Every time it happens, a chorus of alarms sounds — through overhead speakers, as well as cellphones, pagers and other electronic devices hanging from the necks of emergency room staff at Sinai Hospital.
The "delta code" means another serious trauma case is about to arrive at the North Baltimore hospital. Since April, when a spate of violence began in the city, there is a heightened chance it is someone grievously wounded by a gunshot.
"You hear them go off," said Dr. William P. Jaquis, chief of emergency medicine at Sinai, one of three designated trauma hospitals in Baltimore. "A team of 15 to 20 people come running. We know we'll be working harder, with more intensity."
The emergency rooms at Sinai, Johns Hopkins Hospital and the University of Maryland Medical Center are some of the busiest in the city, each tending to 6,000 to 8,000 patients a month. They see ankle twists and broken bones, chest pains and stomachaches, people severely injured in car crashes — and this year in particular, a soaring number of shooting victims. The shootings have led to a record number of deaths and turned hospital emergency rooms into revolving-door care centers for victims, and possibly perpetrators, of gun violence.
The number of homicides in Baltimore in 2015 reached 343 this week, surpassing 300 for the first time since 1999. The number of homicides in the city was 50 percent higher in the first nine months of this year than during the same period last year. Shootings were up more than 70 percent. Experts are unsure why, though much of the violence began to spike in April amid the unrest that followed the death of Freddie Gray, 25, who suffered a severe spinal injury in police custody.
While the overall number of people going to emergency departments in the nine-month period in those hospitals and eight others in the city was down slightly from last year, the number of gun-related injuries has grown. Although the hospitals and staff are equipped to handle the increased volume, the emotional impact of such daily carnage is a different matter.
Close to two shooting victims a day need emergency care, predominantly at the city's trauma hospitals, or about 200 more such patients than last year. They make up a small fraction of patients overall, but Jaquis says they require far more attention from doctors and nurses than those without such devastating injuries.
Such victims can sap medical providers' mental energy in a way that other patients do not because of the seriousness of their injuries and the senselessness of the violence that landed them there.
The victims are most often young black males, and Jaquis said they frequently have mothers, grandmothers, siblings and friends anxiously standing by in waiting rooms hoping to hear that they will survive.
Emergency room doctors and nurses say stress comes with the job, but this year has been tougher. In addition to tending to the broken and bloody young bodies, hospital staff members had to navigate through the protesters and National Guardsmen in the streets last April, and a barrage of media coverage of the unrest after they got home.
Nurse Ellen Chacon said going home to her more rural community in Carroll County helped her through. Dr. Lisa Kirkland, an emergency physician at Sinai, agreed that living outside the city helped but said she felt anxiety driving to work from Harford County.
"I'd wonder how my day would go," Kirkland said. "The people who got shot, they come in cursing and screaming. They were just kids."
Experts say the burnout rate among emergency caregivers can be high and that the victims of violence can weigh more heavily on them.
Criminologist Sam Bieler, a research associate for the Urban Institute, found in 2010 that Marylanders suffered firearms-related injuries at a rate of 15.5 people in 100,000, above the national average of 14.4. Nearly 42 percent were males ages 15 to 24. Most were black and 15.6 percent died in the hospital, more than twice the national rate.
While recent crime spikes in other cities are not reaching the high levels of the 1990s, Bieler said, Baltimore has reached its highest-ever rate of homicides per capita.
Shooting victims also are tougher to treat as weapons have become more powerful, he said. Shootings tend to cost $14,000 more per patient.
"Weapons are purpose-built to cause harm, so it's not surprising to me the injuries are more intense than injuries from a car accident or fall," Bieler said.
Shooting victims also represent a larger share of hospital patients in the city as emergency room visits fell 2 percent and admissions for serious injuries or illnesses dropped more than 3 percent in the first nine months of the year from the same period last year, according to a Baltimore Sun analysis of data from the state Health Services Cost Review Commission.
Continuously trying to treat gunshot victims takes a toll, especially on those who have more empathy for their patients, said Dr. Michael F. Myers, a psychiatrist who treats other doctors at the State University of New York Downstate Medical Center.
"They feel it's all senseless," he said. "Those battling drunk driving can combat the problem with education, and seat belts can help in car crashes, but people feel so powerless against gun violence."
Myers says it is helpful for those involved in tough cases to do short debriefings afterward to acknowledge what happened and everyone's contributions. He said those more deeply troubled should seek mental health care.
Immediate emotional support for first responders is being discussed, says Dr. Ben Lawner, deputy EMS medical director for the Baltimore Fire Department and an emergency physician at the University of Maryland Medical Center.
He says the unrest brought new risks to first responders and that protocols aimed at minimizing those risks sometimes added to their burden. Ambulances were given police escorts and assistance in navigating around protesters. Patients were loaded aboard as quickly as possible rather than being stabilized at the scene.
"Feeling unsafe in their own city was particularly stressful for them," he said. "It was a lot of uncharted territory."
Lawner and others in the emergency room during the worst hours of the rioting watched as a van carrying up to 10 injured police officers pulled up to the emergency department. They were unsure whether more were coming, said Lawner, an assistant professor of emergency medicine.
The hospital was on lockdown with armed guards at the doors. Staff members, trained to handle victims of mass violence, moved patients from the emergency room to make space. Those with severe injuries were sent one floor up to the Shock Trauma Center, which typically handles the worst traumas in the region. Usually, police officers were taken directly to shock trauma, but that night they stayed in the emergency room. None of the officers was severely injured, and no more arrived that night.
"We made sure the emergency department stayed open and functional," Lawner said. "Not everyone is suited to it. And there is a lot we're still processing."
Lawner said attention to medical providers' immediate mental health needs is paramount. Hospitals do make specialists available and are introducing the debriefing recommended by psychiatrists. Karen Doyle, senior vice president of nursing and operations at Shock Trauma, organizes smaller-scale relaxation activities such as yoga, dog therapy and meditation, and mindfulness exercises to help shed "unwanted mental clutter."
Doyle says the staff always felt the intensity of the room but thrived on the rhythms of the day. The unrest upended those daily patterns. Shooting victims used to come in the early morning and on weekends. Since April, they have come at all hours.
One trauma surgeon who missed a regularly scheduled Wednesday morning meeting later explained that he had had to treat two gunshot patients at 9 a.m. Doyle calculated that from July to September, nearly a quarter of Shock Trauma's patients had been victims of violence. During the same period last year, it was 18 percent.
Doyle hopes the trials of the six police officers charged in Gray's arrest and death do not spark more rioting and injuries.
"It's overwhelming," she said. "Humans hurting humans intentionally."