The first priority is to operate to stop the bleeding and control any contamination that might arise from something like a torn intestine. Afterward, hospital staff members wheel the patient from the operating room straight to intensive care, often with the abdomen still open.
The next steps are to seal small blood vessels that may be torn and then to operate, if necessary, to permanently repair damage.
A gunshot victim may undergo two to 10 operations, said Dr. Jeremy Cannon, a trauma surgeon at the University of Pennsylvania, and may remain in the hospital anywhere from days to several months.
Still, the results are far better than in the old days, before the early 1990s, when surgeons tried to do all the repairs at once, operating for hours at a time.
In a study that changed medical practice, surgeons found that trauma patients with the most severe abdominal injuries who received one long operation had just a 15 percent survival rate. But those with the same sort of injuries who got multiple operations to repair the damage had a survival rate of 77 percent.
The lesson for surgeons is that long operations can be fatal to trauma patients. “The body can only take so much,” said Dr. Thomas Scalea, a trauma surgeon at the University of Maryland School of Medicine. Surgeons now employ the multistage approach.
These days trauma patients who do not bleed to death right away usually recover, said Dr. Sean Montgomery, a trauma surgeon at Duke University.
Patients with gunshot wounds through the abdomen may need as much as 10 units of blood — two-thirds of the entire amount in the human body. “The most immediate threat to life is bleeding to death,” said Dr. Alok Gupta, a trauma surgeon at Beth Israel Deaconess Medical Center who is not familiar with Mr. Scalise’s specific injuries.
In the first procedure, as surgeons open the patient’s abdomen, they look for and repair injuries that cause tremendous bleeding, like rips in large arteries and veins. Often, doctors temporarily stanch the blood flow by packing the abdomen with sterile absorbent sponges; later they will go back and do a surgical repair of other organs.
In the initial operation on a patient with abdominal injuries, surgeons also look for damage to the large and small intestines. These injuries can lead to sepsis, widespread infection of bodily tissues, if not immediately repaired.
If the holes in the intestines are small, surgeons can sew them shut. If they are larger, doctors must make a temporary fix; they might remove a segment of the intestines. Later they will carefully reconnect the sections.
In this first pass, where the priority is damage control, time is of the essence.
In the next operation, surgeons usually turn to repair of small blood vessels. Doctors cannot easily fix them in the first operation — there are just too many in the blood-rich abdomen.
The patient is taken to an angiography room, where a doctor threads a catheter into the abdomen and injects a dye that makes the blood vessels, and any leaks from them, visible on X-rays. Then the doctor plugs the leaks with small coils.
Additional procedures will depend on the extent of the patient’s injuries, surgeons say. If there are injuries to organs the patient can live without, like the spleen or one of the kidneys, they might remove them in a subsequent operation.
If there are injuries to major organs, like the bladder, surgeons try to repair them. If necessary, surgeons may cut out a portion of an intestine that was injured.
If they inserted plastic shunts to temporarily reroute blood around leaks in major vessels, they will go back to make a permanent fix.
Broken bones, Dr. Montgomery said, are often simply washed clean to prevent infection. Sometimes, surgeons insert plates and screws in the bones.
The result of this multistage approach is that trauma patients with abdominal injuries often receive operation after operation.
Many stay in intensive care until the abdomen can be closed and their condition is stable. That may take days or even a week, often with patients on ventilators, getting multiple blood transfusions.
In major cities, this situation is all too routine. On any given day, the average trauma hospital will have patients with abdominal wounds in intensive care, their abdomens still open after an initial operation. Even if their abdomens are closed, they tend to need multiple operations to repair fractures or other injuries. All too often, they are shooting victims.
The University of Maryland’s trauma center, in Baltimore, admitted seven gunshot patients on Monday alone, Dr. Scalea said.
“It’s a sad commentary on life in the United States,” he said.