Just after midnight, medics rushed the gunshot victim into the last available trauma bay, and nurses and doctors swarmed. They needed to stop the bleeding.
As one staffer cut off the patient's clothes that night this summer, Dr. Jason D. Pasley began a careful search of the man's body for bullet wounds. The holes can be as small as a pencil eraser, and the team rolled the man to check everywhere — behind knees, in armpits, along the hairline. One by one, Pasley called out what he found — a hole in the back, in the buttocks, in the leg — until he got to six.
Surgeons call it "bullet hole math." An even number indicates that bullets might have gone through. An odd number raises the likelihood that a bullet may still be in the body.
"If the math doesn't add up, you are missing something," said Pasley, a long-serving trauma surgeon at the University of Maryland Shock Trauma Center in downtown Baltimore. "The more you're shot, the more likely you are to hit something serious, the more likely you are to die."
The gruesome ritual has become more common in hospitals nationwide. At Shock Trauma that week, it was the seventh night in a row doctors had had to rely on the crude calculus.
Emergency rooms are struggling to save gunshot victims arriving in worse shape than ever before, with more bullet wounds, increasingly shot in the head. Even as advancements in trauma care have saved countless lives, victims of gun violence have seen their chances of survival drop, exacting a toll on victims' families, medical personnel and taxpayers.
More than $80 million has been spent at Baltimore hospitals caring for patients shot in gun crimes in the past five years. During that time, the number of cases doubled and the annual price tag soared nearly 30 percent. Most of the medical costs are now covered by Medicaid, the federal-state health insurance program for the poor.
"We spend every night trying to row upstream against this," said Dr. Thomas M. Scalea, physician-in-chief at the R Adams Cowley Shock Trauma Center, the first of its kind in the nation. The 55-year-old center is named for the pioneering surgeon who coined the phrase "Golden Hour," the time after injury when trauma patients have the highest likelihood of survival.
Scalea says that time can be mere minutes for gunshot victims. He said his experience treating them has become emotionally numbing. "You get outraged for a while," he said. "Then you get the next one and you go — what are you going to do?"
Outside the hospital, first responders are trying to keep up with the merciless uptick in gun violence. Baltimore police officers have begun carrying tourniquets, which constrict blood flowing from wounds, and a national push is underway to make the devices as widespread as defibrillators and as commonly understood as CPR.
Police officers in some cities — rather than waiting for an ambulance — load gunshot victims into squad cars to get the wounded to a hospital before it's too late. Both law enforcement and paramedics are adopting military-grade equipment and practices from combat situations.
The changes in trauma medicine have coincided with deadly trends on the streets of Baltimore and other major U.S. cities, The Baltimore Sun found in a yearlong investigation. Criminals are using higher-caliber guns with large magazines and bullets that destroy tissue and pulverize organs. Crime scenes are littered with dozens of shell casings, and victims are bleeding out more quickly. Shooters are exhibiting a brazen ruthlessness that surprises even grizzled law enforcement officials.
With so many shooting to kill, The Sun found, odds for gunshot victims have gotten worse. For every three people shot in Baltimore, one person dies, making it one of the most lethal of America's largest cities and deadlier than a decade ago. Other cities are also seeing spikes in gun violence and lethality. Among them: Washington, Chicago and New York.
The onslaught has left surgeons, public health and other medical professionals outraged and looking for ways to stem gun violence.
"What's surprising to me is that we're a society that is willing to live with this," said Dr. Angela Sauaia, professor of public health, medicine, and surgery at the University of Colorado Anschutz Medical Campus. She said that if gun violence were a disease, a one-in-three chance of survival would be considered an epidemic.
"This would be a scandal if it was happening with breast cancer or heart attacks," she said.
What’s surprising to me is that we’re a society that is willing to live with this. This would be a scandal if it was happening with breast cancer or heart attacks.— Dr. Angela Sauaia, professor of public health, medicine, and surgery at the University of Colorado Anschutz Medical Campus
Many police chiefs and researchers say that to make real progress, one crucial piece is missing: better data. With scarce federal funding for gun research and antiquated, inconsistent record-keeping, it's tough to track what's happening. The total number of people shot nationwide, for instance, cannot be accurately counted.
There is some hope, as public-health and other researchers are devising novel ways to try to understand the violence, by analyzing patterns in where victims live, and figuring out better ways to reach the people doing the shooting.
For now, many victims are showing up to hospitals in grave condition. Many will need what surgeons call a "great save."
At Shock Trauma this summer, the patient cried out in pain and begged the medical staff to stop examining him. "Don't do that," he yelled. Then, as if he realized they were trying to help him, he gritted his teeth, urging: "Do your thing, do your thing."
Pasley knew the patient had been shot repeatedly. But he still didn't know how many times. The counting is only part of the equation.
The patient could have been shot three times, or he could have been shot four or more times, the bullets still lodged inside him. Pasley also had to imagine the possible trajectories of those bullets. Any one could have hit a bone that might have then fragmented and cut an artery or a lung.
So the team ordered X-rays and later rushed him to surgery.
Unlike about 200 gunshot victims in Baltimore so far this year, he survived.
'Three, four, five operations'
Scalea has run this storied center and its troop of staff in signature pink scrubs for almost 20 years; he is also Professor of Trauma Surgery at the University of Maryland School of Medicine. When a police officer, medic or firefighter is seriously injured, he is paged to oversee the case. He's one of the most recognized trauma surgeons in the world.
But even at the top of his game, Scalea is challenged by the gun violence coming through the hospital doors. Now more than 60 percent of homicide victims are shot in the head, up from less than 15 percent two decades ago, and the number shot more than five and 10 times doubled in the past decade, The Sun found. It's enough to make physicians feel that they are losing a fight over which they have no control.
A few months ago, Scalea was confronted with a patient on the brink of death, with maybe a 3 percent chance of survival. The victim had been shot six or seven times — in his chest, his abdomen and his arm, where one of the major blood vessels had been hit. As the ambulance arrived, the man's heart stopped.
Scalea opened the patient's chest and began "open massage" on his heart, manually clapping it back to life with the help of blood transfusion and medicine, until his team readied the defibrillator. "We had to shock him three or four times to get his heartbeat to sustain," he said.
It took more than three hours in the operating room for Scalea to get him partially stabilized. The patient was hemorrhaging from his spleen, pancreas and stomach. He needed a transfusion of 20 units of blood — about three times his entire volume. After the man's condition improved, Scalea operated again, this time for more than three hours.
Against the odds, the patient survived.
"A great save is the term we use in the business," Scalea said. "We're not out of the woods, but he is far more stable than he was early on. And I'm hopeful."
Other nights, it's a great loss, and he must tell another stricken family of a loved one's death.
Scalea has witnessed the consequences of two trends behind the increase in lethality. Semiautomatic weapons of a higher caliber are being seized from criminals in greater numbers, and higher-capacity magazines have become the norm in gang and street cultures.
Pasley, an Air Force veteran, sees parallels between the multiple-gunshot victims he sees at Shock Trauma to what he saw as trauma director at Craig Joint Theater Hospital at Bagram Airfield, the main hospital for the U.S. military in Afghanistan, where he was deployed in 2014.
The carnage in both places is extensive, he said. The difference is that when soldiers are hit with improvised explosive devices, they might need amputations but have body armor protecting vital organs. In Baltimore, when victims are hit, it's often with hollow-point bullets that expand on impact, causing tissue damage and blood loss.
At Johns Hopkins Hospital, Dr. Elliott R. Haut, another experienced trauma surgeon, has seen a range of gunshot injuries and patients who have required incisions from "stem to sternum" so that doctors could assess and address the damage caused by multiple bullets. He's seen patients shot in the heart, liver, bowels.
"Every body organ you can imagine," Haut said. "I had a guy recently, he had different gunshot wounds, probably 10 different wounds in and out, here and there, basically from his head to his legs."
Gunshot wounds to different areas of the body can require more specialists for consultation and care. A bullet to the heart could require a cardiac surgeon; a head shot could call for a neurosurgeon. In some cases, surgeons stand on opposite sides of the operating table so they can work simultaneously on different areas of the body.
"Some of these people need three, four, five operations," Haut said of the victims. "It takes a lot of work."
Baltimoreans have come to believe that the city's top-ranked medical systems have kept the homicide count lower than it would be otherwise. "If it wasn't for the fact that Maryland has one of the best EMS systems in the country, our fatality rate would be much higher," said Dr. Carnell Cooper, a former Shock Trauma surgeon who now serves as chief medical officer and vice president of medical affairs at Prince George's Hospital Center.
Others, including former Baltimore Police Commissioner Anthony Batts, suspect a more sinister corollary is at play — that criminals are firing more bullets and aiming at the head to ensure that the world-class surgeons won't succeed.
Baltimore hospitals get three-fourths of the state's gun assault cases, and costs have risen to $19 million a year, state data show. Nearly 80 percent are covered by Medicaid, and patients don't have any insurance in about one-fifth of cases. Those costs, known as charity care, are borne by all residents of the state with insurance as hospital rates are calculated to cover them.
Meanwhile, hospitals are staffing up. In 2004, Hopkins had one trauma surgeon. Now, there are six or seven doctors working full-time in trauma care and emergency surgery. A trauma surgeon has been put on rotation at the hospital around the clock as at Shock Trauma, which is a key part of the state's emergency medical system.
With these doctors come associated services on call, such as a blood bank, CT-scan technician and staff to ready operating rooms even before an ambulance arrives.
Sue Carol Verrillo, nurse manager of the Hopkins surgical inpatient care unit, said shooting survivors can remain hospitalized for weeks, adding to costs. They require vacuum-assisted dressings and extensive pain medications. Many will need long-term care, with occupational and physical therapy.
She sees four to six violent crime victims a week and has come to believe that sometimes shooters are aiming to shame with wounds of humiliation. Earlier this year, she said, two patients' eyes were shot out. She said police have told her that some were shot in the buttocks on purpose, as they were running away. Some are deliberately paralyzed.
"You're going to be in a wheelchair for your whole life," she said. "The nature of the wounds have changed."
In complex gunshot cases, patients can "bounce back" to her unit, before being discharged from the hospital, when they develop complications such as infections or internal bleeding. Over a three-month period through early March of this year, she had a record 23 bounce-back patients.
These patients require double the supplies: another feeding tube, more drains, more dressings that need to be changed two or three times a day, catheters, external fixators to keep bones in place as well as medicine to manage nausea. That can add thousands of dollars to her monthly supply budget, Verrillo said.
Haut can't help but think it's all so unnecessary, that these costly injuries could have been prevented.
"It's a giant waste of money."
Anguish for families, staff
Eight security guards caught Lekya Missouri as she tried to push past them.
"If you don't let me through right now," she told them, "you're going to have a problem."
The halls outside Johns Hopkins Hospital's emergency department were crowded with police, worried family members, doctors and nurses. Eight people had been shot in one incident the last Saturday in September in East Baltimore. Among them: 3-year-old Kendall Brockenbrough, Missouri's daughter.
Missouri spotted a hospital social worker walking toward her and immediately thought, "No, no, no!"
Her mind flashed back to June 2011, the last time a hospital social worker had approached her. Back then, the staff member told her that her husband, Henry Mills, had been shot in the back of the head and killed. Missouri had to identify her husband as he lay on a gurney, his chest and legs covered by a white sheet. She asked hospital workers to wipe up the blood pooling under his head.
Mills had been shot by David Hunter, a member of the Black Guerrilla Family, Baltimore's most powerful gang. Hunter, who is serving two life sentences plus 40 years for the crime, is considered a hit man by Baltimore police. This class of shooters, who take murder-for-hire contracts issued on the streets, are responsible for an outsized share of city homicides, police say.
This time the social worker escorted Missouri to a trauma bay. Kendall was alive. Her father hovered over her, singing "Five Little Monkeys Jumping on the Bed" to distract her from the pain of a broken left femur and a ruptured artery. She had taken a shotgun blast.
"Mommy, mommy," Kendall sobbed when she saw her.
Kendall had been outside with her father when three gunmen approached from different directions and fired on the crowd, according to police. The father had also been hit, in his foot, and it was bleeding. He had refused treatment until he knew his daughter would survive.
Missouri jumped in and sang the nursery rhyme with him. Later, as doctors sedated Kendall for surgery, her mother told her how much she loved her. During an eight-hour operation that included two blood transfusions, doctors removed a section of artery from her right leg and spliced it into her left leg.
Three surgeries later — to remove bone fragments and scar tissue and close wounds — Kendall is on her third week in the hospital. One day last week, she lay under a pink blanket depicting Disney's "Frozen" movie, her left leg held together by a heavy external fixator that resembled metal scaffolding. She alternated between grimaces, uttering "ow," and the unsinkable amiability of a toddler.
She had been a girl who was gaining independence: She had finished potty training, started picking out her own clothes and could tell her right shoe from her left. Now, Missouri said, she would have to relearn to walk in a rehabilitation hospital, where she is scheduled to stay for up to two months after she's discharged.
Kendall wasn't "just shot," Missouri, 37, said. "It was a life-changing event."
Will Kendall have full feeling in her foot? Will her leg grow properly? Will the scars on her skin make her suffer teenage humiliation?
These are her mother's worries, and they go on. How long will Kendall need counseling? How long will she need painkillers? And for today, how long will we be able to entertain her by blowing bubbles or playing with an iPhone? When will the violence end?
Missouri, who lives in White Marsh, is at a loss to understand why gun violence has hit home twice. She recently bought a Bible looking for answers — or at least a different future.
"My kids have suffered. I have suffered," Missouri said. "Now my youngest daughter suffers."
My kids have suffered. I have suffered. Now my youngest daughter suffers.— Lekya Missouri
A nurse walked in with a vial of Valium, and Kendall started crying. "She's not gonna touch my feet. No, I don't want her to hurt me," the girl said.
Last week, a doctor removed his white lab coat in an attempt to put Kendall at ease after she asked, "Are you going to hurt my leg again?" This time the nurse promised to stand by the door as Missouri tried to get her daughter to drink the Valium from a syringe through gritted teeth.
The girl turned her head, smacked her mother's hand, hid her face.
Eventually, Kendall swallowed the medicine. Missouri heaved and hid her face in her hands as she cried. She tells herself she can't be upset at her daughter's lashing out. Missouri says she is grateful.
"She's here," the mother said. "She's here."
It's the fear and anxiety that hospital staff also need to tend to, with the help of social workers and pastoral care. And sometimes, they need extra security, as was the case in the shooting that wounded Kendall. A shootout can bring victims, perpetrators and their families to the hospital, and Verrillo has to ensure they remain on opposite ends of the hall.
"We have to have very clear boundaries," she said.
It can be difficult to remain at a clinical distance. Dr. Rodney Omron, an emergency physician and associate program director of emergency medicine at Johns Hopkins Hospital, recalls the "execution-style" shooting of an apparently homeless man he often saw on his way into work.
Like law enforcement officials, Omron notes a more brazen cold-bloodedness among shooters. That's hard to quantify, but over the past two years, Baltimore, among a number of cities, has seen a steep rise in homicides.
In recent months, it seems as if almost every Friday night he has to tell family members a loved one is dead.
Omron had to put a breathing tube in his own father and watched his mother, who succumbed to cancer, die in his arms. He served as a physician for the Marines in Iraq. "I thought I had seen everything," he said.
Then he came to Hopkins. He said he has seen mothers suffer heart attacks from grief. He's also tried to comfort patients, sharing with one gunshot victim what his mother often said when she was fighting cancer: "Every day is a different gift from God."
The patient disagreed. He'd watched his mother commit suicide and was a victim of abuse growing up. He had just gotten out of jail and, because of his injuries, was facing a life with a colostomy bag. Now he worried his son will never respect him.
So he wanted to die.
Omron felt powerless.
"I have to bear witness to somebody else's sins that I have no control over," Omron said. "It's like a disease I have no cure for."
'Stop the Bleed'
More and more, the wounds of urban gunshot patients look like those from war.
Studies have shown that many of these victims have died from three potentially preventable injuries often seen in battle — massive bleeding, obstructed airways and open chest wounds. A gunshot victim struck in an artery can bleed to death in five minutes. Certain victims, depending on the location of their wounds, could be saved if they receive prompt care.
Those parallels have sparked the health field to institute life-saving practices borrowed from the battlefield. Emergency rooms are stocked with Velcro tourniquets to stop bleeding, something that trauma surgeons and federal officials believe will become commonplace in stores, malls and workplaces in the near future.
Even school districts are looking at acquiring tourniquet kits, said Dr. Richard Alcorta, state medical director for the Maryland Institute for Emergency Medical Services Systems.
Haut, the Hopkins surgeon, carries a tourniquet with him at all times and compares the coming changes to how CPR became more commonplace.
"When it first came out, they said, 'Oh, it's just for doctors.' Now it's for everyone. There are defibrillators everywhere. This is the same thing," said Haut.
The American College of Surgeons and Homeland Security officials are teaming up to make tourniquets widely available and train the public in using them. The national push comes after mass shootings and mass casualty events, such as the Boston Marathon bombing. Homeland Security began the "Stop the Bleed" campaign late last year.
In Baltimore, everyday violence warrants the same preparation. The Police Department started issuing tourniquets in 2015, and officers carry them on their belts. Already this year, at least two officers have saved lives using them, and just Wednesday night, a tourniquet was used to clamp the wounded wrist of an officer who accidentally shot himself while approaching a carjacked vehicle.
Other cities have already expanded their efforts. In Philadelphia, Temple University Hospital is teaching residents in high-crime neighborhoods how to give life-saving care to gunshot victims, including how to use tourniquets.
Also in Philadelphia, police have long practiced "scoop and run" with seriously injured victims. This allows officers to take trauma victims from scenes to hospitals in their patrol cars, bypassing ambulances because speed could save a life. Last year, Philadelphia police took more than 2,250 people, including gunshot victims, to area hospitals.
"There have been a lot of lives saved over here because of that practice," said police spokesman Lt. John Stanford. "We can't just sit here and let this person bleed out, so we throw them in a car and go."
Still, most people killed by gunfire die where they are shot, said Dr. Garen Wintemute, director of the Violence Prevention Research Program at the UC Davis Health System in California. "Trauma people don't have a crack at these people. They're just dead," he said.
Even if they make it to the emergency room where trauma medicine has improved dramatically, their odds of survival are getting worse, according to a number of hospital studies across the country, including in Baltimore.
In most U.S. trauma centers, even though firearm injuries account for a fraction of injured patients, they result in the same number of deaths as motor vehicle accidents — the most common reason people land in emergency rooms, according to a recent report in the Journal of Trauma and Acute Care Surgery.
Researchers say gun violence has become a public-health crisis and needs to be studied like an epidemic. About 11,000 Americans die a year in gun homicides.
"It's complex and it requires a broad investigation much like you would do with any disease," said Dr. Stephen Hargarten, chair of emergency medicine and director of the Injury Research Center at the Medical College of Wisconsin. "We did this with HIV."
But there is a lack of data on what's happening at crime scenes. For instance, many police departments don't track how many people get shot and survive. So researchers can't determine how lethal gun violence has become.
"We centralize data on cancer, we centralize data on vaccinations, things that are important. Let's put more money into it and start a national intervention on this," said Sauaia, from the University of Colorado Anschutz Medical Campus, which undertook one of the latest studies on gunshot patients based on a Denver trauma hospital's data.
By collecting the data available from the nation's largest cities, The Sun found that gunshot victims in at least 10 cities were more likely to die last year compared to the previous year. But half of the 30 biggest cities don't keep statistics on non-fatal shootings.
Funding for gun violence research has dried up in the past two decades, since Congress restricted spending by the Centers for Disease Control and Prevention on studies that could be construed as promoting gun control. Gun rights advocates, including the National Rifle Association, argued that guns are not a disease.
Dan Blasberg, president of Maryland Shall Issue, which advocates for gun owners' rights, said researchers should approach their work comprehensively, rather than ideologically. Instead of focusing on suicide by firearm, he said, they should explore the root causes.
Part of the fallout from the void in research money is the disappearance of gun researchers. Wintemute determined that there are no more than a dozen active, experienced researchers in the country who have focused primarily on firearm violence. To do his work, Wintemute eventually decided to self-fund the research.
"Firearms and the impact that they have on public health gets a very little piece of the pie," said Dr. Cassandra Crifasi, an assistant professor in the Johns Hopkins Center for Gun Policy and Research.
In June, in response to the Orlando nightclub mass shooting, five of the nation's medical associations representing more than 420,000 doctors called on Congress to provide the CDC with funding for gun violence research.
In lieu of scientific study, many medical professionals are intervening in other ways. Many hospitals, like Baltimore's Shock Trauma Center, have noted the "frequent flier" phenomenon, in which victims of violence show up two or more times as patients. Studies have found that these people are much more likely to die in a violent crime once they've been shot or stabbed and survived.
Shock Trauma, under Cooper, created the Violence Intervention Program in 1998. The effort connects patients with resources, monitoring and counseling to steer them away from violence. Cooper studied outcomes of the program and found it had a profound effect on participants who reformed and got jobs. About 900 patients have enrolled in the program.
Last month, the city health department received a $500,000 grant from the U.S. Department of Justice to start a program like Shock Trauma's. The planned program, called the Baltimore City Thriving Communities Project, will use Safe Streets intervention workers, ex-felons who try to interrupt violence by helping to mediate disputes, in hospital emergency rooms.
In Philadelphia, Temple University Hospital's anti-violence program Turning Point does similar work, but goes even further, showing gunshot victims who have recovered a video of their actual resuscitation in the emergency room. It helps victims understand how hard it was to keep them alive, and how many people cared enough to help.
The hospital has another program, Cradle 2 Grave, which takes middle-school children through a simulation of what actually happened to a 16-year-old, Lamont Adams, shot 12 times in 2004. The students lie down on gurneys, while hospital workers put red stickers on their bodies to mark where the bullet holes were on Lamont.
These programs, along with police efforts to "scoop and run" with gunshot victims, have been underway for years, in some cases decades. Philadelphia's lethality rate has remained largely unchanged for years while lethality rates have risen in other cities.
Meanwhile, researchers such as Dr. Daniel Webster, director of the Center for Gun Policy and Research at the Johns Hopkins Bloomberg School of Public Health, are increasingly examining the networks of the victims and the perpetrators. Much of the violence is concentrated in poor, segregated neighborhoods. In the 92 square miles of Baltimore, a Sun analysis found, 80 percent of homicides by shooting in the past five years took place in about one-quarter of the neighborhoods.
Webster describes urban gun violence as mimicking the outbreak of an infectious disease. "It's person-to-person exposure and social contacts," he said.
To investigate this idea, the Baltimore City Health Department is exploring the launch of a survey of residents to determine how many people have been shot or victimized and look for patterns. Health officials want to map where homicide victims lived — not where they were killed — to see if trends can be extrapolated as to how gun violence might spread.
One man is going directly to the shooters to look for answers.
James Evans is the CEO of Illume Communications, a Baltimore advertising firm that has worked for CVS Pharmacy, Timberland boots and Chase Brexton Health Care. He was hired by the city health department to figure out how to the reach the men doing the shooting, to convince them to put their guns down.
It's a challenge that has vexed researchers from Hopkins to Harvard University, as well as police departments, trauma surgeons and grieving families.
So far he has discovered that shooters are more likely to listen to the women in their lives — mothers, sisters — and that they aren't afraid to die. So he's found another angle that does resonate with them, asking: What if you survive a shooting?
What if you're paralyzed? What if you're in a wheelchair for the rest of your life and called "knees down" — a street nickname for these victims. What if you'll need a colostomy bag?
Evans, who grew up in Park Heights and lost two family members to violence and more than 10 to drugs, also learned a big reason some of these young men are carrying handguns — not to be aggressors, but to protect themselves.
"Those who don't live here, don't understand. ... Like the Wild Wild West, real men — John Wayne kind of men — are expected to carry a gun," Evans said.
"If there was a way for people in those neighborhoods to feel less afraid, there would be less impetus to carry a weapon."
In the end, some shooters may be just as scared as everyone else.
Baltimore Sun reporter Meredith Cohn and intern Wyatt Massey contributed to this article.