As gun violence increases, so does its toll on doctors

The ramp at Harborview Medical Center is where most gunshot wound patients arrive. They might be dropped off or walk up the ramp themselves, and when they do, the emergency department springs into gear.

Arvin Radfar Akhavan, emergency department medical director, has seen everything from accidental discharges and bystander injuries to road-rage encounters that escalated because a gun was present, a more common scenario in recent years. First responders — doctors, nurses, police officers, firefighters, EMTs — report they all have seen with their own eyes gun violence increasing across the region during the past decade.

Whether at a Seattle high school or along a busy corridor of I-5, the greatest impact of increased gun violence in the Pacific Northwest is on the people immediately harmed by it.

But for those who witness firearm injuries over and over again while on the clock, these acts of violence are a major source of psychological strain, vicarious trauma and frustration. Many feel powerless in the face of injuries and deaths they believe should never have occurred in the first place.

Seattle may not be known as an epicenter of gun violence, but it is one for treating injuries caused by guns, especially at Harborview, the state’s only level-one trauma center and a destination for patients throughout the Northwest. The concentration of the state’s gunshot wound treatment in Seattle, combined with increased gun violence in recent years, has created a challenging environment for providers meeting patients on the ramp. “Because our catchment area is so large, and because the rate has just been increasing so much, even in Seattle, we’re seeing a lot more of it,” Akhavan said.

‘Hardest stuff that we see’

When a patient arrives at Harborview with a firearm injury, the response involves a vast network of hospital staff, from orthopedic surgeons and anesthesiologists to social workers and ICU nurses. “Everyone’s heightened, everyone’s ready, a bit anxious, ready to go,” Akhavan said.

Triaging cases from least to most acute hinges on where the bullet has entered the body; if someone is shot through their extremities, they’re more likely to survive. “That stepwise approach often includes the emergency physicians, our trauma surgeons, or general surgeons, our anesthesia faculty, a large set of nurses,” Akhavan said. “If it goes through a bone or a vessel, you would get your orthopedic team involved, or your vascular surgeons.”

After monitoring vital signs like blood pressure and breathing, the team will determine what part of the body was hit, which often means the next stop is radiology, to “make sure it didn’t hit something important.” If it did — that “something important” could be the abdomen, a large blood vessel, the head — the next step is usually to bring in trauma surgeons.

Treating gunshot wounds is rigorous, intense labor. John Bramhall, president-elect of the Washington State Medical Association, has experienced it firsthand as an anesthesiologist working on a receiving team treating gunshot injuries in the emergency department at Harborview. He described trauma surgeons with “their gloved hands in the belly, squirming around in the blood — it’s very visceral in every sense of the word.”

But part of what makes treating people with gunshot wounds such demanding work is the long path of recovery these cases take, as well as the sheer volume of hospital staff required. A patient’s journey may begin on that ramp into the emergency department, but they’ll move throughout the hospital during their treatment and recovery, among teams in the operating room, the intensive care unit, the acute care unit and the rehabilitation unit, among others. “The bottom line is that a very large number of people interact with this injured person over time,” Bramhall said.

And while these cases take a toll on hospital resources, they also have a big impact on the people involved in that care.

Some of these clinicians will experience second-hand trauma from these experiences, especially in extreme cases. “I think some of the more violent stuff or some of the stuff that involves children or young people — and then the stuff that involves suicide — is always some of the hardest stuff that we see in the emergency department,” Akhavan said.

‘Picking up the pieces’

For physicians, some amount of secondary trauma is unavoidable. “It’s medicine,” Bramhall said. There’s an understanding that “bad things happen occasionally,” and providers witness them. Much of this can’t be prevented.

But what makes treating gunshot wounds so challenging is that in many situations, they would never have happened if a gun hadn’t been present, and for clinicians, the dissonance of treating an injury that should never have occurred in the first place can be traumatic.

“I think that gun violence in general — whether it’s accidental, self-inflicted, intentional — always feels that way,” Akhavan said. He compared it to witnessing injuries caused by reckless decisions like drunk driving, as did Bramhall.

“In my mind, in both situations, terrible damage is done to individuals, to families, to communities, and it’s done trivially,” Bramhall said. “There’s no reason for this to happen,” and “that adds a particular pain that’s then suffered by the people who are picking up the pieces.”

Among patients injured by guns, some will survive and go on to fully recover, especially if their injuries don’t involve vital organs.

“But a large portion of these patients, obviously, who get shot are either dead or are going to have an extremely long, traumatic clinical course afterwards,” he said. “So I think one of the reasons that secondary trauma is so significant is because you’re seeing this singular event that dramatically changes someone’s life moving forward, and you view it as this thing that’s a potentially modifiable risk factor.”

If a case has a poor outcome — if it ends in death or brain or spinal injuries — it can be even more upsetting. Bramhall said head injuries can be especially distressing for providers because of their severity and the long course of treatment they require. “Everyone knows the long road for recovery and the uncertainty of recovery when you’ve had major head trauma,” he said. “That’s a really poignant set of conditions, I think, for most people.”

As the state’s only level-one trauma center, Harborview regularly receives patients from Idaho, Alaska and western Montana. As part of UW Medicine’s system of hospitals and clinics, providers said it is well-resourced to manage the mental health consequences of secondhand trauma that can emerge from treating injuries caused by gun violence.

But by and large, the state’s smaller rural hospitals don’t have the same resources. And that’s not because they don’t encounter firearm injuries.

“It happens more often at a big trauma center than a smaller regional hospital, but it can happen anywhere,” Bramhall said. “If you happen to be injured in Yakima, that’s where you’re going to be treated, and only if you’re stable enough will you be transferred to Harborview.”

If a patient isn’t stable, that leaves the case in the care of smaller facilities that may be less equipped to deal with the impact on hospital staff. “Even though they’re not dealing with these traumas quite as commonly as someone at Harborview, I think occasionally they actually have a worse deal because they don’t have the infrastructure,” Bramhall said.

‘Little marks on your soul’

In general, people in health care and emergency response professions are vulnerable to the emotional toll of persistent exposure to traumatic incidents like caring for gunshot victims.

According to scholars from the University of Canberra and Australian National University, who conducted a 2022 study of post-traumatic growth among helping professionals, vicarious trauma “involves a disruption in a person’s sense of safety, trust, esteem, intimacy, and control, resulting in negative perception of one’s self, others, and the world.”

Vicarious trauma is particularly insidious because it emerges from an empathic response to another person’s trauma. This is something that often allows people in helping professions to do their jobs, but it can leave them vulnerable to the impacts of cumulative exposure to trauma.

Workers in these roles can also experience post-traumatic stress disorder (PTSD); secondary traumatic stress, which mimics PTSD but is linked to vicarious trauma; and burnout, which, according to the study, “results in gradual loss of optimism, energy, and goals; and on a greater scale, alienation, dissatisfaction, and ultimately departure from a workplace.”

Workplaces can address these mental health risks by introducing on-site trauma-informed support systems, like the one in use at the Tacoma Fire Department. On tough calls, the department’s peer support team comes out and helps crews process their experiences, said Jeff Bambrick, medical services officer. Bambrick, who has spent 28 years working in firefighting and emergency medical services, said this was a relatively new — but much needed — development, implemented to address disproportionate rates of PTSD among firefighters. “We didn’t have that back when I was in the field,” he said. “You just went home and you hugged your wife.”

As a medical services officer, Bambrick has been on numerous calls involving gun violence in Tacoma. The department typically turns these around in under 10 minutes, sometimes fewer, and requires a huge crew — a transport unit, two engine companies and a battalion chief. “I don’t think that people understand the amount of resources, actually, that we’re sending just to try to save that person’s life,” Bambrick said.

The goal is to get the person who’s been shot to a hospital as soon as possible — either Tacoma General or St. Joseph. For first responders, “There’s not a lot in the field that we’re going to do,” he said. “It’s kind of like we’re just preventing death at this point, but we’re really not fixing anything. We’re just trying to get them to the trauma doc as quickly as we can.”

Later this year, Tacoma Fire will start equipping its teams with blood for these calls, so that patients can receive blood even before they go to the hospital: Bleeding is a major cause of death for victims of gunshot injuries. Carrying blood is an emerging practice among emergency departments only recently implemented in King County. Bambrick hopes it will be “a game-changer” for victims of shootings.

As for the psychological impact, he said, the hardest part of responding to these calls is seeing how they impact victims’ loved ones: “It’s the other people around when you respond to a young person that’s been shot … it’s just absolutely devastating.”

The family photos are what stay with him. “That’s what always gets me,” he said. “I can see the pictures of the kid on the wall, and now they’re on the ground, and they have a devastating gunshot injury, and stuff like that sticks with you. It’s not something that you just go home and wash it off. We talk about it making little marks on your soul. It’s just going to be with you.”

Policy solutions

Given clinicians’ frustration with treating injuries they see as preventable, it’s no surprise that major health care organizations have called for gun control. The American Nurses Association has advocated for waiting periods and background checks on gun purchases and a ban on assault rifles.

The Washington State Medical Association, which has characterized gun violence as a public health crisis, advocated for a ban on open-carrying weapons in public parks and hospitals and enhanced criminal penalties for assaulting health care workers. In the 2025 legislative session, the group plans to promote a bill supporting physicians’ access to confidential support services.

Policy solutions are one possible route to preventing some of the violence clinicians witness, but some are more effective than others. While Washington does have a ban on the sale of semi-automatic assault style rifles, that law is unlikely to have much of an impact on a busy emergency department like the one at Harborview, where most firearm injuries involve handguns, according to Akhavan.

In the absence of comprehensive upstream prevention, interventions after a firearm injury has occurred are one way to stop violence from compounding. Harborview is the only medical institution in the state with violence-prevention intervention specialists on site, who are called in alongside the numerous other staffers responding to firearm injury cases.

“We engage with them while they’re still reeling from the effects of this incident,” said intervention specialist Paul Carter III. Often, he said, people are still in shock, with “a lot of displaced emotions at times as well, and we are going in with the mindset of being that extra arm for them to lean on when they need to, to confide in us and to build that trust between the providers as well as other staff members that are working with this patient.”

Intervention specialists like Carter and his colleague Tarrell Harrison build trust with patients who may feel marginalized for having a gun-related injury, and, for patients with firearms at home, they share practical guidance for preventing violence in the future. Sometimes that means sharing information on lockboxes and other ways to make guns safer, and sometimes it means working with the patient to keep the violent situation that landed them in the hospital from escalating again when they leave.

Washington has a so-called “red flag law,” which can lead to removing guns from the homes of people who may be a danger to themselves or others. The state’s extreme risk protection orders involve a court process that can be started by relatives, friends or even roommates.

“I’m not going to sit here and say what somebody can do or not, but just the preventative measures are just keeping it up, keeping it locked, keeping it away from kids, keeping it away from people that are not supposed to have them,” Harrison said. “And, you know, just being responsible. I think that’s the biggest thing. Just being responsible can go a long way.”

When the program launched in 2021, Carter was already a volunteer at the hospital. He’d become a volunteer after receiving treatment for a firearm injury himself: A nurse caring for him suggested he find a way to give back.

“Seeing the amount of people every day now who are like, ‘I’m glad you guys are here,’ and the thank-yous, and the happy tears from families, those are the things that draw me to it … we’ve got a foot in the solution,” Carter said.

He and Harrison work closely with patients throughout their stay and even after they’re discharged, working to identify and meet patients’ needs and help them reenter their lives safely. “When you take the social pressures off of people, of having to return back into society and be in survival mode, and some of those needs are met through our program, it kind of pushes them away from the ledge,” Harrison said.

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