Eight-three percent of those patients presenting with exsanguinating extremity wounds received tourniquets in the field. The median time from the explosion to the hospital for the injured patient was 11 minutes. The severely injured patients, as determined by the Injury Severity Score ISS of 16 or higher on discharge, were relatively evenly distributed among the adult trauma centers Fig. The number of available operating rooms and intensive care unit ICU beds is not monitored by this organization.
Within the first 30 minutes of the blast, those patients with ISS scores greater than 25 were all admitted Fig. The number of patients utilizing the operating room black presented a smoother more linear curve beginning shortly after the bombing and continuing at roughly the same rate into the evening hours.
The remaining 75 patients The ED median length of stay was minutes range: 10— minutes. Seventy-five patients were admitted to the combined hospitals on the day of the bombing.
A majority of the lead operative teams consisted of orthopedic and trauma surgeons with a much smaller initial requirement on behalf of the burn, neurosurgical, plastic, or vascular surgeons. The plastic surgical services assumed a much more prominent and invaluable role in the reconstructive phase of the patient care in the days after the initial bombing Table 3. The median length of stay in the ICU was 4 days range: 1—22 days with a median hospital length of stay of 8. The lower mortality in the Boston bombing may be explained by the ground level location of the open-air bomb and lower grade explosive materials resulting in a fewer number of patients with high ISS scores.
There was an absence of the extreme pressure changes and blast wave seen in the military-grade IEDs of Iraq and Afghanistan that tear apart armored vehicles and dismounted personnel with devastating consequences.
The primary blast injury results from the pressure changes induced from the explosion and present as injury to organs with contained air or air-fluid interfaces.
We believe that this number is an underestimate of the total number given that close follow-up over time is critical to identify all that suffer this injury. Estimates of upward of more than patients out of the have been reported to have sustained tympanic membrane or inner ear damage personal communication, Daniel Lee, MD.
The lung is the second most susceptible organ to primary blast injury. The pressure differentials generated across the fluid filled capillary network of the lung and the air-filled alveoli leads to direct injury with hemorrhage, edema, laceration, cavity formation, and a prominent bilateral infiltrate.
There appear to be 2 individuals, 1 adult and 1 child, who suffered a pulmonary blast injury. There were no hollow viscus injuries in the survivors as a result of blast injury.
The overpressurization most likely was very limited in scope as it approached the 50 to 80 psi required to produce extensive direct pulmonary injury in only 2 patients from the blast wave.
The majority of injuries seen in the Boston bombing resulted from secondary blast injuries as projectiles formed from the disintegrating pressure-cookers with metallic ball bearings and nails packed into the device. The projectiles resulting from this explosive device, although not completely accurate in a semantic sense, are often referred to as shrapnel in common parlance and served as the wounding agent in the overwhelming majority of cases. The fact that the majority of our patients had evidence for external injuries is a testament to the damage wrought by the secondary blast injury.
Some terrorist bombings, termed suicide bomb attacks, involve the explosive charge strapped to the bombers themselves. This introduces the prospect of infectious complications resulting from airborne viral particles. Given that this was an outdoor bombing, we did not see any injuries from structural collapse or human projectiles as reported in tertiary blast effects.
The minimal number of patients who had disaster tags applied 0. Eight-three percent of those patients with exsanguinating lower extremity wounds had a tourniquet applied in the field. It was unclear from the data analysis whether the type of tourniquet employed was of the improvised variety or a commercially available type, who in the field might have placed the device, and whether or not it was properly applied.
Historically, the tourniquet has enjoyed a mixed review over the millennia. In our study of the Boston bombing, the prehospital data are inadequate to draw any new conclusions about the role of the tourniquet from this event.
We remain staunch advocates of prehospital tourniquet use based on the recent well-documented extensive military experience. There was no statistical difference data not shown because the numbers were small. Closer inspection reveals that one center that received 6 severely injured patients was in close proximity to another that received no severely injured patients suggesting that the distribution could have been more equitable.
It is well documented that a single level I institution overwhelmed with mass casualties transforms it from a functional level I trauma unit into a dysfunctional one with a higher mortality rate hence this practice must be avoided. The ability to care for the influx of multiple patients at one time is predicated upon the ability of hospital personnel to evacuate the ED of the existing patients.
At 3 pm , all of the EDs were near or over capacity. Because of the marathon, all of the area hospitals had their Hospital Incident Command System centers up and running, which facilitated the mobilization of the emergency response and rapid decompression of the EDs in preparation for the anticipated patient surge. All inpatient services were notified of the need for rapid triage of those patients in the ED and sent those resources to the ED to facilitate with that process. In all of the trauma centers, the most senior trauma surgeons collaborated with the emergency medicine leaders in the triage of the trauma patients.
These surgeons took on the role of the triage team leader for the more severely injured and assembled care teams that took stock of the resources available and opened immediate communication with the surgical subspecialties, anesthesia, and the operating rooms.
All elective operations underway were completed and no new cases started after 3 pm until more information became available as to the expected number of injured patients. In the ED, emergency airway control was obtained in 12 9. No surgical airways were needed most likely because of the infrequent finding of massive head or facial trauma more characteristic of high-explosive injuries. No chest tubes were placed, consistent with the infrequency of chest injuries seen whether by projectiles or from blast effect.
The lack of skeletal traction and fasciotomies is consistent with a brief length of stay in the ED median 45 minutes for those taken directly to the OR for the lower extremity wounds. The majority of these wounds were major soft tissue defects in which fasciotomies might not be necessary as the compartments were widely decompressed through major tissue defects and the time sequence from injury to operating room was truncated. Routine use of plain radiographs in trauma care has been an essential component of teaching in Advanced Trauma Life Support; however, recently the role of cervical spine films has been called into question.
A few specific head CTs were done for obvious mental status changes or evidence for penetrating cranial wounds. Seventy-five The other 52 patients were seen in the ED and discharged to home. This is standard practice at a number of the trauma centers for life-threatening exsanguinating injuries.
The median length of stay for all patients in the ED was minutes range: 10— minutes , whereas those admitted to the operating room had a median length of stay in the ED of 45 minutes. The ability to predict the total volume of patients and possible additional bombs forced the teams to identify those patients in need of immediate operations and those who had an operative injury but could wait for more information to determine their position in the cue. This might explain the broad range of dwell times in the ED for those patients who required urgent operative intervention.
Only a small percentage A majority of the operative cases were cared for in the ICUs postoperatively for respiratory support and wound care. Although ICU resources were needed for many patients, there was sufficient time to move existing patients out of those occupied beds turn over the rooms and increase the number of nursing staff to prepare for the victims.
Damage control surgery involving arrest of bleeding, completion of amputations, placement of external fixators, soft tissue debridement, and removal of foreign bodies was the standard approach as reported after bombings across the world. This is in stark contrast to the reports from Israel and Madrid, where head injuries were the most frequent location of penetrating wounds and reported in up to The chest location of the bomb in a lone suicide bomber tends to disperse the projectiles at a higher level than ground level, and the closed site bombing in a bus or train tends to involve victims who are seated leading to more direct brain injury as the head is closer to the location of the device that is hidden beneath a seat or again strapped to the bomber.
The combination of subcutaneous hemorrhage, abrasions, and lacerations has been described before as a characteristic triad of cutaneous injury in explosion victims.
The mechanism of injury from an explosion may result from the blast wave but more commonly from penetrating fragments resulting in cutaneous wounds, soft tissue avulsions, and bony fractures. Well-vascularized flaps for the closure of soft tissue defects have been established as an effective method for closure of large soft tissue defects. Vascular injuries comprise about 4. The traumatic amputation at the scene of a bombing has been associated with very poor survival.
Almogy et al 35 reported on 74 patients with traumatic amputation in Israel with 63 Likewise, there were no survivors among the victims who presented with traumatic amputations after the terrorist bombing of the USS Cole off the coast of Yemen in October Major limb amputation is reserved for either a life-threatening limb injury or one in which there is no reasonable success for salvage despite the best surgical efforts. On the day of the bombing, 12 patients 14 limbs underwent either above or below knee lower extremity amputations.
These were staged procedures with the surgical wounds left widely open incorporating a strategy to return at a later date for definitive therapy. Many In general, this is a reflection of the relatively young age of the injured patients and the preponderance of lower extremity injuries. The formal security and recognition of the Boston Marathon as a global event made this a desirable target for the misdirected but at the same time set in place monitoring devices at the starting and finish line to search for biologic or radiation hazards.
There was no evidence at the time of the bombing that we were faced with these hazards. The streets surrounding the marathon were normally cordoned off for the runners, spectators, and the medical tent. This allowed some semblance of traffic control and easier evacuations in contrast to the traffic during a normal workday. The proximity of 5 level I adult and 4 pediatric trauma centers only minutes after the bombings and the dedication of the American College of Surgeons to endorse the programs for the care of trauma patients in each of these centers established a favorable medical environment in Boston to manage the influx of a large number of patients in short order.
The timing of the bombing could not have been more favorable with a relatively light operative day, at the time of nursing shift change, and with Hospital Incident Command System and surgical teams already in place. A plethora of head, chest, and abdominal injuries would require more operative demand of the general, trauma, and neurological surgeons as well as radiology and the blood bank and may not have resulted in as many favorable outcomes.
There was a notable lack of penetrating neurological injuries with the attendant guarded outcomes. The trauma response at each hospital, coordinated with the prehospital providers, did not occur in a vacuum. The communication between the trauma and orthopedic surgeons with the ED and anesthesiologists ensured smooth patient transitions between prehospital, ED, and the operating rooms.
Security at the event was high with members of the Boston Police, Massachusetts State Police, Federal Bureau of Investigation, and reservist troops in place. In many of the hospitals, that level of security continued throughout the day and night. The Indian experience of potential secondary attacks on hospitals was responsible for this heightened response. We would encourage health care facilities to incorporate their local security agencies to participate in drills and form close alliances with the military, Federal Bureau of Investigation, State Police, and SWAT teams to allow seamless understanding of the simultaneous needs of the caregivers and the security forces.
The volume of patients presenting to any one ED could easily overwhelm the clinical services of that hospital and convert a multiple casualty event into a mass casualty event unless the distribution of patients from the field is monitored carefully.
The volume of patients at one time easily overwhelmed the registration practice at the hospitals with the current computer entry systems. In the current system, patient identification differed by one medical record number introducing the risk of a clerical error when tracking laboratory values, radiographic studies, and coordinating operative care.
A corrective action includes changing the unidentified name to that of a state, town, city, or color so as to create a more obvious difference between patients. Other solutions to this uniform problem have been outlined in prior publications. There were patients injured in Boston by a terrorist strike using 2 homemade IEDs. The ease with which widespread injury occurred should serve as a reminder that this is now potentially a part of daily life in the United States and across the globe. It is virtually impossible to predict the nature and location of the next event s ; however, it is clear that we remain at risk across the world.
All health care facilities should perform a gap analysis on their current disaster plans to determine next steps in an effort to minimize morbidity and mortality in the next mass casualty event.
The importance of reevaluation, training, and preparation cannot be emphasized enough. Continued collaboration to identify best practices across the globe and to improve the medical response will serve as the best method for successful outcomes until a time comes when terror is marginalized by the citizens of the world and these events are no longer a threat.
Disclosure: The authors declare that there are no conflicts of interest and that no funding was received in support of this manuscript. National Center for Biotechnology Information , U. Ann Surg. Author manuscript; available in PMC Jul Jonathan D. Michael B. Author information Copyright and License information Disclaimer. Reprints: Jonathan D. Copyright notice. The publisher's final edited version of this article is available at Ann Surg.
See other articles in PMC that cite the published article. Abstract Objective We discuss the strengths of the medical response to the Boston Marathon bombings that led to the excellent outcomes.
Background Multiple casualty incidents from natural or man-made incidents remain a constant global threat. Results A total of people were injured, and patients received care at the participating trauma centers on that day. Conclusions Adequate preparation, rapid logistical response, short transport times, immediate access to operating rooms, methodical multidisciplinary care delivery, and good fortune contributed to excellent outcomes.
Open in a separate window. Demographics and Prehospital Care A majority of the patients were adult spectators initially treated by bystanders, police, and fire personnel or prehospital medical providers prepositioned at the medical tent Table 1.
Yes 1 0. Patient surge into Boston trauma centers by injury severity score: April 15, Yes 15 Initial Operative Interventions and Inpatient Phase A majority of the lead operative teams consisted of orthopedic and trauma surgeons with a much smaller initial requirement on behalf of the burn, neurosurgical, plastic, or vascular surgeons.
So if you want to join the minority — or maximize your chances of running a qualifying time — keep reading. Boston Marathon qualifying is the process of gaining entry into the Boston Marathon. To qualify for the Boston Marathon, runners must meet specific race time standards. And these race times correspond to their age and gender. By running a marathon with the required finish time, a runner gains entry into the annual Boston Marathon.
And sometimes, you need to take a step back to run one hundred steps forward. Specifically, running a marathon takes a runner based on average stride length a total of 55, steps for men and 62, steps for women from start to finish in a Ready to go through the history of qualifying times?
Most runners who qualify for the Boston Marathon get accepted into the race. The reason: cut-off times and the window more on this later. Due to the rise in popularity of running, and field size limitations, a varying cut-off time is the norm. For the Boston Marathon, you must have run your qualifying time on or after Saturday, September 15, After the registration for Boston was complete, here are some statistics about qualifying times:. A total of 24, runners were accepted as qualified athletes.
The total number of Boston qualifying times submissions was 27, Here is a simple step-by-step process on how to run a Boston Marathon qualifying time AND run the best race of your life in Boston without being plagued by running injuries :.
Setting goals is a crucial step in running a qualifying time. In many cases, bad goal-setting results in lots of wasted time and energy. Running a Boston qualifying time is often just a matter of seconds, so everything makes a difference. And there are a lot of factors to consider when setting goals and writing a full or half marathon training plan. For example, you need to consider: your body weight, body fat percentage , recent race times, pain threshold, injury history, and a lot more.
Maybe you need to lose some fat or drop a few pounds. Many of my clients used to say the same something. But they qualified and continue to run personal records in Boston every year. And I can tell you from coaching all sorts of runners that anyone can do it.
Despite being challenging, you can do it. But you need to train intelligently. And train your mind to believe in yourself through training your mind honestly. A lot of runners want to know how to get fast enough to qualify for Boston.
And here is how many miles a week people usually run to qualify for Boston:. According to data from Strava , male qualifiers ran nearly twice as many miles more than male non-qualifiers. The same goes for females. Female qualifiers also ran nearly twice as many miles as female non-qualifiers. Male qualifiers averaged miles in 12 weeks of training. Female qualifiers averaged miles in 12 weeks of training.
This chart breaks down how many times a week people typically run to Boston qualify? In recent years, the B. And they did what they said they were going to do.
In , the fastest qualifying standard was for men in the age group. Also, the qualifying times get significantly slower as you get older. For the Boston Marathon in , qualifying times must be run on or after Saturday, September 14, If you plan on running a qualifying time, make sure you are racing to run a time within the window. And faster than the cut-off time.
Setting the right goals also involves understanding the rules and regulations. Ensure you double and triple check the rules book to confirm if and when they have rule changes. As you can see above, the cut-off time varies every year.
Your running fitness needs to be significantly better than the qualifying time you need to run. The reason: marathons are very unpredictable, and many factors come into place on race day. So if your fitness level is just slightly better than the time you need, you leave barely any margin of error.
Give yourself a cushion and take the cut-off time uncertainty usually around 5 minutes out of play. Again, make sure to look at the qualifying standards for your age group.
Look at recent cut-off times: the times you need to run faster than your qualifying standard qualifies for the race officially. To be extra safe, improve your fitness to 10 minutes under your standard. Write it down in the present tense. Select the specific date you will achieve this goal. Create a training plan that gradually progresses you towards your BQ race. Commit the time and energy to achieve your goal. Train intelligently and prioritize the importance of pacing, fueling, and hydration.
Prioritize training intelligently, which includes injury prevention, pacing, hydration, and fueling. For many, you need to lose weight or lose body fat. Typically, I recommend clients schedule a 10K or half marathon approximately weeks before their goal BQ marathon race. Spend some time and browse through famous qualifying races for the Boston Marathon. The success rate of Boston Marathon qualifying times was based on analyzing previous race times of finishers, the average temperature on race day, and the course elevation.
BQ runners are better at pacing than non-BQ runners. With time, distance runners learn that precise pacing is a crucial element of improving running performance. Running at the appropriate paces to target improving their aerobic fitness , they see better results.
Inexperienced distance runners are constantly trying to push the pace in training and win workouts. The mileage for BQ runners is significantly higher. No magic number of miles you should run to qualify for Boston. The main thing is to focus on incremental progress from where you are today. With consistency and patience, your mileage will get up there. Running a Boston Marathon qualifying time takes discipline. Remember, the name of the game is incremental progress. Concerning the number of runs per week, you also need to exhibit patience.
The high majority of BQ runners completing runs per week have built up this volume over many years. Boston qualifiers run most of their runs at a faster pace than non-BQ runners. This does not mean that BQ runners push the pace on most of their runs.
The reason the paces are faster is due to their fitness level being better. According to the Boston Athletic Association , the same process as previous years was used to register runners with qualifying times.
They begin with the fastest qualifying times in their gender and age group. So basically, the fastest marathon runners control their destiny. Boston Marathon Start Time Waves. Shortly after, usually around am, the elite women runners start.
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