The night a gunman opened fire on a crowd of 20,000 at a Las Vegas music concert, Dr. Kevin Menes was in charge of the emergency department at Sunrise Hospital. “I was pulling people five or six at a time out of patrol cars, pickup trucks, ambulances, you name it,” he recalled after the mass killing.
His team cared for about 250 of the more than 850 victims, performing 28 damage-control surgeries and 67 general surgeries in less than 24 hours.
“We did everything we could,” he said.
Menes is one of many U.S. clinicians who have treated victims of mass shootings. A team of researchers with the Schwartz Center for Compassionate Healthcare is now studying their experiences, mining for insights to buoy a workforce routinely exposed to trauma.
While their research is still early (and only partially funded), two things are clear: Mass casualties are now just part of the job for providers, and they affect them deeply.
What constitutes a mass killing in the U.S. varies. In the wake of the Sandy Hook Elementary School shooting in December 2012, Congress moved to designate a mass killing as three or more deaths in a single incident that was both intentional and indiscriminate. That excludes murder or murder-suicide in which an individual kills multiple close family members (sometimes called familicide) and homicides related to gang violence or organized crime.
According to a database compiled by the Associated Press, USA Today, and Northeastern University, there were more mass killings in 2019 — a total of 41 — than in any year dating back to at least the 1970s.
Although guns are used in most such events, they aren’t the only weapon of choice. In October 2017, a man claiming ties to the Islamic State drove a rental truck into pedestrians in Manhattan, an attack that left eight dead and 11 wounded.
Following a non-accidental mass killing, there are two main threads of conversation: the collective local and national response, marked by thoughts, prayers, and fleeting calls for action; and victims’ journeys to salve the wounds of trauma. The Schwartz Center is attempting to elicit a third conversation: When it’s your job to stop the bleeding, how do you heal?
It was this question that compelled Dr. Beth Lown, a general internist and chief medical officer for the Schwartz Center (housed within Massachusetts General Hospital), to launch the initiative in the fall of 2019. She and her team at the center, along with trained facilitators at sites nationwide, have convened thousands of clinicians in small-group settings through Schwartz Rounds — a signature program of the center that brings together hospital personnel to talk about the emotional and social challenges of patient care.
Lown’s work helping heal the healers came home to her native Boston when the city was rocked by two homemade explosives detonated near the finish line of the Boston Marathon on April 15, 2013.
“Even though doctors are exposed to death on a daily basis, moments like these change us,” Lown remarked in a conversation with me about her research. “It’s our job to save lives. To tell families their kids have died. To manage the resulting, long-term medical conditions. And always, we wish we could have done more. Whether we’re in the hospital or watching events unfold in our homes, it impacts us.”
Shortly after the marathon bombing, a series of Schwartz Rounds in Boston brought together more than 250 staff members and volunteers who had cared for those injured by the bombs. Their pain was palpable. Many exhibited the symptoms of PTSD.
In a white paper describing the rounds, her team recalls caregivers being “unable to finish tasks or focus on schoolwork, disliking crowds, feeling isolated, and being in a constant state of hypervigilance.” Several practitioners talked about the isolation they felt, noting that, “People don’t know what to do, so they do nothing. … It would be nice for someone to say ‘How’s it going?’ When there’s nothing, it’s more painful.”
Most striking, a medical volunteer shared the “administrative betrayal” she experienced when she was denied access to grief counseling and paid leave to recover.
Stories like these are backed by data. Across all fields of medicine, nearly 15% of physicians experience PTSD, with 40% of trauma surgeons exhibiting the symptoms. In a study of doctors who had treated bomb victims, 1 in 4 were diagnosed with PTSD. Clinical staff and nurses, too, are not immune. A study of inpatient nurses found that 18% met the diagnostic criteria for PTSD.
Yet there aren’t resources available to many frontline staff members. Indeed, an initial literature review to be published soon by the Schwartz Center team yielded just eight peer-reviewed articles with any direct connection to how mass killing events might affect health care providers. While there has been ample research into the impact of such events on survivors and the general public, research on how they affect providers is modest at best. Moreover, of the eight relevant articles, none promoted evidence-based interventions intended for hospital staff.
“Two things were immediately apparent: One, we’re not talking about how these events impact care teams. And two, when we do talk about it, we do little to actually intervene,” Patrick Kinner, a mental health counselor who led the literature review, told me. “There seems to be scant attention paid to treatments or services that would specifically benefit health care providers exposed to mass casualty events. This is worrisome since these providers are repeatedly seeing traumatic events as part of their everyday work lives, which can take a toll. Couple that with the community-level trauma caused by a mass shooting or the like and health care providers are very likely in need of additional supports.”
What’s more, this trauma is felt by people working in an industry with the highest level of depression in the nation. For providers, this pain may manifest as burnout. In nursing, it’s called compassion fatigue. Among first responders and mental health professionals, we hear of vicarious and secondary trauma. And for everyone, there’s PTSD.
There’s no question that these are distinct and multifactorial diagnoses. Taken in aggregate, however, they represent a workforce that is suffering. As one emergency room physician told me, “Practicing medicine these days feels a lot more like triaging on a battlefield than treating in an exam room.”
It’s an apt comparison. Military medics respond to injuries at rates 10 to 100 times higher than clinicians in typical hospitals. But following a mass casualty, the scenes look far more alike than different. In fact, the medical community is increasingly seeking insight from its military counterparts, with the National Academy of Sciences calling for better translation of wartime lessons into domestic protocols. As Col. Todd Rasmussen, a doctor who served in both the Iraq and Afghanistan wars, has written, “The only beneficiary of war is medicine.”
That modern-day medicine in the U.S. is analogous to war should make us uncomfortable. Yet here we are, demanding that our providers learn to be better soldiers.
In an interview with Lown and her team, I asked what they hoped their research would achieve. “Mass casualty events leave deep and painful scars. They also have the power to bring people together. As we support health care teams in the aftermath of tragedy, we need to be using their powerful firsthand experiences to shape a national conversation on the policies that have led to the rise of violence and access to means to inflict that violence.”
Clinicians may be doing all they can for their patients, but it’s time that the public does more for its healers.
Elizabeth Métraux is the founder of Women Writers in Medicine.