When a gunman who had coolly calculated his strategy for maximum damage opened fire on a crowded concert in Las Vegas earlier this month, he killed 58 people, making it the deadliest mass shooting in modern U.S. history. Numerous media outlets have painstakingly assembled the stories of those who died and humanized them in death. But somewhat less discussed are the 489 other individuals he injured.
We know from examining the aftermaths of other mass shootings that these hundreds of injured have a long and difficult journey ahead of them, and one that's likely to be forgotten as headlines about the Las Vegas massacre inevitably fade. While they may drop from the news cycle, survivors and witnesses often live with a lifetime of psychological and physical issues – and could struggle to find help as Trump and his fellow Republicans work to gut Obamacare.
Mary Reed was shot three times during the shooting at a January 2011 event in Tucson for then Rep. Gabby Giffords. Reed tells Rolling Stone people have expressed to her, "I don't want to speak with her – she was only injured. I want to speak with someone who was really affected."
Reed, who attended the event with her husband and two young children, was shot while shielding her daughter from gunfire. She now lives with a bullet lodged in a nerve bundle near her spine, causing intractable chronic pain. For her, every new mass shooting reminds her of how society focuses on killers and fatalities, but tends to forget those who live through such tragedies with injuries or disabilities.
Living through these events isn't easy. Jeremy Cannon, a trauma physician at Penn Medicine who served three tours in Iraq and Afghanistan, says the kinds of injuries inflicted by semiautomatic weapons like those used in Las Vegas are distinctive, and especially challenging to treat.
High-velocity weapons carry a lot of kinetic energy, which can cause huge amounts of blood loss, Cannon says. And that's not the only problem. "When they strike tissue, it just creates a tremendous amount of destruction," he says. The full extent of such injuries isn't always apparent, complicating treatment. For instance, tissue death that may not be apparent on initial evaluation can cause serious, even fatal, complications. Survivors may deal with a lifetime of acquired physical disability thanks to bullets that cannot safely be removed, spinal cord injuries or limb loss.
Cannon's experience in military contexts gives him a personal relationship with the kinds of injuries seen in Las Vegas, and he notes many of the improvements that help physicians treat injured patients come from military practice. But, he adds, "in some ways the mental anguish can be as much, if not more, devastating than the physical wounds."
That emotional trauma is a significant fear for mental health providers as well as survivors who have been there and know what Vegas survivors are facing. "I am profoundly concerned about how people are going to be able to heal from this," says Reed, noting she found it particularly hard to find mental health support for her children after the Tucson shooting; she has a vivid memory of watching her son "pick brains and blood out of his sister's long blond hair." The shooting also profoundly changed her sense of personal safety and control. But friends and neighbors didn't know how to interact with the family. Reed remembers people suggesting to her, "Oh, you were only injured."
Steven Berkowitz, director of the Penn Center for Youth and Family Trauma Response and Recovery, stresses that in the aftermath of a shooting, the psychiatric fallout for survivors, especially young people, can be severe. Violent incidents like these, he says, "tend to have worse long-term outcomes than other types of traumatic experiences," with emotional responses punctuated by anger, feelings of helplessness and an erosion of survivors' sense of safety.
While many people may think of post-traumatic stress disorder in the aftermath of shootings, Berkowitz says other mental health conditions can come into play as well. Some people develop severe anxiety or depression, for example, and those with long-term physical impairments may struggle with daily reminders of their experience, like lost limbs or paralysis. The understanding that emotional stress interacts with physical health is also informing trauma care, Berkowitz says, with health care providers recognizing that inadequate mental health services can cause physical, not just emotional, symptoms.
Both Berkowitz and Cannon express concerns about one element of the Las Vegas fallout that's somewhat unusual among recent U.S. mass shootings: Most of the survivors were from somewhere else. After receiving treatment and stabilization at well-resourced hospitals in the area, they're returning home to areas that may not have adequate trauma care programs or follow-up plans in place.
Cannon says that in the military, providers deal with this problem with weekly teleconferences during which physicians across the military health care system can compare notes on patients and track them through recovery. "You have to have a commitment that you're going to get them back to full functional status, not just survive," he says.
Reed says the victims' advocacy program through her local Pima County Sheriff's Office made a tremendous difference in her recovery, helping her regain her sense of control and move forward with her life. It had such a profound impact on her that she later trained to join the advocacy team and spent several years supporting victims of other violent crimes. "It was part of my healing," she says. For victims of the Las Vegas shooting, that kind of long-term follow-through may be more challenging to provide.
Concerns about the immediate and long-term psychiatric and physical needs of shooting survivors aren't the only things weighing on the minds of people like Reed and Berkowitz: The elephant in the room as the United States responds to mass shootings is the tremendous financial cost for those facing both immediate and lifetime medical expenses. In a sense, surviving a mass shooting is the ultimate preexisting condition – and that makes it vulnerable to Republicans' efforts to gut Obamacare. Without protections for preexisting conditions, and coverage through the ten essential benefits at the core of the law, the survivors of mass shootings could face tremendous medical debt.
"We know that we have created a false dichotomy in terms of thinking about health," says Berkowitz, referring to the medical community's history of treating mental and physical health care as separate, often unrelated issues, and of insurance companies not covering mental health needs as well as they do physical ones. The Mental Health Parity Act of 1996, along with several Obamacare provisions, have forced insurers to treat mental and physical health equally – but the stigma associated with mental health care remains.
From 2006 to 2014, the United States spent $735 million on immediate medical care for shooting survivors. A third of that, according to an article in the American Journal of Public Health, was covered by Medicaid – which many Republicans are trying to defund. A quarter of patients were "private pay": uninsured. Long-term costs for people with serious, complex injuries can climb into the millions, according to the Brady Campaign to Prevent Gun Violence.
"What we are experiencing is a unique American nightmare," says Colin Goddard, who survived the 2007 Virginia Tech shooting. Recently – a decade after the attack – he needed surgery to remove migrating bullet fragments that were slowly poisoning him.
Goddard, who now works as a gun violence advocate, says his post-shooting experience was unusual: Unlike the vast majority of victims of gun violence in the United States, he didn't shoulder the cost for his immediate or ongoing care. His recent surgery was covered through a fund developed to support Virginia Tech survivors, with money coming from donations and a settlement paid out by the university. (He estimates the costs for surgery, physical therapy and related care at around $100,000.) But such funds, when they exist, don't always reach victims of mass shootings, and they are rarely established for other victims of gun violence. The reality is that support is limited for most of the roughly 222 people who survive shootings each day in the U.S.
The public health implications of compromising care for victims of the gun violence epidemic in the United States are considerable. For survivors like Reed, those obstacles are combined with a desire to be seen and heard. Rarely hearing about victims doesn't just deemphasize their significant health care and social challenges in the wake of a shooting – it can also be isolating for newly injured people who have entered a world they never thought they'd see. In the wake of events like the Las Vegas shooting, survivors of prior shootings often reach out to offer a helping hand and issue a warning: The road ahead can be long, dark and lonely. "It's a club no one wants to join," Reed says. "And you don't even know [it] exists until you've become a member."