Treating gunshot wounds part of children's care in St. Louis

ST. LOUIS (AP) — Dr. Martin Keller stood to the left of Trevin Gamble's nearly lifeless body as the 15-year-old's chest was doused with Betadine, a yellow-brown disinfectant, in the midst of a hectic emergency room.

Waiting with a specialty knife that resembles a shiny, miniature putter, Keller made an incision starting with the sternum at the fifth rib. He extended downward to the side of the bed.

The emergency room at St. Louis Children's Hospital is not typically the place for such an invasive procedure. But Trevin had no vital signs. Medical personnel had told police officers Trevin was "critical with death being imminent."

Within minutes of being rushed into the trauma bay, Trevin's chest had been opened and a rib retractor inserted in what Keller considered the only chance to save his life.

The St. Louis Post-Dispatch reports that the scene has been repeated more than anyone would like since Keller's arrival as director of trauma in 2007. During his tenure, the hospital has staked a claim to treating more gunshot wounds than any children's hospital in the country, with at least 917 passing through the doors since numbers spiked starting in 2006.

A policy of accepting patients to the age of 21 has created an influx that has been known to strain resources. It also has led to measures aimed at reducing the number of gunshot injuries and repeat injuries.

Trevin was about to become Keller's most notable case and the one that demonstrated the hospital's newfound commitment and preparedness for treating patients with gunshot wounds.

"When I got to Children's I wasn't convinced that they could pass the state review," Keller said. "I didn't tell anybody that. There was so much that wasn't in place. There was no one interested in trauma, and they were running on fumes at that point."

Trevin arrived in 2008, a day after Children's passed its state review. By the time Keller opened his chest, a throng of doctors, nurses, anesthesiologists, social workers, security personnel and gawkers had filled the room. Next of kin were being notified.

The quantity of blood made the injuries difficult to evaluate. Keller called for suction and watched as trauma manager and longtime nurse Diana Kraus reached for the floor. In the midst of the chaos, the device had fallen. Without another at the ready, Keller invoked the five-second rule typically reserved for a fumbled cookie.

"I'm just using it," he said. "If he gets an infection and we're dealing with that down the road, we probably had a good day."

The left lung was bleeding profusely. The bullet had passed through a portion of the hilum, where arteries and veins enter the lung. Keller reached into the teen's chest, grabbed the lung in both hands and twisted the lower lobe over the upper lobe, a maneuver used to stop hemorrhaging.

The sac around Gamble's heart was opened. Keller clamped the aorta with the hope of sending remaining blood to the brain. He grabbed an internal defibrillator and placed the tiny pads on each side of the heart, delivering a jolt equal to 10 joules while a fellow doctor performed a cardiac massage. All the while, Trevin was undergoing a massive transfusion, ultimately getting 10 units after losing about half of his blood.

The combination of twisting, jump-starting and massaging had given him a second chance. After a trip to the operating room, he remained unconscious for weeks before making a remarkable recovery following his transfer to Ranken Jordan Pediatric Bridge Hospital.

The gunshot injuries seen at the hospital range from skin grazes to life-and-death scenarios related to violence, accidents and, occasionally, self-harm. A study of gun injuries among patients 16 and younger showed nearly a third were from accidents. The average age of victims has dropped precipitously in recent years.

The ongoing quandary is how to reduce the numbers instead of just hoping something changes.

Families have access to mentors through a Victims of Violence program that soon will be implemented at other local trauma centers. Children's and Washington University School of Medicine are involved in a gun violence initiative conducted by the university. Keller operates a trauma clinic to increase the likelihood of post-operative treatment.

"We've changed our approach," he said. "We're more active in recognizing it's a major health problem in the city. We've taken the approach that prevention is probably the best medicine."

St. Louis Children's Hospital is a world bombarded with audacious, never-ending color and decorative props, starting the moment you reach the parking garage, where whimsical sculptures by artist Charles Houska line the winding path up seven levels.

The choices of décor and colors fit a young audience. But some cases don't. One night a suspect in a murder and robbery at a downtown restaurant was dumped on the hospital's doorstep after being shot in the chest.

Dr. Kathryn Bernabe opened the victim's chest in the trauma bay. He was rushed to the operating room but there was too much damage, and he died on the table. Dr. Patrick Dillon thought about what he had seen.

"I remembered looking at the guy in the ER and thinking that sure, we see older kids," Dillon said. "But he had a receding hairline."

The man was 30 years old.

Dillon, who started at Children's in 1999, says when gunshot injuries started to escalate he was one of two surgeons on staff. Overwhelmed, he sought to have older teens sent to Barnes-Jewish Hospital. That effort was rejected. And when Brad Warner was hired as surgeon-in-chief in 2007, he supported the idea to accept all ages, and the surgical staff was expanded to six.

"If we isolate gunshots to what we consider the kid population — no facial hair, no tattoos, no bling — our numbers would go way down," Warner said. "So I think by extending it to teenagers we do a better job for the kids that come here. Our experience level is greater, and the systems have all been well oiled with the kinks worked out.

"That came up when we had a gunshot to an 18-year-old. Everyone was real upset that we took this guy, who obviously had gang ties, tattoos and a lot of stuff going on. It kind of spooked a lot of people who choose to work in a children's hospital, and I understand that. But for all the griping we heard, the very next day we had a stab wound in a 4-year-old. What we learned systemwide from that 18-year-old can apply to the 4-year-old."

Many children's hospitals have an age cutoff of 14 or 15 for trauma patients, some younger. Once a hospital starts accepting kids in their middle and upper teens, the number of cases involving violence and gangs increases. Some hospital workers who come in contact with those patients want to do more than simply trying to help them heal.

"There's a lot to be said if a person feels valued in a manner where they feel there's hope or a future," said trauma nurse practitioner Mary Alice McCubbins, who has since left the hospital. "A lot of these kids come from an environment where they don't see a future."

Although Children's takes many older teens, there is considerable overlap with Barnes-Jewish Hospital. From 2006 to 2017, Barnes treated 732 gunshot wounds among patients who were 19 or younger. Barnes and Children's combined to treat more than 1,600 gun injuries among children and teens during that span.

A disturbing trend is the number of young children seen at the hospital with gun injuries. The average age from 2014 to 2016 dropped to 13.2 from 14.3 during the previous eight years. Almost one-third have been preteens.

The trend has not been lost on the hospital's caregivers. Keller had an email message one day from one of his nurses: "OK this is getting ridiculous. Really? I saw a 2 (year) old and 3 (year) old GSW (gunshot wound) in clinic today and now another 2 (year) old and 5 (year) old. Goodness when will it stop?"

Social worker Margie Batek was working with a restricted budget when she implemented an innovative study in 2012 to provide a mentor for some patients and families affected by violence.

She secured $450,000 in funding to run the Victims of Violence Program for three years, starting in 2014, with two mentors. It became a free service available to anyone affected by gun violence, stabbings or assault.

Now, with a $1.6 million, three-year grant from the Missouri Foundation for Health, the program is being expanded to Barnes-Jewish, SSM Health St. Louis University and SSM Health Cardinal Glennon Children's hospitals.

Through St. Louis Children's, two mentors meet regularly with victims ages 8 to 19 and their families to help deal with issues related to their injuries. The goal is to keep kids on track in school and socially to avoid pitfalls that could lead to further incidents or escalation of violence.

"We can change the trajectory," Batek said. "I've been doing this long enough, and when I go to fatality reviews I see it go from assaults to stabbings to gunshots. It's a path. It's rare that a child who dies of violence has not been seen in our emergency department for minor interpersonal violence once or twice. If we end up getting them when they're physically assaulted and teach them coping skills, anger management and conflict resolution, you might not see them a year from now."

The mentors meet with victims in their homes and in schools. The hospital has partnered with schools, police and juvenile officers. Mentor Tyrone Ford said his discussions with gunshot patients are different than with young people injured through other violent acts.

"I don't even go to death because I don't think kids are afraid of death," he said. "I go to paralysis or having to be fed through a tube or not being able to enjoy yourself like you want."

Of the first 40 gunshot victims who agreed to meet with a mentor, none returned with a subsequent gun injury in three years. The only patient who was mentored and returned with a gun injury was originally a victim of an assault not involving a firearm. The overall repeat injury rate of those who have completed the program is 2 percent.

In contrast, repeat injuries among patients who were treated for a gun injury and chose not to meet with a mentor has been 10 percent. Four patients who did not accept services subsequently died from being shot.

Positive results were evident not only in a lack of repeat injuries but in other aspects of children's lives. One early participant injured by gunfire moved out of his grandmother's home to live with his mother because his grandmother was allowing him too much freedom.

Another social worker informed Batek that his grades had jumped to As and Bs from mostly Ds and Fs the previous semester.

"I asked him why the change," the social worker told Batek, "and he replied that he was following the wrong crowd and he wants better for himself and that he was capable of doing better."

Trevin's first memory after the shooting was running down a hospital corridor while being chased by a nurse with a needle.

The image remains vivid, but he knows it never could have happened because he has been in a wheelchair since leaving the hospital. A temporary shortage of oxygen to his brain the day of the shooting affected his muscles, vision and speech. Most at Children's thought he would never reach this point.

"They said they could have pulled the plug," he said. "They said they were going to see if I made it, and I made it."

Trevin spent several months at Ranken Jordan while preparing to return home for a life that would be much different.

Trevin was in eighth grade when he was shot. He went back to school for a short time but eventually dropped out. A nurse visits five times a week to help Trevin with daily tasks such as showering and dressing.

He undergoes physical therapy, but progress has been slow. He dreams of walking and living on his own and of taking classes or getting a job.

Trevin is frail. He weighs 90-something pounds and does not have full control of his arms and hands. The scar from opening his chest is wide and dark, following a line from the middle of his chest and around the curve of his left side.

"That ain't never going nowhere," he said.

Life has been unsettled since the shooting. Trevin spent a year living with one of his sisters. He moved in with a cousin, then his grandmother and then an aunt. He stayed with friends at times. He also spent five months at a rehabilitation center in Columbia, Mo.

After three months in his current building, his mom wanted to find a new place. Trevin has since moved upstairs with his sister.

"We caught 23 mice on traps," he said. "I don't like them mice. They're in my bedroom, too, but they can't get on my bed because it's up high. But they were getting on my mom's bed when it was on the floor. I don't like mice."

Children's trauma bay can accommodate four patients — two on the main beds and two on foldouts. Emergency room personnel have practiced for a moment when the room might be full.

"If we get one very sick trauma patient, it can almost shut down the system, especially at night with one attending surgeon," said Kim Quayle, associate medical director for trauma. "You can have half the nursing staff with that patient. It can shut down the flow of the emergency department. You have people leave without being seen, people being angry."

Gun injuries sometimes come in bunches. Once a surgeon takes a patient to surgery, the backup surgeon has to be alerted or swing into action. Multiple shootings in a night are not uncommon.

"I would say we all hate it," Keller said. "We do it because we take care of kids. You go in and there's a chance you'll be operating, and it's going to be an all-night affair. It's completely unnecessary stuff."

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Information from: St. Louis Post-Dispatch, http://www.stltoday.com

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