Isiah Hester was on his way to get a haircut when he got shot.
As he was walking down the street from his house, a man stopped him to ask the whereabouts of one of Hester's friends. After he said he didn't know, the two exchanged some words.
"I didn't even see him pull out the gun," Hester said.
Four shots rang out, piercing the routine of a Thursday afternoon on Arnett Boulevard. Hester didn't even realize he'd been shot until he turned to run and his leg gave way beneath him. One of the bullets had struck him in the upper right thigh.
Now, some nine months after the incident, the 15-year-old says he remembers the flurry of activity on the street that afternoon in the moments that followed, and the rush of first responders who helped to get him to the hospital.
But more than anything else, Hester remembers the sight of blood pouring from the wound in his upper thigh.
"I was bleeding a lot," he said. "There was a lot of blood."
For most gunshot victims, the loss of blood is the biggest immediate threat to life. Shock can set in quickly, followed by unconsciousness and death. If the femoral artery, a large blood vessel in the thigh, is severed or even nicked, that can happen within a matter of minutes.
Even though he wasn't in a lot of pain, Hester knew the seriousness of the situation. If he didn't get help quickly, he would bleed to death right there on the sidewalk.
"I was worried that I wasn't going to make it," Hester said. "I could've died."
Survival rates rising
Improvements in trauma care over the last decade have helped lead to better outcomes for people like Hester who are the victims of shootings, stabbings, or other violent assaults.
A joint study between Howard University and Johns Hopkins University found that the percentage of shooting victims who died from their wounds has been dropping during the last decade. Local numbers show the same trend.
There have been no definitive studies to quantify the relationship between emergency medicine and the recent decline in homicides. But if you ask law enforcement officers or others on the front lines of crime fighting, they'll say better care by trauma surgeons is the major difference-maker.
"That's what we tell them," jokes Dr. Mark Gestring, director of Adult Trauma at the Kessler Burn and Trauma Center. "But really, it's a number of things."
Gestring says that many of the changes that have occurred have been systemic improvements, starting with better communication and cooperation between staff at the trauma center, paramedics who are transporting patients, and even the police who are the first to arrive on a scene.
Many of those improvements were prompted by lessons learned on the battlefields of Iraq and Afghanistan, where there was a concerted effort to collect and analyze data about patient outcomes. That research showed that the biggest factor in whether soldiers survived gunshot wounds was how quickly they got to a trauma surgeon.
Navy Surgeon Richard Jadick, an upstate native, wrote about those lessons in his book On Call in Hell: A Doctor's War Story. He described his frustration at seeing a soldier die because he'd lost too much blood by the time he arrived back at the base hospital. Transport time, particularly in a combat zone, was just too long, so Jadick decided he needed to get closer to the fighting.
He and his team moved as close to the front as they could during the Battle of Fallujah in 2004, one of the deadliest operations of the Iraq War.
"It took Fallujah to turn theory into practice and to demonstrate the effectiveness of our approach," Jadick wrote. He shared those results with other military doctors, as well as those in the private sector.
"The one that means the most to me and to all those who made it possible is that an estimated thirty Marines who otherwise would have perished in Fallujah were able to make it home to their families."
Quicker response times
Gestring says there's no doubt in his mind that those lessons are paying dividends in Rochester.
"The techniques for managing gunshot wounds and acutely bleeding patients are much better and I think we do have better survival now than we did 10 or 15 years ago," he said.
One of the areas where there has been major improvement is techniques to control bleeding in areas that are difficult to apply pressure, such as armpits, groin or the neck. The use of new kinds of packing materials and clotting agents has had a significant impact.
Improved response times are also important, ensuring that patients get to the hospital as quickly as possible.
Hester was fortunate that there was a medical clinic about 100 feet from the corner where he was shot. A friend carried him inside to get immediate help, and an ambulance arrived soon after.
Within minutes, Hester was on a table in the emergency department at Strong Memorial Hospital, under bright lights in a room full of doctors and nurses. They cut off his clothes so they could assess his injuries. Hester recalls being embarrassed at being naked in front of so many strangers, but he knows their quick work likely saved his life.
"Thank God for those people. Otherwise I could have bled to death," Hester said.
One of the battlefield lessons was to spend less time stabilizing patients at the scene and focus on getting them to the surgeons as soon as possible.
"We joke and say that the most important resuscitating fluid in a gunshot wound patient is diesel, that they should step on the gas and get going," Gestring said. "The quicker they can get to a trauma center the better."
But it also means better communication, not waiting until an ambulance pulls up at the emergency department to let doctors know what's happening. Paramedics and EMTs start talking to the trauma center from the scene, allowing staff to make preparations and have everything in place when the stretcher rolls in the door.
"It's not uncommon to see two or three people shot at the same scene who come in very close together," Gestring says. "When we hear there are two or three victims coming in, we prepare differently."
Having those plans in place has made a difference on the nights when Gestring and his colleagues have had to work on multiple gunshot victims at the same time.
"The one we think back to was the Boys & Girls Club shooting, which was bad but could have been worse," he said. Three people were killed and four seriously injured in a drive-by shooting outside the facility in August 2015.
"We could have easily had seven homicides that night," Gestring said.
Paramedics set the stage
An ambulance sits in the parking lot outside a convenience store at the intersection of Lake and Ridgeway avenues in northwest Rochester. The paramedic and EMT inside are not simply passing the time: They're at a designated staging area, one of many locations across the region identified after an intense data analysis of the time and location of calls received.
Staging ambulances across the city this way has helped reduce the length of time it takes first responders to get to the scene of a medical emergency. That strategy has made a difference, according to Chris Gray, clinical supervisor and chief paramedic for AMR, which provides ambulance service in the Rochester area.
"We used to talk about 'the golden hour' in the '70s and '80s, that you needed to get the patient to the hospital within an hour if they were going to survive," he said. "Now we're thinking about much shorter times."
Getting from the scene to the hospital quickly is important, but getting to the scene in the first place is critical. One of the most important tools has been the ShotSpotter program deployed by the Rochester Police Department. It uses an array of microphones to detect gunfire in real time. Within seconds, it sends an alert to police, paramedics and the staff at the trauma center, setting everybody into motion quickly.
Once on the scene, paramedics and EMTs are working to get the patient loaded up as quickly as possible. The goal is to keep scene times to less than 10 minutes, from the time the ambulance pulls up until it heads out. It's often less if there is not a complicated extraction, such as carrying someone down flights of stairs or cutting him or her out of a damaged vehicle.
The priority is to deal with bleeding and breathing, Gray explains: Stop the bleeding and make sure they're breathing. If that work can be done while the ambulance is en route to the hospital, all the better.
From most parts of Monroe County, transporting the patient to the trauma center takes less than 15 minutes.
"It's all about getting to the hospital quickly to fix the problem," Gray said.
One of the major changes that made its way from the battlefield to the streets of Rochester was the aggressive use of tourniquets. These devices help completely cut off the flow of blood to arms and legs by applying strong pressure to a limb. It's a technique that had fallen out of favor because of concern it could cause tissue damage.
"We'd say, 'The limb can't survive very long without oxygen and blood,'" Gray said. "Well, neither can the patient."
Blood loss can occur rapidly, especially if a gunshot wound strikes a major artery. Minutes often mean the difference between life and death, and Gray says the use of a tourniquet can be a temporary fix, allowing the patient to survive long enough to get to a surgeon.
"We've had several cases in the last year where the use of a tourniquet definitely saved somebody's life," Gray said.
D&C Digital watchdog reporter Sean Lahman tells Virginia Butler the back story about why more people are surviving gunshot wounds in Rochester. Sean Lahman, Virginia Butler
While these improvements have saved lives, it does not mean that stabbing and gunshot wounds aren't often fatal. Nor does it mean that there are no long-term consequences for those who survive.
"If you get shot in the head, chances are pretty good you're not going to survive," Gestring said. "If the bullet truly went through the skull and impacted the brain, those are frequently non-survivable injuries."
Patients with gunshot wounds in their torso face a more uncertain path.
"Ones that impact the abdomen, from front or back, those people almost always need surgery, the quicker the better. The outcome depends on what organs get hit," he said.
Gestring says that they frequently see people who are shot who are not out of the hospital for weeks, and then not back to regular activity for months, if at all. For those who survive, many find that their daily lives are irrevocably altered, even as the reports simply summarize their injuries as "non-life-threatening."
"It's actually a pet peeve of mine," he said. "We see bullets going through spinal cords all the time. Those are still considered to be non-life-threatening injuries when you write about them."
Hester also says he bristles at people who think his getting shot was not a big deal because he looks fine today. Doctors told him the bullet missed a main artery by 3 inches, and his recovery was long and arduous.
"When I left the hospital I didn't know how to walk," he said. It took months of physical therapy and a dedicated workout regimen for him to recover well enough to regain his skills on the basketball court.
He did that, but last October he walked away from his high school hoops team to take a job with Teen Empowerment, sharing his experience with his peers. He hopes that when they hear the story of what he's gone through, it can inspire them to better insulate themselves from the dangers of a neighborhood ravaged by poverty and violence.
"When you are surrounded by so much negativity, by drug dealers and gang bangers, you become accustomed to it," he said. "Even if you're not involved with those things, it's around you and you're going to get what comes with it. I got what comes with it."
Hester says he focused on being positive and productive. He's doing well in school, hoping he can go to college to study culinary arts.
"Getting shot was a wake-up call," he said. "If you keep putting that alarm on snooze, sooner or later, you're the one that's gonna be snoozing."
Survival rates for gunshot victims rising
A joint study by Howard University and Johns Hopkins University found that the percentage of shooting victims who died from their wounds has been dropping during the last decade.
The study found that in 2010, 13.96 percent of U.S. shooting victims died, almost 2 percentage points lower than in 2007. Their data also found a decrease in the mortality rate for victims admitted for stab wounds.
The local data reflects that same progress: In 2007, 194 individuals were shot in the city of Rochester and 39 of them died as a result, roughly 20 percent. A decade later the fatality rate was just under 11 percent — 225 shooting victims and 24 resulting deaths.