Marathon Bombing: Of 176 Injured, Many Are Still Critical

April 16, 2013

The twin blasts of yesterday's Boston Marathon bombing — now officially under investigation as a terrorist act — sent 176 wounded to area hospitals as of Tuesday morning, according to the Boston Police Department.

The number of reported fatalities remains at 3, including 8-year-old Martin Richard, whose father was running the race that day, and 29-year-old Krystle M. Campbell.

NBC News and other media outlets are describing the bombs as improvised explosive devices (IEDs) made from metal pressure cookers packed with explosives along with pellets and nails, which hospital surgeons reported finding in patients. The IEDs were placed near the finish line of the race.

In a press conference today, George Velmahos, MD, PhD, division chief of trauma, emergency surgery and surgical critical care at Massachusetts General Hospital, said that most of the wounded at his facility sustained lower-extremity injuries, which resulted in 4 patients undergoing amputations. The injuries were so grievous that amputation was a foregone conclusion, said Dr. Velmahos.

Investigators in hazmat suits examine the scene of the second bombing on Boylston Street in Boston Tuesday, April 16, 2013 near the finish line of the 2013 Boston Marathon, a day after 2 blasts killed 3 and injured more than 170 people. Source: AP Photo/Elise Amendola.

"We just completed what the bomb had done," said Dr. Velmahos.

Other victims immediately lost their legs at the scene of the explosions.

So far, no one has claimed responsibility for the attack, and authorities have not announced any arrests or suggested a likely perpetrator. In a press briefing this morning, President Barack Obama called the bombing an "act of terror," a label he did not use in yesterday's remarks to the nation about the incident.

"We will find whoever harmed our citizens and we will bring them to justice," Obama said.

The president noted the heroism displayed by a variety of individuals in what resembled a war zone yesterday. They ranged from "first responders who ran into the chaos to save lives" to "the men and women who are still treating the wounded at some of the best hospitals in the world, and the medical students who hurried to help, saying 'When we heard, we all came in.' "

Obama also singled out exhausted marathon runners who, arriving at the scene of carnage, tended to the wounded. Among those runners who responded to the emergency were physicians and nurses, according to news reports.

The Complexity of Blast Injuries

As of late this morning, Massachusetts General Hospital had treated 31 bomb victims, 10 of whom had been discharged. Dr. Velmahos told Medscape Medical News that his hospital's core trauma team has handled the majority of the injuries. Surgical specialists — among them thoracic, orthopaedic, neuro, vascular, and plastic — are called in as needed, as are trauma psychiatrists and rehabilitation physicians.

"We are so fortunate at Massachusetts General Hospital," Dr. Velmahos said. "You name it — we have an army of physicians who are ready to serve according to the type of injury."

His hospital, like others, has trained and drilled to deal with the aftermath of terrorist bombings. The key to readiness, he said, is understanding the complex pathophysiology of blast injuries, which was on display yesterday. Once physicians know how a bomb wreaks havoc on the human body, they can look for the damage.

So-called high-order explosives, he said, produce blast waves that cause severe trauma to gas-containing structures such as the lungs, the intestines, and the ear. Blast waves also can cause concussions. Dr. Velmahos said clinicians at Massachusetts General Hospital did not encounter such blast-wave injuries because the 2 IEDs "didn't have overwhelming power."

However, a "low-order explosive" can produce a superheated blast wind that hurls people against cars and walls. One hospitalized patient had been thrown to the ground from a 5-foot perch in this manner, said Dr. Velmahos.

The blast wind produced by the bombs also burned patients, some to the third degree, he said. The majority of the burns occurred on legs and feet.

Bomb fragments and flying debris that penetrate the body account for an especially devastating category of blast injury.

"Some patients had only a few pieces of shrapnel, and others had dozens," said Dr. Velmahos. "Some of them were really peppered."

"Not every piece of shrapnel has been removed so far," he added. "Our first priority was saving lives." The remaining foreign objects can come out later, although some of them could remain in patients for the rest of their lives.

The combination of shrapnel and a searing blast wind was enough to sever legs on the spot, he said. Other patients arrived at the emergency room with the distal portion of their leg macerated. "It was an amorphous mass of tissue…hanging on by shreds of muscle and skin."

Despite the gruesome injuries, all the bomb-blast patients at Massachusetts General Hospital have survived.

"Some patients barely arrived alive," Dr. Velmahos said. "Everybody stayed alive."

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