Combat-medicine lessons from Iraq, Afghanistan applied to Boston Marathon wounded

Improvised explosive devices caused carnage on the street of an American city this week, but after more than a decade of grim experience treating U.S. troops maimed by such weapons in Iraq and Afghanistan, many of the emergency workers and volunteers along Boston's Boylston Street knew how to react.

They included nurses and medics who had served as National Guardsmen trained in front-line first aid, and a peace activist, Carlos Arredondo, who had lost his Marine son, Alexander, in Iraq in 2004.

"You can see (the bomb) was like an IED,'' he said, sweeping his arm low to the ground where the shrapnel flew as he spoke to reporters soon after helping to evacuate a man with two severed legs to an ambulance.

Civilian trauma experts say the insights gained from keeping severely wounded troops alive have quickly taken hold in civilian emergency departments and ambulances across the U.S.

Many of them are convinced that lessons from military medicine are a major reason why more civilians are surviving gunshot injuries in the U.S., even as the total number of shootings has been increasing, according to figures kept by the federal Centers for Disease Control and Prevention.

Now, the expertise has shifted to bystanders at a footrace hit by bombs, the Boston Marathon.

Dr. Alasdair Conn, the chief of emergency services at Massachusetts General Hospital, told reporters, "This is like a bomb explosion that we hear about in the news in Baghdad or Israel,'' and noted that the hospital received help from a visiting team of Israeli physicians about two years ago in revamping its disaster-response team.

What amazed many observers was how relatively quickly the most seriously wounded were taken from the street.

"They cleared the scene relatively quickly and seemed to do a really good job triaging and moving the most seriously injured out,'' said Dr. David Tan, head of the EMS section in the division of emergency medicine at the Washington University School of Medicine in St. Louis. "They seemed to apply most of the lessons of combat medicine for this sort of event."

Inside a medical tent originally placed to tend to exhausted or injured marathon runners, scores of doctors and nurses reorganized to serve as a forward trauma center. Those with such experience took charge, the rest provided support, and moved the strained and dehydrated runners out of the area.

"It looked like they quickly set up triage with incident commanders as they had likely trained for," Dr. David Ross said. "That kind of organization is critical to maximizing survival."

Ross, medical director for more than 50 Emergency Management Service companies and a physician at Penrose-St. Francis Health Services in Colorado Springs, Colo., observed the particular utility of tourniquets, which are credited with saving the lives of many U.S. combat wounded.

"The one medical item that seemed to be most useful from my televised vantage point was the tourniquet, an item the military has led the way with in treating blast injuries,'' he said. "They may not have had one from a kit, but I think they improvised with belts and other items.''

Medics working in the first-aid tent had IV bags, defibrillators, blood-pressure monitors, even tourniquets, but found themselves somewhat short on bandages and surgical supplies.

Tan, in St. Louis, noted, "We do that sort of first-aid service for a lot of events around the city involving large crowds. From now on, I guess we're going to have to think in terms of having the material to deal with an IED on hand, too. I guess it's the new norm."

Surgeons at Mass General, several of whom served in Afghanistan and Iraq, and at several other Boston hospitals that cared for some 170 victims of the bombings, had to deal with multiple traumas from the blasts, shrapnel and other debris.

Some patients were reported to have 40 or more penetrating wounds. At least 17 were still considered in critical condition Tuesday.

Dr. George Velmahos, chief trauma surgeon at Mass General, told reporters Tuesday that four patients at the hospital have had limbs amputated and that doctors are trying to save limbs on two others. Yet despite the grave injuries, he said he was optimistic that all would survive, since their vital signs had stabilized and bleeding had been controlled.

Physicians at Beth Israel Deaconess Medical Center and Brigham and Women's Hospital also said they are working to save mangled arms and legs of a number of victims, and one at B&W had undergone an amputation.

(Contact Scripps health and science writer Lee Bowman at BowmanL@shns.com.)