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Christopher Colwell still can’t shake what he saw in the library of Columbine High School on April 20, 1999: the lifeless bodies of students who were left without time to defend themselves, crumpled under the desks they hoped would protect them.

What comes back to the emergency physician most is what he was tasked with toward the end of his time at the scene when his job was to pronounce high-schoolers dead as he searched and hoped he might find someone who could still be saved. “The victims’ faces, the ones that were recognizable, that still comes up almost as if it weren’t 23 years ago,” he said.

After every school shooting, the nation goes through a grim routine filled with alerts on cellphone screens, photos of victims trickling onto the nightly news, the familiar cycle of funeral flower arrangements, calls to action and the omnipresent barrage of thoughts and prayers.

But before any of that is the grim routine that the public rarely sees as doctors and nurses ready hospital rooms, wait to hear how many victims they’re receiving and wonder whether they’ll be able to save them.

For many medical providers, the shooting at Robb Elementary school in Uvalde, Tex., which killed 19 children and two teachers, was the latest reminder of how depressingly skilled they have become since Columbine at responding to mass casualty events like school shootings.

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“These tragic events have taught us a lot about preparations for mass shootings, how to focus on the greatest good for the greatest number in a better way than we knew back in 1999,” Collwell said. “I guess that’s a positive, but it’s also kind of bleak.”

In virtually every other medical scenario, doctors said, prevention is king. But what can a doctor do to stop a mass shooting? For years, groups such as the American Medical Association have been calling gun violence a public health crisis and demanding that lawmakers do more to curb gun violence.

“As we have said repeatedly since declaring gun violence a public health crisis in 2016, gun violence is out of control in the United States, and, without real-world, common-sense federal actions, it will not abate,” American Medical Association president Gerald Harmon said in a recent statement alongside the group’s latest letter to members of Congress.

The group praised Congress for passing the recent gun violence bill that President Biden has signed into law, but said more can be done.

On Monday, doctors were again on the scene of a slaughter — this time at a Fourth of July celebration, not a school. A gunmen killed at least six people and injured dozens more in the Chicago suburb of Highland Park.

“The horrific scene of some of the bodies is unspeakable for the average person. Having been a physician, I’ve seen things in ERs, you know, you do see lots of blood,” Dr. David Baum, who treated some of the victims, told CNN. “But the bodies were literally — some of the bodies — it was an evisceration injury from the power of this gun and the bullets. There was another person who had an unspeakable head injury. Unspeakable.”

After the Robb Elementary shooting, pediatrician Roy Guerrero gave the public a glimpse into what it’s like to treat kids in a nation where more than 311,000 students have experienced gun violence at school since Columbine.

Guerrero, who attended Robb Elementary himself as a child, testified at a recent congressional hearing on gun violence. He laid out what he saw that day in stark terms about the blood-spattered cartoon clothes, the children who were pulverized by bullets, “clinging for life and finding none.”

“I chose to be a pediatrician. I chose to take care of children,” he said. “Keeping them safe from preventable diseases I can do. Keeping them safe from bacteria and brittle bones I can do. But making sure our children are safe from guns, that’s the job of our politicians and leaders.”

Guerrero is far from alone. He’s now part of the growing community of doctors across the nation who have had to see what an assault weapon can do to a child’s body.

School shootings in the United States didn’t start with Columbine. But that day, when two gunmen killed 13 people at a high school in Colorado and then themselves, was the first major school massacre in the nation and became a nightmarish blueprint for future shooters. At the time, it was the deadliest school shooting in American history.

In the decades since, school shootings, not to mention mass shootings in general, have been on the rise. According to a Washington Post analysis, there were 41 in 2021, more than in any year since at least 1999. There have been at least 24 acts of gun violence on K-12 campuses during the school day so far this year.

That is aside from the everyday kind of gun violence that rarely makes the news but always makes it into trauma centers, which is also on the rise. Halfway through this year, more than 22,000 people have died because of gun violence in this country. The firearm homicide rate in 2020 was the highest recorded in more than 25 years and is expected to be even higher for 2021 and 2022.

But instead of seeing all of this and passing common-sense gun control legislation, Colwell said, the nation’s handle on guns has “regressed fairly remarkably” over the past two decades. Since Columbine, he has treated victims of two additional mass shootings in two different cities.

He has watched the emergence of an informal brotherhood of physicians who have seen this kind of devastation unfold over and over again. They stay in touch after discovering their shared experience at talks or conferences about trauma, or veterans will contact newcomers after the latest tragedy.

They try to take care of each other, texting to check in after devastating events or on difficult anniversaries. They’re saddened that there are so many of them, but they’re grateful to have people who understand what they’ve seen.

Walking onto the scene at Sandy Hook Elementary School in 2012, Richard Kamin didn’t realize just how much he was going to need that support. He considered himself a solidly trained emergency physician. He had worked with the Connecticut State Police, SWAT teams, and the FBI. But he had never seen so many injured people, especially not children. And their wounds were catastrophic.

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“Quite frankly, I’m not really sure how well you can prepare somebody for something like that,” he said. “Because people frequently say to me, ‘I can’t imagine.’ And I say, ‘Good. That’s good.’”

The Sandy Hook gunman shot and killed 20 children 6 or 7 years old and six adult staff members. Kamin knew what to do at the scene, but he wasn’t ready for what would come after. The intrusive thoughts about his small children, the images of death replayed in his mind, the boundless worry that he was broken, the sleepless nights.

Kamin says he was lucky. He had a boss who was a disaster responder and had seen all kinds of tragedies. He called Kamin up after Sandy Hook, Kamin recalls, and walked him through what to expect with all the different ways this would change his brain. He took him off the clinical rotation. He told him not to use drugs or alcohol to treat his feelings. He told him he needed to exercise every day, and he showed up at his home the next morning to haul him to a workout.

That was the first time someone talked to Kamin about this kind of tragedy and acute stress, but he went on to have countless conversations on the subject and commit himself to making sure other emergency responders were prepared for what they could see in the line of duty.

“We have to be transparent about what happens to people in the wake of these events, so they can prepare themselves, become more resilient, understand better, have resources in place,” he said. “It’s not just active shooters in schools.”

The rise in mass casualties has necessitated all kinds of training for medical workers, from the kind of mental preparation that Kamin wants all of his colleagues to have to the more tangible drills that keep everyone prepared in case of the unthinkable.

Hospitals are bound by regulations and accreditation organizations to keep up with this training, and they must be in compliance with all federal, state and local emergency preparedness mandates to receive funding through Medicare or Medicaid.

When Amy Woods was director of surgical services at Lewis Gale Hospital Montgomery in Blacksburg, Va., her teams would sometimes grumble about all of the planning and drills they did in case of a mass casualty event.

But on April 16, 2007, when an undergraduate student opened fire at Virginia Tech, killing 32 people, she said everyone was grateful for that training. “We owe it to the communities we serve to be prepared,” she said.

David Stoeckle was practicing trauma surgery at the hospital at the time. In his 44 years on the job, he said he would never again see the kind of solidarity he saw that day. “It was just an awful experience, but I can tell you that I’ve never seen the hospital staff get together so quickly,” he said.

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The hospital learned a lot from that tragedy, Stoeckle and Woods said. The main adjustments were organizational, Woods said, making it easier to track patients, organize visitors and media and set up a command center.

The hospital rooms were not labeled clearly enough to be useful to providers and pastors and families looking for loved ones, so that was the first thing to change. They then shared what they learned from the Virginia Tech massacre with other hospitals and communities, giving talks across the country.

Now when they hear about shootings in other communities, they pray. “It just comes back to you,” Woods said. “You absolutely know and can connect with that community because you know what they’re going through. You know what the days ahead look like. You know how difficult it’s going to be to move on for those families. But you also know it’ll strengthen that community like nothing ever before.”

For Lillian Liao, director of pediatric trauma at University Hospital in San Antonio, the mass shooting at Robb Elementary was not a first. Her hospital treated victims of the 2017 Sutherland Springs church shooting, where 26 people were killed at a small Baptist church.

The South Texas medical community learned a lot from the Sutherland Springs shooting, Liao said. They looked into cases where victims didn’t survive and realized more blood needed to be available at smaller hospitals to keep patients stable. When the Uvalde shooting happened, the San Antonio hospital airlifted blood to the town to make sure there would be enough.

Also after Sutherland Springs, physicians in South Texas focused on training civilians through a course called Stop the Bleed, which was developed after Sandy Hook and teaches people how to stop someone from losing a lethal amount of blood. Liao and other doctors successfully lobbied for the training to be made mandatory for certain personnel in Texas schools. “We know that the things that we implemented from Sutherland Springs did help save lives,” Liao said. “Not enough, but it did help.”

When her team was notifying the operating room of the Uvalde shooting, making sure beds were open and getting in contact with the blood bank as they waited to see how many children would arrive, the list of what needed to get done seemed much clearer than it had during the Sutherland Springs response. Her hospital hadn’t just trained for this, they had already been through it. By the time any patients arrived, they had around 100 physicians lined up, at the ready and snaking through the hallways, Liao said.

She said the hardest thing she had to do the day of the Uvalde shooting was call off the mass casualty response, telling the rest of the hospital that they weren’t going to get as many patients as they expected. After all of that preparation, there just weren’t any more survivors to treat.

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