It's been one month since the Boston Marathon bombing, and while those most obviously injured, including the 15 people who lost limbs in the attack, now have a clearer picture of the road to recovery that's ahead, others await unknown challenges.
Victims with shrapnel wounds and fractures may still need plastic surgery. Some sustained hearing injuries, and doctors are only now beginning to find out now whether they'll need further procedures. Dr. Daniel Lee, an ear surgeon at Brigham and Women's Hospital in Boston, said he saw at least a dozen patients with auditory issues caused by the blasts.
"Most, if not all, of these patients reported tinnitus (hearing a ringing sound) or hearing loss in the ear or head," he recalled.
Some patients had their ear drums blown out, meaning a hole in the ear drum was created because of the pressure from the explosion. Others had sensorial neural hearing loss, in which the tiny hairs in the ear that help us perceive sound are damaged.
Lee said that because the majority of his patients from the second bombing site were looking down the street at the first bombing area, they all tended to have right ear injuries. They may have also received some protection from the "head shadow effect," in which the head dampens the sound for the other side. Just because people stood together, however, didn't mean they all sustained the same level of damage.
"I saw a family of three patients that were all standing next to each other," Lee explained. "The father had significant injury to both ear membranes that will require surgery because the holes were so large. The mom had substantial injuries to her legs. The daughter had minor injuries in one ear, but horrible injuries to her legs."
Small holes in the ear drum can heal on their own over time. Larger holes will need a graft harvested from the lining of the muscle, but these patients do have a high success rate of returning to their baseline hearing. Doctors normally check up on patients for three to six months after the incident, so it's uncertain how many patients will still need surgery.
Hairs in the inner ear do not regrow, and these patients will need hearing aids. Luckily, Lee said there's only a handful of his patients that will have this permanent nerve damage; several hearing aid manufacturers have reached out to Brigham and Women's Hospital as well as other Boston-area facilities to donate their products.
Just witnessing the day's carnage had created issues for some. Psychological needs aren't the first thing that people coming into the emergency room are treated for, Dr. Manuel N. Pacheco, chief of emergency service in the department of psychiatry at Tufts Medical Center in Boston, explained.
Pacheco has seen tell-tale signs of acute stress reactions, which is one of the symptoms of post-traumatic stress disorder (PSTD), in the days and weeks after the attack. People began to complain that they were re-experiencing the events. Sometimes it was a smell of smoke or a loud sound of a car backfiring that made them recall the bombing. Tufts had to take down a prosthetic center display because it re-activated the memories in some people, even though the prostheses didn't look like actual limbs.
"Patients have told me it's like a movie is in their head... It's triggered by something that reminds them of the trauma," he explained.
The day of the bombing, the social work staff at Beth Israel Deconess Medical Center in Boston focused on identifying victims and making sure family members knew where everyone was. It was in the days after that they began to help people come to terms with what happened. Lisa Tieszen, senior clinician in the Center for Violence Prevention and Recovery (CVPR) at Beth Israel, said one of their main goals is to assure people that it's completely normal to be overwhelmed and talk to them about the resources they have at their disposal to help them cope.
"Issues may come up for people as life settles down," she said. "Those who don't go back to normal, those who are injured or uninjured and remained unsettled by feeling unsafe or flashing back to the finish line or not feeling safe in large crowds, they may need additional help."
People are only diagnosed with PTSD if their issues persist more than 30 days, so doctors may just be beginning to see the extent of how many people will be affected in a prolonged manner. Less than 20 percent of people who have traumatic experiences will have PTSD.
It wasn't only those injured at the scene who experienced psychological trauma. First responders and receivers who put their own needs aside to help others only came to terms with what happened days after the event. One police officer set to retire was pressed into service on the day of the bombing. He told Pacheco that he never saw anything like that before and was having problems dealing with it.
"(The first responders) actually went to the scene so they had this flood of vivid images and very graphic things in front of them," Pacheco explained. "They all went into survival and protective mode. Our mind has a capacity in times of stress to block things out... These people are going to find themselves with a long, arduous journey in front of them in terms of actually functioning when the smoke stops and the music stops."
Barbara Sarnoff Lee, director of social work and patient/family engagement at Beth Israel, explained that even staff that wasn't in Boston during the bombing was dealing with feelings of guilt. Some members had run the marathon themselves and couldn't come to terms with the fact that they weren't there to help. Lee and Tieszen tell them that by taking people's shifts who need time off and just being there for the clinicians that had to work that day, they are doing their part and making an impact.
"Recovery from this marathon is not a sprint," Lee explained.
Dr. Jo Shapiro, division chief in Brigham and Women's Hospital's otolaryngology department, heads the peer-to-peer support program. After the bombing, the hospital began facilitated debriefing sessions where they invited anyone who felt traumatized by the events to come talk about their experience. She estimates her group, which was partnered with the Employee Assistance Program, has worked with about 150 staff members, but there were other groups ran by the psychology and the social work departments that may have seen other people.
"Clinicians especially appreciate sharing their story with other clinicians," she said. "There's something to be said about sharing the experience with someone who understands what you went through."
Shapiro's sessions involve making sure that people have a place to talk and aren't exhibiting any warning signs, including having problems sleeping and using drugs and alcohol to cope. They also emphasize strategies to help clinicians get through their struggles including exercising and accepting that they may need to take some time off work.
They made a special effort to reach out to staff members who they identified may be less likely to seek help. The medical community is an especially vulnerable population when it comes to hiding their feelings because of the culture of resilience they are expected to display.
"We are supposed to be in charge and strong and not affected by what we see our patients go through somehow," she explained. "We are supposed to be the ones people lean on. We are the caretakers, not the people we care for."