Gunshot victims receive lifesaving care in hospitals throughout the country. This month, U.S. News is running a four-part series with perspectives from health care providers who strive to help patients injured by gun violence. Below,…
Gunshot victims receive lifesaving care in hospitals throughout the country. This month, U.S. News is running a four-part series with perspectives from health care providers who strive to help patients injured by gun violence. Below, trauma nurses describe what happens when gun victims arrive in the emergency room.
More Victims, More Bullets
Trauma nurse Rhonda Browning works in the resuscitation bay of the emergency department at Penn Presbyterian Hospital in Philadelphia. In an average shift, she sees at least one gunshot patient. Members of the ER/trauma team react with a well-honed, rapid response when a gunshot victim arrives.
“Lately it seems to be a lot of abdominal injuries,” Browning says. “So they’re shooting in the abdomen and the back.” Bullets can traverse a patient’s stomach, liver, spleen and bladder. “They’re hitting (patients’) spines, and now they’re paraplegics,” she says.
Patients are increasingly likely to come in with multiple bullet wounds. “It’s actually rare for us anymore to get one gunshot wound — to have a patient come in shot once,” Browning says. “I had a patient last week who was shot 15 times. Fifteen holes.” The patient was a 15-year-old boy.
Philly police now follow a “scoop-and-run” procedure: Rather than waiting for an ambulance to reach a shooting scene, officers immediately place victims in the back of a vehicle and rush them to the nearest trauma center. Staff members meet the vehicle at the designated police drop-off spot, move the patient to a stretcher and take charge.
“As a precaution, even though the police have usually checked them, we still wand them for weapons, no matter what, and then we bring them into the trauma bay,” Browning says. “Within seconds, we cut off their clothes, (which land) on the floor.”
It’s a busy scene as the trauma team first looks for injuries in the patient’s head and neck. “One of the nurses is putting in an I.V.,” Browning says. “The paramedic is getting vital signs. The trauma attending surgeon and fellow are counting bullet holes.”
When unstable victims without any pulse have upper-body bullet wounds, the team performs an intense procedure called a thoracotomy. “We cut open their chest so we can examine their heart,” Browning says. If you’ve seen images of blood-splashed floors in ER areas where gun victims are cared for, blood pouring out from the heart because of the bullet wound is the source, she notes: “And it’s on my shoes.”
Browning’s recent 15-year-old patient had no vital signs. “This kid had a hole in his heart so they sutured (it),” she says. “We gave him blood — filled the heart back up and tried to get it started again. We weren’t successful with him. But sometimes we are. Sometimes we get lucky.”
When signs of life reappear, the patient is rushed to the operating room. “The minute we have a pulsating heart, we throw a sheet over top of (patients) and immediately get them up to the O.R.,” Browning says.
Frequently, patients’ other vital organs are involved. “They may also have a hole in their spleen or their liver,” Browning says. “They could have a hole in their intestines and now the contents of their intestines are now pouring out into their abdomen.” Many patients leave the O.R. with at least a temporary colostomy.
Begging to Live
Some more-fortunate gunshot victims only sustain superficial graze wounds. Others with relatively mild injuries may be discharged from the E.R. to home to later receive follow-up orthopedic care.
When gunshot patients arrive with life-threatening injuries, “It’s truly heart-wrenching,” Browning says. “They’re young and they come in begging. And they look at you with fear.” She and her colleagues hear: “Miss, don’t let me die.” “Call my mom; I want my mom. Don’t let me die.”
For Browning, who has young adult sons, it becomes personal. “It’s like, ‘You’re not dying on my shift. I’m not letting it happen — you’re not going to die,'” she says. However, she adds, “Sometimes, you know they might. And you don’t want that to be their last thought, so you try to comfort them.”
Some fatalities stand out for Browning, like her recent teen patient. “He was just a young kid in school,” she says. She never learned the circumstance of his shooting, but recalls small, wrenching details, like his Oxford-type school shirt cut off by the trauma team to examine him.
Meeting bereaved parents is challenging. “They’re totally devastated,” Browning says. “They’re on the floor. They’re begging you to go back and try again. And it breaks your heart. Many of us are parents. It’s always heartbreaking.”
The grief is palpable. “The whole ER knows it,” Browning says. “They all hear the mother screeching. Family members are punching walls; throwing chairs.” Anger isn’t directed at the staff, she emphasizes: “They’re so upset that they don’t know what else to do.”
In November, an impassioned Twitter debate took place over whether health professionals should speak up about the gun-related carnage they witness and publicly advocate for gun safety.
Health promotion, like encouraging people to wear bike helmets, has always been a part of the nursing role. Gun safety deserves attention as well, says Browning, who received a grant to disperse gun locks when patients come in following gun-related episodes.
“I can’t tell you not to have a gun,” Browning says. “But I can tell you, if you do have a gun at home: ‘Put a lock on, so your kids can’t get it or some bad guy can’t steal your gun and then shoot somebody else with it.'”
“Gunshots should never be routine,” says Becky Powers, nurse coordinator in the trauma unit at John H. Stroger, Jr. Hospital of Cook County in Chicago. “But with the kind of world we’re living in, our nurses don’t bat an eye, because of their experience and the training that we provide to them.”
As with any patient, Powers says, care starts with the initial check from across the room. “(Is it a) gunshot wound to the head that’s a graze and they’re sitting up talking to you?” she says. “Or is it somebody who’s unresponsive and you have to figure out: Do they need an airway?”
The trauma team responds en masse to determine a patient’s most urgent priorities. “From that point, we either help them breathe, or we send them for their CT scans to find out exactly what’s going on,” Powers says. “And we always call neurosurgery in case they were to progress to possible surgery.”
Family members are part of the picture. “As we’re taking care of these people, to begin with, there’s somebody else behind me who’s thinking: ‘Let me have a driver’s license; let me get a hold of this family,'” Powers says. “We truly believe a family is an integral part of the healing process.”
Gunshot victims are coming in younger than ever. “From the beginning of my career, it was usually the 18- to 26-year-olds we would see come in,” Powers says. “We would get an occasional pediatric patient at 13 or 14. Now, (that’s) much more prevalent.” If anything, she adds, “It just makes us want to get more involved.”
The scene is fast-paced and vivid when a gunshot victim is initially treated. However, that’s often followed with a far less dramatic, grueling recovery period. Continuity of care is essential, Powers says, noting that the Cook County trauma department has 37 beds dedicated solely to the care of trauma patients including gun-violence victims. “Whether they get discharged from our resuscitation area and admitted to the ICU or (to) the step-down unit, they are all cared for by the same nurses.”
Eventually, patients may become long-term inpatients in other hospital units, sometimes for months, to undergo multiple surgeries and receive rehabilitative therapy necessitated by gunshot injuries.
There are glimmers of hope. The Cook County hospital is seeing a dip in the number of gunshot patients. Although 2018 numbers aren’t final, the hospital is estimating a 10 to 15 percent decline from the nearly 1,250 gunshot victims seen by the staff in 2017.
Severely injured gunshot patients can recover. Powers mentions a former patient who visited her trauma department last week. The “ecstatic” patient was dancing and hugging everyone on staff. “(That) love makes you realize and recognize why you come to work every day,” she says. “It was so great.”