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Part 1: Oct. 2, 2016More guns, bigger bulletsBy Justin GeorgeQuinzell Covington went on a shooting “caper” for the first time in the late 1990s with his cousins and friends. The tough guys who raised him in ways of the streets pulled the trigger that day. Afterward, over Chinese takeout, Covington tried to ingratiate himself with the crew by declaring that their victim got what he deserved.He was about 13 years old. Growing up in Baltimore, he knew it was wrong to shoot a man. Still, he said, he didn't feel remorse. What he did feel was that his crew had newfound respect for him.By 15, he was the one doing the shooting. Over the next dozen years, Covington learned to do it well. He used 9 mm guns that held 16 bullets and Mac-10 submachine guns. He lured victims to his turf, where he could scout for witnesses and surveillance cameras, in what he called his "Miranda check" - a macabre reference to the right to remain silent.He also knew where to aim."If I shoot you in the leg, I know what I'm going to get, " said Covington, who is serving a 25-year sentence for murder. "If I shoot you in the stomach, I know what I'm going to get. If I shoot you in the head, I definitely know what I'm going to get. I'm going to get your demise."Covington's evolution into a killer encapsulates a trend driving gun violence around the country: Increasingly, people are shooting to kill. Criminals are stockpiling higher-caliber guns, many with extended magazines that hold more than 20 bullets. Police and hospitals are seeing a growing number of victims who have been shot in the head or shot repeatedly. And trauma doctors are finding it more difficult to save gunshot victims.In many places, if you get shot, you are more likely to die than ever before.In Baltimore, one of every three people struck by gunfire dies, up from one death in every four shootings the previous decade. It ranks as one of the most lethal of America's largest cities, according to a Baltimore Sun analysis. Two other cities - Washington and New Orleans - shared the brutal distinction of one in three shootings ending in a homicide in 2015. Like Baltimore, several cities have seen the death grip tighten. In Chicago, one in 10 people died after being shot in 2000; now one in six perishes.Last year, the odds for gunshot victims worsened in at least 10 of the nation's largest cities, The Sun found.The Baltimore Sun undertook a yearlong investigation into this rarely studied phenomenon, documenting patterns of lethality based on hundreds of crime statistics, hospital data and gun trace reports as well as interviews with police chiefs, homicide detectives, criminologists, medical experts, community activists, victims of gun violence and the perpetrators themselves.DETAIL PHOTO OF A GLOCK .40-CALIBER HANDGUN BEING FIRED AT THE NORTHEAST DISTRICT POLICE STATION’S QUALIFICATION RANGE.Researchers said lethality is a significant part of the homicide equation, with implications for policing, public health and trauma care, but in-depth study has been hampered by a paucity of statistics.Historically, gun violence research in the U.S. has been inhibited by a lack of federal funding and data - many police departments only track what they are required to report to the FBI, which doesn't include how often people survive shootings, where on the body people are shot and how many times.That leaves a focus on body counts and homicide rates, which can be traced back nearly a century. While the nation's overall violent crime rate declined, starting in the 1990s, a city's homicide rate typically fluctuates, sometimes significantly, leaving criminologists to puzzle over the causes behind spikes and dips.Just five years ago, Baltimore public officials were celebrating a drop in the annual homicide count below 200. This year, that marker was crossed in August.The latest crime wave in a number of cities - Baltimore, Chicago, Milwaukee and Washington, to name a few - has prompted deeper soul-searching. Deteriorating police-community relations have been blamed for a sharp increase in shootings and homicides, as have gang conflicts and entrenched societal ills such as segregation, poverty and joblessness.But one often-overlooked trend has been consistent over the years, the Sun analysis found: Lethal force has become more so.In Baltimore, where there were nearly 1,000 shootings last year, a one-in-four lethality rate means about 250 victims die. A one-in-three rate means more than 330 people die. So even if shootings subside, the number of gun deaths remains elevated.On the streets, particularly in poor, black neighborhoods, residents are witnessing increasingly deadly tactics. More shooters are aiming for the head and firing multiple rounds into victims.The number of fatal head shots rose steadily from about 13 percent two decades ago to 62 percent last year. Meanwhile, the number of cadavers with 10 or more bullets more than doubled in the past decade, according to the Maryland medical examiner's office, which tallied the bullet wounds at the request of The Sun.Now, roughly two-thirds of city homicide victims are either shot in the head or multiple times. Many suffer both fates.Guns have also become more deadly, as the weapon of choice for criminals and then law enforcement shifted from the revolver to the semiautomatic pistol, which can fire more bullets without reloading. Nationally, the number of 9 mm and .40-caliber guns taken off the streets surged during the past four years, as seizures of less powerful .22-caliber guns remained relatively flat.In Maryland, seizures of 9 mm handguns overtook .22-caliber guns for the first time last year. Most were recovered from Baltimore's streets, where the saying goes: "Buy every gun that comes through; don't let it be the gun that kills you."Many of the guns are equipped with extended magazines, allowing a shooter to fire from a distance and "walk down" a victim, continuously firing. The sale of "extendos" with more than 10 rounds is banned in Maryland, where they are prized in street cultures, tucked under belts and into pants as a fashion statement. In Baltimore, police are finding up to 80 shell casings at a single crime scene.Metropolitan Police Chief Cathy L. Lanier, who retired last month after more than a decade in Washington, keeps a photo of a 100-round magazine seized by police on her cellphone as a reminder of the firepower out there.Law enforcement officials across the country say they've observed insidious circumstances that are difficult to quantify. Reckless shootings in the daytime. Vigilante justice and contract killers. Gang rules that codify when violence should be used - and street rules limiting violence against bystanders being ignored."The criminals are more brazen, " said Baltimore police Maj. Donald Bauer, who leads the homicide unit.While shooters' motives vary, experts and those caught in the crossfire note a ruthlessness on the streets where criminals with more sophisticated weaponry aren't just using guns to intimidate rivals or rob. They are using them to take people out with greater success.In Baltimore and other cities with a deeply entrenched "no-snitching" ethos, the emphasis is on leaving behind no witnesses and no one to retaliate."It's very common for someone to walk up and empty a pistol at close range, " said criminologist David M. Kennedy, describing the "extreme" hold that gangs and drug crews have in cities like Baltimore, Washington and New Orleans. "It's going in with a heightened intent to actually kill you."Those same criminals have honed strategies to keep weapons at the ready. Guns are stashed in trash cans, hung from gutter grates by string and stashed in other nooks where they can be quickly recovered when needed. (Covington says he kept part of his arsenal under an apartment complex's washing machine.)Or people serve as "human holsters, " carrying guns for felons, according to Milwaukee Police Chief Edward A. Flynn.And in Baltimore, hit men for hire have become fixtures on the streets.Police recently began tracking the so-called 10 Grand Club, an organized gang of hit men willing to kill for that price, and prosecutors say that's double the typical fee. (Covington became a contract killer but also says he "killed out of friendship" for free if a woman approached him about taking out her rapist or her child's molester.)Not even decades of advancements in trauma medicine can stem the carnage.Even as patients with major injuries from other assaults and car accidents have seen their chances improve dramatically, gunshot victims have watched their chances of survival plummet. Studies by hospitals and trauma centers across the country, including Baltimore's top-ranked medical systems, have documented this contrarian trend."We feel this represents a true change in violence intensity, " researchers with the Johns Hopkins Medical Institutions concluded a decade ago. Doctors say it has gotten worse since then.This has left communities nationwide reeling, with violence concentrated in traumatized neighborhoods where mothers are forming support groups, not only to help each other cope but in a desperate search for ways to stop the killing. A nationwide network of grief is starting to take shape, with more support groups banding together and becoming politically active."We're all facing similar dynamics, " said Corneilius Scott, who volunteers as executive director of Mothers of Murdered Sons and Daughters United in Baltimore. "There's a lot of concern and not many answers."At the group's meetings, parents are talking about "sensitizing" young men to the effects of violence. They believe - and social science is finding - that their boys need to be taught empathy, lest they become trapped in a cycle, repeatedly exposed to violence and becoming more likely to commit it.More guns, bigger bulletsRodney Chase sensed trouble when three young men approached him on Gay Street in Baltimore, but he didn't run, saying he's not the kind to back down from anyone. One of the men pulled a gun; they wanted his NFL Starter jacket, his wallet, anything of value.As Chase took off his jacket, one of the men tried to yank it off, and Chase instinctively hit him. The gunman fired into Chase's belly, and Chase felt as if hot grease had been thrown at him.A woman nearby screamed and called an ambulance. He underwent surgery. Doctors put a screen under his skin to hold in his organs. He wasn't discharged for nearly two months.That was more than two decades ago. Had he been shot today, with the kinds of guns prevalent on Baltimore's streets, he believes he'd be dead."Luckily it was a .22, " the 58-year-old said recently, lifting his shirt to show off a scar slicing down the middle of his stomach. "I'm grateful for that. If it was bigger, I'd be done."He knows Baltimore's streets because that's where he's spent most of his life. He was a drug addict living in an abandoned house when he was seriously injured in a knife attack and ended up at the University of Maryland Shock Trauma Center nearly a year ago. He also was admitted into a hospital program that connects patients with social services in hopes of reducing the recidivism of violence."I call it ‘Clip City, '" Chase said of Baltimore and the proliferation of guns. "What they got now - they're death dealers. And it's not hard to get 'em."Gun production in the U.S. set a blistering pace beginning in 2011 through 2014, the latest years for which data is available, doubling and sometimes tripling the annual manufacturing reported in the previous 25 years. Moreover, guns sold now are more powerful - higher-caliber weapons that come with larger magazines and discharge bullets with more force."All of these factors, over the last several decades, have progressed, " said Jay Wachtel, a 20-year agent of the Bureau of Alcohol, Tobacco, Firearms and Explosives who lectures at California State University Fullerton. That has led to what he called an "incredible increase in the lethality of guns."Even an inexperienced shooter, Wachtel said, can do a lot of damage with a high-caliber semiautomatic gun. "You don't need to be a very good shot because any organs nearby are going to be pulverized, " he said.Eventually, many of the newer models end up on the streets despite laws aimed at keeping guns out of the hands of felons. Law enforcement officials nationwide say they have noticed an increase in the quality of guns wielded by criminals."All the cheap guns made in the '80s have either quit functioning or have been recovered by police, " said Los Angeles Homicide Detective John Skaggs, the protagonist in the best-selling book "Ghettoside, " who has closed nearly all of the homicide cases he's handled. "They seem to all be expensive and high-quality now."In Milwaukee, police are tracking this trend. A decade ago, the top guns seized by police were a 12-gauge shotgun and pistols that cost less than $200 with standard, eight-bullet magazines. This year, the most seized guns were .40-caliber and 9 mm handguns that cost more than $400 and come with magazines that hold nine to 16 bullets.DEVANTE TURNER-FORDBEY STANDS AT A PLAYGROUND NEAR WHERE HE WAS SHOT 27 TIMES TWO YEARS AGO. Flynn, Milwaukee's police chief, said most of the guns used in crime - nearly 90 percent - are bought, not stolen. He blamed "straw purchases, " in which people purchase guns for others who wouldn't pass a background check."The gun of choice of street offenders has shifted over time to higher-quality, higher-caliber of semiautomatic pistols, " said Kennedy, the criminologist who directs the National Network for Safe Communities, a project of the John Jay College of Criminal Justice in New York City."Since those are the guns that gangs and drug-involved offenders are more likely to have, they're more likely to kill somebody, " he said.In Baltimore, gun seizures this year have already surpassed last year's total by more than 25 percent. The once-ubiquitous "Saturday night specials" - cheaply made .22- or .25-caliber handguns that were banned for a time in Maryland - are no longer as prevalent.Now 9 mm guns are the top gun seized by police, and a Glock .40-caliber was most often used in crimes last year. Those weapons are capable of firing a bullet nearly twice the diameter of the one fired from the original Saturday Night Special."A lot of big guns out there, " said James "J.T." Timpson, a community liaison officer with Safe Streets, the city's violence mediation program, which works in high-crime neighborhoods to resolve conflicts without police intervention.Timpson said shooters believe they need "stopping power" to ensure their mark is dead. "We don't have .22s no more, " he said.Measures aimed at limiting high-capacity magazines haven't kept them off the streets, either.A decade after the federal assault weapons ban expired, Maryland again restricted the number of bullets when lawmakers passed one of the nation's strictest gun control laws in 2013. The law, which regulates certain gun purchases, also prohibits the sale of magazines with more than 10 rounds.Since the law passed, however, dozens of "extendos" have been confiscated in the city, according to police. Officials don't keep exact statistics on the sizes of magazines.Still, only 11 people have been charged in Baltimore and fewer than 100 statewide under the magazine statute. The penalties under the law are stiff. If convicted of committing a felony or violent crime with an extended magazine, defendants face a minimum of five years in prison and a maximum of 20.Baltimore Police Commissioner Kevin Davis said the department's gun violence enforcement division, a new partnership with prosecutors, would investigate why more people haven't been charged.Police in other cities are also finding bigger magazines. In Washington, where gun seizures by the police gun recovery unit were up nearly 50 percent so far this year over last, police noticed more rounds being shot at scenes and signs of multiple shooters. So they began keeping statistics.Last year, about one-third of guns recovered had high-capacity magazines. Through June of this year, nearly half had large clips.With that kind of firepower, homicides spiked in Washington, Baltimore and more than a quarter of the largest American cities last year, pushing the nation's annual murder rate up by the largest margin in nearly 50 years. The higher pace of killing has continued in many cities this year.At the same time, the odds for gunshot victims worsened last year in a number of cities, including Washington, Detroit, San Francisco, Milwaukee, Louisville, Ky., and Charlotte, N.C., The Sun's analysis found. In New York, one in five shooting victims died last year, up from one in seven in 2014. In Nashville, the odds of dying increased year-over-year from one in nine shootings to one in four.That surprised researchers who said they expect surges in violence to become more haphazard, less planned - therefore resulting in fewer killed.The Sun reviewed statistics from the nation's largest cities that tracked the shooting data necessary to calculate the lethality of gun homicides over the past five years. Half of the 30 biggest cities do.In some cities that kept statistics for a decade or longer, including Baltimore and Chicago, shootings proved to be deadlier over the years, not just last year.Former D.C. Chief Lanier, who has worked with police chiefs across the U.S., sharing ideas and data on the surge in homicides, noted a shift in the mindset of shooters. Criminals are emptying their clips, she said, leaving crime scenes littered with 50 to 60 shell casings, and opening fire in the daytime."Something's changed in the mentality of the people shooting, " she said. "Very reckless. Everyone's got a gun, and everyone is willing to do these shootouts."Trauma care falls behindThe first bullet ripped into his thigh, and he crumpled. Devante Turner-Fordbey dropped to the asphalt on a spring day in West Baltimore two years ago, turned and saw his assailant in a hoodie pointing what looked like a 9 mm. The gun was jammed, and Turner-Fordbey began pulling himself up the street on his elbows and forearms as quick as he could. Then he heard the next shot blast.Now the bullets felt like hammer blows. The more the shooter closed in, the more he felt the force of the bullets, which were moving at more than 900 feet per second. Turner-Fordbey turned onto his back and put his hands up."You're good, you're good!" Turner-Fordbey yelled. "You got me!"But the shots kept coming. A bullet pierced his chest. Nine sank into his right thigh. One just missed his heart, striking his chest where the words "Nana" for his grandmother are tattooed along with some clouds and doves.Figuring he was going to die, he began to taunt the man standing over him with a gun. "You're a bitch. You're a bitch."Then a slug sliced into his head, and he blacked out just as he saw the man run away. He figures his survival instinct must have taken over, and he came to as he was trying to crawl away again."He heard me shuffling on the ground, and I'm trying to get myself off the ground, " Turner-Fordbey said. "He came right back and slapped in another clip in the gun. Boom. Boom. Boom. Boom. … I blacked out."In and out of consciousness he went, while his mother, who lived nearby and came running when word reached her, dug out the slug from his skull and pressed her hand against his neck to stop the bleeding."I'm sorry, Ma. I'm sorry, Ma. I feel myself leaving, I feel it, " he told her.As a paramedic called his name in the racing ambulance, he thought it was God. "Devante! Devante! Devante!"With advancements in trauma medicine over decades, emergency room patients now have a far better chance of surviving. Patients who have been stabbed are more likely to live. Better care, coupled with safety advancements, has driven deaths from motor vehicle accidents to historic lows.Gunshot victims, however, are less likely to live.In Baltimore, at the University of Maryland Shock Trauma Center, the nation's first hospital devoted to trauma injuries, doctors sought to assess improvements in care. They studied patients over a dozen years and found that chances for surviving "improved significantly."A notable exception: gunshot victims. In 1999, 9.8 percent of those patients died. By 2008, that rate had risen to 17 percent.The study's authors, including Thomas Scalea, the physician-in-chief at the center, blamed the increasing availability of lethal automatic and semiautomatic weapons on the street. Scalea says that trend continues today. The trauma surgeon said in an interview that he's seeing more "higher-velocity injuries" from high-caliber guns and more bullet wounds per patient.Johns Hopkins researchers also studied trauma outcomes and found that the fatality rate for patients with gunshot wounds nearly doubled from 9.5 percent between 2000 and 2003 to 18.3 percent for the period through March 2005.The study concluded that the overall fatality rate jumped because patients were arriving in grave shape. More patients were dead on arrival, and more succumbed to their injuries within minutes of arriving at the hospital.The median time before they were pronounced dead: six minutes.The researchers at one of the nation's most respected medical institutions concluded that there was little they could do. "The only way to save these patients is to reach out to them in the community before they are victims of violence, " the study concluded. That was when one in four shooting victims died; now it's one in three.RODNEY CHASE HAS PARTICIPATED IN THE VIOLENCE INTERVENTION PROGRAM AT THE UNIVERSITY OF MARYLAND SHOCK TRAUMA CENTER. THE PROGRAM TAKES PATIENTS WHO COME WOUNDED INTO THE HOSPITAL FROM VIOLENCE AND WORKS TO HELP THEM NOT BE A VICTIM OR PERPETRATOR OF VIOLENCE AGAIN. RODNEY CHASE SHOWS HIS SCAR WHERE HE WAS STABBED IN AN ALTERCATION.On the streets in a number of cities, gunmen have increasingly aimed for the head. The number of fatal head shots in Milwaukee doubled in 2015 over the year before, and gunshot victims with three to seven bullet wounds jumped 150 percent.It has been a clear, long-term trend in Baltimore, with the number of fatal head shots rising fivefold over the past two decades.Some criminals are cunning enough to know that more of their targets could be wearing body armor, said Baltimore police Maj. Donald Bauer. This year, police seized body armor in multiple drug house raids - something veteran officers said they haven't seen before.And in a cruel twist, some shooters are taking into account that Baltimore has top-notch trauma care, said former police commissioner Anthony Batts. That's why they aim for the head - to "take the trauma center out of the equation, " said Batts, now a consultant with the AWW Group training police commanders.Gunmen are pumping more bullets into victims. People shot multiple times made up less than 60 percent of homicide victims in 2005, the earliest year for which data is available. That rose to 70 percent by last year.The Maryland office of the chief medical examiner recently studied homicide autopsy reports of gunshot victims dating to 2005. About one-third of the victims died from a single gunshot, and that remained constant over the past decade. But the number of victims shot five to nine times doubled, as did those shot 10 or more times. In one case last year, a victim had been shot 38 times."I never get a single gunshot wound - never, " said Sue Carol Verrillo, nurse manager of the surgical inpatient care unit at Johns Hopkins Hospital.Hospitals across the nation, including in Denver and Newark, N.J., have reported the same trends - the severity of wounds and the sheer number of them increasing year by year.Angela Sauaia, professor of public health, medicine, and surgery at the University of Colorado's Anschutz Medical Campus, was among a team of researchers that completed a study in June of patients at a Denver trauma hospital, comparing chances of survival from various injuries.Again, they found that gunshot victims stood out for falling behind. Their fatality rate jumped 6 percent - every two years."There are more injuries to treat, so no wonder the case fatality is increasing, " Sauaia said. "That was not the norm 10 years ago."Doctors couldn't keep up. "We do know there are more bullets, and the injuries of each bullet are more serious, " she said. "The holes are bigger."Turner-Fordbey, now 24, was one of the lucky ones. Shot 27 times two years ago, he says he was the victim of "karma" after years of Percocet-popping, drug dealing, fights and shootouts.He saw his shooter and believes he was targeted by a rival drug crew over turf. Turner-Fordbey toyed with the idea of retaliating - gathering his "boys, " finding the suspect, and shooting him and everyone with him, leaving no witnesses.But he says he gave up "the game" to focus on being a father to his four children. He's relearned how to walk with extensive physical therapy and keeps the bullet his mother dislodged from his head in a box near his bed.Still, he isn't about to give up his credibility on the streets."I can't be labeled a snitch. I can't be labeled a rat, especially in this city, " he said, explaining why he didn't cooperate with police. "Snitches die.""Code of the streets, period, " he added. "Snitches get stitches. I honor the street code - the G code. I honored it my whole life. I can't tolerate snitching. I can't. My body, my mindset won't let me tell."No one has been arrested in his shooting.‘Rocking you to sleep'The "code" has many connotations on Baltimore streets. To some it's a "gangster" or street code that strictly prohibits snitching to police. To others it's a set of guidelines for when violence is prohibited - no shooting near children or the elderly, for instance - and when violence is warranted, or even required.The Black Guerrilla Family, Baltimore's most powerful gang, distributes typewritten and handwritten rule books to members on the streets and in jail cells. The militaristic rules dictate that infractions can lead to punishment, sometimes death, and include protocols for carrying out violence, such as no shooting near "religious institutions."Covington, the hit man who says he was an enforcer for the BGF gang, describes the "golden rules" as nuanced in some ways, clear-cut in others.You're never supposed to snitch, even on your enemy, he said. And you're not supposed to target your enemy's "law-abiding citizens" - family members who aren't in the drug game. But if those relatives are "in the life, " he said, they can be targeted.Nowadays, however, rules that might have helped to keep a lid on random, collateral violence are regularly broken, according to law enforcement as well as community activists and residents.Davis, the police commissioner, noted that about half of shootings in Baltimore are carried out in the daytime and most are outside.Baltimore Homicide Detective Vernon Parker said perpetrators no longer use darkness "as a mask." They are "more bold, " he said, shooting near churches, schools and other public places."People more cold-hearted these days than when I was growing up, " said Turner-Fordbey, the man who survived 27 shots. "Everybody wants to be a killer. It's more killings going on now because everybody feel like they got to prove themselves."Back in the day, I was told, it was like a kind of rule: The old dudes wouldn't allow outsiders to come in the 'hood, and everybody respected the women and children. Now, it's like no respect for nothing. People don't care."In West Baltimore this summer, shooters opened fire at a church after a funeral and at a candlelight vigil, both being held for other shooting victims. Six people were wounded in those attacks. Eight people were shot last weekend in East Baltimore steps from a makeshift memorial where three weeks earlier a man died and two women were injured in a triple shooting.In Chicago, a South Side gang war sparked a series of shootings. Last year's retaliatory execution of 9-year-old Tyshawn Lee, which became emblematic of the ruthlessness plaguing that city, led his father this year to shoot the girlfriend of a suspect in his son's killing, according to police.The challenge for police is knowing when someone might pull the trigger. Police departments nationwide have turned to predictive policing to try to understand who might be the next killer, or next on a hit list.Chicago police have created the Strategic Subject List, the product of an algorithm that calculates someone's propensity to become a party to violence. A person's score is based on previous police contacts and criminal activity, known affiliations with gang members, social connections or networks, and past injuries from gunshots or assaults.Once a person lands on the list, Chicago police make in-person visits to warn of the "consequences that will result should violent activity continue." Police hope to reach out to 1,500 people this year.They make up a fraction of the city's population but take part in an outsized share of the violence - in the first three months of this year, about three-quarters of the shooting victims and homicide suspects were already on the list.In Baltimore, a similar undertaking has identified 600 "trigger pullers, " who police believe are the most likely to shoot or be shot. People land on the list for a combination of factors, including a history of violent crime or handgun violations, parole or probation, involvement in previous gun violence.Officers monitor them with a "laser focus, " said Baltimore police Col. Stanley Brandford.In many cities, it's a select club. Suspects and targets often know each other. They may have been friends, lived on the same the street or even be related. Many are in the drug trade together. That familiarity allows for face-to-face disagreements that can end with a trigger pull."The distance has closed in a lot of these cases, and now they're up on each other, " said Brandford, who has led the Baltimore police homicide unit two times in his career. "These guys stay in these neighborhoods. They really don't travel very far. And the opportunity to get close and do some damage is prevalent in some of these neighborhoods."Police say a common tactic shooters use to gain proximity is to work with an accomplice who knows the target. The accomplice lures the target to an area, putting the person at ease to ensure a blind-side attack.In gang parlance, it's known as "rocking you to sleep."Criminals today know to get close to their target and fire a lot of bullets, said Stuart Myers, a former police officer who runs OpTac International, which trains law enforcement in Maryland and elsewhere on weapons and tactics. That's because most criminals aren't good shots, he said.Even police officers, who train and are certified, miss their targets more than they hit them. One study put the average hit rate for officers at less than 30 percent."If you're close enough to a target, you could close your eyes and pull the trigger, " Myers said. He estimated that range is within three yards. Then, he said, "you will hit your target."Shooters are also reaching for high-caliber guns with large magazines to ensure they hit their mark, according to advocates working to stem the violence. In some neighborhoods, friends or drug crews pool money to buy guns, and they become shared weapons on a given street corner.Chris Wilson said shooters prefer long magazines, as well as hollow-point bullets, which expand upon impact, causing greater tissue damage and blood loss. The "extendos, " which carry more bullets, have become "an obsession" in street culture, he said."When you get a gun, you got to put an extended on it. You got to. That's policy. You got to be official, " said Wilson, who grew up in Washington, where he was in more than a dozen shootouts.He was sentenced to life in prison at 17 after he shot and killed a man. He served nearly 15 years and moved to Baltimore, where he started a contracting company that connects ex-offenders and the unemployed with jobs.Former Baltimore Deputy Police Commissioner Jerry Rodriguez, who spent the last few years of his law enforcement career in Baltimore after more than 25 years with the Los Angeles Police Department, said he was struck by the "level of determination" among killers in Baltimore. He noted the high number of head shots."I think there's a meaning behind that. I think there's a purpose behind that, " he said. "It's sending a message, but it's also making sure the outcome is what they want."Rodriguez, who works for a company developing technological solutions for police departments, said he found "a much more personal type of killing in Baltimore" - a city of 92 square miles - compared to Los Angeles, which sprawls over 470 square miles.But even on the West Coast, police have noted a shift in shooting dynamics. In Los Angeles, gangs in the 1990s often carried out drive-by shootings, which could be indiscriminate and ineffective if the intent was to kill someone in particular. In the last decade, police said, they've been getting out of the car."You want to kill 'em, not wing 'em, " said LAPD Homicide Detective Chris Barling, describing the mentality of shooters.Police also note an almost cavalier attitude among killers.In Baltimore, a gunman caught on video burst into a barbershop in 2013 and pulled the trigger, but his weapon jammed, so he briefly took a step back, fixed it and took aim again. A gunman who had just shot a man in the head late last year did a three-point turn in his car with a nonchalance noted by Davis, the police commissioner, who said he took his time and "drove away like it was nobody's business."Covington, who said in a series of jailhouse interviews with The Sun that he killed 14 or 15 people and helped carry out hits on several others, explained that he believes the majority of them deserved to die. They were drug dealers, criminals - "people just like me, " he said.He does say that he wishes he hadn't targeted one young victim, a teenager."But generally speaking, I never really think about it, " he said.Hit men for hireIn the Murphy Homes public housing project in West Baltimore, which has since been demolished, Covington grew up on the floor above Solothal "Itchy Man" Thomas, one of the city's most notorious hit men.Covington said he regularly saw people shot, beaten, killed. He was 8 or 9 when he saw a man he only knew as "Country Dave" shot to death at the corner of West Lafayette and Argyle avenues. Dave had been a friend, who gave kids in the neighborhood dollars to buy snacks at the corner market.But Covington didn't turn away from the streets, despite dreams of becoming a boxer or an Orioles baseball player like Cal Ripken Jr. Instead, he sized up one of two paths available to him and other teens in his neighborhood: drug dealing or becoming a "cowboy, " someone who robs drug dealers.He chose cowboy.Covington, now 30 and incarcerated in Westover, Md., can't recall whether the man shot on his first shooting caper survived but said he could have gone to jail for his involvement.As a teen his "neighborhood fame" grew - "I had grown men scared of me" - and as a man he shifted from random violence to targeted murderousness.He was paid to kill. He once charged as much as $50,000, he says, but that was a "package deal." He says that he has also helped set up victims in about three other cases and that he worked in Maryland, Virginia, West Virginia and Ohio.Covington declined to give details about many of his crimes. Baltimore police have suspected his involvement in six to 14 homicide cases.He pleaded guilty to one homicide in Baltimore County. He also pleaded guilty to his role in two other homicides in the city, but received no additional time in exchange for his testimony against a co-defendant. He has been acquitted in another homicide and in one shooting."He was the guy that would kill people for money, plain and simple - that's how he made a living, " said Baltimore Homicide Detective Frank Miller, adding that Covington was part of a clique of gunmen who took murder-for-hire contracts and robbed drug dealers. "There's been several guys over the years that we've encountered, that was their thing."Covington joined the Black Guerrilla Family and intimidated witnesses for the gang. He said inmates held on homicide charges would call and ask him to visit witnesses in their cases. Being a friend - "I take friendship very seriously" - he would oblige.Sometimes he didn't have to say a word; he would smell their fear, see the sweat rolling down faces. Other times, he had to say "some pretty hard and nasty words" to make them think twice about testifying."I don't want to say witness tampering, but in hindsight, it's sort of what it was, " Covington said.The Baltimore Police Department has long struggled with closing homicide cases because investigations are often stymied by a lack of cooperation from witnesses. So far this year, police have only closed 35 percent of homicide cases.As a killer, Covington says, he took steps to evade capture: He wore a ski mask and gloves unless he planned to shoot a victim when they were alone in the woods or in a house - he knew they wouldn't survive to identify him. He lured victims to him so that he could "control the environment."Covington, who now says he wants to help young people avoid the life he chose, was part of an insidious underground world of hit men for hire in Baltimore.Police say these shooters commit an outsized number of homicides in the city. They embody an intent to kill that's ingrained in the city's street culture.In some cases, federal authorities suspect a single hit man in more than 20 homicides going back decades.In recent months, police said they have been tracking the 10 Grand Club, an organization of hit men. Officers said they learned about the "club" from confidential informants but didn't want to jeopardize investigations by releasing more information."It's not hard to shop around for a murder for hire, " said Assistant U.S. Attorney Jim Warwick, who has prosecuted a number of hit men in the city. "They will do it very quickly with no thought involved. They just need the money, the weapon, preferably a photograph of the person, if they don't know the person, and where the person can be found."The typical fee for a hit in Baltimore is $5,000, which may be split between trusted accomplices and subcontracted shooters the hit man may call into action, Warwick said. Some hit men have grown savvy over the years and begun to recruit "younger, violent and cold-blooded individuals" to do the job for them, " he said.They are hired to settle an outstanding drug debt, to kill a woman owed child support or to get back at someone who was perceived to be disrespectful. They typically aim for the head or fire into their victims repeatedly, Warwick said; witnesses are considered collateral damage."The hit man will kill whoever is with the target as well, " Warwick said. "They're expected to finish the job."Three cousins who were gang hit men - Kenneth "K Slay" Jones, Donatello "Little Don" Fenner and David Hunter - rank among Baltimore's most notorious shooters, police said. They grew up in their grandmother's home, and police said they provided each other alibis."Those are some hit men right there, " said Baltimore Homicide Detective Dawnyell Taylor, who considers working Hunter's case, with its sprawling connections to victims, shooters and the BGF, to be her "life's work."Taylor said they are suspected in connection with four to five dozen shootings, often working in tandem to lure victims and then ambush them. Fenner was shot to death in 2010. Hunter got two life sentences plus 40 years last year for shooting a man in the back of the head, and Jones got two life sentences plus 15 years in August for shooting one man and killing another who was rumored to be cooperating with law enforcement.Jones' lawyer, Fareed Hayat, denied that his client and Hunter were hit men - he said they were broke. He questioned whether police have evidence they committed multiple murders because he hasn't seen it. Both men are appealing their convictions.Surveillance video recorded Hunter's hit: walking on a sidewalk in the daytime and passing his victim, who was headed the other way. That's when prosecutors said Hunter wheeled around, shot Henry Mills in the head, and fled through traffic on busy Greenmount Avenue in East Baltimore, near a playground.Deputy Attorney General Thiru Vignarajah, who prosecuted the case, told jurors it was a "public execution."Hours after the killing, surveillance video recorded another scene. Hunter and fellow gang members gathered in Mund Park, a few yards from where police had just cleared the crime tape. One man points his finger as if it were the barrel of a gun at another's head. Another man gives Hunter a high five. Prosecutors said they were celebrating.Police worry about the cycle of violence continuing. "I guess the next one's just, you know, just growing up, " said Miller, who investigated Covington.Pat Brown, a criminal profiler in Maryland, said shooters often develop an "attachment disorder" during troubled childhoods, so that they have difficulty forming long-term relationships and often fail to develop a conscience. They often witness death and violence, becoming numb to it."It becomes a survival of the fittest and you lose empathy for others, " Brown said. "They see people as tools, objects and things."Baltimore streets breed this kind of mindset, she said. "It has gotten out of control with the lawlessness and hopelessness."At age 5, Hunter witnessed a man shot in the back of the head. His mother, fearing retaliation, told him not to snitch, to pretend that he saw nothing, Vignarajah said at Hunter's sentencing. Hunter would grow up to kill a man the exact same way."Mr. Hunter grew up to become the agent of fear, the angel of death that his mother warned him of, " Vignarajah told jurors.Mothers marchAcross the nation, those left behind are consoling each other. Some are reaching out to others who have lost loved ones to shootings. Others are getting organized.Cheryl Hayes, whose 27-year-old son was shot to death last year as he was headed to his postal route in Chicago, commiserates with a co-worker whose son was fatally shot after a dispute at a club. They share pictures of their sons, and of their tombstones. The Chicago Bulls insignia is carved into Anthony Hayes' grave marker."We should be showing each other baby pictures or wedding photos, " said Cheryl Hayes, 54.Her family, it seems, is surrounded by gun violence.Hayes' daughter, Veronika Hayes-Copeland, taught at Harlem Park Elementary/Middle School in Baltimore in 2006 and watched in horror as students were killed in street violence and at least one was suspected in a homicide. At one point, when shooting broke out at a church across from the school, Hayes-Copeland instinctively ducked while her students ran to the window, unfazed.TURNER-FORDBEY'S SCARS FROM THE BULLETS IN HIS LEG.?Last month, Hayes' cousin, Gregory Anthony Sims Jr., 25, was shot dead in the afternoon in Chicago. "Shot him in the leg and he was still running, " she said. "Shot him in the leg again, and then when he fell, shot him five times in the chest. That's overkill."She said she wants to become more involved in the mothers' movement against violence but has yet to find the strength. Support groups for mothers of slain children are cropping up in Baltimore, Chicago and cities across the country, and their memberships are growing. Once an insular crowd, they are becoming more active.Mothers of Murdered Sons and Daughters in Baltimore plans to set up a booth at festivals and other events to reach more parents and anizers are trying to devise novel ways to reach out to children, using toys and games to teach them to get in touch with their feelings and respond appropriately to the violence to which they have become desensitized.They are also trying more explicit ways of drawing attention to gun violence. This summer, with the help of area funeral homes, the group led a march alongside 10 empty hearses on North Avenue. Similar marches have been held in Atlanta, Cleveland and other cities.Escorted by Baltimore police, the demonstrators stopped several times: at a school, at a church, at a March Funeral Home. During the long walk, they loaded their children, hot and tired, into the backs of the hearses, which held coolers of water.At each destination, the several dozen marchers stopped and prayed.They prayed for the people of Baltimore, and they prayed for their sons and daughters in the hearses - the children they had left.Baltimore Sun reporter Justin Fenton and intern Wyatt Massey contributed to this article.A VICTIM BEING PREPPED FOR SURGERY AFTER BEING SHOT A NUMBER OF TIMES, DURING A NIGHT IN THE TRIAGE/RECOVERY AREA AT UNIVERSITY OF MARYLAND'S SHOCK TRAUMA CENTER.Part 2: Oct. 9, 2016Neighborhood violenceBy Justin GeorgeFrom the porch of his neat rowhouse in Northeast Baltimore, the Rev. D. Doreion Colter saw two young men several times that summer three years ago. They would talk and laugh, acting like brothers.Then one weekday afternoon, one shot the other in the head at close range.Colter had watched the pair walk by his house and soon afterward heard a boom, then a second. He looked up to see one of the young men fall and the other run off. Within minutes, Colter pushed back neighbors who crowded around, trying to see the body of Andre Miller, 31, who lay on his back in the street. No one tried to help Miller, though, or see if he was alive.That's because in this neighborhood, Coldstream Homestead Montebello, like other areas in the city, people know criminals are shooting to kill."Most of the time, they assume you already dead, " Colter said of residents.One out of every two people who are shot here die, making it the most lethal of Baltimore's deadliest neighborhoods. The homicides have become so frequent that the community association recruited Colter, a resident, to be its chaplain. His job: to shepherd relatives at crime scenes, organize street vigils and help bury the dead."I sort of guide them through the waters, " said the trim, dignified 71-year-old. From his corner, he can point out the spots in the nearby blocks where a dozen people have been killed over the past several years. "When I hear gunshots, I go."A yearlong Baltimore Sun investigation found that gunshot victims are now more likely to die. Gun violence in Baltimore - and in cities across the nation - is concentrated in poor, predominantly black areas. In the past five years, according to a Sun analysis, 80 percent of homicides by shooting were committed in about one-quarter of Baltimore's neighborhoods.Residents of a few select neighborhoods are condemned to endure a shocking degree of violence. As in Coldstream Homestead Montebello, some neighborhoods saw shooting victims die at a higher rate than the citywide average of one death for every three shootings.And that's in a city that ranks as one of the most lethal in America.The years have brought a devastating and under-recognized shift in Baltimore. Criminals are increasingly aiming for the head and shooting victims repeatedly, often at close range, using higher-caliber guns with extended magazines that enable them to fire more bullets. It's a new degree of ruthlessness that's shocking veteran police detectives and making it tough for trauma surgeons to keep up.The odds for gunshot victims got worse in at least 10 of the nation's largest cities last year - an overlooked trend behind a surge in shootings and homicides in urban areas around the country, The Sun found. The violence is often confined to certain impoverished areas, such as southeast Washington D.C., Chicago's south side and the north side in Milwaukee.Colter, police and criminologists see a potent mix of forces at play- here and across the country.Retaliatory shootings play out over years - not only among rival gang members but among families and friends. The no-snitching ethos is well-established and systematically enforced. The relationship between some communities and the police has fractured, leaving police with fewer clues to solve crimes and parents desperate to try to solve homicide cases. Children grow up exposed to violence, becoming more likely to commit violence."It's just a culture that they're in, " said Daphne Alston, co-founder of Mothers of Murdered Sons and Daughters United. She said killers aren't born, but shaped by their circumstances."Poverty went into their gun, homelessness, bad parents, bad schools, bad communities, bad church, everything went into those guns - everything that they're not getting goes into those guns, and that's what they shoot, " Alston said.But many residents believe gun violence defines the city more than it should, pointing to multibillion-dollar waterfront developments, national attractions and major league sports teams. Over the past five years, in one-third of the city's 280 neighborhoods, including many of the wealthiest areas, not a single person died in a shooting.Still, the power brokers, from police to politicians, know the high homicide rate threatens economic vitality and efforts to draw new residents. And they are scrambling to stop it.In the violence-torn neighborhoods, many residents are simply afraid. Sometimes they are too frightened, or too accustomed to the sound of gunshots to call 911. In a few cases, shooting victims lay in the street all night until someone stumbled upon the body the next day.Some seek comfort in a growing number of ministers who focus on helping residents heal. Over and over, Colter finds distraught people looking to him.Just this summer, he awoke about 3:45 a.m. to the sound of blasts. A few minutes later, he heard two more, bursts loud enough that they seemed to come from a cannon. He jumped out of his bed and peered out the bathroom window.A young man was lying on his back just feet away on the cracked and buckled sidewalk, bleeding under a tree. The street light spotlighted his splayed body. Colter recognized him as Davon Harper, nicknamed "Turtle, " from the neighborhood.The gun violence in Baltimore - and in cities across the nation - is concentrated in poor, predominantly black areas. Coldstream Homestead Montebello is the most lethal of Baltimore's deadliest neighborhoods, according to a Baltimore Sun investigation.?Colter said the 23-year-old victim had been shot and then chased down the alley toward his house. It was there that someone jumped out of a car and blasted him point-blank with a shotgun. Police arrived within minutes.Illuminated by an officer's flashlight, Harper's eyes were closed, his top lip quivered. The minister watched as he gasped."Oh my God, " Colter whispered to himself when the young man's face went slack. "He's gone."In quick succession, paramedics loaded Harper's body onto a gurney, pulled a sheet over his head and drove off. No sirens. Colter remembers Harper's distraught older sister asking over and over: "Why, why? No matter what he did, he didn't deserve this."Colter felt he was able to provide a little peace to Harper's mother, who had cancer and would follow her son to the grave within a few weeks. At the memorial service, Colter told Harper's mother that he sensed her son, who had a criminal record, wanted redemption just before he passed away.No one has been arrested in the deaths of Miller or Harper, and police don't know the motives. Colter knows many people are without closure. The Unitarian minister often recites an old prayer with those who have lost someone to violence: "Thou who are known by many names ... thou who are known and expressed in many ways, it's to thee we come. ... Our request is to make yourself known to us in this hour."He always prays for one revelation: an understanding why so many are gunned down.The same question that haunts Baltimore.Neighborhood violenceOverlooking Lake Montebello and a golf course, Colter's neighborhood in Northeast Baltimore once ranked as one of the city's wealthiest. In the 1800s, William Patterson - whose name is on the Southeast Baltimore park - entertained friends with champagne and strawberries on his lush lawn.In the next century, the city became the first in the nation to pass a law establishing segregation block-by-block. After legal segregation was abolished, unscrupulous real estate agents convinced white residents to sell low by stoking racist fears. African-Americans, limited in where they could live, bought Coldstream Homestead Montebello homes at a markup. Since then, the enclave for working-class black residents has seen a slow decline and a shift to more subsidized housing.Today, the area known as CHuM looks like any of Baltimore's progress-stalled communities where boarded-up vacant homes sit next to rowhouses with neatly kept postage-stamp yards and blooming flower beds.Mark Washington, executive director of the community association, said partnerships with residents, police and city officials have helped make improvements, such as exercise equipment along Lake Montebello and a new picnic pavilion to replace one that burned down. He pointed to one corner where drug dealers were evicted and a store that attracted loiterers was shut down.But Washington and others are not blind to the gun violence in the neighborhood.On one block since May of last year, a man and a woman were fatally shot multiple times. An 18-year-old was shot in the head. Another man was shot in the arm and buttocks but survived.On Colter's own block, police charged a 23-year-old resident with murder in 2014. A bullet grazed a 16-year-old girl last year, and in August detectives arrested a 26-year-old resident in a homicide."They are up-close shootings, " Colter said. "If they're driving by, they're going to jump out and come up and storm your porch or your house, and if you run, they're going to chase you down."Remembering the cries of a man stabbed to death several homes away at midnight a decade ago, Colter sighed. "Oh mercy, " he said, "I call them death screams."Other Baltimore neighborhoods also witness a disproportionate level of gun violence. The streets proved lethal over the past five years in Belair-Edison in the northeast, where 92 people were shot and 33 of them died. In Oliver in East Baltimore, 55 people have been shot since 2011 and 21 died. In Central Park Heights in the northwest, about one-third of 90 shootings were fatal.Underscoring those statistics, Baltimore health officials say as little as half of 1 percent of Baltimore's population is responsible for most of the violence.Many of the homicides are followed a few days later by vigils. Colter helps to organize them in CHuM, explaining to the family the unwritten rules that aim to keep people safe and prevent retaliatory shootings. Stay out of the street, don't hold the gatherings in the heat of the day, and never past dark.Relatives bring candles to spell out the name of the victim. They share memories. A family member usually reminds the group of the grim reality: "This could have been your brother, this could have been your sister, this could have been your child."Washington believes the high rate of lethal shootings is linked to the neighborhood's deep roots. So while drugs and gangs play a part, families have lived on the same block for generations, creating long-standing friendships and deeply felt disputes. The bonds allow suspects to get close to victims, resulting in sure shots.That's not unique to the neighborhood, according to Baltimore Police Commissioner Kevin Davis. Some of the killings in the city this year are over quarrels dating back eight or nine years, he said."The streets don't forget, " he said.As violence becomes an acceptable alternative, the next generation's beefs are playing out on social media, which is used to mock rivals, issue warnings and make daring taunts. Street outreach workers and police detectives say that social media postings have made disputes more contentious and longer-lasting. Threats and insults live forever on the internet.Even jail inmates post threats online. In one video, an alleged shooter being monitored by authorities made veiled threats against people he believed had been labeling him a snitch. On the private Facebook video shown to The Sun, he said: "If you're involved in my motherf - - line, you just need to know that a lot of motherf - - changes is coming today. I'm putting my foot down."Hit men, who take murder-for-hire contracts issued on the streets, advertise on social media, according to Davis. Police are tracking a number of hit men suspected in multiple homicides as well as an organized gang known as the 10 Grand Club that will take out targets for that price.Gang life has become ingrained in many neighborhoods. Some young people find a sense of security and structure in gangs that they don't have at home, even in the face of infighting that has led to a number of homicides in recent years, police detectives say. Gang codes dictate fierce loyalty. Kill orders can't be questioned.The reach of gangs extends to the women in members' lives - mothers, sisters and girlfriends known as "Bonitas." In the Black Guerrilla Family, Baltimore's most powerful gang, they are not allowed to be members, but they know the code and follow it.Officers investigate a fatal shooting at the corner of York Road and Coldspring Lane in early September. The mid-day shooting is like many others in Baltimore, where bold criminals are killing, without masks, in front of witnesses. The shooter in this case has not been identified.Baltimore homicide detective Dawnyell Taylor remembers a case in which police suspected that a 19-year-old killed a fellow gang member. Taylor brought in the victim's mother, who had taken the suspect in as a child because he had no one to care for him. The youth and her son had grown up as brothers and best friends.When the mother pleaded with the youth to come clean to her, the suspect reminded the Bonita that he didn't have a choice: "Ma, you know the rules." ‘No snitching' takes holdBaltimore homicide detective Martin Young understands the fear of cooperating with a homicide investigation. Young grew up in Edmondson Village, a community that has struggled with violence. In a collection of about 10 streets, half of the 14 people shot since 2011 died.His father still lives there. Even the veteran could imagine being reluctant to get involved. He thinks about that when he's off-duty, visiting his childhood neighborhood, and hears gunshots ring out."It would be hard for me to come forth, " Young said in an interview. "I would be hesitant. ... It's not that I don't want to help, but you don't know what the repercussions are."He also knows the alternative all too well - if no one comes forward, the shooter remains free. "Do you leave the individual out there and allow him to kill at will, " Young asked, "or do you do something about that?"Still, the trail remains cold on many cases. Young recalled two brothers hanging out near the intersection of Cold Spring Lane and York Road one Friday last month. It was about 1:30 p.m. when a man walked up and shot one of them in the stomach at close range. Shoppers crowded the busy commercial strip, and surveillance cameras captured the killing. The shooter didn't even bother to wear a mask.But the key witness, the victim's brother, has refused to meet with Young, and police haven't been able to identify the shooter.Young also pointed to a case from January when a young man was kidnapped during the day from his front steps in front of his friends. No one got a license plate number or description. Not a single person called 911. The perpetrators drove the young man to another street, threw him in an alley and shot him to death.In both killings - and about 65 percent of homicides this year - no one has been arrested. Nationally, about 40 percent of homicide cases remained open last year.Police say many city residents do call in tips, but they often aren't witnesses or don't have direct knowledge. Others may know something, but are either involved in criminal activity or are too indifferent or scared to speak up. Echoes of a deadly 2002 firebombing of a family's East Baltimore home, in retaliation for reporting drug dealing, still reverberate."People who don't live in neighborhoods ravaged by poverty can't understand, well why wouldn't someone tell the police?" said Davis, the commissioner. But, he said, they've got reasons."It's fear. It's fear for your own safety, your family's safety. It's very real."While "no snitching" is a common street rule of nearly every city in the United States, its connection to Baltimore became solidified in 2004, when Ronnie Thomas, nicknamed "Skinny Suge, " distributed a DVD featuring drug dealers warning people to "Stop Snitching" with threats of violence.The DVD became an underground and national sensation boosted by the cameo of NBA star and Baltimore native Carmelo Anthony, who has since said he does not endorse the message.More than a decade after the firebombing and the DVD, criminals have not only convinced many residents to stay out of their way, they've devised a way to reiterate and enforce their so-called code.In the past, Baltimore police Sgt. Robert F. Cherry said, snitches found currency in helping police. As they were often involved in criminal activity, it was to their benefit to trade information for possible reduced sentences or charges.But because of the power the Black Guerrilla Family has amassed in Maryland prisons, he said, the gang has been able to widely disseminate the message: Don't snitch, join us and we'll take care of you in and out of jail.The gang's hold became so strong that, for a time, it ruled over the Baltimore City Detention Center. Gang members had sexual relationships with corrections officers and smuggled cellphones and drugs into the center. Last year, Gov. Larry Hogan closed the jail down.The BGF gang continues to hold sway, according to members of Safe Streets, an organization of violence "interrupters" and mediators, including former inmates, who are based in high-crime neighborhoods. Arrestees must prove to gang members that they're not witnesses in any criminal cases.When they arrive in jail, they must show what's called their "paperwork, " or court documents such as pre-sentence reports and testimony. Once the inmate is cleared, the gang offers protection.Police say the court system has inadvertently helped the streets keep its secrets, solidifying the BGF's tight grip, because in recent years they've had trouble quickly obtaining writs, or orders that allow detectives to interview inmates on cases they are working. Sometimes, detectives would take the inmates out of jail and treat them to lunch to try to ply information from them.The process is now delayed, the detectives said, to involve defense attorneys and prosecutors. Homicide detective Vernon Parker said his understanding was that judges didn't want to be construed as an arm of law enforcement, and not impartial jurists. State Courts spokeswoman Terri Charles said judges were not aware of any problems interviewing inmates.Even ex-inmates, felons who have long been out of the drug and gang world, abide by the code. Carmichael "Stokey" Cannady served 12 years in federal prison for drug dealing and reformed. He works as the community outreach coordinator for Shoe City, the Baltimore regional shoe seller that puts on anti-violence events.But, he says, he has been able to maintain his credibility in the community, in part because he remained silent."I didn't tell on nobody. I came home with a good name, a good reputation, " Cannady said. "I dealt with the consequence of my actions. I never thought, never, to turn nobody into authorities."Broken relationsBaltimore's police commissioner, Kevin Davis, remembers the day vividly. It was cold, and Davis, then a newly hired deputy commissioner, was on the scene of a West Baltimore homicide. When he walked into a nearby corner store to use the bathroom, he spotted the owner hurriedly walking up to shoo him away."It quickly dawned on me based on her demeanor ... that she wanted me to get the hell out of her corner store, " recalled Davis, who was in uniform. He realized the owner was terrified that someone might spot him in her business and conclude that she had given him information.In 25 years of police work, Davis had never experienced anything like it.Since then, he has taken over the department and has had to weather scathing criticism about its practices in poor, black neighborhoods.The U.S. Department of Justice, which conducted a civil rights investigation here, recently outlined at length how the department routinely violated the constitutional rights of residents by conducting unlawful stops and using excessive force. It was the culmination of years of practices, including "zero tolerance" policing that led to mass arrests, which alienated young black men - and the community.The effects were also felt in the judicial system, said Cherry. City juries are more suspicious of police, and witnesses are less likely to cooperate."Old Miss Betty who sits out on the stoop" isn't giving police tips anymore, said Safe Streets community liaison J.T. Timpson."She sees them doing all this unlawful stuff she feels shouldn't be going on, so guess what? She is not going to say nothing because you're just as bad as they are, " Timpson said. "Not every police officer is like that, and we know that. But you have too many boys working that have no business policing the city."Even the Rev. Andre H. Humphrey, commander of the Baltimore Trauma Response Team, is frustrated. He leads a group of chaplains that work with Baltimore police, responding to violent crime scenes to help victims and family members. He said he has watched officers slam heads on car hoods and treat family members rudely. "Why should you have to get indignant?" he asked, referring to police.Some say widely publicized incidents across the country in which black citizens died after altercations with police stoked last year's surge in shootings and homicides in a number of the nation's largest cities. That deadly trend continues this year in many highly segregated and impoverished urban areas, including Baltimore.In Baltimore, police, union officials and the mayor have acknowledged one version of the "Ferguson effect, " or "Freddie Gray effect" - that officers shied away from doing their jobs for months after coming under increased scrutiny. Gray died in April 2015 from injuries sustained in the back of a Baltimore police transport van. In turn, some criminologists say the city saw a related effect - that criminals were emboldened by the perception that officers weren't policing.A broader definition of the effect - that violence escalates when communities lose confidence in police - is harder to prove. A study commissioned by the National Institute of Justice recounted the theories: The breakdown can lead to people taking matters into their own hands, to honor codes that encourage people to respond with violence to threats and disrespect, to more "predatory" violence because offenders believe victims and witnesses will not contact police.The study also noted previous research that found when trust in government erodes, homicide rates increase - before the American Revolution, in the Civil War, and during the political turmoil in the 1960s and '70s.But more research is needed to determine whether that's what's happening today, the study concluded.Davis says he's been working to repair community relations and has become a fixture at public forums where residents air grievances. Without the public's help, he knows police can't do their jobs.Dante Barksdale, an outreach coordinator for Safe Streets, said more needs to be done to protect witnesses. He said prosecutors and police are not careful enough in keeping the identities of cooperating witnesses confidential. When police play witnesses off each other, for instance, saying one had cooperated, the stigma for that witness is impossible to shake, and potentially dangerous.Retired Baltimore homicide detective John F. Riddick said he has seen detectives, frustrated by a lack of cooperation and under pressure to solve cases, coerce tipsters and force confidential informants to testify in court. In the past, this network of informants was never expected to go to court and had been the lifeblood of investigations.He also called the department's witness protection program "a joke." He said many Baltimore witnesses have a homing instinct, returning to the city after being placed out of state - "If you grow up in a neighborhood all your life, that's all you know."I can understand why people wouldn't get involved" by cooperating with police, Riddick said.Davis acknowledged that the department needs to improve. "We have to find better ways to incentivize people to come forward with information, and then when people do come forward with information, " he said, "we probably have to find better ways to protect them."Neighborhood as a trapThomas Abt, a Harvard Kennedy School of Government researcher who has studied places like Baltimore and Watts in South Central Los Angeles, has seen that when homicides aren't solved, neighborhood residents may look to street justice, perpetuating violence. He said the feelings in those urban areas can be bleak: "You're on your own. Nobody cares about you. No one is helping you. No one is coming for you."Many families feel trapped in neighborhoods where homicide is a part of life. It can feel as if they are left to fend for themselves. Parents from a number of cities that have seen an uptick in violence, from Baltimore to Washington, D.C., Chicago, New Orleans and San Francisco, recount some universal rules they impart to their children to keep them safe.Don't linger around large crowds in neighborhoods prone to violence because the chances for disputes or gang shootings increase. Don't ride in a car with people you don't know well - they may be involved in criminal activity - or in a car with a large number of young black men, which could make you a target for a police stop.Ursula Newell-Lewis, a longtime social worker in New Orleans, instructed her son, Charles Newell, 24, not to ride in cars with other people. Some of her friend's sons had been killed.When he was laid off from his job, Newell thought it was his chance to get out of New Orleans. She bought him a plane ticket to live with her sister in Waldorf, Md. Upon his arrival last November, a family friend invited Charles to go on a short trip to D.C. to show him how to get around safely.The car was shot up, and Newell was killed.Raichele Jackson's niece, Ranisha Raven, was killed when at least one gunman fired into a crowd last year at the San Francisco public housing project where she had grown up. She was there to visit friends. "Don't discount having a conversation with the wrong person because now you're with them. It's really that simple, " Jackson said.Raven died about 15 feet from where her father, Burnett Raven Jr., was fatally shot in 2006.Andrew Papachristos, a Yale researcher, said violence shows many of the markings of a communicable disease. The closer you are to people who are involved in violence, the more likely you are to get drawn in. Getting a ride or standing with the wrong people can get you killed, as can living next to the wrong person.He tracked gun homicides in Chicago between 2006 and 2012 and found that, just like HIV, gun violence can be transmitted from person to person through "risky behaviors, " he said. In Chicago, more than 40 percent of all gun homicides he researched occurred within a network of about 3,100 people or about 4 percent of the community's population.Being a part of that network increased your chances of being killed by 900 percent.Even a recompense for living in a blighted Baltimore neighborhood can put people in danger. Generations of Baltimore children have been poisoned by toxic lead paint that can cause health and developmental problems. In a sad twist, police said families who received legal settlements stemming from the exposure have become targets of robberies. Police Col. Stanley Brandford said a triple shooting in 2014 was over a lead paint settlement.Ultimately, a stack of studies has shown that growing up and witnessing so much violence affects children's mental and physical health. The stress that the kids suffer can lead to depression and anxiety, and even affect the development of crucial areas of the children's brains - those involved in attention, memory and behavior control. Nearly one-third of the children will develop post traumatic stress disorder.Tara Carlson, director of the Center for Injury Prevention and Policy at the University of Maryland Medical Center, said many people in Baltimore see crisis on an almost daily basis. A study by the center found that adults exposed to violence scored an average of 3.8 on an Adverse Childhood Experiences Study test - comparable to people in war-torn Afghanistan - and half of the clients exhibited PTSD symptoms at a higher rate than some living through the war in Iraq.Though many factors are involved, researchers say the exposure also can put children at risk of becoming violent.Felton J. Earls, a Harvard emeritus professor of human behavior and development, studied gun violence in Chicago from 1990 to 2005 and its effect on children. He found that exposure to firearm violence doubles the chance that an adolescent will perpetrate serious violence over the next two years.Parents as detectivesThat night in 2015, Cynthia Bruce got the call from her sister. She could only hear her son's name being shouted: "Marcus! Marcus!"Bruce drove frantically to the 5500 block of Rubin Ave. in Northwest Baltimore, where she saw crime tape and patrol cars and a paramedic pumping her son's chest. Marcus Tafari Samuel Downer, named after the early civil rights leader Marcus Garvey, would be pronounced dead not long after. The 23-year-old graduate of the Baltimore School for the Arts had been shot 19 times while sitting on a porch."What gun has so many bullets?" she asked.Bruce doesn't know who killed her son or why. She has heard different theories. He was killed because he messed with a child's stroller, and the father came and shot him. Maybe it was because he was talking to a neighborhood girl who was someone else's girlfriend.The shooting occurred during daylight hours and was seen by multiple neighbors. Bruce knows of only one detail that police gleaned from witnesses, that the suspect left in a gray car.She said the Baltimore police detective won't disclose much in the case - only that someone must have witnessed it but is afraid to come forward. At the Baltimore state's attorney's office, she said, homicide chief Don Giblin asked her if she believed in "karma" because maybe karma would catch up with the killer. She was furious.Giblin said "the remark was not intended to give this grieving mother the impression that we would not aggressively pursue justice on behalf of her son." A trained advocate helped Bruce's family through the process, and the state's attorney's office now requires that one is assigned in every homicide case.Bruce decided she had to take matters into her own hands. Whenever she returned to her sister's house from her Carroll County home and saw the woman who owned the stroller, she would ask her: "When are you going to tell the detective who murdered my son?"The woman told her she had told police everything she knew. Unsatisfied, Downer visited her mother's workplace to confront her about a perceived lack of cooperation.The woman filed harassment charges against her. Court records show they were ultimately dropped.Baltimore police spokesman T.J. Smith said the department is trying to be more responsive to family members seeking answers and updates. He said the department is hiring two victim advocates for the Homicide Unit.Other parents around the country who carry the same heartbreak have been driven to take action on their own.Marna Winbush, the founder of Mothers against Gun Violence in Milwaukee, blames deteriorated relations between police and the community. Police Capt. Aaron Raap points to a telling statistic: The number of motorists who failed to stop for police more than tripled to more than 2,500 last year. And Ivy League researchers found in a study released this month that 911 calls dropped 20 percent in black Milwaukee neighborhoods after the beating of a black man by off-duty white officers.Winbush's son, DeShaun Winbush, 19, was shot and killed in 2003, along with two of his friends. She believes it stemmed from an incident months earlier when a girl stabbed another girl she suspected of fooling around with her boyfriend, one of Winbush's friends. Had someone called the police then, Winbush's mother believes, the events that led to her son's killing might have been prevented.Winbush said too many cases of officers harassing or physically mistreating African-American teens or young men have made family members of homicide victims silent. She tells them to give her the information, and she will provide it to police and keep their anonymity.Another mother, Salahaquekyah Chandler, a San Francisco activist, felt that police and the city weren't doing enough to solve the killings of African-Americans. Her 19-year-old son, Yalani Chinyamurindi, was killed last year when he accepted a ride from his job and the car was shot up. She chafed at social media references to her son and other victims as "thugs."Chandler scratched her son's name, the date he was killed and other case facts into the side of her bronze Nissan Pathfinder - turning it into a rolling billboard seeking tips.In March, Chandler and other mothers of homicide victims succeeded in lobbying the San Francisco Board of Supervisors to increase the amount of reward money to as much as $250,000 per unsolved case.In Baltimore, one father is trying to raise money so he can hire a lawyer to investigate the shooting death of his 20-year-old son, Shakim Gilliam.The young man drove to Belair-Edison with friends in October 2014 to buy some marijuana. From talking to police and his own sleuthing, the father believes he entered an alley near a vacant house to make the purchase when he walked into a setup. He was made to kneel on the ground before someone shot him through the head.The friends who brought his son there did not call 911. No neighbors called about the gunshots. His son's body wasn't found in the alley until the next day.Gilliam's father has felt stymied in his attempts to get information from police. Determined to get justice, Shakim Shabazz drove down many times from his home in New Jersey, knocked on doors, and talked with folks. His theory is that two men with ties to the BGF gang held his son responsible for a friend's drug money that went missing.He uses words like "uncontrollable" to describe what's happening in Baltimore and other cities. "It's kind of like outrageous and like unbelievable how people's lives right now have no value, " he said.He is angry that no one has been arrested, and he is devastated. It feels to him like it happened yesterday."It's been two years, " said an exasperated Shabazz. He tries not to think about timing, and what might have been. Shabazz was working on getting a larger apartment, so his son would move up to Jersey with him, away from Baltimore. Just before his death, Shabazz assured his son the move would happen, telling him to hang on for a few more weeks.Healing woundsLast Sunday night, the Rev. Jay Baylor grabbed the microphone and walked to the front of the fellowship hall at the Church of the Apostles in the City, an Anglican church in Mayfield. The neighborhood borders CHuM in the northeast part of the city."We experience loss and trauma, " the lead pastor told about 40 attendees. "But that was not God's plan." It was the first of several healing services in response to recent violence. Over a period of six months last year, at least three people close to members of his congregation had been killed. Among those hurting was the church's assistant pastor, Carletta Wright.In January, Wright's nephew, Lamont Raheem Malloy, 24, was shot to death in the 1200 block of Patterson Park Ave. in East Baltimore.Wright grew up in East Baltimore and has overseen candlelight vigils, presided over a dozen funerals for shooting victims and worked to stop violence. Six years ago, when she saw a man armed with a gun chasing another man, she launched herself off her front steps."Don't shoot him, in the name of Jesus!" she yelled at them. She was shoved to the ground, and the men scattered. She heard the would-be shooter tell the targeted victim, "You're lucky this time."Baylor, who was in the area that day, happened to see the encounter. The two ministers paired up to found the Church of the Apostles in the City two years ago. "These are important issues to the Lord. Issues of justice, issues of healing. … We believe the church has a vital role ... and we've been silent, " Baylor said at last Sunday's service.A band soon launched into gospel music, and after a few songs, Baylor introduced Betsy Stalcup, who directs the Healing Center International, a faith-based counseling and mentoring ministry in Virginia.Over the soft notes of a guitar and keyboard, she spoke soothingly, taking attendees into a group therapy session. She told parishioners she would "walk you through grief" and urged them to breathe deeply and slowly."In the name of Jesus, " she said. "Release the grief. Release the grief."Even as they breathed, police detectives were investigating the latest homicide in Southwest Baltimore.In his neighborhood of CHuM, Colter also has come up with a plan to help the families. He's mulling over a way to promote it, maybe with fliers.The minister rues that Davon Harper, whom Colter watched die from his bathroom window, had to have his memorial service at the local neighborhood center, and had to be cremated, because his family couldn't afford anything else. The minister knows most parents want a coffin and a grave for their children.His proposal is to get parents whose children are involved in drugs and gangs to purchase life insurance for them. "For $18 a month, " Colter says, "they could have put them away decent."Colter realizes that for these families, even that small amount is a sacrifice. But after years of seeing things play out on the streets, he understands that just as some families save for cars or college, the parents here should save to bury their children.Interactive designer Jin Kim contributed to this article. Part 3: Oct. 16, 2016Wounds like combatBy Justin GeorgeJust after midnight, medics rushed the gunshot victim into the last available trauma bay, and nurses and doctors swarmed. They needed to stop the bleeding.As one staffer cut off the patient's clothes that night this summer, Dr. Jason D. Pasley began a careful search of the man's body for bullet wounds. The holes can be as small as a pencil eraser, and the team rolled the man to check everywhere - behind knees, in armpits, along the hairline. One by one, Pasley called out what he found - a hole in the back, in the buttocks, in the leg - until he got to six.Surgeons call it "bullet hole math." An even number indicates that bullets might have gone through. An odd number raises the likelihood that a bullet may still be in the body."If the math doesn't add up, you are missing something, " said Pasley, a long-serving trauma surgeon at the University of Maryland Shock Trauma Center in downtown Baltimore. "The more you're shot, the more likely you are to hit something serious, the more likely you are to die."The gruesome ritual has become more common in hospitals nationwide. At Shock Trauma that week, it was the seventh night in a row doctors had had to rely on the crude calculus. Emergency rooms are struggling to save gunshot victims arriving in worse shape than ever before, with more bullet wounds, and increasingly shot in the head. Even as advancements in trauma care have saved countless lives, victims of gun violence have seen their chances of survival drop, exacting a toll on victims' families, medical personnel and taxpayers.More than $80 million has been spent at Baltimore hospitals caring for patients shot in gun crimes in the past five years. During that time, the number of cases doubled and the annual price tag soared nearly 30 percent. Most of the medical costs are now covered by Medicaid, the federal-state health insurance program for the poor."We spend every night trying to row upstream against this, " said Dr. Thomas M. Scalea, physician-in-chief at the R Adams Cowley Shock Trauma Center, the first of its kind in the nation. The 55-year-old center is named for the pioneering surgeon who coined the phrase "Golden Hour, " the time after injury when trauma patients have the highest likelihood of survival.Scalea says that time can be mere minutes for gunshot victims. He said his experience treating them has become emotionally numbing. "You get outraged for a while, " he said. "Then you get the next one and you go - what are you going to do?"Outside the hospital, first responders are trying to keep up with the merciless uptick in gun violence. Baltimore police officers have begun carrying tourniquets, which constrict blood flowing from wounds, and a national push is underway to make the devices as widespread as defibrillators and as commonly understood as CPR.Police officers in some cities - rather than waiting for an ambulance - load gunshot victims into squad cars to get the wounded to a hospital before it's too late. Both law enforcement and paramedics are adopting military-grade equipment and practices from combat situations.The changes in trauma medicine have coincided with deadly trends on the streets of Baltimore and other major U.S. cities, The Baltimore Sun found in a yearlong investigation. Criminals are using higher-caliber guns with large magazines and bullets that destroy tissue and pulverize organs. Crime scenes are littered with dozens of shell casings, and victims are bleeding out more quickly. Shooters are exhibiting a brazen ruthlessness that surprises even grizzled law enforcement officials.?The increase in the number of gunshot victims creates a challenge for trauma surgeons at area hospitals.?With so many shooting to kill, The Sun found, odds for gunshot victims have gotten worse. For every three people shot in Baltimore, one person dies, making it one of the most lethal of America's largest cities and deadlier than a decade ago. Other cities are also seeing spikes in gun violence and lethality. Among them: Washington, Chicago and New York.The onslaught has left surgeons, public health and other medical professionals outraged and looking for ways to stem gun violence."What's surprising to me is that we're a society that is willing to live with this, " said Dr. Angela Sauaia, professor of public health, medicine, and surgery at the University of Colorado Anschutz Medical Campus. She said that if gun violence were a disease, a one-in-three chance of survival would be considered an epidemic."This would be a scandal if it was happening with breast cancer or heart attacks, " she said.Many police chiefs and researchers say that to make real progress, one crucial piece is missing: better data. With scarce federal funding for gun research and antiquated, inconsistent record-keeping, it's tough to track what's happening. The total number of people shot nationwide, for instance, cannot be accurately counted.There is some hope, as public-health and other researchers are devising novel ways to try to understand the violence, by analyzing patterns in where victims live, and figuring out better ways to reach the people doing the shooting.For now, many victims are showing up to hospitals in grave condition. Many will need what surgeons call a "great save."At Shock Trauma this summer, the patient cried out in pain and begged the medical staff to stop examining him. "Don't do that, " he yelled. Then, as if he realized they were trying to help him, he gritted his teeth, urging: "Do your thing, do your thing."Pasley knew the patient had been shot repeatedly. But he still didn't know how many times. The counting is only part of the equation.The patient could have been shot three times, or he could have been shot four or more times, the bullets still lodged inside him. Pasley also had to imagine the possible trajectories of those bullets. Any one could have hit a bone that might have then fragmented and cut an artery or a lung.So the team ordered X-rays and later rushed him to surgery.Unlike about 200 gunshot victims in Baltimore so far this year, he survived.Wounds like combatScalea has run this storied center and its troop of staff in signature pink scrubs for almost 20 years; he is also professor of trauma surgery at the University of Maryland School of Medicine. When a police officer, medic or firefighter is seriously injured, he is paged to oversee the case. He's one of the most recognized trauma surgeons in the world.But even at the top of his game, Scalea is challenged by the gun violence coming through the hospital doors. Now more than 60 percent of homicide victims are shot in the head, up from less than 15 percent two decades ago, and the number shot more than five and 10 times doubled in the past decade, The Sun found. It's enough to make physicians feel that they are losing a fight over which they have no control.A few months ago, Scalea was confronted with a patient on the brink of death, with maybe a 3 percent chance of survival. The victim had been shot six or seven times - in his chest, his abdomen and his arm, where one of the major blood vessels had been hit. As the ambulance arrived, the man's heart stopped.Scalea opened the patient's chest and began "open massage" on his heart, manually clapping it back to life with the help of blood transfusion and medicine, until his team readied the defibrillator. "We had to shock him three or four times to get his heartbeat to sustain, " he said.It took more than three hours in the operating room for Scalea to get him partially stabilized. The patient was hemorrhaging from his spleen, pancreas and stomach. He needed a transfusion of 20 units of blood - about three times his entire volume. After the man's condition improved, Scalea operated again, this time for more than three hours.Against the odds, the patient survived."A great save is the term we use in the business, " Scalea said. "We're not out of the woods, but he is far more stable than he was early on. And I'm hopeful."Other nights, it's a great loss, and he must tell another stricken family of a loved one's death.Scalea has witnessed the consequences of two trends behind the increase in lethality. Semiautomatic weapons of a higher caliber are being seized from criminals in greater numbers, and higher-capacity magazines have become the norm in gang and street cultures.Pasley, an Air Force veteran, sees parallels between the multiple-gunshot victims he sees at Shock Trauma to what he saw as trauma director at Craig Joint Theater Hospital at Bagram Airfield, the main hospital for the U.S. military in Afghanistan, where he was deployed in 2014.The carnage in both places is extensive, he said. The difference is that when soldiers are hit with improvised explosive devices, they might need amputations but have body armor protecting vital organs. In Baltimore, when victims are hit, it's often with hollow-point bullets that expand on impact, causing tissue damage and blood loss.At Johns Hopkins Hospital, Dr. Elliott R. Haut, another experienced trauma surgeon, has seen a range of gunshot injuries and patients who have required incisions from "stem to sternum" so that doctors could assess and address the damage caused by multiple bullets. He's seen patients shot in the heart, liver, bowels."Every body organ you can imagine, " Haut said. "I had a guy recently, he had different gunshot wounds, probably 10 different wounds in and out, here and there, basically from his head to his legs."Gunshot wounds to different areas of the body can require more specialists for consultation and care. A bullet to the heart could require a cardiac surgeon; a head shot could call for a neurosurgeon. In some cases, surgeons stand on opposite sides of the operating table so they can work simultaneously on different areas of the body."Some of these people need three, four, five operations, " Haut said of the victims. "It takes a lot of work."Baltimoreans have come to believe that the city's top-ranked medical systems have kept the homicide count lower than it would be otherwise. "If it wasn't for the fact that Maryland has one of the best EMS systems in the country, our fatality rate would be much higher, " said Dr. Carnell Cooper, a former Shock Trauma surgeon who now serves as chief medical officer and vice president of medical affairs at Prince George's Hospital Center.Others, including former Baltimore Police Commissioner Anthony Batts, suspect a more sinister corollary is at play- that criminals are firing more bullets and aiming at the head to ensure that the world-class surgeons won't succeed.Baltimore hospitals get three-fourths of the state's gun assault cases, and costs have risen to $19 million a year, state data show. Nearly 80 percent are covered by Medicaid, and patients don't have any insurance in about one-fifth of cases. Those costs, known as charity care, are borne by all residents of the state with insurance as hospital rates are calculated to cover them.Meanwhile, hospitals are staffing up. In 2004, Hopkins had one trauma surgeon. Now, there are six or seven doctors working full-time in trauma care and emergency surgery. A trauma surgeon has been put on rotation at the hospital around the clock as at Shock Trauma, which is a key part of the state's emergency medical system.With these doctors come associated services on call, such as a blood bank, CT-scan technician and staff to ready operating rooms even before an ambulance arrives.Sue Carol Verrillo, nurse manager of the Hopkins surgical inpatient care unit, said shooting survivors can remain hospitalized for weeks, adding to costs. They require vacuum-assisted dressings and extensive pain medications. Many will need long-term care, with occupational and physical therapy.She sees four to six violent crime victims a week and has come to believe that sometimes shooters are aiming to shame with wounds of humiliation. Earlier this year, she said, two patients' eyes were shot out. She said police have told her that some were shot in the buttocks on purpose, as they were running away. Some are deliberately paralyzed."You're going to be in a wheelchair for your whole life, " she said. "The nature of the wounds have changed."In complex gunshot cases, patients can "bounce back" to her unit, before being discharged from the hospital, when they develop complications such as infections or internal bleeding. Over a three-month period through early March of this year, she had a record 23 bounce-back patients.These patients require double the supplies: another feeding tube, more drains, more dressings that need to be changed two or three times a day, catheters, external fixators to keep bones in place as well as medicine to manage nausea. That can add thousands of dollars to her monthly supply budget, Verrillo said.Haut can't help but think it's all so unnecessary, that these costly injuries could have been prevented."It's a giant waste of money."Anguish for families, staffEight security guards caught Lekya Missouri as she tried to push past them."If you don't let me through right now, " she told them, "you're going to have a problem."The halls outside Johns Hopkins Hospital's emergency department were crowded with police, worried family members, doctors and nurses. Eight people had been shot in one incident the last Saturday in September in East Baltimore. Among them: 3-year-old Kendall Brockenbrough, Missouri's daughter.At Johns Hopkins Hospital, Lekya Missouri, 37, prepares to give her daughter, Kendall Brockenbrough, 3, Valium and apple juice. Missouri has been staying overnight and helping the medical staff care for her daughter. Kendall was shot in an octuple shooting last month. Kendall has been in so much pain that whenever she sees medical personnel enter the room, she gets upset. She has an external fixator device on her left leg where she was shot. Pins are placed through the bone to keep it immobilized; the device is very painful.?Missouri spotted a hospital social worker walking toward her and immediately thought, "No, no, no!"Her mind flashed back to June 2011, the last time a hospital social worker had approached her. Back then, the staff member told her that her husband, Henry Mills, had been shot in the back of the head and killed. Missouri had to identify her husband as he lay on a gurney, his chest and legs covered by a white sheet. She asked hospital workers to wipe up the blood pooling under his head.Mills had been shot by David Hunter, a member of the Black Guerrilla Family, Baltimore's most powerful gang. Hunter, who is serving two life sentences plus 40 years for the crime, is considered a hit man by Baltimore police. This class of shooters, who take murder-for-hire contracts issued on the streets, are responsible for an outsized share of city homicides, police say.This time the social worker escorted Missouri to a trauma bay. Kendall was alive. Her father hovered over her, singing "Five Little Monkeys Jumping on the Bed" to distract her from the pain of a broken left femur and a ruptured artery. She had taken a shotgun blast."Mommy, mommy, " Kendall sobbed when she saw her.Kendall had been outside with her father when three gunmen approached from different directions and fired on the crowd, according to police. The father had also been hit, in his foot, and it was bleeding. He had refused treatment until he knew his daughter would survive.Missouri jumped in and sang the nursery rhyme with him. Later, as doctors sedated Kendall for surgery, her mother told her how much she loved her. During an eight-hour operation that included two blood transfusions, doctors removed a section of artery from her right leg and spliced it into her left leg.Three surgeries later - to remove bone fragments and scar tissue and close wounds - Kendall is on her third week in the hospital. One day last week, she lay under a pink blanket depicting Disney's "Frozen" movie, her left leg held together by a heavy external fixator that resembled metal scaffolding. She alternated between grimaces, uttering "ow, " and the unsinkable amiability of a toddler.She had been a girl who was gaining independence: She had finished potty training, started picking out her own clothes and could tell her right shoe from her left. Now, Missouri said, she would have to relearn to walk in a rehabilitation hospital, where she is scheduled to stay for up to two months after she's discharged.Kendall wasn't "just shot, " Missouri, 37, said. "It was a life-changing event."Will Kendall have full feeling in her foot? Will her leg grow properly? Will the scars on her skin make her suffer teenage humiliation?These are her mother's worries, and they go on. How long will Kendall need counseling? How long will she need painkillers? And for today, how long will we be able to entertain her by blowing bubbles or playing with an iPhone? When will the violence end? Missouri, who lives in White Marsh, is at a loss to understand why gun violence has hit home twice. She recently bought a Bible looking for answers - or at least a different future."My kids have suffered. I have suffered, " Missouri said. "Now my youngest daughter suffers."A nurse walked in with a vial of Valium, and Kendall started crying. "She's not gonna touch my feet. No, I don't want her to hurt me, " the girl said.Last week, a doctor removed his white lab coat in an attempt to put Kendall at ease after she asked, "Are you going to hurt my leg again?" This time the nurse promised to stand by the door as Missouri tried to get her daughter to drink the Valium from a syringe through gritted teeth.The girl turned her head, smacked her mother's hand, hid her face.Eventually, Kendall swallowed the medicine. Missouri heaved and hid her face in her hands as she cried. She tells herself she can't be upset at her daughter's lashing out. Missouri says she is grateful."She's here, " the mother said. "She's here."It's the fear and anxiety that hospital staff also need to tend to, with the help of social workers and pastoral care. And sometimes, they need extra security, as was the case in the shooting that wounded Kendall. A shootout can bring victims, perpetrators and their families to the hospital, and Verrillo has to ensure they remain on opposite ends of the hall."We have to have very clear boundaries, " she said.It can be difficult to remain at a clinical distance. Dr. Rodney Omron, an emergency physician and associate program director of emergency medicine at Johns Hopkins Hospital, recalls the "execution-style" shooting of an apparently homeless man he often saw on his way into work.Like law enforcement officials, Omron notes a more brazen cold-bloodedness among shooters. That's hard to quantify, but over the past two years, Baltimore, among a number of cities, has seen a steep rise in homicides.In recent months, it seems as if almost every Friday night he has to tell family members a loved one is dead.Omron had to put a breathing tube in his own father and watched his mother, who succumbed to cancer, die in his arms. He served as a physician for the Marines in Iraq. "I thought I had seen everything, " he said.Then he came to Hopkins. He said he has seen mothers suffer heart attacks from grief. He's also tried to comfort patients, sharing with one gunshot victim what his mother often said when she was fighting cancer: "Every day is a different gift from God."The patient disagreed. He'd watched his mother commit suicide and was a victim of abuse growing up. He had just gotten out of jail and, because of his injuries, was facing a life with a colostomy bag. Now he worried his son will never respect him.So he wanted to die.Omron felt powerless."I have to bear witness to somebody else's sins that I have no control over, " Omron said. "It's like a disease I have no cure for."‘Stop the Bleed'More and more, the wounds of urban gunshot patients look like those from war.Studies have shown that many of these victims have died from three potentially preventable injuries often seen in battle - massive bleeding, obstructed airways and open chest wounds. A gunshot victim struck in an artery can bleed to death in five minutes. Certain victims, depending on the location of their wounds, could be saved if they receive prompt care. Those parallels have sparked the health field to institute life-saving practices borrowed from the battlefield. Emergency rooms are stocked with Velcro tourniquets to stop bleeding, something that trauma surgeons and federal officials believe will become commonplace in stores, malls and workplaces in the near future.Even school districts are looking at acquiring tourniquet kits, said Dr. Richard Alcorta, state medical director for the Maryland Institute for Emergency Medical Services Systems.Haut, the Hopkins surgeon, carries a tourniquet with him at all times and compares the coming changes to how CPR became more commonplace."When it first came out, they said, ‘Oh, it's just for doctors.' Now it's for everyone. There are defibrillators everywhere. This is the same thing, " said Haut.The American College of Surgeons and Homeland Security officials are teaming up to make tourniquets widely available and train the public in using them. The national push comes after mass shootings and mass casualty events, such as the Boston Marathon bombing. Homeland Security began the "Stop the Bleed" campaign late last year.In Baltimore, everyday violence warrants the same preparation. The Police Department started issuing tourniquets in 2015, and officers carry them on their belts. Already this year, at least two officers have saved lives using them, and just Wednesday night, a tourniquet was used to clamp the wounded wrist of an officer who accidentally shot himself while approaching a carjacked vehicle.Other cities have already expanded their efforts. In Philadelphia, Temple University Hospital is teaching residents in high-crime neighborhoods how to give life-saving care to gunshot victims, including how to use tourniquets.Also in Philadelphia, police have long practiced "scoop and run" with seriously injured victims. This allows officers to take trauma victims from scenes to hospitals in their patrol cars, bypassing ambulances because speed could save a life. Last year, Philadelphia police took more than 2,250 people, including gunshot victims, to area hospitals."There have been a lot of lives saved over here because of that practice, " said police spokesman Lt. John Stanford. "We can't just sit here and let this person bleed out, so we throw them in a car and go."Still, most people killed by gunfire die where they are shot, said Dr. Garen Wintemute, director of the Violence Prevention Research Program at the UC Davis Health System in California. "Trauma people don't have a crack at these people. They're just dead, " he said.Even if they make it to the emergency room where trauma medicine has improved dramatically, their odds of survival are getting worse, according to a number of hospital studies across the country, including in Baltimore. In most U.S. trauma centers, even though firearm injuries account for a fraction of injured patients, they result in the same number of deaths as motor vehicle accidents - the most common reason people land in emergency rooms, according to a recent report in the Journal of Trauma and Acute Care Surgery. Researchers say gun violence has become a public-health crisis and needs to be studied like an epidemic. About 11,000 Americans die a year in gun homicides."It's complex and it requires a broad investigation much like you would do with any disease, " said Dr. Stephen Hargarten, chair of emergency medicine and director of the Injury Research Center at the Medical College of Wisconsin. "We did this with HIV."But there is a lack of data on what's happening at crime scenes. For instance, many police departments don't track how many people get shot and survive. So researchers can't determine how lethal gun violence has become."We centralize data on cancer, we centralize data on vaccinations, things that are important. Let's put more money into it and start a national intervention on this, " said Sauaia, from the University of Colorado Anschutz Medical Campus, which undertook one of the latest studies on gunshot patients based on a Denver trauma hospital's data.By collecting the data available from the nation's largest cities, The Sun found that gunshot victims in at least 10 cities were more likely to die last year compared to the previous year. But half of the 30 biggest cities don't keep statistics on non-fatal shootings.Funding for gun violence research has dried up in the past two decades, since Congress restricted spending by the Centers for Disease Control and Prevention on studies that could be construed as promoting gun control. Gun rights advocates, including the National Rifle Association, argued that guns are not a disease.Dan Blasberg, president of Maryland Shall Issue, which advocates for gun owners' rights, said researchers should approach their work comprehensively, rather than ideologically. Instead of focusing on suicide by firearm, he said, they should explore the root causes.Part of the fallout from the void in research money is the disappearance of gun researchers. Wintemute determined that there are no more than a dozen active, experienced researchers in the country who have focused primarily on firearm violence. To do his work, Wintemute eventually decided to self-fund the research."Firearms and the impact that they have on public health gets a very little piece of the pie, " said Dr. Cassandra Crifasi, an assistant professor in the Johns Hopkins Center for Gun Policy and Research.In June, in response to the Orlando nightclub mass shooting, five of the nation's medical associations representing more than 420,000 doctors called on Congress to provide the CDC with funding for gun violence research.Another approachIn lieu of scientific study, many medical professionals are intervening in other ways. Many hospitals, like Baltimore's Shock Trauma Center, have noted the "frequent flier" phenomenon, in which victims of violence show up two or more times as patients. Studies have found that these people are much more likely to die in a violent crime once they've been shot or stabbed and survived.Shock Trauma, under Cooper, created the Violence Intervention Program in 1998. The effort connects patients with resources, monitoring and counseling to steer them away from violence. Cooper studied outcomes of the program and found it had a profound effect on participants who reformed and got jobs. About 900 patients have enrolled in the program.Last month, the city health department received a $500,000 grant from the U.S. Department of Justice to start a program like Shock Trauma's. The planned program, called the Baltimore City Thriving Communities Project, will use Safe Streets intervention workers, ex-felons who try to interrupt violence by helping to mediate disputes, in hospital emergency rooms.In Philadelphia, Temple University Hospital's anti-violence program Turning Point does similar work, but goes even further, showing gunshot victims who have recovered a video of their actual resuscitation in the emergency room. It helps victims understand how hard it was to keep them alive, and how many people cared enough to help.The hospital has another program, Cradle 2 Grave, which takes middle-school children through a simulation of what actually happened to a 16-year-old, Lamont Adams, shot 12 times in 2004. The students lie down on gurneys, while hospital workers put red stickers on their bodies to mark where the bullet holes were on Lamont.These programs, along with police efforts to "scoop and run" with gunshot victims, have been underway for years, in some cases decades. Philadelphia's lethality rate has remained largely unchanged for years while lethality rates have risen in other cities.Meanwhile, researchers such as Dr. Daniel Webster, director of the Center for Gun Policy and Research at the Johns Hopkins Bloomberg School of Public Health, are increasingly examining the networks of the victims and the perpetrators. Much of the violence is concentrated in poor, segregated neighborhoods. In the 92 square miles of Baltimore, a Sun analysis found, 80 percent of homicides by shooting in the past five years took place in about one-quarter of the neighborhoods.Webster describes urban gun violence as mimicking the outbreak of an infectious disease. "It's person-to-person exposure and social contacts, " he said.To investigate this idea, the Baltimore City Health Department is exploring the launch of a survey of residents to determine how many people have been shot or victimized and look for patterns. Health officials want to map where homicide victims lived - not where they were killed - to see if trends can be extrapolated as to how gun violence might spread.One man is going directly to the shooters to look for answers.James Evans is the CEO of Illume Communications, a Baltimore advertising firm that has worked for CVS Pharmacy, Timberland boots and Chase Brexton Health Care. He was hired by the city health department to figure out how to the reach the men doing the shooting, to convince them to put their guns down.It's a challenge that has vexed researchers from Hopkins to Harvard University, as well as police departments, trauma surgeons and grieving families.So far he has discovered that shooters are more likely to listen to the women in their lives - mothers, sisters - and that they aren't afraid to die. So he's found another angle that does resonate with them, asking: What if you survive a shooting?What if you're paralyzed? What if you're in a wheelchair for the rest of your life and called "knees down" - a street nickname for these victims. What if you'll need a colostomy bag?Evans, who grew up in Park Heights and lost two family members to violence and more than 10 to drugs, also learned a big reason some of these young men are carrying handguns - not to be aggressors, but to protect themselves."Those who don't live here, don't understand. ... Like the Wild Wild West, real men - John Wayne kind of men - are expected to carry a gun, " Evans said."If there was a way for people in those neighborhoods to feel less afraid, there would be less impetus to carry a weapon."In the end, some shooters may be just as scared as everyone else.Baltimore Sun reporter Meredith Cohn and intern Wyatt Massey contributed to this article.jgeorge@baltsun.justingeorgeABOUT THIS SERIESBaltimore Sun reporter Justin George spent nine months during the 2015-2016 school year at Marquette University in Milwaukee as part of the O'Brien Fellowship in Public Service Journalism, working on “Shoot to Kill” while mentoring college students and speaking to journalism classes. He traveled to five cities to research gun violence; analyzed crime data from cities across the U.S.; reviewed dozens of studies on violent crime, trauma and guns; and interviewed more than 80 people, including homicide detectives, police chiefs, hit men, ex-offenders, researchers, emergency room doctors, nurses, trauma surgeons, family members of victims, neighborhood residents, prosecutors and survivors of shootings. Four college students served as research assistants as part of the O'Brien Fellowship program. They were Wyatt Massey, Hannah H. Kirby, Natalie Wickman and Matthew Kulling. ................
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