Warning. This is graphic.
I still remember those two blood vessels deep in that boy’s brain, shredded by a bullet fired into a crowded playground. The same bullet that blew fragments of one side of the teenager’s skull into his brain on its way in and a larger chunk of skull on the opposite side of his head off. There was so much damage that it didn’t even look like a human brain. When he came in, blood was spurting out of both the entrance and the exit, up and out from those two injured deep vessels as we would come to find out directly. How did he even make it to the hospital with this much damage? I remember thinking that as we moved him in unison from the stretcher to the OR bed. Most of these kids that are shot in the head die at the scene. That’s been the case for as long as I’ve done this work.
Once we were able to get a larger part of his skull off to try and get better access, bright red arterial blood shot up from the depths of his frontal lobe past my own head and the head of my assistant, a senior neurosurgery resident who calmly and efficiently worked at my side. Our surgical loupes were both covered in a fine red spray and smudged on the side where the circulating nurse had tried to help by wiping them while we frantically worked. No matter what we did, the blood kept coming from deep inside the boy’s head.
“Clip!” I called out to the scrub nurse, louder than intended but above the chaos of the operating room as everyone struggled with trying to save his life.
“Which one?” she asked.
“I don’t care,” I came back. “Any of them!”
She carefully handed me a spring-loaded straight aneurysm clip on the end of an instrument designed to allow me to release the clip off the end and occlude the offending vessel to stop the bleeding. I blindly put the clip-applier down between the frontal lobes of the brain where the blood was coming from in rapid pulsating geysers. I released it, hoping that at least some of the bleeding would stop.
“We’re losing the blood pressure,” came from the anesthesiologist on the other side of the surgical drapes.
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The brain was swelling up and out of the remaining skull. After a few more seconds, I could no longer see the actual two vessels—I think it was two vessels—that were pumping this boy’s life away and onto the floor.
By the end, the resident and I had applied four clips down in the gap and the rapid blood loss had stopped. We got the boy off the table and to the pediatric intensive care unit. He lived just long enough for his parents to say goodbye. Then his brain swelled one last time and he was gone. I remember the wails of his parents as I walked back down the hall of the ICU after a conversation that no parent should ever have to have as they realized their teenage son would never come home again.
Over the past few weeks, I have received waves of emails from the leadership of organized pediatric neurosurgery, surgeons I have known for decades, from every part of the U.S. The sense of frustration is clear. We have to do something. Somebody has to do something. Why does this keep happening?
As surgeons, we find ourselves left trying to fix the ghastly results of so much of this gun violence that seems endemic in our country. There is an idea among my colleagues that we should write something up and send it “somewhere where a lot of people will read it.” A colleague from St. Louis mentions me and it takes off from there.
“When you write it, Jay, you tell them about the kids we see who come in after a gunshot to the head where it looks like a bomb went off on their CT,” one said. “How the parents cry and cry and cry when we tell them their child is brain dead. Tell them how awful it is when there is nothing you can do.”
All of us in our field understand that.
“Or tell them about my patient,” said Tina, an experienced pediatric neurosurgeon at Massachusetts General, “who spurned the advances of her brother’s ‘friend’ enough times that he finally took out a handgun and shot her in the neck, immediately paralyzing her and committing her to a ventilator for the rest of her life.” She continued, “I still remember her mouthing several days later, ‘I thought I was doing all the right things.’”
“Yes,” said Sam, a pediatric neurosurgeon from Seattle who co-founded a start-up trying to make spinal surgery safer. “You tell them the stories and then tell them that we implore, no demand action on the part of our leaders.”
Then from a colleague in Connecticut, Jon, a military veteran and leader of our field in advocacy for common sense gun laws: “Understand that the events in Texas this week are the result of deliberate choices, actions, and policies that have been pursued over the last half century by citizens, industry, and politicians. Unlike other issues that have been pursued by public health advocates, firearms have constitutional and legislative protections that confound approaches that have been utilized for motor vehicle safety and tobacco. Any solutions will require a well-considered strategy and long-term commitment.”
Jon and I talk directly offline. He is a close friend of many years. His life was forever affected by his time serving our country in the United States Army. It was also forever affected by the time he stood in an emergency department close to Sandy Hook Elementary years ago as the calls began to come in, he and his surgical team in medical gowns ready for the waves of injured children. Waiting and waiting until they realized, No one is coming. No one survived to make it here.
The emails from pediatric neurosurgeons all across our field continue to come in. Ideas, stances, arguments on how strong to come out with a position, how political to be, who to team up with, ‘should we act now or is it too late?’, ‘Who do we call’, ‘Does anyone know a Senator?’ All of it, the back and forth, the frustration, the anger, welling up from a place of completely helplessness. Helplessness from pediatric neurosurgeons who, like many in health care, are used to leaning in, used to running toward the inferno, to saving lives, to seeing problems and doing something about them.
Let me be clear, the death of children from any injury or any reason is heartbreaking, and the fact that gun-related death is the number one killer of our children, more than motor vehicle collisions and childhood cancer—what our medical journals have been telling us over the last few months—is a failure of our society and needs to be changed. Drills will not stop that first classroom a shooter enters from becoming a slaughterhouse. The reliable effectiveness of guards with guns is by now a proven fallacy. Finding a common ground between those on both sides should not be so very hard if we start with, “No child should be shot at school.”
I am not a political person. In fact, as a son of the South—I’ve lived in Mississippi, North Carolina, Alabama, and now Tennessee—guns and gun culture are second nature to me. My friends and I were brought up to understand the importance of their responsible use. Just a few months ago, I found my old .22 rifle as we cleaned out our family’s Mississippi home of fifty years. I brought that gun home, cleaned it, and taught both my teenage son and daughter how to target shoot and be safe around it. The same day I found that gun in my father’s old gun cabinet, however, I also found a baseball nestled in a little golden baseball glove in a trophy that was sitting on top of that that same cabinet. It was signed by my entire Little League team that I played with as a ten-year-old. The fact that nearly 40 years ago, 2 of those 14 little boys lost their life to gun violence before reaching adulthood tells me that the effect of gun misuse on children has been around for a long time.
What has not been around for some time however are these modern readily available weapons that combine large capacity, low recoil, and high velocity rounds designed to inflict maximum destruction to human tissue. To be clear, surgical knowledge and weapons of war have always been partners. Advances of one has often led to advances of the other. With war and the business of maiming comes the ability to learn medical lessons that are then are taken back to the civilian world. With the Civil War, it was finally understanding aspects of postoperative wound care, from the Great War came knowledge of the function of the peripheral nerves, from World War 2, the Korean War, and the Vietnam conflict, advances in modern resuscitation and antibiotic use. But in modern war, the destructive power of armaments has increased exponentially, and would have been unimaginable just a generation ago, much less to those who regarded the use of arms during the musket era. Body armor is now standard issue. If you were so unlucky as to be hit by a musket ball, your likely cause of death would have been infection. A round from an AR-15 explodes flesh, shatters bone, and causes a cavity of destruction significantly larger than the bullet itself, destroying everything in its path. When I was a junior faculty member fifteen years ago, I remember a visiting Army surgeon lecturer telling us that even the wrong helmet design can result in exposed occipital areas of the head, a perfect target for snipers in the Middle Eastern conflicts.
But what we are talking about here is not war. Civilians have no Kevlar helmets or body armor (unless you are the shooter himself who has purchased body armor along with the assault weapon). The damage caused by modern weaponry far outpaces our ability to educate or resuscitate. Civilians in a place of worship or a school or a bus stop are not thinking about how to best attack and defend their position. Or how to best escape a room while taking live fire. And they shouldn’t have to. The very idea that one of the recent victims covered herself with her dead friend’s blood in order to trick the killer into thinking that she was also dead should stop every citizen of this country cold.
I am just a brain surgeon and will leave the politics to the politicians. We will keep trying in the emergency departments and operating rooms of America, but there is nothing that trauma surgeons, neurosurgeons, or emergency department personnel can do if these children are injured so grievously that they die at the scene. We can teach our children to run, to hide, to hold pressure, to wait for the police, even to fight back, but until we acknowledge the role that assault weapons have had on these horrific events, the same cycle will continue to repeat over and over again. The unimaginable has become the routine. If people could only see what my colleagues and I see in those trauma bays across our country, I believe that their politics of extremism would give way to their humanity, and commonsense legislation would be within our grasp.
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