As victims of Monday's Boston Marathon bombings streamed into their emergency rooms, surgeons at numerous Boston hospitals had to make the difficult decision of whether to amputate limbs. It's never an easy choice, but it's sometimes better to amputate quickly than try to save a damaged leg or arm.
To get a sense of how doctors weigh amputation decisions, WBUR's All Things Considered host Sacha Pfeiffer spoke with Tracey Dechert, a trauma surgeon at Boston Medical Center, who said whether to remove a limb hinges on the extent of the damage.
Tracey Dechert: You have the bone, you have muscle, you have nerves, arteries, veins, all the different parts that you look at to get a sense of, is this going to be any function left whatsoever? But then also, is there enough there to keep it? A lot of times the soft tissue — meaning all the muscle and skin and all that — is gone. So you don't have anything to really save. One thing might still be intact, like the bone, but there's not really anything on the bone.
Sacha Pfeiffer: What are the pros and cons of deciding to amputate versus deciding to try to salvage a limb?
The things you want to think about are prosthetics are very good now, so if you amputate, sometimes it's better to make that decision and do it and just then be ready for that. Because sometimes when you do try to save, you end up eventually amputating later and you've, in a sense, then spent more time working to save it — and then, in actuality, they ended up in the same place. So we try not to do that, of course.
When you've had cases where you tried to save a limb, but somewhere down the line you had to amputate — I mean, certainly that's a different kind of heartbreak, a different type of trauma. What does the patient go through in the interim? For example, multiple surgeries, I assume?
It depends. I mean, they might go through multiple debridements of the tissue that's been traumatized.
Where you keep washing it out and having to open it up and clean it?
Yup, and clean and take away tissue that has died. Like muscle. Pieces of muscle can die, so you would clean that out.
And every time that patient goes through another surgery and another round of pain and recovery.
Even though, as a trauma doctor, you're making a very clinical medical decision about whether to take off a limb, is that still a very hard decision?
Always. Yes, always. Of course you would want everyone to have all their limbs. And even though you know down the road this is the best thing for them given the situation, it's still very sad, obviously, though.
Are there times that you're having this conversation with the patient and other times when the patient is not conscious and you have to make that call all on your own?
Yes, there are many times with the traumas that they are unconscious and you're making the decision and they don't know.
Is it harder or easier when the patient's involved?
Why is that?
You're seeing what they're going through and their reactions and their pain, whereas when they're not conscious you don't have to see it. I mean, you know it's going to happen eventually but you can not to be thinking about that right now and do what you have to do and then that part comes later.
It's waking up and the patient sees it's done, versus having to have some role in deciding that it should be done?
Were there cases in the past two days with marathon patients that you had to sit down and talk with them and say, "We need to decide whether to try to keep this leg?"
Most of them, it was obvious and it was done that first night/day. There was one patient where she has one amputation already, and we're trying to save the second.
One amputation from this incident, and you're trying to see if the other leg can make it?
Yes. But there's a lot of soft tissue — meaning muscle, skin, all that — that's gone.
So it sounds like, in this case, there are patients who have woken up or are going to wake up and find that their leg had to come off?
What's the conversation that you have to have ready to have with that person?
What we often do is the family is already involved, so you can from them learn what the patient's like or all about, or who they are and a little bit about them. And the family can somewhat guide you on how it's going to go or what the patient's going to feel or what's going to be most concerning to them. Then that way you can sort of anticipate. Because everyone can react a little differently. I mean, of course everyone's upset and in shock about that, but people have somewhat different concerns.
One interesting thing I've read is that some marathon patents who were conscious when they saw themselves losing so much blood were very afraid that they weren't going to live. And they wake up and they have been so grateful to find that they are alive, even if it means they lost a leg. But they still lost a leg. I mean, that has to really sink in and have enormous impact later.
Yes. Later. I think some of it is later. You can't process it all right away. Your brain, I think, has a way of protecting you a little bit from everything. So that fact that the pre-hospital did such a good job — all the paramedics and EMS with these tourniquets — that's why none of our patients, I think, did bleed to death, because they had tourniquets on right at the scene.
Are you and your staff doing as well as possible considering what you've been through in the past 48 hours?
I think so. The good part of it is that you're still very busy. You can't really think about it yet. You just keep working.
This program aired on April 17, 2013.