Lower extremity practitioners were among the first responders after two explosions ravaged the Boston Marathon last month, and are continuing to help heal the hundreds of victims who lost limbs or experienced other traumatic lower extremity injuries.

By Emily Delzell

Lower extremity clinicians helped save lives at the April 15 Boston Marathon bombings, which killed three and injured 264, and now are at victims’ sides as they begin to recover.

Podiatrist Kirk Neustrom, DPM, was back in Boston for his 19th year as a volunteer in the marathon’s medical tent, which was located just around the corner from the finish line. The day had brought perfect running conditions and the healthcare professionals inside the tent were dealing at a relaxed pace with the routine injuries—blisters, cramping, tendinitis, potential stress fractures—that go along with running more than 26 miles.

Neustrom, a former marathoner who gave up the long races after completing the 100th Boston marathon 17 years ago, was thrilled to be back in the city.

“I did an externship at Cambridge Hospital in 1985 and fell in love with Boston,” said Neustrom, who practices in Des Moines, IW. “I look forward every year to going back. As some people have said, Boston is one of the happiest places on the planet that day—it’s a holiday, the Red Sox are always in, the race begins in Hopkinton and comes into Boston with people celebrating all the way—it’s just an awesome place to be.”

Neustrom had just finished helping a runner with some minor issues—the man, a soldier in the US Army, had run the race in full fatigues complete with boots and was dealing with some blisters—and was heading out of the tent toward the finish line with a friend so they could watch the runners come in and “slap some high fives.”

To Neustrom, the first explosion sounded like a cannon. He had a few seconds to wonder who might be shooting off a cannon and why, and then the second explosion went off.

“I knew then what had happened and took off in the direction of the finish line; I knew there would be injuries, casualties,” he said.

First responders

Neustrom arrived at the scene of the first bomb 30 or 40 seconds after the explosion.

“There were already first responders there getting people into wheelchairs and I started triaging people, addressing injuries, talking to victims to help calm them down,” he said.

Lyle Micheli, MD, was among those first responders. The orthopedic surgeon was at the finish line when the first bomb exploded, directing the advance medical team that is positioned to help exhausted or injured runners as they cross the finish line.

This year the finish line medical team, which Micheli has directed since 1978, included five physicians, 12 athletic trainers, and more than 20 students manning wheelchairs for quick transport of runners to the fully equipped medical tent.

“After the second bomb went off, a group of us ran toward the barrier between the street and spectators and started to tear it down. I could see people lying on the sidewalk,” Micheli said.

With most of the medical supplies in the tent some 50 yards away, Micheli and others began improvising. A store that sold running gear was in front of them and they went in, pulling shirts off racks and using them to pack wounds. Micheli made a tourniquet out of a running jacket for a victim who had lost part of a leg, using part of a coat hanger to twist it tightly onto the residual aspect of the injured limb.

“People were just pitching in. I saw a number of makeshift tourniquets, several belts used as tourniquets,” he said. “Victims with traumatic amputations were put into the wheelchairs and the kids were racing them down to the medical tent, where they’d set up a triage system and were quickly getting people treated and transported to various hospitals.”

Neustrom noted that while the scene was chaotic and urgent, it was also quiet.

“There was no screaming, no yelling, not really from the victims or the responders. Everyone was professional, doing their job,” he said. “The only voices you’d hear were occasional shouts for a backboard or some gauze or something.”

Micheli was also struck by the largely silent scene of rapid response amid the violent traumatic injuries, most of which were to the lower extremities.

“There was one young woman with her leg pretty well opened up, and in five minutes or so we had her wound packed, inserted an IV, applied a splint, and carried her cot down to the triage area. That was pretty typical of what happened,” said Micheli, who is director of the Division of Sports Medicine at Boston Children’s Hospital and clinical professor of orthopaedic surgery at Harvard Medical School.

John Cowin, MD, an orthopedic surgeon from Lake County, FL, was at the race with his family to watch his daughter complete her third Boston Marathon, which she has run each year since her breast cancer diagnosis to raise funds for research. Cowin was on the east side of Boylston Street when the second explosion went off just across from him. He and some other spectators crossed their barrier to the opposite side of the street to try and aid the injured.

“There was blood everywhere,” said Cowin. “There was a guy lying on the ground with his foot mostly gone, held on by maybe three tendons. Next to him was a stroller with a three year old, his son, and the father’s major worry was his son. I went over and picked the boy up—he had a scalp laceration—and held onto to him to help calm him down, but then it occurred to me that are were other people with worse injuries and I can’t spend time like this. So I handed the child to a policeman and moved on.”

Cowin aided other victims, including Lu Lingzi, a Boston University graduate student from China who was one of the three spectators who died that day. He also witnessed the mother of a dead boy, later identified as 8-year-old Martin Richard, asking for a few more minutes to hold her son’s body before she was loaded into an ambulance.

A family member of the injured father-and-son pair later contacted Cowin; she wanted to return his belt, which had been used as a tourniquet. Cowin asked for a picture of the injured boy and the woman told him the child had appeared on the cover of a special tablet edition of Time magazine.

Neustrom, Micheli, and Cowin all said that the close proximity of hundreds of fast-acting medical staff, police, fire department personnel, and other first responders to the explosion sites saved many lives that day.

“If the bombs had gone off six blocks further down, we would have had many more fatalities,” Micheli said. “We already had a system of getting injured people—though not badly injured people—to the medical tent and triaging them. We’ve worked this system for 20 years and it worked pretty well, though this time we had very different people in the wheelchairs.”

Ambulances backed up the medical tent, transporting victims to nearby hospitals, which include six major trauma centers—one for children and five for adults—all within a mile or so of the blasts. The explosions occurred a few minutes before the 3 pm shift change common in area hospitals, many of which were working with reduced surgical schedules because of the Patriot’s Day holiday, and, when patients began arriving just minutes after the explosions, two shifts of medical staff were on hand to provide care.

“We were able to get the most serious injuries on the road to the hospital pretty quickly, and from what I heard, they got them into the ORs quickly—and that’s the key, of course,” Micheli said.

All injured victims who made it to Boston’s hospitals survived.

Cowin, who has treated many orthopedic injuries in his 30-plus years as a surgeon, said he had never seen the kind of explosive trauma he treated that day.

“I was surprised at how much the scene affected me. I finally wrote about it and posted it on Facebook, and the writing lifted a tremendous burden,” he said.

Recovery

Two weeks after the bombing, medical teams caring for victims were focused on wound healing and other care to maximize patients’ chances for the best possible recovery. Many of the seriously injured had endured multiple surgeries, including 14 who had undergone lower extremity amputation.

“The biggest priority right now is wound healing and shaping of the residual limbs. The surgeons have been very careful in their surgical plans to provide the best limb they can surgically, which helps with the success of using a prosthesis,” said Linda Arslanian, PT, DPT, MS, director of rehabilitation services at Brigham and Women’s Hospital.

“With traumatic amputations, this work is usually done in stages—they rarely do the definitive amputation right away. The goal is achieving the optimal residual limb, one that is well-shaped, symmetrical, and very vascular and that will heal with minimal scarring and diminish the potential for neuromas to form or other complications that make prosthetic use less well-tolerated,” Arslanian said.

At Spaulding Rehabilitation Hospital, Advanced Clinician Lisa Pratt, MSPT, was also working with victims in the early stage of recovery.

“We’re doing things like teaching patients about phantom sensations and postsurgical pain, working on range of motion and strength, both of their lower extremities as well as their core and their upper body—it’s a comprehensive approach to building and regaining strength after trauma and hospitalization,” Pratt said.

Patients were also learning about positioning and pressure relief, the importance of skin care and skin integrity during the healing process, edema management, and mobility, she said.

“We’re also talking with them about discharge planning, and we’re working with them to address their goals and assist them in returning back to their traditional activities and all the things they want to get back to doing,” said Pratt, who works with traumatic amputees during the preprosthetic phase of recovery as well as in Spaulding’s limb loss amputee clinic.

Arslanian noted that, although these injuries are not physically different from other traumatic amputations that occur in high-velocity settings, the circumstances under which they occurred mean patients’ psychological reactions are highly variable, and all are at different emotional stages.

Some want to talk to other amputees. Jason Rizzo, CPO, director of prosthetics for Rogerson Orthopedic, an 80-year-old family practice in South Boston, arranged a peer visit for one victim who was trying to decide whether to try and salvage her injured limbs or go ahead with amputations.

“I was told she wanted to speak with an amputee of similar function and the level at which she’d be amputated. One of our high-level amputees is a triathlete and she talked with him. They had a long session and he spoke with her family as well. They had a lot of questions,” said Rizzo, who noted he was told the visit helped the patient decide on amputation.

Rizzo and other lower extremity clinicians are working with local and national organizations, such as the American Orthotic & Prosthetic Association (AOPA), to make sure all victims, especially the uninsured and underinsured, will have access to the artificial limbs and mobility assistive devices they need. (To find out how you can help, contact AOPA staff member Steve Custer at scuster@ aopanet.org or 571/431-0876.)

Arslanian, who has been working with traumatic amputees for more than 30 years, noted medical advancements, while bought at the high cost of wars in Iraq and Afghanistan, will make a big difference in outcomes for these patients.

“There are possibilities that exist now for saving patients with traumatic dismemberment and preserving soft tissues to optimize prosthetic use; also, prosthetics and rehabilitation far exceed what they used to be,” she said. “There are a lot of positive things that can happen here. Fortunately, I think these patients will get the best possible care they can get and will restore their lives to their maximum potential.”