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Q & A

When a Bullet Enters a Body: Gun Violence as Seen by a Trauma Surgeon

'In movies you always die quickly from a gunshot wound. But not in real life.'

Last week, The Trace spoke with sociologist Jooyoung Lee, who documents the myriad psychological and physical wounds endured by gunshot survivors. Many of the victims featured in Lee’s work would (or should) have been treated at a medical facility called a trauma center. Unlike conventional emergency rooms, Level 1 trauma centers are uniquely equipped to deal with critically injured patients, with highly-trained rapid-response teams —including surgeons — on call 24 hours a day. When a gunshot victim enters a Level 1 trauma center, his chances of survival increase by 25 percent.

As a matter of patient privacy, the doctors and nurses at the frontline of America’s gun violence epidemic rarely speak about their work. But in January 2013, less than a month after the mass shooting at Sandy Hook Elementary School, an op-ed appeared in The New York Times written by Dr. David Newman, the director of clinical research in the department of emergency medicine at Mount Sinai Hospital, in New York City. He’d spent most of his career treating all manner of gunshot wounds, and for 14 years served in Level 1 Trauma Centers around the East Coast. In 2005, he was deployed to a combat hospital on the outskirts of Baghdad. He has, in other words, pretty much seen the worst of it.

Horrified by the Newtown massacre, Newman felt compelled to speak out about the hundreds of gunshot victims he’d treated over the years. “If the carnage remains undiscussed,” he wrote in his op-ed, “we risk complacency about an American epidemic — one that is profoundly difficult, but necessary, to watch, and to confront.”

Two years later, Newman is still pushing for the gruesome details to be confronted. Here’s what he has learned about what happens when a bullet enters a body.

What incidents stick out most in your mind from your time in the ER?

I recall one in particular, a 14-year-old boy who was caught in a crossfire — I remember this one because I was training in Pittsburgh and it was the first time that I’d seen a young person dying from a gunshot wound. I recall him being conscious when he arrived but not alert enough to understand what was happening around him. He was very sweaty, and breathing hard, and suffering. I remember thinking he’s still alive, we’ll be able to save him. And then, about an hour later, I heard from the operating room that he’d died. That was the first time in training that I realized gunshot wounds often do too much damage to ever fix.

I also remember a 17-year-old who was shot in the abdomen, and when we saw him in the emergency department he was in a lot of pain, but totally alert and with it. I remember having the same thought — he’ll survive, we can fix this. I remember hearing back a few hours later that he had died, that the wound was irreparable. I remember telling him he was going to be okay, and I remember being stung when I found out I was wrong.

Is the abdomen a particularly bad place to take a bullet?

When you’re shot in the head, you at least lose consciousness; there’s certainly less suffering. But with an abdomen wound, or a back wound, or a wound to the groin or neck — pretty much anywhere except the outermost areas of extremities—it’s always agonizing. Unless you get shot in the heart — in which case you will die in minutes — it will usually take hours to die. In the movies you always die quickly from a gunshot wound. But not in real life.

What’s the protocol when a gunshot victim comes into a trauma center?

From the moment they’re transferred over to our bed, there’s an immense mobilization of resources. The physicians start working together, trying to figure out which injuries are present and where. We build a rapid-fire plan to see if there’s a fix that can be done. That includes IVs and blood draws and X-rays and transfusions and sometimes CAT scans. If they have a fatal or near-fatal wound, they’ll be rushed off to the operating room within minutes to see if the internal damage can be controlled.

What happens when they get to the operating room?

Typically, people who die of a gunshot wound die of internal bleeding. When they’re taken to the operating room, they’re filleted open, wide open, to offer the greatest view into the cavity where blood is being lost — it’s not always obvious which structure is injured, so part of the procedure is diagnostic. You identify the exact the spots where there’s bleeding and you try to control it. You clamp off blood vessels or tie off blood vessels or occasionally sacrifice parts of organs.

If the spleen has been injured by a bullet, you often tie off the blood vessel that feeds the spleen and take out the spleen entirely. If the intestines have a bullet hole through them, you’ll often cut out a piece of the intestines, remove it, and either create a passage to the outside — a colostomy — or reattach one area of the intestines to the other.

Trauma surgery sounds like a nightmare.

When I do an operation, it’s bad. It means someone is often dying in front of us. If the heart stops, we’ll do an emergency thoracotomy — that’s when you open the chest in the ER and look through the lungs and heart for injuries you might be able to repair, temporarily as damage control, until you can get the heart beating again.

When we have to do an emergency thoracotomy, the chances of survival are incredibly low, less than ten percent. I remember a young man who came into the ER and ceased to have an effective heartbeat. I opened his chest with a scalpel, spread his ribs, did open heart massage, and found a catastrophic wound in the blood vessels feeding his lungs. We were not able to stop the bleeding. And he died within minutes. I remember his girlfriend standing just outside the room watching, but she couldn’t watch for long. She turned away. When we informed her that he had died, she already knew. Her eyes had already lost their lights.

Can you describe the surrounding scene in a trauma unit when you treat an incident with multiple gunshot victims?

We mobilize extra people, extra teams, and there’s usually a whole lot of chaos. There’s a lot of blood on the floor, and usually the patients are screaming. It sort of looks like you’d expect it to look, like somebody’s dying and we’re racing to try and stop it. In that case, you’re doing triage. There are very few places that are prepared to operate on two, three, or four people at once, and so when you get that kind of trauma, you have to decide who’s salvageable, and therefore who should get priority.

That sounds like a difficult decision.

You can figure it out pretty quickly. Sometimes people are dying and we know there’s very little we can do. And sometimes people are on the verge of death and we know they have an injury that we can treat. And sometimes there are people who aren’t that sick, and they get priority because they’re salvageable.

Does it matter what kind of gun a victim is shot with?

It matters a great deal. If it’s a small caliber gun, the wounds are visibly smaller. If it’s a shotgun wound, it’s more visually striking. I’ve seen children who have been shot with a shotgun. I remember this one boy, I think he was eight, he and a friend were playing with a shotgun, and his friend shot him in the face. When he came in, he was still very much alive, but he was in terrible pain and didn’t really have any facial features.

But the worst is a wound from an AR-15 or AK-47 — high-muzzle velocity weapons, which impart a tremendous amount of kinetic energy into the body. Those are much more destructive. You’re looking at a wound that, externally, is two, three, four times bigger than any handgun wound.

And that is reflective of the damage that happens on the inside. When a bullet from a high-muzzle velocity weapon hits the intestines, it’s like an explosion, whereas a low-muzzle velocity can be very similar to a knife going through the intestines; there’s bleeding, but it doesn’t destroy the whole area. A high-muzzle bullet, however, destroys whole areas of body. With a bone that’s been shot with a standard-issue caliber handgun, you’ll see a break, a hole in the bone, and maybe some displacement. But a high-muzzle weapon shatters that bone into hundreds of microscopic pieces, in a way that cannot be repaired. You need to essentially clean out the bone that has been struck and remove it from the body; it’s now a worthless tissue. You can’t believe that a bullet could do this amount of damage.

Does the job ever get easier? Do you get used to treating gunshot victims?

When you first start taking care of these kinds of patients, it’s a real shock to the system. Over time, though, you start to build up infrastructure for coping. And your coping mechanisms usually aren’t as good as you think. For most people, after many years, it gets harder again. You start to feel a little lonely because you think people don’t get it. Over time, there’s a deep-seated frustration and sadness that does affect you. It certainly affected me. After my first incident, I started to feel good at my job. But now it’s shifted again. It feels like it’s a never-ending stream of suffering that very few people see.

[Photo: Flickr user Airman Magazine]