Recovery: What happens after leaving the hospital with a gunshot wound

As a trauma surgeon, I frequently meet people on the worst day of their lives. While the X-rays get taken and the tubes and medications go in, I reassure them, saying things like, “I’m so sorry this happened to you. We are going to take great care of you. You are going to be okay.”

I want to share with them my confidence that they are being treated in one of the world’s leading trauma centers where they will benefit from the best we have to offer in knowledge, skills, training, and resources to stop their bleeding, repair their injuries, and help them recover. I am telling them the truth: Three in four patients with a firearm injury due to interpersonal violence survive, and of those who make it to the hospital, the proportion is closer to 95 percent. There is nothing better in my specialty than to see a critically injured patient heal and walk out of the hospital.

But for many patients, that marks only the beginning of their recovery. They need a lot more before they can be okay.

Even bullet wounds that pass through skin or muscle without harming critical anatomical structures can still shatter patients’ sense of safety. Researchers at Stanford have shown that the emotional and social challenges patients encounter mean that for many, even if they recover physically, they never fully achieve “recovery of the self,” or the ability to return to important roles, identities, and functions.

Most of my firearm-injured patients were shot in their own neighborhoods, near their homes, most often while they were simply going about their usual activities. When they leave the hospital, many live with fear for their lives, become reluctant to set foot outside, or must contemplate the costs of moving far from home.

This dangerous combination of physical, economic, social and emotional impacts of trauma means that approximately 20 percent of survivors suffer a second violent injury. It’s a pattern Dr. John Rich of Drexel University explored in his crucial book Wrong Place, Wrong Time: When patients feel threatened, they are more likely to carry weapons. When they have pain and symptoms of depression or anxiety, they are more likely to use alcohol or drugs. When they are out of work, they are more likely to engage in marginal or underground economic activity. These factors all increase their risk of criminal justice involvement and repeat injury.

Systemic racism has a major impact in recovery after trauma. The overwhelming majority of firearm-injured patients that I treat at Penn are young Black men. The structures and systems of disadvantage that put them at risk for injury in the first place also interfere with their recovery by erecting barriers to employment, educational access, health care, and housing.

All these factors pile up on top of the physical aftermath of trauma and trauma surgery. Some patients may have major fractures and reconstructions to heal. For others, our team may have opened their chest or abdomen and removed, reconnected, or rearranged vital organs. Post-surgical home care and doctors’ visits mean that patients must ask for help with the most basic activities. And many patients report that that there is no one with whom they can talk openly about their experiences. Depression and post-traumatic stress disorder are present in up to half of gunshot-injured patients years after injury, according to research published last year in JAMA Surgery by a team of my Penn Medicine colleagues.

When we see what patients go through after they leave us, we have to ask, how can we help... more? What role can our hospital play in bringing about comprehensive recovery? The Penn Trauma team is partnering with concerned clinicians throughout the United States to identify effective strategies and to collect the long-term data that can help us understand what works. How clinicians treat our patients can make a difference. Patients value when the health care team acknowledges the impact of their injury and addresses their broad concerns. Inspired by the work of Dr. Rich and others, trauma centers around the country have developed hospital-based violence intervention programs that provide wraparound services, peer mentoring, and case management to help patients recover. To connect with patients, these employ individuals who do not have medical training but do have a shared background and an extraordinary ability to build trust and form lasting bonds with patients and to connect them to the comprehensive services they need to thrive. In a new program supported by grant funding made available through the Pennsylvania Commission on Crime and Delinquency, Penn Trauma has brought on staff our first Violence Intervention Specialist. Across the board our team has welcomed him, recognizing how much unmet need our patients have.