{"id":11262,"date":"2018-08-23T01:51:56","date_gmt":"2018-08-23T01:51:56","guid":{"rendered":"https:\/\/magazines.uthscsa.edu\/mission\/?p=11262"},"modified":"2018-08-30T16:41:27","modified_gmt":"2018-08-30T16:41:27","slug":"operating-in-the-new-normal","status":"publish","type":"post","link":"https:\/\/magazines.uthscsa.edu\/mission-old\/operating-in-the-new-normal\/","title":{"rendered":"Operating in the new normal"},"content":{"rendered":"

By<\/em> Lety Laurel<\/strong><\/p>\n

\"Trauma

Trauma surgeons Lillian Liao, M.D., M.P.H. \u201904, and Ronald Stewart, M.D. \u201985, both graduates of UT Health San Antonio, treated several injured victims of the First Baptist Church shooting in Sutherland Springs.
Photo courtesy of Rachel Denny Clow\/Corpus Christi Caller-Times<\/em><\/p><\/div>\n

It wasn\u2019t the first time they had seen the ravaging effects of high-velocity gunshot wounds on a body, or the first time they had to rush to prepare multiple operating rooms at once, bracing for a group of trauma patients to arrive.\u00a0<\/span><\/p>\n

It wasn\u2019t the first time trauma surgeons Ronald Stewart, M.D., and Lillian Liao, M.D., M.P.H., had lost a patient in the operating room.\u00a0<\/span><\/p>\n

But this time was different. It was a mass shooting in a church. On a Sunday, during a worship service. There were kids. So many kids.\u00a0<\/span><\/p>\n

The rampage in the quiet town of Sutherland Springs on Nov. 5, 2017, the one that made Texas history for being the deadliest mass-shooting event in the state and ranks as one of the largest mass-shooting events in modern U.S. history, threw the trauma surgeons, both alumni of UT Health San Antonio, on the frontline of what they call a national public health crisis.\u00a0<\/span><\/p>\n

As surgeons in University Hospital\u2019s Level 1 trauma center, the only Level 1 pediatric trauma center in South Texas, they had drilled for mass-shooting events dozens of times with their partners from San Antonio Military Medical Center, the city\u2019s other Level 1 trauma center. They knew what to do.<\/p>\n

But this was real. This was close. This was theirs.\u00a0<\/span><\/p>\n

If there is a first time for everything, those firsts come with a sobering reality\u2014they\u2019re typically not the last.\u00a0<\/span><\/p>\n

This, the surgeons fear, could be the new normal.<\/p>\n

7:00 a.m.<\/b><\/p>\n

If there is anything fortuitous about the day of the Sutherland Springs shooting, perhaps it is that the entire trauma leadership team was already gathered in a conference room in University Hospital on an otherwise quiet Sunday morning, reviewing the results of a site visit with members of the American College of Surgeons.<\/p>\n

\u201cSutherland Springs happened in a rural area in South Texas that has an outstanding trauma system,\u201d Dr. Stewart said. \u201cThat trauma system is essentially the backbone, or the framework, for disaster response in South Texas.\u201d<\/p>\n

And that morning, nearly every one of its trauma surgeons was already in the building at 11:20 a.m. when a lone gunman began
\nfiring on worshippers inside First Baptist Church, using a variant of an AR-15 rifle.<\/p>\n

\u201cNormally we have two attending trauma surgeons on call on weekends in addition to our very large team of residents and physician extenders\u2014our physician assistants and nurse practitioners\u2014who are here taking care of the trauma that comes in.,\u201d Dr. Liao said. \u201cBut we were all already here. So in a way we were kind of lucky.\u201d<\/p>\n

When the first emergency alert sounded, nearly every phone in the conference room lit up.\u00a0<\/span><\/p>\n

12:05 p.m.\u00a0<\/span><\/b> | <\/b>Emergency alert<\/b><\/p>\n

\u201cWilson County is responding to a mass shooting, <\/strong>the possibility of 30 patients. Update yourselves.\u201d<\/strong><\/p>\n

As soon as they heard it was a church shooting, they knew there would be kids. The trauma surgeons immediately left the conference room and ran upstairs to prepare. They didn\u2019t know how long they\u2019d have before the first patients began arriving, but they knew they would be ready.<\/p>\n

\u201cWe paged everyone and said this is real. Trauma surgeons started coming in. Anesthesia. By the time we received our first patient, we were prepared to run 15 rooms,\u201d Dr. Stewart said.<\/p>\n

But they wouldn\u2019t need them. Of the 46 people shot, 26 died before ever making it to a hospital.\u00a0<\/span><\/p>\n

It takes time before the first emergency medical service responders can get to the injured at a mass-shooting event. Police have to make sure it is safe for anyone to enter. As the minutes tick away, people die from blood loss.<\/p>\n

\u201cThere were more people who died on the scene than who made it,\u201d Dr. Stewart said.\u00a0<\/span><\/p>\n

12:45 p.m.<\/b><\/p>\n

After the rooms had been prepared and the blood bank notified, the surgeons and their teams waited.<\/p>\n

\u201cWe were just like \u2018Where are they? Where are they?\u2019 Then we started getting the children first,\u201d Dr. Liao said. \u201cYou don\u2019t know the number of injured that are going to come in because it could be zero. We got a total of nine patients. Four of them were children.\u201d<\/p>\n

It took nearly an hour for all the patients to arrive, many of them with multiple gunshot wounds. \u00a0<\/span><\/p>\n

Among them was 5-year-old Ryland Ward, who was shot five times. His 7-year-old stepsister arrived later with severe abdominal injuries.\u00a0<\/span><\/p>\n

\u00a0<\/span>\u201cYou have nine patients with gunshot wounds with a high-velocity firearm at close range and a mix of children and adults. That\u2019s not common. That\u2019s different. Almost all of them needed an operation. That\u2019s not true in \u2018normal\u2019 situations,\u201d Dr. Stewart said. \u201cYou\u2019re trying to find family members. And you have in the back of your mind that they\u2019re not here because they\u2019re dead.\u201d<\/p>\n

12:50 p.m.<\/b><\/p>\n

Ryland\u2019s body was riddled with bullet wounds to his leg, arm, bladder and kidney. While Dr. Liao worked on controlling the hemorrhage in his arm and leg, another surgical team worked to close the holes in his intestines.<\/p>\n

\u201cAR-15 type weapons are high-velocity firearms, so at close range, it creates a big blast. It\u2019s a lot on a small body,\u201d Dr. Liao said.<\/p>\n

It wasn\u2019t the first time she had seen traumatic wounds from high-velocity rifles. But it was the first time she\u2019d ever seen so many at once. She\u2019s never served in a war zone, and that used to worry her about her preparation for mass-casualty events, she said.<\/p>\n

\u201cI never thought it would happen here,\u201d she said. \u201cWe drill two or three times a year, and you always think you\u2019ll be ready for it. The real test comes when it happens.\u201d<\/p>\n

When it did, her eight years as a UT Health San Antonio trauma surgeon kicked in.\u00a0<\/span><\/p>\n

\u201cIn this day and age, in this country, you get to see all that as a trauma surgeon,\u201d she said. \u201cMass shootings are becoming more common. And I think we\u2019ll see it again.\u201d<\/p>\n

2:20 p.m.<\/b><\/p>\n

While the patients came in, Dr. Stewart took on the role of triage officer, assigning the most critical patients to surgical teams. After the last patient was assigned, he went into the operating room of the 7-year-old girl.\u00a0<\/span><\/p>\n

She was unstable. After hours, multiple units of blood and several resuscitation attempts, there was nothing more that they could do.<\/p>\n

Dr. Stewart turned the operation over to his former student, Dr. Liao, so he could speak with family members and let them know that despite everything they tried, they couldn\u2019t get her back. \u00a0<\/span><\/p>\n

She was the only victim from the Sutherland Springs shooting to die in the hospital.<\/p>\n

\u201cI think probably the one thing that I\u2019ll remember the most from that day was just pronouncing her dead,\u201d Dr. Liao said. \u201cIt\u2019s always the one thing that you remember\u2014the patient you couldn\u2019t save.\u201d\u00a0<\/span><\/p>\n

7:00 p.m.<\/b><\/p>\n

It was finally quiet. After the controlled chaos of the last few hours, the exhausted surgical teams gathered together to decompress. They talked about their patients\u2019 operations. They gave each other updates on their well-being. They sketched out a plan for the next day.<\/p>\n

They did not talk about Sutherland Springs, or the shooter, or the fact that now they had joined an ever-growing number of surgeons to respond to yet another mass shooting.<\/p>\n

\u201cYou don\u2019t have time for the emotional aspect of what just happened,\u201d Dr. Liao said. \u201cYour mind is still running through \u2018What do I need to do tomorrow to take care of the patients?\u2019<\/p>\n

\u201cNone of us asked how we felt. We were all glad we stabilized the patients and took care of their injuries. I didn\u2019t think about the magnitude of this experience until weeks later.\u201d<\/p>\n

Today<\/b><\/p>\n

It would take two months for Ryland to recover enough from his wounds to go home. He was the last survivor of the church shooting to leave the hospital. He returned to a new, harsh reality. While he survived, his stepmother and two stepsisters died in the massacre.\u00a0<\/span><\/p>\n

Dr. Liao watched him leave the hospital Jan. 12 in a bright red fire truck, driven by the first responder who found him wedged between the floor and the body of his stepmother, and carried him to safety.<\/p>\n

\u201cHim going home was great for Sutherland Springs and for us. It was symbolic. It was really emotional,\u201d she said.<\/p>\n

But the tragic event should never have happened.<\/p>\n

There is no widely accepted definition of \u201cmass shooting,\u201d but it is loosely defined as an event in which four or more people are killed at random in a public place by one or two shooters. Over the last 10 years, they have become more frequent and more deadly, placing the U.S. at the top of the world in the number of mass-shooting events.<\/p>\n

All horrific in their savagery, the worst of them have become known simply by their locations: Mandalay Bay in Las Vegas, the Pulse nightclub in Orlando, Sandy Hook Elementary School in Newtown and, frighteningly close to home, First Baptist Church in Sutherland Springs.\u00a0<\/span><\/p>\n

\u201cI don\u2019t think any of us [trauma surgeons] thought a mass shooting was going to be a routine day for us until recently,\u201d Dr. Liao said.\u00a0<\/span><\/p>\n

In 2017, there were 346 mass shootings. In 2018, the numbers have continued to climb, reaching 134 by June, according to the Gun Violence Archive.<\/p>\n

In the months since Sutherland Springs, both trauma surgeons have traveled around the country advocating for a \u201ccommon-ground approach to make firearm ownership as safe as reasonably possible, and for training the general public on bleeding control,\u201d Dr. Stewart said.<\/p>\n

The way to address a public health crisis such as this, they said, is to approach it as any scientist would: by focusing on prevention strategies, while simultaneously working to improve treatment.<\/p>\n

\u201cWe all own this epidemic of violence,\u201d Dr. Stewart said. \u201cAnd we all must take steps to address the crisis of mass violence. It\u2019s unacceptable that nearly 50 people sitting in church on a Sunday morning were brutally attacked, assaulted and murdered. We can, and we must, work together to end this type of violence.\u201d<\/p>\n

Trauma is the leading cause of death of children, and bleeding is a major preventable cause. It can take as little as five minutes for a person to bleed to death. But simple steps can save lives, and these steps are being taught to emergency personnel and medical professionals so that they can, in turn, empower bystanders to become lifesavers. In 2015, the White House launched the \u201cStop the Bleed\u201d<\/a> campaign to better prepare the public to save lives by raising awareness of basic ways to stop life-threatening bleeding following everyday emergencies, and man-made and natural disasters. To learn more, read story here<\/a>.<\/p>\n

 <\/p>\n","protected":false},"excerpt":{"rendered":"

Trauma surgeons Ronald Stewart, M.D. \u201985, and Lillian Liao, M.D., M.P.H. \u201904, respond to emergency calls routinely. But this call, of a mass shooting in nearby Sutherland Springs, made U.S. history.<\/p>\n","protected":false},"author":47,"featured_media":11264,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[66,229],"tags":[77],"class_list":["post-11262","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-alumni","category-summer-2018","tag-medicine"],"yoast_head":"\nOperating in the new normal - Mission magazine | UT Health Science Center San Antonio<\/title>\n<meta name=\"description\" content=\"Surgeons Ronald Stewart, M.D., and Lillian Liao, M.D., M.P.H., respond to emergency calls routinely. 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