Explosions at Boston Marathon finish line

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VacationGuy234 said:
There would be no New Years Eve without the 4th of July!
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ok. either way - just posted info that backpacks are not allowed in both events but apparently for July 4th - only large backpack is not allowed. perhaps you were carrying a small backpack.
 
RIght NYC is not special. Purretty a lot of people purrretty much are all over NYC.
 
Jiro said:
ok. either way - just posted info that backpacks are not allowed in both events but apparently for July 4th - only large backpack is not allowed. perhaps you were carrying a small backpack.
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Apology accepted..
 
I think this thread is moving a tad off the main subject.
 
Yep. I'm just as guilty, too.

Since it was my thread in the first place, it would be appropriate for me to say, "Please, let's stay on topic."

If interested, anyone can feel free to start a new thread about security at large public venues.

I already started another thread about the ricin letters.
 
VacationGuy234 said:
Rincin is on topic as a related issue, no coincidence there..
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But I did start a new thread for the ricin topic.

Right now there is no evidence that the two events are related.
 
Americans have got to become more alert to their surroundings. Anything that looks out of place these days probably is and should be taken seriously and reported. We have paid a very sad and high price for our freedoms and we all know that Americans don't like to be inconvenienced. Freedom is never free. It is time for us to wake up and listen to the Israelis. They do things the smart way and profile criminals and terrorists. They are also very alert to their surroundings and guns are a part of their everyday life. We must admit that life as we knew it has changed. It can happen anywhere at anytime. I'm not saying we have to give up our freedoms, God forbid it but it is time for us to realize that it has come to America. We will never be able to stop this type of terrorism. We can only deter it. That is part of having our freedom. Praying for the victims of Boston and America as a whole.
 
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Why Boston's Hospitals Were Ready : The New Yorker
The bombs at the Boston Marathon were designed to maim and kill, and they did. Three people died within the first moments of the blast. More than a hundred and seventy people were injured. They had their limbs blown off, vital arteries severed, bones fractured, flesh torn open by shrapnel or scorched by the blasts’ heat. Yet it now appears that every one of the wounded alive when rescuers reached them will survive.

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.
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War expertise on display in care of Boston bomb victims
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.
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Jiro said:
....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.
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Exactly right.

In my son-in-law's amputee support group, and other amputees that he knows, the consensus is amputation is better than struggling with a dead leg.

In my SIL's case, there was no question--the leg had to be taken immediately. However, he tells us of story after story from the amputees that he meets with that say, "If I had known the difference it would make in my quality of life before, I would never have kept the injured leg; I get around better, and with less pain and repeated surgeries." He's never met one that regretted the decision to amputate a leg that didn't heal.

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.
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Very true.

My SIL lost his leg in an industrial accident, not an explosion, but it was still traumatic. His leg was caught under 1,000 pounds of steel for an hour, then in an ambulance for another hour before he got any pain medication. When he saw his leg, he knew it couldn't be saved. Some of his co-workers suffered from PTSD just from witnessing the accident.

I can sympathize with those parents who got the call that their child lost a leg. I remember that moment very clearly. It's a real punch to the gut.

It's very true that the field of prosthetics has advanced tremendously due to the military casualties from Iraq and Afghanistan.

I hope the amputee victims of Boston get all the follow-up counseling and therapy that they need. My SIL says that the support groups of fellow amputees are the best therapy. His group welcomes family members to also attend their meetings.
 
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