“It was a perfect day for a marathon—55 degrees and sunny,” said Vivek Shah, MD, of April 15, 2013, the day a terror attack rocked Boston. The air of jubilation on the cool, crisp day of the Boston Marathon quickly turned to one of horror when two bombs exploded near the finish line just before 3 p.m. Eastern time, killing three people, and wounding more than 200 others.

Dr. Shah and many other orthopaedic surgeons experienced the disaster firsthand—as runners or spectators who helped stabilize the wounded, as physicians who went from treating race-related injuries to applying tourniquets, or as surgeons providing lifesaving medical care at Boston-area hospitals. The rapid medical response saved countless lives that day.

Reacting to the blasts
Dr. Shah, an orthopaedic surgery fellow at New England Baptist Hospital, was about 25 yards from the finish line when the first bomb exploded. He stopped running as a cloud of smoke engulfed the area.

“I thought it was something that was planned, but had gone wrong,” he said. When the second bomb went off and people began running in every direction, Dr. Shah realized the danger.

“One of the scrub techs from my hospital came running toward me—away from the site of the explosions—and frantically told me to go the other way,” said Dr. Shah. “I looked at him and said, ‘My family is there. I’ve got to find them.’”

Dr. Shah would eventually locate his wife, daughter, parents, and sister, who had been waiting for him at the finish line and had not been harmed. But before he found them, Dr. Shah helped provide emergency care to severely wounded people.

“I saw people with one or both legs completely missing,” he said. “I don’t remember seeing many cuts, scrapes, bruises, or other minor injuries.”

Dr. Shah and others put long-sleeved t-shirts and blankets around the limbs of people with compound fractures and applied makeshift tourniquets to stem the bleeding and stabilize the injuries.

Nothing in Dr. Shah’s experience compared to the number and type of injuries he saw that day.

“I would be lying if I said I’ve seen anything even remotely similar to it in my life, despite having gone through my orthopaedic residency and fellowship,” he said. “It seemed unreal, like a television show.”

Although Dr. Shah uses an algorithm to treat patients in the emergency department, “It’s not the same when you’re running a race and something like this happens,” he said. “I was lucky enough to remember the basics of stabilizing injuries and applying tourniquets.”

Dr. Shah has high praise for the medical personnel who responded immediately to the disaster, including Lyle Micheli, MD, director of the division of sports medicine at Boston Children’s Hospital, who served as the director of the Finish Line Medical Team, and orthopaedic surgery fellows Farshad Adib, MD; Marie-Lyne Nault, MD; and Albert Pendleton, MD.

“The fellows and I were 20 yards from the first bomb and were in the front ranks of the first responders,” said Dr. Micheli, who has served as the director of the Boston Marathon’s Finish Line Medical Team since 1975. “We dismantled the barrier fences as we crossed over to the injured, applied makeshift tourniquets made out of clothes hangers and running jackets, and directed the injured in wheel chairs to the medical tent.”

“I saw at least two people treating each wounded person, with some providing emotional support, and others providing medical care,” said Dr. Shah.

From spectator to medic
John A. Cowin, MD, of the Florida Musculoskeletal Institute, was another orthopaedic surgeon on hand when disaster struck. He and his wife, Anna, were there to cheer on their daughter, Lynda, who was racing.

Dr. Cowin knocked down a barricade so he could cross the street and reach the wounded.

“Blood was everywhere,” he said. “One man had his leg blown off at mid-thigh. Someone had used a belt as a tourniquet to stem the bleeding.”

Dr. Cowin helped a man who had lost his foot. After stabilizing him, Dr. Cowin moved on to treat a woman who was going into shock due to a shrapnel wound to her abdomen.

“People from a nearby restaurant were bringing out tablecloths to use as bandages,” he remembered. “I tried to help the medics identify the most critically injured so they could be moved first. Some ambulances carried two or three wounded.”

Meanwhile, said Dr. Cowin, his wife was across the street, helping some of the walking wounded. Nurses and medical personnel from the crowd also responded.

“As I was leaving, the police and fire fighters kept asking me if I was injured, because my clothes were covered with blood,” said Dr. Cowin. “I looked more like an injured person than a physician.”

He added that “the police, fire fighters, and emergency medical technicians did a wonderful job in moving the wounded. I believe the death toll would have been much worse without their response.”

Hospitals mobilize
Paul Tornetta III, MD, director of orthopaedic trauma at Boston Medical Center (BMC), and Michael J. Weaver, MD, of the department of orthopaedic surgery at Brigham and Women’s Hospital (BWH) in Boston, both treated the wounded that arrived at their hospitals within minutes of the blasts.

According to Dr. Weaver, the emergency care provided by first responders was critical to patients’ survival.

“Despite the horrific nature of the attack, only three people died,” he said, “which is a testament to the planning and preparation of the Boston Athletic Association, the City of Boston, as well as emergency medical personnel, police, fire fighters, and other first responders.”

He noted that patients received expert care in the field. Injuries were appropriately triaged, fractures were stabilized with splints, and hemorrhages were stopped with dressings and tourniquets.

Dr. Tornetta agreed that emergency medical personnel, including those with military experience, helped keep the death toll low.

“What happened at the site was extremely well-organized for such a difficult event,” he said. “We had patients with amputated limbs who arrived with tourniquets placed by the medical personnel on site.”

“The injuries we saw on April 15 were blast injuries that had more in common with injuries seen in Iraq and Afghanistan,” said Dr. Weaver. “Many patients had severely mangled extremities, often with grossly contaminated wounds and significant bone loss.”

The lower limb injuries Dr. Tornetta treated were severe. “Very few had any chance of salvage, even from the initial onset,” he noted.

In total, 39 patients received care at BWH for blast-related injuries, while approximately 25 patients were treated at BMC. According to Dr. Tornetta, BMC’s emergency drills helped prepare medical personnel to respond. “The entire Boston system of hospitals worked very well,” he said.

Dr. Weaver emphasized the importance of good communication and organization during an emergency.

“At BWH, we had a master list of all the patients in the emergency department with a summary of their injuries,” he said. “This enabled us to confirm that each patient was assigned to both a resident and an attending physician, that injuries were appropriately evaluated, that antibiotics and tetanus prophylaxis were given, and that the patient was assigned to an operating room.”

Compiling and updating this list was the responsibility of one surgeon, who worked in conjunction with the general surgeons, anesthesiologists, and operating room staff members to ensure that the most severely injured patients were prioritized and that the appropriate resources were made available.

Dr. Weaver underscored the value of planning ahead for emergencies and the importance of teamwork.

“It is important for orthopaedic surgeons to be familiar with their hospitals’ emergency protocols,” he said. “In addition, at BWH, the orthopaedic surgery department has fostered a close relationship with general surgery trauma physicians, which enabled us to collaborate quickly and effectively to deliver care to a large number of patients in a short time.”

Those with serious injuries face a long recovery period.

“The needs of individual patients vary greatly,” said Dr. Weaver. “Many of those with amputations have begun the process of prosthetic fitting and rehabilitation while those who underwent limb salvage are healing and working with therapists to regain strength and mobility.

“As trauma surgeons,” continued Dr. Weaver, “we have learned much from the experiences of our colleagues and partners who serve in the military. These injuries were lower energy, but many of the treatment principles were the same.

“Many of my friends and partners were running that day, and my wife and child were on their way to the finish line when the bombs went off,” he said. “It was hard not to think of my loved ones then, and it is difficult not to think of them now as we continue to care for the injured.”

As for Dr. Shah, he had planned that this year’s race would be his last Boston Marathon. He has now reconsidered that decision, in honor of those who lost their limbs in the disaster.

“I have no choice but to run next year,” he said. “I have two legs that work, so how could I not?”

Jennie McKee is a staff writer for AAOS Now. She can be reached at mckee@aaos.org