Lessons From the Battlefield

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Like anyone living in Boston in the spring of 2013, I remember where I was when I heard that bombs had gone off at the Boston Marathon finish line on Patriots’ Day, April 15. Three people, including an 8-year-old boy, were killed instantly. More than 260 were injured, many critically — bodies crushed, limbs shattered, arteries severed.

A medical student at the time, I was in awe of the speed, purpose and composure with which emergency workers and medical personnel operated. Scores of patients were transported to eight nearby hospitals. The median time from blast to hospital was 11 minutes, and the first patients were in the operating room within 35 minutes. Every patient who reached a hospital survived.

The story of that day and its painful aftermath is recounted in a new H.B.O. documentary, “Marathon: The Patriots’ Day Bombing,” airing on Nov. 21. It follows several families as they piece together their lives: learning to live as amputees, struggling with post-traumatic stress, undergoing surgery after surgery.

One newlywed couple, Patrick Downes and Jessica Kensky, find their future together transformed after each loses a leg from the blast, and they are among the civilians transferred to Walter Reed Medical Center. Ms. Kensky, an oncology nurse, ultimately has to have her other leg amputated as well. A year later, after countless hours of rehab, she and her husband attend the wedding of one of their fellow survivors.

“If I was going to try dancing on two high-heeled prosthetic legs,” Ms. Kensky says in the film, “I was going to be somewhere where there were seven other amputees to help scrape me up off the floor.”

But the survivors’ continued physical and psychological struggles raise a broader and more complicated question: How can we, as a country, care for civilian victims of terrorism when the trauma they experience is typically seen only in war?

Treating injuries caused by bombs and shrapnel is far from routine for most doctors. And while Boston was as prepared as any major city could be, the quality of trauma care across the United States varies substantially, with large differences in expertise, triage and best practices. After suffering a trauma like a car crash, fall or fire, a patient is twice as likely to die at the worst trauma centers compared to the best. So in many regions, unlucky trauma victims become unlucky trauma patients.

Yet trauma remains something of a secret epidemic. Trauma is the leading cause of death for Americans under 45, and the fourth leading cause of death over all — accounting for more than $670 billion in medical costs a year. There are nearly 150,000 trauma deaths annually — 20 percent of which could be prevented with optimal trauma care, according to the National Academies of Sciences, Engineering and Medicine.

A new report from the academies suggests that we could substantially reduce the health and economic burden of trauma in the United States if we integrated insights from military care into civilian hospitals. Even as weapons have grown more deadly, the fatality rate for wounded soldiers has fallen significantly over time, from nearly 25 percent in Vietnam to less than 10 percent in Afghanistan and Iraq. From just 2005 to 2013, the percentage of soldiers who died because of their injuries was cut nearly in half — an extraordinary accomplishment of military trauma care.

This didn’t happen by chance. It’s a result of years of battlefield leadership, systematic reflection and redesign of care delivery processes. New protocols to control bleeding and transfuse large quantities of blood have saved hemorrhaging patients, and more extensive use of tourniquets has improved survival rates. Telemedicine and web-based applications allow treatment teams real-time access to expert knowledge and critical information about patients before they arrive. Innovative surgical techniques have been designed to stabilize patients before they’re transported. And strategic evacuation of injured soldiers, sometimes over thousands of miles, by trained transport teams allows patients to receive necessary care en route.

Congresswoman Tammy Duckworth of Illinois, herself a combat veteran and blast survivor who lost both of her legs in the Iraq war, now wants those hard-won insights to permeate civilian trauma care. With input from Mr. Downes, she recently introduced a bill to bridge the expertise and resources of military doctors with those in civilian hospitals.

“There’s this incredible brain trust and experience portfolio in the military,” Mr. Downes told me recently. “But it’s only available to military personnel. Most people can’t access it. We need to make sure everyone who needs it can get it.”

Merging civilian and military trauma care would make it easier to consistently and uniformly collect information about treatments and outcomes, and allow for a central data registry that could lead to higher quality care. Another change would involve more seamless integration of the emergency services that patients receive before arriving at hospitals and the rehabilitation services they receive after their stay. And both systems would benefit if more military doctors practiced in civilian hospitals and more civilian patients received care in military hospitals, allowing military trauma teams to acquire and maintain the expertise needed to deliver specialized casualty care.

“In Boston, we’ve shown what happens when we band together,” Mr. Downes said. “We need to share this knowledge, and hopefully, that means injuries are prevented and lives are saved.”