“Code Trauma. Resuscitation doctor required.” Dr. Glen Bandiera was working an evening shift in the emergency department at St. Michael’s Hospital when he heard the announcement come over the intercom, his alert that patients were on their way. It was, as has been the case too often this year, a shooting. Multiple gunshots. Multiple victims.
As one of two trauma-specialty hospitals in Toronto, and the one located in the city’s core, shootings are a familiar call at St. Michael’s – even more so as the city’s gun-violence rates have spiked in recent months. Just in the past week, five people were shot in the downtown entertainment district and four others in the Kensington Market area.
At 51, Dr. Bandiera has been an emergency doctor for 20 years, and is now chief of emergency medicine at St. Michael’s. He says where they might once have seen a shooting victim every month, it’s now closer to a weekly occurrence. St. Michael’s has seen 33 so far this year.
Police have attributed the shootings largely to gang activity and turf wars, although many of the victims have no known gang connections.
Inside the emergency department, motivation doesn’t matter.
News of a shooting usually comes in to St. Michael’s through the red phone, a landline specially dedicated to Toronto Paramedic Services. The red phone is answered by a triage nurse who gets the basic information, then sets the hospital’s protocols and preparations in motion.
While the majority of traumatic injuries seen at St. Michael’s remain traffic-related, Dr. Bandiera says gunshot wounds are different, not only in the physical effects on the victim, but also for those treating them. The victims tend to be young, their injuries severe, intentional and preventable.
“It’s hard to see this kind of violence happening in the city, so that’s disturbing on one level, and the wounds themselves, to think that they are inflicted on one another by other people, is disturbing,” Dr. Bandiera says.
“The wounds can be quite dramatic, quite graphic, and some of the surgical interventions that have to be done immediately to save a life can also be quite dramatic and disturbing for people. It causes a lot of stress on the team for a lot of reasons, and when a multiple-casualty incident happens, it just magnifies it even more.”
St. Michael’s has a dedicated trauma resuscitation room that can handle three patients at once, and in a mass-casualty situation, adjacent rooms can be used for trauma resuscitation as well.
In most cases, shooting victims are met at St. Michael’s by a specialized and highly trained trauma team. Like Dr. Bandiera, many of those working in the emergency department have trained in hospitals in the United States, where gun violence is more common.
In the minutes before victims arrive, the trauma rooms are readied to ensure supplies and equipment that may help with the call are close at hand. Often, there are airway kits with scalpels to cut into a patient’s neck, or tools to open the chest cavity and access the heart or lungs. There are needles, chest tubes, rib spreaders and operating scissors. There are clamps to hold tissue, balloon devices to plug holes.
Over in the hospital lab, the massive infusion protocol is activated to co-ordinate the administration of large amounts of resuscitation fluids and blood to multiple people. Nearly all gunshot victims will have some kind of surgery, so the operating room is notified and staff there begin their own preparations, calling in extra surgeons and anesthetists if necessary.
Dr. Bandiera says he feels nervous in these moments before the patients arrive, waiting to see what the call will bring and how the emergency response will go, knowing what hangs in the balance.
“We realize this is one of the few situations in emergency medicine where time is absolutely critical, where mistakes will make the difference between life and death,” he says. “And for many cases, there really is an opportunity to intervene and alter the outcome.”
That is becoming even more true, as developments in medical protocols and techniques, emergency-response systems and technology contribute to steady increases in overall survival rates for gunshot victims.
Dr. Bellal Joseph, a trauma surgeon at the University of Arizona Medical Center, was part of a team that was able to raise survival rates for people with gunshot wounds to the brain exponentially – from about 10 per cent up to 40 per cent – using aggressive new resuscitation protocols. He says 25 per cent of victims in the study were able to leave hospital with normal function. Among those treated with those protocols in place was U.S. politician Gabrielle Giffords, who was shot in the head in 2011.
But even with such advancements in treatment, Dr. Joseph says it is important to invest in prevention, to try to stop the problem before it gets worse.
“You don’t want to let this cat out of the bag,” says Dr. Joseph, who estimates he has worked on 2,000 gunshot victims in his 15 years as a doctor, in Detroit, Baltimore and Arizona.
At the same time doctors and nurses at St. Michael’s prepare to receive the injured, a number of security protocols are activated to protect the hospital. Areas are locked down and movement is restricted, sometimes police officers are stationed in and around the building. That there have been shootings in schoolyards, in restaurants and on crowded streets shows bystanders and innocent victims are not a deterrent, and there is always a chance the violence will follow victims to the emergency department. Training exercises at St. Michael’s include scenarios where there’s a shooter inside the hospital.
And then, there are the wounds.
Bullets enter the body at high speed, tearing through flesh and blood. The damage they do is not only devastating, but sometimes unpredictable and hard to immediately locate. When a patient arrives, the trauma team works quickly, looking for possible entry and exit wounds, doing X-rays to look for bullets, piecing together information to try to figure out exactly where the injuries might be, what damage is the most pressing and the most dangerous. Dr. Bandiera says the goal is usually to have patients stabilized and into an operating room or the radiology suite within 20 minutes. Every minute, even every second, matters.
There are successes. People who come in unconscious with no vital signs, who have their chests opened right there in emergency and are brought back to life, who have their holes in their heart or lungs hurriedly stitched closed, so they can be rushed off to surgery. People who survive, who are saved.
“If that happens, it’s really validating for the whole team. The training, skills and practice, it’s really a testament for while we are there,” Dr. Bandiera says. “That’s a really uplifting experience.”
But sometimes, it is not enough. Even a perfect resuscitation cannot reverse a bullet, and sometimes nothing can fix the damage that has been done. In those cases, those who tried to help are left to grapple with the senselessness and the violence. Then they clean up, debrief and get ready for the red phone to ring again.