Despite her serious injury, the woman was still conscious, expressing regret for her suicide attempt and love for her husband. Dr. Garen Wintemute, the E.R. chief, and his colleagues connected intravenous lines, inserted a chest tube to keep her lungs from collapsing and took X rays before cleaning and sewing up the small wound next to her breastbone. In the midst of their lifesaving struggle, Wintemute reflected on a disconcerting fact: how much easier it is to inflict serious--even fatal--injury with a firearm than with just about any other hand weapon.
Indeed, according to Wintemute, gunshot wounds are about 7 1/2 times as likely to result in death as attacks with a knife--and 145 times as likely as blows from feet or fists. Gunshots tear through flesh and bone with the force of a tornado, destroying everything in their path and, depending on the kind of bullet, spreading damage well beyond their trajectory.
Today Wintemute is a professor of epidemiology and preventive medicine at the University of California at Davis medical school, and he continues to put in 12-hour tours in the emergency room. But much of his energy goes into leading a crusade against the "national epidemic" of gun violence--which, with 35,000 deaths a year, he says, "ranks among the top-10 killers of Americans, after cancer, heart disease and automobile deaths." It is an extremely costly epidemic too; the annual bill for treating gunshot wounds inflicted only in assaults is more than $63 billion.
Wintemute's weapon is a pioneering study effort called the Violence Prevention Research Program, which he established at the Davis campus in 1991. The program has not only focused renewed attention on a national tragedy but also produced a fistful of studies that illuminate the problem in new and more subtle ways. It has shown, for example, that some people who are legally entitled to buy guns are very likely to commit crimes with them, and that denying them the right to buy weapons can actually reduce crime. "I realized," says Wintemute, "that the most effective way to treat a gunshot wound was to keep it from happening in the first place."
From his experience with hundreds of gunshot victims, Wintemute knows only too well that their wounds are among the hardest for doctors to deal with. The gaping holes torn into the flesh by bullets of any kind can easily destroy major organs, unleash torrents of blood, produce severe infection and in general cause widespread bodily mayhem. Gunshot wounds also account for a major part of the rise in spinal injuries in the U.S.; even the grazing passage of a bullet along the spinal cord can be enough to cause paralysis. Two-thirds of gunshot victims do not live long enough to receive medical attention.
On the other hand, gunshot victims who live to tell about it often owe their survival to the vast improvements in emergency trauma care since the 1960s. Not only are response times faster, but treatment often begins right at the scene as highly trained paramedics work under the direct radio supervision of physicians back at the hospital. In the most serious cases, paramedics may have already started intravenous fluids, inserted breathing tubes and alerted doctors about what to expect even before the victim arrives.
When the patient is wheeled into the "resus" (resuscitation) room, a fully mobilized team is usually ready and waiting. At a large urban medical center such as U.C. Davis, this may include a physician specializing in emergency medicine, five residents (including an anesthesiologist), three nurses, a respiratory therapist, X-ray and trauma technicians and several aides. While one doctor tries talking to the patient and checks for major injury, another starts drawing blood for tests. Other team members may be inserting catheters, stanching bleeding, administering blood or other fluids. Within five to 15 minutes, the patient may be on the way to the operating room. Says Wintemute: "We've come to recognize that there is this 'golden hour'--the first hour after trauma--when we have the best chance of saving the patient."
In fact, he says, emergency care of gunshot victims has reached such a high level of skill that little can be done to increase the survival rate. For this reason, he is looking to prevention as the best way to curb gunshot deaths. He and like-minded colleagues represent a new breed of physician eager to affect public policy about gun violence by using their special insights as healers. "The doctors realized people were being shot faster than they could sew them up," says U.C. Berkeley law professor Franklin Zimring, the "dean" of firearms-policy scholars. "So they decided to do something about it."
Relying on the same epidemiological techniques used to track dangerous pathogens, Wintemute and his associates at U.C. Davis seek out patterns and trends in the data that federal and state governments keep on firearms: types of guns sold, who buys and sells them and the background of shooters and victims alike. Wintemute's 1994 study Ring of Fire, for example, takes a hard look at gunmakers around Los Angeles. It has been hailed as a major indictment of the cheapie pistols known as "Saturday-night specials," the weapons of choice of inner-city gangs. The California effort to impose tough new regulations to control their manufacture and sale is largely in response to this study.
Wintemute, 46, who knots his dusky blond hair into a discreet ponytail, could easily be cast in TV's ER series--if he were not so determined to play by his own script. Born and reared in Long Beach, Calif., the son of a chemist-turned-businessman father and a schoolteacher mother, he majored in biology at Yale and later did some graduate work in neurophysiology. Eventually switching to medical school at U.C. Davis, he decided to study emergency medicine, a pressure-cooker specialty that suited his go-go personality. "It's practicing medicine on the run," he says. "It's about making instantaneous decisions."
He was so good at his job as an E.R. physician in the Sacramento area that he was recruited for an unpaid three-month stint caring for Cambodian refugees at a bush camp in eastern Thailand. Treating the injuries resulting from Cambodia's civil war reinforced his feelings about gun violence. "We saw 20 or 30 cases of battle trauma a day," he says."
During an interlude at Johns Hopkins University's school of public health, he co-authored a law-journal paper with his professor, Stephen Teret, in which he used epidemiological evidence to explore handgun injuries: how they occurred and who was involved. The study raised the intriguing possibility of assessing gun manufacturers for damages. "We have learned since the 1960s, with both tobacco and motor vehicles, that explicitly holding the manufacturers accountable for what their products do has real benefit," says Wintemute.
On his return to California, he began looking more deeply into gun violence by examining the instruments of death themselves. Though he had a childhood familiarity with some guns and had later taught shooting at a ymca summer camp, Wintemute began to approach the subject more seriously. He got a gun seller's license, went to gun shows to learn about the firearms business, joined the National Rifle Association--"to find out what they were up to"--and began target shooting to try to understand the allure of guns. At a recent conference of physicians studying gun violence, he turned out to be the best shot.
Wintemute also discovered that he had a flair for communicating his findings. An early study, published by the Journal of the American Medical Association in 1987, linked accidental shootings by children to the strong similarity between toy guns and real guns. At a press conference--his first--he displayed side-by-side photographs of real guns and their toy look-alikes. "If you can't tell the difference, how can you expect your kids to tell the difference?" he pointedly asked. The dramatic story and pictures made national news and helped shame manufacturers into taking the toy clones out of production.
Wintemute took a particular interest in Saturday-night specials, favorite "starter" guns because of their low price (as little as $25), easy availability and compact size. He found that their chief makers--the companies mentioned in Ring of Fire--did not exist until after 1968, when Congress, reacting to the assassinations of Martin Luther King Jr. and Robert Kennedy, banned handgun imports but did not prohibit domestic manufacture. The study showed that the guns were dangerous not just to people who found themselves looking down their barrels but also to their owners. The guns often misfired, were inaccurate and, lacking safety devices, easily went off when dropped. This contradicted the makers' portrayal of them as sturdy weapons of self-defense for law-abiding folks who could not afford high-ticket Colts, Rugers or Smith & Wessons.
Wintemute and his colleagues provided a clear statistical link between Saturday-night specials and youthful crime. Their 1996 study showed that even teenage buyers of these guns with no criminal record were more likely than purchasers of more expensive handguns to commit violent crimes with them.
This was not what gun enthusiasts wanted to hear. "Dr. Feel-Good of the gun-ban crowd," one of them labeled Wintemute. Under pressure from the gun lobby, federal funding for gun studies has been slashed. But Wintemute insists he is not on an antigun vendetta. Rather, he wants to get at the roots of firearms violence: why it has climbed to the highest levels of the century, why so many children are shooting children, whether easy access to guns is in itself a stimulus to violence. If that means putting heat on manufacturers and dealers, so be it.
He also favors tighter controls on who should be allowed to buy guns, holding that selective denial of purchase and possession can reduce the risk of criminal activity by 20% to 30%. Still, he does not want his program to be adversarial. "We consider ourselves researchers, not advocates," he insists, moving away from the more strident position reflected in Ring of Fire. "We want to help policymakers make informed and effective decisions on ways of reducing rates of firearms violence without impinging significantly on the legitimate role of firearms in our society."
Encouraged by his studies so far, he hopes to widen their scope by examining other types of violence, such as child beating and spousal abuse. That, of course, would mean trimming his cherished time in the emergency room. But there would also be a major benefit: it would let Wintemute minister more broadly to the ills of a nation racked by violence of all kinds.