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An Open Letter to My Elected Officials on Firearms and the Deaths Trauma Surgeons See Daily

An Open Letter to My Elected Representatives

February 23, 2018

Dear Elected Official:

As a trauma surgeon and one of your constituents, I was heartened to hear that you are reconsidering your views on how to protect Americans from the ravages of our national gun violence epidemic. I am writing to share my first hand experiences along with known facts about widespread use of guns in the US today. In my line of work I am all too familiar with the lethal potential of firearms, especially when coupled with a cavalier attitude that many legal gun owners in America have that they or their families are somehow immune to the deadly power of guns. While every life I save is a privilege, my greatest success as a trauma surgeon would be to significantly reduce the number of people who need my care. Injury prevention is as fundamental to my work as is operating. In the case of firearms-related injury, there is much work to be done. I hope my perspective on the morbid consequences of Americans’ unfettered access to firearms will be helpful as you consider what should be done to protect each and every one of us from a death that is truly 100% preventable.

As a trauma surgeon, I have held countless ounces of brain matter in my hands while examining a self-inflicted gunshot wound. Occasionally, someone shoots themself in the chest, aiming at the heart. Most often, however, the suicide victim points a gun, legally purchased by themself or a family member, at the temple or roof of the mouth aiming at the brain. At such close range, despite my expert skill in trauma care, the damage is far too severe to reverse. It is a uniquely American reality that homes across the nation, occupied by residents experiencing deep depression, are also filled with firearms acquired for sport, hunting, or presumed personal protection. Of the nearly 96 Americans who die a firearms-related death in the US daily, nearly 59 die as the result of suicide. People with suicidal thoughts are three times more likely to succeed if they live in a home with a firearm. Furthermore, while 9 out of 10 suicide attempts with a gun are successful, only 1 out of 10 attempts by all other means succeed. To be sure, we as a society need to lift the stigma on psychiatric disease and enact policies that increase our nation’s mental health workforce and require both insurance companies and hospital systems to treat mental health conditions like any other illness. However, given that the leap from suicidal ideation to death by suicide is shortened by the presence of firearms, we must also take steps reduce access to firearms in US homes.

As a trauma surgeon, I have felt the anguish of too many parents who learned that their child was dead from me. Occasionally, the child was a teen who, in the absence of strong public education, housing security, and hope for an economically sound future, turned to a life of gang warfare in our urban centers. But more often, a child’s death has been deemed in our societal discourse an “accident.” Yet, the presence of the firearm used in the “accident” is in fact very intentional. Our fellow citizens routinely purchase these deadly weapons and keep them in their homes, thinking they are for defense, sport, or hobby. I wish I did not know the horror of a child killed “accidentally” by a sibling, a friend or even themself, but I do. The adult gun owners in each of these cases would swear to be well-versed in firearm safety. But, having seen that child lying cold and lifeless in my trauma bay, I know that they were overconfident in their ability to safely store their firearms. Nearly 1,300 American children die of gunshots every year. Worldwide, of all children who die this way, the US accounts for 91% of them. And, despite the characterization of our nation’s urban centers as the source of the majority of our dead American teenagers, it is important to note that only one in five teens who suffer a firearms-related death was involved in gangs; the vast majority of firearms-related deaths among teens in our nation are, in fact, due to suicides and these supposed “accidents.” Certainly, we should address the problem of urban violence among our youth and the illegal firearms trade that makes it so easy for them to kill each other (recalling that all illegal guns were at one point legally acquired). And, as the number of children lost in school shootings impossibly rises, we absolutely should address the pervasive issues affecting our boys today which might make any one of them turn against their classmates with lethal force. But these efforts would not be nearly enough given that the vast majority of children killed by firearms in the US die in settings with legally acquired guns one “accidental” death or suicide at a time. We must reduce the widespread presence of firearms in American homes and we must stop giving those who choose to keep deadly weapons near their children a pass when their carelessness results in a death.

As a trauma surgeon, I have also taken care of too many people, most often women, who have been shot dead in an act of domestic violence. When my patients have been beaten (by hands or weaponized object such as a bat or pipe) or stabbed (by weaponized knife or bottle) by their abuser, I have a realistic chance to heal them of their physical and mental wounds and get them to a safer place. However, firearms make it too easy for the abuser to become a murderer and I am robbed of the opportunity to end the cycle of domestic abuse in a positive way. Of all women murdered in this country, 45% are murdered by someone who supposedly loves them. This risk of intimate partner violence spans all sociodemographic groups but women residing in homes with firearms are 5 times more likely to be murdered by their abuser than those whose abusers do not have easy access to a gun. To be sure, we need as a society to address the root causes of domestic violence in the US and expand services nationally to help people in abusive relationships leave. However, it is clear that easy access to firearms is the major cause of domestic abuse fatalities; we must at the very least put a halt to how easy it is for abusers to acquire guns.

As a trauma surgeon, I have been fortunate not to have to care for victims from a mass shooting event; but I have trained repeatedly for mass casualty response. Years ago, we used to prepare for something like a bus crash or a building collapse; these days we prepare for shooters. Sadly, I have had to learn from the experiences of my fellow trauma surgeons in places like Newtown, Orlando, Las Vegas, and Fort Lauderdale. There is no glory in caring for victim after victim arriving with bullet holes, only grief; and then one must have the fortitude to bury the grief and move on to the next victim. Often, however, the grief is not from the patients coming into our trauma bays. Rather it is the eerie quiet in the empty bay picturing all the lifeless bodies that never needed to come to the trauma center. We have seen over and over in our country the highly lethal mix of angry people (some with true mental illness but most simply filled with rage) and easy access to firearms, typically legally acquired by self or family member. Surely, reducing overall access to firearms must be part of the equation in improving our collective right to life, liberty, and the pursuit of happiness while we are at school, the movies, and other public venues.

As a trauma surgeon, I have also trained for active shooter events because sadly, in additional to training for years to become the highly skilled professional that I am, I must now also be prepared to get shot in the line of duty as a healthcare provider. From 2000 to 2015 in the US, there were 241 hospital-related shootings. This statistic really hit home when cardiac surgeon Michael Davidson was shot dead in his clinic by a disgruntled family member whose mother had died of a known complication of major heart surgery. He was around my age. His wife was a college classmate. He was killed by a volatile man who lived in my community just 40 miles away. Complications are a part of what we do as surgeons no matter how expert we are, or how much caution we exercise in doing our work. To live in fear that my own death might be the consequence of my professional efforts, because so many of my patients and their families are legal gun owners, is something that my years of training simply did not prepare me for. Here again, the lethal combination of rage and access to firearms is painfully apparent. To be sure, we must make efforts to understand why people come to hospitals prepared to kill – whether it is a critically ill loved one or a physician who they see as responsible for a complication; but, we cannot simply continue let the answer to rage be grabbing one’s readily available firearm.

As a trauma surgeon, I can also provide some insight into the “good guys with guns” concept that people sometimes put forth as a solution to our nation’s gun violence epidemic. As evidenced by the seasoned hunter who shot off his reproductive organs cleaning his rifle or the experienced officer who shot himself while moving firearms from one cruiser to another, I have seen that even the most highly trained “good guys” sometimes don’t understand the power of their guns. Furthermore, the few times that I have been the one to care for a fallen police officer has taught me that even the “best of guys,” armed, well-trained, and experienced, can be taken by the actions of an enraged person with a gun. I was not on call recently when an officer shot while responding to a domestic altercation was brought to our trauma bay; my partner’s efforts to save his life proved to be futile. I can hear the wails of the grown men in blue who lost their partner that night as if I had been present because, sadly, I have heard those wails before. They are somehow even more haunting than the cries of a parent who has a lost child. To be sure, criminals intent on killing will find a way; however, in the decade leading up to 2016, 537 US police officers were killed by a perpetrator wielding a firearm. In contrast, those attacking with a knife, a bomb, or fist/strangle caused just 26 officer deaths in the same time period.  It seems clear that even the “good guys” are not immune to rage-filled persons armed with guns. Therefore, seriously limiting access to firearms will necessarily make more of a dent in our nation’s firearms-related death epidemic than arming others who are unlikely to respond quickly enough to make a save or, worse, might accidentally shoot themselves or someone else.

As a trauma surgeon, I have also seen the impact of high-powered military style assault weapons. As an interested professional, I have deliberately read reports on the autopsies of so many killed with such weapons in our nation’s most recent mass shootings. While all firearms are manufactured with the purpose of maiming or killing, make no mistake about it: the destructiveness of high velocity missiles that can be fired multiple rounds at a time makes semi-automatic assault rifles like no other gun. These kinds of weapons cause tissue damage that is unfathomable, leaving unrecognizable parts that were once part of a living, breathing human. Regarding ownership of such deadly weapons for the sport of hunting, I would argue that if you are such a bad shot that a bow & arrow or a shotgun does not suffice, then you should buy your meat from the store and take up a new hobby. Having seen firsthand what these assault weapons do, I see no reason why any civilian should have access to them for any purpose.

I am grateful that you have taken the time to read about my experiences. Based on my vantage point as a trauma surgeon, and as a concerned citizen, I have several suggestions that I hope will protect all of us from dying from a gunshot(s).

  • Firearms buybacks for those who simply no longer want to live subject to the possibility of the kinds of death I see daily
  • Deny gun permits to those with any history of domestic abuse, restraining orders, anger management issues, school suspensions, animal torture, and the like which all point to tendency for moments of rage
  • Mandate biometric trigger locks so that only the one legal owner of any firearm could use it, and not a thief, or a child, or a suicidal family member
  • Regulate firearms use and liability as we do with automobiles through required firearms training and testing and insurance to cover death/injury/anguish should anyone else get struck by a bullet from your gun
  • Allow survivors and states to sue gun manufacturers for wrongful death as we do for other consumer products (e.g., swimming pool drains, fertilizer, toys, airbags)
  • Prosecute adults whose negligent storage of a firearm leads to “accidental” death at that hands of a child
  • Ban the manufacture and sale of high velocity semi-automatic weapons and multiple rounds of ammunition along with a mandatory buyback of all such weapons followed by fines or jail time for those later found to be in violation of such laws

Again, I am heartened to know that reducing the burden of firearms related death in our society is among your legislative priorities. While I am not an expert in any such policy issues, as you have read, I am sadly an expert in people who die with bullet holes and buckshot wounds. Please do what you can to rid me and my colleagues of these horrific images and make all of us safer.

Sincerely,

 

Heena P. Santry, MD MS

Unimaginable Grief: Reflections on the Newtown Film

Originally published on heelskicksscalpel.com

I grew up in a home with the subtle lingering sorrow of parents who have lost a child. An older brother I never got to meet.

I have dear friends who have lost their children. Mothers and fathers who will never be the same.

I am gripped with grief every time I enter a windowless family waiting room to tell a parent that their child is dead. I often wonder how they are doing now, months or years later. How do they move on the way my parents and my friends who have lost children have moved on?

This is the hardest thing I ever do in my job. I operate on beating hearts. I cross clamp aortas. I whip out spleens 20 minutes skin to skin. But this, this is the hardest thing I have to do as a trauma surgeon, telling parents their child is dead. 

Last night at a trauma surgery professional meeting we were privileged to watch the Newtown Film documentary with the filmmaker and an ER physician who provided care that day and is a Newtown resident. It was a gut wrenching story about the evolution of grief.  It followed the parents who lost their children in this particularly gruesome and entirely preventable way. The grace and dignity with which they tackled life after 12/14 was remarkable, inspiring, and heartbreaking. It followed the teachers, the students, and the first responders who saw and heard what was simply unimaginable in even our worst nightmares…until then. Until 12/14/12.

Carnage: 20 dead first graders. 6 dead educators.

We are having myriad civil discussions at this meeting on what we as a profession can do to reduce firearms injuries. To be sure it’s a careful line to walk in our current societal climate. Avid readers of this blog already know where I personally stand on this issue based on my experiences as a trauma surgeon and the fact that I am human.

But today, today I just can’t get my mind of those dead children. They were loved and cherished lives filled with infinite potential. A lone gunman whose mother thought it appropriate to have a semi-automatic weapon and multi-round bullets in her home took them all away.

They didn’t stand a chance. Not with that weapon. Not with that kind of ammo. All gunned down in <5mi.

How many of us wave good bye to our little tykes, back packs all snug on their shoulders, expecting them to return home at the end of the school day? My own child was a sitting in a first grade classroom not too far north of Newtown, CT on that day. Any of us could be these parents experiencing unimaginable grief.

I am once again listening to the words of Lin Manuel Miranda from Hamilton to try to buoy me through these emotions as a mother, as a surgeon, as a human with a soul.

In ‘It’s Quiet Uptown’ Eliza who has lost her son to gun violence sings:

“There are moments that the words don’t reach.

There is suffering too terrible to name.

You hold your child as tight as you can

and push away the unimaginable.

The moments when you’re in so deep,

it feels easier to just swim down.

…

There are moments that the words don’t reach.

There is a grace too powerful to name.

We push away what we can never understand,

we push away the unimaginable.”

Her husband Alexander sings:

“If I could spare his life,

If I could trade his life for mine,

he’d be standing here right now

and you would smile, and that would be

enough.

I don’t pretend to know

the challenges we’re facing.

I know there’s no replacing what we’ve lost

and you need time”

The chorus repeatedly adds:

“They are trying to do the unimaginable.”

The Newtown Film chronicles a community trying to do the unimaginable. While I cried through most of the film watching the grief unfold, the most powerful moment for me was when David Wheeler who lost is son Ben was testifying to a CT legislative task force. He said “The liberty of any person to own a military-style assault weapon and a high-capacity magazine and keep them in their home is second to the right of my son to his life.” That line took my breath away like a sucker punch to my gut.

The Newtown Film is powerful and difficult to watch but I hope that all of us Americans- parents, teachers, first responders, policy makers, legislators, and professional organizations – all of us  see it.  With this film, I hope that the national dialogue will become less contentious as we realize that no one, no parent, no school, no community, should ever have to suffer such imaginable grief.

Trauma Surgeon’s Ballad by Lin Manuel Miranda

Originally posted on heelskicksscalpel.com

Like much of America, my family is currently obsessed with everything Hamilton on Broadway. We jammed to the sound track all summer. The season culminated with a late August trip to the show which I described on social media as the best day of my life. Seeing the show, the actors, the set, and choreography, come to life with lyrics we had all memorized was such an amazing experience.


I cried.

Part of that was pinching myself that it was actually happening (NB: Tickets now that the original cast is gone are not that hard to find on resale sites but still cost quite a bit above face value.) And the other parts were one particular segment that just cut into my soul when I saw the character of Aaron Burr singing it.

I sobbed.

Let me provide you context. Burr is an orphan who is in love with a married woman. He has decided that with everything he has gone through, all of the losses he has suffered, he is willing “to wait” for the woman he loves. As someone who was taught to hate Burr by her high school history teacher who was a Hamilton scholar, this humanization of Aaron Burr was a bit off-putting at first. But the reason I simply could not stop the tears while experiencing the song with all of my senses as the show was not about the forbidden love story behind it, rather is was the commentary on death.

“Death doesn’t discriminate

between the sinners

and the saints,

it takes and it takes and it takes

and we keep living anyway.

We rise and we fall

and we break

and we make our mistakes.”

These words resonate so strongly with my trauma surgeon’s soul. We provide care indiscriminately, irrespective of race, socio-economic status, mechanism of injury, insurance, etc. And we lose people. Sometimes they arrive lifeless; sometimes our efforts fail. When that happens we are broken. We wonder if we could have done anything differently; did we make a mistake? But we have to go on “living” because there are more patients waiting. Some of them are sinners while others are saints and it doesn’t matter we treat them all the same. Then we wait for the next patient to arrive.

The title of the song is Wait for It.

The Hamilton sound track is still more or less played in a continuous loop in my home, in our cars, on my runs. And every time I hear this song I cry. I can’t help it. It simultaneously breaks my heart for all my patients who have died and provides me reason to keep coming back to this very emotionally challenging and physically exhausting profession. I know it was not Lin Manuel Miranda intent to write this segment of music (the lyrics and the accompaniment which is haunting) for the trauma surgeon in me but that has been it’s effect and I am so grateful.

And as for the burnout that is particularly rampant in my specialty, despite the tears from this particular song, the overall experience of seeing the show on Broadway was truly one of the happiest days of my life – a perfect way to spend a weekend off and return to work refreshed and ready to wait for it. 

We don’t need data, we need to ban semi-automatic assault rifles

Originally posted at heelskicksscalpel.com

I am on call today. It’s been an average day for this trauma surgeon. 1250 miles away, it has been a day of extraordinary carnage at a trauma center in Orlando, and that was for the 53 people who survived the incident. Another 50 were left dead at the scene, all shot by a single person.

Yes, a single gunman.

This tragedy brought up a lot of issues that torment and divide us Americans today.

Anti-gay bigotry.

Islamophobia.

Gun control.

No doubt the perpetrator was a horrible, soul-less person. While whether he was driven by hatred for gays or misappropriation of Islam or an obsession with ISIL are issues worth considering, the fact of the matter is that, regardless of what drove him to do this, his impact would have been far less severe if he had not been in possession of an AR-15 semi-automatic rifle.

In the hours since news of the horrific event emerged, several friends shared a clip of President Obama on the PBS Newshour responding to a query on gun control where he discusses how the reduction of automobile-related mortality was data driven and how we are hamstrung by the NRA and those who are backed by the NRA when it comes to finding data-driven solutions to the gun problem. The President assured his audience that no one is going to take away guns from “lawful, responsible gun owners [who use them] for sporting, hunting, protecting yourself.” In fact, it appears that Moms Demand Action (an organization that emerged after the Sandy Hook tragedy) used data to change its focus from a ban on assault weapons to a focus on background checks and common sense use of firearms. Evidently, the data showed that the 1994 assault weapon ban, which existed for a decade before it was allowed to expire in 2004, did not save that many lives, and the organization wants its efforts to save as many lives as possible.

But let me ask you this:

Did the lives of the 50 people killed and 52 wounded in the Pulse night club not matter?

Did the lives of the 26 people killed and the 2 wounded in Sandyhook Elementary School not matter?

Did the lives of the 12 people killed and 70 wounded inside the Century 16 Theater not matter?

In his PBS town hall, the President also commented on restrictions on background checks which some believe may have prevented this man in Orlando from becoming a gunman. Many people posted the list of the 45 senators who blocked legislation that would have kept someone on a terror watch list, a person of concern to the FBI, from getting any gun legally. However, when there is not a legal way, someone truly intent on killing will find an illegal way. An so this single person who killed so many instantly in such rapid succession would have found a way.

He might have built as bomb as we saw in Oklahoma City and at the Boston Marathon. But, fertilizer, diesel fuel, pressure cookers, and ball bearings have other purposes.

He might have flown a plane into the building as was done in a calculated, multi-person, multi-year scheme set up by a worldwide terror group on 9/11/2001. But planes are intended for transport.

I could go on and on. And I often hear these myriad ways that others can kill cited when people state “Guns don’t kill; People kill.” Heck, I see them daily in my job: beer bottles, baseball bats, ice picks, kitchen knives, pipes, motorized vehicles…These all can be used to commit murder but are nowhere near as efficient as a semi-automatic rifle.

And for these reasons, yes it is worth discussing what motivated this man to commit mass murder. It’s worth trying to understand how he became this venomous monster. It’s worth examining our processes of surveillance by law enforcement of those whom we suspect might become venomous monsters. But come on, do we really need to amass any quantity of data on semi-automatic rifles? A single magazine can hold 20 to 100 rounds of military grade bullets and fire up to 60 times a minute. Do we need really need study if this kind of weapon is necessary for decent law-abiding folks to shoot tin cans in their back yards, or take down deer for sport, or protect themselves from home intruders?

Don’t get me wrong. I am both a surgeon and a health services researcher. I thrive on studying vexing issues through data collection and robust statistical analysis. I believe evidence-based approaches. Like many trauma surgeons and injury prevention researchers, I too want to know if biometric locks would reduce accidental deaths due to handguns. I wonder what psychometric tools might be used to optimize background checks if we ever could effectively implement them. I just don’t think we need data on this particular kind of weapon.

In case you missed it before, the kind of weapon that was used to kill 50 people nearly instantly and injure 52 more in Orlando overnight, was also used to killed 12 and wound 70 in Aurora, CO and was used to kill 20 children and 6 adults while injuring 2 more in Newtown, CT.

I was recently attended a talk by Dr. Lenworth Jacobs, a renowned surgeon at Hartford Hospital. He spoke of what steps they took on the day of the Sandy Hook massacre to ready their trauma center. Alas, no one was transported there because the vast majority were dead at the scene. Dr. Jacobs had the difficult task of reviewing every single autopsy while preparing a consensus statement on how to handle active shooter events. The air went cold as he described to a room full of surgeons what the military grade ammunition did to those poor kids’ bodies. They never had a chance.

The Hartford Consensus statements that would emerge from this review of Sandy Hook and other mass shooting focused on how to prepare civilians, first responders, and trauma centers to save as many lives as possible in the face of such horrific events. Nothing was said about the weapons themselves. When asked about this, the Dr. Jacobs responded that it’s too politically charged; and since active shooter events will presumably continue to happen, our role [as surgeons] was to identify a problem that is addressable (people dying of possibly preventable hemorrhage) and address it (education on hemorrhage control within the context of active shooter events). The logical person in me who understands that the right to bear arms in part of the fabric of US society admired the pragmatism and ingenuity regarding active shooter events described in Dr. Jacob’s talk.

Less than 3 weeks later there was the deadliest ever active shooter event in Orlando. To be sure, some of the 53 who lived must have benefited from the data reviewed for the Hartford statements. But please don’t tell me that you need data or that data is the reason why you won’t stand up and say “no, not ever” to a type of gun that can rip holes in the aorta, pierce through the brain, pummel through the heart, and break strong bones into bits and pieces in an instant up to 60 fucking shots a minute. There is no need for civilians to ever have this kind of a weapon. Not ever.

And while it’s true that people will continue to die because those intent on killing will do so with criminally acquired firearms or by weaponizing everyday objects, because law-abiding gun owners will continue to be careless with their hunting rifles and handguns, and because those suffering from depression will commit suicide by firearm, we simply cannot stand behind this veil of data in not calling for a ban on semi-automatic assault rifles.

The overall number of people killed by the AR-15 and similar military grade firearms might pale in comparison to the aggregate numbers of lives lost through other forms of gun violence but lets not devalue the lives of those killed and injured with these heinously destructive weapons by pretending we need data to ban them.

We don’t need data. We need to stand up and do the right thing. We need to put an end to the ‘single shooter able to kill multiple victims in just a few minutes’ phenomenon made possible by the deadly combination of soul-less perpetrators and powerful semi-automatic assault rifles.

_______________________________________

Since this post was first shared a number of people have posted petitions regarding a ban on assault rifles. I don’t know what if any impact any of these will have but I am sharing them below.

https://petitions.whitehouse.gov/petition/ban-ar-15-civilian-ownership

Renew the Ban On Assault Weapons

http://petitions.moveon.org/sign/ban-assault-weapons?source=s.fb&r_by=15891390

https://www.change.org/p/tell-congress-the-president-reinstate-the-assault-weapons-ban