Chicago Sun Times May 30, 2004
BY LORI RACKL Health Reporter
The eardrum-rattling bang reverberated off the parking garage's walls. It sounded like someone had set off an M-80 firecracker a few inches from Nora Schneider's face.
Schneider's head burned with the scent of gunpowder.
Finally, her eyes told her what her brain could not yet compute: She'd been shot.
The bullet had torn through the palm of her left hand, leaving a ragged, bloody hole.
The impact from the slug made a mess of the slender bone that bridged between her pinky finger's knuckle and wrist. Same for the nearby network of blood vessels, nerves, tiny muscles and tendons.
"The truth is I didn't know I was shot right away," Schneider says of the day she was robbed at gunpoint five years ago in a garage in the West Loop. "I didn't feel instant pain."
It took less than a second for the bullet to destroy part of the intricate structure that renders the hand the most flexible part of the human skeleton. But it took about 15 minutes for the pain to kick in. And, once it did, it eclipsed any physical anguish Schneider had ever felt -- including that of bones broken while skiing.
"This was just so much more intense," Schneider says. "It was a steady, searing pain."
The interior designer wound up losing her little finger. Five years later, she still has 18 bullet fragments buried in her hand.
"Time seemed to slow down during the shooting," she says. "You feel like you're watching this happen to you, like you have a bird's-eye view of the whole situation. I was calm, but my heart was pounding. I was dripping blood like crazy."
Schneider's experience -- survival instinct trumping pain, a distorted sense of time, the body going into fight-or-flight mode -- mirrors that of many shooting victims. And there are plenty of them. Each year, roughly 55,000 Americans survive firearm injuries.
Their stories lend insight into a question many of us wonder but hope we'll never have to answer: What's it like to be shot?
'It's like terror consumes every cell of your body'
Plenty of ballistics experts and pathologists have studied the tangible effects of bullets on the body. But little research has ever been done on what it feels like to be shot, the mental and physical sensations of a slug piercing the skin and wreaking its internal havoc.
The answer isn't simple. It depends on a multitude of factors, including the type of bullet used and, more important, where that bullet happens to hit the body. Getting shot in the liver can feel very different from taking a bullet in the rib. Both hurt; they just hurt in different ways.
And the magnitude of that hurt depends not only on where the bullet lands, but who was hit. That's because pain is highly subjective. Everything from the circumstances of the shooting to cultural beliefs come into play.
"Some of the toughest guys on the street will come in crying, screaming, 'Am I gonna die?' " says Dr. Steven Salzman, a trauma surgeon at Advocate Christ Medical Center in Oak Lawn. "Others come in with horrendous injuries, but they're not screaming at the top of their lungs, when we think they should be. Pain is a very individual thing."
No time for pain
Martin Leon had just dropped off his girlfriend and was driving through the Little Village neighborhood one early Sunday morning last month.
Leon, 20, says gang-bangers spotted him and started lobbing beer bottles at his car. He thinks they mistook him for a rival gang member.
The Humboldt Park man lost control of his car and crashed into a parked truck. He jumped out and started running. He didn't get far. A few of the guys began punching him. One pulled out a handgun.
Leon broke free and tried to run -- but you can't outrun a bullet traveling 1,000 feet a second. The tiny missile hit him on his left side, near his hip. It punctured Leon's skin and sliced through a layer of fat before lodging in his abdominal muscle by his belly button.
"I felt the impact and a burning sensation at the same time," says Leon, who kept on running despite being hit -- which happens more often than Hollywood would have us believe, says Dr. Martin Fackler, a nationally renowned expert on what bullets do to the body.
"People don't even get knocked backward when they get shot, but you see this in the movies all the time," says Fackler, a retired military surgeon in Florida who had testified about ballistics in dozens of court cases. "Unless the guy gets hit in the head or the spine, the most common reaction to getting shot is no reaction at all."
Leon felt like he was running in slow motion as he tried to escape. Another shot rang out. This time, the bullet clipped him above his left knee, tearing through the soft tissue in his thigh.
"My leg felt cold and numb right away," he says. "But I didn't really feel pain yet. The only thing I could think about was how to get away."
Whether it's a bullet or a hot stove or a blade on a knife, we sense these noxious stimuli thanks to an intricate network of nerves that branch through the body like a tree, says Dr. David Martin, an anesthesiologist and pain specialist at the Mayo Clinic in Rochester, Minn.
On the very tips of those branches are nerve endings designed to detect temperature, pressure and other sensations. These sensitive endings send electrical signals along nerve fibers that branch out from the spinal cord. Signals travel from there up to the brain, where the message gets interpreted as pain.
"When a bullet passes through a hand, for example, those nerve endings are going off the scale," Martin says. "They're saying, 'I felt something with a whole lot more pressure or pinching than I'm supposed to feel.' The purpose of that pain signal is to tell us to get out of harm's way."
Leon's network of nerves quickly delivered the message to his brain that he'd been shot. But like many shooting victims, he didn't feel pain right away. That's largely because pain can take a back seat when the brain is busy trying to figure out how to stay alive.
"It's called stress-induced analgesia," says Michael Feuerstein, a psychologist who specializes in counseling shooting victims in the Washington, D.C., area. "When you're in a life-threatening situation, your body goes into fight-or-flight mode. Blood flows to your muscles so you can either run or fight. Stress hormones are released that have been shown to reduce the amount of pain a person feels."
That isn't the only reason it can take at least a few minutes for pain to register. Part of the delay can be chalked up to the time it takes the body to rally its repair crews at the injury site, which can take an hour or so to reach its peak, Martin says.
Damaged tissue unleashes chemicals that serve as a battle cry, marshaling the body's infection-fighting white blood cells and other healing agents to the wounded area. The injury site becomes swollen, or inflamed. Tiny nerve fibers pick up on this inflammation and respond by firing off pain signals to the brain.
"By making it extremely painful for you to move that area, it promotes healing," Martin says. "But this phenomenon of inflammation takes a little while to get started."
'Hurts like hell'
Heat followed by numbness. That's all Dana Tierney-Smith felt right after Luther Casteel fired a 9mm bullet into her ankle three years ago at a bar in Elgin.
"At first, I was just so wired on adrenaline," says Tierney-Smith, 29, of Winfield, one of 18 people shot by Casteel at JB's Pub.
Casteel went on a shooting rampage after being kicked out of the bar. He's now serving a life sentence.
"It's like terror consumes every cell of your body," she says. "I kept telling my friends I had to get out of there or I was going to bleed to death."
The bullet shattered a portion of her tibia and fibula, the two long bones below the knee. She needed a pair of titanium plates and a dozen screws to put her leg back together.
After the ambulance brought Tierney-Smith to the hospital, a technician moved her leg so she could take X-rays. Suddenly, it was as if every neuron in her body screamed out in protest.
" 'Excruciating' doesn't do it justice," Tierney-Smith says. "There isn't a word in the English language to describe it."
She plowed through a month's worth of Vicodin in five days in an attempt to stifle the pain.
At the hospital, the morphine drip delivered only temporary relief.
"I'd be fine one minute, and then, 'Boom!' " she says. "It's like a hammer comes down and whacks you. I just kept pushing that damn button on the morphine pump. Sometimes, the pain was so bad, I wished I was dead."
Getting shot in the bone hurts. So does getting shot in the kidney. But each produces a different kind of pain.
"It's roughly true that crampy, achy pain tends to be a quality of pain from organs," says Martin, the Mayo Clinic doctor. "Sharper pain is more likely to be musculoskeletal -- from the muscles or bones -- and burning or searing pain tends to be a quality of injury to the nerves."
The degree of suffering sparked by a bullet to any one of these areas can vary greatly from person to person. Everyone has a different threshold for pain, and circumstances count when computing just how much something hurts.
A study of injured World War II soldiers -- one of the few ever done on the subject -- found that pain didn't correlate with the degree of damage.
"Those with severe enough wounds to be sent back home reported less pain than those who had minor injuries and were going back to the front," Martin says.
Culture plays a big part in how we handle pain, too.
"If you were to interview patients in Japan about their response to a gunshot wound, it would be different than the response you get from Americans," says Dr. Paul Christo, director of the pain-treatment center at Johns Hopkins Hospital in Baltimore. "They tend to be more stoic. They would tend to downplay the pain and not describe it as intensely as Americans generally would. Chemically, though, we think the same thing is going on in both groups."
Bullet behavior
In Leon's case, despite having two bullets in him, he managed to run far enough ahead of his attackers to flag down a passing van. The driver rushed him to the hospital. That's when the pain in Leon's gut gripped him like a vise and wouldn't let go.
"The doctors were trying to take off my shirt, and I was screaming because it hurt so much all over my belly," Leon recalls of sitting hooked up to a morphine drip at Mount Sinai Hospital on the West Side. "It was like they were pushing on a really tender bruise."
The bullet -- most likely .22-caliber, according to Leon's surgeon -- didn't penetrate far enough to hit any organs. If it had enough momentum to perforate his bowel or stomach, the acidic contents of those organs could have seeped out, sparking an extremely painful inflammatory response akin to a burst appendix.
How a bullet behaves in the body depends on several factors, such as its mass and velocity. A smaller slug like a .22 might bounce off a rib and change direction; a larger .45-caliber would be more likely to blow right through the bone.
Some bullets will travel further into the body if they're traveling at greater speed. But the high velocity delivered by some pistols and rifles, which can send bullets flying at least three times as fast as most handguns, also can make bullets flatten or fragment after impact. This limits how deep they can penetrate.
Just as important as mass and velocity is the bullet's design, says Fackler, who used to oversee the U.S. military's wound ballistics lab in San Francisco. Bullets basically come in two types: military and hunting.
Military bullets are covered by hard metal jackets that keep them from deforming once they meet their target. These bullets tend to sail right through a person, sometimes turning several inches after impact.
Hunting bullets -- which are much more common -- are built to expand after they hit. Their soft, lead noses or hollowed-out tips are designed to flatten or mushroom. That means they spread wider inside the body and, as a result, destroy more tissue. They often stay inside the shooting victim's body. And unless a surgeon happens to stumble upon it, that's where the bullet is likely to remain -- a fact that surprises many shooting victims.
One of the first questions patients ask trauma surgeons is whether they got the bullet out. It's such a common query, Christ Medical Center's Salzman used to have a T-shirt emblazoned with that very question.
"We don't go looking for bullets intentionally," says Dr. Andrew Dennis, a part-time police officer and trauma surgeon at Cook County's John H. Stroger Jr. Hospital. "If we find it, great. If not, we leave it. You end up doing more damage trying to get it out."
The destruction caused by a bullet isn't necessarily limited to what's directly in its path. The impact sometimes stretches and tears surrounding tissue. This "splash" can be powerful enough to break nearby bones.
"But what's more important than the type of bullet or how fast it's going is where it ends up," Fackler says.
Location is key
The bullet in Leon's leg went in and out, missing the bone, as well as major blood vessels and nerves.
Had it smashed into his femur, it could have shattered the bone, sending out splintered fragments like tiny pieces of shrapnel. If it hit the femoral artery in the thigh, Leon could have bled to death before reaching the emergency-room doors.
"Gunshot-wound victims who die almost always die of massive blood loss," says Dr. Scott Denton, a forensic pathologist and Cook County deputy medical examiner. "If the bullet hits anything with blood flow through it -- the heart, the liver, the aorta -- it can cause massive bleeding."
That massive bleeding often takes place internally.
"You might have a two-tenths-of-an-inch bullet hole in the chest, with a little blood trickling out of it, but that doesn't tell you how much damage is inside," Denton says.
Had the bullet pierced the long motor nerve in Leon's leg, he might have lost use of that limb for good.
"The sensory nerves, the ones that give you pain, those generally grow back," says Dr. Michele Holevar, trauma chief at Mount Sinai and the surgeon who operated on Leon. "The motor nerves . . . we can try to splice them together. But, more often than not, they don't grow back, and these people are disabled for the rest of their lives."
Police didn't catch Leon's attackers. His case illustrates what several emergency and trauma doctors say is a growing problem in Chicago: The single gunshot wound is becoming more of a rarity.
"When I was training, people came in and they were generally just shot once. It was a lot easier to deal with," Holevar says. "Now, we're seeing a trend towards multiple gunshot wounds.
"If they have an injury in their chest, their abdomen and a vascular injury to their leg, it's very difficult to save these people," she says. "They're bleeding from everywhere."
Even if Holevar does manage to save them, there's a good chance they'll be back. About one out of three shooting victims treated at Mount Sinai returns with another gunshot wound in the future, according to Dr. Les Zun, the hospital's head of emergency medicine.
"Gunshot wounds often are not a one-time event," Zun says. "They're a chronic disease."
Bleeding out
Mike Robbins knows a good deal about multiple gunshot wounds. Thirteen bullets from a 9mm semiautomatic Taurus handgun pummeled the former Chicago police officer's body at point-blank range.
It happened 10 years ago. Robbins and his partner were driving slowly down a dark alley in an unmarked police car, looking for gang members. One appeared at Robbins' open car window and stuck a gun in his face.
Robbins grabbed for the pistol. As the men wrestled for control of the gun, the gang member squeezed the trigger, unloading 13 shots into Robbins, whose bulletproof vest managed to stop three of them.
The struggle felt like it went on for minutes, Robbins says, but it really lasted a matter of seconds. That's all the time it took for the officer to be shot in the chest, abdomen, both arms and legs and once in the back.
He doesn't know which bullet went in first. He just knows the shot to his back was the last.
"During the struggle, I was losing my strength," says Robbins, 52. "I thought, 'If I'm going to die here in this alley, I don't want to see that final flash of gunfire in my face.' So I let go of his hands and turned to my right, so he'd have to shoot me in the back of my head."
As Robbins turned away, he saw a vision of his mother, who had died a dozen years earlier, in the back seat of the car.
"She pulled me to her bosom," Robbins recalls. "Then, there was this elephant kick to my back. And my mother let me go. That's when I felt this sense of survival. I realized I wasn't going to die."
Out of bullets, the shooter took off. Robbins sat in the car, bleeding, waiting with his partner for help to arrive.
Robbins was losing a lot of blood -- fast. When this happens, the body reacts by kicking the heart into high gear. Blood pressure plummets. What blood is left gets pulled away from the arms and legs and skin and gets routed to key organs, namely the heart and brain. That's why the body becomes pale, cold and clammy. People can get confused or lose consciousness. Eventually, there isn't enough life-sustaining oxygen coursing through the body.
"Older folks don't do as well with significant blood loss," Mount Sinai's Zun says. "Younger people do much better. They can tolerate significantly more blood loss before they go into irreversible shock."
Before the paramedics arrived, Robbins was drifting in and out of consciousness. In the ambulance, he started shaking violently. He was cold and couldn't feel his legs. All he could think to do was pray. He repeated Hail Marys and the Lord's Prayer.
"I guess someone was listening," Robbins says.
Ten years later, Robbins' physical pain has largely subsided. The emotional pain hasn't.
The man who shot him was sentenced to 120 years in prison.
"I haven't had a full eight hours sleep since 1994," Robbins says. "I still have nightmares, all kinds of nightmares. I'm being shot, stabbed, drowning, stomped by elephants, hit by lightning. I'm always on the verge of dying, and I always wake up right before it happens."
GUNSHOT INJURIES IN ILLINOIS
The number of nonfatal firearm injuries treated at Illinois trauma centers has remained relatively constant for the last few years.
© 2004, Digital Chicago Inc.