The guilt never leaves because it was so close to my heart, my home and my work family. Your work family is that group of people that you see every day, more often than your biological family. They are destined to enter your life to challenge you and make you better, but also to care about you and relate to you in ways that others simply can't. The physician assistants at Brigham & Women's Hospital Emergency Medicine are a family of emergency providers and part of your healthcare team.
Most lay people still don't know what PA-C stands for or what we do. We are often confused with nurses or doctors and have trouble finding our place in the minds of society; meanwhile, our role in medicine has been very well identified, accepted and embraced as irreplaceable members of the healthcare team.
We did not go into this profession to have our names recognized, to make hundreds of thousands of dollars or to be called doctor. We don't care because we have the best jobs in the world, providing quality medical care to our neighbors, friends and patients.
I have to say that as a write this introduction, I am smiling knowing that I am one of the proudest emergency medicine physician assistants in the world. I work with some of the most highly trained, talented, brilliant, professional and warmhearted physician assistants, who love providing the best patient care to the best of their abilities every day.
Somehow, as our PA director, I feel responsible for their pain. Seeing the pain and trauma in the eyes of your fellow PAs, nurses, paramedics, physicians -- our "work family" -- is one of the hardest things that I have ever gone through. I have never seen this kind of hurt. The tears and trauma make my heart ache with sorrow, yet extreme pride.
You are about to read the raw responses dictated from words spoken by the emergency medicine PAs who were at the bedside of many of the 39 Boston Marathon victims seen on April 15, 2013 at Brigham & Women's Hospital. You will see and hear from EM PAs and get a sense of what these PAs did for patients and the hospital to help save limbs and lives.
Mackenzie Bohlen, PA-C: 6 years experience
The day started out like many other days. I was glad it was my last of three night shifts in a row and sad that this year I was not going to be at the Boston Marathon. The Boston Marathon is one of my favorite events of the year and I make a point to take the day off so I can head to Kenmore Square to see the elite runners stream by, and then walk the last few miles to the finish line.
I love the hope, the happiness, the success and the triumph of the day. This year was different. I had planned to volunteer at the medical tent at the finish line. However, the Friday before the race, I decided to cover a shift for a colleague and would be working in the ED at 2pm instead.
Despite all of this, I was glad to see a great group of physician assistants, nurses and doctors when I walked in to work. I settled in to finish my charts from the day before and just 45 minutes into my shift a call came in that there had been a "mass casualty event."
We were notified that we needed to expedite all patient discharges and make room for multiple injured patients. I turned to my fellow PAs and we immediately tried to find out what happened on the Internet. At first, we found nothing on local news sites, but then we saw it: A bomb at the marathon finish line. My first thought was, "Who would be so stupid? This has to be some teenager playing a prank." I didn't even consider that real damage could be done.
I took the warning seriously and quickly spoke to my only patient and informed him he would be admitted. There was no way we could finish his work up and discharge him safely. There was no other safe option, and we needed his bed. At first he protested, but when I explained that there was a citywide emergency, and we needed to have extra space in the ED, he quickly changed his mind, stating, "I understand. Do whatever you need to do."
I walked to the hallway to see another patient and expedite their work up, when I was confronted with a line of EMS teams streaming through the ambulance doors. Crews began rushing down the hallway with injured patients, one after another, sometimes two at a time. There was no time to hesitate or question your actions. We all just acted.
The first patient I encountered was bleeding heavily despite active pressure from EMS. He was dripping blood from the stretcher down the hallway. Myself, an attending, a nurse and our senior resident enveloped the patient. He was critically ill with multiple facial wounds and what appeared to be an arterial bleed from his leg. The resident and another attending moved him to another stretcher, wheeled him to a room, and I turned my attention to a new patient.
I rushed to the opening of the Bravo unit with an attending, and we met another EMS crew escorting a woman into a room. Fortunately, she was awake, lucid and could recount the events of the day as well as her injuries without difficulty. She was on a backboard with a tourniquet on her leg, and she was tearfully trying to contact her family.
I started to tear up a bit when introducing myself, but quickly moved to what we know best: the care of the emergency patient. We proceeded with her trauma workup and identified a large open wound to her posterior leg without signs of fracture or other injuries. She would require wound irrigation, wound closure, pain control and antibiotics, but she was safe.
From that point forward, I met colleagues who had rushed to the ED from home or other events, and I helped them find locations where they could be helpful. I aided with the stabilization of another patient with an open fracture of her leg and coordinated the discharge of patients with minor injuries as well as those not associated with the bombing. The feeling of urgency and solidarity permeated throughout the ED.
There were teams of surgeons, trauma, orthopedics and plastics, as well as medicine residents and emergency medicine providers all working together to quickly, safely and effectively manage a high volume of severely injured patients. When the acuity of the day's events slowed and we could return to a more typical pace and volume of patients, I felt proud to have been part of a team of providers that could so quickly come together to give great care to so many injured and scared patients.
Only when leaving the ED later was I able to absorb what had truly happened. When I walked out of the ED and to the front doors of the hospital -- a walk I've done numerous times -- I was confronted by armed guards standing at the single available exit. It gave me chills to see this and an eerie feeling walking down the street past news trucks actively reporting on the events that taken place less than eight hours before.
I was saddened to know that a day that typically is filled with hope, success and joy was destroyed by a senseless act of hatred. I had no idea who committed these terrible acts, but I felt sorry that his or her life had led them to take this day away from so many. However, I am proud to work with the team I do and to know we helped to soften the impact of that hatred.
Michelle Higgins, PA-C: <1 year experience
Having graduated from PA school less than a year ago, I was anxious and excited to work my first Boston Marathon shift in the ED as a PA. I was up late the night before, reading about how to identify and manage common medical presentations of marathon runners such as hyperthermia and heat stroke.
Nowhere in the BWH 2013 training manual was there anything about the management of blast injuries. Even if there had been, it wouldn't have mattered, because even my senior colleagues and those who have traveled overseas to do disaster relief work couldn't have prepared themselves for what was about to come through the door.
Over the scanner, amidst an ED nearly full to capacity with a full waiting room, we hear, "Possible explosive in Copley Square, stay tuned." Just five minutes later we receive the first of the 39 patients, some hemodynamically unstable, bleeding out, with the types of injuries I close my eyes to during the movies.
The help that appeared was remarkable. There was an outpouring of doctors, PAs and nurses from trauma, ICU, neurosurgery, plastics, orthopedics, medicine and psychiatry services who were all eager to assist in every way they knew how. At one point, our senior resident asked me to be in charge of standing at one of the entrances to prevent any more people from coming through the doors. I will never forget one of the physicians pleading with me, "I drove in from home. Please just let me start an IV or hold someone's hand. Please let me help."
It was like being in a vortex. Hours into it, most of us still had no real sense of what had happened or what more we could be expecting. Was this an act of terror or some horrible mistake? Could my colleagues and loved ones who were runners, spectators and volunteers be hurt? Truly there was no time to think about any of these things. It was not until we had all the patients moved out that those questions and concerns started arising.
The most memorable part of the experience for me was how everyone came together from all over the hospital to help in any way they knew how. The outpouring of support and compassion during and after the event was simply overwhelming and inspiring.
It is unbelievable how we all felt so unprepared for something so unimaginable, but yet things could not have been better orchestrated. Organized chaos is what I have heard many of my colleagues referring to it as. However chaotic it was, it had to have been somewhat organized because 13 days later, all of the patients who made it to the hospital are still alive. I will always remember all of the beautiful examples of selfless heroism.
Noah Askman, PA-C: 5 years experience
We were on the bus heading to the marathon at about 2:50 or 3:00 p.m. In the middle of the trip down there, we heard the MBTA bus driver say that he was changing the route, which seemed kind of weird since the buses were running the marathon route all day.
About three minutes after that, someone on the bus behind me was on the phone, and they said that they heard some sort of bomb went off. The bus driver pulled over and let everyone off. I live in Jamaica Plain [a neighborhood near Brigham and Women's Hospital], so I was walking back home in the neighborhood towards the Brigham.
As I got to Brigham Circle, after walking about a mile and a half and seeing so many ambulances rush both ways, I thought it would be responsible to see if there was any help needed.
When I walked into the Emergency Department, I saw the triage nurse at the desk and asked if she needed my help. All she could say was, "It's bad." When I opened the door, EMS was wheeling people in left and right. I thought it was pretty well controlled and that the hospital was moving well. There was a lot of staff, including many who looked shell-shocked. The one thing that really struck me was despite the fact that we do this every day, no one was emotionally ready for it at this level. The systems worked fine, and the patients were taken care of right away.
I walked into a room with an attending and saw a patient with a surgical intern. The three of us just talked about what to do and ran the trauma, identified his lower extremity injuries and then walked out into another pod.
I happened to see an orthopedic surgeon, and it was basically like you looked at the orthopedist and said, "I have a patient with a lower extremity open fracture from a blast injury that needs to go to the operating room." It was as easy as that. They then just immediately evaluated the patient.
I think it is just weird to see how the systems can work without paper or anything like we are used to. It was all word of mouth. It was just kind of an interesting process. I think the hospital did a really great job, and the staff was amazing. It was more than staffed; there were plenty of people. There were several other people that came in from home. I would say probably half the people I saw were in jeans and t-shirts coming in from somewhere, whether they were in the neighborhood or at home. It was pretty impressive -- an unexpectedly organized system that worked well.
The most memorable part was that each unit had one leader. There was one person in Alpha, Charlie, Bravo and the observation unit who was streamlining everything. They were like the captain of the pod, checking with the nurses and making sure patients were not hypotensive, making sure they were stable and had pain medications.
This is how the hospital is supposed to work everyday, but that day it worked perfectly. We took away all the other limiting factors of working in the emergency department -- the paperwork, the politics -- and the system became a functional system out of necessity, the way it was supposed to be organized.
The image I will never forget was realizing how frantic the emergency department was at first. There was a lot of noise, an abundance of people and this huge amount of staff that we are not used to. Within 45 minutes to an hour of me being there, the whole department was eerily quiet. Things were handled, patents were taken care of, people were in the operating room and things just seemed to be on an even keel again. It was almost as if nothing had ever happened.
Kristen Vella-Gray, PA-C: 4 years experience
My most memorable moment of the day was that I appreciate that one of the ED attendings broke us into trauma teams in each bay; it felt organized in an otherwise chaotic situation. She also came around to each team and gave us updates and told us what type of triage patient to expect next. We were getting mostly "red" patients, which represents the acuity level of their medical condition.
I have seen many traumatic injuries and burns before, so the actual injuries were not what shocked me or still stays with me. It was the fear in my patient's eyes. This was different than anything I have seen before because it was not an accident. It was an intentional action to hurt others, and it was done to my home.
It was strange to be questioned by the FBI about what clothes my patient was wearing and what I did with the clothes after their removal. It was also unusual to see men with guns walking the halls of the hospital. These experiences were certainly not part of my typical day at work.
Hannah Dodd, PA-C: 7 years experience
The call came in through ambulance dispatch, and before we knew it the patients started coming in. They came so quickly. We had no idea how many people we were getting and what was coming next. There was very little to no time to think and process. You just had to "do."
It was wild to be in the vortex of it all, the front line, yet really have no idea what was going on. I just knew what I was seeing was so real. It was amazing the way people came together. Everyone came down from all floors and departments of the hospital to help. Medical students were running around asking how they could help. Orthopedic surgeons were there as well as surgery, anesthesia and nursing. FBI agents were everywhere to assist with the forensics of it all. The medicine team took any patients who were waiting in the ED to complete their work up.
The teamwork was amazing. I felt so proud and privileged to be part of such an incredible group of dedicated people who really stepped up and gave the most incredible, selfless care. I was amazed at how quickly it all happened. Patients came in; it was chaos, yet controlled chaos. Patients went to the OR, imaging, admitted, home, questioned by FBI and then it was over. I didn't process it all until days later. I think I am still processing it all.
My physician mentor always told me that patients don't care about the initials behind their provider's names, as long as they are receive high quality care. It could be the attending physician, intern, medical student, PA or nurse, just as long as the patient is simply seen, cared for and informed.
On that day, we saw the epitome of evil in a cloudy, smoke-filled finish line, but then we saw the best in humanity. We now have a break room wall full of pictures and cards from elementary school kids with smiles, hearts and colorful, misspelled words.
We have the various Emergency Departments from across the country sending pizzas, southern barbeque, homemade cupcakes and flowers; therapists offering services for trauma; and most of all, a sense unity in healing together.
I hope that someday I get to hear children say that when I grow up, "I want to be a PA!" We simply have the best jobs in the world as emergency medicine PAs and appreciate working on a team with our EM physician colleagues. Thank you for hearing the story from the PA perspective and I hope that you will pass the word along about our PA profession.
Introduction and conclusion written by Jessica J. Britnell, MS, EM CAQ, PA-C.
View the PAs quoted in this article, and others working at Brigham & Women's Hospital.