Operating in the new normal
By Lety Laurel
It wasn’t 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.
It wasn’t 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.
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.
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.
As surgeons in University Hospital’s 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’s other Level 1 trauma center. They knew what to do.
But this was real. This was close. This was theirs.
If there is a first time for everything, those firsts come with a sobering reality—they’re typically not the last.
This, the surgeons fear, could be the new normal.
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.
“Sutherland Springs happened in a rural area in South Texas that has an outstanding trauma system,” Dr. Stewart said. “That trauma system is essentially the backbone, or the framework, for disaster response in South Texas.”
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
firing on worshippers inside First Baptist Church, using a variant of an AR-15 rifle.
“Normally we have two attending trauma surgeons on call on weekends in addition to our very large team of residents and physician extenders—our physician assistants and nurse practitioners—who are here taking care of the trauma that comes in.,” Dr. Liao said. “But we were all already here. So in a way we were kind of lucky.”
When the first emergency alert sounded, nearly every phone in the conference room lit up.
12:05 p.m. | Emergency alert
“Wilson County is responding to a mass shooting, the possibility of 30 patients. Update yourselves.”
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’t know how long they’d have before the first patients began arriving, but they knew they would be ready.
“We 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,” Dr. Stewart said.
But they wouldn’t need them. Of the 46 people shot, 26 died before ever making it to a hospital.
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.
“There were more people who died on the scene than who made it,” Dr. Stewart said.
After the rooms had been prepared and the blood bank notified, the surgeons and their teams waited.
“We were just like ‘Where are they? Where are they?’ Then we started getting the children first,” Dr. Liao said. “You don’t 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.”
It took nearly an hour for all the patients to arrive, many of them with multiple gunshot wounds.
Among them was 5-year-old Ryland Ward, who was shot five times. His 7-year-old stepsister arrived later with severe abdominal injuries.
“You have nine patients with gunshot wounds with a high-velocity firearm at close range and a mix of children and adults. That’s not common. That’s different. Almost all of them needed an operation. That’s not true in ‘normal’ situations,” Dr. Stewart said. “You’re trying to find family members. And you have in the back of your mind that they’re not here because they’re dead.”
Ryland’s 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.
“AR-15 type weapons are high-velocity firearms, so at close range, it creates a big blast. It’s a lot on a small body,” Dr. Liao said.
It wasn’t the first time she had seen traumatic wounds from high-velocity rifles. But it was the first time she’d ever seen so many at once. She’s never served in a war zone, and that used to worry her about her preparation for mass-casualty events, she said.
“I never thought it would happen here,” she said. “We drill two or three times a year, and you always think you’ll be ready for it. The real test comes when it happens.”
When it did, her eight years as a UT Health San Antonio trauma surgeon kicked in.
“In this day and age, in this country, you get to see all that as a trauma surgeon,” she said. “Mass shootings are becoming more common. And I think we’ll see it again.”
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.
She was unstable. After hours, multiple units of blood and several resuscitation attempts, there was nothing more that they could do.
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’t get her back.
She was the only victim from the Sutherland Springs shooting to die in the hospital.
“I think probably the one thing that I’ll remember the most from that day was just pronouncing her dead,” Dr. Liao said. “It’s always the one thing that you remember—the patient you couldn’t save.”
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’ operations. They gave each other updates on their well-being. They sketched out a plan for the next day.
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.
“You don’t have time for the emotional aspect of what just happened,” Dr. Liao said. “Your mind is still running through ‘What do I need to do tomorrow to take care of the patients?’
“None of us asked how we felt. We were all glad we stabilized the patients and took care of their injuries. I didn’t think about the magnitude of this experience until weeks later.”
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.
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.
“Him going home was great for Sutherland Springs and for us. It was symbolic. It was really emotional,” she said.
But the tragic event should never have happened.
There is no widely accepted definition of “mass shooting,” 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.
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.
“I don’t think any of us [trauma surgeons] thought a mass shooting was going to be a routine day for us until recently,” Dr. Liao said.
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.
In the months since Sutherland Springs, both trauma surgeons have traveled around the country advocating for a “common-ground approach to make firearm ownership as safe as reasonably possible, and for training the general public on bleeding control,” Dr. Stewart said.
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.
“We all own this epidemic of violence,” Dr. Stewart said. “And we all must take steps to address the crisis of mass violence. It’s 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.”