‘Sometimes You Hear the Bullet’

“Sometimes You Hear the Bullet” is the title of my favorite show from the first season of M*ASH. In this episode, Captain Hawkeye Pierce realizes that war is not something distant or abstract but something close enough to make a whizzing sound as it touches those we love. Sometimes, unfortunately, we hear the bullet.

I am an emergency physician with Cottage Hospital and a professor at UCSB. I had the burden and the privilege of working in the emergency room the evening of May 23, 2014.

It was a terrible night. The emergency department was busy before the first shot was fired. The crisis of emergency department “overcrowding” is not a word to those in emergency health care and response; it’s a daily reality. The waiting room was full. Our doctors, nurses, and technicians were scurrying to keep up with the overwhelming pace. We never turn any patients away. Throughout the country, emergency rooms are a safety net for the most ill, the most critically injured, the mentally sick, and those with nowhere else to go. As our health-care crisis escalates, more and more people are without options and come to the emergency department suffering and in need of care.

In that moment when a gunman attacked our community, our emergency room was already busy: Every room held critically ill patients, patients on gurneys were parked in the hallways, the waiting room was packed with coughing, aching, and hurting people counting the minutes to be seen.

A phone call came in from EMS (emergency medical services). It was a heads-up. There was an active shooter in Isla Vista, unknown how many injured. We looked at each other in a brief moment of silence. It was an MCI or “mass casualty incident.” We knew what to do. We needed to clear rooms and get ready for incoming wounded. We called in help. We quickly sent patients to other departments in the hospital or sent them home ― anything to open up a room in the ER for incoming injured. Our minutes were precious, and we used them sparingly in preparation for what was to come.

The medic radio rang. The first patient. The second patient. The third. The fourth. The fifth. They kept coming. Our trauma surgeons were already in the ER, and the operating-room staff was ready by the time the first ambulance arrived. The hospital rallied around us. Physicians came in on their night off. On-call doctors came in before we called. One colleague sent a text message: “Do you have anything for me?” I replied, “Not yet. But they are coming.” And he said, “I am on my way in to help.” And that was the most common reply of the evening … I am on my way to help. A testament to the commitment of our local medical community.

At one moment, I was taken by the calmness of it all — our doctors, nurses, techs, paramedics working in synchronized poetry. There was a grace about it that words cannot capture. Each person doing his or her part with professionalism, compassion, competence, and solidarity alongside the colleagues next to them. No pee breaks. No coffee breaks. No sitting down. A dissonance of noise in the background — ringing phones, radios, whistling alarms, familiar voices asking to hang blood or give medications. The enormity of the tasks in front of us. That night we took care of our community. We did what we were trained to do as a team. We did it well.

A special recognition needs to be made of the brave men and women who work on ambulances. As the situation evolved, our dispatchers struggled to get law enforcement, fire, and EMS where they needed to be. Unlike other active-shooter incidents, our situation involved a shooter in a car. He always seemed to be one step ahead of where our dispatchers were sending help. Paramedics and EMTs confronted some of the toughest circumstances people in our line of work can face.

I will always remember one of our EMTs who had a horrified look on her face after dropping off a patient. She said, “I hope they don’t send me back there.” And then her radio chimed. Like all our paramedics and EMTs, who took exemplary care of patients and remained calm in the shadow of immense adversity, she went where she was dispatched, back into the chaos. If Hemingway was right, and courage is grace under pressure, then I can think of no better symbols of courage than the women and men of EMS who went into harm’s way to care for patients, delivered them to the safety of the hospital, and then went back in to do it again.

There is a vague concept of time in emergency. A meditative clarity of having a great challenge in front of you that must be met as the surrounding world shrinks into insignificance. What were hours felt like minutes. We got the word from the incident commander on scene. There would be no more injured coming from Isla Vista. As quickly as it started … it ended. Without missing a beat, we turned our attention to the waiting room, which had grown in population over the last two hours ― the patients who had no connection to Isla Vista but were in the waiting room. Back to a routine Friday night in the ER.

Some of us have experience working in busy trauma centers. In Atlanta, Georgia, where I did some of my training, six patients with gunshot wounds over the span of an hour was nothing unusual. The reality of that dark truth is subject for a different dialogue. In my career, I have made too many haunting phone calls to worried parents in the middle of the night, but this time I had to remind parents not to listen to the radio as they drove to Santa Barbara. Isla Vista had made the world news. At about 3 a.m., one of our techs asked, “I live in Isla Vista. Is it safe for me to go home?” Some of our hospital ER staff and EMS personnel live in Isla Vista. Some coworkers are UCSB students. Some are alumni of the UCSB sorority that was attacked. This night was different. We heard the bullet.

About 5 a.m., sitting on my porch after a tough night at work, the immensity hit me. I teach a seminar at UCSB with 200 enrolled students. Were any of the deceased my students? I help run a nonprofit that provides medical care to the homeless with 150 student volunteers, most living in Isla Vista. Were any of the deceased one of our volunteers? As an educator, had I given a lecture to an audience that included the perpetrator?

I had spent my career working in inner-city trauma centers and war zones. I had taken care of people shot in gang violence, shot in ethnic cleansing, shot in war; the victims seemed from a different world. But this time, our community had been attacked. Our students were the victims. This was not supposed to happen in our Santa Barbara. This is not supposed to happen anywhere.

In emergency care, we have hard nights. That is part of the job we all sign up for. We shake it off and return to work. The ER that next evening was the same ER that I have grown to love. But something had changed. We felt a stronger connection. We told awful jokes. We shared junk food. We supported one another. Cottage Hospital had coordinated an incident stress debrief, which many of us participated in. We continued to take excellent care of our Santa Barbara because healing others is oftentimes the best way to heal ourselves. Whether or not we admit it, that night affected all of us. Rule #1, take care of the patient. Rule #2, take care of each other. Always do both.

Over the next few weeks, I was left with haunting questions. Questions that remain unanswered.

Why is it so much easier and so much less expensive to acquire a firearm and large quantities of ammunition than it is to get an appointment with a mental-health professional within three months? Why is the wait longer to see a psychiatrist than to acquire a gun?

Why are there so many more discount gun stores than psychiatric hospitals and mental-health clinics in our country?

Would a well-armed Isla Vista, armed teachers, armed students, or armed fire fighters and EMTs make the body count higher or lower?

Why do we invest so little in mental-health surveillance and mental-health interventions in our schools? Why do so many of the perpetrators slip under the radar? Why are we so often caught off guard?

For all my friends who are responsible gun owners, how do we keep guns and ammunition out of the wrong hands? Would a tax on ammunition to fund mental-health resources be reasonable? What if it were necessary to have certification of having met with a mental-health professional prior to obtaining a permit to purchase a gun?

Why is there so much hate and anger in our society that drives young men mad with feelings of isolation, hopelessness, and rage? What can we do as a community to limit people acting out this anger with violence?

Six months ago, I was in the Democratic Republic of Congo; I was part of a team collecting data predicting whether the rebels were rearming to prepare for another wave of ethnic violence. We interviewed nurses in rural clinics who described how armed groups inflicted machete wounds, gender-based violence, and gunshot wounds to the villagers to inspire terror. One of the nurses asked, “Dr. Jason, do you know what it is like to have an armed man come into your village and kill the women?” Yes, I do. It is unacceptable.

My final question, one year after this event: Why did we stop talking about it? Sometimes it takes hearing the bullet to remind us that events such as this should never happen. And yet they do happen … over and over again. We must do what we can to prevent these acts of violence from ever happening again. This incident affected us all. Please continue to talk about it. And maybe the dialogue will progress to action and then to change. Not one more.

A special thank you to our brave men and women in EMS, fire, law enforcement, 9-1-1 dispatch, and emergency health care who stand ready, capable, and willing to care for our community during its darkest hour. It is an honor to serve our Santa Barbara alongside you. Thank you. What you do matters.

Jason Prystowsky MD, MPH, FACEP is an emergency physician at Santa Barbara Cottage Hospital. He is also medical director for Doctors Without Walls – Santa Barbara Street Medicine and the Santa Barbara City Fire Department. As a visiting assistant professor at UCSB, he teaches a seminar on Underserved Medicine in the Department of Interdisciplinary Studies.