Dr. Niladri Basu, an orthopedic trauma surgeon based in Dallas, Texas, has grown increasingly worried over the past few months about how the novel coronavirus will affect people injured in shootings. He has been especially concerned about access to care at overburdened hospitals: Will gunshot patients, each of whom requires extraordinary hospital resources, be able to find beds when coronavirus patients are showing up in droves? When we spoke by phone, I asked Basu how his hospital, located in a city on track to become one of the country’s coronavirus hotspots, was preparing to handle these dual crises, and about whether gunshot victims who do manage to find a bed faced an increased risk of contracting the virus. Our conversation has been edited for length and clarity.
It’s been less than a month since the World Health Organization declared COVID-19 a pandemic and a little bit longer since the first U.S. case. How has work for you changed?
So two things have changed. First, we’ve cancelled elective surgery cases: things like breast implants, tummy tucks, hip replacements, knee replacements — things that can just wait. Right now, it’s a lot more preparation than actually physically treating patients, and we need the resources from these surgeries. We’ve opened up a lot of extra hospital beds, pulled a lot of extra ventilators in anticipation.
The second change is that we have just not been as busy with trauma cases. I haven’t had a single shooting since this whole thing started, and we otherwise routinely see shooting victims here. I was on call this weekend and my pager hasn’t gone off once. That is hardly ever the case. Now that’s anecdotal, of course, but it’s a good sign.
What happens if the shootings pick back up?
That would present a number of problems. We’re not overwhelmed with coronavirus patients at the moment, but we’re anticipating an uptick.
The problem with gunshot patients is that the amount of resources it takes to treat one patient is unfathomable. Treating one of them requires multiple surgeries, multiple surgeons, operating rooms, anesthesiologists, and millions and millions of dollars. The resource burden — if we were to see any gunshot patients while overloaded with coronavirus patients — would be tremendous. We have a certain number of dollars to spend and we would have to make some tough decisions about who survives and who doesn’t. If they’re going to need 30 units of blood and weeks in the ICU, they’re going to have a hard time getting a bed.
It would come down to who’s most likely to live.
Exactly. And it would be a tough choice to make when having to allocate resources during critical supply shortages.
You have spoken with me in the past about how important it is to treat gunshot wounds quickly. What’s likely to happen to ambulance response times if a hospital is bulging with coronavirus patients?
If a patient is even suspected to have coronavirus and an EMS driver has to pick them up, that ambulance has to do a full, hours-long decontamination. That can be hours of that ambulance not being available for pickup. So I could definitely see a shortage of ambulances if there was a critical shooting, just stemming from those decontaminations alone. That would increase response times, and we know time-to-hospital plays a large role in survivability.
But there’s an additional risk. When a hospital is overburdened with coronavirus patients it will sometimes go on diversion and refuse to accept any trauma patients. I was actually speaking to my colleagues in New York earlier and my orthopedic floor at my prior hospital has been converted into a COVID unit. That means ambulances possibly have to travel further, [to transport patients to different hospitals] which also means longer response times.
Much has been made recently about a severe supply shortage in hospitals — not just of personal protective equipment like masks and gloves, but also of life-saving treatments. New York Governor Andrew Cuomo said the state will need more than 30,000 additional ventilators in less than a month, and the Red Cross has reported debilitating shortages in blood supplies. How would these shortages affect the treatment of gunshot victims if they do make it to the operating room?
So with the typical hemorrhaging gunshot patient, we’ll do a massive transfusion protocol. That’s 20 to 30 units of blood just to keep the patient alive. If this quarantining prevents people from going out, we don’t know how or when we’re going to get blood.
There will be a shortage at some point. For me, personally, I’m gonna have a much higher threshold to transfuse. This is one of the reasons we’ve limited the number of surgeries we’re doing and cancelled elective cases. By decreasing surgeries, we’re decreasing demand for blood.
The thing is, there’s a critical point where we can no longer provide medical supplies to patients. We haven’t hit that limit yet but it’s something that could potentially happen. And a gunshot patient can spend 20 to 25 days on a ventilator, sometimes more than $2,000 a day. If you have a patient on a ventilator with COVID, it would be really hard to take them off the device and give it to someone with a gunshot injury [who’s going to put such a significant strain on the hospital]. There’s just a lot of difficult medical ethics to consider.
In a best-case scenario, if a gunshot patient does make it to the O.R. and does get treated appropriately, there’s still the risk of contracting the virus in a hospital filled with it, right?
Right. And the risks for these patients to both contract the virus and to die from it are probably higher than average. Just like a hospital has critical resources, the body has critical resources and a certain amount of energy it can devote to healing. If it doesn’t have as much energy and resources, that can lead to a potentially immunocompromised state. We don’t have enough data on this, but just from a general understanding standpoint, it’s another added hit. The resources they’re expending to stay alive cannot be spent fighting the virus.
Is there a message in all of this for those thinking about turning to their guns in the next couple of months, when shootings typically reach their annual peak?
Stay indoors. Just stay in, and resolve your differences later. Now is not the time.
