Treating a gunshot wound isn’t just closing an entry and exit wound, or even just treating the places a bullet directly traveled through. When a bullet shoots through an organ, it often causes trauma to the surrounding area. That needs to be part of the treatment plan as well.
“Gunshot wounds are not what you see in the movies, (where) a bullet goes through the front and then it comes out in the back,” said Dr. Kenneth Lee, division manager of the Spinal Cord Injury Center at the Milwaukee VA Medical Center, which cares for patients in need of rehabilitation, including those who suffer from paralysis after a gunshot wound.
There could be tissue damage, shock to various organs or pieces of the bullet stuck in a patient’s body, not to mention mental health consequences like post-traumatic stress disorder and depression.
“The trauma that bullet causes through its travel through the body is not just a tunnel,” Lee said. “There are all these … hidden (injuries) that we have to keep an eye on as we take care of people with gunshot wounds.”
The trauma team at John H. Stroger, Jr. Hospital of Cook County Health in Chicago treats hundreds of firearm injuries a year.
The hospital’s Level 1 trauma center includes seven trauma attending physicians, as well as a trauma fellow, nurses, various specialists and physical and occupational therapists who cared for more than 1,100 gunshot wound patients in 2020, up from 815 in 2019.
Dr. Faran Bokhari, chair of trauma at Cook County Health, started working at the system more than two decades ago. Since then, he said he has noticed an increase in patients coming in with multiple gunshot wounds and patients coming in with injuries from firearms that destroy more of the surrounding tissue.
To treat those injuries, Stroger Hospital has various programs focused on continuous quality improvement, so that clinicians are prepared for the next traumatic injury that comes through the hospital’s doors.
Every morning, trauma staffers meet to review each case from the previous day and present the unit’s current patients to that day’s clinicians. Bokhari describes it as a daily “peer review” of patient cases, to better understand what went well and what didn’t the day prior, as well as to explain any decisions that deviated from the standard of care.
It also offers an opportunity for clinicians to ask questions about how certain cases were managed.
“The environment that you create has to be a collaborative (and) healthy one,” Bokhari said. “It cannot be an egotistical, standoffish one.”
Stroger Hospital implemented the daily review sessions decades ago, as a way to ensure care was being delivered according to standard protocols and to provide quality assurance.
That was during the tenure of Dr. John Barrett, former director of the trauma center at Cook County Hospital, Stroger’s predecessor, from 1982 to 2002. Since retiring in 2002, Barrett has advocated for gun control legislation, a decision he said grew out of his experiences working in the trauma center.
He recalls an increase in more severe gunshot wound injuries in the 1990s, which he attributed to higher velocity weaponry, chiefly semiautomatic handguns.
When Barrett started as trauma director, he said only 5% of trauma patients were struck with more than one bullet; that rose to 25% of patients by the ‘90s.
Barrett said that if a patient experienced an adverse event—or even died—the case would be reviewed in more detail after the daily review to draw out lessons.
Attending physicians in the trauma unit are also required to do research, so that they’re constantly studying how to improve trauma care, according to Bokhari. Some physicians recently focused on how obese patients might need different treatment than patients with lower BMIs.
The trauma center has also worked on bolstering its quality assurance process, by having front-line physicians and researchers review patient cases with quality assurance staff.
Together, they identify possible areas for improvement and develop new protocols. That has helped staff to better understand various steps that take place during patient care, such as at what time of day certain staffers might have competing responsibilities that could result in delays, or other areas where processes could be streamlined.
It’s important to include clinicians in those quality improvement conversations, Bokhari said, since they’re ultimately the ones who know what efforts will have the greatest effect on patient care.
“You don’t want to focus your efforts on the wrong thing,” he said. “The only person that’s going to know that is the practitioners.”