Chris was dying when I first met him. He had been shot a few minutes before and was now in the trauma bay bleeding to death. I was the trauma surgeon on call; I operated on him. He had an iliac artery and colon injury. We repaired the artery and resected the colon, forming an ostomy. He survived to discharge.
It was a few weeks after his discharge that I saw Chris again in my clinic. He had missed two of his appointments and hadn’t answered any of my attempts to get in touch, but he eventually made it back for a follow-up appointment. (He had missed his earlier appointments because he was in jail but was eventually given a medical furlough to come to his appointment).
Chris is tall, with a head full of has long, caramel colored dreadlocks and tattoos that cover his chest and back and creep onto his neck and face. And on our first appointment back, he was angry. He didn’t remember me; which isn’t all that uncommon for patients who have are as sick as he was.
In his first follow-up appointment, Chris didn’t talk much. He mostly appeared annoyed about his bag and wanted to know when we could take down his ostomy. I said it was too early, but we’d most likely plan for a few months from now. I asked him a few questions to assess for any symptoms of PTSD and didn’t get very far. He did tell me that this was gang related and that he had no idea if the police had caught the person who shot him. But other than that, he didn’t say much more than ‘this isn’t my first time around.’ I knew this was true. Right before he left he turned to me and said “Why do you even ask?”
***
In modern trauma surgery, especially in anything larger than a moderate sized city, gun violence is bread and butter clinical practice. This seems trite, but it’s true. The effect of gun violence is a part of everyday practice for trauma surgeons. We spend a good deal of our day, and training, for that matter, learning how to deal with the holes in the tissues left by bullets in their path. We have strategies for quickly assessing patients, and specialized operative techniques to get at major bleeding quickly. There’s physiologic parameters and signs thereof that we learn to recognize in trauma patient. We learn to get our operative and resuscitative timing right to optimize the likelihood that our patients survive to get off the table. We get very little training in preventing the gun violence in the first place though. And, it’s variable, if we decide to include it in our practice at all.
In defense of those who don’t include gun violence prevention in their practices, the question of “What would you expect me to do?” isn’t exactly easy to answer either. Gun violence prevention isn’t a one size fits all, not to mention it’s not even clear what may help prevent gun violence.
Chris’s story is related to gang violence, and while that gets reported in the news, it isn’t even what accounts for the majority of gun-related deaths in this country: suicides account for that. And anyone who takes care of those injured by guns knows that the pathology of gun-violence is as variable as that of cancer. Comprehending that makes any sort of primary prevention strategy daunting, even if we know sometimes we’re the best or, the only ones, available to do it.
Chris came back to my clinic last week to schedule his surgery for colostomy takedown. And this time he looked different. His hair was short and he had his tattoos covered with a long sleeve shirt and a hat. I told him he looked different and he said, “I’m trying to make some changes, doc.” I asked what made it for him, and he said jail mostly. But he also said his experience in the hospital, with the nurses and the doctors caring for him did some of that to. He couldn’t put his finger on it, he just said the experience made him want to make a change.
***
So what is the trauma surgeon’s responsibility, when it comes to gun violence in the US? Do we have a moral responsibility to address this disease? Can we even call it a disease? And if we do call it a disease, should we own a professional responsibility to try to prevent it, like we do by advocating for seat belts and bike helmets?
I certainly don’t know the answer to these questions, but I do admit, especially as someone whose research focuses on ethical questions in trauma, that I’m concerned that I should.
Allan B Peetz