Behind the story: ‘What bullets do to bodies’ by Jason Fagone

Gunshot victim Lamont Randell, shot twice during a robbery, begins his long recovery process. Photo by Finlay MacKay for Highline.

Senator Chris Murphy, a Democrat from Connecticut, took to the floor of the Senate late last month. As he stood next to a placard adorned with photos of faces, clustered around the hashtag #VoicesOfVictims, Murphy told his colleagues about a story published a day earlier—“What Bullets Do To Bodies” by Jason Fagone in Huffington Post’s longform vertical Highline. He continued:

We don’t like to talk about that a lot because, you know, the popular image of a gun today almost is divorced from its actual function. People collect them, people buy them in order to convey a certain image or lifestyle. … But very few Americans actually understand what these guns are designed to do. They’re designed to kill people. They’re designed to hurt people gravely. And in particular the AR-15, and AR-15 variantsthey’re dedicated to killing people as fast and as gruesomely as possible.

And then, for several minutes, Murphy read the story to his colleagues, and into the Congressional Record.

“What Bullets Do To Bodies” is a hybrid: Primarily, it’s a profile of a trauma surgeon named Dr. Amy Goldberg. But it’s also a detailed examination of how bullets devastate human flesh. Fagone conveys the damage and the pain to a degree that is remarkable:

During trauma surgery, when the blood flow is redirected to the brain and heart by an aortic clamp, blood goes away from other areas, and tissue in the lower extremities can die, causing gangrene, in which case surgeons must amputate the leg at higher and higher points, first at the shin, then at the knee, then at the thigh, to stay ahead of the necrotic tissue as it spreads.

The story has been unusually well read; Huffington Post told CJR it was one of Highline’s highest-trafficked stories of the year, at more than million readers. And yet, massive traffic aside, “What Bullets Do To Bodies” fits comfortably into the Fagone archive. He’s that increasingly unusual breed: a generalist freelancer, whose subjects range from teen mathletes to swatting and Urban Outfitters.  (He also writes books; the latest, The Woman Who Smashed Codes, about the American codebreaker Elizebeth Smith Friedman, will be published by HarperCollins on September 26.)

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What follows is another installment of Behind the Story, in which we’re given a peek behind the curtain at how a story was conceived, reported, written, and edited—as told to CJR by the author, Jason Fagone.

***

Four or five years ago, I was out with friends, one of whom had been a city prosecutor. He worked on gun cases, and we got to talking about them. He said if I really wanted to know about gun violence in Philly I should spend a weekend at Temple University Hospital and watch them treat shooting victims. The doctors, he said, were amazing: People would walk in with these incredibly grievous injuries; the doctors did their thing, and the patients lived. I thought this would be worth investigating because I’m local. It made sense to know more about the city’s gun epidemic.

I thought, well, it would be really tough to do because it’s difficult to get access to report in hospitals. So I put it in the back of my mind. Then, a couple of years ago, Dr. Amy Goldberg was named chair of the surgery department at Temple. She’d been a trauma surgeon there for 30 years. And I wondered how many women have that high position at American hospitals. Not a lot, it turned out; she’s one of 16. More recently, I started following Temple’s trauma outreach coordinator, Scott Charles, on Twitter. He’d debate gun proponents on Twitter, which is something I have no desire to do. I saw that he organized programs at Temple where he’d go out in a community and talk about gun violence. So all the elements of a story were there: a person who has been doing the work for 30 years; a program at the hospital that’s committed to actually talking about gun violence in an unusual way; and, hopefully, access.

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My own views on guns are completely run-of-the-mill. I’ve always been horrified by American gun violence and the lack of response by legislators. My views are totally in keeping with the strong majority of Americans who don’t get why we’re uniquely unable to do anything about the epidemic. After Sandy Hook, particularly, the media coverage was crazy. It very quickly devolved into these extremely specific, abstruse arguments about the caliber of the bullet, or statistics about risk, or the fine points of the Second Amendment. It was all this wonk shit. Is the crime rate going up, is it going down, are you more likely to be killed in a mass shooting or be hit by lightning? It’s just a ridiculous set of ways to not deal with what’s happening. It’s a way to erase what’s happening—erasure that’s disguised as sophistication.

I pitched Temple first, last June, on a straightforward profile of Goldberg. I’d like to shadow her as she works, watch her treat trauma victims, and try to understand the gun violence problems through her eyes, I said. Then I had a phone call with Goldberg, Scott, and Jeremy Walter, the communications guy. Usually nothing gets said on these phone calls, but this was completely different. Almost right away, Goldberg started talking about Sandy Hook and the 20 kids and six adults who were shot and killed, and the horror of that, and her opinion that America lost this teachable moment because we never got to see the bodies. She had thought, she said, that maybe this would be the one thing that would change the debate. But nothing changed, and she despaired; if America didn’t care about 20 white kids killed in Sandy Hook, they would never care about the black patients she treats on a daily basis in North Philly.

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To get access I had to sign an agreement stating that I was a volunteer medical observer and I would abide by patient privacy regulations. I also took a TB test. After that I was invited to observe my first call shift with Dr. Goldberg. I’d already gotten Huffington Post on board. My editor there is Greg Veis, and we had talked about the agreement and the terms of getting access before I went in for the first time. I should note: I need to be vague about dates, because that’s an element of the HIPAA privacy law. I can’t really say exactly when I saw certain things. We were careful to obscure the identity of patients who didn’t sign consents.

HIPAA is the main obstacle to reporting inside a hospital. It makes the building kind of inimical to journalism. It’s a big part of why the story took so long to report. I don’t think I appreciated how much of a challenge it would be. It’s a strong law, for good reason. Everyone on the hospital side was very aware of it at all times and very careful. We heard a story about a TV crew that was filming at a hospital. They weren’t even filming patients’ faces, so as to keep everyone anonymous, but they happened to show a patient’s cowboy boot. Apparently, the boot was distinctive enough that the patient felt he was identifiable. He sued the hospital for violating HIPAA.

I shadowed Goldberg on six or seven different call shifts over an eight-month period. I was always accompanied by Jeremy Walter, who carried around a folder of consent forms. If I wanted to observe a surgery in the trauma resuscitation area, which is where they treat incoming trauma patients, Goldberg would ask the patient—assuming the patient was conscious—if it was all right if I observed. If the patient said yes, I could go into the trauma area. Then there was another level of consent required to interview a patient. Jeremy would produce this very hairy-looking legal consent form. If the patient signed it, I could interview him.

I think patients agreed to be observed because during trauma surgery there’s already, like, 20 or 25 people in there. The patient is surrounded by doctors and nurses, and sometimes even police. So one more person wouldn’t even be noticeable. But the majority of the time, the patient rejected my request. With the next level of consent—Can I interview you?—the answer was almost always no. Only a few people signed the form. I’m not sure why they wanted to talk. One, Lamont Randell, had been shot twice during a robbery, and had just recently regained his ability to speak. Maybe that’s why he talked to me. Perhaps the other patients, all of whom had gone through a difficult experience, simply wanted to give a sense of what recovery in the hospital is like.

Some shifts were 24 hours or nearly so; some were 12 hours. But I was not awake and reporting for 24 hours straight. During the first shift, they let me sleep in the call room, which is where the doctors sleep. It’s really bare bones, with a rowing machine and a picture of Vince Lombardi on the wall because Goldberg finds inspiration from famous coaches. Then Jeremy wheeled a cot for me into a reception area, and I would sleep during quiet hours. The security guard would come in, turn on the light, and see me sleeping on this cot. I remember feeling pretty ridiculous because I’m a large guy and I was sleeping on this cot in a reception area. Quite honestly, I felt like a loser. I have a wife, I have a kid, what the fuck am I doing here? The security guard looked at me with a bit of confusion and maybe pity.

The trauma unit at Temple University Hospital. Photo by Finlay MacKay for Highline.

The trauma unit at Temple University Hospital. Photo by Finlay MacKay for Highline.

I never saw a patient pronounced dead, and I never saw a thoracotomy, which is the most dramatic surgical intervention that they do on a gun patient. A thoracotomy is where they crack the chest. They make an incision and insert the finochietto retractor so they can get between the ribs and into the cavity to do their work. I talked to doctors and nurses about what it’s like to perform thoracotomies. They did 70 last year.

Temple sees about 450 gun victims a year and it seemed, for a while, like they were all coming in around me. They would come in before I arrived at the hospital and after I left, but not while I was there. I’m not superstitious at all, but even I thought it was absurd that as soon as I left, Scott’s trauma pager would light up. I actually wondered if I was trying to force it. Was I trying to see something that’s not really happening? I thought about that, but the fact was, gun victims were coming in before and after these call shifts, so I decided I wasn’t trying to manufacture a story about a problem that doesn’t exist. Goldberg, who is very superstitious, told me that sometimes it’s like the trauma gods can tell that someone is watching who isn’t usually there.

There was a joke about how I was some kind of anti-crime force in North Philadelphia. When I showed up people stopped shooting each other.

What stuck with me? It wasn’t the sounds or the smells. I’m trying to remember. It was how quickly the doctors and nurses appeared in the trauma area. The pager would go off, and we would go down there. It would only have been a couple of minutes, but by the time we got there, there’d be 20 to 25 people gowned up and ready to go. That was impressive. Then I was struck by just the appearance of pain that recovering gun victims seemed to experience. There was this one young patient who had his spleen and kidney removed after a shooting. There had been some swelling, so doctors couldn’t close the incision. This is not an unusual thing, having to sit in the hospital with an open incision. I talked to one shooting victim who was shot once in the abdomen with a handgun and had to stay at Temple for 11 months with a open wound on the front of him the size of a basketball. He could look down and see his intestines. For 11 months. When I saw Goldberg talking to the young patient, lying there with that open incision, the pain was inescapable.

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The worst thing I saw wasn’t a shooting victim. It was a mother and a daughter who had been stabbed with a screwdriver. They both required trauma surgery. One had been stabbed more than 10 times. I had consent to observe their trauma surgeries, so I saw them when they were first brought in. That didn’t end up in the story.

We brought in photographers at the end, but for the bulk of the reporting I was alone. It was just me there with a notepad and a digital recorder, which I only used to interview Goldberg, as she walked the halls, and one patient who consented to an interview. Otherwise I was just taking notes. I’ve got the notebooks right here, a little stack of six tiny ones and two oversized. I didn’t fill every one front to back, but there’s notes from the story in all of these throughout.

I know journalists give PR people a lot of shit. But I felt like there was a real decency on the part of hospital communications, sticking with me through this story. It would not have been possible without Jeremy wheeling out a cot for me and staying up all night, multiple times, with a trauma pager. He has his own family and kids, too, so that was pretty remarkable. And that was true for everyone I met at Temple. They were taking a risk by giving me access and talking to me, and they were putting up with the awkwardness of having a journalist around because they thought it was important for people to know some of these things.

I would ask Goldberg what was going on in her life aside from work, in part, just to keep things light before her call shift. But I was also curious about her life, as you should be with any person you profile. I was interested in how she sustained a level of devotion and energy over 30 years, and how she avoided total despair. I was curious about her personal routine. It involved a lot of running. It seemed like every time I went to the hospital after not being there for a while, she had just run another half marathon.

Even before I was done with the initial reporting, I’d written the lede, and it was the one part of the story that never changed. The lede, like the ending, is about futility. It’s a very common emotion these days, probably for a lot of reporters. Nothing’s going to change. Your story’s not going to change anything; don’t think that it will. That’s demonstrably true. Even solid gun journalism hasn’t changed anything because legislators are resistant. I thought it was important to acknowledge up front that, in all likelihood, my story would be no different. In some sense, that’s Goldberg’s life, too: acknowledging the larger futility and then trying to do something on a smaller scale to make the lives of people better at her hospital and the surrounding community. Goldberg’s life, and her career, are about fighting against the larger futility, finding a way to do something good even when it’s clear no help is coming down the pike. But it’s worth noting that Goldberg wasn’t entirely discouraging. On our first call, she said, “You want to win a freaking Pulitzer? Find a way to show what bullets do to bodies.”

I used “poop” in the story because, unlike “shit,” it’s kind of an innocent word, right? There’s something vulnerable about it. There’s something about trauma surgery that reduces adults to children. Goldberg and Scott told me that when tough guys get shot, they come into the ER and they’re like kids asking for their moms. They’re scared and they’re in pain. There’s a regression to a childlike state of fear. Well, “poop” is a word children use.

Photo by Finlay MacKay for Highline.

Photo by Finlay MacKay for Highline.

I filed a draft in late January. It took maybe a week to write. At that point, I was writing around the fact that I hadn’t really seen many surgeries on gun victims. The notion that you might go to a hospital that treats hundreds of gun patients a year, multiple times, and not see a lot of gun surgeries, was more central to the story. It was about the lack of rhyme or reason. But then Greg called me. He told me I nailed the draft, but that I had a lot more work to do. He kept telling me to go back. I think you don’t want to hear this, but I think you’re going to have to go back, he’d say. At the point where I’d already been there like four or five times, done four or five shifts, and slept on the cot. I didn’t want to go back. But he was right. I hadn’t accumulated enough time there to get a representative picture of what was happening.

I’ve always believed time is the only thing that reliably improves writing. It’s a luxury. The writing process is less an inspirational bolt from the blue, and more like the ocean polishing a stone. Sometimes you can spend inordinate amounts of time and come up with nothing, but most of the time you will get something done. The ocean is never really going to fuck up that stone; it’s always going to come out smooth. So I kept going back for more material. I’d ask for more access to shadow Goldberg and try to talk to more patients. As I went back, over two and a half months, I’d get a better picture of the violence and the surgery. The piece became not just about what I’d seen, but about Goldberg, her life, her views, and her experience.

The biggest challenge was the four paragraphs about what surgeons actually do to gun victims in the trauma bay. That’s the heart of the piece. Greg and I worked really hard to make sure those grafs were medically accurate and easy to understand. People really don’t know what it’s like to be shot and what is required to save you. This is the misconception doctors deal with. They’ll ask kids, What do you think it’s like to be shot? What do you think surgeons do? And the kids always say the point of surgery is remove the bullet. Well, it’s not. The point of surgery is to repair the damage done to the body by the bullet. So in those four paragraphs, we described what a thoracotomy is, what it looks like, what it sounds like, what tools are used. This is crucial because if more people understood what a thoracotomy was, they’d be a lot more afraid of guns. There’s just no question. Part of Goldberg’s job is to open up the chest cavity and massage the beating heart, you know?

I kept hearing from the surgeons who were annoyed at the Bourne movies. Jason Bourne is shot and he’s shirtless in the safe house and performing surgery on himself. And all he needs to do is get the bullet out with tweezers and a knife. And then he puts on the bandage and he’s fine. That kind of thing is what fucks with people’s mental image of gun violence.

Anyway, after a couple of months of editing, it was done. We went through six drafts, all significantly different.

Greg, for his part, was meticulous, driven, and cheerfully ruthless at times. He worked right up until the end. The final day we went back and forth on Gchat, editing individual lines and paragraphs. Greg cut 800 to 1,000 words from the last draft. He just thought it read better. But that’s always painful, right? I have never really believed in my bones that less is more. Sometimes, intellectually, I can buy it, but I’ve just never believed it at a level of faith. I always think that more is more, and one thing Greg did was prevent me from messing up the story at the last minute by trying to reinsert details that had been cut or trying to insert new details.

The fact checker saved me from myself. At the beginning of the story, I wrote about Philadelphia as if it were a spinal column. It’s a pretty easy metaphor to use because Broad Street runs north/south from South Philly to the city line in North Philly. So, just thinking about it quickly, using my mental picture of Philadelphia, I thought, Well, Temple Hospital is about level with the neck of Philadelphia, and City Hall is near the pelvis. The fact checker, however, looked at a map. And he emailed me: I’m sure that you know Philadelphia better than I do, but it looks more to me like Temple Hospital is at the level of the heart. As soon as I read that, I had, like, an hour of self-hatred. My mental picture of Philly was wrong. My pride as a Philadelphia reporter was wounded. But it makes for a better metaphor! So I fucked up the mental picture of my own city and then I fucked up the literary part of it, too. And a fact checker in New York had to save me. Thanks, man.

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Elon Green is a writer in Port Washington, New York. He's an editor at Longform. Find him on Twitter @ElonGreen.