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A pediatric trauma surgeon on what bullets do to kids

In 2020, guns surpassed car crashes as the leading cause of death in the United States for children. The rate of child firearm death has spiked 42 percent in the last two decades, according to the Kaiser Family Foundation, and a new Pew Research Center report shows that the crisis is only getting worse: Gun deaths among children and teens in the US rose 50 percent between 2019 and 2021 — the highest increase since at least 1999, the earliest year for which Centers for Disease Control data is available.

While school shootings, like the one at the Covenant School in Nashville in March that resulted in the deaths of three children and three adults, tend to get the most attention, they are only a small part of the overall picture. The overwhelming majority of kids who die by guns are victims of homicide in their homes and communities, suicides, or unintentional injury. Some populations are more at risk than others: According to Pew, boys are more likely to be killed by guns, and Black children are disproportionately represented in the population of victims. The vast majority of Black children and teens who die by gun violence are victims of homicide. The majority of white children who die by guns die by suicide.

Dr. Chethan Sathya, a pediatric trauma surgeon and the director of Northwell Health’s Center for Gun Violence Prevention, has treated children for gunshot wounds, and has made ending gun violence a central focus of his career. Vox spoke with Sathya about his experiences treating children, and what he thinks needs to be done to address a stark — and growing — crisis.

This interview has been edited for length and clarity. Please note that while there are no images of violence accompanying this interview, there are descriptions that some readers might find disturbing.

What’s it like to treat children for gunshot wounds?

I’m part of a trauma team. It’s like 30 people in one room, all waiting and ready for a patient. When it’s a kid coming in with a bullet wound, that room is silent. What’s this kid gonna look like? There’s all this emotion around it. It’s a very tense situation, and it’s way quieter than other trauma bays, because I think everybody is, at some level, scared. You never want to lose a life, but just having a child in front of you that has bullets in them and is bleeding out or could die — that’s a very traumatic thing.

The parents come into the trauma bay with us. So you’re dealing with a child with a bullet injury, and the parents are there. You can only imagine how traumatic a situation that is, and the immense horror on the faces of these parents.

You can’t help but reflect on your own kids. I’m a father myself. You start thinking about the fact that you don’t want to lose this child, and then you do everything you can to treat the injury. It’s a hard thing to grapple with. It doesn’t ever become easier.

What do bullets do to children’s bodies? Are there differences in terms of how they affect kids versus adults?

When it comes to children, people don’t understand: Everything, all their vital organs, the big blood vessels, they’re all that much closer together. And unlike with an adult, there’s no buffering from abdominal fat, or protection from muscles. When you look on the outside, you might just see a bullet hole. But when we, as surgeons, open up that child, we see the devastation on the inside. One bullet can cause catastrophic injury to organs, and in many cases, it’s stuff that we can’t even repair.

I hate to ask you what that is like when you can’t repair the damage. But I’m wondering if you can describe it for me.

In medicine, we lose patients. When it comes to losing a child in such a traumatic way, from a gunshot injury, there’s this unspeakable sense of frustration and sadness that you experience.

The only way we stay centered is that we think about the parents, and what we can do for the parents. But then inevitably, you think about your own kids, you think about your own community, you think about your own school. Is it safe to send your kids to school? There’s a component of the fact that there’s these kids’ lives that have been cut drastically short and in such a violent way, and then there’s the secondary trauma that affects all of us.

Most of us follow stories about community gun violence and school shootings in the news. We see the images of crying children, but we don’t see what you see — and most of us, I think, would rather not think about what guns really do to kids. What’s one thing you really want readers to know?

Sometimes people say it’s about the individual, not the gun, right? But it is about the gun. The amount of destruction that guns cause is devastating. I invite anybody who doesn’t believe that to come in and see firsthand. Think about your own family members. Would you rather have them have a knife injury? Or would you rather them have gun injuries from an assault weapon?

It’s kind of a no-brainer. The fact that that’s even debated is pretty ridiculous. These are weapons that can cause mass destruction and kill many people quickly. From an injury standpoint, the wounds from car injuries, and stab wounds are way less complex to deal with and way less lethal than gunshot injuries.

Can you say more about that?

When we see a patient who comes in with a stab wound, even multiple stab wounds, the chance that the blade actually pierces a vital organ or blood vessel is way less likely than with a bullet, because the bullet, when it enters the body, causes a significant thermal reaction and secondary effects — it creates a huge cavity of destruction. It’s not like a knife that just goes in and causes a cut in the area of concern. Don’t get me wrong: Knives, stab wounds, can be extremely lethal. They cause devastating injuries, too. But they’re definitely not one-for-one.

The murder rate surged during the pandemic. Did you see this in your work?

Yeah. In 2022, compared to 2021, there was a 350 percent increase in the number of kids with bullet injuries coming to our Level 1 trauma centers. During the [beginning of the] pandemic, we did see a spike, but that was the biggest spike we have ever seen. And this year already, we’ve surpassed that trajectory with respect to gun injuries, not to mention many, many cases of stab wounds. It’s definitely at a level that we haven’t seen before.

Guns are now the leading cause of death for children in this country. How do you make sense of that?

We think that there’s a public health approach that can be taken to curb this issue. There is a way to take a public health approach that promotes firearm safety and holds the gun industry accountable. Car manufacturers didn’t decide to put in seat belts and rearview cameras on their own, right? That was done through data, studies, and then industry responsibility through liability. The gun industry doesn’t have that. There has to be a sense of responsibility and accountability here. And that’s actually something most Americans agree on.

We know, for example, that safe storage legislation, simple background checks, and so on will help stop things like mass shootings, suicides, unintentional injuries. They may not do that much for firearm violence, which disproportionately affects Black and brown communities. We need a more robust approach to tackle root causes when it comes to firearm violence, like structural racism. We need more support for violence prevention programs. There’s a lot of social determinants that are at play. So I think we have to have that nuanced discussion.

What are the components of a comprehensive public health approach to gun violence prevention?

There are certain things that we know can be affected on an individual level — for example, education around firearm safety, promotion of firearm safety in general, whether it be with your physician, in conversations, in public awareness campaigns. We ask all patients questions about firearm injury risk, we screen and then intervene as needed. No matter what you come into a hospital with — a headache, a urinary tract infection, whatever — you get those questions. That’s an example of an effective solution, because if you talk to people about safe storage, there is a positive correlation with behavior change, and safe storage of a weapon will reduce risk of suicide, unintentional injury, and mass shootings.

Violence intervention programs, we know that they work, and they need to be evaluated more. And then I talked about addressing the root causes. There’s obviously an intersection with inequity and structural racism when it comes to firearm violence. When it comes to firearm suicide, there’s obviously a correlation with behavioral health.

The last thing is policy. Policy is just part of public health — like age limits for tobacco, licenses for cars. So things like red flag laws, background checks, licensing requirements, waiting periods. Then there are ways to make guns themselves safer, smart gun technology or so on — but there’s no impetus to move forward because of the lack of the federal law that bans them from being held liable for anything.

If you think about public health, in general, the government has to play a role in stepping in at times. You can’t just rely on people to make decisions that are going to benefit the safety of the community. That’s one example. Taking weapons of mass destruction, like assault rifles, off the streets — it is critical.

Update, April 7, 10:30 am ET: This story was originally published on March 29 and has been updated with new information on child gun deaths from the Pew Research Center.

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