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Important Take-Aways From the Boston Marathon Bombing

2013; Elsevier BV; Volume: 71; Issue: 10 Linguagem: Inglês

10.1016/j.joms.2013.07.014

1531-5053

James R. Hupp,

Radiology practices and education

The events surrounding the Boston Marathon bombing are remarkable in many ways. The impressive number of photographs and videos of the scene at the moments that the bombs detonated and in the aftermath are unparalleled. Many of these images graphically brought the immensity of the tragedy into our lives as we watched the lives of others being forever changed. We were also witnesses to the hunt for the perpetrators and learned that eyewitnesses and videotapes played a major role in cornering the individuals thought to have committed this act of terrorism. The major reason there was such extensive documentation of the bombing was that the devices were set off near the finish line of one of the most famous sporting events in America. The Boston Marathon has a proud 117-year history, and draws thousands of runners and fans, as well as worldwide media attention. The race always takes place on Patriot's Day, a statewide holiday in Massachusetts. Unfortunately, the notoriety of the marathon and perhaps its occurrence on a patriotic holiday seem to be why the bombers chose that day and that location to “make their political statement.” There is another remarkable side to this story as well. I was in Boston several weeks after the marathon bombing attending an oral-maxillofacial surgery meeting. One of the featured speakers was David King, MD. Dr King is a trauma surgeon at the Massachusetts General Hospital (MGH). Interestingly, he serves as the designated surgeon for the President of the United States whenever he travels to the Boston region; and in 2012 he also served in that role for all official presidential candidates during their travels to the area. David King is a veteran Army surgeon who served in both the Iraq and Afghan theaters of war. His talk touched on his military experiences, but most of his presentation focused upon the extraordinary medical events surrounding the Boston Marathon bombing and how a number of fortuitous circumstances affected the medical outcomes. Dr King appeared on many national news reports in the days following the bombings in Boston. There is a good chance you saw him; and if you did you could tell he is very physically fit. That is because he does things like running marathons, including the 2013 Boston Marathon. Dr King had finished the race and met up with his family. He was just about to go home when the bombs went off. Knowing there would be serious injuries, he instead made his way over to the MGH in his running outfit to prepare to receive the wounded. Boston is a medical care mecca, with several world-class medical centers. Anyone who knows the city of Boston is well aware that the Copley Square area, where the marathon ends, is basically the most central point equidistant from all level I trauma centers in the city. Thus, if someone was forced to choose a site in Boston in which to have mass casualties, Copley Square is the place. This was the first of several remarkable coincidences aiding the survival of so many of the seriously injured. I have already mentioned a second of the series of beneficial coincidences on the day of the bombing; namely, it was Patriot's Day. Normally, on a regular weekday, both Copley Square and the routes leading to all the trauma centers are clogged with traffic. However, on Patriot's Day, most city, state, and private businesses are closed, leaving the city relatively free of traffic. Thus, after the bombings, emergency transport vehicles were able to rapidly move the injured to the nearby emergency centers. A third factor related to the bombs exploding near the finish line was that there was an emergency medical tent in place staffed by top notch healthcare providers and full of supplies such as wound dressings and intravenous fluids. There were also a large number of emergency medical vehicles and technicians at the scene. A fourth coincidence that more closely represented luck than any of the other factors was that the bombing took place around 4 pm. In many medical centers, including those in Boston, this is the time of shift change from day to evening shifts. This meant that, for the most part, the areas of a hospital most critical to managing mass casualties (emergency department, blood bank, operating rooms) were double staffed. In addition, because it was Patriot's Day, the operating rooms were running reduced schedules, making them ready to aid patients needing life- and limb-saving procedures. Dr King and other colleagues who had experience treating injuries in Iraq and Afghanistan have great expertise in handling trauma caused by ground level explosives. Therefore, they had the ability to make very well-educated decisions on how to optimally manage lower extremity blast injuries. They were, thus, not only able to save lives, but also to provide the best possible outcomes for those harmed by the blasts. David King shared with us that it is likely that this remarkable series of coincidences made it possible for every patient who made it to any of Boston's major medical centers with any sign of life to survive and be able to eventually leave the hospital. He added that this included the surviving bombing and Massachusetts Institute of Technology (MIT) shooting suspect. Dr David King's presentation on the Boston Marathon bombing held the audience's rapt attention for over an hour. However, he then went on to discuss a topic that for me was, by far, the most important take-away message of his talk. While Dr King served in the Middle East treating the wounded, he observed that many soldiers died from excessive bleeding from lower extremity injuries that he thought were survivable. The wounded would receive quick attention on the battlefield from medics embedded with the troops. The treatment commonly included the use of standard issue tourniquets. Dr King and some colleagues decided to investigate the problem. They interviewed Army medics about when and how they applied tourniquets and monitored wounded patients arriving with tourniquets applied for any bleeding in spite of a tourniquet. They discovered that in a significant number of cases the tourniquets were not tight enough. In some cases, they only exerted enough pressure to constrict venous flow but were not tight enough to overcome arterial pressure. This actually worsens bleeding below the tourniquet. To be effective, a tourniquet must deliver enough pressure to stop all arterial blood flow. If this occurs, a soldier can survive even a relatively long transport time to a base staffed with surgeons. Dr King's first conclusion from their study was that medics did not realize how much pressure is actually required to stop arterial bleeding in a leg. The second conclusion was that it was difficult for the then standard issue tourniquets to apply sufficient pressure, even when properly used. David King then worked with engineers to design a tourniquet usable in the field that would more easily and reliably deliver the needed constricting pressure. The prior design used a strap with Velcro attached to tighten around the extremity, but even with aggressive tightening, the tourniquet was commonly inadequate. The new design also consists of a strap with attached Velcro. However, there is an added rod with a ratcheting mechanism that, when turned, further tightens the strap, providing the critical pressure needed to stop all blood flow. This new design has now become standard issue for the US military and is saving lives. David King's critical assessment of patients with less than optimal outcomes and his urge to improve the chances of survival for his future patients led him to work to make changes to patient management. This quality is one of the hallmarks of outstanding clinicians, like Dr. King. It serves as a strong reminder of how we as surgeons should constantly assess our outcomes, learn from those that merit improvement, and take the steps necessary to consider changes in how we deliver care. The practice of always looking for ways to try to improve patient care was a wonderful reminder of one of our key responsibilities as clinicians. The events surrounding the Boston Marathon bombing were truly remarkable; especially that so few people lost their lives after such powerful bombs exploded in very crowded spaces. A number of fortuitous circumstances helped make this possible. I appreciated the organizers of the meeting asking Dr King to speak and that he graciously agreed to share his story. However, another result of this sequence of events is that I now own a tourniquet that I know I can reliably use to stop serious bleeding should I come upon an accident or other traumatic event. ∗Available online for about $25, shipping included—the C-A-T Combat application tourniquet. Dr King advised to be careful not to purchase ineffective lower cost copies.∗Available online for about $25, shipping included—the C-A-T Combat application tourniquet. Dr King advised to be careful not to purchase ineffective lower cost copies.And, with this editorial, I am encouraging you to do the same.