I am a general urologist in Muskegon, Michigan. Muskegon is a small to midsized community on the shore of Lake Michigan. In many ways, Muskegon is much like any other Midwestern community. It is a historically industrial city, trying hard to adapt to the challenges of the new global economy.
In January 2014, our local hospital opened a Level II Trauma Center. Since that time, the service has admitted and treated 25 pediatric patients with gunshot wounds. Many more gunshot victims have been treated and released from our emergency department (ED) without requiring surgical intervention. Of the patients that have been admitted, some have died, some ultimately have been able to walk out of the hospital, and some, with spinal cord injuries, have rolled out of the hospital in wheelchairs, never to walk again.
Dodging a bullet, losing the war
Recently, I was called to the operating room to assist in the care of one of these victims. A seventeen-year-old boy had just been shot in the abdomen. As the bullet traveled through his body, it lacerated his liver, avulsed his right ureter, and came millimeters from shredding his vena cava. I repaired his ureter. The trauma surgeon chose to manage his liver injury conservatively. From a life-and-death perspective, this young man literally had just dodged a bullet.
On that day, we might have won the battle, but it suddenly became clear we were losing the war.
That evening, I visited the intensive care unit (ICU) to follow up on the patient. Fortunately, he was doing well. The nurses were strangely familiar with him. What happened next shocked me. I learned that this wasn’t his first visit to the ICU after a gunshot injury. It was his third.
Adverse childhood experiences
Later that evening, when my wife, a social worker, asked me about my day, I told her, in generalities, what I had seen and experienced. I lamented that I couldn’t understand how something like this could happen in our community. She shared with me that she had recently been to a conference on the effects of adverse childhood experiences, or ACEs.
As our conversation continued, my interest grew. Over the next few months, I did some further reading, and asked more and more questions. My wife suggested we watch the movies Paper Tigers and Resilience together. Suddenly, everything made more sense.
The original study on ACEs was undertaken by Drs. Vincent Felitti and Robert Anda at Kaiser Permanente, San Diego, in the mid-1990s. More than 17,000 volunteers were questioned during the study.
Study volunteers were asked questions about 7 categories of ACEs including:
· Physical, psychological, and sexual abuse;
· Household presence of mental illness, substance abuse, or suicide;
· Parental separation or divorce;
· Violence against their mother or stepmother; and
· Incarceration of a household member.
The authors of the study found exposure to ACEs was common. The most remarkable finding of the study, however, was that as the number of ACEs increased, so did the risk of these same patients developing coronary artery disease, cancer, chronic obstructive lung disease, and other chronic diseases in adulthood.
Even though I take care of pediatric and adult patients, somehow in my mind I had always separated these 2 groups of patients. It never occurred to me that what happens to a person during childhood could go on to increase his/her risk of developing chronic disease(s) during adulthood. For me, this was a real paradigm shift.
If, like me, you have never heard or read about ACEs research, I would recommend that you start by taking a look at the Centers for Disease Control and Prevention (CDC) webpages on the topic.