Fewer people are dying from gunshots in Chicago: Stroger hospital is a big reason why

In early August, a series of shootings in Chicago left 41 people wounded and seven dead in a single day. Most of the shootings were on the city's South and West sides, sending many of the wounded to Cook County Health & Hospitals System's flagship John H. Stroger Hospital.

The violence spike forced the hospital's trauma center to limit visitation to immediate family. Dozens of trauma patient visitors lined up outside Stroger on the city's West Side. But in spite of the chaos and surge of wounded patients, Stroger's trauma team never diverted a single trauma patient to another hospital, the Chicago Sun-Times reported.

The team's work on Aug. 5 was predicated on decades of experience. In 2017 alone, the 50 clinicians in Stroger's trauma center treated more than 1,100 gunshot wound patients — roughly one-third of the people shot in Chicago that year — a stat that reveals why Stroger's trauma center is one of the busiest in the nation.

Stroger is home to one of the city's five level 1 adult trauma centers — a network so proficient at treating high volumes of gunshot wound victims that its lifesaving work often is overlooked. This is a hospital that is a safety net in more than one sense of the word. Amid years of political turmoil within the Chicago Police Department, the city's trauma network has been hard at work: Data shows gun-related homicides declined from 1995 to 2015, while the number shootings did not.

A look at the inner workings of Stroger reveals the contradiction of world-class trauma care in communities mired in poverty and violence.

"It's a weird thing to have as the bridge to community trust, to say, 'We were really good at taking care of your son, or your daughter, or neighbor, when they got shot,'" John Jay Shannon, MD, CEO of the Cook County health system, told Becker's. "At the same time, it is widely acknowledged as being one of the things that we do very, very, very well."

When the Becker's editorial team asked Chicago hospitals in 2017 how many gunshot wound patients they had treated over the year, Stroger was the most forthcoming. Some declined to share figures or did not respond to Becker's request for information. One hospital's communication team stated it had no interest in being known as the Chicago hospital treating the most gunshot wounds.

It's unclear why some hospitals were unwilling or unable to share information on the number of gunshot wound patients they treated. But Harold Pollack, PhD, an urban public health researcher and co-director of the University of Chicago Crime Lab, suggested two possible obstacles: reputation concerns and the availability of data.

"If they are major trauma centers, people would expect many gunshot wounds to be treated there," Dr. Pollack told Becker's. "Some hospitals treat markedly fewer gunshot trauma [cases] than one might expect. This is quite embarrassing. Others do not want to become known as safety-net providers. I would not rule out that many hospitals don't actually have this information in a sufficiently accurate form to go public with it."

For this article, members of the Becker's editorial team spoke with several Stroger administrators and providers, past and present. What follows is a look inside one of the nation's most storied trauma centers and its relationship with gun violence and the community.

From the 1960s to today: Chicago's evolving trauma landscape

Stroger's trauma center traces its comprehensive trauma care roots to the 1960s.

Robert Baker, MD, and the late Robert Freeark, MD — physicians at Cook County Hospital, Stroger's predecessor — imagined a single hospital unit to care for traumatically injured patients, beginning before the patient entered the hospital and extending to the outpatient and rehabilitation settings.

The launch of such a unit in 1966 was not without controversy, as it marked a paradigm shift in the care of trauma patients. A major point of contention involved the role of prehospital care providers — such as emergency medical technicians and paramedics — in determining whether a patient was taken to the nearest trauma center rather than the closest hospital.

"That was incredibly complicated and very controversial, because surgeons in [Chicago] hospitals had managed trauma — they were general surgeons, but they did some trauma. We were essentially saying, 'We can do this better,'" said John Barrett, MD, who served as director of the trauma center at Cook County Hospital from 1982 to 2002.

Born in Cork, Ireland, Dr. Barrett came to Chicago in 1975 with abundant interest in the treatment of gunshot wounds. He describes gun violence as a uniquely American problem, and since retiring from medicine in 2002, has advocated for gun control legislation in the U.S.

During his time as head of trauma at Cook County Hospital, Dr. Barrett witnessed an evolution in the treatment of gunshot wounds as the caliber of ammunition and the velocity of weapons increased from the 1980s to the 1990s. The advances in weaponry made for more complex wound care. Dr. Barrett described 1995 as a year that stands out to him as particularly gruesome for Chicago gun violence.

"It was a horrible, horrible year," he told Becker's in 2017. "It gradually began to get better, until [2016] and [2017] together."

But policing strategies credited with driving down homicides in the 2000s and early 2010s have failed to keep shootings at bay in recent years. A Chicago Tribune analysis cited 4,369 shootings in Chicago in 2016 and 3,567 in 2017.  

The success of Chicago's trauma network is likely the reason a general increase in shootings hasn't translated to a surge in homicides, an analysis of Chicago homicide and shooting data published in February reveals.

In collaboration with The Atlantic's CityLab and the Center for Investigative Reporting's Reveal, reporters from the Chicago-based Data Reporting Lab found gun-related homicides in Chicago trended downward 30 percent from 1995 to 2015. However, the number of people shot did not decline during the same period, according to the report. CityLab used only CPD data and hospital data in its analysis.

In 1995, about 726 people died from gun violence in Chicago. That same year, Cook County hospitals discharged 677 gunshot victims, according to the report. That puts the total of known shooting victims at 1,403. Compare that to 2015, when Chicago counted 1,377 known gunshot wound victims — just 26 fewer people than 1995. However, of those shot in 2015, gunfire killed about 507 people and Cook County hospitals discharged 870. Although shootings didn't decline significantly over the 20 year period, the survival rate of known gunshot wound victims increased from 48 percent to 63 percent.

Chicago hospitals and emergency providers reduced gun-related homicides through cohesive collaboration. Emergency responders work together to route patients to the facilities best equipped to deal with gunshot wounds. These patients not only need to reach a hospital — they need the right hospital.

The Illinois Department of Public Health appoints four hospitals — including Stroger — to provide trauma oversight for emergency medical services. Emergency medicine physicians from these hospitals serve as medical directors and establish field triage protocols for all regional EMS providers. The protocols are adapted from national standards developed by the CDC, American College of Surgeons and National Association of EMS Physicians.

When it comes to triaging gunshot wound patients, the main challenge is "we see too many of them," Joseph Weber, MD, an EMS medical director at Cook County health system and an emergency medicine physician at Stroger, told Becker's.

"The paramedics are highly trained and adept at assessing and caring for victims of penetrating trauma, specifically from handguns," he added. "They roll up on scene, they do a quick assessment — a patient's vital signs, what type of wound they have — and then [decide where to direct the patient] based on our algorithm."

Processes and algorithms help pair patients with hospitals, but this is Chicago — a city that spans 237 square miles and has nearly 3 million residents. This makes the proximity of trauma centers a strong determinant of patient survival. In 2010, 18-year-old Damian Turner died en route to the nearest level 1 trauma center at Northwestern Memorial Hospital, more than 9 miles from where he was shot on the South Side in a drive-by shooting.

Mr. Turner was shot just four blocks from the University of Chicago Medical Center. At the time, its level 1 adult trauma center had been closed for 19 years. The incident sparked a national conversation about the layout of level 1 trauma centers in Chicago, which had been clustered around the city's North and West Sides. This composition left the southeast corner of the city in what some called a "trauma desert," according to CityLab. The University of Chicago reopened the trauma center after 27 years in May.

Stroger's trauma center: An expensive community asset

The high cost of trauma care is what forced University of Chicago Medicine to close its trauma center only two years after it opened in 1986. It lost $2 million both years.

"Contraction of trauma services in this area is in no small part related to the fact that [trauma] costs health centers money," Dr. Shannon said. At the time of Becker's interview with Dr. Shannon, UChicago Medicine had not yet opened its new $39 million level 1 trauma center.

Chicago hospitals treated 12,000 documented gunshot wound patients between 2009 and mid-2016, billing patients and payers more than $447 million. Nationwide, hospitals spend nearly $2.8 billion annually treating firearm-related injuries.

The Cook County health system spends, on average, between $30,000 and $50,000 to treat each gunshot patient at its trauma center. Collectively, the system spends $30 million to $40 million annually treating gunshot wounds — and this total only covers initial hospital care, not rehabilitation or other outpatient services.

Why, then, can Stroger lean into its trauma center as a strength? One grim reason is demand for gunshot wound care continues to rise, Dr. Shannon said. Another is Illinois' expansion of Medicaid in 2014. Now, 75 percent of Stroger's gunshot wound patients are insured — and their services are largely paid for by Illinois taxpayers. A third "troubling" reason the trauma center is an asset, Dr. Shannon said, is an increasing amount — now 10 percent — of his hospital's gunshot wound patients are children, 90 percent of whom are insured.

Stroger also leverages its reputation in trauma care to increase patient volume across the hospital, according to Caryn Stancik, executive director of communications at Cook County health system. One of Stroger's recent marketing campaigns highlighted its six-week training program for Navy hospital corpsmen, during which corpsmen treat gunshot wound patients alongside Stroger's trauma physicians. An ad from the campaign showed a physician caring for an older woman with the text, "Look at us now. Training the Navy and treating your grandmother."

"The crude philosophy behind that is if we're good enough to train physicians [in the Navy], people should look at us for other services," such as orthopedics, anesthesiology and radiology, Ms. Stancik said.

But Stroger's trauma center is more than a national resource for physicians in training, it's a bridge to the surrounding community.

"We look at our trauma experience as an asset — in an unusual way, it is a community asset," Dr. Shannon said.

'A lot of our patients, we've known them for 20 or 30 years'

For the staff at Stroger, Chicago's gunshot violence statistics aren't just numbers — they're neighbors.

"In our trauma unit, we have staff that live in the communities where gunshot wound victims come from," Dr. Shannon said. "Staff tend to be activists and outspoken," drawing the system's care philosophy beyond its four walls, he said.

There aren't many avenues for formal follow-up care that address the environmental effects of continuous exposure to violence. One way Stroger takes a longitudinal approach to trauma care is through Healing Hurt People-Chicago. The program is informed by hospital-based violence intervention strategies developed by the Center for Nonviolence and Social Justice at Philadelphia-based Drexel University.

"Just as in medical trauma care that has a 'golden hour' to save somebody's life, we also have this opportunity when somebody is brought to the hospital to provide a type of violence intervention and to stop the cycle of violence," said Andy Wheeler, one of the trauma center's licensed clinical social workers.

The Chicago program, launched in August 2013, is a collaboration between teams at Stroger, Drexel and the UChicago Medicine Comer Children's Hospital, which operates a pediatric level 1 trauma center. It encompasses a team of specialized social workers, called trauma intervention specialists, who identify pediatric patients in need of ongoing case management, mentorship and group therapy services for six months to one year after the patient's discharge from the hospital.

There are nearly 60 active street gangs in Chicago, with 100,000 members, according to estimates from the Chicago Crime Commission, contributing to a culture of retaliatory shootings where the same patients might cycle in and out of the trauma center multiple times. Healing Hurt People-Chicago's mission is to reduce the likelihood a gunshot wound patient will return to the hospital with another violent injury, largely by giving patients strategies to avoid crime and other risks in their community.

Five hundred patients have gone through HHP-Chicago's program since 2013. Only 7 percent of patients who participated for six months or longer returned to the hospital with another violent injury. None of the patients committed an act of retaliation, according to the Rev. Carol Reese, HHP-Chicago's program director.

"Whether they're in a gang or not, the issue is about ongoing safety of the people taking part in Healing Hurt People," she said. "Just being from the 'wrong neighborhood' can make people a target in some areas, so it's more about helping patients identify where it is safe for them to be. Social connections with peers are powerful for young people and can serve to protect, as well as create increased risk."

Even back at the hospital, recovery doesn't end post-discharge. Stroger's trauma physicians remain in contact with the patients they've treated.

"Our patients belong to our group of physicians forever. It's not like we back off of them after we patch them up in the ED," Faran Bokhari, MD, chairman of Cook County health system's trauma and burn unit, told Becker's. "This is interpersonal violence and you're often dealing with the re-injury of these same people over a long period of time. A lot of our patients, we've known them for 20 or 30 years. They were really young when they [first] came to us."

'If it doesn't bother you, then you're burning out'

The high stress environment and impossibility of saving every patient admitted to Stroger's trauma center — along with the repetitive nature of caring for patients in a city affected by gang violence — can take an emotional toll on even the most resilient providers. The work can also be physically taxing, as it can take up to two hours to stabilize a gunshot wound patient.

One way the trauma team at Stroger combats burnout is by talking through difficult outcomes.

"We review every death, and everybody gets to say, 'Well, what did we do?'" Dr. Barrett said. "And this is not a 'what did we do wrong' conversation."

These conversations are meant to improve protocols and allow staff to emotionally process the situation. It's not about blaming anyone for the outcome, he said.

"I recall a woman who was pregnant with twins, and we lost her and both of the babies," Dr. Barrett said. "It doesn't matter whether or not you did everything right, you're [going to wonder] how could this possibly happen. If it doesn't bother you, then you're burning out, and that's bad too. As a leader you need to be very cognizant of that."

Staff at Stroger said the camaraderie among the trauma center's 50 clinicians is a hallmark of the unit. Most nurses and physicians stay with the trauma center for 20 years.

"Being a trauma nurse, it's very important to have that communication with the trauma doctors," said Cristina Federighi, RN, MSN, who has been a trauma nurse at Stroger for more than 25 years. "To achieve the best care for our patients, it's all about communication. It's the key to effective care. We have to have that relationship."

Trauma staff have the option to meet with the same social workers their patients see. Mr. Wheeler said clinicians who witness traumatic injuries daily can display some of the same behavioral symptoms as someone who's been injured.

Mr. Wheeler conducts self-care workshops for Stroger's critical care and palliative care providers, which include mindfulness and meditation.

"When you go through social work training, you learn a lot about self-care," Mr. Wheeler said. "As far as I know that isn't taught as much in medical school and through residency."

Stroger on the front lines

Cook County health system's leadership, administrative staff and clinicians work tirelessly to uphold the trauma center's role as a community asset.

"The success of the trauma unit would really be the lack of its existence," Dr. Bokhari said. "The challenge is the socioeconomic factors that lead to this violence. This is something that has evolved over hundreds of years, and you can't fix it in a day."

The hospital also recognizes the factors at play beyond the city's limits. On March 24, Dr. Shannon, staff and former patients joined the student-led March for Our Lives demonstration in Washington, D.C., in support of universal background checks and stricter laws on buying guns, along with other firearm legislation.

"These are areas where you realize that your health system as a healthcare delivery platform is limited. You've got to think beyond that to start thinking about the social circumstances in the communities that you serve," Dr. Shannon said. "You're not doing your job well if you're working in a safety net [and] not addressing violence in the community."

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