The Bullet and the Damage Done

In Hollywood movies, gunshot wounds are quick and clean. But in West Philly — and countless other urban killing grounds — getting shot is ugly business

A 357 Magnum Revolver Is Fired Producing A Huge Muzzle Blast, July 20th, 1999 Credit: Tom Mihalek/Getty Images)

On a recent Thursday afternoon at the hospital of the University of Pennsylvania, one of the busiest and best gunshot-wound hospitals in the country, the call came in about a "scoop and run." That's cop speak for a victim so full of holes that the officers on the scene don't wait for an ambulance to respond. This' victim, the dispatcher told Dr. Elliott Haut, a thirty-two-year-old surgeon on call, had been shot multiple times, including once in the face, in broad daylight inside a Jamaican restaurant about twenty-five blocks away.

That would be West Philadelphia, Haut knew, and he wasn't surprised. Sometime around the late 1980s — when crack hit the city — that neighborhood of abandoned buildings and crumbling hope had become an urban battleground. Last year, 1,320 people were shot in Philadelphia, many in West Philly. In the last six months alone, Haut himself had treated about 100 of them.

A white police van driven by two young patrolmen squealed to a stop outside the HUP trauma bay minutes later. Facedown on the floor in the back of the van, in an already drying pool of blood, lay a muscular black man about six feet two inches tall. Paramedics slid the man onto a stretcher and hustled him inside, where Haut and a colleague, Dr. Ruby Skinner, set to work. Trauma patient No. 843, who carried no identification, had taken at least seven rounds, probably from a 9 mm handgun, including one that tore through the roof of his mouth, flipping the patient's teeth upward grotesquely, like the wet mustache of a sea lion. That shot looked like it came from almost point-blank range.

On the streets of Philadelphia, as in most major American cities, the 9 mm semiautomatic remains the weapon of choice, having replaced bulky, inaccurate Saturday Night Specials about fifteen years ago. Shooters like the "9" because it is small and thin and holds more ammo than most revolvers — between seven and thirty-two cartridges — thus increasing the chances of hitting a target. From a trauma surgeon's perspective, that means that people who get shot with a 9 mm tend to get hit, on average, with two bullets, increasing the likelihood of grievous injury.

"No pulse!" cried a nurse, feeling in the man's groin area and around his neck, as another nurse cut his clothes from his body. A doctor struggled to insert an airway through the man's bloody clump of lips and teeth. A CO2 sensor confirmed what the surgeons already knew: Trauma patient No. 843 was not breathing. Haut turned the man on his side; a crushed, blackened slug dropped onto the examining table.

Skinner ordered the insertion of intravenous lines to pump in drugs that might restart the heart. If the patient wasn't revived within a couple of minutes, Skinner would decide whether or not to open the man's chest and take his stopped heart into her surgical-gloved hands and massage it. A young hospital chaplain looked on apprehensively, clutching his Bible.

HUP was not always one of America's top trauma centers. Until 1987, it was a second-rate inner-city hospital. That year, Dr. C. William Schwab, a professor of surgery at the hospital and head of its division of Traumatology and Surgical Critical Care, installed a helipad on the roof — so patients can be coptered in — and led a campaign to transform HUP into what is known as a Level One Trauma Center, meaning it has highly trained staff and state-of-the-art systems in place that enable it to offer care for critically ill patients twenty-four hours a day.

Bullets injure 100,000 people and kill 28,000 a year in the United States, second only to car crashes in terms of deaths related to injury. HUP averages one gunshot victim per day, more on hot summer weekends; fully fifty-one percent of the people who died in its trauma center in 2002 had been shot. Wounds inflicted by-high-powered rifles, which can fire bullets at more than 3,000 feet per second, are rare, although two young people rushed to the HUP trauma bay last year lost parts of their legs to slugs from an AK-47.

Contrary to what Hollywood teaches us, many gunshot injuries are not simple through-and-through holes that either kill the victim instantly or heal up after being cleaned and dressed. Bullets, depending on their trajectory, can inflict horrible wounds that damage vital organs and blood vessels and require radical, debilitating and expensive surgical procedures in order to prevent death. In many cases, life after being shot is never the same. "These events take place in less than a tenth of a second, followed by a lifetime of trying to get patched up and rehabilitated," said Dr. Stephen Hargarten, a firearm-injury expert at the Medical College of Wisconsin, in Milwaukee. "And we're all affected, either emotionally or in our pocketbook."

Take the case of Stanley Ramsey, 19, shot one night in July 1999 outside a Southwest Philadelphia chicken restaurant, in an all too typical dispute over money and drugs. Within minutes, Ramsey lay unconscious in the HUP trauma bay, a bullet having severed his spine and spinal cord, while a team of five doctors and five support staff tended to his wounds. The surgeon in charge that night, Dr. Patrick Reilly, HUP's trauma program director, figured Stanley Ramsey would not do well at all.

Ramsey lived, barely. He stayed in intensive care for six weeks and underwent four surgeries. And that, for Stanley Ramsey, now a quadriplegic, was only the beginning. During the two-year period following the shooting, Ramsey required a ventilator to breathe for him and, at various times, developed blood infections, contracted pneumonia, came down with a chronic hip ulcer and suffered uncontrollable muscle spasms. Speaking in a hoarse, barely audible stutter, he testified lying supine on a hospital gurney at the trial of his assailant.

Even today, after many months of dispiriting and exhausting rehab, Ramsey cannot even push a button; he pilots his motorized wheelchair by blowing into a straw. "Ramsey's future is bleak," Reilly said. "I don't think his quality of life will ever improve." Nonetheless, the total cost to date of Ramsey's care and the police investigation of his case already exceeds $2 million, much of that covered by Pennsylvania taxpayers. Should he live another forty years, that $2 million figure will mushroom to $15 million. Add that to the costs incurred by others in Ramsey's predicament: Every year, HUP treats about fifteen people who have been shot in the spine.

Rocketing along the barrel of a gun, a bullet accelerates continuously, building the energy that becomes the basic source of its lethal doings. Just how fast it accelerates depends on muzzle velocity — a poky 855 feet per second from a .38, vs. 1,155 feet per second for a slug from a 9 mm semiautomatic. On impact, two cavities typically form in the body: a relatively thin, permanent cavity, as tissue is instantly pulverized; and a larger, temporary, oval-shaped one, as tissue is thrust away from the wound track. Cavity size depends on the bullet and its velocity: A .357 Magnum slug, traveling at 1,393 feet per second, forms a permanent cavity much larger than that formed by a .45 round, traveling at 869 feet per second. And, often, it does a great deal more damage.

The carnage does not stop in the cavity-forming stage. It's where the bullet goes afterward that spells the difference between recovery and obituary. "If I know the exact path that the bullet takes through the body, I can figure out what may or may not be injured," said Haut, a mild-mannered physician's son who grew up in the suburbs of Philadelphia.

If you get hit in the torso, for example, you'll most likely be in big trouble. The abdomen is packed with vital structures — the stomach, the liver and the intestines, as well as major blood vessels. (Nonelastic tissue, such as that found in the liver and the brain, tends to fare the worst.) The chest is another place you don't want to get plugged; if a bullet nicks your heart or aorta, you'll probably die at the scene.

One afternoon at HUP, Haut went up to the sixth floor of the Dulles Pavilion to visit a gunshot victim whom we'll call Fred. He had been hit multiple times about five weeks earlier on a street in West Philadelphia, under circumstances that remained murky. The slugs hit Fred, an unemployed twenty-year-old, in his back and thighs, leaving him with significant wounds to his colon, stomach, small intestine and a leg. "My stomach went numb," Fred says in a gravelly mumble, recalling that night. "I saw my bowels hanging out of my stomach, out of the hole."

Haut's colleague, Ruby Skinner, had been the surgeon in charge when Fred arrived at 11:42 P.M. on October 15th. She saw how much blood he'd lost. Behind her surgical mask, Skinner whispered to a colleague, "This guy's going to die."

And Fred, had he not had the good fortune to be lying in a Level One Trauma Center, probably would have expired. Within ten minutes, he was upstairs in the operating room undergoing an extremely painful Hail Mary procedure known as an emergency laparotomy. Using a large scalpel, Skinner made a long, straight-line incision from the bottom of Fred's breastbone to the top of the pelvis. "When we opened his abdomen to explore," Skinner says, "pretty much his entire blood volume bled out. We almost lost him."

Fred lived, but he wasn't the same Fred. And, like Stanley Ramsey before him, he probably never will be. Fred remained in intensive care — a room there runs $8,000 to $10,000 per day — for a month. His belly was so swollen from blood loss and the fluids that he'd received that the surgeons could not close his abdomen. It remained open, and oozing, like the shell of a large tortoise, for five weeks. Doctors partially covered the wound by taking skin grafts from Fred's legs.

By late November, Fred had undergone six surgeries. A leak remains where his colon was repaired, and stool regularly drips out through the edge of this wound. In six to nine months, Fred will require yet another major operation to essentially reconstruct his abdomen and, with the assistance of plastic surgeons, close it up. Surgeons will begin by removing the grafted skin currently covering Fred's bowel and freeing the muscle from underneath it. They will fix the hole in the colon, where the stool is leaking, then cut the muscles and rotate or flip them to cover the wound to the colon. The procedure takes four to six hours. Fred will remain in the hospital for another week.

Once a fit and toned young man, Fred now looks almost middle-aged, though he's barely out of his teens. In recent days, and with a nurse's help, he'd been able to shuffle to the bathroom — as ambitious a journey as Fred had taken since the night of October 15th, 2002, on the streets of West Philadelphia. Upon entering Fred's room, Haut turned off a blaring Oprah and unfastened Fred's white abdominal binder, carefully peeling back the dressing over Fred's bloated abdomen. The dark, wet tissue glistened between the rough patches of grafted skin that rested directly on Fred's exposed bowel. He winced as Haut covered him up again.

Fred hopes to go back to school and study computer graphics, but he probably won't be playing any ball for a long while. Only the day before, doctors had removed Fred's tracheotomy tube and Fred, for the first time in the five weeks since he'd been shot, was breathing on his own. "I feel good," he said. A tear slid down Fred's cheek, and his hands trembled. "You did good for me," he told Haut. "I thank you."

Fred knew he was fortunate. "If one of those bullets had hit two inches to the right," he said, "it would have hit my spine, and I would have been paralyzed." Fred, nevertheless, wasn't completely sound. The bullet that slammed into his left leg had damaged the peroneal nerve, which controls the muscles that help the foot bend upward. Now, when he walks and lifts his left leg straight up in the air, the toes of that foot drag awkwardly on the ground. Physical therapists had already fit Fred with a splint that keeps his left foot at a ninety-degree angle. But his lack of control over the leg had left Fred feeling defeated.

Fred was also lucky that the shots to his belly didn't cost him any major organs. "A lot of times you end up having to take out a kidney or the spleen or part of the liver," Haut said later, standing at the nurse's station. "He lost some of his colon and small intestine. Those are all things you can live without." Haut snapped shut Fred's chart, which was already three inches thick. "But he's not going to be normal for a very long time."

One Sunday morning at HUP, Dr. Bill Schwab sat down to review some recent gunshot-wound cases in his second-floor office. Warm, plain-spoken and unfailingly even-tempered, in a world where hot tempers and outsize egos are common, Schwab, at fifty-six, enjoys near-legendary status at the busy hospital. In 1984, Esquire named Schwab as one of its "Men and Women Under 40 Who Are Changing America." In 1997, he founded the Firearm Injury Center at Penn, a research group devoted to curtailing gun violence. Perhaps his greatest achievement has been building HUP's trauma department.

Trauma surgery is one of the few disciplines in medicine where split-second decisions are absolutely necessary to save lives. Schwab calls trauma "the crown jewel of surgery." Trauma surgeons are also probably the last true generalists in the increasingly specialized world of medicine. A trauma surgeon must be able to solve problems in the emergency bay, the operating theater and the intensive-care unit. The hours are brutal, the burnout rate high. Trauma surgeons see it all, every night. Images of children who have been shot tend to stay with them the longest.

The case of the AK-47 victims who arrived at HUP last year with parts of their legs shot off flashed on Schwab's computer screen. They were a young, attractive couple, sitting on a porch in West Philadelphia, victims of a drive-by shooting. The typical AK-47 slug is fairly small in diameter, about the size of a .22 caliber bullet. Its lethality derives from its high speed — two to three times that of a 9 mm shell.

Both victims took two rounds each, including one to each of their left thighs. The shots came from below, from a car, toward the porch. "They were shot with the trajectory coming up, so the bullets proceeded up, into their pelvises and their abdomens," Schwab said. Both had their abdomens opened after arrival at HUP, to stop bleeding and to repair injuries to a number of internal organs.

Their left legs were a different story. They had no blood flow below the point of impact, and nerves and blood vessels in the area were damaged beyond repair. HUP surgeons had no choice but to amputate. Schwab knew that if these two young people had been shot with a handgun instead of an AK-47, their legs probably could have been saved.

Schwab pulled up some more slides on his computer. One showed tissue and blood billowing in enormous waves from a man's chest — another example of a high-velocity gunshot wound. The wound looked like a chicken of the woods, the bright-orange fungus that grows on the dead wood of trees. Schwab clicked his mouse. There, with Schwab's hands around it, was a bloody purple and red pulp — what was left of the liver of a man who'd taken multiple shotgun pellets in the midsection. "The slug came in at close range, hit the liver and literally exploded it apart," Schwab explained. "We got in there and tried to save his life, but he died."

Schwab clicked onto a picture of a femur broken by a .357 Magnum: "The bullet came in and destroyed the bone, set off multiple fragments, kept on going and blew out." The cavity formed was as big as a cantaloupe. "He had no blood going into his leg. We immediately opened it, resuscitated him, put in shunts, packed this whole thing, brought him back two days later and reconstructed his artery, and then reconstructed the leg. This man, interestingly, came in with no vital signs, no blood pressure and no pulse."

Dr. Skinner looked grim. After seven minutes in the trauma bay, patient No. 843 still showed no vital signs. Examining the man from head to toe, Haut kept shouting, "Gunshot wound! Gunshot wound!" There were fourteen holes in him altogether, including sucking chest wounds. Skinner felt tiny puffs of air leaking from those.

The bullet to the man's mouth could have traveled into his brainstem and killed him instantly. Any of the several rounds he'd taken to the chest could have severed a vital artery or even struck the heart. Skinner figured that's what killed him.

Haut peered at a monitor; the flat line hadn't budged. While CPR continued, Skinner thought better of opening the guy's chest. He had no pulse or blood pressure. This guy was dead. He'd come in dead, and stayed that way.

Pat Reilly, the surgeon who treated Stanley Ramsey, the victim of the $2 million bullet, hurried in, looking grave, and consulted briefly with Skinner. It was time to "call it," they agreed — to declare the man dead and cease resuscitation efforts. And so, eight minutes after arrival at HUP, trauma patient No. 843 received a toe tag. While nurses zipped the corpse on the gurney into a body bag, Reilly rummaged around on a desktop and located a form titled Discharge Instruction Following Gunshot Wound. Trauma patient No. 843 wouldn't be needing this document, but plenty of other people who get shot in and around Philly do. It's sort of a handout for survivors, counseling victims on wound care and dressing, and how to deal with bullets the surgeons can't take out. Helpful hint: "You will not be affected by Airport Security if you have retained a bullet."

"It's almost laughable that we have them," Reilly said. But HUP did so much gunshot business, a set of instructions like this had become essential.

Homicide detectives, delayed by another murder, showed up twenty minutes later. Haut checked his watch and headed upstairs to complete his rounds in the ICU, well aware of the challenge the detectives faced. Few shooters are found, in part because many gunshot victims who survive remain tight-lipped about their attackers. "We joke around a lot as to 'Who shot you?' " Haut said. "It's either 'some dude' — that 'some dude' shoots three or four people a week. Or 'mean guy' — he shoots people, too. And 'that bastard' -'that bastard' gets them, also."

That night, news of the shooting inside the Jamaican restaurant received some play on the ten o'clock news, and the next day, the Philadelphia Inquirer ran three paragraphs on the killing. It was reported that the dead man had been twenty-eight years old and that police were searching for a black Nissan Maxima seen leaving the crime scene. The coverage surprised Haut and Skinner both. Oftentimes, a person goes down like that in a spray of bullets on the streets of Philadelphia and it doesn't even make the papers.