Tag: Emergency Medicine

Boston Marathon, How They Saved So Many Lives

Cross posted from The Stars Hollow Gazette

Last week I wrote about the use of tourniquets in a pre-hospital emergency to save someone from bleeding to death. Tourniquets were used very effectively in Boston and were a key factor in getting so many to the hospital alive. At the finish line there were two medical tents with cots, blankets and IV fluids to treat dehydrated, hypothermic runners. Both were staffed with doctors and nurses. An emergency-room physician from Georgia, Dr. Allan Panter, was waiting at the finish line for his wife. He was just 10 yards a way from the first explosion. He assisted with victims and after went to the tents to assist. He described the events:

While there was some initial chaos in a medical tent near the finish line, and some screaming and moaning by victims, it was generally an orderly scene, Dr. Panter said. He assisted others in wheeling in a female victim who died, he said. He described 20 to 30 cots in the tent with IV bags that had been intended for dehydrated runners.

At least eight doctors and what seemed to be 20 or more nurses were stationed in the tent. A man with a microphone stood in the center of the tent to coordinate medical care. Arriving victims were assessed and categorized as 1 for critical, 2 for intermediate, 3 for “can wait” and “black tag” for anyone who appeared to be dead, Dr. Panter said. An emergency medical technician outside the tent coordinated ambulance service to hospitals.

“All in all, it was a pretty controlled environment,” said Dr. Panter, who has been an emergency-room physician for 30 years. “I’ve seen a lot worse. They were without question ready – not ready for those type of injuries, but they were prepared.”

There usually aren’t those provisions or medical staff on site and this still required the actions of bystanders to help control bleeding and move patients to the tents and ambulances. The night after the bombings on MSNBC’s “The Last Word,” host Lawrence O’Donnell spoke with Dr. Lyle Micheli, the head physician at the finish line and Massachusetts General Emergency Room Nurse Meghan McDonald about their experience:

But what happened in the hospitals was even more critical. It wasn’t like the ER’s were empty and waiting for these patients. As Nurse McDonald described in the interview Massachusetts General hospital had 90 patients being treated, waiting for admission or discharge when the explosions happened. The other four other ER’s that would receive the bulk of the casualties were in not much better shape. Luckily they all have similar disaster plans in place and have frequent drills to keep the staff prepared. Prepared they were. Of the initial 170 patients the five level one trauma centers received that day only one patient, who arrived in cardiac arrest, died. The other two fatalities were pronounced dead at the scene. That is a quite a feat and a testament to the training and skills of the doctors, nurses and other support staff. This article in the New York Times describes how Massachusetts General Hospital handled the disaster:

The first priority for those who were severely injured was to prevent them from dying, often from bleeding to death. Many had tourniquets on their legs when they arrived at the hospitals. But that was just a temporary measure to slow the bleeding. They needed immediate surgery to get their bleeding under control and prevent muscles and nerves from dying for lack of blood. [..]

That requires a vascular surgeon to repair the torn blood vessels and restore blood to legs and feet that may no longer have a blood supply. To do those repairs, surgeons often sew in part of a vein from the other leg, if it is uninjured, or from an arm. Or they use a synthetic tube.

Meanwhile, an orthopedic surgeon must stabilize a bone that might be flopping because it is fractured in several places. Surgeons do that with a temporary solution – they drill into the bone from outside the leg and attach pins that they screw into a metal bar also outside the leg.

Plastic surgeons clean the wound. In this case, blast victims had BBs or nails or debris embedded in their legs and feet. Everything the surgeons took out of the wounds was placed in plastic bags for the F.B.I., said Dr. Samuel J. Lin, a plastic surgeon at Beth Israel Deaconess Medical Center who helped care for blast victims.

“The crime scene extends to the hospital,” Dr. Lin said.

It’s definitely an art. It might appear chaotic to the casual beholder as everyone seems to be moving and talking at once. Each staff member has his or her job and is looking and listening so as not to miss details. Usually there is one coordinator, in situations like this there are some times more, as the ER is sectioned off into areas that depend on the patient’s status. Life threatening are first, then go back to treat and repair everything else. The decision to amputate a limb is not made lightly and is done most often to save a patient’s life. The other reason is that the bone, tissue and vascular damage is so severe there is no other option. The doctors in Boston had the luxury of having an immediate second opinion, it doesn’t always happen that way in combat zones or parts of the third world.

MSNBC’s Rachel Maddow saluted the thorough, professional and remarkably successful performance of the medical professionals who responded to the emergency injuries of the Boston Marathon Bombings and kept the public informed with honest straightforward briefings.

“Who ever came in alive, stayed alive.”

Dr. George Velmahous, Chief of Trauma Surgery, Massachusetts General Hospital

Thank you to all. Well done.

Tourniquet: How to Save a Life

Cross posted from The Stars Hollow Gazette

Within seconds of the two blasts that ended the Boston Marathon, doctors and emergency personnel were faced with decisions that are only usually made in combat, life or limb. Confronted with horrific lower extremity injuries the life saving device that was used over and over was the tourniquet. Around for millennia but fallen into disfavor years ago, tourniquets were only to be used as a last resort to stop life threatening bleeding from a limb when direct pressure, elevation and pressure above the wound did not work. The common belief was that the prolonged cutting off the blood to the limb would lead to amputation. The problem was that there were no good studies to prove it. So up until recently the tourniquet was a last resort.

Then along came the wars in the Middle East. Studies showed there that the timely use of a tourniquet resulted in survival rates as high as 90 percent. 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. Considering that blood loss is the leading cause of death in a trauma patient and a person can bleed to death in three minutes from a severed femoral artery, the large blood vessel in the upper leg, the choice is simple. Every paramedic is now trained to apply a tourniquet. Since 2006, a tourniquet is issued to every soldier.

Here are some simple guidelines to use if you are ever confronted with a major limb bleed:

First, apply direct pressure with your hand or a cloth. Don’t worry about clean, at this point it doesn’t matter. If you’re not alone have someone call 911. If you are alone do it first, you can always put the phone down and yell into it while you’re applying pressure.

Elevate the extremity if possible.

If you’re unable to control the bleeding quickly, or the injury is really big, or an partial or full amputation, then you need a tourniquet. Find something long, strong and pliable. Shirts, pants, something that can be torn onto a long strip; belts (Should be at least 1 1/2 inches wide).

Place the tourniquet around the arm or leg between the wound and the heart.

Tie a half-knot – the same as the first part of the knot when you tie a shoe, but have not finished the knot.

Place a strong stick on top of the half knot. Anything long and rigid will do, improvise. If at home, a large serving spoon or kitchen utensil; in the workshop a screw driver; a pen, pencil, you get the idea.

Tie a full knot over the stick.

Twist the stick until the material is tight around the limb and/or the bright red bleeding has stopped.

If you have enough length, loop the loose ends of the tourniquet over the ends of the stick. Bring the ends around the arm or leg and tie the ends together around the limb. This is so that the tourniquet cannot loosen. Or, tie other material around to hold the stick.

Belts of course can be pulled as tight as needed to stop the bleeding but you may be “married” to holding it tight until help arrives, if it can’t be secured so it won’t come loose.

Outside a controlled hospital setting, this is called damage control, or how to save a life.

Living In Emergency

Living in Emergency

For the first time ever, MSF gave a documentary crew uncensored access to its field operations. Set in war-torn Congo and post-conflict Liberia, “Living in Emergency” interweaves the stories of four doctors as they struggle to provide emergency medical care under extreme conditions. Two volunteers are new recruits: a 26-year-old Australian doctor stranded in a remote bush clinic and an American surgeon from Tennessee trying to cope under the load of emergency cases in a shattered capital city.

Two others are experienced field hands: a dynamic head of mission, valiantly trying to keep morale high and tensions under control, and an exhausted veteran, who has seen too much horror and wants out. Amid the chaos, each doctor must find their own way to face the challenges of the work, the tough choices, and the limits of their idealism.

Living in Emergency Trailer from LivinginEmergency on Vimeo.

This documentary opens in cities around the US this weekend. I urge you to see it, it will gives you a far better picture of what we do than I can ever put into words. Bring a strong stomach and a few tissues.