Missouri's poor public health response drives gun violence and COVID, doctors say

Nov. 16--Kristen Mueller was in the final stages of her emergency medicine residency at Washington University when a patient who had attempted suicide with a gun was brought in. The bullet had gone through both of the patient's eyes.

That patient survived, but was left blind and with severe facial injuries

"Most people who try and kill themselves with a gun don't survive to get help," Mueller said.

That was seven years ago. Mueller, who now researches firearm violence and injury prevention at Washington University, has treated hundreds, if not thousands, of St. Louis gun violence victims. Some have faded from memory, but others, like the suicide patient Mueller treated as a new doctor, haunt her long after they leave the hospital.

"Every now and then you get those cases that just stick with you, and you roll over at 3 in the morning and you're awake thinking about it," Mueller said. "I don't think that part's ever gonna go away."

Those types of cases have only become more common over time.

Missouri, fueled by the violence in its largest cities, is on pace to have more gun-related deaths this year than any year before. And it's not just police and prosecutors trying to find solutions.

As part of the Missouri Gun Violence Project, The Star partnered with the St. Louis Post-Dispatch to produce a series of stories about gun violence in St. Louis. The project is part of a two-year, statewide solutions-oriented journalism effort supported by the nonprofits Report for America and the Missouri Foundation for Health.

Public health experts say gun violence is an epidemic, and the way it spreads continues to infuriate the doctors trying to contain it. They point to easy access to high-caliber weapons and poor public health infrastructure as key factors driving the violence they see in their operating rooms.

Poverty, social unrest, racial inequality, food and housing insecurity -- all contribute to how comfortable people feel in their environment and could be addressed with a robust public health system, they say.

When people feel insecure in their environment, they try to find ways to help themselves feel safe, often turning to guns for a sense of security.

But with little support or funding from the Missouri General Assembly to change the conditions in vulnerable communities, physicians say, there is a limit to how many lives they can save.

"I can't really remember a time when this wasn't part of the expectation in St. Louis, but it still really bothers me," Mueller said. "The longer I'm in this work, the more frustrating I find it that this hasn't been fixed already."

St. Louis' level-one trauma centers have treated at least 11,000 firearm injuries over the last 10 years, according to a data repository shared by Washington University and St. Louis University.

Adult gunshot victims are coming into the city's hospitals daily. At children's hospitals, the rate of firearm-related surgeries matches common procedures like appendicitis.

The violence intersects with almost every medical specialty: emergency room physicians, trauma surgeons, psychiatrists to help address lasting PTSD, dermatologists for wounds, and pain management specialists.

"There's no part of medicine that's safe from the impact of gun violence anymore," Mueller said. "Just like COVID, it's touching every aspect of our medical care."

Gun violence was already difficult to manage before the pandemic, but now physicians must handle two widespread, life-threatening health crises together.

"It's really emotionally and physically exhausting," Mueller said. "I put my N95 mask on at the start of the shift, and I do not take it off once until the end of the shift. So most of the time, I'm going eight to 10 hours without any water or any food."

Hospitals try to administer COVID tests to every patient who comes in for treatment, but there is no time to test those who come in with severe injuries like gunshot wounds. Doctors have no way of knowing if they are at risk to catch COVID from the person they are operating on.

"At the beginning, especially, it was so hard. It was like a walking nightmare almost," Mueller said. "I just kept thinking one of the senior mentors and attending physicians I had was going to come in with COVID, and I was going to have to intubate her."

There have been many days at Barnes-Jewish Hospital, which is affiliated with Washington University, when the emergency room is overflowing with patients. When it becomes full, patient beds are pushed into hallways while patients wait to be transferred to a different area of the hospital.

At times, every single person Mueller sees is teetering between life and death. She has treated half a dozen gunshot victims in one shift, and almost as many suspected positive COVID patients in another.

Mueller has grown used to what she calls "survival rounds," where she will walk around the critical care pod, where the sickest patients are, asking the same question over and over, "What does this person need to be alive?"

"It does carry over to other parts of our lives," Mueller said. "Every now and then I'm at the grocery store and I knock a box of cereal off the shelf or something by accident. I feel myself tearing up and I'm like, 'Oh, this is not where these emotions are supposed to be.'"

Inequality and gun violence

During the onset of the pandemic, visits to the ER were down overall. Gun-related cases, however, remained the same. The reason is simple, but has far-reaching consequences: gun violence and the pandemic are linked by inequity, according to Randi Foraker, director of the Data and Training Centerfor the Institute for Public Health at Washington University.

"It's just so telling when gun violence isn't impacted by something as major as a pandemic," Foraker said. "The issues surrounding gun violence are systemic, and they're things that don't change with the pandemic, and might actually be exacerbated with the pandemic."

The majority of the city's gunshot victims come from low income neighborhoods and are Black. In fact, gun violence is the leading cause of death among young Black Americans. COVID, too, disproportionately impacts Black communities in St. Louis and across the country.

"A lot of the inequalities have been bared due to the pandemic," Foraker said. "We see our underserved communities in St. Louis, having been hit harder by the pandemic, and we see those same communities also more likely to be affected by gun violence."

A lack of access to healthcare, housing and social services increases the likelihood of suffering from gun violence or COVID.

Experts call it the social determinants of health -- people's surrounding environment and the resources available to them influence the impact health-related issues will have on them.

Missouri has one of the country's lowest funded public health systems. In 2019, the state ranked sixth-to-last: Missouri spent about $57 per person, compared to the national average of around $87 per person, according to the United Health Foundation.

State officials and lawmakers have also implemented very few of the guidelines recommended by medical experts for both guns and the pandemic.

"Freedom is often at issue here: freedom to own a gun versus the freedom for the rest of us to live safely," Foraker said. "Same thing with the mask wearing: (people) want to be free of wearing masks, whereas on the other side, you have people who want to be free from COVID."

"We need to be in support of the public's health, ultimately, and rethink and reframe freedom in that regard."

Physicians at the city's hospitals say state officials have given no funding for gun-violence research that could shed light on what is causing the shootings, nor for St. Louis hospitals' primary intervention program that addresses the root causes of violence.

And things have only gotten worse.

Hospitals are seeing more firearm-related casualties and more severe bullet injuries than what they saw a decade ago, said Martin Keller, who is the director of trauma surgery at St. Louis Children's Hospital and has treated gunshot victims for more than 20 years.

"I wish those in the legislature could follow us around and see what we'd see, I think that would open some eyes," Keller said.

Every year, physicians go to Jefferson City to speak with legislators about restricting availability of certain guns, and every year, nothing changes.

Firearm injuries are now the second most common reason trauma surgeons are called to the ER at St. Louis Children's Hospital. The pediatric trauma-care team has gotten so used to treating gun violence patients, the treatment has become very "slick," something that was not even needed at the start of his career, Keller said, when there was not a gun-related health crisis of this magnitude.

"There's a tremendous amount of frustration for all the caregivers at our institution dealing with this problem. We view this as an almost completely avoidable event. It's so needless," Keller said. "When you get a bad firearm injury patient in your emergency room, the emotions will range from people who are crying, to people who just want to go out and scream, to just complete anger over this problem."

Keller, like Mueller, has learned to expect gun violence as a routine part of his care.

"You just, you sigh and you shake your head every time your trauma beeper goes off for another one and say, 'When is this going to end?'" Keller said. "'Not again.'"

Life Outside of Violence

In 2018, three St.Louis-based research centers and the city's four level-one trauma hospitals came together to create a collaborative gun violence intervention program known as Life Outside of Violence, which also receives grant-funding from the Missouri Foundation for Health.

It helped fill some of the gaps physicians were seeing while working in Missouri's underfunded public health system. The four hospitals shared firearm-injury related data with each other, something the state has been collecting but has never made public.

The program also assigned a social worker to participants, ages 18-24, who have been injured by guns, stabbing or blunt trauma. The social worker works with them for up to a year after the incident.

Gun violence has a high rate of repeat injury, and Life Outside of Violence aimed to reduce the recidivism rate in youth.

The idea was gun violence care needed to not only treat physical injury, but through a more holistic approach also address underlying causes of gun violence like poverty and racial inequality.

"It's such a significantly high indicator for death for young people, so it's definitely a crisis," said Kateri Chapman-Kramer, project coordinator for Life Outside of Violence. "To be able to address it means to be able to put interventions into place to prevent it going forward."

Two brothers recently enrolled in the program after a shooting. The family was struggling with basic needs like bedding to create a safe living space, Chapman-Kramer said.

The program got them beds and comforters, and also taught the younger brother coping skills to navigate his environment.

"He was sleeping with a (baseball) bat next to him, very concerned, if (he) heard a little sound that it was somebody coming back to shoot his family," Chapman-Kramer said. " Unfortunately, you're still going to be in a violent space in the community -- not that somebody was coming after them, but as a young kid, you don't know the difference."

Mueller, who works as the physician liaison for Life Outside of Violence, found working toward intervention efforts helped break up the cycle of violence she saw in the hospital.

"Anytime somebody gets shot, there's a lot that goes into that." Mueller said. "The public health work makes me feel better that we're trying to get to some of the preventative root causes versus just continuing with the way things have always been."

Gun violence is the subject of a statewide journalism project The Star is undertaking in Missouri this year in partnership with the national service program Report for America and sponsored in part by Missouri Foundation for Health. As part of this project, The Star will seek the community's help.

To contribute, visit Report for America online at reportforamerica.org.

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