patient stories

This is My Lane

Another month, another massive shooting fills the news cycle. This time, it’s a shooting in Thousand Oaks, California, less than two weeks after a shooting at a synagogue in Pittsburgh. What is different about this round (and I do not like that I can casually use the phrase this round) is that much of outrage is coming from doctors, nurses, and all kinds of other medical providers who take care of the victims of such shootings.

It all started with a tweet on November 7th from the National Rifle Association:

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The blog article was inflammatory from the start, stating, “Everyone has hobbies. Some doctors’ collective hobby is opining on firearms policy. Half of the articles in the “Latest from Annals” email from the Annals of Internal Medicine journal are related to firearms.” What’s curious is the phrase, “stay in their lane” was never mentioned in the article, but whoever tweets for the NRA decided to tell the “self-important anti-gun doctors” to “stay in their lane” just hours before a mass shooting at a bar in Thousand Oaks, California. 12 victims died of gunshot ones. Sadly and most ironically, one was a survivor of the 2017 Las Vegas shooting.

The rebuke on Twitter was quick, blunt, and quite visceral:

 

 

I even recognized one of the trauma surgeons speaking out on Twitter as I used to work with her and deeply respect her skills as a surgeon. She was one of my favorites, probably ever, as I remember vividly running around the unit giving each patient pain medications when she chided her resident to not treat nurses like a human PCA (patient-controlled analgesia, a pain pump controlled by the patient). I also vividly remember her compassion and frustration as we had a woman on our unit who claims she shot herself in the abdomen when the trajectory did not make sense and we all knew that her abusive (but now very over-the-top helpful) husband did it. Unfortunately, because she was an adult and denied it, a proper criminal investigation could not happen. This trauma surgeon was amazing and tried very hard to take care of both the patient and staff in the most compassionate way possible during that emotionally and ethically difficult situation.

Another trauma surgeon speaking out is Dr. Joseph Sakran, a trauma surgeon at Johns Hopkins in Baltimore who himself was shot in the throat at 17. According to an article by the LA Times, he was applying to medical school while recovering from the injury and even trained alongside the surgeons who saved his life. Now as the surgeon giving the news to families, Dr. Sakran said, “I think about what my own family must have felt when the surgeon walked out to talk to them.”

What frustrates me about the NRA’s blog post is how dismissive they were of the horrific experiences of trauma surgeons, nurses, doctors, and everyone who encounters victims of violence. The literature calls it “vicarious trauma.” Woolhouse et al. (2012) describe vicarious trauma as “a normal part of any caring professional’s emotional response” to “[l]istening to patients’ narratives of traumatic events” which “can provoke intense emotions such as profound sadness, helplessness, frustration, and anger.” Empathetic caregivers experience vicarious trauma, not only from patients with gun shot wounds or trauma patients, but even from patients who experience sexual assault or who experience the suffering of the interventions from the ICU and much, much more. Vicarious trauma is a newer thought in the literature, but it is discussed among a variety of health care professionals in a wide variety of settings. Berg et al. (2016) discuss its effects on the trauma team. Woolhouse et al. (2012) discuss it with family practice physicians working in the inner city. Devilly et al. (2009) discuss it related to mental health professionals. Wilson (2016) discusses it related to social workers. Mathieu (2016) goes as far as to call it  an “occupational hazard.”

Going into health care, you know you’re going to “help” people, but I never knew how much I would realize my own suffering and brokenness in helping others. I never knew how much certain cases would haunt me, literally in my dreams at times.

A couple months ago, almost every night I was having stress dreams, most of them revolving around work. This all happened after working non-stop for 2 hours to resuscitate a trauma patient, an innocent bystander who was hit by a car and sustained a massive head trauma.* After doing everything possible and seeing a very abnormal head CT with massive amounts of blood, her telemetry (heart monitor) noted more and more unusual beats and a slower and slower rhythm. The resident – a friend of mine – asked us all if there was anything else we could think to do as her heart beat in the 30s. No one had any ideas. The pressure from the head bleed was too much, and she was slowly herniating. We switched her monitor to comfort care to stop the incessant beeping, and I held her hand saying whatever prayers I could think of as she died.

I went home that night, crying and drinking wine in the bathtub. The vicarious trauma stuck with me for a couple months, though. And the vicarious trauma of victims of violence sticks with me too. Like the gun shot victim shot in the neck who we poured 27 blood products into in an hour who ended up dying in the ICU. Like the gun shot victim shot in the chest who needed an emergency cricothyrotomy, the procedure that looked more graphic than anything I’ve ever seen on television or in the movies. Like the gun shot victim who cried and cried for his mother.

The NRA blog post stated that the most recent American College of Physicians position paper on firearms “leaves one wondering if the authors reviewed the evidence, or just found works that suited their needs.” I wonder if the NRA has reviewed the available evidence about vicarious trauma, compassion fatigue, and burnout syndrome of medical professionals or if they just wrote inflammatory blog articles to suit their needs and appeal to their base. If the latter (which is most likely), I look forward to reading their opinion on the American College of Surgeons most recent statement since that committee thought to include the number of firearms each member carries (which averaged out to 9.5 each). I also wonder if the NRA has reviewed the available evidence about gun violence.

As I was working on this post, I went at a Trauma Care After Resuscitation (TCAR) educational program. It was an extensive overview of trauma care, and I was really impressed by the breadth of the course. One section reviewed the physics of trauma and how basic physics principles can help determine the extent of injury aka the kinematics of trauma (of which literal books are written). We reviewed at length how the kinetic energy (aka the force) of a trauma is mass times velocity. Large mass at a slow velocity (aka a pedestrian struck by a train) can still produce a devastating trauma, but so can a small mass at a high velocity (aka a gun shot wound).

However, force is equal to half the mass times the velocity squared. (Article from Khan Academy here). Therefore, the how fast an object is going to create more force more quickly than the weight of the object.  That’s why a bullet can be more deadly than car, and that’s why some guns are more deadly than others. 

Not everyone who is shot will die. Obviously, trajectory matters. The proximity to a trauma center matters. The function of the organ the bullet is hitting matters. Even the characteristics of the tissues matter. Skin and muscle are fairly elastic while vascular structures like arteries and veins have fixed points that can shear or tear, causing massive amounts of damage. Trajectories mere millimeters apart can matter, based on the tissues in that path. (John Paul II ‘s assassination attempt, how the bullet was fractions of an inch away from his aorta, anyone?)

The University of Utah School of Medicine has a really comprehensive page about the relationship between force, mass, and velocity in guns as well as trajectory. In essence, as Stefanopoulos et al. (2014) reviewed as well, the type of gun that you’re being shot with matters. A small handgun has a small case with a relatively low diameter still has a high velocity. The kinematics of a bullet is a complex process, but what I have learned and remains shocking to me is how more and more massive shootings are happening with military grade weapons, as the New York Times discussed. Military grade weapons have a much higher velocity than hand guns or shot guns,  inflicting more damage on civilians that used to be reserved for the battlefield.

How? When a bullet enters the body, it is moving with some degree of force. The bullet itself creates a cavity called “the permanent cavity,” but the energy the bullet unleashes in the body creates a “temporary cavity” which can crush and injury surrounding tissues that the bullet never physically touched. Higher velocities mean more force and a larger temporary cavity, therefore more tissue injury and greater possibility of death.

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from Stefanopoulos et al. (2014)

It never clicked for me until that class how logical gun control can be. Why does a civilian need a military grade weapon? If indeed guns are used to protect our homes and hunt, why does anyone need a gun with such a high velocity which can inflict a greater amount of damage and increase the risk of death?

And too, can we please talk for just a minute about how easy it is to get a concealed carry license? I went to a nursing conference last year where they offered a 3-hour lecture about guns. I expected to learn what I learned in TCAR: gun ballistics and trauma kinematics. What I learned was how to handle them and that I qualified for a concealed carry license afterward when I had touched a total of 1 gun once in the class. Cars kill people annually too, but driving one of those has a lot more requirements!

Sadly, while writing this, gun violence hit home yet again. On November 19th, Juan Lopez shot his ex-fiancee, Dr. Tamara O’Neal in the parking lot of Mercy Hospital in Chicago before going into the hospital and shooting 2 others before himself, including a police officer. One of the doctors I worked with works at that hospital and with that physician.

So, dear NRA, do not tell me that gun control is not my problem. In dealing with the immediate emotional and physical trauma after a gun shot wound, gun violence becomes my problem. As this Philadelphia doctor described so well, “Look at your own children’s pictures that you keep in your home, at your desk, on your phone. Now imagine those photos taped above the bed in ICU Room 7. Imagine.” Gun violence is our lane, so you better start sharing.

*Please remember details (such as and ESPECIALLY names and other personal health information) have been altered or omitted to protect patient privacy. See about page for more information!

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