Boston blast injuries required battlefield savvy, experts say

The chief of emergency services at Massachusetts General, Alasdair Conn, describes the injuries that his hospital has seen since the explosions at the Boston Marathon.

By JoNel Aleccia, Senior Writer, NBC News

For the doctors, cops and other emergency personnel who responded to the Boston marathon bombings Monday, it was nothing less than a war zone, disaster experts say.

The explosive devices that shattered the festivities of the iconic event were filled with shrapnel, law enforcement experts told NBC News, and they caused injuries and other effects as devastating as any seen on far-flung battlefields.

?Some of the patients received traumatic amputations at the scene. Their legs ? were blown off,? said Dr. Alasdair Conn, chief of emergency services for Massachusetts General Hospital in Boston, which received an early influx of patients.

Hospitals throughout the region reported injuries that included massive blood loss, many lower leg injuries -- including open fractures, in which bone protrudes through the skin -- and shrapnel wounds. Victims ranged from a child as young as 3 to adults in their mid-60s, officials said.

"This was a powerful blast; there were serious injuries," Boston Police Commissioner Ed Davis told reporters during an evening briefing.

Indeed, Dr. Peter Fagenholz, a trauma surgeon at Mass General, said that complex damage to the lower extremities was the dominant type of injury suffered by the blast victims taken to his hospital, where 29 patients we treated. He said those injuries involved blood vessels, soft tissues and bone.

Many of those victims sustained shrapnel injuries, he said, and several amputations were required. Eight of the patients remain in critical condition, Fagenholz said.

Faced with injuries like those seen following roadside or marketplace bombings in Baghdad or Israel, emergency crews had to respond with combat-like expertise to treat the reported three dead and at least 100 injured in the incident.

?The best experience we have with this has been with the improvised explosive devices in Afghanistan and Iraq,? said Dr. Tom Moore, director of orthopedic trauma at Grady Hospital in Atlanta, who agreed to comment on Monday's attack.?

Blast injuries follow a typical pattern: First there?s a pressure effect from the concussion of the explosion, which can rupture eardrums and even intestines, said Dr. Chris Kahn, emergency preparedness and response medical co-director at the University of California, San Diego.

Then come injuries cause by shrapnel and other projectiles that hit people, followed by injuries caused when people slam into buildings and other objects.

Crews on the scene and at trauma centers faced all of those, hospital reports showed.

That meant that crews had to use battlefield strategies to triage the wounded and to ensure that the most seriously injured were transported to care as quickly as possible, said Dr. Ken Miller, an emergency trauma expert at the Orange County Fire Authority in Irvine, Calif., who is a national adviser for the Federal Emergency Management Agency, or FEMA.

?The real challenge in a trauma triage thing like this is incident management,? said Miller, who was on site within hours of the 9/11 World Trade Center attacks in 2001 and in the first hours of Hurricane Katrina in 2005 New Orleans.

Triage strategies focus first on finding a safe place for the initial wave of victims who are typically not the most seriously injured. They?re people who are hurt, but who can still walk and talk.

?The discipline is to move past those walking wounded and look for those who have higher acuity,? Miller said.

Workers stabilize vital functions such as breathing and bleeding for those seriously injured people, but then they?re rushed away from the scene for further care, Miller said.

The difficult cases are when a patient is critically ill and likely to die. First responders and those in actual combat conditions have to decide whether to use scarce resources trying to save that person -- or trying to save someone else who?s more likely to live.

?That?s more likely when there?s truly a mismatch of resources and need,? Miller said. ?In civilian things like this, in a metropolitan area like Boston, there will be ample resources showing up. Though it may take a few minutes to amass enough response, you know you?re going to get help.?

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