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When she heard that a nursing assistant had shot his colleague overnight at Jefferson University Hospital, Dr. Priya Mammen's first thought was the enormous amount of pressure health care workers have been under.

"We've all been pushed to our limit, and then we've been pushed some more," she said. "All of us can take that if it's in a finite period, but this is not finite anymore."

Mammen is an emergency room physician who works part time at Roxborough Memorial Hospital and as a public health consultant. Until 2019, she was a doctor in the emergency department at Jefferson.

Mammen said she and her colleagues are used to stepping up in the face of a crisis--they have the skills necessary to help, and it's the job they signed up for.

But that becomes more difficult when workers experience an 18-month deluge of unrelenting crises: the rolling coronavirus waves, a surging overdose epidemic, and a record high increase in gunshot victims.

Mammen said normally, she and her colleagues rely on hospital systems to look out for them, and have their backs after periods of intense work. Instead, nurses are leaving the profession in record numbers and remaining workers are asked to do more with less.

And so, she thought, it's no wonder that someone may have cracked.

"There's no end to the sense of vulnerability," she said. "It gets harder and harder and harder to take."

Philadelphia police confirmed that a certified nursing assistant was shot and killed on the ninth floor of Jefferson's Center City hospital, just after midnight on Monday. Family members identified the victim as 43-year-old Anrae James, a father of three. The suspect, a 55-year-old also identified by WHYY news partner 6abc as Stacey Hayes, was also a nursing assistant and according to police, appears to have targeted the victim.

The suspect allegedly fled the scene in a U-Haul van to the city's Parkside neighborhood, where he opened fire on four officers chasing him, hitting two. Police said they exchanged gunfire, and the suspect was also struck. All three were taken to Penn Presbyterian Hospital in West Philadelphia. The officers appear to have survived their injuries. The suspect was in critical condition as of Monday morning, according to Police Commissioner Danielle Outlaw.

Jefferson said in a statement that it is offering counseling for employees and patients affected by the shooting, and it is "very proud of the professionalism and dedication of our colleagues, who despite this tragic incident, continued to carry out their duties taking care of their patients and each other." The hospital also said it will review its safety and security protocols.

A Jefferson employee who has worked with James and Hayes described both nursing assistants as helpful and great with patients. WHYY News agreed not to reveal the employees name to protect their job. The employee, who has worked with both men in the emergency department, said that though they generally worked in the med-surg unit, they were willing to "float" down to the ED when extra bodies were needed, which not all nursing assistants were willing to do. The employee said both men had great patient rapport and had impression de-escalation skills when patients became aggravated. That's why, the employee said, the shooter's identity came as such a shock.

"It's like it's not real," the employee said.

Violence in health care settings on the rise

Violence against health care workers is not a new phenomenon. In 2019, the American Journal of Managed Care called it a "rising epidemic." A patient shot a psychiatrist at Mercy Hospital in Philadelphia in 2014, and earlier this year, a patient stabbed a doctor at Pennsylvania Hospital.

"No one is really prepared for the spectre of violence at work," said Dr. Jennifer Taylor, a researcher at the Center for Firefighter Injury Research ad Safety Trends at Drexel's Dornsife School of Public Health. Her center has focused on injury prevention for first responders where work hazards are common, especially among firefighters and emergency medical technicians.

According to OSHA, more workers are injured in the health care industry than any other. And nursing assistants have rates of injury higher than other professions within the field. Taylor said this is due in part to the concept, which applied across industries, that the more direct patient contact someone has in their role, the more likely they are to experience violence.

Taylor stressed that the best way to both respond to and prevent violence at work is to acknowledge it as a real and regular threat and create policy around it.

"Workers, whether they're firefighters or in hospitals, they are going to care for patients," said Taylor. "They're not going to think about themselves, so someone's got to have their back, and that's got to be policy."

Mammen, the emergency room physicians, said that's exactly what's been missing since the pandemic began: feeling like the system has health care workers' backs.

"It's so strange how medicine feels like an unstable field right now," she said. "You could get laid off or your hospital could close. You could get threatened on your way to work. You could go to work and someone within the hospital might have a gun. It's just sort of craziness. It's the bizarro world. Everything is upside down."

Taylor's center has prepared an occupational checklist developed for EMTs, which she said can be applied in any type of high-risk environment to help the workplace be better prepared for violence. The tasks range from creating strict, zero-tolerance to violence policies to communication strategies when an incident occurs to responding efficiently. The Centers for Disease Control and Prevention also provide training for nurses to prevent workplace violence.

'It's omnipresent, everywhere'

While the trend of violence within health care settings is increasing, gun violence researchers also say that the shooting occurred inside a hospital simply reflects the pervasiveness and ubiquity of gun violence. Philadelphia's epidemic has seen at least 1,718 people shot so far in 2021--including near schools, in playgrounds and parks, at restaurants, and on residents' stoops. The city has seen two mass shooting incidents near a major transportation hub this year.

"It affects you and me in the middle of our communities," said Dr. Jose Pascual, a professor of surgery and neuroscience at the University of Pennsylvania Perelman School of Medicine, and a trauma surgeon and neurocritical care intensivist at Penn Presbyterian. "It's not something far away in a different area with different people that we can sit back and observe. It happens to us. It's omnipresent, everywhere. What are we going to do about it?"

In a forthcoming research paper, Pascual and colleagues found that while shootings surged during the 2020 stay-at-home orders, these incidents are on track to increase by 30% in 2021.

Pascual said the approach toward the nationwide spike in gun violence needs to shift from one that looks at this as a pandemic specific problem. He said he's already seeing the generational affects of treating trauma injuries. Because Penn is a teaching institution, the high volume of patient with critical needs also stretches instruction time thinner. He said about 10 years ago, his unit saw about three gunshot victims a week, compared to roughly three per day now. That increases the amount of critical care and shrinks the amount of time for instruction.

That, he said, coupled with the layers of emotional trauma piled onto health care workers confronted with more and more violence every day, is feeding a vicious cycle of people leaving the field and placing an even greater stress on those who remain to care for patients.

"This is not pandemic related," he said. "It's only getting worse."

Credit: Nina Feldman at WHYY Philadelphia