It may have lacked the dust and dirt of battlefields in Iraq and Afghanistan, but Monday's bomb attack on the Boston Marathon produced a number of injuries rarely seen outside of war zones — traumatic limb amputations.
Medicine has made great strides in the reattachment of severed limbs in the last two decades, but the nature of bomb blast injuries makes such repairs impossible.
"The only types of injuries that can be re-implanted are those involving clean separations, like a limb that's been cut off by a sword or industrial machinery that cleanly cuts the arm or leg off," said Dr. Jeffrey Eckardt, chairman of the orthopedic surgery department at UCLA. "With an explosion, whole sections of the bone and muscles are gone. Vessels and nerves get pulled and stretched and yanked."
At Boston Medical Center, where emergency physicians have treated 23 blast victims, seven amputations were performed on five patients as of Wednesday morning, said Dr. Peter Burke, the hospital's chief of trauma services.
Burke told reporters at a news briefing that it is never easy to discuss limb removal with a patient.
"It's a very difficult thing for both the patient — especially — and their families," he said. "The caregivers have to be honest. We do the best we can with the situation."
Many of the worst injuries suffered by Boston victims involved shrapnel-like material that was embedded in wounds. Surgeons were still working to remove these materials.
"We've taken out large quantities of pieces of things," Burke said. "It's hard to tell exactly what they are."
In some cases, small pieces of shrapnel that did not pose an immediate threat to blood vessels and other structures would probably be left in the body.
"You actually don't go dig it all out," Eckardt said. "The pieces tend to be rather sterile due to the heat of the blast.
"The presence of metal per se does not dictate an amputation," he added. "It depends on how much of it there is, and what it has done to the critical structures, which are the vessels and the nerves."
It remains unclear how many amputations will result from the bombings.
Brigham and Women's Hospital in Boston has treated 35 patients who were injured in the explosions, according to spokeswoman Lori Schroth. Surgery was performed on nine of those patients, one of whom required amputation.
At Massachusetts General Hospital, eight of the 34 patients treated were in very severe condition and required extensive surgery, said Dr. George Velmahos, chief of trauma surgery. Those operations included an unspecified number of amputations, he said.
Patients who have lost limbs face a long road to recovery, experts say, but not as long as the one they would have faced decades ago.
Dr. Christina Skoski, a retired anesthesiologist who lives in Huntington Beach, was 15 years old when she had her left leg surgically amputated at the hip. She is now a member of the scientific and medical advisory committee of the Amputee Coalition, a national group that provides resources to those who have lost limbs.
"Losing a limb under any circumstances is emotionally and physically devastating," Skoski said. "But traumatic amputation is always more difficult to deal with, because one day you're normal, and the next day you're not. That's more difficult than if you lost your limb to diabetes, or like my situation, cancer."
Generally, Skoski said, it takes a year for a patient to recover. In that time they will learn to use a prosthetic device and adapt to their new circumstances. Before that happens, however, they will go through a grieving process over their lost limb.
"It's like a death," Skoski said.
There are about 2 million people with amputations in the United States. Partly in response to veterans returning from Iraq and Afghanistan, as well as a growing elderly population, the services and technology available to patients have advanced.
When Skoski lost her leg 51 years ago, there were far fewer options and resources available. Noting that her first prosthesis was carved out of wood, Skoski said new devices that feature microprocessors and other enhancements are far safer and more useful.
In addition, organizations like the Amputee Coalition help match patients with peer supporters, who help them recover.
"A soldier wants to speak to another soldier," Skoski said. "A young woman wants to speak to another young woman. A below-knee wants to talk to another below-knee."
Skoski said that from her reading of news accounts, it appeared that many of the Boston victims were young and in good health. Those factors will greatly improve their prognoses, she noted.
"I have no doubt that half these people who had their limbs blown off are going to be at the next marathon," Skoski said. "They may not be running, they may be in a wheelchair, but they'll be there.
"You don't need your limbs to live," she said.