COMMENTARY

What Gunshots Do to Bodies: Docs Speak Out

Robert Glatter, MD; Heather Sher, MD; Amy J. Goldberg, MD; Joseph V. Sakran, MD, MPA, MPH

Disclosures

April 17, 2018

Robert Glatter, MD: The sheer devastation and loss of life that occurred in the wake of the school shootings at Marjory Stoneman Douglas High School in Parkland, Florida, have been weighing on the minds of everyone in the United States, but especially among healthcare providers.

The number of mass shootings in the United States has significantly increased since the Federal Assault Weapons ban expired in 2004. According to data from the Centers for Disease Control and Prevention (CDC), more than 36,000 people died of gunshot wounds in 2015.[1] The public has been largely shielded from seeing the destruction that high-velocity bullets cause, how they rip organs apart and injure precious nerves, blood vessels, and tissue.

The firearm we will discuss today is the AR-15. This weapon was the recent topic of a very powerful essay in The Atlantic by Dr Heather Sher,[2] a radiologist who was on call the day of the Parkland shootings. In her article, she vividly describes the horrific and destructive CT findings caused by the bullets from the AR-15 and contrasts these with the wounds of bullets from a 9-mm semiautomatic handgun.

Here to discuss the ballistics as well as the care of patients after such gunshot wounds are Dr Heather Sher, a board-certified diagnostic radiologist; Dr Amy Goldberg, chair and professor in the department of surgery, and surgeon-in-chief, at Temple University Health System in Philadelphia, Pennsylvania; and Dr Joseph Sakran, director of emergency general surgery and assistant professor of surgery at Johns Hopkins Medical Institutions in Baltimore, Maryland. Welcome, doctors, and thank you for joining me.

Low- Versus High-Velocity Gunshot Wounds

Glatter: It is quite an honor to have everyone together to discuss this. Dr Sher, I want to begin by asking you to describe the differences seen on imaging studies between low- and high-velocity gunshot wounds and how the velocity of these bullets fired from the AR-15 compares with, for example, a standard 9-mm handgun.

Heather Sher, MD: I am a diagnostic radiologist. I have spent my 14-year career in level-1 trauma centers. I have seen many, many handgun injuries over the years. As a radiologist, I have a unique perspective in that most of these patients, if they are stable enough that they do not require emergent surgery, are scanned from head to toe. I have kind of a bird's-eye view of what these injuries look like.

I have seen two recent mass shootings, which is a unique position to be in. One occurred at the Fort Lauderdale International Airport, in which the gunman used a 9-mm semiautomatic handgun with a low-velocity bullet. The second mass murder involved the care of patients from Parkland, in which the shooter used an AR-15. These were very different injuries and led to very different outcomes for the patients.

Handgun injuries are the type we are used to seeing in day-to-day practice. The bullet leaves a linear track through the body and we can see that track on imaging.[3,4,5,6] If the bullet travels through the liver, for example, we can generally see the linear track of the bullet from entry wound to exit wound, and there will be some bleeding. The injury is the permanent cavity that the bullet leaves and it is traceable through the liver.

That is in stark contrast to the injuries we see with the AR-15. This is something that I had read about, but in 14 years of practice I had seen it only once before, in a SWAT injury, and only recalled it after seeing the injuries from the Parkland shooting. These are high-velocity bullets.

Glatter: This obviously took you by surprise. All of a sudden you have an image, a scan, of some devastating wound here, which certainly sparked a memory.

Sher: In the airport shooting, I did not even realize that anything like a mass shooting had occurred until I read the scans from the third case, because simple gunshot wounds are what I see in day-to-day practice. The AR-15 causes a huge swath of tissue damage from something that is called temporary cavitation.

Glatter: Can you explain what cavitation means?

Sher: It is similar to a radial stretch injury. You have the permanent cavity where the linear track of the bullet passes, but there is a wave of energy that, as kinetic energy is imparted to the patient, causes the elastic tissue to move away from the bullet and then return. That whole swath of tissue is damaged. It results in a 4- to 6-inch area that is damaged. It is completely different. Injury from a low-velocity gunshot wound depends on what the bullet hits. If you hit an artery directly, that is lethal. If you hit the heart directly, it is still lethal. But with an AR-15, you only have to be in proximity to something like a vessel to have a catastrophic event.

Glatter: These AR-15 bullets are smaller, nimble bullets and they travel faster. Their muzzle velocity is much greater, correct?

Sher: The injury is a function of the velocity. Low-velocity injuries with a handgun occur at 1200 feet per second, more or less. These assault rifle bullets cause injuries at 3200 feet per second. These really fast, small bullets result in a totally different pattern of injury. The physics is different in terms of the cavitation phenomenon, and in the patient, it is completely different.

In a solid organ, you see a large area of tissue destruction. If the bullet tracks anywhere near the porta hepatis or the vascular pedicle of the spleen, that patient would never make it to us. In a long bone injury, the bone is absent; it is like sawdust— a whole 6-inch segment of bone is just gone when you shoot it with an AR-15. There are images from military surgeons that are posted in the New York Times that illustrate that point perfectly.[7]

A video from the Smithsonian Channel shows the devastating effects of assault rifle fire on the human body

Source: Smithsonian Channel

Treating Entry and Exit Wounds

Glatter: Dr Goldberg, you are on the front lines, in the operating room and the ICU; you resuscitate these patients. Can you tell me what you are seeing physically with these wounds, exit and entry, and how you are managing them from a damage-control standpoint?

Amy J. Goldberg, MD: I have been a trauma surgeon in north Philadelphia Temple Hospital for about 25 years now. I cannot say that I am a ballistics expert, but unfortunately, I am an expert on what bullets can do to bodies.[8] You can take what Heather has said and apply that to what it looks like when you make that incision and you are now peering at a liver that has been morselized by the high energy of these assault rifles.

The wounds are so large. They are large cavitary wounds, whether it is the liver or the spleen, the aorta or the vena cava. You are doing your best, first of all, to stop the bleeding, whether by packing or clamping. You are feverishly trying to stop the patient from exsanguinating and dying immediately on the operating room table.

Glatter: In terms of damage control techniques and what came out of the battlefield, these wounds are problematic, and just to resuscitate the patients to get them to the ICU is a challenge because patients often will die. With a standard handgun injury, you at least have some time, but with the sheer internal destruction from these high-velocity bullets, I imagine that you simply do not have that time.

Goldberg: If you are lucky enough to get the patient to the operating room, then at least you have a chance to stop that patient from bleeding. Many of the patients we have seen in these mass-casualty incidents have died at the scene and have not made it to the hospital. If you are lucky enough to get the patient to the hospital, you know that your first job is to try to stop the bleeding and, at the same time, resuscitate the patient with blood and blood products—and doing whatever you can, packing and clamping.

Gun Violence Beyond Mass Shootings

Glatter: Dr Sakran, how do you manage patients at Johns Hopkins who come in after these types of situations? I imagine that you have seen both assault weapons injuries and handgun injuries. Is there anything in your management that you would like to discuss?

Joseph V. Sakran, MD, MPA, MPH: This is a very relevant and timely discussion. As Dr Goldberg mentioned, we have a couple of priorities when we are approaching this from a damage control perspective, but the number-one priority is to control hemorrhage.

Unfortunately, in cities like Philadelphia and Baltimore, we are seeing this on a daily basis. We see victims in a spectrum of critical illness, including those who need to be rushed to the operating room for life-saving hemorrhage control and those who are simply admitted and subsequently discharged.

It is important to note that while these mass shootings get the majority of the media attention, we need to recognize that firearm deaths are happening every day, affecting communities all across this country. Sometimes we forget about those individuals who are suffering these violent tragedies.

Glatter: That is an important point. Statistics indicate that 90 or more people a day are dying of gunshot wounds.[9] Yet, certainly they do not all make the papers; it is these mass shootings that are in the news. Drawing attention to this entire epidemic is imperative.

Goldberg: I could not agree more. Patients are being shot and dying on the corners of our communities and our cities every day and night, in Philadelphia, Baltimore, Chicago, and Detroit. It is so very tragic and, as Joe said, attention is paid primarily to the mass casualties and mass shootings. These are absolutely terrible, but we should never lose sight of the ongoing shootings in our cities.

Glatter: What interventions do you use in your emergency department and ICUs for the young victims of gun violence? Is there any way to get to these children and their families, to have an impact?

Goldberg: We really believe that education is the first step toward prevention. Right now, if you ask students what they know about gun violence, what they know is what they see on TV or in a video, or from listening to hip-hop. We want to educate them about what bullets and guns can do to them. For about 12 years, we have been running the Cradle2Grave Program where we educate students in junior high school and high school about what guns can do.

Sher: I am a radiologist, so we like to categorize things. I do not see gun violence as one disease. Mass murder, as you have mentioned, is just one small portion of it. The toll is more than the death toll; it is the toll taken on society, as we have seen here in Fort Lauderdale.

Gun violence is many different diseases. It is domestic violence, it is drug and alcohol abuse, it is accidental shootings, it is suicide, it is crime related. These are all individual societal problems and diseases, and they all have different root causes and different solutions. That is why research is so essential, because all of these can be prevented, but you cannot treat them all the same way. There are different ways to address these problems from a societal standpoint.

Gun Violence by Root Cause—All Age Groups[10,11]


Source: Heather Sher, MD

Pie chart based on gun-related deaths. From 2010 to 2012, more than 32,000 people (N = 32,529) died per year in the United States from a firearm-related injury; 62% were suicides (n = 20,012), 35% were homicides (n = 11,256), and 2% were unintentional firearm deaths (n = 582).[10] The remainder deaths (n = 679) were classified as "undetermined" and "legal intervention."

In 2014, homicides involving strangers represented 11% of the nationwide total in the Federal Bureau of Investigation's Uniform Crime Reporting Program.[11]

The mental health component in mass murders is played up too much, in my opinion. I love a quote from Dr C. Everett Koop (former Surgeon General of the United States), who said that you cannot talk about the dangers of snake poisoning without talking about the snakes. You have to talk about the guns themselves within the context of mass murder. For these other, more societal issues, there are societal fixes, like improving mental health care, domestic violence intervention, and truancy prevention. These will help to address the larger problem of gun violence, which is the vast majority of what we see in clinical practice.

Addressing Gun Violence as a Community

Sakran: What you are hearing from Amy and Heather is that reducing firearm injuries and deaths in our communities will take a multipronged approach. Part of it is education. Another part involves federal research dollars so that we can study the causes of gun violence. The omnibus budget bill that was signed recently includes wording that perhaps will get rid of the 22-year-old ban on research, known as the Dickey Amendment.

We need our elected officials to allocate dollars to look at the etiology of gun violence. That will be critical, because when you look at the proportion of research dollars that goes to firearm violence compared with diseases like sepsis, it is quite low. Thus, we need education, research, and then—obviously—common-sense legislation, like strengthening our universal background checks and so forth.

Goldberg: We need to view this as a public health crisis. I believe that is what Joe and Heather are saying. This is a public health crisis that we cannot wait another minute to address.

Glatter: The children have mobilized. We have teens mobilizing in our country now. This movement inspires everyone. Certainly, I never saw it in my generation, but we are seeing it in this generation. This is very impressive.

Most of the folks being shot in our cities should be looking toward a bright future. Instead, they find themselves with colostomies, or being paraplegic or quadriplegic, with long bone fractures.

Sakran: I am glad that you mentioned that, because a few weeks ago, the Harvard Kennedy School had a Parkland forum that involved some of the students from Parkland, including Emma Gonzalez and David Hogg. They made a critical point that we have to look not only at the victims of mass shootings, but also at the people who are affected by gun violence on a daily basis. When you compare African Americans to whites, you see a disproportionate burden when it comes to African Americans.

African Americans are four times more likely to be killed by firearms,[9] in part because they are 14 times more likely to be killed in firearm-related homicides (as opposed to suicide or accidents). This disparity must be addressed. We cannot forget about it. I was glad that the March for Our Lives included individuals who represented those communities. As Amy pointed out, we see this on a daily basis in our cities, and this is something that the American public has to recognize.

Glatter: I think the public needs to see the vivid images of what these weapons can do. If they could see them, I believe it would certainly help reduce gun violence.

Goldberg: I agree. I surely do not want to be disrespectful to anyone, but I can tell you that the citizens of America have not seen what these bullets can do to our kids and adults, and people need to see this.

Sher: For a doctor, this is not an abstract issue. People look at this as a policy issue on paper, but for us, when you see the damage that is done, it is crushing. I agree. It is very heartening to see doctors stepping up and saying, "This is a public health emergency." The solutions lie in science, they lie in public policy, and the CDC is critical. I was very happy to see that they put some language in the new omnibus bill to support gun violence research.

We still have to get rid of the chilling effect [of the Dickey Amendment] on the fact that we need funding. The CDC needs a clear mandate to address this as the public health emergency that it is and propose solutions that can become policy.

From Victim to Surgeon: A Telling Story

Glatter: With legislative changes, that certainly is a start, but we also need education, starting in the home—making that part of a comprehensive approach to the problem. Joe, I want to ask you about a very personal experience. You were a victim of gun violence at the age of 17. How did that motivate you to do what you do now?

I was nearly killed after a .38-caliber bullet ripped through my throat and ended up in my shoulder. It inspired me to go into medicine and to become a trauma surgeon.

Sakran: It has definitely been a big part of who I am and what I do. I do not know what you were like at 17, but I think most 17-year-olds cannot really see past Friday night, as I think Brad Paisley says in one of his songs. At that age, you do not know what you want to do with the rest of your life. You do not appreciate the fact that you are mortal. You do not appreciate the fact that you have people in your life who are looking out for you and trying to guide you.

I was nearly killed after a .38-caliber bullet ripped through my throat and ended up in my shoulder. But I was given a second chance, and it really opened up my eyes. It inspired me to go into medicine and to become a trauma surgeon. Most recently it got me asking, how do we work at the nexus of medicine, public health, and public policy to make our communities safer all across this country?

I am grateful for the second chance I have been given. I only hope to be able to translate that horrible experience into something positive.

Glatter: Your story is inspirational. I got chills when I read about you and saw your convocation into the American College of Surgeons. It certainly made me think, because I have done some surgical training. It rang true and brought back so many memories of seeing young kids and teens on the front lines, getting injured. Thank you again for your dedication.

A Patient's Long Road to Recovery

Glatter: The long-term prognosis after these gunshot wounds is something we do not talk much about. Chronic pain, wound healing, post-traumatic stress disorder, and the psychiatric fallout need to be brought up. What is your opinion on these issues?

Goldberg: Yes. It can be devastating. As Joe said, most of the folks being shot in our cities are young African American males who, at 17 and 18, should be looking toward a bright future. Instead they find themselves with colostomies, or being paraplegic or quadriplegic, with long bone fractures, and whatever injuries you can think of. Even when the physical wounds are healed, they may not be completely healed, and they have all of the emotional and mental wounds that come with that. We are not always able to provide them with the support they need in the long term.

Glatter: That is a good point. We do not have a system in place that deals with the chronicity of care after this horrific injury. It also wields an economic toll. This could put people forever in an economic disadvantage for their entire lives, beyond just the physical and the psychological aspects.

Goldberg: It will affect them and their families forever.

Glatter: Heather, I am sure you have dealt with the fallout of these injuries. You may be consulted about an interventional procedure. What is your experience with this?

Sher: I am a diagnostic radiologist, so this may be a better question for surgeons. We do see that with the AR-15 injuries, patients have a much rockier hospital course. The care and the complication rates are significantly higher. As Dr Goldberg pointed out, these are rare injuries and most of these patients die in the field. I think the ones that make it to us clinically are those who have extremity wounds and were shot in the periphery of the body. But injuries from the AR-15 are typically lethal.

Glatter: Any further issues to bring up, Dr Sakran?

Sakran: We are at a point in time where we must seriously look at a multipronged approach that incorporates education, research, and common-sense legislation. We have to remember that, as healthcare providers, all of us are responsible to transform and shape the public narrative into action.

Sometimes we underestimate how important and powerful that is. It does not have to be as dramatic as being shot in the throat. Each one of our panelists is an expert in his or her own right and has tremendous experience. I encourage folks to go out and advocate; to have a voice and stand up, just as the young people in this country are. I believe it is powerful and that we are at a tipping point.

Glatter: Dr Goldberg, any final thoughts?

Goldberg: We can't stop the conversation. We can't stop our action. We must continue on and make sure that we effect some implementable change.

Glatter: I want to thank this incredible panel, Dr Sher, Dr Goldberg, and Dr Sakran. Thank you again for your time.

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