There are many benefits to living and practicing medicine in a small community that's 140 miles from the nearest large city, where patients are referred for specialty care. As a family practice PA, I've had the opportunity to develop a wide range of clinical skills under the tutelage and guidance of experienced doctors and other PAs. I've also developed close relationships with many others, including medical colleagues, fellow church members, clinic patients, and neighbors. But one of the most difficult things about being a medical provider in a small community is that when a patient dies, he or she could be my neighbor, a friend, a friend's child, or even one of my own relatives. It's bad enough when someone I know dies in the hospital or presents to the ER in critical condition. It's impossible to be prepared for a senseless tragedy that hits even closer to home.

One ordinary day, a Sunday morning, I was at church. I wasn't on ER call that day, unlike on so many other Sundays. I had attended this same church since I first moved to town. I had been through some difficult situations over the years while working in the ER, but none of that had prepared me for what happened this Sunday in church.

Since the church service had barely ended, everyone was still standing around talking. I was in the front of the church talking to someone too, when I suddenly heard a gunshot. I looked toward the back of the church to see The author is a clinical assistant professor at the Idaho State University Physician Assistant Program, Pocatello. smoke rising from a gunshot, people in a panic, and the shooter running up the street. I ran to the back of the church to find our retired, 80-year-old former pastor with a gunshot wound to the chest. He was a well-loved, kind man who had befriended my family when we first came to town and who later became a patient of mine. He lay so still on the floor that at first I wasn't sure he was still alive. I knelt down and, after some uncertainty, found that he was still breathing. My natural inclination was to grab my stethoscope to listen to his chest, but I was in church and my stethoscope wasn't available. I started to unbutton his shirt and then just tore it open, making buttons fly. I placed my ear on his chest to listen to his breath sounds. Amazingly, they seemed equally present in both lungs. Another PA who attended the same church soon was there with me. Though it was hard, we finally found the pastor's pulse. He was unresponsive, despite having vital signs. I felt pretty helpless there, waiting for the ambulance without any of the usual ER supplies to begin to provide him life support, especially since he appeared to be just hanging on. When the ambulance crew got there, we loaded him quickly and headed to the hospital with sirens blaring and me at his head.

In the ER, he still was not responding. I intubated him and IV's were started, and by this time, thank goodness, the on-call doctor had arrived and taken over the pastor's care. Things were pretty hectic, but they got even more intense when the ambulance was summoned to the scene of another shooting. The man who shot the pastor had run to an open field and wouldn't surrender to the police. The standoff ended in a gun battle with the shooter being critically wounded also. The ER was really crazy at this point, with two critically wounded gunshot patients along with lots of people from the church who were trying to understand what had just happened and worrying about the pastor's condition.

I assisted the physician in caring for the pastor. As I took specimens to the lab and picked up blood for transfusions, I passed members of the church congregation and could see the horror and shock in their faces. I wanted to stop and cry with them, but there wasn't time.

The physician was summoned to take care of the injured perpetrator. Extra nurses were called in to help, as was an extra ward clerk. The dedicated EMTs remained at the ER to help in any way they could. This incident had really stretched the capabilities of our little hospital.

An air ambulance had been summoned to collect the pastor. Another one was called in an attempt to get the shooter transferred, but this one was unable to respond. Ground transport was not an option because of the distance to the receiving hospital and the lack of advanced care capability in our ground ambulance. We now faced the dilemma of which of the two critically wounded men to put on the helicopter first. There was considerable discussion about who had the best chance of living—and about who deserved to go first. In the end, the perpetrator went first since he was younger and deemed to have a better chance of survival.

As a result of the delay in transport, the pastor died in our ER. The pastor's family had already left for Missoula, Montana, assuming that he was being airlifted to a hospital there. They had to be retrieved by the police. I just simply broke down in the ER crying. This was way too hard. Whoever said that medical professionals should park our emotions at the hospital door has probably never worked in a rural community. Despite being transferred, the shooter died too, later, at the referral hospital.

This senseless murder rocked the community. How many people ever witness a murder, let alone a murder in church and of a person they know well? Murders just didn't happen in our quiet community. Fortunately, the bullet that wounded the pastor exited and lodged into the floor, not hitting anyone else. I found out after the fact that two of my sons were still in the church and relatively close to the pastor when he was shot. At the time, I had assumed that they had already headed out on their short walk home. The church called for help and provided a “debriefing” with a Christian counselor. The hospital personnel and EMTs had a critical stress debriefing. This incident was extremely hard on everyone involved. The funeral for our beloved and well-known pastor was attended by the entire community, church members and nonmembers alike. Many people came from out of town. This pastor had obviously touched the lives of many, including people who hadn't belonged to our church, and the gospel message was heard by hundreds at his standing-room-only funeral.

For the next year or so, I would get a sudden flash in my mind, lasting a few seconds, and a feeling that something horrible was going to happen. This recurrent experience is hard to describe, but it happened a number of times before I realized that it was a kind of posttraumatic stress. That understanding helped me begin to deal with it. Choosing to rethink the event, and in a way to relive it and reexperience the pain, was helpful in overcoming it. With time, these “flashes” subsided and finally disappeared. Even as I write this, however, I still have tears of pain.

The church seemed to recover from this horrible event and is strong today. Many of us asked why such a senseless tragedy occurred, and there was never a very good answer. Some may even have questioned God as to His faithfulness to the church. But relying on God for strength and comfort in this difficult situation became
very important for the church, and for me personally. We, as a congregation and as individuals, came out stronger for having done so. We realized that God is always there for strength and comfort and that hate and bitterness just aren't good options. I also found strength and comfort in my friendships with fellow church members and medical colleagues. This tragedy touched many lives, but we healed, strengthened, and grew closer by facing a difficult situation together. The Biblical principle that we are perfected and strengthened through suffering has never seemed more true to me than on that Sunday. It began just like any other day in my small community, and it ended with my gaining strength from God as I assumed my role as a provider of medical care. JAAPA

The author is a clinical assistant professor at the Idaho State University Physician Assistant Program, Pocatello.