Tracing the Bullet

I’ll never shake the sight of that glint of metal. The bullet shimmered in chokecherry red blood beneath the surgical lights, twin moons suspended in sterile air. Layer by layer, we sutured the patient up, mending what we could after the bullet reverberated through his body.

Over the next week, I helped coordinate the patient’s postoperative care across half a dozen specialties. The internists managing fluids and pain, the neurosurgeon interrogating spinal cord function, the psychiatrist brought on board to manage the psychological trauma often following its physical corollary. Nephrologists, cardiologists, urologists: they were all essential in saving and rehabilitating his life.

And yet, as the specialists discussed the particulars of mesenteric avulsion repair, I found myself drifting to a question farther away, beyond the hospital and its machinations: where did this bullet come from?

This bullet, an entity whose sole purpose is to crush and lacerate. I thought about its heat: boring through nerves, shattering vertebrae and radiating shrapnel into the astral depths of his abdominal cavity.

I contemplated the clock, running in reverse. Jigsawed bone settled back unto bone. A plume of smoke, dissolving into invisible dust. A flash of metal back into cartridge. At last, a bullet reposed in its cloister, an electric hum enshrined in blue-black darkness.

Lifting off the trigger is a rough and callused finger belonging to a man named Corey,^* come undone after years of stress. A man struggling to find a job stable enough to feed small mouths, to keep his PTSD at bay. A man once a teenager who cycled in and out of “juvie," whose heart weighed heavy each time the blue lights flitted across bedroom curtains. A teenager once a child, an emotionally abusive mother and absent father his only shades of refuge.

As a student, I was lucky to have the time to uncover these glimpses of his story. But rarely in medicine are we really able to trace the arc of bullets, or myocardial infarctions, or fulminant liver failures. So much of our attention is spent mending bodily and psychic injury, it is little wonder we lose sight of the cascading factors that lead human beings into states of illness and disrepair. We also run the risk of ignoring the social and environmental contexts that people move through before ever becoming patients. In earnest, I resisted the temptation to reduce Corey to a problem list, the pressures of preceptor evaluations and ticking clocks ever present.

Throughout training, I have found myself drawn to that “what if.” The missed opportunities. The counterfactual realities. Perhaps that is why I find such a spark in primary care, where we sometimes have the chance to apprehend a looming illness in its tracks. Unfortunately, much of our health care system is designed to provide sick care, largely driven by profit-oriented financing mechanisms that valorize the problem lists above those who bear them. Rather than attending to the environmental, social, and structural conditions that create physiologic dysfunction, we wait until the natural compensatory mechanisms of human bodies fall into disarray before affording our patients the resources that might help.

It is clear that the bulk of our efforts as health care workers fixates on present management—the mending of wounds, the palliation of suffering. Yet I ponder another world, where our conception of time broadens beyond our patients’ symptoms in the here and now. How can we reimagine the responsibility of our care as transcending beyond today, to yesterday? And even tomorrow?

Altering the course of time would not have prevented every situation like Corey’s. Yet when we outline the events that allow tragedies like Corey's suicide attempt to occur, we discover layers of opportunity where coordinated clinical and social intervention could have bent the trajectory, just enough. A coalition of community and health leaders could have identified firearm violence as a public health threat in his community. They could have developed strategies to foster mental health in schools or churches, investigated why his neighborhood was subject to so much policing. They could have helped ensure youth in impossibly fraught circumstances, like Corey, didn’t fall through the cracks.

Although he survived his immediate injuries, deeper wounds remain—untouched by scalpel, among the cells and spirit. Corey and his family carry a lifetime of burdens—physical, psychological, and financial alike.

This morning, as our team plans for discharge, his callused hand grabs onto mine, “I just gotta figure out how I’m going to heal myself.” He is alive, yes, though not yet healed. For Corey and far too many others, the hands of time continue to tick.

But it is not too late for us, we providers and healers. It is not too late to change. In addition to repairing states of pathology, we can involve ourselves in the difficult work of dismantling the clock. To care for our patients’ past, present, and future is a heavy task, for certain, but it may be the truest path to the healing so many desperately seek.

^*Patient name and certain details have been changed to support confidentiality.