Chapter 5: A Neglected Disease
In the fall of 2004, several months after finishing my emergency medicine residency, I thought of Jeffrey Mains and wondered where he was and what he was doing. I am not sure what triggered my memory because there were many patients that had slipped from it, but whatever it was, the recollection was clear and bittersweet. I remembered how painful his recovery had been and how it was uncertain, even when he was discharged, whether he would ever be completely well again.
“You should try to find him,” suggested my wife. His phone number wasn't listed in the Sacramento area, but I found some Internet news reports of the shootings that mentioned Linda Mains. AT&T gave me her phone number, but when I called, I only heard empty rings. Months went by and every once in awhile I thought of Mains, and at some point I began to contemplate the contradiction that his case represented. A rapid, coordinated trauma response had saved Jeffrey Mains’ life, but at the same time, his society's permissive attitude toward firearms had placed him in danger in the first place. And, of course, Mains was not alone. Despite amazing advances in the care of traumatic injury, trauma remains the leading cause of death for Americans between the ages of 1 and 44, and one-third to one-half of all trauma deaths still occur in the field. Most victims succumb to injuries that not even the best trauma system could effectively treat. Did this mean, I wondered, that these deaths were inevitable, and that we were bound by the maxim “shit happens” to accept a certain level of civilian casualties?
And so, as I searched for Jeffrey Mains, I concurrently researched the topic of trauma prevention and in particular the question of how best to keep innocent bystanders out of the resuscitation room. I called William Blaisdell, MD, and met him in his office at UC Davis Medical Center, where he still spent a couple afternoons a week helping David Wisner, MD, navigate administrative politics. I cracked a smile when I saw the only painting on his office wall, that of a tiger stalking in the jungle. The painting was a gift, he told me, from a former surgical resident. In an assured baritone, Blaisdell expressed pride at the progress made in the treatment of traumatic injury.
“Nowadays,” he told me, “we can salvage just about any patient that comes into the emergency department alive.” But as incredible as this is, he explained, there is a dangerous caveat; modern trauma care has become so good that its success distracts from prevention efforts and takes away from the urgency of state-sponsored safety mandates. “I've testified and testified about auto safety and gun control,” the old surgeon said wistfully, “but it is like running into a brick wall.”
I phoned David Wisner, and he echoed his mentor's sentiments. “Prevention is an open field,” he told me, “and I'm thinking passive…cars can be made safer and guns made safer. That is where we can make the greatest progress.” And while Wisner agreed that trauma surgeons had to some extent become victims of their own success, he noted that there are perceptions that form a barrier to preventive measures. One of these is that many people think of trauma as the fate of losers — of criminals, drunks and the mentally ill — and therefore not worthy of great concern. Still others feel that their freedom is threatened by mandated safety. “If you look at it from a libertarian point of view,” Wisner said, “some say that there's nothing wrong with millions of people dying young from trauma because at least they have the freedom of will to kill themselves with reckless behavior.”
The more I read about the history of trauma care, the more I discovered that not only public perception but also semantics had heavily affected the approach to prevention and treatment. For much of the past century in America, traumatic injuries were considered random and unpredictable “accidents” and not a disease process, like atherosclerosis or cancer, that could be studied and treated. Under this paradigm, the root causes of accidents pretty much broke down into three categories: bad luck, the well deserved result of stupidity, or something arranged by the mafia. Prevention efforts, to the extent they existed, were predicated on warnings such as “Watch out for drunken drivers,” “Don't drive too fast,” or “Don't talk to strangers with loaded pistols unless they have a police badge.” Fortunately for the duly warned but not particularly safe U.S. civilians of the 1960s, contemporaries of William Blaisdell endeavored to transform this concept of “accidents” and in particular motor vehicle “accidents.” Foremost among these, was a man whose name was familiar to me: consumer activist and former presidential candidate Ralph Nader, whose 1965 book, Unsafe At Any Speed, first brought him into the public spotlight. In this highly publicized work, Nader exposed the Big Three automakers'unconscionable resistance to instituting basic safety measures such as seat belts. While Nader grabbed the headlines, a physician named William Haddon Jr. focused on overhauling the basic conceptual framework of the topic.
Before researching this book, I'd never heard of William Haddon Jr., but as soon as I pulled some articles, I realized that this was not because of his deficiencies but rather my own. Haddon was the seminal director of the National Highway Traffic Safety Administration and the first person to champion the concept that there's nothing “accidental” about energy transfer causing traumatic injury. It didn't matter if the energy transfer was from a high-speed projectile or from rapid deceleration in a car crash, its interaction with human anatomy could be studied, and it could be modified. Accidents, Haddon argued, and car accidents especially, weren't unpredictable or random after all, and so when a vehicle hit a wall, it shouldn't be termed an accident but rather a crash. Furthermore, the outcome of that crash, in terms of human injury, was not inevitable but dependent on key variables such as speed, object malleability, and passenger restraint.
Haddon attempted to classify and study these variables using a conceptual tool that came to be known as Haddon's Matrix, a simple 3x3 grid identifying the factors leading to mortality and morbidity in trauma. One axis of Haddon's matrix listed three time periods: pre-event, event, and post-event. The other axis listed three physical components: human, vector, and environment. From his matrix, Haddon extracted ten conceptual strategies for injury prevention. It would be tedious to list them all here, but it is worth noting that half of them involved the event phase of injury and predominantly supported the idea of passive injury protection built into existing systems and not dependent on individual compliance. To illustrate, consider strategy number four, which recommends “modifying the rate of spatial distribution of the release of the hazard from its source.” This is a long-winded way of saying that an absorbed blow is less destructive, which of course is the concept supporting the use of airbags in a motor vehicle. Strategy number five suggests that we “separate in time or space the hazard being released from the people to be protected,” which quite simply means that the farther you are from the action the safer you are (e.g., a pedestrian on a sidewalk is less likely to be struck by a car than one on the shoulder.)
Today, Haddon's strategies sound like common sense, but what you must remember is that before him, American culture wasn't hip to prevention. Haddon's goal was to inspire a paradigm shift, to make prevention groovy, groovy in a long-winded academic way. And, I realized, in many ways he had succeeded; today we accept that there are strategies, such as seat belts, air bags, and highway speed limits that prevent or limit injury in car crashes. We recognize that crashworthy vehicles save lives and that federally mandated improvements in car safety were the single biggest reason that U.S. car occupant fatalities (per mile of travel) decreased by two-thirds between 1964 and 1990. So while further innovation and progress is possible, there is no doubt that road safety has dramatically improved in the past 40 years. But what about other forms of traumatic injury such as gun violence? Far from getting better, I found, this is a problem that has only gotten worse.
Every year nearly 30,000 U.S. civilians are eliminated by guns, making death by firearms the fourth leading cause of preventable death for those under 65 behind heart disease, cancer, and all other types of trauma combined. Homicide is a major component of the carnage; in 2001 alone there were 11,348 firearm homicides in the United States, and according to the Centers for Disease Control and Prevention, there are as many as 90,000 nonfatal gunshot wounds annually. While the total number of motor-vehicle deaths decreased 21 percent between 1968 and 1991 (54,862 to 43,536), firearm deaths rose 60 percent (23,875 to 38,317) over the same time period. Why, I wondered, has the problem of gun violence gotten worse? This is a complicated question that defies simple explanation, but it is nonetheless illuminating to view it through the lens of William Haddon Jr. Unlike many other types of trauma, injury from firearms is most effectively modified in the pre-event phase.
More than 50 fifty percent of gunshot wound fatalities are pronounced dead at the scene. This means that even if all citizens carried cell phones and could immediately call for help and even if that emergency response was proficient and a trauma center with the best possible care was nearby, post-event interventions could only decrease a community's firearm fatality rate by about half. Furthermore, event-specific interventions are limited and unlikely to garner public support. Bullets could be made with less mass and thus could be less destructive, or the momentum-producing powder charge of firearms could be reduced. But because the whole point of a gun is to be destructive, these aren't practical options. Body armor is effective (commercially available vests can stop anything up to a .38 caliber cold) and widely used by military and police personnel, but only the most paranoid civilian is likely to accept body armor as a daily wardrobe addition.
So this takes us back to the pre-event phase and the simple observation that no one dies from a shooting that doesn't happen. But is it possible to stop gun violence before it happens? Many gun control advocates say “yes,” and would argue that the Jeffrey Mains shooting would never have happened if the United States, like many other civilized countries, prohibited gun ownership. There is ample evidence to support this claim; many other industrialized countries have, per capita, far less morbidity and mortality from guns than we do. There are numerous possible reasons for this discrepancy, and the shoot ’em up nature of American culture is certainly one of them, but common sense argues that lax U.S. firearm laws also play a role. A complete ban on firearms in this country, while likely to improve the problem of gun violence, is politically impossible, and that's not likely to change in the near future. Are there other options? I asked William Blaisdell this question, and he suggested that I speak with one of my former emergency physician colleagues at UC Davis.
“The flow of guns from manufacture to criminal use is not random,” Dr. Garen Wintemute told me. “The bullet can be viewed as a pathogen, and there are patterns, analogous to a life cycle, that may allow for focused and more effective intervention.” Wintemute, with his sun-browned face and sleek ponytail, had always struck me as more of a river rafting guide than a doctor. I recalled him as an excellent physician — analytical and comprehensive — but also laid-back, so much so that he was often mistaken for a lab or x-ray tech. During my residency, he had been on leave on two separate occasions to recover from an illness, and although I respected his clinical skills and knew that he had done some public health research, I didn't know the extent to which he was a leader in the field of violence prevention.
I was surprised to discover that he was the author of Ring of Fire, a book detailing how a single Southern California family monopolized the cheap handgun market for decades. He'd also been honored by Time magazine as a “hero in medicine,” and is currently the director of the Violence Prevention Research Program at UC Davis. When we spoke on the phone, Wintemute's voice caught when I asked him about William Haddon Jr. It turns out that his own research career had been largely based on applying Haddon's conceptual framework to the problem of firearm violence. Later, when I asked him what key interventions short of absolute gun control could be instituted to limit gun-related injuries, he apologized and said that he would have to give me “a Haddon Matrix sort of answer,” one that focused on three basic categories of pre-event interventions. Some of his proposed interventions seemed obvious to me, but I reminded myself that, much like car safety before William Haddon Jr., obvious doesn't always mean appreciated. They break down like this.
First, said Wintemute, certain people shouldn't be allowed to have guns. Foremost on this list are teenagers, criminals, and the mentally ill. Even though many states have laws restricting gun ownership in these populations, they are extremely ineffective at enforcing them. A 1999 survey reported that 54 percent of high school students thought it would be “easy” for them to get a gun, and one of Wintemute's California-based studies found that the peak age for gun possession and arrest for firearm-related crimes was 18 to 20. You might expect that it would be impossible for a convicted felon to obtain a new gun, and in some instances this is true, but what about the guns he already owns? There are virtually no programs in place to divorce newly convicted criminals from their previously purchased firearms. That's fine if we're talking about someone with a life sentence, but what about a parolee with a history of violence or a youth like Joseph Ferguson who exhibits violent and erratic behavior (such as attacking a car with an ax)? In these cases, all we have to rely on is the hope of successful rehabilitation and parental oversight.
I don't know of anyone who would like the idea of an ax-wielding car assailant or a convicted felon with a stockpile of revolvers, but as far as I'm concerned, neither of these is as scary as a paranoid schizophrenic with an empty bottle of medication and a semiautomatic. Shockingly, there is virtually no cross-referencing of state registries of the mentally ill. A florid psychotic, recently hospitalized in California could, upon his release, simply travel over a state line and purchase a gun. According to Wintemute, it is because of information-sharing failures like this that laws mandating waiting periods for gun purchases have met with mixed results. A background check without the necessary background is really no check at all.
Not only should certain civilians be kept away from guns, certain guns should be kept from civilians. These include assault weapons like the AK-47, a weapon banned by Congress in 1994 (but which was allowed to lapse in 2004) and illegal in California since 1989. How did Joseph Ferguson obtain his? None of the numerous media reports covering the story answer this with certainty, and Ferguson isn't around to ask, but according to Wintemute, it “wouldn't have been hard” for any Californian to get an AK-47. Loopholes in federal law allowed gun manufacturers to make small modifications to their assault weapons, and then sell them legally at gun shows in many states, including those neighboring California. But while assault weapons like the AK-47 are disproportionately used in high profile shootings like Ferguson's and the Stockton, CA, school massacre that left five dead and 30 wounded, overall they represent a small percentage of crime guns. Perhaps it is more important to regulate cheap and easily accessible pistols, popularly known as “Saturday night specials,” that often end up in the hands of juveniles and young adults. Wintemute's research suggests that these types of guns are three times more likely to be involved in crimes, and a group of Johns Hopkins scientists estimate that Maryland's ban on Saturday night specials has resulted in a seven percent to 12 percent decrease in the state's firearm homicide rate.
A third and final category of pre-event interventions involves targeted law enforcement. Comprehensive research by Wintemute and others has identified certain types of gun purchasers and retailers who are linked to crime guns. Emergency physician and public health researcher Arthur Kellermann, MD, has written that “strategic firearms enforcement can block the chain of illegal events, including illegal demand, illegal supply, illegal carrying, and illegal use that leads to firearm violence.” Specifically, evidence suggests that many crime guns are initially obtained from resellers who use “straw” purchases in which surrogates (without criminal records) help them purchase multiple firearms. Close tracking and investigations of transactions involving multiple firearms would help identify straw purchasers and possibly interrupt the flow of guns to criminal use. Alternatively, multiple gun purchases could be restricted (e.g., one gun per person per month) to make straw purchases more of a hassle. It also turns out that certain retailers are disproportionately tied to crime guns. Wintemute found that 10 of 3500 retailers in California (0.2%) accounted for 13 percent of criminal firearms, and nationally one percent of retailers account for 57 percent of such guns. These statistics indicate that enforcement should be targeted toward a handful of retailers and that this could have a distinct impact on firearm crime. Prevention could also focus on high-density and high-risk environments where gun violence is more likely to occur and more likely to cause harm. Certain locales, such as airports and some inner-city schools, have already modulated risk by screening for firearms. These policies acknowledge the fact that disputes will occur but are often transitory. If a gun is not available in the heat of the moment, the prospect of serious injury or death is diminished. If enforcement of existing laws regarding carrying firearms were stricter in high-density areas and carried enough disincentive (such as confiscation of the firearm), then it is reasonable to infer that fewer disagreements would end in death or serious injury.
After speaking with Wintemute, I was convinced that some of America's gun violence was preventable, and preventable without strict firearm prohibition. Perhaps, with the right pre-event intervention, I concluded, Joseph Ferguson could have been stopped. If he had, it sure would have saved Jeffrey Mains a lot of suffering.
Eventually, after months of intermittent effort, I tracked down Jeffrey Mains. He was in Napa, his mother told me, living with a friend, studying art, and trying to start fresh. I called Jeffrey, and he said he remembered me, but didn't sound completely sure. That wasn't surprising, I hadn't seen him in three years, and even back then I'd never spoken with him for longer than the two minutes I'd allotted his case each morning. Nonetheless, he agreed to meet me at a coffee shop in a nearby strip mall.
Jeffrey Mains was a lot taller than I remembered and much more robust. His 6’5” frame had filled out, and his cheeks were rounded. His overall appearance was, however, softened by loose-fitting clothes and reddish-blond curls looping around a grey skull cap. The only outward sign of his ordeal was a hand tremor, a slight quake that began during his recovery. We spoke for quite a while, over hot chocolate and a tape recorder, and he told me how leaving the hospital to be at home with his mother had been immediately therapeutic. Within hours, his mood brightened, and within a day he was getting up from bed and walking to the dinner table. Food still passed straight through him, but at least he had had the will to eat it. Moving around continued to hurt, but at least he had had the will to walk.
After a week of being under his mother's care, he returned to the medical center to see Dr. Wisner. At first, seeing him standing in the lobby, Wisner did a double-take. Like me, he had never realized how tall Mains actually was. Mains remembered that Wisner told him he was doing well, that his weight was up a couple pounds, and that his abdominal incisions and scars were healing nicely, with just a minimal amount of drainage from the midline scar. By then, his anxiety was waning, and he was completely off the Valium and taking only Aleve for pain. Still, there was a lot to worry about, including $2 million in medical bills, repairs to his Toyota truck, and getting healthy enough to go back to work. And, there were times when he questioned the fairness of it all. “How could God do this to me?” he recalled asking his mother, and she'd replied, “I don't know why it happened, but don't blame it on God.”
Eventually, as our drinks cooled and the evening wore on, Jeffrey and I caught up to the present, and he told me that most of the restrictions that once ruled his life were gone. He could eat anything and do any sort of physical activity, although he had not returned to the basketball court. Tightness in his abdominal scars occasionally nagged him, but he was not embarrassed to work outside bare-chested. He didn't have much disposable income, but at least the insurance companies had paid off his $2 million in medical bills. Some months after the shooting, he recalled, “I realized how much this all messed me up…but it also forced me to focus on what I want to do with my life.” Jeffrey still dreamed of teaching art, as he did before September 2001, and now he seemed determined to make the dream a reality. He was interning with Don Hatfield, a well-known and successful impressionist painter, and taking community college classes to get his bachelor's degree. “Life goes on, life does go on,” he told me and he seemed hopeful — damaged but hopeful.
A year after our meeting, when I talked to Jeffrey Mains again, he seemed even better, although his career was not progressing as quickly as he would have liked. He had moved south to a small Sonoma County town called Cotati and was still in school, taking classes on Mondays and Wednesdays. The rest of the week he worked for a local butcher (a combustible chauvinist who yelled at his female employees and paid Jeffrey close to nothing), and drove to work in the same white Toyota 4x4 that had redirected Joseph Ferguson's bullet some four years before. He said he'd been writing about his ordeal for an English class, and while it had been freeing, writing had also caused him to break down several times, once calling his mother in tears.
Six months later, in August 2006, I heard from Linda Mains. Jeffrey was beset with recurrent and disabling panic attacks and bouts of severe abdominal pain. His doctor thought he was suffering from post-traumatic stress disorder, and he was back, after many years, on anti-anxiety medication, taking as many as 30 Xanax in a week. He had quit his job in Cotati, and was living at home with his mom in Sacramento, sometimes not leaving his bedroom for days at a time. I'd visited this home, a modest one with green shutters and a well-cared-for lawn, several months earlier to meet with Linda Mains and knew that the note Jeffrey had scribbled five years earlier, “We will make it,” was still framed on her bedroom wall.
Linda wasn't sure what had triggered her son's setback; maybe it was the impending five-year anniversary of the shooting. Or perhaps it was the cruel realization that his dreams were proving more ephemeral than he had hoped. Whatever it was, Jeffrey wasn't ready to talk about it, at least not with me. I scheduled a meeting with him and was afraid that I'd see a man in emotional retreat, a man still suffering from the bullet's yaw. But I needn't have worried, Jeffrey Mains didn't show, and didn't call either. I don't know why, but I'd like to think that it was because, five years later, he had decided once again to move on and not soak in the sour waters of the past. Or maybe the proposed date of our meeting, September 11, 2006, carried with it too much overwhelming sadness and pain. Either, way, despite his near-miraculous salvation and nearly full recovery, the Jeffrey Mains story remained bittersweet.