Thursday, April 18, 2013
Medically speaking, this is no small accomplishment. We've seen bombs like this in the battlefields of the Middle East, but rarely in cities like Boston. In the past century of wartime conflict, explosive devices have escalated to become the predominant cause of military casualties. Among American personnel wounded in our wars in Iraq and Afghanistan, they have accounted for three-quarters of injuries; gunshot wounds for just twenty per cent. It has been an historic accomplishment for military medical units to bring case-fatality rates from such injuries down from twenty-five per cent in previous conflicts to ten per cent today. And according to data from the Israeli National Trauma Registry, explosives used in terror attacks have tended to be three times deadlier than those used in war—because civilians don't have armor, because victims span a wider range of age and health, and because preparedness tends to be less systematic. Nonetheless, in Boston, they survived.
How did this happen? Something more significant occurred than professionals merely adhering to smart policies and procedures. What we saw unfold was the cultural legacy of the September 11th attacks and all that has followed in the decade-plus since. We are not innocents anymore.
The explosions took place at 2:50 P.M., twelve seconds apart. Medical personnel manning the runners' first-aid tent swiftly converted it into a mass-casualty triage unit. Emergency medical teams mobilized en masse from around the city, resuscitated the injured, and somehow dispersed them to eight different hospitals in minutes, despite chaos and snarled traffic.
My hospital, the Brigham and Women's Hospital, received thirty-one victims, twenty-eight of them with significant injuries. Seven arrived nearly at once, starting at 3:08 P.M. All required emergency surgery. The first to go to surgery—a patient in shock, hemorrhaging profusely, with inadequate breathing and a near-completely severed leg—was resuscitated and on an operating table by 3:25 P.M., just thirty-five minutes after the blast. The rest followed, one after the other, spaced by just minutes. Twelve patients in all would undergo surgery—mostly vascular and orthopedic procedures—before the evening was done.
This kind of orchestration happened all across the city. Massachusetts General Hospital also received thirty-one victims—at least four of whom required amputations. Boston Medical Center received twenty-three victims. Beth Israel Deaconess Medical Center handled twenty-one. Boston Children's Hospital took in seven children, ages two to twelve. One emergency physician told me he'd never heard so many ambulance sirens before in his life.
There's a way such events are supposed to work. Each hospital has an incident commander who coördinates the clearing of emergency bays and hospital beds to open capacity, the mobilization of clinical staff and medical equipment for treatment, and communication with the city's emergency command center. At my hospital, Stanley Ashley, a general surgeon and our chief medical officer, was that person. I talked to him after the event—I had been out of the city at the time of the explosions—and he told me that no sooner had he set up his command post and begun making phone calls then the first wave of victims arrived. Everything happened too fast for any ritualized plan to accommodate.
So what did you do, I asked him.
"I mostly let people do their jobs," he said. He never needed to call anyone. Around a hundred nurses, doctors, X-ray staff, transport staff, you name it showed up as soon as they heard the news. They wanted to help, and they knew how. As one colleague put it, they did on a large scale what they knew how to do on a small scale. They broke up into teams of six or so people, one trauma team for each patient. A senior nurse and physician stood at the door to the ambulance bay triaging the patients going to the teams. The operating-room director handled triage to, and communication with, the operating rooms. Another staff member saw the need for a traffic cop and began shooing extra clinicians into the waiting room, where they could stand by to be called upon.
Richard Wolfe, the chief of the emergency department at Beth Israel Deaconess Medical Center, told me he had much the same experience there. Of twenty-one casualties, seventeen were serious and seven required emergency surgery. One patient came in with both legs almost completely amputated already. Another's leg was too mangled to save. Numerous victims had open, bleeding wounds, with shrapnel and shards of fractured bone. One had a lung injury from the blast. Another was burned on over thirty per cent of the body. One had to have an eye removed. Wolfe arrived in the emergency department expecting to take charge of assigning everyone responsibilities.
"But everybody spontaneously knew the dance moves," he said. He didn't have to tell people much of what to do at all.
I spoke to Deb Mulloy, the nurse in charge of our operating rooms that afternoon, and a few of the other nursing leaders to find out how they knew the dance moves. Mulloy began mobilizing as soon as she saw the news flash onto a television screen. Others learned through Twitter, text messages, smartphone news apps. They all began to act before the alarm had been sounded.
"We just knew this was real," Mulloy said, "and a lot of people could be hurt."
Change of nursing shift is at three o'clock. So she immediately notified the day shift to stay on. No one wanted to leave, anyway. This doubled the available staff.
The nurses put all scheduled surgery on hold and began readying eight rooms. They ordered equipment trays for vascular and orthopedic procedures to be brought up from stock supply. They called an orthopedics-manufacturer representative for extra hardware to be mobilized. They got in touch with the blood bank, which was already securing blood from other states. They communicated with other operating rooms around the city to make sure they had enough supplies of equipment, too.
How did they know to get eight rooms ready, I asked. And how did they know to get them ready for vascular and orthopedic procedures? "Did someone tell you?"
"No," said Brenda McKonly, one of the senior nurse leaders. She just saw the descriptions of the explosion like everyone else, made a surmise about the injuries, and recognized that they needed to get as many rooms ready as they could. To be on the safe side, the staff also got equipment for one room to be ready for a neurosurgical injury and another for a thoracic injury. But as word filtered down from the emergency department, it became clear that their original surmise was correct. All eight rooms would be required, and nearly all the cases involved vascular and orthopedic injuries.
Talking to people about that day, I was struck by how ready and almost rehearsed they were for this event. A decade earlier, nothing approaching their level of collaboration and efficiency would have occurred. We have, as one colleague put it to me, replaced our pre-9/11 naïveté with post-9/11 sobriety. Where before we'd have been struck dumb with shock about such events, now we are almost calculating about them. When ball bearings and nails were found in the wounds of the victims, everyone understood the bombs had been packed with them as projectiles. At every hospital, clinicians considered the possibility of chemical or radiation contamination, a second wave of attacks, or a direct attack on a hospital. Even nonmedical friends e-mailed and texted me to warn people about secondary and tertiary explosive devices aimed at responders. Everyone's imaginations have come to encompass these once unimaginable events.
Hence the grim efficiency with which the city responded. Organizers halted the race. Runners who'd trained for weeks for the event turned away from the finish line in bewildered but stoic acceptance. The press, for the most part, rightly hesitated to amplify unsubstantiated claims about the identity of the perpetrators.
Risks of further attack required assessment. Panic had to be averted. Criminal evidence had to be secured. And above all, victims needed to be saved.
What prepared us? Ten years of war have brought details of attacks like these to our towns through news, images, and the soldiers who saw and encountered them. Almost every hospital has a surgeon or nurse or medic with battlefield experience, sometimes several. Many also had trauma personnel who deployed to Haiti after the earthquake, Banda Aceh after the tsunami, and elsewhere. Disaster response has become an area of wide interest and study. Cities and towns have conducted disaster drills, including one in Boston I was involved in that played out the scenario of a dirty-bomb explosion at Logan Airport on an airliner from France. The Massachusetts General Hospital brought in Israeli physicians to help revamp their disaster-response planning. Richard Wolfe at the Beth Israel Deaconess recalled an emergency physician's presentation of the medical response required after the Aurora, Colorado, movie-theatre shooting of seventy people last summer. From 9/11 to Newtown, we've all watched with not only horror but also grave attention the myriad ways in which the sociopathy of killers has combined with the technology of inflicting mass casualty.
We've learned, and we've absorbed. This is not cause for either celebration or satisfaction. That we have come to this state of existence is a great sadness. But it is our great fortune.
Last year, after the Aurora shooting, Ron Walls, the chief of emergency medicine at my hospital, gave a lecture titled "Are We Ready?"
In Boston, it turns out we all were.
Wednesday, April 17, 2013
Surgeon’s suit over criticism posted online by patient’s husband is part of wave of such claims - Metro - The Boston Globe
To examine those questions, scientists at the University of Missouri in Columbia recently interbred rats to create two very distinct groups of animals, one of which loves to run. Those in the other group turn up their collective little noses at exercise, slouching idly in their cages instead.
Then the scientists closely scrutinized and compared the animals' bodies, brains and DNA.
For some time, exercise scientists have suspected that the motivation to exercise — or not — must have a genetic component. When researchers have compared physical activity patterns among family members, and particularly among twins, they have found that close relations tend to work out similarly, exercising about as much or as little as their parents or siblings do, even if they grew up in different environments.
These findings suggest that the desire to be active or indolent is, to some extent, inherited.
But to what extent someone's motivation to exercise is affected by genes — and what specific genes may be involved — has been hard to determine. There are only so many human twins around for study purposes, after all. And even more daunting, it's difficult to separate the role of upbringing from that of genetics in determining whether and why some people want to exercise and others don't.
So the University of Missouri researchers decided to create their own innately avid runners or couch potatoes, provide them with similar upbringings, and see what happened next.
They began with ordinary adult male and female lab rats. These rats generally embrace the opportunity to run, although individual mileage can differ substantially among rats.
The scientists put running wheels in the animals' cages and, for six days, tracked how much they ran. Afterward, the males and females that had logged the most miles were bred to each other, while those who'd run the least were likewise paired. Then the pups from each group were bred in a similar way, through 10 generations.
At that point, the running rats tended to spontaneously exercise 10 times as much as the physically lazier animals.
Now, the researchers set out to determine why.
In very broad terms, two elements are especially likely to influence whether we, as individuals, habitually exercise or not. One is physique. Animals or people that are overweight or ill, or who have poor muscle quality or tone or other physiological impediments to activity, tend to be sedentary. If moving is difficult, you don't do it.
So, the researchers now compared their two sets of animals' bodies. You might expect that after 10 generations of running frequently or running almost not at all, the animals' builds would be substantially different. But they weren't. The non-runners were slightly heavier, but the two groups' average body compositions, or percentage of muscle versus fat, were very similar. Both groups also had similarly healthy muscles and good appetites.
Differences in physique were not driving differences in exercise behavior.
So the researchers began to examine the other primary determinant of exercise behavior: psychology. How closely rats' emotions echo our own, if at all, is hard to know. But the runners in this experiment did seem to enjoy running, while rats in the other group appeared to want to avoid it.
And it was here that genetics entered. The scientists compared the activity of thousands of genes in a specific portion of the brain that controls reward behavior, or the motivation to do things because they're enjoyable.
They found dozens of genes that differed between the two groups.
The rats' decision to run or not to run, in other words, was being driven, at least in part, by the genetics of motivation.
What this study means for those of us with two legs and many excuses for not making it to the gym is not yet clear. "It does seem likely that there is a genetic element to the motivation to exercise," in people as well as in rats, says Frank Booth, a professor of physiology at the University of Missouri who oversaw the study.
But whether the same genes are involved in people as in lab rats isn't known, although part of the rationale for developing these strains of rats is to isolate genes that can be tested for in people.
At some point, Dr. Booth says, scientists conceivably could develop a test that would reliably inform someone whether he or she is genetically predisposed to being physically lazy, or the reverse.
But genetic profiles will never be destiny, Dr. Booth adds. His study's findings "are not meant to be an excuse not to exercise." Behavior, he says, remains a mix of innate tendencies and personal choice. So, even if it is in your nature to enjoy long hours on the couch, you can choose to get up and move.
BOSTON — So many patients arrived at once, with variations of the same gruesome leg injuries. Shattered bones, shredded tissue, nails burrowed deep beneath the flesh. The decision had to be made, over and over, with little time to deliberate. Should this leg be amputated? What about this one?
"As an orthopedic surgeon, we see patients like this, with mangled extremities, but we don't see 16 of them at the same time, and we don't see patients from blast injuries," Dr. Peter Burke, the trauma surgery chief at Boston Medical Center, said.
The toll from the bombs Monday at the Boston Marathon, which killed at least three and injured more than 170, will long be felt by anyone involved with the city's iconic sporting event. For the victims, the physical legacy could be an especially cruel one for a group that was involved in the marathon: severe leg trauma and amputations.
"What we like to do is before we take off someone's leg — it's extremely hard to make that decision — is we often get two surgeons to agree," Dr. Tracey Dechert, a trauma surgeon at Boston Medical, said. "Am I right here? This can't be saved. So that way you feel better and know that you didn't take off someone's leg that you didn't have to take. All rooms had multiple surgeons so everyone could feel like we're doing what we need to be doing."
The widespread leg trauma was a result of bombs that seemed to deliver their most vicious blows within two feet off the ground. In an instant, doctors at hospitals throughout the city who had been preparing for ordinary marathon troubles — dehydration or hypothermia — now faced profound, life-changing decisions for runners and spectators of all ages.
Some victims arrived two to an ambulance, some with huge holes in their legs where skin and fat and muscle were ripped away by the bomb and with ball bearings or nails from the bombs embedded in their flesh. Others had severed arteries in their legs or multiple breaks in the bones of their legs and feet. The shock wave from the blast destroyed blood vessels, skin, muscle and fat. And at least nine patients — five at Boston Medical Center, three at Beth Israel Deaconess Hospital and one at Brigham and Women's Hospital — had legs or feet so mangled they would need to be amputated.
Some of the attendant medical professionals, said Julie Dunbar, a chaplain at Beth Israel, were faced with "more trauma than most ever see in a lifetime, more sadness, more loss."
There were only three fatalities, which doctors say was because the blast, low to the ground, mostly injured people's legs and feet instead of their abdomens, chests or heads. And tourniquets stopped what could have been fatal bleeding in many.
Dr. Allan Panter, 57, an emergency-room physician from Gainesville, Ga., was standing 10 yards from the blast near the finish line, waiting for his wife, Theresa, to complete her 16th Boston Marathon. Assisted by others, he said he used gauze wraps to apply tourniquets to several victims, including a man who appeared to be in his late 20s who lost both of his lower legs in the blast. He said he saw another six or seven victims with belts tied around their wounded legs.
Tourniquets, once discouraged because they were thought to cause damage to injuries, have returned to favor and have been used to treat wounds inflicted by explosive devices in the wars in Iraq and Afghanistan, Dr. Panter said.
"With blast injuries to the lower extremities that we're getting in the Middle East, you bleed out," he said. Tourniquets "can help save lives. I don't know if they helped in this situation, but it sure couldn't hurt."
While there was some initial chaos in a medical tent near the finish line, and some screaming and moaning by victims, it was generally an orderly scene, Dr. Panter said. He assisted others in wheeling in a female victim who died, he said. He described 20 to 30 cots in the tent with IV bags that had been intended for dehydrated runners.
At least eight doctors and what seemed to be 20 or more nurses were stationed in the tent. A man with a microphone stood in the center of the tent to coordinate medical care. Arriving victims were assessed and categorized as 1 for critical, 2 for intermediate, 3 for "can wait" and "black tag" for anyone who appeared to be dead, Dr. Panter said. An emergency medical technician outside the tent coordinated ambulance service to hospitals.
"All in all, it was a pretty controlled environment," said Dr. Panter, who has been an emergency-room physician for 30 years. "I've seen a lot worse. They were without question ready — not ready for those type of injuries, but they were prepared."
Once victims were transported to Boston's hospitals, doctors had to carefully coordinate their response. Each has a story of where they were when the bombs went off and how they rushed to help and how, in some cases, they somehow just missed being victims themselves.
Dr. Alok Gupta, who directed the surgical response at Beth Israel, said he often goes to the finish line of the marathon to watch the race. But this year he was so tired that he took a nap. Then he heard ambulance sirens and helicopters outside his home in Back Bay, near the marathon finish. He was just beginning to wonder why the sirens had not dissipated and why the helicopters were hovering when his cellphone rang.
"The call was broken up," he said. "All I heard was 'mass casualty.' " And "we need you," he said.
He was out of the house in less than a minute and at the hospital five minutes later. Then he and his colleagues set to work. They cleared the emergency room, sending home those who could leave and sending others to beds elsewhere in the building. They cleared intensive care, sending patients to other areas of the hospital. Dr. Gupta directed a central command.
"Surgeons were notified, emergency-room physicians were notified, operating-room personnel were notified, everyone was notified," he said. Cellphone service in Boston had been limited to prevent terrorists from using cellphones to detonate any more bombs, so doctors, nurses and other medical professionals were contacted with text messages.
About 10 minutes later, patients began to arrive. Each was put in a room and assessed. Doctors described the situation as calm and efficient.
Seven patients at Beth Israel went directly to the operating room for emergency surgery to stabilize them, stopping bleeding for example. Five went to intensive care. At Brigham and Women's Hospital, six patients went to the operating room and nine to intensive care.
"I think a lot of these injuries are so devastating, it was pretty straightforward — they weren't going to be able to salvage these things," said Dr. Burke of Boston Medical Center. "We all would like to salvage whatever extremities we can, but one thing we've learned in trauma is when you get too much damage, you can create too much hassle, so you may get the amputation but it may be a year down the line. Ten operations, failed operations, addictions to narcotics for the chronic pains, all these kinds of things." An early amputation, Dr. Burke added, can mean a quicker return to a normal life.
Borrowing a tactic used by the military in Iraq, doctors at Beth Israel used felt markers to write patients' vital signs and injuries on their chests — safely away from the leg wounds — so that if a patient's chart was misplaced during a transfer to surgery or intensive care, for example, there would be no question about what was found in the emergency room.
Those who needed surgery would often need more than one operation on subsequent days. Those with huge blast wounds that ripped out skin and muscle would need plastic surgery. Those with severed arteries would need surgery, too.
Most of the injured taken to Beth Israel were no older than 50, said Dr. Michael Yaffe, a trauma surgeon at the hospital. A few were runners, but most were spectators who had prime viewing positions near the finish line.
At about 2 a.m. on Tuesday, the Beth Israel medical team left for home, to return again at 6. They examined each patient before they left and again when they returned. Often, in trauma, the doctors said, patients will not notice some of their injuries until the major injury is taken care of.
The Boston Marathon is so special, a day to celebrate athleticism and the thrill of the sport. For those runners who trained for months and now can be facing months or years or rehabilitation, and the end of their running days, the bombs took away "the thing they loved," Dr. Yaffe said.
In the moments after the explosions, some patients recalled that they "thought they would die as they saw the blood spilling out," said Dr. George Velmahos, chief of trauma services at Massachusetts General Hospital. When they awoke Tuesday and realized they were still alive, they said they felt extremely thankful, some even considering themselves lucky, Dr. Velmahos said.
"It's almost a paradox," he said, "to see these patients without an extremity to wake up and feel lucky."
Tuesday, April 16, 2013
I worked as an attending doctor in New York City ERs for four years, but I never had to deal with anything like what Boston's ERs handled yesterday. You just don't see these types of injuries in an urban American hospital. In fact, ERs are usually boring places to work. Yes, there are moments of TV-worthy drama and tension, but in general, serviceable health care is delivered as quickly as possible with a forced smile.
But then comes the momentous tragedy of April 15, and everyone's frame of reference is changed. I cannot imagine the sort of mayhem and fear, as well as nausea and tears, the ER staffs across Boston must have experienced. No one is ready for anything like this—the missing limbs, the bleeding, the shrapnel, the smell of burnt flesh, which once experienced remains forever present. Plus, there was an apparent concern that hospitals themselves might be targets of additional bombs, given the reports of SWAT teams in and around hospitals in the early aftermath.
The ordering of just what to do when so many people who are so sick roll in the front door requires a level of teamwork and triage that civilian hospitals simply cannot prepare for. Thankfully, the Boston blood supply was replenished quickly by volunteers, but victims of this tragedy have, by report, suffered an unusual number of detached limbs. This latter, chilling detail relates to the force of the bombexploded in a dense crowd. Though grizzly to consider, the main trauma of, for example, the Oklahoma City bombing of 1995 was the Murrah building collapsing onto those within. Though limbs might have been lost by the initial explosion from Timothy McVeigh's bomb, the people were subsequently crushed as the building fell apart. On this Boston afternoon, though, it was the incredible force of the bomb, as well as the broken glass, that caused most of the injuries.
As for the reattachment of missing limbs and fingers, unfortunately the chaos that ensued after the explosions makes this just about impossible. In the best situation, a single individual loses an extremity and so a quick search can be made for the limb while the patient is stabilized. The Copley Square descriptions, however, suggest there was flesh everywhere. Even the basic task of matching the correct limb to the patient was not assured. On arrival to the hospital many amputations then had to be done, not to smooth away a traumatically amputated limb but rather to remove a hopelessly mangled and dysfunctional extremity that would only serve as a source for infection and complication. The many people now without legs or arms eventually will be fitted with prostheses and will start the long, painful road of rehabilitation.
At terrible moments like this, ERs call on an unexpected resource: those people who are literal war veterans, people who were medics or physicians in Iraq or Afghanistan or Vietnam, who have learned to survive in the MASH-like unreality of medical crisis. They typically step forward to calm the nerves, ease the panic, and provide rapid decisiveness for those too stunned to react. Their readiness to step into the unimaginable is itself a bitter irony, given that each of them lost so much in the past to be able to help in the present.
By all accounts, the various ERs in Boston did a superlative job doing as much as they could for the many patients delivered to their doors. Hopefully, those critically ill at present will stabilize and the death toll will stay at three. That said, there is almost no silver lining to be found in the brutal event of yesterday except perhaps this: emergency rooms are strange living organisms with a long memory and a vast oral tradition of stories, some true, some less so, of what the staff there has seen and done.
For example, in my medical school an older surgeon would tell each successive group of bright-eyed, 23-year-old kids about his experience in the Parkland Hospital ER in Dallas that day in 1963 when JFK was brought in. He told us what he and his surgical colleagues had done to try to save the president. And I imagine that all of us remember not just the fact that this guy had touched JFK, but the importance, even when it's the president, of trying to establish an airway, trying to give intravenous fluids, of fighting to get a palpable blood pressure, of doing the routine doctor things even when—and especially when—your heart is broken and you can't much think.
Given the way ERs work, I suspect the many 2013 Boston ERs and surgical teams will carry all they saw and did—and all they were unable to do—for the rest of their careers. In the tradition of ERs, which have long stretches without much to do (have a visit at 3 a.m. some time to see what I mean), staff will sit around and talk, exchange their own stories, some horrible, some amusing. And it is likely that somewhere, many years hence, a young doctor will make a rapid smart decision on a patient not because of what he learned in a medical-school lecture, but from the stories he had once heard of the marathon massacre.