In the hours after the 2001 attacks on the World Trade Center, New York City’s hospitals braced for an onslaught that never came. On the morning of September 12, a sea of empty white gurneys sparkled in front of Manhattan’s St. Vincent’s Hospital. The building was already papered with pictures of people who had vanished forever. In Boston this week, the aftermath of violence looked different. Only three people died within 24 hours of the blast on Boylston Street. But like the improvised bombings that plague Iraq and Afghanistan, the attack left scores of civilians mortally injured, many with lower limbs hanging by threads. The incident may be remembered less for the deaths it caused than for the flesh and bone it ravaged.
But the Patriots’ Day bombing reveals the tremendous strides that emergency physicians have made in the past decade. The assault occurred within blocks of what President Obama called “some of the best hospitals in the world.” A medical team was already working the finish line when the shrapnel started flying. And thanks to this country’s recent experiences in Iraq and Afghanistan, physicians and emergency workers almost surely saved patients who would have died from the same injuries a decade ago.
For all their failings, America’s recent foreign wars have driven medical breakthroughs that are now saving civilians at home.
It’s hardly the first time this has happened. The need to keep wounded fighters alive has long been an engine of medical progress. Roughly one soldier died for every 1.7 injured in World War II. In Iraq and Afghanistan, one died for every seven wounded—a decline of more than 75%. The advances fueling that progress span fields as diverse as orthopedics, pharmacology and bandage design, and most are now common in civilian medicine.
Some of the breakthroughs have been astonishingly low-tech. Take the tourniquet, for instance, a device that dates back at least to the second century BC. Blood loss is the leading cause of death among trauma victims. A tourniquet can stop bleeding cold when applied to an injured arm or a leg. But 20th century medical dogma said it should be used only as a desperate last resort, lest it starve the limb of sustenance. “We learned early in the Iraq War that we needed to test these assumptions,” says Dr. Andrew Pollak, a senior trauma surgeon at the University of Maryland School of Medicine and the R Adams Cowley Shock Trauma Center. “So Congress has started funding research to compare and evaluate treatment protocols.”
Researchers at the Army Institute of Surgical Research did just that, and their findings have transformed trauma care. In studies involving more than 2,800 trauma patients at a combat support hospital in Baghdad, they found that tourniquets dramatically improved survival following major limb injuries, especially when medics applied them quickly in the field. Patients died at more than twice the rate (24% versus 11%) when tourniquets were restricted to hospital use. Some 87% of patients bled to death if they didn’t receive tourniquets at all.
Contrary to past fears, the tourniquets themselves didn’t cause any limb loss, even in the rare cases when patients had to keep them on for two to three hours. “We’ve rewritten all the text books to reflect this,” says Pollak. “Every paramedic is now trained to apply a tourniquet at the scene of a motor vehicle crash. The message is very clear and well accepted, even in the civilian environment.”
Tourniquets figured prominently in the grim tableaus that followed Monday’s blast, and they no doubt kept some survivors alive. They’re no good for head or abdominal wounds (“If your scalp is bleeding, a tourniquet to the neck is not helpful,” says Pollak), but combat physicians have devised other ways to stem blood loss. Newly developed dressings can accelerate clotting when applied to an open wound or infused into a bandage. And military research has shown that synthetic clotting factors—the mainstay of hemophilia treatment—can quickly stem blood loss when administered to trauma victims.
“We used to slowly transfuse platelets to help them,” says Dr. Don VanBoerum, director of Trauma Care at Salt Lake City’s Intermountain Medical Center. “Newer treatments like activated factor 7 work almost instantaneously. They carry some risk, but they definitely make a difference.”
Blood loss isn’t the only threat bombing victims face. Improvised bombs drive debris and shrapnel deep into the body, shredding the soft tissues that support and nourish bones and seeding potentially deadly infections. Once they stabilize a trauma victim, emergency physicians aggressively excise damaged tissues. Debridement helps ward off gangrene, but it can also leave shattered bones fully exposed. “It’s hard to repair pulverized bone under the best of conditions,” says VanBoerum. “It’s impossible if the bone isn’t sheathed in soft tissue.”
But even that challenge is sometimes surmountable. Borrowing from combat surgeons, trauma docs have learned to secure bone fragments with rods that are bolted to a frame surrounding the injured limb. And if a shattered bone lacks soft-tissue cover, a plastic surgeon can sometimes transfer live muscle tissue—blood vessels intact—from the back or the forearm to the site of the injury. “If it works,” says VanBoerum, “you end up with a blood supply that can keep the tissue alive and carry antibiotics into it while the bone starts to heal.”
There are limits, though. Even when surgeons can reconstruct a leg this way, they can’t always salvage the nerves needed to preserve sensation in the foot. And as VanBoerum puts it, “an insensate limb isn’t a good outcome.” A foot that lacks feeling is prone to sores and injuries that can lead to infection and, ultimately, amputation. So trauma patients sometimes face a stark choice: give up the shattered limb at the outset, and learn to use a prosthesis, or embark on a long surgical odyssey that may ultimately fail. A wise surgeon may advise the patient to give it up and move on.
That may sound harsh, but military research has greatly revolutionized prosthetic limbs in recent years, and studies suggest that wounded veterans often prefer them to salvaged but damaged limbs. Civilian research suggests that patients fare about equally well with amputation or limb-salvaging surgery. But in a study called METALS (for Military Extremity Trauma Amputation/Limb Salvage), researchers assessed outcomes among 317 U.S. service members whose legs were damaged by bombs in Iraq or Afghanistan. Though all of them were significantly disabled three years after their injuries, the amputees reported greater mobility and less emotional distress than those who had kept their limbs.
These warriors’ experiences may tell us little about the folks now fighting for their lives in Boston hospitals. But they suggest that life and hope can survive even the most harrowing trauma. Improvised explosives don’t discriminate between soldiers and civilians. People who encounter them come home broken. But as trauma surgery improves, more and more of them will come home.
