What Bullets Do to Bodies

The gun debate would change in an instant if Americans witnessed the horrors that trauma surgeons confront every day.The first thing Dr. Amy Goldberg told me is that this article would be pointless. I was interested in Goldberg because she has spent 30 years as a trauma surgeon, almost all of that at the same hospital, Temple University Hospital in North Philadelphia, which treats more gunshot victims than any other in the state and is located in what was, according to one analysis, the deadliest of the 10 largest cities in the country until last year, with a homicide rate of 17.8 murders per 100,000 residents in 2015.Over my years of reporting here, I had heard stories about Temple’s trauma team. Even though Amy Goldberg has been treating gun patients for 30 years, the sense of horror has never completely gone away. In my initial conversation with her, which took place shortly after the mass shooting in Orlando, where 49 people were killed and 53 injured by a man who walked into a gay nightclub with a semi-automatic rifle and a Glock handgun, she was joined by Scott Charles, the hospital’s trauma outreach coordinator and Goldberg’s longtime friend. “As a country,” Goldberg said, “we lost our teachable moment.” She started talking about the 2012 murder of 20 schoolchildren and six adults at Sandy Hook Elementary School. Goldberg said that if people had been shown the autopsy photos of the kids, the gun debate would have been transformed. As Jeremy Walter, Temple Hospital’s amiable director of media relations, reminded me more than once, “Temple isn’t just a hospital that treats drug addicts and gun victims.” Still, it was founded 125 years ago by a Samaritan to provide free care, and that public-service mission persists. “Unfortunately we get a lot of penetrating traumas,” she said. This has been Goldberg’s policy for years, she explained to me as she exited the trauma bay and walked down a hallway toward the CT scanner. “It’s so hard to take care of patients without making mistakes that you need every edge.” She recently hired a sports psychologist to talk to the residents about strategies for peak performance. Goldberg said, “That seems more appropriate.” Now they gave him some pain medicine. Goldberg attended to the patients in the trauma unit. “I’ve been doing this 30 years,” she said. LEVEL 1 SECOND GSW MALE.Goldberg didn’t know much about guns or gun violence until she got to Temple. It is so miraculous.” Surgery, for Goldberg, was a way of honoring the miracle. She might be operating on the carotid artery in the neck, or the heart in the chest, or the large bowel or small bowel in the abdomen, or the femoral artery in the thigh, at any given moment, on any given night.In her first or second year of residency at Temple, when she was in her mid-20s, she helped treat a young boy who had been shot in the chest by his sibling who picked up a loaded gun that was lying around. “And then of course the third time he came in, he was shot through the head, and he was dead,” Goldberg said.She started thinking that Temple should find a way to intervene—to try to talk to patients while they’re in the hospital so they would never need to come back. And as five years stretched into 10, and 10 into 20, Goldberg built up a deep well of experience in doing the things that are necessary to save the lives of gun victims, the things that are never shown on TV or in movies, the things that stay hidden behind hospital walls and allow Americans to imagine whatever they like about the effects of bullets or not to imagine anything at all. In especially serious cases, 70 times at Temple last year, the surgeons will crack a chest right there in the trauma area. She can also clamp the aorta, the largest artery in the body, so that instead of the blood going down into the bowels, where it’s needed less, the blood goes up to the brain.“These crossing bullets are just so challenging,” she said. Others develop cascades of life-threatening complications in the following days that surgeons race to manage.Goldberg said she saw a movie a few years ago that captures what it’s like to operate under these conditions. And he said, God and the Devil were with me.” Goldberg thought that was perfect. “They’re so angry,” Goldberg said. During trauma surgery, when the blood flow is redirected to the brain and heart by an aortic clamp, blood goes away from other areas, and tissue in the lower extremities can die, causing gangrene, in which case surgeons must amputate the leg at higher and higher points, first at the shin, then at the knee, then at the thigh, to stay ahead of the necrotic tissue as it spreads. “I’m so haunted by that,” she said.Eighty percent of people who are shot in Philadelphia survive their injuries. “Yeah,” Goldberg said. “We will miss you,” Goldberg said, “but there comes a day.”“Cut the umbilical cord, huh?” he said, and laughed softly.Goldberg descended to the eighth floor to meet with another gun victim. “It’s better if I don’t know.”She went over to the side of the patient’s bed as the cops watched and said she was Dr. Goldberg and she wanted to explain what was happening and help him if he needed anything.He looked young. Police statistics show that shootings decrease in the cold winter months and pick up when the weather warms, but any given trauma shift in the winter can be busy and any shift in the summer perfectly quiet.Goldberg has always found the senselessness of violence frustrating, and when she was promoted to chief of trauma 15 years ago, she started thinking about how to engineer some control, to help patients “above and beyond just being a trauma surgeon.” She imagined a comprehensive approach to prevent shootings and keep patients from showing up in a trauma bay in the first place. Some of his students from North Philly started collecting the stories of families who had lost children to gun violence, which is how Charles made the connection to Goldberg—Temple had treated one of the victims, Lamont Adams, a 16-year-old from North Philly who was shot and killed in 2004 after a false rumor was allegedly spread about him.Goldberg hosted a tour for Charles and his students, inviting them into the trauma unit and explaining what gun patients experience there. He brings groups of kids and adults into the trauma area and shows them how surgeons save gun patients. And most disturbing of all, the two bullet wounds on his hand, a sign that Lamont was trying to shield his face from the bullets at close range.Charles also runs the Fighting Chance program, a series of training sessions for community members, where doctors show people in neighborhoods how to give first aid to gunshot victims, to apply tourniquets and stop blood loss in the seconds immediately following a shooting, before the EMTs or police arrive. “They come in, they’re very scared,” Goldberg said. It’s called the Philadelphia Immediate Transport in Penetrating Trauma Trial (PIPT), an elaborate undertaking that has involved close coordination with emergency personnel and also dozens of community meetings where doctors explained how the study works (over the next five years, some victims of penetrating trauma will receive immediate transport and some won’t) and how people can opt out of the study (by wearing a special wristband). According to Temple’s data, the Turning Point patients showed “a 50% reduction in aggressive response to shame, a 29% reduction in comfort with aggression, and a 19% reduction in overall proclivity toward violence.” Goldberg told me she was proud of the study, not only because it suggested that the program was effective, but also because it represented a rare victory over the status quo. It took her that long to get the authority, to gather the data, to get it published, to shift the system a little bit.Twenty-four years.Each time I went to the hospital, I asked Goldberg what else was going on with her aside from work. Her religious faith is still strong—it’s not that she goes around talking about it, she told me, it’s just that she has worked for 30 years in trauma and seen a lot of death, and it’s hard to do that and not feel something about God. I noticed one day she was wearing a white Lokai bracelet, a ring of plastic capsules said to contain mud from the Dead Sea and water from Mount Everest. One of the speakers at the investiture called Goldberg a “realistic idealist,” and when I saw her later, she said she’d been thinking about the phrase. “When I get angry, and hurt,” she told me, “it’s because I can still be a little naïve.” Even after all this time, the sense of horror she first experienced as a resident treating gun patients has never completely gone away.One evening when I was at the hospital, I saw what she meant. “Very small,” she said, pointing to the slug, “like a .22.” As so many other patients do, the patient asked the trauma surgeons if they were going to take the bullet out, and the surgeons explained that they fix what the bullet injures, they don’t fix the bullet.They left the wound open to prevent infection and put a dressing on it. “We’ll probably send her home tonight,” Goldberg said. A woman gets shot through no fault of her own, she comes to the hospital scared, and if she’s OK, Goldberg says, “It’s like, here, take a little Band-Aid.” The woman goes home, and for everyone else in the city, it’s as though the shooting never happened. In a perverse way, the more efficiently Goldberg does her job inside the hospital, the more invisible gun violence becomes everywhere else.Which is why she pours so much of herself into the outreach programs, the scientific studies and any other method she has of finding control and making the problem visible.