- Email: [email protected]
Drive-By Shootings
CASE REPORT
Drive-ByShootings From the Department of Emergency Medicine, Los Angeles County and University of Southern California Medical Center, Los Angeles.
Marc Eckstein, MD H Range Hutsen,MD Deirdre Anglin, MD
Receivedfor publication April 21, 1994. Acceptedfor publication May 23, 1994. Copyright © by the American College of EmergencyPhysicians.
Gang violence has reached epidemic proportions in Los Angeles and is occurring with increasing frequency in many other US cities. Gang members and innocent bystanders often suffer severe and sometimes fatal injuries in drive-by shootings. We present the case of one such innocent victim and discuss the personal and societal ramifications of drive-by shootings. [Eckstein M, Hutson HR, Anglin D: Drive-by shootings. Ann EmergMealJanuary1995;25:107-110.] INTRODUCTION The numbers of drive-by shootings perpetrated by violent urban street gangs are increasing in many cities across the United States.>3 During a drive-by shooting, gang members shoot at rival gang members from a moving vehicle. Because high-capacity semiautomatic handguns or shotguns are the weapons most often used, innocent bystanders often fall victim. <5 In one Los Angeles series, an average of 1.4 individuals was shot at per drive-by shooting. Of people shot at, approximately 63% sustained a gunshot wound. 6 In Los Angeles, almost one fourth of all gang-related homicide victims are innocent bystanders.1 The following case report is presented to illustrate the injuries and devastation that can result from this manifestation of gang violence.
CASE REPORT A 14-year-old girl was brought to our trauma center by paramedics after sustaining a gunshot wound in a drive-by shooting. The patient was walking down the street with her sister when shots were fired from a moving vehicle. (Later investigation revealed that the shooting occurred on the patient's first day in Los Angeles while she was visiting relatives.) The intended victim, a gang member, was shot and pronounced dead at the scene. The patient was shot once in the left flank. She had stable vital signs in the field but could not move her lower extremities.
JANUARY 1995
25:1
ANNALS OF EMERGENCY MEDICINE
1 O7
SHOOTINGS Eckstein, Hutson & Anglin
On arrival in the emergency department, the patient was awake and alert despite her injuries. Her vital signs were blood pressure, 98/54 mm Hg; pulse, 150; respirations, 28; and temperature, 36.5°C. There was no jugular venous distention or cervical tenderness. There was a single entrance wound at the seventh intercostal space along the midaxillary line, with no active bleeding from the wound. No exit wound was seen. The patient had normal chest expansion with clear lung sounds bilaterally and no subcutaneous air or palpable foreign bodies. Heart tones were normal. The abdomen was soft, with moderate tenderness of both upper quadrants, with no rebound tenderness or peritoneal signs. Bowel sounds were diminished. There were no deformities of the back or the extremities. Pulses were equal and strong throughout. Rectal tone was absent. Neurologic examination revealed normal motor strength of both upper extremities, with areflexic, flaccid paralysis of the lower extremities. There was a complete sensory loss below the level of T10. The patient was resuscitated with fluid, and a left subclavian central catheter was inserted for central venous pressure monitoring, which measured between 12 and 1z}cm H20. After 2 L of crystalloid, blood pressure was 126/80 mm Hg, and the pulse was 125. Serial hematocrits remained stable between 33% and 30%. A chest radiograph revealed no hemopneumothorax (Figure 1). Kidney, ureter, and bladder and cross-table lateral abdominal films
showed a large-caliber bullet, most likely a .45 caliber, projecting over the right upper quadrant, just to the right of the spine at the T11-T12 level. Multiple metallic and bony fragments projected posteriorly and to the right (Figures 2 and 3). A Foley catheter drained 200 mk of grossly bloody urine. A "one-shot" IV pyelogram showed a functional and normal right kidney and ureter and a poorly visualized upper pole of the left kidney. Cefoxiun 2 g and solumedrol 1.5 g were given intravenously, and the patient was taken to the operating room for exploratory celiotomy. Operative findings included a large hemopentoneum, a 2x3-cm diaphragmatic perforation, two through-andthrough colon injuries, transection of the pancreas at the junction of the middle and distal thirds, a through-andthrough injury to the upper pole of the left kidney, and a palpable vertebral fracture with moderate bleeding. The
Figure 2. On kidney, ureter, and bladder film, the bullet is seen over the right upper quadrant. Metallic fragments are seen just to the right of the T11-T12 interspace.
Figure 1. Initial supine chest radiograph in the ED with the patient still on a backboard shows the bullet projecting over the right upper quadrant. No pneumothorax or hemothorax is seen.
I 08
ANNALS QF EMERGENCY MEDICINE
2 5 : 1 JANUARY 1995
SHOOTINGS Eckstein,Hutson& AngIin
probable trajectory of the bullet is illustrated in Figure 4. Primary diaphragm repair, primary colon repair, distal pancreatectomy, left partial nephrectomy, and splenectomy were performed. The patient had a stormy postoperative course, including return to the operating room for ligation of bleeding splenic vessels and again for open drainage of a left upper quadrant abscess. Before her third exploration, several computed tomography-guided percutaneous drain insertions were performed for a perinephric fluid collection. Computed tomography of the spine revealed a T11 lamina fracture with bullet and bony fragments in the spinal canal. The patient spent a total of 62 days in our hospital before transfer to a rehabilitation facility. Her hospital bill was $102,297. She spent another 98 days as an inpatient at the rehabilitation facility for an additional charge of $96,633. Initial stabilization and physical therapy resulted in charges of almost $200,000. Because the patient's parents had no medical insurance, these costs were borne by taxpayers. DISCUSSION
The cost in human terms is impossible to measure. The second victim of this drive-by shooting died of his injuries. This homicide had an estimated societal cost of more than $500,000. 5-r It is strikingly apparent from this case how a single act by a violent gang member can result in an inordinate cost in terms of human suffering, loss of life or limb, loss of potential, and a huge public financial burden. Unfortunately, our patient was one of more than 1_,500 victims of drive-by shootings in 1993 in Los Angeles. 4 Drive-by shootings have a tremendous impact on the lives of victims and their families, on the local economies, and on our already overburdened health care system. As illustrated in this case report, one need not be a gang member to be a victim. Emergency physicians must become involved in efforts to curb gang violence. As previous studies have pointed out, more law enforcement is not the solution, s Legislation to control the manufacture, sale, and distribution of firearms may be effective but will not provide an immediate solution. Inner-city youths need positive role models, real career opportunities, and alternatives to a life of violence. Root causes of gang violence, including stressed families, poverty, racism, lack of education, and alienation, must be addressed. Parents must be
The initial charges of almost $200,000 are only the beginning. A previously healthy 14-year-old girl, now a paraplegic, will require a lifetime of medical, supportive, and rehabilitative care. The cost of care over her remaining life span has been estimated to be approximately $3 million.
Figure 4. Bullet trajectory (D, diaphragm; 5, spleen; K kidney; C, colon; P,pancreas).
Figure 3. Cross-table lateral film, taken @er surgery, shows the bullet in the spinal canal at the level of rl 1. / J
J
J
"! I C%o Ki s
l
J A N U A R Y 1995
25:1
ANNALS OF EMERGENCY MEDICINE
1 09
SHOOTINGS
E&stein, Hutson & A~glin
taught that their responsibilities begin before their child is caught holding a smoking gun opposite another child's lifeless body. As emergency physicians, we see the carnage of gang violence each day. We are in a unique position to enact positive change.
Reprint no. 47/1/60871 Address for reprints: Marc Eckstein, MD Department of Emergency Medicine Los Angeles County and University of Southern California Medical Center 1200 N State Street, Room 1011
SUMMARY
Los Angeles, 0alifornia 90033
Drive-by shootings by violent street gangs have become a major health problem. The human and economic costs of the resultant injuries and homicides are enormous. To prevent drive-by shootings an emphasis must be placed on alleviating the root causes of formation of violent street gangs.
213-226-6667 Fax 213-226-6806
REFERENCES 1. Rice D, Mackenzie EJ, et al: Cost of injury in the United States: A report to Congress.Institutes of Health and Aging, University of California, San Franciscoand Injury PreventionCenter, Johns Hopkins University, Baltimore, 1989. 2. Bureau ef Labor Statistics Index: 1985 and 1991. 3. Hutson HR, Anglin D, Mallen W, et al: Caught in the crossfire ef gang violence: Small children: Innocent victims of drive-by shootings. J EmergMed 1994;12:385-388. 4. Hutson FIR,Eckstein M, Anglin D: Drive-by shootTngsin the city of Los Angeles: A five year analysis from 1989 to 1993 (unpublisheddata, 1994). 5. Hutson HR, Ang]in D, Mallon W: Injuries and deaths from gang violence: They are preventable. Ann EmergMed 1991;21:1234 1236. 8. Hutson HR, Angiin D, Pratts M: Adolescents and children injured or killed in drive-by shootings in Les Angeles. N EnglJ Med 1994;330:324-327. 7. Los Angeles Police Department, Gang Information Section: Citywide gang crime summary, 1993. 8. Miller WB: Why the United States has failed to solve its youth gang problem, in Huff CR (ed}. GangsinAmedca. Newbury Park, California, Sage Publications, Inc, 1990, p 263-287.
1 1 O
ANNALS OF EMERGENCY MEDICINE
25:1
JANUARY 1995
Drive-ByShootings From the Department of Emergency Medicine, Los Angeles County and University of Southern California Medical Center, Los Angeles.
Marc Eckstein, MD H Range Hutsen,MD Deirdre Anglin, MD
Receivedfor publication April 21, 1994. Acceptedfor publication May 23, 1994. Copyright © by the American College of EmergencyPhysicians.
Gang violence has reached epidemic proportions in Los Angeles and is occurring with increasing frequency in many other US cities. Gang members and innocent bystanders often suffer severe and sometimes fatal injuries in drive-by shootings. We present the case of one such innocent victim and discuss the personal and societal ramifications of drive-by shootings. [Eckstein M, Hutson HR, Anglin D: Drive-by shootings. Ann EmergMealJanuary1995;25:107-110.] INTRODUCTION The numbers of drive-by shootings perpetrated by violent urban street gangs are increasing in many cities across the United States.>3 During a drive-by shooting, gang members shoot at rival gang members from a moving vehicle. Because high-capacity semiautomatic handguns or shotguns are the weapons most often used, innocent bystanders often fall victim. <5 In one Los Angeles series, an average of 1.4 individuals was shot at per drive-by shooting. Of people shot at, approximately 63% sustained a gunshot wound. 6 In Los Angeles, almost one fourth of all gang-related homicide victims are innocent bystanders.1 The following case report is presented to illustrate the injuries and devastation that can result from this manifestation of gang violence.
CASE REPORT A 14-year-old girl was brought to our trauma center by paramedics after sustaining a gunshot wound in a drive-by shooting. The patient was walking down the street with her sister when shots were fired from a moving vehicle. (Later investigation revealed that the shooting occurred on the patient's first day in Los Angeles while she was visiting relatives.) The intended victim, a gang member, was shot and pronounced dead at the scene. The patient was shot once in the left flank. She had stable vital signs in the field but could not move her lower extremities.
JANUARY 1995
25:1
ANNALS OF EMERGENCY MEDICINE
1 O7
SHOOTINGS Eckstein, Hutson & Anglin
On arrival in the emergency department, the patient was awake and alert despite her injuries. Her vital signs were blood pressure, 98/54 mm Hg; pulse, 150; respirations, 28; and temperature, 36.5°C. There was no jugular venous distention or cervical tenderness. There was a single entrance wound at the seventh intercostal space along the midaxillary line, with no active bleeding from the wound. No exit wound was seen. The patient had normal chest expansion with clear lung sounds bilaterally and no subcutaneous air or palpable foreign bodies. Heart tones were normal. The abdomen was soft, with moderate tenderness of both upper quadrants, with no rebound tenderness or peritoneal signs. Bowel sounds were diminished. There were no deformities of the back or the extremities. Pulses were equal and strong throughout. Rectal tone was absent. Neurologic examination revealed normal motor strength of both upper extremities, with areflexic, flaccid paralysis of the lower extremities. There was a complete sensory loss below the level of T10. The patient was resuscitated with fluid, and a left subclavian central catheter was inserted for central venous pressure monitoring, which measured between 12 and 1z}cm H20. After 2 L of crystalloid, blood pressure was 126/80 mm Hg, and the pulse was 125. Serial hematocrits remained stable between 33% and 30%. A chest radiograph revealed no hemopneumothorax (Figure 1). Kidney, ureter, and bladder and cross-table lateral abdominal films
showed a large-caliber bullet, most likely a .45 caliber, projecting over the right upper quadrant, just to the right of the spine at the T11-T12 level. Multiple metallic and bony fragments projected posteriorly and to the right (Figures 2 and 3). A Foley catheter drained 200 mk of grossly bloody urine. A "one-shot" IV pyelogram showed a functional and normal right kidney and ureter and a poorly visualized upper pole of the left kidney. Cefoxiun 2 g and solumedrol 1.5 g were given intravenously, and the patient was taken to the operating room for exploratory celiotomy. Operative findings included a large hemopentoneum, a 2x3-cm diaphragmatic perforation, two through-andthrough colon injuries, transection of the pancreas at the junction of the middle and distal thirds, a through-andthrough injury to the upper pole of the left kidney, and a palpable vertebral fracture with moderate bleeding. The
Figure 2. On kidney, ureter, and bladder film, the bullet is seen over the right upper quadrant. Metallic fragments are seen just to the right of the T11-T12 interspace.
Figure 1. Initial supine chest radiograph in the ED with the patient still on a backboard shows the bullet projecting over the right upper quadrant. No pneumothorax or hemothorax is seen.
I 08
ANNALS QF EMERGENCY MEDICINE
2 5 : 1 JANUARY 1995
SHOOTINGS Eckstein,Hutson& AngIin
probable trajectory of the bullet is illustrated in Figure 4. Primary diaphragm repair, primary colon repair, distal pancreatectomy, left partial nephrectomy, and splenectomy were performed. The patient had a stormy postoperative course, including return to the operating room for ligation of bleeding splenic vessels and again for open drainage of a left upper quadrant abscess. Before her third exploration, several computed tomography-guided percutaneous drain insertions were performed for a perinephric fluid collection. Computed tomography of the spine revealed a T11 lamina fracture with bullet and bony fragments in the spinal canal. The patient spent a total of 62 days in our hospital before transfer to a rehabilitation facility. Her hospital bill was $102,297. She spent another 98 days as an inpatient at the rehabilitation facility for an additional charge of $96,633. Initial stabilization and physical therapy resulted in charges of almost $200,000. Because the patient's parents had no medical insurance, these costs were borne by taxpayers. DISCUSSION
The cost in human terms is impossible to measure. The second victim of this drive-by shooting died of his injuries. This homicide had an estimated societal cost of more than $500,000. 5-r It is strikingly apparent from this case how a single act by a violent gang member can result in an inordinate cost in terms of human suffering, loss of life or limb, loss of potential, and a huge public financial burden. Unfortunately, our patient was one of more than 1_,500 victims of drive-by shootings in 1993 in Los Angeles. 4 Drive-by shootings have a tremendous impact on the lives of victims and their families, on the local economies, and on our already overburdened health care system. As illustrated in this case report, one need not be a gang member to be a victim. Emergency physicians must become involved in efforts to curb gang violence. As previous studies have pointed out, more law enforcement is not the solution, s Legislation to control the manufacture, sale, and distribution of firearms may be effective but will not provide an immediate solution. Inner-city youths need positive role models, real career opportunities, and alternatives to a life of violence. Root causes of gang violence, including stressed families, poverty, racism, lack of education, and alienation, must be addressed. Parents must be
The initial charges of almost $200,000 are only the beginning. A previously healthy 14-year-old girl, now a paraplegic, will require a lifetime of medical, supportive, and rehabilitative care. The cost of care over her remaining life span has been estimated to be approximately $3 million.
Figure 4. Bullet trajectory (D, diaphragm; 5, spleen; K kidney; C, colon; P,pancreas).
Figure 3. Cross-table lateral film, taken @er surgery, shows the bullet in the spinal canal at the level of rl 1. / J
J
J
"! I C%o Ki s
l
J A N U A R Y 1995
25:1
ANNALS OF EMERGENCY MEDICINE
1 09
SHOOTINGS
E&stein, Hutson & A~glin
taught that their responsibilities begin before their child is caught holding a smoking gun opposite another child's lifeless body. As emergency physicians, we see the carnage of gang violence each day. We are in a unique position to enact positive change.
Reprint no. 47/1/60871 Address for reprints: Marc Eckstein, MD Department of Emergency Medicine Los Angeles County and University of Southern California Medical Center 1200 N State Street, Room 1011
SUMMARY
Los Angeles, 0alifornia 90033
Drive-by shootings by violent street gangs have become a major health problem. The human and economic costs of the resultant injuries and homicides are enormous. To prevent drive-by shootings an emphasis must be placed on alleviating the root causes of formation of violent street gangs.
213-226-6667 Fax 213-226-6806
REFERENCES 1. Rice D, Mackenzie EJ, et al: Cost of injury in the United States: A report to Congress.Institutes of Health and Aging, University of California, San Franciscoand Injury PreventionCenter, Johns Hopkins University, Baltimore, 1989. 2. Bureau ef Labor Statistics Index: 1985 and 1991. 3. Hutson HR, Anglin D, Mallen W, et al: Caught in the crossfire ef gang violence: Small children: Innocent victims of drive-by shootings. J EmergMed 1994;12:385-388. 4. Hutson FIR,Eckstein M, Anglin D: Drive-by shootTngsin the city of Los Angeles: A five year analysis from 1989 to 1993 (unpublisheddata, 1994). 5. Hutson HR, Ang]in D, Mallon W: Injuries and deaths from gang violence: They are preventable. Ann EmergMed 1991;21:1234 1236. 8. Hutson HR, Angiin D, Pratts M: Adolescents and children injured or killed in drive-by shootings in Les Angeles. N EnglJ Med 1994;330:324-327. 7. Los Angeles Police Department, Gang Information Section: Citywide gang crime summary, 1993. 8. Miller WB: Why the United States has failed to solve its youth gang problem, in Huff CR (ed}. GangsinAmedca. Newbury Park, California, Sage Publications, Inc, 1990, p 263-287.
1 1 O
ANNALS OF EMERGENCY MEDICINE
25:1
JANUARY 1995