Artificial cadavers, daily huddles helping hospitals care for firearm injuries

Dr. Gainosuke Sugiyama was tucking his son into bed when he got a call: a teenage patient had been unexpectedly dropped off at his hospital's emergency department with multiple gunshot wounds.

“I rushed (to the hospital) with a T-shirt and shorts and slippers,” he said. “I literally ran out of the house.”

Sugiyama is not a trauma surgeon. He’s chief of general surgery at Northwell’s Long Island Jewish Valley Stream (N.Y.) hospital, and can typically be found performing a range of procedures like appendectomies and bowel obstruction surgeries.

But on that night in May, he was called into the hospital at 10 p.m. to operate on a 17-year-old boy whose friends had dropped him off at the hospital’s ED.

Surgeons at Long Island Jewish Valley Stream, a community hospital, rarely see gunshot patients. An ambulance, if called to the scene of a firearm injury, would typically transport a patient directly to the nearest trauma center, which Long Island Jewish Valley Stream doesn’t have. If a patient presents at the ED on their own, the hospital usually transfers them to a trauma center after they've stabilized. The nearest Level 1 trauma center is a 20-minute drive away.

In this case, the patient was too injured and bleeding too much to be moved right away.

He had been shot through the abdomen, with a “significant” amount of blood in his abdomen and chest, Sugiyama said.

The injuries looked as if they were from a high-caliber firearm, but Sugiyama said he doesn’t know any other circumstances of the shooting.

“His liver was shattered, spleen had a bullet through it,” Sugiyama said, as well as wounds through the stomach. “It was a major trauma.”

Once the patient was stabilized and no longer bleeding, he was transferred to a pediatric hospital that was better equipped to care for him.

“It was a team effort to get him to survive,” Sugiyama said.

Nearly 20,000 people died from shootings and firearm-related injuries last year, marking the deadliest year for gun violence since the 1990s. That number rises to more than 43,000 people who died from firearm-related injuries when including 24,000 who committed suicide, according to the Gun Violence Archive.

And the severity of non-fatal gunshot injuries is also on the rise, in part linked with a rise in injuries from high-caliber firearms—which have larger bullets—and those that shoot at a higher velocity, sometimes leaving patients with worse wounds. Mortality rates of gunshot wounds have also improved thanks to better trauma care and the ability to quickly transfer patients to a specialized trauma center, leading more patients to survive severe injuries.

“That’s likely translating into an increase in injury severity that we’re seeing in trauma centers,” said Dr. Patrick Carter, director of the University of Michigan Injury Prevention Center and an associate professor of emergency medicine at U-M Medical School.

“There’s a lot of different factors that probably are driving that.”

Increasing severity doesn’t necessarily change the way trauma surgeons care for gunshot injuries.

“The basic principles really haven’t changed,” said Dr. Eileen Bulger, chair of the American College of Surgeons’ trauma committee and chief of trauma at Harborview Medical Center in Seattle. “All gunshot wounds are a high-risk mechanism. We treat all patients that come in with a gunshot wound as if they’re in a life-threatening circumstance.”

New York City’s experience with gun violence over the past year has mirrored much of the U.S. There were 1,531 shootings in New York City last year, up from 776 reported in 2019.

While shootings had been dropping in recent years, during summer 2020, patients presenting at the trauma center with gunshot wounds started to “dramatically increase,” said Dr. Matthew Bank, executive director of the Northwell Health Trauma Institute and trauma medical director at Manhasset, N.Y.-based North Shore University Hospital, “for reasons that we’re still struggling to understand.”

Northwell treated 83 gunshot wounds last year, almost double the 46 they treated in 2019. This year, through May 1, the system has treated 29 gunshot wounds.

To help prepare trainees for trauma, Northwell since 2016 has run a course on advanced trauma surgical skills—developed by the American College of Surgeons—a couple of times a year.

The course involves using cadavers to simulate various traumatic wounds. That is one of the main ways the system trains surgical residents on trauma and ensures all Northwell trauma surgeons maintain competency, according to Bank. Northwell requires all active trauma surgeons to be instructors for at least one course a year.

Bank estimated it costs the system around $1,000 to $2,000 to run each course, plus staff time, but said it’s hard to break out the cost since cadavers are the main equipment needed. They use cadavers from Northwell's bioskills education center, which does surgical training and continuing medical education for various specialties.

There are also more frequent education programs. Every Friday, North Shore hosts a simulation of a trauma case using mannequins, and the entire trauma team participates.

NYC Health + Hospitals, the city's public health system, two years ago started using a surgical simulator, called the Cut Suit, to train senior surgical residents and fellows on trauma operative management. The suit, a prop worn by an actor or placed on a mannequin, is made of silicone but realistically simulates various traumatic injuries, letting trainees stop bleeds and move organs as they would during a real surgery without needing a live animal or cadaver.

“It looks and feels like you’re operating on a live human being who’s bleeding,” said Dr. Sheldon Teperman, trauma medical director at NYC Health + Hospitals’ Jacobi Medical Center.

The Cut Suit was developed by Strategic Operations, part of a former television and film studio in San Diego. It was first sold to military hospitals, which still make up the majority of Strategic Operations' customers. NYC Health + Hospitals was the first civilian hospital to incorporate the company’s surgical simulators into training.

The Cut Suit and related equipment cost roughly $100,000, according to Kit Lavell, Strategic Operations’ executive vice president. It’s a one-time cost, since customers can mostly repair the surgical simulator on their own. It costs $1,500 to rent surgical skills packages that are put inside the suit to simulate a specific injury or scenario.

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.”