Speed, temperature and leaving well enough alone.
By paying attention to those three things, trauma doctors have revolutionized the care of gunshot wounds over the last 30 years, says Andrew Peitzman, chief of general surgery and UPMC trauma services.
Half of all those who are killed by gunshot wounds in the United States still die at the scene, Dr. Peitzman said, but doctors have been able to make major progress in saving the others. That shows up clearly in national statistics. From 1970 through 1990, gunshot fatalities in the U.S. held steady at about 14.6 deaths per 100,000 people, but since then, the rate has fallen to 10.2, in part because of better medical treatment.
One major reason for the progress has been an emphasis on stopping bleeding quickly, which often translates into getting the patient into an operating room as soon as possible, he said.
Thirty years ago, paramedics were taught that their first job was to stabilize gunshot victims' blood pressure, often by giving them intravenous fluids, but since then, "we have done laboratory studies that show that when you try to get the blood pressure up to normal, you blow the clot off the patient and make him bleed even more."
Instead, it's important to open up a patient and stop the bleeding, especially if it's in the chest or belly, he said. One study by John Clarke at the University of Pennsylvania showed that for every three-minute delay in getting a trauma patient to a hospital, mortality goes up 1 percent. "So if you spend 30 extra minutes getting that patient into the hospital," he said, "it doesn't sound like a lot, but it makes a huge difference in survival."
Once the patient is in the operating room, temperature becomes a critical issue.
When a gunshot victim goes into shock, Dr. Peitzman said, his body temperature often drops, and if it gets below about 95 degrees Fahrenheit, the patient's blood won't coagulate properly.
While an operating room used for elective surgery is typically a little chilly, trauma operating rooms are often kept at about 85 degrees. The patient is put on a warming blanket, and fluids and gases used during surgery are also kept warm.
To stop bleeding quickly, doctors also need to be able to see where to operate, and the advances in ultrasound and X-ray technology over the past few decades have greatly increased their ability to quickly look inside "the black box" of a gunshot victim's torso.
CT scans also allow doctors to avoid doing surgery when it isn't necessary, particularly on the liver and spleen.
Fifty years ago, surgeons routinely removed the spleen if it was injured in a shooting, thinking that it wasn't a vital organ and simply increased the chances of blood loss. But now, they know that the spleen helps filter toxins out of the blood and boosts the immune system, so "you can live a normal life without your spleen, but you are at higher risk of infection."
Because of better visualization technologies, he said, about 85 percent of liver injuries and 75 percent of spleen injuries today are treated without surgery.
One other important factor in gunshot wound treatment is the type of weapon and ammunition that are used.
Injuries from rifles are generally much more damaging than those from pistols. A rifle bullet travels at 3,000-5,000 feet per second, he said, vs. 800 feet per second for a 9 mm pistol.
Most shootings in the U.S. involve pistols, but where the typical shooting of 30 years ago might have been a .22-caliber Saturday Night Special, the common shooting today involves a 9mm semi-automatic pistol, which has bigger bullets and can fire more quickly.
One result is that the typical shooting victim today has at least three bullet wounds, Dr. Peitzman said.
Once a bullet enters someone's body, it not only damages the tissue and bone that it strikes, but creates a "blast effect" that harms surrounding tissue. For that reason, experienced trauma surgeons know that when they reattach intestines or blood vessels, they have to cut away additional tissue that would probably die from the blast effect over the following few days.
Finally, trauma surgeons do one other thing when gunshot victims arrive -- they count the number of bullet holes.
It is often hard to tell whether a hole is an entrance or exit wound, he said, but if there is an odd number of holes, it means there is a bullet inside someone that might need to come out.
Because gunshot patients often "won't tolerate a lot of physical insult," the goal today is to stop their major bleeding and get them into the ICU. "All we're trying to do is damage control, and then come back another day for anything that is not completely life saving."