Emergency

04.16.13

What It’s Like to Be in a Boston Emergency Room Today

No doctor can truly prepare for a tragedy like this. Kent Sepkowitz, a former ER physician, on the prognosis for victims with missing limbs and how medical workers cope amid crisis.

As yesterday’s statistics in Boston—three dead, more than 100 seriously injured—turn into specific, heartbreaking human stories, the role of the emergency rooms scattered throughout Boston will fade quickly into the background. This is as it should be; emergency health care is the job of the emergency room, after all. But the roles of hundreds of doctors, nurses, and other staff will be forever traumatized by what they witnessed, as described so vividly in December after the Newtown shootings. 

I worked as an attending doctor in New York City ERs for four years, but I never had to deal with anything like what Boston's ERs handled yesterday. You just don’t see these types of injuries in an urban American hospital. In fact, ERs are usually boring places to work. Yes, there are moments of TV-worthy drama and tension, but in general, serviceable health care is delivered as quickly as possible with a forced smile.

But then comes the momentous tragedy of April 15, and everyone’s frame of reference is changed. I cannot imagine the sort of mayhem and fear, as well as nausea and tears, the ER staffs across Boston must have experienced. No one is ready for anything like this—the missing limbs, the bleeding, the shrapnel, the smell of burnt flesh, which once experienced remains forever present. Plus, there was an apparent concern that hospitals themselves might be targets of additional bombs, given the reports of SWAT teams in and around hospitals in the early aftermath.

The ordering of just what to do when so many people who are so sick roll in the front door requires a level of teamwork and triage that civilian hospitals simply cannot prepare for. Thankfully, the Boston blood supply was replenished quickly by volunteers, but victims of this tragedy have, by report, suffered an unusual number of detached limbs. This latter, chilling detail relates to the force of the bomb exploded in a dense crowd. Though grisly to consider, the main trauma of, for example, the Oklahoma City bombing of 1995 was the Murrah building collapsing onto those within. Though limbs might have been lost by the initial explosion from Timothy McVeigh’s bomb, the people were subsequently crushed as the building fell apart. On this Boston afternoon, though, it was the incredible force of the bomb, as well as the broken glass, that caused most of the injuries.

You just don’t see these types of injuries in an urban American hospital.

As for the reattachment of missing limbs and fingers, unfortunately the chaos that ensued after the explosions makes this just about impossible. In the best situation, a single individual loses an extremity and so a quick search can be made for the limb while the patient is stabilized. The Copley Square descriptions, however, suggest there was flesh everywhere. Even the basic task of matching the correct limb to the patient was not assured. On arrival to the hospital many amputations then had to be done, not to smooth away a traumatically amputated limb but rather to remove a hopelessly mangled and dysfunctional extremity that would only serve as a source for infection and complication. The many people now without legs or arms eventually will be fitted with prostheses and will start the long, painful road of rehabilitation.

At terrible moments like this, ERs call on an unexpected resource: those people who are literal war veterans, people who were medics or physicians in Iraq or Afghanistan or Vietnam, who have learned to survive in the MASH-like unreality of medical crisis. They typically step forward to calm the nerves, ease the panic, and provide rapid decisiveness for those too stunned to react. Their readiness to step into the unimaginable is itself a bitter irony, given that each of them lost so much in the past to be able to help in the present. 

Video screenshot

A doctor who witnessed the bombings describes the scene, including the many 'mangled limbs.'

By all accounts, the various ERs in Boston did a superlative job doing as much as they could for the many patients delivered to their doors. Hopefully, those critically ill at present will stabilize and the death toll will stay at three. That said, there is almost no silver lining to be found in the brutal event of yesterday except perhaps this: emergency rooms are strange living organisms with a long memory and a vast oral tradition of stories, some true, some less so, of what the staff there has seen and done. 

For example, in my medical school an older surgeon would tell each successive group of bright-eyed, 23-year-old kids about his experience in the Parkland Hospital ER in Dallas that day in 1963 when JFK was brought in. He told us what he and his surgical colleagues had done to try to save the president. And I imagine that all of us remember not just the fact that this guy had touched JFK, but the importance, even when it’s the president, of trying to establish an airway, trying to give intravenous fluids, of fighting to get a palpable blood pressure, of doing the routine doctor things even when—and especially when—your heart is broken and you can’t much think.

Given the way ERs work, I suspect the many 2013 Boston ERs and surgical teams will carry all they saw and did—and all they were unable to do—for the rest of their careers. In the tradition of ERs, which have long stretches without much to do (have a visit at 3 a.m. some time to see what I mean), staff will sit around and talk, exchange their own stories, some horrible, some amusing. And it is likely that somewhere, many years hence, a young doctor will make a rapid smart decision on a patient not because of what he learned in a medical-school lecture, but from the stories he had once heard of the marathon massacre.