SPECIAL ARTICLE

Marathon Monday—A reflection Christie J. Lucente, MS, PA-C

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pril 15, 2013. Patriots’ Day. This Massachusetts holiday is always an exciting day for the area because it’s also the day of the Boston Marathon. The air is festive as runners flood the city, and families, friends, and spectators line the streets for 26.2 miles to cheer on the runners—those they know and those they don’t. On this day, our emergency medicine “work-family” volunteers to staff medical tents, and those of us working in the ED prepare to care for runners with marathonrelated complaints such as musculoskeletal injuries, hyponatremia, and simple dehydration. Things were pretty typical in the ED at first. Patient flow was steady, and all of our beds were full, but we had yet to experience significant patient volume related to the marathon. Then a PA colleague came to tell us that someone from the medical tent called and said there had been an explosion and many were injured. We spent what little time we had trying to gather more information and evaluate the plan for our current patients as the overhead announcements of pending emergency medical services (EMS) arrivals began. Our facility is only a mile from the marathon finish line, so patients were arriving within minutes. I was putting on protective gear as EMS walked past me with a patient. The patient was on a makeshift backboard that looked like a piece of scaffolding, with bandages covering her lower extremities. A harried and obviously shaken paramedic gave us an unusually brief report. When I asked the paramedic for additional information, I quickly realized I had not fully understood the gravity of the situation and the potential for a large number of casualties. The paramedic called the explosion a “bombing” and explained that each

Christie J. Lucente practices emergency medicine at Brigham and Women’s Hospital in Boston, Mass. The author has disclosed no potential conflicts of interest, financial or otherwise. Tanya Gregory, PhD, department editor DOI: 10.1097/01.JAA.0000446994.79681.c6 Copyright © 2014 American Academy of Physician Assistants

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ambulance coming in was carrying two or three severely injured patients. All the incoming paramedics were soon rushing out the door to go back to the scene. As I turned my attention to my patient, my first thought was how easy it was to relate to her. She was an innocent victim who could have been me, a family member, or a close friend. The patient could not fully remember the event, and her affect was such that I couldn’t tell if she was stoic, suffering from traumatic brain injury, or in a state of posttraumatic distress. I still did not quite grasp the ordeal she had just been through. I began evaluating my patient using advanced trauma life support and other trauma-related skills I had learned, training that I now couldn’t be more thankful for. I was lucky to be joined by two of our department’s fantastic nurses. My attending and a senior surgical resident joined us shortly after we started our evaluation. Ours is a Level I trauma center with the best and brightest interdisciplinary staff and state-of-the-art resources at hand. These resources have been comforting during highly stressful, high-acuity situations, but what happens when we have an influx of 39 or more critically injured patients to assess and treat all at once? Volume 27 • Number 6 • June 2014

Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

SPECIAL ARTICLE

The proximity of the event to the hospital worked against us in that our department had very little time to prepare. Despite this, with the influx of patients came a concomitant influx of clinicians. Emergency medicine providers and nurses joined the many trauma and orthopedic surgeons and OR staff who came in from other areas of the hospital, from home, and from the marathon itself. An emergency medicine nurse and I assumed primary responsibility for the patient I had begun evaluating. One of us was at her bedside at all times, constantly reexamining and checking her hemodynamic status, ensuring that the ordered tests were being obtained, that the necessary medications were being given, and treating her pain. In addition, we tried to tend to her emotional needs. We were concerned about the family members she had been with at the time of the blast. Their status and whereabouts were unknown. My patient had multiple open fractures, soft tissue defects, and lower extremity pulse deficits that indicated potentially limb-threatening vascular injury. With the large number of patients being seen with similar or potential life-threatening injuries, a fair amount of triage, coordination, and repetitive communication were required to make sure that all the patients were getting the care that they needed in a timely manner. Having never experienced a mass casualty event firsthand, I went through a series of emotions during the event and for days and weeks afterward. Initially I was detached—I felt as though I was on autopilot, evaluating and treating my patient’s injuries without considering what the emotional toll might be on me. Eventually my patient went to the OR, and I resumed caring for my previous patients and helped out where I could. I stayed in the ED until late that evening, not because I had to but because I knew my own family was safe and for reasons I haven’t quite figured out, I just couldn’t bring myself to leave. I returned early the next morning for my scheduled shift with very little downtime, having watched horrific video clips of the bombing on the news throughout the night. Not until I was asked to see the family member of an injured patient the following afternoon did my “detachment” turn into grief and guilt. In retrospect, I also internalized some unrealistic sense of responsibility for being unable to prevent my patient’s injuries from happening or to cure them instantly. I was fearful for her and her loved ones, whom we had had difficulty locating for quite some time. Despite not knowing my patient personally, I felt somehow responsible for her injuries. I kept replaying the events of the night before and kept identifying things I could have done better. I repeatedly asked myself questions: Could I have done a better job at preserving evidence, such as the burned clothing and shrapnel that I had pulled from her body? Should I have been able to locate her family members faster? Could I have been more prepared to deal with the horrors of terrorism? 14

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I felt grief for what my patient might have lost and might lose in the future: family members, full function of her legs, and trust in the good of society. I also spent a great deal of time focusing on the disadvantages we had in preparing for the rapid influx of trauma patients rather than commending my colleagues, and myself, for our expedient response in mobilizing all available resources, as well as our excellent treatment of severely injured patients. I wanted to have what my colleagues seemed to have: the confidence that we provided world-class care in a mass casualty event and the belief that we are prepared if it were to happen again. One year after this event, in the aftermath of a citywide lockdown, with the police chases and shootouts over, I am in an emotional phase of acceptance and appraisal—not of the cruel acts by terrorists but of my personal performance as a clinician and the amazing response from others around me. Everyone’s efforts, from bystanders and EMS to surgeons and social workers, contributed to the medical successes of the day. I am in awe at the brave and rapid response of those close to the event, particularly those who ran toward the injured immediately after the blast with little concern for their own safety. I am amazed at the EMS personnel who triaged, stabilized, and transferred the injured to area hospitals. I am proud of my emergency medicine physician assistant colleagues, many of whom were taking care of trauma patients of their own: the new graduate who spent the day before reading about treating dehydration and exercise-related injuries and instead was faced with blast injuries and multitrauma casualties, and the experienced PA who was caring for victims with the knowledge and confidence she developed over years. I am thankful for the attending and resident physicians, nurses, and technicians who participated in the team effort to do what was right for each and every patient. I feel indebted to the inpatient and specialty teams who swiftly and thankfully came down to take over the care of those patients who had the misfortune of being in the ED at the time. And let me not forget the hospital and departmental leaders, who succeeded in their efforts to care not only for the needs of the patients but also for the physical and emotional needs of the staff. Ultimately, my patient underwent a series of surgeries aimed at salvaging limb tissue and function. Her family members were located and, although severely injured, had survived the devastating event. Our department and institution successfully enacted a disaster plan that we had hoped would never be needed. We participated in debriefing sessions where we shared our experiences and emotions and identified ways to improve. We came together as a team, bonding and supporting each other in ways that I would never have been able to imagine before the disaster happened. From all of this, I am a true believer that we are “Boston Strong.” JAAPA Volume 27 • Number 6 • June 2014

Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

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