Case 11-2014

Abstract

case records of the massachusetts general hospitalT h e ne w e ngl a nd jou r na l o f m e dicine n engl j med 370;15 nejm.org april 10, 2014 Pr esentation of C a seDr. John T. Nagurney (Emergency Medicine): A 34-year-old man was brought to the emergency department at this hospital because of multiple traumatic injuries that he sustained when a bomb exploded while he was watching the 2013 Boston Marathon. At the scene, the patient reportedly lost consciousness, had a complete amputation of his right leg directly below the knee, and had copious blood loss. A tourniquet had been applied to the right upper leg. He was placed on a backboard, immobilized, and transported to this hospital by ambulance, arriving at 3:20 p.m., 31 minutes after the explosion. He was brought immediately into a trauma bay in the emergency department. No additional history was known.On examination by Dr. Timothy Fallon (Emergency Medicine Resident) in the emergency department, the patient was covered with ash and smelled of smoke; he was somnolent but arousable to verbal stimuli, and he was oriented to date, self, and place (the hospital). The blood pressure was 98/52 mm Hg, the pulse 128 beats per minute, the respiratory rate 28 unlabored breaths per minute, and the oxygen saturation 100% (oxygen supplementation not recorded). He opened his eyes in response to speech. The Glasgow Coma Scale score was 14 on a scale of 3 (indicating coma) to 15 (indicating normal). There was soot and dirt on the face, and the nasal hairs and eyebrows were singed. The pupils were equal and reactive to light. The mucous membranes were dry. The cervical spine was not tender to palpation. The lungs were clear to auscultation, and there was no tenderness, crepitus, or deformity of the chest wall. The heart sounds were normal. The femoral pulses were 2+. The abdomen was soft, nontender, and nondistended, without guarding. The extremities were pale and cool. There was venous bleeding and a large pool of blood at the site of the amputation of the right leg, as well as an open fracture of the left foot. There were burns involving the face, trunk, and extremities; a puncture wound (3 cm in length) in the posterior aspect of the left thigh with some tissue destruction and no active bleeding; and multiple smaller penetrating wounds. Detailed wound and burn examinations were deferred. The patient moved all extremities and had no gross focal neurologic deficits.

The Processing of Surgical Specimens With Forensic Evidence: Lessons Learned From the Boston Marathon Bombings

“…Of note, only one person should handle each specimen, per chain of custody guidelines. 14 A dedicated team approach minimizes confusion, increases consistency, and provides structure to the process. It also provides law enforcement a point person for immediate and future communication.…”