ACEs: Caught in the cross fire

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.

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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.

NEXT: ACEs in urology

ACEs in urology

As I began to learn more about ACEs-how they function to modify genes, change protein expression, alter brain development, and affect behavior-I started to see how this model could be used to explain the inability of my trauma patient to change his social situation and behavior(s).

Reflecting back, I started to remember that many of my patients with bed-wetting, or nocturnal enuresis, had a history of ACEs as well. A quick Google search revealed there was evidence in the urology literature showing ACEs adversely affect children’s ability to make progress with bowel and bladder retraining and reduce their likelihood of staying in treatment.

ACEs and urologic disease in adults

Might the ACEs model also be used to help explain the behavior of some of my adult patients with chronic conditions?

When I started asking, ACEs were present in many of my adult patients, most notably in patients with recurrent bladder cancer who had failed multiple previous attempts to stop smoking. I suspect the incidence of ACEs will be found to be high in patients suffering from interstitial cystitis and sexual dysfunction as well.

Healing our communities

As a urologist, I take care of a wide variety of medical and surgical problems. Being a specialist, when it comes to viewing a patient within the framework of his or her greater community, admittedly my lens is narrower than that of many of my primary care colleagues. Learning about ACEs has helped me view my patients with a wider lens. I’d like to think it makes me a better doctor. At the very least, I know it makes me a more empathetic and compassionate doctor.

Life is messy. If you want to make a positive change, sometimes you have to get your hands dirty.

Outside the office, the information I have gleaned from the ACEs study has motivated me to get involved and see what is actually going on in my community. Often, what I see isn’t pretty. It is, however, the reality that many of my patients live.

Over the past several years, I’ve made a real effort to try to make a positive change in my community. I fundraise, donate, and volunteer for an organization called Step Up. Step Up is a nonprofit, cofounded by one of our local general surgeons, that provides housing, mentoring, and other assistance for children as they transition out of foster care and into the, many times, harsh realities of adulthood. As you learn more about the long-term effects of ACEs, I would encourage you to take inventory and think about doing something similar.

Prescription: Love

I’m not trying to suggest that every gunshot victim we treat has previously been exposed to ACEs. Some children, tragically, find themselves in the wrong place at the wrong time. I can tell you that, when I sit at the bedside and talk to these children, ACEs are common in many of their homes and families. I would think, at the very least, a gunshot wound represents a powerful, life-changing, adverse childhood experience of its own.

Next: Adverse childhood experiences are linked to ADHD

The good news is this: Research has repeatedly shown the kindness and caring of just a single adult change the trajectory of children affected by ACEs. In a society that finds itself so polarized on the issues surrounding gun control, as adults, I believe, love is what the children in our community need from us most.