Deadly odds
JAs one staffer cut off the patient’s clothes that night this summer, Dr. Jason D. Pasley began a careful search of the man’s body for bullet wounds. The holes can be as small as a pencil eraser, and the team rolled the man to check everywhere — behind knees, in armpits, along the hairline. One by one, Pasley called out what he found — a hole in the back, in the buttocks, in the leg — until he got to six.
Surgeons call it “bullet hole math.” An even number indicates that bullets might have gone through. An odd number raises the likelihood that a bullet may still be in the body.
“If the math doesn’t add up, you are missing something,” said Pasley, a long-serving trauma surgeon at the University of Maryland Shock Trauma Center in downtown Baltimore. “The more you’re shot, the more likely you are to hit something serious, the more likely you are to die.”
The gruesome ritual has become more common in hospitals nationwide. At Shock Trauma that week, it was the seventh night in a row doctors had had to rely on the crude calculus.
Emergency rooms are struggling to save gunshot victims arriving in worse shape than ever before, with more bullet wounds, and increasingly shot in the head. Even as advancements in trauma care have saved countless lives, victims of gun violence have seen their chances of survival drop, exacting a toll on victims’ families, medical personnel and taxpayers.
More than $80 million has been spent at Baltimore hospitals caring for patients shot in gun crimes in the past five years. During that time, the number of cases doubled and the annual price tag soared nearly 30 percent. Most of the medical costs are now covered by Medicaid, the federal-state health insurance program for the poor.
“We spend every night trying to row upstream against this,” said Dr. Thomas M. Scalea, physician-inchief at the R Adams Cowley Shock Trauma Center, the first of its kind in the nation. The 55-year-old center is named for the pioneering surgeon who coined the phrase “Golden Hour,” the time after injury when trauma patients have the highest likelihood of survival.
Scalea says that time can be mere minutes for gunshot victims. He said his experience treating them has See
become emotionally numbing. “You get outraged for a while,” he said. “Then you get the next one and you go — what are you going to do?”
Outside the hospital, first responders are trying to keep up with the merciless uptick in gun violence. Baltimore police officers have begun carrying tourniquets, which constrict blood flowing from wounds, and a national push is underway to make the devices as widespread as defibrillators and as commonly understood as CPR.
Police officers in some cities — rather than waiting for an ambulance — load gunshot victims into squad cars to get the wounded to a hospital before it’s too late. Both law enforcement and paramedics are adopting military-grade equipment and practices from combat situations.
The changes in trauma medicine have coincided with deadly trends on the streets of Baltimore and other major U.S. cities, The Baltimore Sun found in a yearlong investigation. Criminals are using higher-caliber guns with large magazines and bullets that destroy tissue and pulverize organs. Crime scenes are littered with dozens of shell casings, and victims are bleeding out more quickly. Shooters are exhibiting a brazen ruthlessness that surprises even grizzled law enforcement officials.
With so many shooting to kill, The Sun found, odds for gunshot victims have gotten worse. For every three people shot in Baltimore, one person dies, making it one of the most lethal of America’s largest cities and deadlier than a decade ago. Other cities are also seeing spikes in gun violence and lethality. Among them: Washington, Chicago and New York.
The onslaught has left surgeons, public health and other medical professionals outraged and looking for ways to stem gun violence.
“What’s surprising to me is that we’re a society that is willing to live with this,” said Dr. Angela Sauaia, professor of public health, medicine, and surgery at the University of Colorado Anschutz Medical Campus. She said that if gun violence were a disease, a one-in-three chance of survival would be considered an epidemic.
“This would be a scandal if it was happening with breast cancer or heart attacks,” she said.
Many police chiefs and researchers say that to make real progress, one crucial piece is missing: better data. With scarce federal funding for gun research and antiquated, inconsistent record-keeping, it’s tough to track what’s happening. The total number of people shot nationwide, for instance, cannot be accurately counted.
There is some hope, as public-health and other researchers are devising novel ways to try to understand the violence, by analyzing patterns in where victims live, and figuring out better ways to reach the people doing the shooting.
For now, many victims are showing up to hospitals in grave condition. Many will need what surgeons call a “great save.”
At Shock Trauma this summer, the patient cried out in pain and begged the medical staff to stop examining him. “Don’t do that,” he yelled. Then, as if he realized they were trying to help him, he gritted his teeth, urging: “Do your thing, do your thing.”
Pasley knew the patient had been shot repeatedly. But he still didn’t know how many times. The counting is only part of the equation.
The patient could have been shot three times, or he could have been shot four or more times, the bullets still lodged inside him. Pasley also had to imagine the possible trajectories of those bullets. Any one could have hit a bone that might have then fragmented and cut an artery or a lung.
So the team ordered X-rays and later rushed him to surgery.
Unlike about 200 gunshot victims in Baltimore so far this year, he survived.
Wounds like combat
Scalea has run this storied center and its troop of staff in signature pink scrubs for almost 20 years; he is also pofessor of trauma surgery at the University of Maryland School of Medicine. When a police officer, medic or firefighter is seriously injured, he is paged to oversee the case. He’s one of the most recognized trauma surgeons in the world.
But even at the top of his game, Scalea is challenged by the gun violence coming through the hospital doors. Now more than 60 percent of homicide victims are shot in the head, up from less than 15 percent two decades ago, and the number shot more than five and 10 times doubled in the past decade, The Sun found. It’s enough to make physicians feel that they are losing a fight over which they have no control.
A few months ago, Scalea was confronted with a patient on the brink of death, with maybe a 3 percent chance of survival. The victim had been shot six or seven times — in his chest, his abdomen and his arm, where one of the major blood vessels had been hit. As the ambulance arrived, the man’s heart stopped.
Scalea opened the patient’s chest and began “open massage” on his heart, manually clapping it back to life with the help of blood transfusion and medicine, until his team readied the defibrillator. “We had to shock him three or four times to get his heartbeat to sustain,” he said.
It took more than three hours in the operating room for Scalea to get him partially stabilized. The patient was hemorrhaging from his spleen, pancreas and stomach. He needed a transfusion of 20 units of blood — about three times his entire volume. After the man’s condition improved, Scalea operated again, this time for more than three hours.
Cost of gun assaults