Feature Boston Marathon bombing

A tale of two physicians: reflections on the Boston Marathon bombing

BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f2993 (Published 10 May 2013) Cite this as: BMJ 2013;346:f2993
  1. Alefiyah Rajabali, internal medicine resident,
  2. Harmony Caton, medicine pediatrics resident
  1. 1Massachusetts General Hospital, Harvard Medical School, Boston, USA
  1. arajabali@partners.org

On 15 April, I found myself thinking for the first time, “I wish I was a surgeon.” As a second year internal medicine resident, I am training to be a diagnostician. If a patient’s leg is red and swollen, I can differentiate between a clot and an infection. If a patient has abdominal pain, I can identify the culprit organ and determine if he needs medical or surgical intervention. If a patient has chest pain, I can decide if he is having a heart attack. But when disaster struck Boston on Monday afternoon and I saw a trauma victim point to a leg that had been ripped open, there was no diagnostic dilemma that needed my expertise. When the woman on the stretcher buckled over with pain lifted her hands for me to examine her, the third degree burns were explanation enough for her excruciating pain. And when the man with chest pain had a piece of shrapnel protruding from his chest, you didn’t need me to tell you why he was in pain. As our emergency department was inundated with victims, I started to think these patients needed a trauma physician and not an internal medicine doctor.

As a third year medicine pediatrics resident, I spent the night before the marathon reviewing the basics of treating hyponatremia. I was working in the emergency department and anticipated an influx of patients requiring careful sodium repletion after drinking too much water during the race. When the announcement that two bombs had exploded in Copley crackled over the emergency radios, there was a brief moment of stunned silence. And then a flurry of activity began. Patients were triaged out of the acute area of the emergency department to areas of lower acuity. Janitorial staff rapidly cleaned the trauma bays. Supply personnel began moving code carts, locating ultrasound machines, and stocking the blanket warmers. Nurses and residents collected tourniquets and central line kits, and donned blue plastic gowns. The emergency department was quickly filled with physicians, surgical teams, and nursing staff, ready to take care of the victims.

Having attended medical school in Pakistan, I have seen more bomb blast casualties than I care to remember. But in Karachi, when victims from a bomb blast were brought to our emergency department, I knew exactly what to expect: an emergency department flooded with more than 100 victims because we lack the resources and systems to distribute patient care to other hospitals. Next, sobbing relatives will pour into the emergency department searching for their loved ones, delirious with fear as they comb through the bodies. Medical students will wheel patients off to the operating room because of a shortage of ancillary staff, pediatric residents will suture face lacerations because the plastic surgeon is tending to an amputated limb, the internal medicine resident will administer tetanus shots as the nurses are trying to get intravenous fluids running, and the anesthesia resident will hang bags of antibiotics on patients with open wounds as the timing of their surgery is still to be determined. Our head trauma surgeon will move from stretcher to stretcher to decide if limbs, organs, or lives are salvageable. My job in this situation was to help wherever needed. I found myself reducing fractures, finding the entry and exit wounds, or holding a retractor steady in the operating room. It was easy to know how to help in this situation: there was just so much to be done. Roles had to be fluid.

My pager went off. “How can I help?” Two colleagues arrived in the acute area of the emergency department. “What can we do to help?” Their questions echoed the doubts in my head. I saw my program director and chief residents conferring with the emergency department physicians ensuring plans were in place for the patients being moved from the emergency department. Immediately the answers came to me. “Go see if they need help in the other areas of the emergency department where the non-trauma victims were triaged. Check with the medicine floors as patients are being sent up from the emergency department and will need further work up.” Knowing my other patients were well cared for allowed me to focus on simple but needed tasks: elevating a leg, grabbing a central line kit, calling for more tourniquets as more trauma victims arrived.

As I would have in Pakistan, I rushed to the emergency department, ready to be of service. I expected chaos and a shortage of physicians. Instead, I found the emergency department running like a well oiled assembly line. As each bomb victim entered our doors, a team of surgeons and emergency department residents stabilized, evaluated, and transported them to the operating room providing timely and efficient care. Patients had been triaged to three large Boston hospitals so that individual hospital capacity was not exceeded or overwhelmed. Hospitals were alerted to incoming casualties so trauma teams could stand ready. Everything seemed taken care of. I turned to leave—embarrassed and ashamed that as a physician I was not alleviating suffering but walking away from it.

As I walked from room to room asking what assistance I could provide, I saw an intern from my program bringing warm blankets to patients, many of whom had their clothes torn from the effects of the blasts. She was providing care. Although we cannot repair lower extremity wounds, as medical residents we are experienced in caring for patients and their families in times of crisis. As the influx of victims slowed, I followed-up on the patients I had seen before the attack and whose care I had passed off to other providers. As other residents began arriving for their evening shifts, I finished my notes for the day.

I turned to leave but then noticed an emaciated grey haired patient talking softly to a medicine resident. He was not a trauma victim, but his care was just as important to my colleague. Another resident from my program was using his cell phone to update a patient’s family member on their loved one’s condition. “Drink this and stay calm or you will faint from dehydration,” said my classmate as she thrust a glass of ginger ale into the hands of a terrified, bruised victim. Ginger ale—perfect for his sodium, I chuckled. A senior medicine resident started pulling off dirty sheets from a stretcher in anticipation of a possible second wave of victims. Although we were not on the front lines today, I watched my co-residents integrate themselves with the surgeons, the emergency department physicians, and the ancillary staff to become part of the team. To be a successful physician this skill is critical; realizing when to lead, and when to follow.

As I left the emergency department, I saw a stack of papers near the computer. Highlighted was the hyponatremia section of a journal article. I smiled, and left the papers in a neat stack next to the computer. I paged a co-resident who lives in my building, hoping she would be available for dinner. I knew she would be able to relate to my experience today. An hour later I sat in her apartment relaxing to the smells of Pakistani cooking. We talked about our experiences in the emergency department—but not about the horrific injuries, the fear of more explosions, or the distraught families. Instead, we talked about how our community came together to do their job—taking care of patients. And now, continued taking care of one another.

After she left I did the dishes while watching the news. Another bomb blast in Pakistan today. I dried my hands and reached for my phone to begin the ritual of calling friends and family to make sure everyone was safe.


Cite this as: BMJ 2013;346:f2993


  • Competing interests: We have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Not commissioned; not externally peer reviewed.

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