By Laura McKnight
NOLA.com | The Times-Picayune
Dr. Juan Duchesne remembers treating his first gunshot wound -- and his amazement at the particular ways a bullet can devastate the human body.
The teenage patient had been "sprayed" with an assault-style rifle while playing basketball in a New Orleans park, but his exterior wounds were small, and he seemed to be doing okay.
"I said, 'Okay, well, the patient has a pulse, doesn't look bad," Duchesne recalled to a room full of local medical students gathered Sept. 17. "At the end of the week, he lost both legs."
Duchesne, medical director for University Medical Center's Trauma Intensive Care Unit, was a first-year intern at Charity Hospital when he handled that first gunshot case. He said he did not yet understand how a bullet's small entrance can hide severe damage along its trajectory through muscle, bone and other tissue.
As bullets tear through the human body, they can rotate or hit with such high velocity that they leave large cavities in their wake. The cavities may be temporary, but the affected tissue can be permanently damaged or killed, Duchesne said.
The mechanics of bullets and how their caliber, velocity and other variables cause different types of injuries are not typically part of medical school curriculum, Duchesne said, but they should be. Though he could not have saved the teen shooting victim's legs, it's important for doctors to grasp the way bullet injuries work, he said.
"We need to understand ballistics," Duchesne said.
The doctor, who also serves as a surgery professor and Division Chief of Trauma and Critical Care at Tulane, has developed a one-day program to help train doctors on ballistics.
He spoke Sept. 17 as part of a panel on gun violence held at Tulane University's Murphy Building downtown. The event was hosted by Tulane University Medical School's American Medical Student Association in conjunction with a national AMSA campaign, said Abby Solomon, advocacy chair for Tulane's AMSA chapter and second-year medical student at Tulane.
The discussion centered on treating gun violence as a public health issue, deserving of study and incorporation into medical training and practice.
From learning ballistics to screening patients for risk factors associated with getting shot, panelists offered a glimpse of what it might look like for the medical field to treat gun violence as a prevalent health problem.
"It's a public health issue in lots of ways: It's very preventable, it's very predictable and it causes a great deal of economic burden on this country, and we need to pay a lot more attention to it," said Stephen Phillippi, director of the Institute for Public Health and Justice at Louisiana State University -- and a lifelong gun owner.
Phillippi and Peter Scharf, a criminologist and adjunct professor at LSU's School of Public Health, gave the crowd an overview of the issue from a public health standpoint:
* 85 people a day die from gunshot wounds in the U.S., making gun violence a leading cause of premature death in the nation. In addition, 201 people are treated daily for non-fatal gunshot wounds.
* The U.S. homicide rate is seven times higher than in 22 other high-income countries, according to a 2016 study in the Journal of American Medicine using World Health Organization data from 2010. The U.S. rate was driven by a gun homicide rate that was 25 times higher than other developed countries.
* Although New Orleans' 157 murders last year represented a dip in the city's murder rate, it still holds one of the highest rates in the country. Most New Orleans murders are committed with guns. Most are intentional and targeted, as opposed to killings of bystanders, Scharf said.
* There are 10 times more guns in civilian hands in the U.S. than in the next closest country.
* Motor-vehicle deaths once exceeded firearm deaths, but that is no longer the case. "We made cars safer," Phillippi noted. He later described how guns could be made safer with available technology, such as "smart gun" tech that allows only the authorized user to fire the weapon.
* Firearm injuries in the U.S. cost an estimated $229 billion annually, including emergency services, police investigations and long-term medical and mental healthcare needs, among other costs. Phillippi added that gun violence has been shown to cause socioeconomic harm. "It depresses business growth, it harms neighborhood economics, and it also furthers cycles of disadvantage," he said.
* Though cost estimates differ, gunshot wounds are expensive. During the panel, Scharf said gunshot wounds cost an estimated $1 million to $6 million, depending on whether the patient dies or requires long-term care. A 2015 Mother Jones report placed the cost at about $583,000 for each gun injury requiring hospitalization and an average $6 million for each gun death.
Gun violence research trapped in political battles
Despite the prevalence of guns and the many costs of gunshot wounds, research on gun violence in the U.S. has long been a contentious political issue, especially since passage of the Dickey Amendment in 1996. The legislation said the U.S. Centers for Disease Control couldn't "advocate or promote gun control," which essentially froze any research into gun violence.
The amendment, pushed by the National Rifle Association, came with a significant budget chop and was passed on the heels of a 1993 CDC-funded study that showed having a gun in the home raises the likelihood of homicide.
In speaking with students, Phillippi and Scharf encouraged the future doctors to ask patients about risk factors for falling victim to gun violence, such as whether patients have access to guns or involvement with social groups prone to violence, much as doctors now screen patients for risk factors for diabetes or other health problems.
Doctors are in a unique position to screen people for risk factors for being shot, Scharf said.
"When you're doing your rotations, are you asking kids if they're packing, who they're hanging out with?" he asked.
For patients deemed at risk of gun violence, Angelle Bradford, leader of Louisiana's chapter of Moms Demand Action for Gun Sense in America, suggested doctors direct those patients to community groups and other resources intended to help people escape cycles of violence.
Scharf also mentioned hospital-based ceasefire programs that train medical staff to intervene when shooting victims or their family or friends express a desire to retaliate.
Part of prevention could be helping patients to change their perspectives on gunshot wounds, considering how some shooting victims have been shot repeatedly, Scharf said.
"There's a banality to getting shot. How do you make this not a banal event, but a serious life-changing event?" Scharf asked. "When somebody has high blood sugar, you intervene...I don't think we're quite that way with gunshot injuries and we need to be."
Information collected by doctors and healthcare workers could also aid groups like Bradford's in passing legislation intended to curb shootings, both intentional and accidental.
Phillipp described himself as "a huge advocate for gun safety for many, many reasons," including those related to public health.
The common thought is that Americans do not like "gun control," but polls have shown that most Americans are in favor of "gun safety," he told the group.
"If you frame the issue correctly, people will come to the table and they'll talk about it," Phillippi said.
He advocated for greater responsibility and accountability on behalf of legal gun owners.
"I cannot count the number of patients, in terms of my own work as a social worker and the number of individuals who I consider some of my dearest friends, who have lost kids simply because they were also hunters, gun owners, and they failed to lock up their weapon and went to work one day and came home and found their child dead," he said. "And these are good, good human beings. But they failed to lock up their guns. And kids are curious."
Children are not the only ones taking unsecured weapons, Scharf said. Many crimes committed in the city involve stolen guns. A number of those are stolen from unlocked vehicles, a fact NOPD commanders and Jefferson Parish Sheriff's Office leaders have cited while pleading with locals to lock their vehicles' doors.
It's a "sticky area," Philippi said. "Are you blaming the legal citizen for the crime? No, but I do think that you have a lot of responsibility to keep your weapon very safe."
Even with medical training on ballistics and gun-safety legislation, panelists acknowledged, the deeper, socio-cultural issues that lead to intentional gun violence must also be addressed. Scharf described alienated, often poverty-stricken pockets of society whose members, often failed by the education system and barred from the legal workforce by a felony conviction, are driven to earn livings in illegal ways.
"It's not just a gun problem--it's a poverty and also an education problem," Scharf said. "It's a very complex problem."
Duchesne, who since his days as an intern has treated many shooting victims, agreed.
"We need to do better as a community," he said.
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