The AR-15, the semiautomatic rifle used at Marjory Stoneman Douglas High School in the deadliest high school shooting in U.S. history, uses bullets that can cause softball-sized exit wounds, leaving behind a significantly larger trail of mangled tissue compared to handgun bullets.
For trauma surgeons, the injuries are harder to repair. For victims, the chances of survival are lower.
“We’re surgeons, we’re not gods,” said Dr. Nicholas Namias, the director of Ryder Trauma Center at Jackson Memorial Hospital in Miami, which treats about 400 serious gunshot injuries every year. “If you have an injury from a bullet going through an artery at a low velocity, you repair it and go on your way. If you have a high velocity bullet, now you have a huge cavity. Imagine a cavity the size of your fist where everything that should have been there no longer is. How do you fix that?”
The AR-15 and similar rifles fire bullets at a speed of about 2,800 to 3,000 feet per second, compared to a 9 millimeter handgun, which fires bullets at a speed of between 700 and 1,100 feet per second, according to Dr. David Shatz, a trauma surgeon at the University of California, Davis. The difference in speed is what leads to more fatal injuries from people wounded by AR-15s and similar rifles than handguns.
“The bullets hit tissue then fall apart, they tumble and have all these fragments that go all over the place in the tissue,” Shatz said. AR-15 bullets and handgun bullets both tumble through the human body, but the sizes of holes inside the body are vastly different.
Shatz said bullets cause permanent cavities, where tissue is destroyed, and temporary cavities, which are areas around the permanent cavity that open up for a fraction of a second because of the “sonic force” of a bullet. Cavities caused by bullets like the .223 caliber bullet typically fired by the AR-15 are much larger than the cavities caused by handgun bullets.
Arizona Democratic Rep. Ruben Gallego, an Iraq War veteran who trained extensively with the M-16 assault rifle, the military-grade fully automatic version of the AR-15, said the bullets fired by AR-15s are purposely designed to inflict as much damage as possible on human targets.
“The bullet, it travels so fast that it won’t exit cleanly in a line; it will bounce,” Gallego said. In one case, he recalled, a fellow Marine in Iraq was killed by a bullet from an enemy AK-47 assault rifle that entered just below his armpit, tearing through organs and never leaving the body.
“It disrupts their internal organs,” Gallego said. “In boot camp I was taught this was by design. The military wanted us to shoot somebody and cause so much internal bleeding that it would cost extensive resources from the enemy to keep someone alive. If you think about this round in the hands of civilians and using it in crowded areas, that’s how you get in four minutes 17 people killed.”
Rep. Brian Mast, a Treasure Coast Republican who lost both of his legs while serving as a bomb technician in Afghanistan, said in a New York Times op-ed that he used a rifle similar to the AR-15 while in combat. The 9mm handgun he carries to protect himself as a civilian can’t compare in firepower, he said.
“I have fired tens of thousands of rounds through that rifle, many in combat,” Mast wrote. “We used it because it was the most lethal — the best for killing our enemies. I am confident I can eliminate an active shooter who is attacking with a pistol because the attacker would have to be close to me. But the defense my concealed 9 millimeter affords me is largely gone if the attacker is firing from beyond 40 yards, as he could easily do with the AR-15.”
Heather Sher, a Broward County radiologist who treated victims of last week’s shooting from an AR-15 along with victims of the 2017 Fort Lauderdale–Hollywood International Airport shooting, where a 9mm handgun was used, said in a first-person piece in The Atlantic that the AR-15 injuries she witnessed last week were much worse than the injuries she saw after the airport shooting.
“With an AR-15, the shooter does not have to be particularly accurate,” Sher wrote. “The victim does not have to be unlucky. If a victim takes a direct hit to the liver from an AR-15, the damage is far graver than that of a simple handgun shot injury. Handgun injuries to the liver are generally survivable unless the bullet hits the main blood supply to the liver. An AR-15 bullet wound to the middle of the liver would cause so much bleeding that the patient would likely never make it to a trauma center to receive our care.”
Dr. Carnell Cooper, a trauma surgeon and associate professor of surgery at the University of Maryland School of Medicine, said high velocity bullets make his job of saving lives more difficult, and that shooters using AR-15s are often able to hit their target five to six times instead of one or two times in the case of most handgun injuries.
“If they have five to six bullet holes as opposed to one, it may make me think it’s a high-velocity weapon,” Cooper said, adding that low velocity and high velocity bullet wounds are both serious and will often be fatal without proper treatment.
Since the Sandy Hook elementary school shooting in 2012, where 26 children and adults died after the gunman used an AR-15, surgeons like Namias and Shatz are trying to spread word of the Stop the Bleed program, which is run by the Department of Homeland Security. The program aims to train average citizens about how to stanch blood flow during active shooter situations, particularly when first responders may be prevented from intervening as law enforcement attempts to apprehend a shooter. The larger cavities that AR-15 bullets cause mean the chances of bleeding to death from a wound caused by a bullet that doesn’t directly hit a major organ or artery are much higher.
“The low velocity bullet is like clipping the corner of your car versus getting slammed by an 18-wheeler,” Namias said. “The high velocity bullet totals you.”