4 years after Boston Marathon attack, new hope for trauma patients

For trauma patients faced with limb loss, the old axiom about necessity and invention has never seemed more true.

Four years after the tragedy at the Boston Marathon, medical professionals are combining what they have learned from that tragedy with new expertise in treating trauma patients, from saving limbs to improving the lives of amputees.

Dr. Jeffrey Kalish has been at the forefront of this endeavor. A vascular surgeon at Boston Medical Center, he was amid the horror as many of the most critically injured Marathon trauma patients arrived.

He and his colleagues saved many patients due to their experience handling traumatic injuries, but he recognized that there was a wealth of additional information available that could help shape his approach to future amputation patients.

He applied for and earned the prestigious, year-long, E.J. Wylie traveling fellowship from the Society for Vascular Surgery Foundation to learn how amputations and limb preservation are handled around the U.S. and Canada.

His research found that innovation for trauma patients was not just changing techniques and technology, but changing the way amputation is regarded.

“Even though amputation is catastrophic and devastating, it is not the end of the road that someone might imagine,” he said. “We can restore someone’s function to a level they would never have dreamed possible, and amputees are in a better position today than at any prior point in history. Right now our prosthetic technologies are beginning to seem like something from a science fiction movie. We are not quite in Luke Skywalker territory – yet.”

In the past surgeons would consider amputation a failure, he said, in that, “we tried to save the limb but decided the patient was better off without it. Now we are starting to see amputation as another tool in bringing a patient back to full function.”

Since his experiences from the Marathon bombing and his traveling fellowship, he has inspired several changes at Boston Medical Center and will be spreading the word about how these techniques improve outcomes for trauma patients:

• Instead of having multiple caregivers providing different updates to patients at BMC, a new multi-disciplinary team coordinates every day regarding patient care. Breaking down silos between caregivers means that patients do not get different messages from different caregivers that can cause confusion and fear; in addition, coordinating ahead of time with prosthetists allows prosthetic technology to be factored in before amputation

• Social workers and mental health professionals are introduced early to the patient, and they receive regular reminders that help is available. Amputees not only need emotional support, but they are likely to face physical mobility issues at home

• Pain is managed using an algorithm that distinguishes between nerve pain and physical pain, which can be treated differently

• Long-term patient/surgeon relationships, which are commonplace for vascular surgeons, should be the standard for amputees. Years ago, amputees tended to be older or in poor health, but today, many trauma patients that become amputees have lead healthy and active lives and anticipate many more years ahead of them

Dr. Kalish said there is much to be learned from active military and veterans’ hospitals, which are at the leading edge of amputation treatment. “They have experience with blast injuries that most civilians lack,” said Dr. Kalish. Whether to save a limb or not is often a judgment call, “but we can look to the military studies of limb salvage and benefit from their experience.”

Other exciting innovations for amputees are new procedures such as targeted muscle reinnervation, where existing muscles can be taught to move an attached robotic hand. Osseointegration, a technique that started with dental implants, is now being used to embed rods in existing bone to better attach certain prosthetics.

From a personal perspective, the traveling fellowship gave Dr. Kalish even more reason to dedicate the rest of his career to helping trauma patients.

“Nothing is more rewarding than to see them walk into your office a few months later,” he said. “After the Boston bombings, I saw that vascular surgeons can make a tremendous difference, not just in the moment, but also over time, to give patients hope and inspiration.”

## The Society for Vascular Surgery® (SVS) is a 5,600-member, not-for-profit professional medical society, composed primarily of specialty-trained vascular surgeons, which seeks to advance excellence and innovation in vascular health through education, advocacy, research and public awareness. The SVS Foundation funds research that improves the quality of vascular patient care. Many of the Foundation’s recipients are younger vascular surgeons just beginning their research careers. Editors notes:
The 2017 Boston Marathon will be Monday, April 17.
April is National Limb Loss Awareness Month.