This is the second part of a series looking at how victims of gun violence and trauma are treated by Toronto’s medical teams. Click here to read part one.
In the basement of the Li Ka Shing Knowledge Institute at St. Michael’s Hospital in downtown Toronto, members of the trauma team gather inside a state-of-the-art simulation lab for a full-scale exercise — one that is painfully too familiar to many in the room.
“He’s got a right-sided GSW (gunshot wound) to the chest and a left abdominal GSW. He was hypotensive with EMS (paramedics),” Dr. Andrew Petrosoniak, an emergency physician and a trauma team leader at St. Michael’s Hospital, said while overseeing the work of his team in this mock scenario.
“Let’s do a quick assessment. Let’s get him undressed, IVs, two large bores and then we’ll reassess where he’s at. Get him on the monitor.”
The patient in this demonstration is an 18-year-old man who was shot in his torso while at an establishment. Over the course of the exercise, Petrosoniak watches carefully as a team of professionals methodically move in to stabilize the victim. A respiratory therapist listens to the patient’s breathing as another team member cuts away his shirt, applies monitors and takes the victim’s vitals.
While asking for a chest tube to be inserted, Petrosoniak called for the on-duty trauma surgeon to be paged as teams work to provide blood and prepare the operating room (OR).
As the trauma bay team worked to stabilize the patient and aim to move him within a 10-minute period, trauma surgeon Dr. Najma Ahmed responds to Petrosoniak’s page. Before moving to the OR, Ahmed and the team need to “log roll” the victim — physically lifting him onto his side — so she can check for penetrating wounds in his back. With no visible gunshot wounds, which Ahmed noted is a good sign, she and Petrosoniak continue the debrief on the initial medications and treatments given.
In the span of five-and-a-half minutes, a plan of action was put in place — which is roughly the same time it takes for staff to move a patient to an OR suite from the emergency department.
WATCH: Simulation specialist Sue Zelko discusses importance of simulation exercises, lab capabilities
And although this was only a simulation, the treatments provided, directions given, and how the trauma team responded, were all real.
“When we look at patients, we’re looking at their vital signs. We’re looking for a low blood pressure, we’re looking for a high heart rate, we’re looking for their level of consciousness,” Petrosoniak told Global News.
“All of it together, that will give us an indication a small hole may be impacting a patient’s hemodynamics … It’s rare for us to miss seeing the actual gunshot wound.”
He stressed that seconds and minutes truly count in terms of saving lives — information that’s backed up through intensive study at other institutions. At St. Michael’s Hospital, officials even put trackers on their medical staff to map out treatment areas in real time. By changing the placement of devices and supplies, that efficiency has improved the odds of survival.
WATCH: Dr. Najma Ahmed describes physical, emotional effects for victims of gun violence
“For every minute it takes to get blood, there’s an associated increase in mortality with that,” he said.
“If we’re talking about something as short as even a couple of minutes, we can tighten that up and get blood to a patient faster, get their airway secured faster, get them to the OR faster, then we’re actually talking about saving lives during that period.”
Ahmed, a University of Toronto surgery professor and a trauma surgeon for 17 years, has been one of many on the front lines responding to the incidents of gun violence and trauma that Toronto witnessed in 2018.
“Despite all the simulation training, and all of the effort, and work, and study, and research, and the over and over again, we still can’t save everybody,” she told Global News.
“And even when we do, people suffer enormously and it’s tragic. And the biggest tragedy is that it’s preventable.”
WATCH: St. Michael’s Hospital trauma team talks impact of gun violence. Shallima Maharaj reports.
A large amount of the record-high number of homicides in Toronto last year involved guns — something that Ahmed most noticeably dealt with as the on-call trauma surgeon who was paged and responded moments after the Danforth shooting.
“What happened on the Danforth on that summer evening … it really was a frank and clear example, and demonstration, that none of us are immune from this, that it could happen to anyone at any time,” she said.
“I think sometimes we think that gun violence is something that affects only a certain segment of society, only at a certain time of day or night, only in certain neighbourhoods, and the evidence from many countries where they have a lot of gun violence is that this is not the case.”
When asked about the severity of gun violence in Toronto, Ahmed called it a “catastrophe” and said that in her opinion a public health crisis should be declared.
WATCH: Dr. Najma Ahmed reflects on speaking with victims’ families, self-care
“It’s an epidemic that’s happening in our city and rippling across the country, and it behooves us to pay attention and do something about it,” she said.
“The things that we see in medicine, and maybe even in surgery more so, are outside the realm of normal human experience. It’s not normal to witness a 17-year-old young man die in the trauma bay, or hold someone’s heart as it beats its last beat on earth.”
The uptick in gun violence has meant the St. Michael’s Hospital trauma team has had to turn to military battlefields for guidance.
“Trauma surgery is like war surgery. We have undefined injuries and a very unstable patient. There’s no time for CAT scans and MRIs and fancy investigations, 3D reconstructions — we take the patient directly from a stretcher in the trauma bay to a stretcher in the operating room and we open body cavities and we fix the injuries that we can find,” Ahmed said.
“We often, because these patients are so critically injured, use an approach that was developed in wartime called damage control, where a commander may decide to sacrifice a ship in order to save a mission, and that’s what we do.”
WATCH: Dr. Najma Ahmed says team uses wartime techniques to treat victims of gun violence
Ahmed said when it comes to treating patients with critical injuries, medical staff only fix what’s life-threatening before taking a pause — and it can mean leaving body cavities open and a trip to the intensive care unit for resuscitation. While it may sound unorthodox, Ahmed said patients can reach a point of “physiologic exhaustion.”
“They’re so sick that spending another hour on the operating room table would likely result in their demise, so we just stop the hemorrhage as best we can — it’s not perfect, but we slow it down,” she said.
“We close the holes in organs that are leaking intestinal contents into the abdomen, we sew holes in big blood vessels, and then we bring the patient to the ICU to rewarm them, correct their metabolic status, give them more blood, make sure their volume status is better, and then they go back to the operating room in 24 hours or so for further surgery.”
For victims who are shot, there are major impacts on hospitals and patients in the short and long terms. Ahmed said it’s not uncommon for a patient to require dozens of units of blood in the first few days of a patient’s hospitalization.
“You can imagine the consequences that arise for the patient from that – the tissue swelling and the multiple infections that arise when we give patients such a large volume of blood,” she said.
But beyond the initial treatment, a gunshot wound victim or a victim of a violent act faces lifelong impacts.
“Trauma becomes a chronic disease. If patients survive their initial operation, there are many more operations in hospital and then reconstructive operations following that. Many infections and complications that result with this single bullet – and that’s just the physical stuff,” Ahmed said.
“Then there’s the emotional burden of being a victim, being socially ostracized because you’re associated with that kind of injury. For the families, it’s horrific what they go through. If the victim doesn’t survive, it’s a terrible tragedy for their community and for that family.”
WATCH: Dr. Andrew Petrosoniak addresses misconceptions about gunshot injuries, treatment
For physicians like Ahmed, she said while advances in medicine are increasing the odds of survival, the question about prevention has become top of mind.
In addition to her role as a doctor, Ahmed is also an advocate. She is one of the medical professionals behind a grassroots group called Canadian Doctors for Protection from Guns. She said she wants to raise the level of awareness on the profound impacts violent acts are having on patients, families, medical institutions, and society as a whole.
“ come in from all over the city – close to schools, close to playgrounds, near large municipal structures – it’s alarming because these are centres of large urban population, which means it’s a threat for all of us,” she said.
“This is an issue for all Canadians, for all citizens, to really think thoughtfully about what kind of society we want to live in. Who do we want to be as Canadians?
“This is a little bit of a defining moment on the issue of gun violence and civilian access to guns that we have right now, and I think it behooves us all to steep in that moment and think who we want to be and what image we want to portray to the world out there, and what legacy we want to leave for our children.”
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