Tina Rosenberg
FIXES MARCH 20, 2018
Dr. Kenji Inaba outside the emergency entrance at the Los Angeles County General Hospital.CreditJake Michaels for The New York Times
Kenji Inaba is a trauma surgeon at Los Angeles County General Hospital and director of the surgical intensive care unit. He’s also a sworn reserve police officer, part of a two-man patrol in the Rampart Division of the Los Angeles Police Department. Between policing and doing emergency surgery, he gets a lot of exposure to gunshot wounds, both entry and exit — how people get shot, and how they get better.
In his police car he has a bag with basic medical emergency equipment, along with something that’s not so basic — a syringe called Xstat that is full of tiny, absorbent sponges to stop the bleeding from a gunshot wound. It’s one of several new and almost-new pieces of technology that can keep a shooting from becoming a murder.
We rivet our attention on guns when a mass shooting occurs. But those shootings make up only a tiny fraction of homicides. As for the rest, they are concentrated among young men of color. The gun death rate among white males is 17 per 100,000, with a vast majority suicides. For black males the numbers are 34 per 100,000, with a vast majority homicides. For black males between 20 and 29, the rate is 89 per 100,000.
Many grand reforms could help lower those statistics by addressing policing strategies, gun policies, institutional racism, police-community relations and the economic fortunes of poor neighborhoods.
But technology can also make a difference.
Most gunshot victims die of blood loss. Xstat is a new product that can stop the bleeding from penetrating wounds — from guns, knives, shrapnel, whatever — that are narrow and deep. It’s especially useful for wounds in the hip or shoulder, where tourniquets cannot be applied. Xstat’s sponges instantly absorb the blood and expand to put pressure on the wound. They’re physically tagged with a marker that will show up on an X-ray so that doctors can check that they were all removed.
Dr. Kenji Inaba outside the emergency entrance at the Los Angeles County General Hospital. Credit: Jake Michaels for The New York Times
Xstat was designed for and first used by the military. Will Fox, a spokesman for RevMedx, the company that makes Xstat, said that all United States Army Special Forces and Ranger medics carry two types of syringes — a fat tube version designed for exit wounds from high-velocity automatic weapons and a thin tube version, which works for entrance and other small wounds and is more appropriate for civilian use. RevMedx is also working on a version for postpartum hemorrhage, the leading cause of maternal deaths. Fox said that medical personnel in about 15 cities carry Xstat in their ambulances or employ it in trauma centers. Inaba, who has yet another job, as vice chairman of the Department of Surgery at the University of Southern California, is doing the first study of its use on civilians. (He has no ties to RevMedx.) He hasn’t used Xstat yet while out on patrol — he hasn’t seen appropriate wounds — but he and his team have used it 14 times in the hospital.
“It works, Inaba said. “It’s a simple mechanical device. We’re very selective about who’s gotten it, and it stops the bleeding. It fills a relatively specific niche where there isn’t a good alternative right now.”
Xstat has drawbacks as well. “You have to pick all the pieces out, and you never know how many there are,” Inaba said. “So everyone has to have an X-ray. And in 20 to 30 percent of cases, you can expect to see a sponge retained. And then there’s one more X-ray.”
Another issue is price. A tourniquet costs $27 and can be used repeatedly. Fox said the price of the small Xstat is now $80, down from $120 — and it’s not reusable.
“They’re going to have to drop their costs in order for it to be appropriately used,” Inaba said. “To equip every single ambulance with something that sits on the shelf in the vast majority of cases, that’s a huge cost outlay. I think that’s excessive.”
Xstat is one of several innovative products that stop bleeding. The British company Celox Medical makes granules and gauzes impregnated with chitosan, made from shells of shrimp and crabs. They form an effective emergency plug when packed or poured into a wound. They can be used for more kinds of wounds, on more places on the body, than Xstat. But they take longer to stop bleeding, the powder is hard to use anywhere there’s wind, and they aren’t good for treating gunshot wounds that spurt blood from a nicked artery or vein — a task Xstat can do.
Speed matters for gunshot wounds. A slow response can mean not only that victims die, but also that evidence and eyewitnesses melt away.
That is a problem. In a large majority of cases, the police never find out about shootings; researchers looking at Oakland, Calif., and Washington found that only one in eight gunshot incidents are reported. (Homicides are well reported, but fortunately, 99 percent of shootings don’t kill anyone.)
When people do make a call, it can be after precious minutes are lost to debate about whether what they heard was a gunshot. And callers often can give the police only the vaguest description of the direction the gunshot noise came from. So the police drive around the area. If they find nothing suspicious, they might sit in their car with the lights out for a while to see if anything happens. If they do happen upon a crime scene, of course, they will be going in blind, which is always dangerous.
What could help is technology that instantly reports gunshots and their location. In fact, it already exists and is provided by a company called ShotSpotter. More than 85 American cities and Cape Town, South Africa, use it — some across the entire city, many just in high-crime areas. New York City has 57 square miles covered by ShotSpotter.
Cities lease the technology and services, and the company puts up acoustic sensors on buildings and lampposts. They can pinpoint the location of a shot by how fast the sound reaches different sensors. Machine algorithms and then a panel of human acoustics analysts sitting in California look at the sound patterns and determine whether it’s gunfire — and if so, how many shots and whether automatic weapons are involved. The police get the audio file and location, to within 27 yards, on their cellphones or car computers within 45 seconds of a shot.
“Before it was ‘my best guess is down the block somewhere,’” said Brian Foley, the deputy police chief of Hartford. “ShotSpotter puts us within meters and sometimes within the foot, and it does not sleep. It’s a much more accurate picture.”
ShotSpotter has critics. It is expensive — $65,000 to $85,000 per square mile of coverage. (Some cities get Justice Department or other federal grants to pay for it.) Before 2011, computers made the determinations alone, and often mislabeled other noises as gunshots. But since humans entered the process, it has become much more accurate.
It’s easy to see how ShotSpotter could save victims by providing paramedics with faster and more accurate location reports. But how — and even whether — ShotSpotter also reduces shootings hasn’t been proved. “There haven’t been any rigorous studies of the impact of ShotSpotter,” said Jennifer Doleac, an assistant professor of public policy and economics at the University of Virginia. One reason is the company goes to extraordinary lengths to keep cities from releasing their ShotSpotter data.
Some cities have seen large decreases in shootings after using it, but they are often making other changes as well, and it’s hard to say what role ShotSpotter played. The company points out that since 2011, about 10 times more cities have expanded their ShotSpotter coverage than have ended it.
One way the technology could reduce crime is by giving police accurate data. If a police department knows the number, location and time of shootings, it can test crime-control measures: Did the night basketball program reduce shootings? Also, the police can focus their resources: Once it’s known that a particular corner has lots of gunfire at midnight on Fridays, they can better patrol it.
Hartford is planning to send not just police officers and paramedics to the scenes of shootings but — as soon as the area is secure — therapists as well, to work with children who heard or saw the shooting.
“It tells us where we need to patrol,” Deputy Chief Foley said. “But it’s also going to tell us where the most traumatized neighborhoods are — the kids most likely to have mental health concerns down the road, and most likely to be in the criminal justice system.”
Having the audio file and an exact location also tells the police more about what they’re walking into, which keeps them safer.
Foley believes that ShotSpotter has helped Hartford’s police to solve crimes; the clearance rate has jumped to 65 or 70 percent from 35 to 40 percent, he said. “We’ve done more than use the tech, but it’s absolutely helped,” he said.
ShotSpotter’s audio files are admissible in court. If a city has video cameras, the sensors can activate and point them. The location accuracy allows the police to get out of their car and look at a small area. That way they have a better chance of finding shell casings, which can tie the shooting to a specific gun.
The police can arrive while witnesses are there, and they can interview witnesses differently. Instead of asking “What happened?” they can say: “There were three shots right across the street. What did you see?”
The technology can also strengthen the relationship between the police and the community. All those unreported shootings? Local people don’t know they’re unreported. They will just assume that the police didn’t show because they didn’t care. And that helps to normalize gunfire. “That has all kinds of bad consequences,” said Ralph Clark, ShotSpotter’s chief executive.
Clark grew up in a high-crime area of Oakland but now lives in a safer neighborhood. “If someone fires a gun in the place in Oakland I live now, I definitely expect the police to show up,” he said. “They knock on doors to make sure people are O.K. That’s exactly the same way they should respond in the community I grew up in.”
Tina Rosenberg won a Pulitzer Prize for her book ”The Haunted Land: Facing Europe’s Ghosts After Communism.“ She is a former editorial writer for The Times and the author, most recently, of "Join the Club: How Peer Pressure Can Transform the World" and the World War II spy story e-book “D for Deception.” She is a co-founder of the Solutions Journalism Network, which supports rigorous reporting about responses to social problems.
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