Story and photos by John Howser

Dr. Richard Miller keeps a photo in his office. In it, the trauma surgeon stands beside a tall, athletic woman; the two of them have just completed running a triathlon, and are wearing running shorts, t-shirts and racing numbers. They are smiling the smile of tired accomplishment that most runners wear after such a grueling event.
The woman, Stephanie Styles, is a friend of Miller’s, and on one level that’s why he has the photo in his office—a picture of a friend at a happy time together.
But there’s another level of meaning to this picture. It is there as a reminder—a reminder of what a bullet can do to the human body, and, just as important, to a trauma surgeon, a reminder of how, if everything goes perfectly, things can turn out OK.
It never hurts to be reminded that things can turn out OK, because of all the literally hundreds, if not thousands, of gunshot victims Miller has cared for, Styles’ injuries were among the worst he has ever seen.
Miller, who is now associate professor of Surgery in the division of Trauma and Surgical Critical Care at Vanderbilt, treated her while practicing in Greenville, S.C. Styles, a schoolteacher who lived alone, owned a .38 caliber revolver for protection. One night after thinking she heard a prowler, she retrieved the handgun from a nightstand. While walking across her house in the dark she tripped and shot herself in the abdomen. The bullet passed through her body with devastating results.
Even years later with many gunshot injuries in between, Miller still remembers every detail.
“The bullet went through her stomach, through the major branch of her abdominal aorta, through her pancreas, and out her back. This was a beautiful, blonde six-foot-tall woman who was dying in our emergency department. She was in severe hemorrhagic shock. The bullet had blown a huge hole in her stomach, which happened to be full at the time, so food was everywhere inside her abdominal cavity,” he says.
“We rushed her to the OR and had to go to heroic efforts to stop the bleeding. On the first resuscitation we used over 50 units of blood and blood products. After surgery she was so swollen we had to leave her abdomen open and cover it with a sheet of plastic.”
The story then takes an even more bizarre twist.
“After we took the woman to the intensive care unit and were trying to stabilize her again, someone in the unit asked who the woman was. Finally someone else called out the patient’s name and a nurse on the unit upon hearing this exclaimed ‘What! That’s my sister!’
“The entire unit went completely silent for a few seconds, then everyone stepped it up a notch and we went right back to work.”
Styles survived her injuries. After 12 operations and multiple complications over a year’s time she is now recovered and back to doing two things she loves, teaching school and competing in triathlons.
Miller talks with her from time to time by phone, and keeps this photo over his desk. As a reminder.

Level One

It would be nice to think that the story of Stephanie Styles’ injuries is an isolated thing, but unfortunately it’s not. Not in the U.S., not in Tennessee, and not in Nashville. At VUMC the number of firearm injuries is significant, both in terms of the number of victims and consumption of healthcare resources.
Patients arrive day and night by ground ambulance and by LifeFlight. On occasion a gunshot victim will be driven here by a “business associate” to be deposited unannounced outside the Emergency Department as the driver speeds away.
During the last five years VUMC has added a dedicated Trauma Unit, offering highly specialized care for victims of firearm injuries, and an additional two new LifeFlight air ambulances to transport patients from as far away as 150 miles.
Thanks to highly specialized Level One trauma care available for these patients, greater numbers than ever are surviving such devastating injuries.
Gunshot wound (GSW is the abbreviation used in the trade) victims fall into several categories, Miller says.
“While there are many stories of an innocent person at the wrong place at the wrong time, the vast majority are not. [Most shootings] are drug and gang related,” Miller says.
“Another group we see in significant numbers are firearm-related suicide attempts,” Miller adds. “Gunshot wounds are very common in suicide attempts, especially to the face and mouth.” And, he adds ominously, “At least half, or more, of suicide attempts are not successful.”
Miller says another group of gunshot victims are related to law enforcement — either someone shot by officers while in the commission of a crime, or officers themselves injured in the line of duty. Since finishing his trauma surgery fellowship here at VUMC, Miller has cared for four police officers who suffered gunshot wounds in the line of duty.
Hunting-related injuries round out the list of activities common to firearm-related injuries treated at VUMC.
“About fifteen percent of our trauma patients each year are a result of penetrating trauma, usually gunshot wounds. As far as being labor-intensive to manage, these patients take up a lot of resources,” he says.

By the numbers

Over a five-year period ending with fiscal year 2001, VUMC treated 1,302 victims of gunshot wounds. If this violence could be thought of as an epidemic, it is an epidemic that feeds on testosterone; 89 percent of gunshot patients were male. Unfortunately no age group is excluded. Typically about 9 percent of VUMC’s gunshot victims each year are under age 18. Young adults, ages 18 to 35, make up the bulk of victims, about 56 percent. About 33 percent are over 35.
The average VUMC hospital charge per gunshot victim over the five-year period from 1997-2001 was $30,000. Average physician charges per gunshot victim at VUMC are typically in the neighborhood of $15,000.
Based on average charges, from 1997 through 2001, the cost of care for gunshot victims at VUMC totaled approximately $58.5 million. It is not unusual for combined hospital and physician charges to accumulate into the hundreds of thousands of dollars for the care of a single patient. These charges do not include rehabilitative or long-term care, almost always a necessity for patients suffering injuries of this severity.
Caring for the vast majority of Middle Tennessee’s gunshot victims requires a substantial financial commitment from VUMC. Typically about 21 percent of these patients have commercial insurance, 35 percent are insured by TennCare, and another 8 percent are insured by workers comp or Medicare. The remaining 36 percent of gunshot victims are “private pay,” which means they have no form of insurance.
Patients treated at VUMC for gunshot wounds have an average survival rate of about 80 percent. About 60 percent of these patients of all ages, the lucky ones, are treated and discharged directly to home. Two percent of VUMC’s gunshot victims are discharged directly to jail.

Of ricochets and the blast effect

Miller says often doctors and nurses don’t want to know details about how a patient was shot . The information usually isn’t necessary for patient care.
“Sometimes it’s just better not to know,” he says. “We want to treat every patient the same and it serves no purpose to have your judgment skewed by a story that may not even be true.”
However, Miller says knowing how many times a patient was shot, or where on the body, is vital. You might think this would be obvious, but it’s often not the case.
“Knowing how many entrance and exit wounds there are, and what type of weapon used, is very important in the management of a patient,” he says.
Damage done to the body by a firearm depends on a number of factors. Of course where a bullet enters the body has a significant impact on the outcome. Engineering specifications of a particular weapon contribute to its overall impact on the human body, a phenomenon known to health care providers as the blast effect.
The blast effect refers to the zone of damaged tissue around a gunshot wound caused by the bullet itself, and by shock to surrounding tissue caused by the sheer speed with which the projectile enters and travels around inside the body.
“Blast effect is determined by the size and velocity of the bullet. Some of the bullets are engineered to tumble upon entrance into the body, or implode upon impact. Bullets are designed to do the maximum damage, which creates a lot of havoc for us,” Miller says. “Some of these bullets are absolutely designed to maim.
“Bullets have an amazing ability to ricochet off of things inside the body. I’ve had patients shot in the chest where the bullet then winds up in the leg,” he says.
“The hardest thing for us as trauma surgeons is to find the bullet’s trajectory and find all the bullet holes, which is not an easy thing at times. Usually there is an even number of holes in a gunshot victim. If there is an uneven number of bullet holes, then we really have to search around.”
There is an entire science on the pathophysiology and management of gunshot victims, complete with in-depth textbooks on the topic.

Human toll

The human cost of firearm injuries is recognized every day not only by the loved ones who must live without a son or daughter, father or mother, husband or wife, but by the health care workers who must care for the victims.
If you ask health care professionals who care for victims of firearm injuries whether they have memories of particular patients, there is almost always an immediate response. Maybe it’s a memorable case of physical carnage left in the bullet’s wake; maybe it’s the pure senselessness of how a particular victim was shot. But caring for gunshot victims is not work that it is easy to leave behind. Images linger.
Miller, as a trauma surgeon, treats firearm injury victims on an almost daily basis. He’s seen lifetimes of the effects of bullets and the damage done.
He has vivid memories of many of the gunshot victims he’s cared for. One patient in particular Miller treated here at VUMC stands out, both for the uniqueness of the injury, and the tragic outcome.
“One of the gunshot victims here at VUMC I remember well was a young woman who happened to be about eight months pregnant. Unfortunately, she got shot when two of her relatives were in an argument and she was trying to break it up. In the midst of all this a gun went off and shot her in the belly,” Miller says.
“She came in, in significant shock. We had to do an emergency C-section in the Emergency Department to deliver the baby. The bullet had passed right through the baby’s head; it was dead on delivery. The mother lived, and had actually suffered very little injury to anything other than her uterus.”
But, most everybody who does this kind of work has the same answer when asked about the most tragic victims—the young ones.

Innocent victims

After working in VUMC’s Emergency Department for 14 years, Brenda Smith, R.N., has cared for hundreds and hundreds of Middle Tennessee’s gunshot victims. She’s literally seen it all. When asked what upsets her most about gunshot victims she doesn’t even have to think: “The children,” she says.
Even after ten years, Smith has to choke back tears when recalling the gunshot victim she remembers as most tragic, a 3-year-old who found his father’s gun under a bed and shot himself in the heart.
“Everyone here worked on the child as hard as we could. We had to repair the hole in his heart right here in the ER, but we couldn’t get it to restart. He died down here,” says Smith. “If you get where things like this don’t bother you, then you need to quit. I will never forget that for as long as I live.”
Miller says VUMC sees its share of children who suffer gunshot wounds.
“Most of these injuries are accidental because parents do not have appropriate safety measures in place to keep children from getting their hands on the guns,” he says. “There are kids we see who have shot themselves because they think the gun is a toy.”
Pediatric trauma prevention specialist Mary Fran Hazinski, MSN, assistant in Surgery and assistant in Pediatrics, has worked for years to educate Middle Tennessee parents about the importance of handgun safety when it comes to their children.
“When you look at the data, younger gunshot victims tend to have higher injury severity scores, and very high charges associated with their care,” says Hazinski. “When you look at the outcomes, about 20 percent go to rehabilitation and 20 percent require home health care—which means 40 percent required ongoing medical care.”
About 9 percent of all VUMC’s gunshot victims are under the age of eighteen. From 1997 through 2001 Vanderbilt Children’s Hospital treated five children under the age of 4 who suffered gunshot wounds. These patients spent an average of nine days in Children’s Hospital with an average hospital charge of more than $25,000, not including physician charges. There were no recorded deaths due to firearm injuries at Vanderbilt Children’s Hospital in this age group from 1997 to 2001, which, Hazinski is quick to say, is not the same thing as saying every child had a good outcome.
“Studies have shown that twenty-five percent of children who are injured by firearms are left with chronic health problems,” Hazinski says.
She says the reason firearm injuries in children are much more devastating than in adults is simple physiology.
“Children are smaller, so the chances of a bullet hitting a vital organ are much higher, and many times the bullet ends up crossing the midline of the body and injuring vital vascular structures,” she says.
Hazinski cites Centers for Disease Control and Prevention data stating firearm injuries are the leading cause of death in adolescents. CDC data suggests that over 66 percent of U.S. households have a handgun, and these guns are often stored loaded and unlocked.
From 1997 through 2001 Vanderbilt Children’s Hospital treated 48 gunshot victims ages 4 through 15.9. This group didn’t fare well. Twenty-one percent died, another 16 percent ended up requiring long-term care, while a lucky 58 percent of this group were discharged to home. Already at this age, 2 percent of patients were discharged to jail.
“In this age group there are more suicides, so there are a significant number of self-inflicted firearm injuries in this age group that don’t survive. Firearms are a very effective way to commit suicide,” she says. “Literally there isn’t time for a second thought.”
What’s shocking among the under-16 age group is the number of homicides. CDC data from 2000 indicates that 68 percent of fatal firearm injuries in children under age 4 were homicides. In the 5 to 9 age group, 71 percent of fatal firearm injuries were homicides. In children 10 to 14, suicide accounts for 36 percent of firearm deaths, while homicides account for 45 percent of deaths.
Hazinski has studied this issue for years, talked to anyone who will listen for years, and is passionate about the need of adults to protect children from the damage that guns can do.
“If parents want to prevent firearm injuries in children, they need to use trigger locks, or store guns in lockboxes. To be skeptical and say these methods won’t work isn’t true. If the guns are locked up then the kids can’t get to them,” she says.
The toll gets to the doctors and nurses, and it gets to the cops, too.
Metro Nashville Police Department spokesman Don Aaron says that any time children are shot, or are in a home where they witness a shooting, it’s particularly troubling to law enforcement officers.
“You can’t help but feel a great deal of emotion. You can see it in the faces of the officers at the crime scene, particularly if they are a parent,” Aaron says.
Children, adults, rich, poor, male, female, black, white. A bullet doesn’t care, and the cumulative toll is staggering.
Brenda Smith, the trauma nurse who is a 14-year veteran of VUMC’s Emergency Department, sums up the state of affairs best. “It breaks my heart that we have to waste so many resources on senseless violence,” she says. “We have patients, some as young as 17 years old, who have been here for repeat visits due to gunshot wounds. It’s really sad.”