FRIDAY, JUNE 4, 2021
Trauma surgeons can describe in graphic detail the horroric injuries a gunshot can inflict. A “million-dollar wound” might be played for laughs in Forrest Gump, but as Dr. Robert Winfield, Director of Trauma Research at the University of Kansas Medical Center, lamented in an article posted here last year, there’s absolutely nothing funny about a “GSW to the butt”—especially if the bleeding can’t be stopped. (“GSW” is medical shorthand for gunshot wound.)
Even for those fortunate enough to survive a bullet piercing their skin and violating their body, recovering physically might be only half the struggle.
“To not address the psychological trauma done to survivors puts them at grave risk,” stresses Jackson County Prosecutor Jean Peters Baker. “That’s something those in the medical profession and those of us in the legal profession are responding to because the odds increase once a person has been shot that they will be shot again—and the next time their wounds might be fatal.”
That’s why Peters Baker worked with Truman Medical Center/University Health (TMC/UH) administrators and front-line staff to introduce Project RISE in September of 2019. The Responsive Individual Support and Early intervention program consists of behavioral health professionals, nurses, social workers and chaplains working to make sure people who’ve suffered from gun violence have all the resources needed to fully recover.
COMBAT has funded Project RISE from its inception, with $235,450 allotted for the program in 2021.
81.3% Of Those Screen Receive Psychological First Aid
At a minimum, Project RISE offers every gunshot victim treated at TMC/UH an initial assessment of their risk for developing chronic Post-Trauma Stress Disorder (PTSD). To date, September 2019 – May 2021, 295 GSW patients have been screened. (From September 1, 2019 through May 31, 2021, there were 812 non-fatal shooting across all of Jackson County.)
Of the patients screened through Project RISE, slightly less than half (44.1%) were deemed high risk for chronic PTSD symptoms. Most—81.3%—received acute crisis intervention, regardless of whether considered high or low risk, according to the program’s coordinator, Dr. Joah Williams.
“We’ve had very few people decline to do the initial screening,” says Williams, a TMC/UH Behavioral Health Unit psychologist and an assistant Psychology professor at UMKC. “That assessment is one of the first things we do when a patient is stabilized. The vast majority of the folks we have seen have gotten at least Level 1 intervention in the form of Psychological First Aid in the hospital or within a few days if they weren’t admitted for their injuries.”
Higher Levels Of Care Available
Additional psychological care is available through Project RISE. Level 2 focuses on equipping patients with the skills necessary for a full “psychological recovery,” with treatment often beginning at the patient’s bedside before they’re released from TMC. The Behavioral Health Unit provides Level 3 care for those GSW victims with chronic trauma-related symptoms or other emotional problems.
About one in four (24.8%) GSW patients screened for PTSD opt for Level 2 services. Through RISE’s first 21 months, among those patients receiving Level 2 care, Williams points out, “Significant decreases in PTSD symptoms were observed.”
But Dr. Williams warns RISE is still “relatively young.” It is too soon to gauge the program’s effectiveness or to draw any conclusions from the data collected.
“The number of screenings we’ve done is fairly on track with what we were anticipating just given the general volume of gunshot wound victims we see at Truman,” he says. “I think it’s a pretty impressive number just in terms of how many victims have been willing to participate. We were just six months into the project when we had to regroup and reframe how we were doing some things because of the challenges that came up with the pandemic. The important thing is that we were able to find work-arounds, change procedures and keep providing the crisis intervention.”
“Through this program, the whole person—and not just the bullet wound they’ve suffered—is being treated and, hopefully, that will be a life-saving difference maker.”
Increased Probability Of Being Shot Again
A study conducted over five years (2012-17) tracking what became of gunshot wound victims treated in the Seattle area reached some startling conclusions: these GSW victims were 21 times more likely, compare to the general public, to get shot—again—and four times more likely to die in a firearm-related homicide.
“One aspect of Project RISE is trying to do a similar study here in our community, at least related to the gunshot wound patients being treated at Truman Medical Center,” says COMBAT Director Vince Ortega. “In that its focus is on trying to reduce the chances of revictimization, through helping people make a full recovery, Project RISE fits perfectly within COMBAT’s mission to prevent further violence.”
Williams reiterates that it’s too early, after only 21 months, to determine if Project RISE might be having an impact on revictimization.
“I know early on in the project some of the folks we were screening for the first time had been shot two or three times before we ever started Project RISE,” he says. “I think I can count on one hand the number we’ve seen subsequently be treated for new gunshot injuries.”
Reducing The Odds Of Revictimization
In fact, through May, exactly five Project RISE patients have been readmitted to TMC/UH for new gunshot wounds. Though that is certainly a promisingly low figure, Williams emphasizes, “These numbers are likely an underestimate in that there may be delays in successfully identifying victims upon admission and victims may have been treated for new injuries at other medical centers.”
- Dr. William talks at length about key factors that can reduce the risks of a victim being shot again—and the “mixed bag” impact of COVID-19 on Project RISE.
Prosecutor Peters Baker appreciates Williams’ frankness that Project RISE’s early “results should be interpreted with caution,” but she is hopeful that this program can at the very least mitigate the risks of revictimization.
“We are now collecting some local data,” she says, “though I think we know the trend seen in Seattle probably wasn’t unique to Seattle. Being shot, most people might assume, is a once-in-a-lifetime experience—that the odds of it happening again are like being struck by lightning twice. In reality, a person who has survived being shot in one incident sees their odds of being fatally shot in a later incident increased dramatically.
“At the very least, I think Project RISE is doing something to reduce those odds. Through this program, the whole person—and not just the bullet wound they’ve suffered—is being treated and, hopefully, that will be a life-saving difference maker.”
Caring For Crime Survivors
“Although a case might never be passed along the to the Prosecutor’s Office for charges, that doesn’t mean there isn’t anything we can do to help these crime victims become crime survivors who are better able to get on with their lives.” The Caring For Crime Survivors program—created by the Prosecutor’s Office and operated in partnership with the AdHoc Group Against Crime, with funding from COMBAT—can provide referrals to counseling and facilitate repairs to property damaged during a crime. AdHoc has many of the doors pierced with bullets transformed into artwork.
Keeping Surivovrs Alive!
A new COMBAT-funded program at Truman Medical Center is focused on treating all the wounds—seen and unseen—a gunshot can cause. Studies have tracked what becomes of gunshot wound (GSW) survivors long-term. They’ve discovered some alarming trends, including the high risks of survivors being shot again and eventually dying in another firearms-related incident. The TMC program, Project RISE, seeks to identify shooting victims with severe PTSD symptoms and provide early intervention. TMC doctors and nurses can start administering “psychological first aid” the moment a wounded patient has been physically stabilized.
From 9/11 To Katrina To GSW Survivors
Suffering a gunshot wound is obviously a traumatizing experience. At Truman Medical Center, the staff is adapting methods developed to treat the survivors of the World Trade Center attacks, Hurricane Katrina and other mass disasters to help GSW victims cope with their PTSD symptoms. “We understand the need for more immediate intervention to treat people beyond the gunshot wound, itself,” says Dr. Joah Williams, a clinical psychologist with the TMC Behavioral Health Unit. A full recovery entails treating both the physical and psychological harm done.
Vets Spark Progress On PTSD
During the Civil War, amputations were routinely performed to “treat” arm and leg wounds. In both World Wars doctors observed the psychological toll combat wounds had on “shell-shocked” soldiers. Then Vietnam veterans—and women displaying similar symptoms after suffering domestic violence or sexual assault—pushed for more research to be done. In 1980 Post Traumatic Stress Disorder was finally recognized as an official diagnosis. Early intervention to treat PTSD is being widely viewed as the latest progression in the overall treatment of gunshot wound survivors, whether they sustained their wounds in a war zone or a crime committed in our community.
A Trauma Surgeon's Perspecitve
'I Opened My Eyes More Widely...'
A case that began with what sounded like a funny announcement in the Emergency Department—“GSW to butt, ETA 5 minutes”—has forever changed Dr. Robert Winfield, a trauma surgeon at KU Medical Center. He writes about his experience treating gunshot wounds and how he is now willing “to speak to anyone, anywhere, at any time, who wants to talk about gun violence and its root causes.” We consider his first-person account a must-read, but be warned that it does include graphic details that some readers might find disturbing. The case that started with the “GSW to butt” announcement ended with a heartbreaking encounter with a grieving mother: “The anguish she expressed when I told her of his death was like a bullet fired into my soul.”
SUMMER IS UPON US — It is encouraging that through the first five months of 2021 the rate of non-fatal shootings in Jackson County appears to be declining compared to last year. But keep in mind, as this chart indicates, when temperatures heat up, violence tends to increase as well.
Project RISE was in its infancy when the pandemic struck last March. The COVID impact on the program and gunshot wound survivors who receive mental health care through it were not entirely adverse—“a mixed bag,” according to Project RISE coordinator Dr. Joah Williams.
In Dr. William's Words:
With PTSD, there’s a natural tendency to want to avoid the places and people who are going to remind you of the shooting—remind you of what happened. And during the pandemic, due to the restrictions put in place, a lot of folks have actually been more comfortable in some ways not having to go out. A lot of people were happy they didn’t have to go out places where they potentially risked being seen, risk being re-victimized. They felt more comfortable being at home.
A lot of people felt more comfortable wearing masks in public if they did have to go out. They had a certain level of anonymity, especially if there were concerns about the perpetrator having not been apprehended, for example. They realized they can mask up and go out—have it be far less likely people could recognize them, at least at a glance.
From that being said, one of the treatment challenges during the pandemic has been that a lot of times with PTSD symptoms we want to get people back out in the community, being active, particularly in activities with good healthy social supports. And that’s been really, really challenging for us.
We’ve had to get creative to get people the social support needed, so that they aren’t completely isolated. We’ve had to find creative solutions and that has involved using technology. Technology has been and is going to continue being a lot more important part of what we use to connect to victims now.
The mixed bag was in trying to coordinator with our resources to get victims help with finances and housing—resources to address basic needs. If a person’s basic needs aren’t met, their emotional and psychological wellbeing are going to obviously suffer.
While it’s too early to determine if Project RISE will have a lasting impact on revictimization, the data collected after 21 months shows few victims screened and/or treated through RISE have been readmitted to Truman Medical Center for another gunshot wound. Williams is cautiously optimistic.
In Dr. William's Words:
Victims have, over and over again, told us they would never wish on anyone else what it is that they are going through because they know the kind of pain these kinds of experiences have had on themselves and their families and their communities.
If anything, I think sitting down with them has actually helped to just begin a discussion about all the broader ways an injury affects their lives, so we can provide help and support, so we can create conditions where they can recover and become really resilient.
This is something that resonates with victims.
I think there is a real affirmation of what we are doing through Project RISE on the part of the victims who say, “I’ve gotten care not just for my physical injuries but for all the ways these injuries have affected my life.” Particularly their emotional and psychological wellbeing.
And we’re finding just talking about the emotion toll of a bullet injury during a brief crisis intervention can be meaningful. People leave with a sense of dedication to make sure that this cycle of violence doesn’t continue for someone else.
So, I guess the question becomes how do we, as a broader community, provide resources to these victims so that they can live up to the commitment that they want to make.
We’ve shifted our dialogue in a sense about what it means to be a gunshot wound victim. We are recognizing that victims are really just that: victims. They aren’t part of the problem. They’re victims. And they deserve the treatment and respect that all victims should get.
There are other factors involved in preventing revictimization, of course.
There was an interesting article in The Kansas City Star recently about high rates of homelessness and how evictions in certain areas are associated with surges in gun violence and violent crime more broadly. I know a lot of our victims are in areas where evictions are more prevalent. A lot of our victims are in areas where they may struggle with issues related to housing and other social economic ills.
All those factors are going to contribute to risks of revictimization and perpetration—independent of anything we can do. Those things are going to undermine any individual’s mental health, if we can’t provide some of those most basic necessities and supports.
Williams believes Project RISE reflects not only a shift in the medical profession’s approach to treating gunshot wounds—going beyond just patching the actual bullet holes—but in the attitudes survivors may have toward understanding the extent of the harm done to them.
In Dr. Williams' Words:
When we are doing our initials screening, we’re up-front and explain what kind of questions we’re going to be asking and why. We give the patients a choice: “We don’t have to do this now. We can come back later. What is your preference?” That empowers them to have say in what they want and need.
And that’s how we begin to heal the wounds of trauma, just giving people a voice in what is happening to them. Transparency, honesty and giving people choices can go a long way toward winning trust—and people are very open to sharing with us.
If anything, I think people generally appreciate that we ask these questions because it opens up a dialogue about different aspects of their experience that they often would never be asked about before and that they would never think to share with others.
Dr. Joah Williams testifies before the COMBAT Commission in 2019 to discuss the creation of Project RISE.