Bullet wounds have been a constant in Dr. Marc Futernick’s career for the last two decades.
He recalls seeing an average of seven people, nearly all men, bleed their way through the emergency room each day when he was a medical intern at Tulane University in New Orleans. It was a similar scene at California State University, Fresno, where Futernick did most of his emergency medicine training after school.
Futernick is now medical director of the emergency department at California Hospital Medical Center in Downtown L.A., and the gunshot stories are so frequent and common that he struggles to pick one out when asked to remember a particularly bad instance. But the images and characters always come back, especially when there’s horrible irony. “I saw a police officer who had shot himself in the right hand while trying to show his wife how to use the gun safely,” he recalls. “And I remember there was a 5-year-old girl who was shot in the chest by her grandfather as he was trying to teach her gun safety.” The girl died, while the cop had to retire: “It was his dominant right hand, just completely shattered,” Futernick says.
There are more than 30,000 gun deaths a year in the U.S., with more than 22,000 of those deaths attributed to suicide. The numbers on firearms injuries are a bit fuzzier: About 1,565 patients are taken to the emergency room for a firearm-related injury each week in the U.S., and experts suggest many other gun injuries aren’t reported. Emergency-room doctors are the first people to see this endless string of gun victims in the U.S., and they’ve been in the front row as gun deaths, gun injuries and the deadliness of mass shootings have increased in recent years.
Trauma doctors have been in the spotlight since a National Rifle Association tweet questioning medical gun violence research and mocking doctors to“stay in their lane” set off a massive reaction in November. Waves of doctors took to social media to detail stories of gun victims and advocate for policy changes, including researching gun violence as a public health crisis. Some observers suggested the backlash could be a turning point in the fight over gun regulations, in the same way that the medical community helped push automobile reform and accountability for Big Tobacco.
The common link between those historical battles and the doctors speaking out on gun violence today is that the advocacy is motivated by what they’ve seen on the job, day after day. Futernick compares the severity of a gunshot injury to that of a car wreck: If you’re lucky, you’ll suffer a small flesh wound, but if you’re unlucky, it’s a devastating (and often irreversible) outcome for the human body. The difference is that it’s a lot easier to be unlucky at the end of a gun barrel than inside a car, given the slim margin between a flesh wound and a fatal shot. This is why the unique damage that a fired bullet can sow puts extra stress on hospital staff and resources, he says.
“It’s a more invasive hands-on type of intervention for us. There are very few medical issues where we’re opening someone’s chest in the emergency department, or we’ve got a lot of blood and everybody is gowned up and trying to control bleeding, or where you’re cutting down to get to blood vessels and stop the flow,” Futernick says. “There’s a lot more equipment and intervention that takes place for a bad trauma patient, in general. But with a gunshot wound, you tend to have a lot of outward bleeding and that affects your ability to work on the patient. It’s all hands on deck.”
The impact of gun violence on the nation’s economy is massive. A 2017 study published in the American Journal of Public Health showed the financial burden of firearm injuries reached $6.61 billion just for initial hospitalizations between 2006 and 2014. Forty percent of the total was covered by government insurance, while a quarter of the cost was covered by self-paying individuals. This led researchers to conclude that“firearm-related injuries are costly to the U.S. healthcare system and are particularly burdensome to government insurance and the self-paying poor.”
Meanwhile, another report found the average per-person emergency and inpatient charges for a gunshot victim were upward of $100,000 total, putting the estimated financial burden to be in the ballpark of $2.8 billion annually. (This didn’t count the cost of readmissions for extra treatment, which is more common with gunshot victims than other patients.) The authors found that implementing universal background checks for all firearm purchases and generally restricting people with a history of violence from getting firearms could help bring healthcare costs down.
One of the study authors, Dr. Joseph Sakran, had his own encounter with a bullet at a young age. He was milling around in a playground with a group of friends after a high school football game in Fairfax, Virginia, when a fight between two other teens lit up within earshot. One of the men pulled out a .38 handgun and began shooting errantly. Sakran, then 17, felt a white-hot heat rip through his throat, and looked down. Creeks of red blood were flowing down his white shirt.
Sakran was rushed to the emergency room and was lucky to live given that his carotid artery had been severed. Soul-searching during the long recovery propelled him to apply to medical school, and a young Sakran ended up specializing in trauma surgery, which has been his specialty for the last 20 years. He works today at Johns Hopkins Hospital in Baltimore, where it’s obvious there that some things, like the strings of young men who show up in the ER riddled with lead and on the verge of consciousness, haven’t changed much in the time Sakran has been practicing.
But other aspects of the violence have shifted in significant ways, he says, pointing out several factors that have increased the lethality of guns in Baltimore. “It’s what I call an increase in the ‘intensity of violence’ over the past two decades. In Baltimore, one in three people who are shot are killed. Last year, the 9mm handgun overtook the .22-caliber,” Sakran tells me. “What’s interesting is that headshots have increased by five times over the past two decades. Two-thirds of victims are shot in the head or multiple times. And since 2005, the number of victims shot five to nine times doubled.”
A 2017 study from UAB reviewing gun violence data from 2001 to 2012 found that while gun homicides decreased over that time, it wasn’t because of an overall decline in gun violence — gun assaults had actually increased during that time period. What changed was modern medicine’s ability to adapt and cope with gunshot victims, with the rise of trauma centers around the U.S. helping catch gun victims at an early enough stage for treatment.
Patients are now getting to ERs more quickly, even in rural areas, Futernick notes. There are better blood bank networks and delivery systems to quickly assist someone who has lost fluids rapidly. And the evolution of compact ultrasound machines, which can be quickly deployed to check for internal bleeding and damage, go a long way in saving a life, he says. “Blood pooling around the heart is deadly, and it can happen if you’re shot in the chest. So we use ultrasound to look at the heart right away, because blood around it can turn into a lethal situation in a matter of seconds,” Futernick adds.
In myriad ways, doctors and modern medical techniques have been crucial to the gun death rate from suicides, accidents and homicides. But many doctors, including Sakran and Futernick, observe that the severity of gun wounds take a toll not just on surgeons or nurses or the healthcare economy, but on other patients who are in life-threatening situations. Reducing gun violence would mean a palpable difference in the way an emergency department operates, experts say. “Gun trauma is unique in that even in a trauma center, a gun wound is an ER-altering situation, where so many staff and resources must be directed to that one patient in that moment,” Futernick says. “Imagine all the other patients — those are resources that no one else can get, then. The impact is really basic to see, given an ER is already strained to begin with.”
This fact, combined with research that suggests that the ease of gun access is a significant predictor of gun violence, is why so many doctors are pushing toward stricter gun ownership laws, background checks and further research into why the U.S. has some of the highest gun violence rates per capita in the developed world. Indeed, even some of our military medics have taken to training in inner-city hospitals — because they provide the closest recreation of war wounds they can find.
One longtime trauma surgeon in L.A., who asked to remain anonymous because she didn’t have permission to speak with the media from her employer, pointed out that even those who survive gun wounds carry trauma from that incident for the rest of their lives. “It can lead to PTSD, it can develop behavioral issues for young kids and there are permanent disabilities from a bullet hitting the wrong place. It’s horrible to see people who have been shot, especially when they’re an innocent bystander. And bystander victims is something I’ve seen too many of in this city,” she notes. “But you even see these young tough guys, gang guys, just crying for their moms because of how much a bullet hole is scaring them. It breaks my heart every time to see how many people are wrapped up in this.”
This is a big reason why, when asked whether modern medicine will continue to evolve to treat bullet wounds more effectively, Futernick murmurs hesitantly. The answer to a blood clot in a heart isn’t to merely get better at taking one out, but to prevent it altogether, he says. So it is with gun wounds. “Being a victim of gun violence is very disempowering,” he says.“It’s life-changing, and it’s a complicated injury to deal with in a lot of ways, physically and mentally.”