Photograph by Charles Krupa, AP

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An emergency responder and volunteers push a man in a wheel chair after he was injured in an explosion near the finish line of the Boston Marathon.

Photograph by Charles Krupa, AP

Boston Marathon Injuries Echo War Zone

Treating the Boston Marathon's injured is like operating in a battlefield.

On a sweltering July evening in 2006, a young Marine arrived in Lt. Commander Erin Felger's emergency department at a forward base in central Iraq. His body was shattered, his left arm amputated by a bomb blast. There wasn't much time to think. The Marine was awake, but losing blood fast. So Felger, a Navy surgeon well into a seven-and-a-half-month tour, let something deeper guide her—the memory of training, reflexes rooted in experience. She ordered her team to crack open the Marine's chest and clamp an artery shut.

It was a big risk, balanced against a bigger need to stop his bleeding. And it worked. Exactly the kind of rapid action that doctors in Boston almost certainly faced this week, Felger said, as they struggled to save lives and limbs after two bombs exploded near the finish line of the Boston Marathon on Monday, killing 3 and injuring more than 170.

"You make sure the patient is breathing," Felger said. "Then you close the holes and see what you can save."

The attack used bombs similar to the improvised explosive devices, or IEDs, common on the battlefields of Iraq and Afghanistan, and many have compared the carnage in Boston to the chaos of a war zone. For a deeper look at what patients and doctors endure after such trauma, we talked with Felger, who was featured in an earlier National Geographic video on combat medicine. Now an endocrine surgeon at the MedStar Washington Hospital Center in Washington, D.C., Felger spoke about the decisions and dangers of trauma treatment, and what doctors have learned during the nation's decade of war.

What thoughts came to you upon hearing of the bombings?

I was at a meeting in Chicago. My husband, who is an active-duty Marine, emailed me and said two IEDs went off in Boston, and my heart just sank. Even though the news didn't use that term, it's clearly what it was. I had the feeling I used to get in Iraq when we'd have a call letting us know that wounded were coming in.

What is the most destructive aspect of such an attack?

It depends on the blast itself. Is it a high-explosive or is it a low-explosive [bomb]? From what I can tell, this is a lower explosive than what we'd see in Iraq. You can still have blast injuries to the lungs, to the intestines. But a lot of what they're seeing is to the lower extremities.

You experienced firsthand modern wars' so-called "signature injuries," mostly resulting from IEDs. The Boston bombings appear similar, and we're reading of amputations in emergency departments there. What are some of the challenges surgeons face?

I'll tell you what the biggest challenge is—and I saw it in Iraq—do you take the limb or do you not take the limb? We're always taught, in everything that we do, that it's life over limb, life over limb. In theory that seems pretty black and white. It never works that way in real time. I saw other surgeons I worked with in Iraq struggle over whether they should amputate.

The end result is that often people would be better off with an amputation. If they go on to have a nonfunctional limb, that's worse. You lessen their quality of life if they've got a nonfunctional limb.

The bombs were apparently packed with ball bearings and other material. How do surgeons deal with that?

You have to get the wounds clean because the other thing that's packed in with all that metal is bacteria and dirt and all this other stuff that was propelled into the tissue. These folks probably have a lot of this inside them now. It turns out that metal fragments can be left in. You're not necessarily going to dig it out because all you're going to do is open up the wound more.

And after surgery, what lies ahead for patients and doctors?

I think the patients are going to have a lot of things to work through. I think the doctors are going to have their own feelings to work through. You could call that PTSD. And the process isn't over when you come out of surgery. If you lose a leg, that's not one surgery. I would say that could be ten surgeries. You've got to repair skin, repair nerves, cover the end of the limb. This isn't going to be done in a week or two. This is going to be months.

We've come a long way in understanding such injuries after a decade of war. What are some of the things we've learned?

We've learned that time is not on our side. The quicker you can get to a facility, the better off the patient is. The "golden hour" has gone to more like the golden 30 minutes. We've gotten so much better at using speed.

We've also figured out how to deal with extremity injuries. We were able to keep almost all the soldiers alive, get them to the next point. We've figured out how to deal with these injuries pretty squarely. I think it's easy to translate that knowledge to people who haven't done a lot of it. For these people in Boston, I'm sure they're reaching out to colleagues who had battlefield experience.

How is this sort of event different from what trauma doctors routinely see?

If you look at the scope of trauma in this country, the majority is blunt trauma: things like car crashes and falls, assaults. Then there's the penetrating trauma: gunshots, stab wounds. At the end of the day, we see more blunt trauma. So this trauma in Boston is penetrating and blunt. It's a very specific trauma to the mechanism, the IED, the bomb. Even the bomb blast in Oklahoma City was a different kind of bomb.

This has its own signature. It's polytrauma that we're just not used to in this country.