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How Boston Is Managing Pain After the Blasts

First responders tend to the wounded, including a young boy in a wheelchair, where two explosions occurred along the final stretch of the Boston Marathon on Monday.

Dr. David Mooney sees bleeding children all the time. As director of the trauma program at Boston Children’s Hospital, he knows how to soothe overreacting kids and their parents, and most times “the wounds aren’t quite as bad as advertised,” he said.

Monday was different. Monday left him speechless. The children being hauled into Boston Children’s Hospital didn’t need to say a word to express the severity of the explosions near the finish line of the Boston Marathon.

“The first two that came in had soot on their faces, singed eyebrows, burned hair, tourniquets on their legs that were clearly preventing so much blood loss it would have been a death sentence without them,” he said. “There were nails sticking out of a young girl’s flesh, just poking through the skin.”

‘It’s not unusual that the mental health issues will last a lifetime.’
— Dr. David Mooney

Shrapnel still remains lodged in the muscles of some of them — waiting to be removed on a day when the doctors aren’t in life-saving mode. Like many of the victims of Monday’s terrorist attack in Boston, the long recovery for these children has only begun. Physical wounds will take months, if not a year or more, to heal, Mooney said. And in a case like this, “it’s not unusual that the mental health issues will last a lifetime.”

In emergency rooms throughout Boston, the controlled chaos looked much the same, with shards of metal, nails and ball bearings being carefully removed from the ankles, calves and thighs of many victims, which now includes three dead and more than 170 wounded. At Massachusetts General Hospital, Dr. George Velmahos said the wounds were so severe that many of his patients were “automatic amputees,” and that doctors “just completed what the bomb had done.”

Across town, at St. Elizabeth’s Medical Center — a facility more accustomed to treating marathon fatigue victims due to its proximity to “Heartbreak Hill” — emergency department chief Dr. Mark Pearlmutter and his team spent have much of their time removing chunks of metal and “what turned out to be ball-bearing components” from flesh and muscle.

But even many hours after the blast, the emotional gravity of what that meant was still sinking in for victims. While Pearlmutter noticed some trying to cling to the “very good mood” from the festival atmosphere of Patriots’ Day, he treated others who were “petrified” to step outside again. One of the wounded first responders he met couldn’t shake the realization that his post near the finish line was about eight feet from the second bomb. On the verge of a panic attack, the patient kept “wondering whether he should have seen something sooner,” Pearlmutter said. “The survivor’s remorse he was experiencing was terrible.”

Terrible and likely to continue for some time, if similar terror attacks in other parts of the world are a guide, said Dr. Arieh Shalev, a professor of psychiatry at New York University’s Langone Medical Center.

In Jerusalem, Shalev saw “very similar events occurring frequently — shocking, traumatizing and totally unexpected,” while he was serving as the chair of psychiatry at Hadassah University Hospital in Jerusalem. Those attacks happened in public places and targeted random bystanders — just like in Boston, he said.

And just like in Jerusalem, Post-Traumatic Stress Disorder is the likely long-term result for some. While Shalev warned against early diagnoses, he also said that victims “should be managed in some form very early on.” Anyone who was in or near the blast should be monitored closely and encouraged to communicate how they’re feeling at both a physical and emotional level.

“If they’re in pain, the pain should be the primary target. If they need to talk to someone, they should be allowed to do that,” Shalev said. “Reducing the stressfulness of the event itself by whatever means possible should be at the core — so that it doesn’t progress further.”

Physicians are also on the lookout for another covert disorder that could have been triggered by the improvised explosive devices: hearing loss. The double blasts created a pressure wave on Boylston Street that ricocheted off the buildings, leading to hearing problems for some of those in the crowd.

Dr. Alicia Quesnel, an ear specialist at the Massachusetts Eye and Ear Infirmary, has seen a steady stream of patients complaining of ear pain and ringing since the blasts. Those symptoms are often traced to holes in the ear drum itself, injury to the bones in the middle ear and damage to the nerves in the inner ear, Quesnel said. Anyone experiencing the telltale signs of hearing damage — including ear pain, continuous ringing, blood drainage or dizziness — should be examined as soon as possible, she said.

‘Some of the principles we’ve learned from those conflicts (in Iraq and Afghanistan) — pain control, how to help people use prosthetic limbs, how to treat concussive blasts and head injury — all of those lessons are going to serve us well here.’
— Dr. Ross Zafonte

As the true toll for Monday’s attacks continue to become more clear — and as the response moves from crisis and surgery to long-term care — another group of Boston health care providers is preparing for the recovery phase.

None of the victims have moved to Harvard’s Spaulding Rehabilitation hospital yet but the facility is preparing the beds. Dr. Ross Zafonte, the hospital’s vice president of medical affairs, said the facility is well-equipped to teach the victims of the Boston Marathon bombings how to do things they considered basic just days ago, like how to walk — or perhaps for some, even how to eat and talk.

The facility developed many of its techniques after treating veterans wounded in Iraq and Afghanistan, many of whom were also injured by an improvised explosive device.

“Some of the principles we’ve learned from those conflicts — pain control, how to help people use prosthetic limbs, how to treat concussive blasts and head injury,” Zafonte said, “all of those lessons are going to serve us well here.”

Spaulding’s mental health unit will also help patients come to terms mentally with what happened as they work to rebuild their lives. True PTSD often emerges 30 days after event, especially as numbness and shock wear off and a full range of emotional responses return. It will be one of center’s biggest tasks, Zafonte admits.

For now, the chaos of the moment is serving as a temporary ointment in itself. At Brigham & Women’s Hospital, Dr. Parveen Parmar and her team have been so busy treating wounds that she says few have taken time to process what they’ve seen.

“I think eventually we’ll have a little bit more time to deal with that piece of it,” she said. “But not yet.”

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