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Almost two weeks after the Boston Marathon bombings, which killed three and injured more than 260, the medical toll is becoming clearer, with many of the victims suffering complex wounds that are causing intense pain and that will require several more surgeries.
Thirty-one of the victims remained hospitalized at the city's trauma centers on Thursday, including some who lost legs or feet.
They are people like Heather Abbott, 38, whose left foot, mangled in the first blast, initially was saved by doctors at Brigham and Women's Hospital. She chose to have her leg amputated a few inches below the knee this week, after doctors essentially told her that life would be more difficult with the foot than without it.
"I walked maybe 10 feet today on a walker and everybody was so proud of me," Abbott, a human resources manager from Newport, R.I., told reporters at the hospital on Thursday. "And I thought, 'Oh gosh, this is going to be a long time.'"
Sixteen people lost legs or feet in the blasts, ranging in age from 7 to 71. But in a way, their cases are the simpler ones, said Dr. David King, a trauma surgeon at Massachusetts General Hospital.
For some whose limbs were preserved, King said, the wounds were so littered with debris that five or six surgeries have been needed to decontaminate them.
"The idea is to spread out the physiological stress over multiple operations," he said.
Some of the wounded also still need surgeries to repair bones, veins and nerves. Many will need physical therapy as well. About 10 patients already have arrived at Spaulding Rehabilitation Hospital in Boston, said Timothy Sullivan, a spokesman, and that number could soon double.
For many of the wounded, managing pain is a constant challenge. Dr. Alok Gupta, a trauma surgeon at Beth Israel Deaconess Medical Center, said the hospital was giving patients oral and intravenous narcotics and, where possible, regional nerve blocks using catheters.
King said that for those who lost limbs, so-called phantom pain - which feels as if it is coming from the body part that is no longer there - can be excruciating and particularly hard to treat.
"You have to balance between taking the pain away," he said, "and them being interactive and able to participate in their own rehabilitation."
The ailments are not just physical. Some patients are upbeat, doctors said, but others are angry, anxious and depressed.
Joan Smith, the manager of social work services at Tufts Medical Center, said that virtually all of the 14 victims who came through the hospital were experiencing post-traumatic stress disorder that may continue indefinitely.
"I also personally did a lot of work with family members who were trying to be strong for their children but at the same time were falling apart behind closed doors," said Smith, who made sure all the patients and their families had a list of mental health specialists to contact if they felt the need.
Dr. Scott Ryan, chief of orthopedic trauma at Tufts, said he could not stop thinking about how traumatic it must have been for the victims, most of whom remained conscious after the blasts, to see the extent of their wounds as they were raced to hospitals.
"The most disturbing thing for me in treating these patients is that they were awake after it happened and looked down and saw these terrible wounds," he said. "Most of the time, patients with that bad injuries, they're from a car accident or motorcycle accident and by the time they get to hospital they're not with it enough to look down and say, 'Oh my God, look what happened to my leg.' "
At Spaulding, the rehab hospital, a team of doctors, nurses, psychologists and physical therapists will focus exclusively on the bombing victims, many of whom will be fitted with prosthetic legs while they are there. Inpatient rehabilitation usually lasts a few weeks, said Dr. Ross Zafonte, Spaulding's chief medical officer, although some of these patients will be there longer. Months of outpatient rehabilitation will follow, he said.
"They're learning to walk with a prosthetic, regain balance, take care of that extremity, perform their own activities of daily living," Zafonte said. "They have to deal with all of those rather life-changing issues rather quickly."