Part 2:
No studies have quantified the relationship between emergency medicine and the recent decline in homicides. But many on the front lines of crime fighting believe they are linked. "Presbyterian,Mercy and Allegheny are our three main trauma centers in Pittsburgh. If it wasn't for those hospitals our homicide rate would be skyrocketing," said Maurita Bryant,Pittsburgh assistant police chief and president of the National Organization of Black Law Enforcement Executives. Homicides in Pittsburgh fell to 43 in 2011 from 54 in 2010.
A national study in the New England Journal of Medicine in 2006 concluded that the risk of death was "significantly" lower when patients were treated at trauma centers compared with regular hospitals. As of 2010, 90% of the U.S. population was within 60 minutes of a trauma center by helicopter or ambulance, according to the American Trauma Society. Driving the advances in treatment is a symbiotic relationship between trauma centers and military medicine. Military doctors honed the use of blood banks and helicopter transport during the Korean and Vietnam wars, said Thomas Scalea,Physician-in-Chief at the R Adams Cowley trauma center in Baltimore. Civilian doctors made advances in the treatment of gunshot wounds during the late 1980s and early 1990s, when U.S. homicides peaked. They learned that patients were more likely to survive if doctors first stabilized them and then treated one injury at a time, Dr. Scalea said. That allowed the patient to recover between operations. Methods were refined by the military over the past decade in Iraq and Afghanistan War doctors learned how to better deal with blood loss, a major cause of death from such injuries. Previously, doctors gave patients red blood cells, along with crystalloid fluids given intravenously, because they thought bleeding victims needed more oxygen from blood cells. Today, based on battlefield experience, patients are instead pumped full of platelets and plasma to aid in clotting.
Advances by the military also helped refine the work of emergency first-responders. Emergency medical technicians now administer less fluids to patients and maintain a lower blood pressure "so they don't bleed so fast," said Norman McSwain, an expert on pre-hospital trauma care and professor of surgery at the Tulane University School of Medicine.
State police paramedics in Daniel's case limited the fluids the teenager received at the scene of the shooting and a helicopter carried him to a trauma center. The trauma team gave him plasma and platelets to stave off coagulopathy, a condition where the blood doesn't clot. In the 1990s, the team would have used techniques to keep more blood flowing to vital organs, which would have made controlling the bleeding more difficult. The teen remained in critical condition through multiple operations over several days. Three months later, he returned to school. The wound, which still holds shotgun pellets,is healing. Daniel's parents consider their son lucky. "From the first person who got a hold of him, to bringing him here, to what they did here—all of it working together gave our son back," said Milton Borowy, the boy's father.
R Adams Cowley is the nation's oldest shock trauma center. It was named for the emergency-room surgeon who coined the phrase, the "Golden Hour," for the period immediately after the injury, when patients have the greatest chances of survival. The facility handles about 8,600 cases a year, one in six of which is caused by violence. The work is costly. Trauma centers across the U.S.lose about $230 million a year treating the uninsured, according to estimates by the Trauma Center Association of America, a trade group that lobbies for better government funding. Emergency care is reimbursed by Medicaid at a rate less than the cost of treatment, the group said. The Cowley trauma facility is operated like a mini-hospital, with 12 patient bays arrayed in a horseshoe shape. In the middle, monitors display patient vital signs. A platelet separating machine shakes bags of blood, readying the clotting agent. A portable X-ray machine provides instant imaging. A roof helipad serves emergency helicopter rescue units,including several from the Maryland State police. In the middle of the high-tech tools is an off-white push-button telephone that takes calls from ambulances and helicopters. On a recent fall weekend, the phone rang at 11 p.m., drawing all eyes and ears. A voice on the telephone speaker said an assault victim was heading their way with head injuries. The speaker reported the victim was unresponsive and added such vital statistics as blood pressure and estimated time of arrival. The injuries didn't turn out to be life threatening. At midnight, the phone rang again and a voice squawked, "We have a GSW," shorthand for a gunshot wound. A man had been shot several times,including in the chest. Unit members donned plastic gowns. Blood, platelets and the X-ray machine were wheeled into Bay 3. The patient arrived eight minutes later and 16 people squeezed into the bay. Some began examining the wounds. Others began the transfusion of fluids. Workers cut off bloodied clothes. The man bled so fast that empty bags of platelets and blood piled up on the floor. Within 20 minutes, the man was wheeled to surgery and Bay 3 was cleaned and sterilized. What happens here, said Dr. Scalea,is "the ballet of organized chaos." The center's mortality rate for gunshot wounds is about 4%,including the patients who are dead on arrival. "There are crappy things that come with every job and going down and telling some mama her kid is not coming home ranks right at the top of that," Dr. Scalea said. On the other hand, he said, "To take a young kid, to take anybody who comes in essentially dead and return them to their family in a good functional state and to see them reintegrate back into society is fabulous.What can be a better feeling than that?"
The trauma unit phone stayed quiet until 1:40 a.m. A pedestrian was hit by a car and critically injured. It would take hours to stabilize the man for surgery. At 1:43 a.m., the phone rang again: Another man was shot several times,including once in the face. At 2 a.m., before he could be moved to surgery, the phone rang with the third gunshot victim of the night. Around that time, news arrived from surgery: The night's first gunshot victim had died.
Dr. Scalea said he pushes away emotions, otherwise "the next patient doesn't get my A game." Twenty minutes later, a young man arrived with stab wounds, gaping holes in his side and chest. As his gurney rolled into Bay 6, workers were attending to 15 patients in 12 bays. The unit filled with more than 80 people,including emergency-medical personnel and police and hospital-security officers. T. Daryl Reece, a detective in the criminal division of Baltimore County had been out on two calls overnight. He had been working a shooting when he learned of the stabbing, which took place at a gas station. "He had words with some other guys and he ends up here," the detective said.
By the time the sun rose, 24 people had been admitted,including five people shot or stabbed. One man died. "Violence down?" said Dr. Scalea. "I don't think so."