The trigger can be unpredictable, but when the flashbacks come, they feel like spasms, rippling through her mind and body, rending her as she relives that day with harrowing clarity.
They take Nicole Fluet McGerald back behind the thin canvas walls of the medical tent, where she hears the thud of the two Boston Marathon bombs. She feels sealed in, trapped, an easy target. She braces for a third blast, expecting
She relives the screams and the chaos, sees the severed legs, inhales the acrid smoke of the bombs. She watches the torso of one victim slide off a gurney as doctors try to revive her, while a soldier tries in vain to wash all the blood off his hands and face, as if he just left a battlefield.
“The pain I felt was so deep that it felt like the worst thing on the face of the earth,” said McGerald, 31, who was so distraught that she had to take a leave from her job as a physical therapist. “Imagine the hardest emotional moment you’ve ever had in your entire life, and multiply that times 200 . . . It felt like it would never end.”
Six months after the Marathon bombings, the terror of that long, frantic afternoon on Boylston Street still haunts many of those who treated the wounded. Loud noises, sirens, screams, and less obvious sparks continue to reel them back into the darkness of that day, when many of them treaded through pools of blood, and feared they, too, were about to be maimed or killed.
Hundreds of officers, firefighters, paramedics, and medical volunteers who helped the wounded received counseling immediately after the Marathon, but for most, the therapy lasted for a short period, often amounting to a brief conversation with a department therapist or in a group session.
Public health officials and trauma therapists warn that first responders who took part in the rescue of the more than 260 people hit by the shrapnel or otherwise injured should remain vigilant about symptoms such as heightened anxiety, inability to relax, increased irritability, and feeling detached – small fissures that, over time, could widen into deep, psychological cracks.
First responders are especially vulnerable to post-traumatic stress disorder, mental health specialists say, because they often work in professions that value stoicism and they can be chided or castigated for revealing signs of distress. Ignoring their symptoms can compound their misery, allowing problems to fester, especially when added to the cumulative strain of responding to other tragedies.
“Avoidance behaviors are among the worst things you can do when you go through a distressing or traumatic experience,” said Rebecca Rosenblum, co-coordinator of the Boston Area Trauma Recovery Network, which has offered free counseling to first responders. “These things get stuck in the nervous system.”
She and other therapists said they have been surprised by what seems to be a dearth of first responders seeking the kind of sustained counseling that could help them avert a later crisis.
“I’m guessing some people don’t really have a sense of the toll this event has been taking,” she said. “It may have caused an imperceptible crack in their foundation, which will allow a later event to come along and wreak some more notable havoc.”
First responders often feel the full effects of PTSD years after the traumatic event. A 2002 study in the American Journal of Psychiatry found that of 181 rescue workers who responded to the bombing of a federal building in Oklahoma City, 13 percent had PTSD symptoms nearly three years after the attack, while 6 percent had panic disorders and 24 percent were diagnosed with a substance-abuse disorder. The Fire Department there reported conducting nearly 80 suicide interventions among firefighters after the bombing, while surveys found divorce rates among firefighters and police officers more than doubled.
A study of World Trade Center rescue workers published four years ago in the Journal of the American Medical Association found 12 percent had signs of PTSD two to three years after the Sept. 11, 2001, attacks, while nearly 20 percent showed symptoms five to six years later.
In general, about one-third of first responders to terrorist attacks will experience some symptoms of anxiety, depression, or post-traumatic stress, said Yuval Neria, director of the Trauma and PTSD Program at Columbia University Medical Center. Of those, about half will make a full recovery within a year, often without help. The rest are likely to struggle, he said.
“If not treated on time, the symptoms can linger and become chronic, bringing more pain and problems,” he said.
Barbara Ferrer, executive director of the Boston Public Health Commission, said she understands the challenge and her agency has provided counseling, support groups, and other services to many first responders over the past six months.
“It has been overwhelming emotionally, for a lot of us, as we recognize the extent of hurt that occurred in our communities,” she said. “My job is to support survivors and responders, to make sure people have what they need to heal.”
Among those still healing is Christina Hernon, an emergency medicine doctor who was also volunteering at the medical tent when she was called to the finish line to treat the wounded.
Over the past six months, she has experienced the trauma in waves, triggered by something as simple as a dump truck bounding down her street or a car trunk slamming.
When the images of that terrible day come back, she sees a young boy with an empty expression, ghostly pale, his hair singed, wounds on his arm and legs that look like shark bites. She sees a man being wheeled down the street with shards of flesh flapping in the wind, his lower legs blown off, his face ashen gray. She smells the smoke, hears alarms blaring, sees glass littering the sidewalk in a river of bright blood and remembers her fear of slipping, her fear another bomb was about to detonate, her fear that if the two exploded bombs spewed radiation or toxic spores, she already would have been exposed.
Hernon has had trouble sleeping and difficulty concentrating, occasionally lacked an appetite or energy, felt nauseous, and doubted herself and what she did that day. She has had nightmares about arms reaching out of kitchen cabinets with knives, trying to cut off her legs. She has felt reproached by colleagues who say that she seems distracted, like she wasn’t herself anymore.
At a yoga session this summer, when prompted to clear her mind, she suddenly started to sob, uncontrollably, and the tears flowed well after she left.
“I felt vulnerable, sad, and raw, and helpless, exposed, and overwhelmed,” said Hernon, 41, who has spent years treating patients in the emergency room at the branch of UMass Memorial Medical Center in Marlborough. “It made me very aware that, even on a day-to-day basis, all of that emotion is right below the surface. It’s packed and still raw, and that I’m not done processing this.”
She has tried counseling, but found it unsatisfying. Yoga has become a refuge.
“As care providers, we often feel like we haven’t done enough,” she said.
Bill Dockham was among the scores of registered nurses who remained in the main medical tent after the bombings, where officials said they treated 97 victims in about 20 minutes. The duration, however, is deceptive, as time seemed to slow down for him and so many others.
The experience has been etched in his memory, frozen like a bad rerun. The 54-year-old volunteer too vividly recalls seeing the first serious victim, Jeff Bauman, who lost both of his legs, being rolled through the tent on a wheelchair. He remembers seeing another victim in cardiac arrest and wrapping a bandage around the foot of a someone whose heel had been blown off.
As a primary care nurse, he found it unlike anything he had experienced. “My first response was, ‘Oh my god, I’m going to die today,’ ” he said.
In the days afterward, he couldn’t sleep and had trouble focusing. Since then, thunderstorms have made him jumpy, and taking the T, especially sitting near people with backpacks, has sparked fear.
“I’ve had several panic attacks on the train,” he said. “It feels like impending doom.”
He works at a veterans clinic on Causeway Street in Boston and says he now has more empathy for his patients.
“I have a deeper understanding of PTSD,” he said. “I now know what sets them off. I know what they witnessed. Hearing the bombs and seeing the body parts blown off, I can relate to them. It just didn’t register the way it does now.”
In the aftermath of their experience, some first responders have had trouble dealing with things that seem inconsequential, especially trivial grievances they hear from friends and colleagues. Others have been irritated by intentionally loud noises, such as fireworks, or in one case, cannon blasts from the USS Constitution during a ceremony to honor them.
Each of them has sought to cope with what they experienced in their own way.
For Nicole Fluet McGerald, a physical therapist at Southern New Hampshire Medical Center, that has meant a lot of hiking. When simple tasks such as food shopping or laundry have felt like enormous feats, and flashes of anger or bouts of despair strike without easy explanation, she has found peace in climbing mountains.
Over the coming year, she plans to climb all 48 of New Hampshire’s peaks that are more than 4,000 feet high. This weekend, she climbed her 15th.
“Standing at the top of a mountain is like my church,” she said.
At each summit, she leaves a box containing a small American flag, a handmade Boston Strong ribbon, and a plastic-sealed message explaining that she was a first responder at the Boston Marathon and remains ready to help anyone who needs it.David Abel can be reached at email@example.com. Follow him on Twitter @davabel.