Several years ago, an 8-year-old Chattanooga boy was shot while riding in the back seat of his mother's car as she drove through East Lake when a gunman opened fire in an attempt to kill one of his relatives, who was sitting up front.
He was rushed to the hospital and landed on pediatric trauma surgeon Dr. Dave Bhattacharya's operating table, where the boy underwent a three-hour surgery to repair his lung, liver, stomach and diaphragm.
"I remember he was eating Doritos, because when I opened his abdomen, I could smell the Cool Ranch Doritos emanating from out his abdomen," Bhattacharya said.
Though he was able to repair the boy's physical wounds, like many health care providers who treat trauma victims, Bhattacharya knows that the mental damage of either witnessing or experiencing an act of violence makes it more likely that a child will later become a perpetrator and get tangled in a cycle of violence that's hard to break.
Traumatic events also create ripple effects that can devastate families emotionally and financially, and in the case of shootings in particular, destroy local businesses, decrease property values and tear communities apart.
"It's not just that a kid got shot," Bhattacharya said. "There were so many layers to what had happened to him that day, and his story is not unique."
From the perspective of local trauma surgeons tasked with putting victims' bodies back together, gun violence is an ever-present reality.
Dr. Robert Maxwell, surgical critical care fellowship program director of the University of Tennessee College of Medicine Chattanooga, said Chattanooga experiences trauma surges, particularly during warmer months, but that firearm injuries - which run the gamut from acts of violence to accidental shootings and suicide attempts - are "pretty constant."
"With the gang violence, if an event happens, there may be several other related events that may be retaliation," Maxwell said. "Then, it settles down and we'll go through several weeks or several months where there's very little activity, and then it starts all over again."
The recent downtown and McCallie Avenue shootings in Chattanooga were higher casualty events and "surprising" for most Chattanoogans, Maxwell said. And with so much national attention on gun violence in response to other mass shootings, he said it's created a heightened awareness around gun violence locally.
"It's brought more attention to an ongoing problem in our community," Maxwell said.
Both Maxwell and Bhattacharya practice at University Surgical Associates, the surgical services provider for Erlanger hospital - home of the only Level 1 trauma center for both children and adults in the Chattanooga region.
As a level 1 trauma center, Erlanger sees the bulk of the most serious and life-threatening injuries in an area that spans hundreds of miles from Western North Carolina, across Southeast and parts of Middle Tennessee and into North Georgia and Alabama.
Chattanooga area shootings
Of the nearly 23,000 adult traumatic injuries (which mostly includes patients ages 15 and up) treated at Erlanger from January 2018 through March 2022, 943 were related to gunshot wounds.
And while firearm injuries can happen to anyone, the distribution of those injuries isn't equal.
Men accounted for 796 of the 943 firearm-related injuries treated at Erlanger in the past four years, and the most common age for victims was the 20- to 29-year-old range.
Of the 156 who died from their injuries, 19 were women and 137 were men.
The pediatric trauma team treats victims younger than 15 and saw far fewer gun injuries during the same timeframe (42), but Maxwell said those are the cases that are the most difficult for staff.
"We have an expectation that we're going to be involved in these tragic sorts of events, and I think we're mentally prepared," he said. "But when you see children that are victims of interpersonal violence or firearm injuries, I think that's when it just makes absolutely no sense whatsoever."
When young patients can't be saved or have bad outcomes, it's like "rocks that go in a backpack that you carry with you for forever," Bhattacharya said.
"By the time that you're done with your career, your backpack is incredibly heavy," he said.
It also takes an incredible amount of resources to be ready 24/7 for mass casualty events on top of routine traumas. At the same time as the McCallie Avenue shooting, Bhattacharya said there was a "terrible" car accident that left two children critically injured.
"Being able to be that deep with blood available, that deep with nurses that are coming in from home, that deep with surgeons that are coming in off the bench is what Erlanger does. That shouldn't be undervalued," he said. "And I don't work for Erlanger, but it's a partnership."
Maxwell said Erlanger treated a gunshot victim on Thursday night who required 40 units of blood during surgery. Each unit represents blood collected from a single donor.
"Sometimes we'll use over 100 units of blood when there're multiple gunshot wounds or they've hit a major blood vessel," he said.
When a patient is bleeding profusely from a ruptured blood vessel, the trauma team activates its "massive transfusion protocol," which uses trauma resuscitation nurses who are responsible for hanging blood in a specific order so that it will clot properly.
"That's a huge part of our trauma program - having specially trained trauma nurses that know how to resuscitate a bleeding patient and can do that autonomously while we're operating," he said. "While they're doing that, we have an experienced anesthesia team that knows how to treat somebody who's bleeding and unstable. It's a real team effort."
When it comes to gunshot wounds, the type of firearm used significantly impacts the severity of the injury, Maxwell said. Handgun injuries, which are the most common type of firearm injury, typically damage just the area where the bullet hits, while high-velocity gunshot wounds caused by rifles cause extensive soft tissue damage.
"It creates these cavitary wounds where the actual tissue trauma is considerably bigger than the diameter of the bullet," he said. "When you talk about injury to the chest or the abdomen like that, it has very serious consequences."
All bullets take unpredictable paths once they enter a body, and Maxwell said it's "a mystery every time" figuring out the trajectory of bullets and the extent of a patient's injuries as they're bleeding and being rushed to the operating room. The more times someone is shot, the more difficult the mystery is to solve.
"When there's multiple gunshot wounds, you have to try and figure out what entrance wound goes with what exit wounds and what bullet wound is associated with a [retained bullet] because you have to know how much exploration you have to do at surgery," he said.
Bhattacharya said that there are also many non-clinical staff members who help guide trauma victims and their families through their recovery and connect them to resources outside of the hospital.
"It's not just us taking care of these kids. It's about us taking care of that family afterwards, too," he said.
Though the trauma team is prepared to deal with the aftermath of gun violence, Maxwell said he wishes there was more that could be done to prevent shootings in the first place.
"Because it's just needless loss of life and people have serious disabilities that occur after a lot of these injuries," he said. "We can save them, but they're not going to be the same."
Maxwell said that Erlanger does trauma prevention outreach for distracted driving and seatbelt, car seat and helmet use but would need more resources to spearhead a gun violence prevention program. Erlanger, which is currently a public hospital, receives some trauma fund support from the state but only gets $1.5 million from Hamilton County and no funds from the city each year.
"There are trauma centers that have Ph.D. level psychologists and social workers that have a lot of funding to develop programs to try and intercept these individuals," he said, noting that the bulk of those who come to the hospital for gunshot wounds are uninsured or underinsured. "Erlanger doesn't have those sorts of resources."
Bhattacharya preaches prevention at home and tackling systematic issues that perpetuate violence and trauma, such as poverty, education inequity, affordable housing and health care access.
"Thinking about trauma in your home will make it real," he said. "As boring as it sounds, make sure that your kid knows how to deal with a gun. As boring as it sounds, make sure your guns are locked in a safe. As boring as it sounds, make sure your kids are home at a reasonable hour."
He thinks more adults should talk about gun safety, too.
"I take my next-door neighbor's kid to the pool and I always say, 'Hey, I need your booster seat.' We talk about that, but I've actually never asked them if they have a gun in their house," Bhattacharya said. "Why do we not talk about that?"