the limb can be destroyed. Victims can suffer another constellation of traumatic injuries from being thrown to the ground or against walls.
Finally, there are the psychological issues. Those are addressed last, but may take longest to heal, doctors said.
During the U.S. invasion of Iraq a decade ago, Borrego’s team of four surgeons and medics were traveling just behind the combat line outside Baghdad, seeing a steady stream of blast victims.
“From February to May 2003 we were very, very busy, doing 15 to 20 surgeries a day,” he said. About a third of the blast victims he treated were children.
“It was exactly what you would see in Boston,” he said. “There were tons of IED (improvised explosive device) injuries, most of the people we took care of were civilians who hit an IED or a land mine.”
“At least 30 percent of the people we treated were children,” he said.
Borrego now mends victims of car accidents, gunshots, stabbings and industrial accidents who are brought into St. Mary’s by ambulance and helicopter through Palm Beach County’s trauma system.
Borrego had studied medicine at the University of Florida School of Medicine, and done a trauma residency at Jackson Memorial Hospital in Miami before the war. But it was his combat experience that most resembles what the doctors in Boston are seeing, he said.
Dr. Michael Busse, acting chief of mental health at the VA Medical Center, recently returned from a tour in Afghanistan where he provided counseling to troops that had just been in combat.
The psychological support the blast victims will require is very similar to combat post-traumatic stress, he said.
Early treatment and regular counseling and group therapy sessions can speed recovery, Busse said. The best thing friends and family can do for someone affected is to listen, and if they see changes in their loved-one’s regular behaviors and activities, speak up and help them get counseling, he said.
“Early treatment is so important,” Busse said. “The emotional consequences of this are significant, and those are things you cannot see on a CT scan or an MRI, and those are things that linger for years.”