21.5.13

PLAYING 52 PICK-UP

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PLAYING 52 PICK-UP

I’m 52, alone, and starting over. And that’s exactly the way it should be. Pass the half-century mark and vitality is no longer a given; it becomes a conscious pursuit. Denzel Washington nailed it recently when he said, “The first fifty (years) was for them, this fifty’s for me.”I’m not sure if I’m going to get a full second fifty--heck, the way I feel some days I’m not sure if I’d even want to sniff 100--but I definitely align with Denzel. At 52, I feel like a human deck of playing cards; if I’ve seen just one card a year, there are no surprises left in the deck (check that, there’s the Joker; but isn’t he always lurking about?). That being the case, it falls upon me to find a new way to play the game.

It seems I come by this reinvention streak honestly. I remember the day my mom turned 70. When I asked her how she felt about the milestone, she answered with a single word:

“Absurd.”

Absurd?

“Matty, I look in the mirror and I see an old lady. But inside, I’m still the same young girl.”

That she kept this youthful outlook throughout life is beyond doubt--both she and dad went to see Aerosmith at The Garden when they were 68, which is a story for another day--but I get the gist of the growing absurdity of aging. When I was 5, mom’s older brother, my Uncle Jack, stayed in our small home for six weeks. He’d leave the door to the tiny bathroom open to take his daily shave; standing there in his wife-beater, blade in hand, hairline in rapid recession, he seemed to me to be a mountain of a man.

Guess who stares back at me from the mirror these days?

Hello, Jack.

So me and my five-head get the being 52 part. As for being alone, though my delightful girlfriend of four years disputes it (“You’ll always have me,” says she. Maybe, yes; maybe, no.), I am alone. I am an orphan. Not a born-into-this-world-not-knowing-who-my-birth-parents-are orphan (and, yes, I know a few of those and, brother, it ain’t easy); no, mine came about in the so-called natural order of things.

My dad, whose idea of softening an emotional blow was to first hit you with a metaphorical 2 x 4 between the eyes, sat in a diner a dozen years ago gently explaining to me my onrushing future. He and mom had both managed to be discharged from the hospital on the same day; she after a chemo treatment, he after some cardiac nonsense. “Son,” he boomed over Greek-style liver and onions, “your mother and I are rushing to see who can make you an orphan first.”

Nice.

Now they’re both gone: Mom, ten years (can it really be?) this June; Dad, three years come October. I won’t say dad’s death was easier, though the second go-round at the grief rodeo meant the whipsaw ride was at least somewhat familiar.  In retrospect, the effect of his passing on my psyche was like a huge data dump. While he was alive--and he was sick the last 14 years of his life, and in desperate straits in his final years--this only child had mental space for only one thing.

Keeping Charlie going.

The sudden absence of that task--and believe me, it doesn’t end the day your last parent dies, but lingers through more meniality and minutiae than one can imagine--eventually creates a vacuum into which new thoughts can rush. Good thoughts. Healthy thoughts. About one’s future, and how, finally, you get to be the captain of the ship.

The universe had taken my parents and given me a gold braid. No one had told me how lonely command was without counsel, or how satisfying it could be to re-plot one’s life course. My wise Aunt Fran used to say, “With knowledge comes responsibility.” Put another way, once you know something, you can’t un-know it, no matter how tempting ignorance might seem. With my focus finally shifted from my dad to myself, I realized that my passion for writing in the form it had taken for a decade had played out. Writing for an institution that was far more interested in marketing than journalism, I felt I was on the verge of ‘mailing it in,’ which for those of us who’ve turned avocations into vocations is tantamount to sacrilege. Athletes and actors know this feeling all to well; when the outcome of the game no longer matters, and the performances feel rote, it’s time to step away and re-evaluate.

Which for me means starting over. The first writing that ever got my blood pumping and my prose noticed, at least by an encouraging English teacher, wasn’t about the Iroquois, or Catcher in the Rye, or Cool Hand Luke (cool as he was). No, those were assignments, which were about as appealing as eating flannel. What caught Mr. Johnson’s eye (and heaven bless teachers that tell us we’ve got a gift to share with the world) was something far more personal; a heartfelt year-end essay about my illiterate but determined immigrant grandfather. This wasn’t an assignment, but admiration scribbled through a blue book. When Mr. Johnson scrawled ‘See Me!’ across the top, I flinched, but he fawned. “You don’t understand,” he said when I attempted to deflect his praise, “this was one of the best essays in the state. Have you thought about being a writer?”

Uh, no. It would actually take until my early-30’s before I realized I was a writer, and by then I had started over (much to my parent’s chagrin) many times. As a network go-fer. A stereo salesman. An auctioneer. A locker room attendant (hey, at least it was the U.S. Open). A national radio reporter. A pizza delivery boy. A magazine writer. And, later, a book author. My security?

Hell, if it didn’t work, I could always go back to the last thing I did. Fortunately it never (ok, rarely) came to that. And so I start again, at 52, with an idea I feel passionate about. Stepping out of the safety (or so it feels) of third-person reporting, and into the world of column writing, where I can switch gears as often as a trucker on a 7% downhill grade. Opinion one day, essay the next, elbow-grease throughout, no filter, no buffer, just one-to-one, me and you.

Hopefully, I’m worthy of your time.




[1] 'http://m.imdb.com/name/nm0000243/quotes

15.5.13

CHARLIE & ME

(Published in Urbanite Magazine)

CHARLIE & ME

They say parents can't change. And they're right. So how do you learn to love the father you can't begin to understand...by Mat Edelson
 

I could feel his body tremble as I held him, and it felt oh so strange, for I had never held him before. Nor, truth be told, had he held me. At least not since I was out of diapers (and maybe, as I had never asked my mother or him, not even then).  For well over a week Mom and I had waited by his bedside. Somehow, at age 73, he had survived the nine-hour surgery, the one his first assigned cardiac surgeon had refused to perform, telling me—quote—Son, there are some things that are worse than death.
Of that brutal operation, the one that wrapped seven inches of fraying aorta in a protective mesh that looked uncannily like the safety net into which a high-wire specialist could tumble and yet not die, my father would have no memory. He would not recall his body swollen to the bursting point with fluids, his head the size of pumpkin, or that I cried at the sight of that handsome face so grotesquely distorted.
He would also forget his painful struggles against the repeated intubations that cut off his commanding voice, his thick fingers attempting to communicate in sign language the fog that was filling his mind—h-e-d h-u-r-t…w-a-t-r…t-u-b-e o-u-t n-o-w. It was though the anesthesia washing slowly from his body was pulling his thoughts away as well.

But what was happening at this moment he would not forget, never. Nor would I. The surgery had literally shut his body down. His heart, lungs, even kidneys had been taken off-line, their jobs temporarily turned over to machines. The body doesn’t take kindly to this division of labor, and tends to kick like an old mule when it’s given the job back. The colon is especially stubborn; after more than 144 hours, Dad’s was still on hiatus. If it didn’t wake up soon, surgery loomed.

Suffice to say, the alarm went off. Suddenly. Violently. One minute Charlie was in bed, the next he was trying to do a ten-foot dash to the bathroom in a hospital Johnny, moaning IhavetogoIhavetogoIhavetogo!! I jumped, Mom jumped, he jumped, 200-plus pounds suddenly thrust upon short legs that had atrophied far quicker than any of us realized. My dad’s mind had just written a check his body couldn’t cash, and as he sagged off the bed and into my arms, and the horror and shame crumpled his always proud face as his body let go its burden, I rocked him gently, the two of us, at once both lost and found. And I whispered in his ear the only thing I could think of to say. It’s okay, Dad, it’s okay, Dad, I’ve got you, it’s okay.


***
More than one male friend of mine has said their own childhood ended the instant they first held their first-born in their arms, a moment freighted with a single weighty word: Responsibility.
But underneath that awesome burden is (hopefully) choice, a conscious desire to create a life out of a shared love, to prove that one plus one can equal a joyful three, math be damned. Parenthood, in its ideal form, is an act of heroic volunteerism.
But parenting your parent? In the case of my father, I was one pissed-off draftee. I get the feeling I’m not alone. It’s tough enough caregiving a parent you both love and like, who operates on the same wavelength as you, shares a part of your soul, and is cognizant of the burden of caregiving because, dammit they did it themselves. For you.
But what about that old-school dad, the one who parented by providing cash, not comfort, and now expects you, his caregiver, to pick up the pieces by listening to orders instead of requests? A person who once told you, straight-faced and sober in a bar—the only time you ever asked him out for a drink—“What makes you think fathers and sons are supposed to be friends?”
We yiddishe-folk have a word for taking care of someone like this: Oy.
Now let’s get something straight right here. Lots of people (like my best friend) grow up in truly abusive situations--drugs, violence, alcohol, the works--with parents who should never have been allowed to procreate. Not me. Never saw any of that. My old man did the best he could considering the emotional IQ ran pretty low in his family. My Polish grandfather believed children were only good for one thing: labor. Charlie went to school, worked at the family’s 24-hour newsstand from 4 to past midnight, studied (OK, crashed out) on the subway back to the Bronx, and would’ve likely slept through high school if his friend Sammy hadn’t thrown pebbles at his window to wake him at sunrise. Nor was Grandma Jane exactly touchy-feely. Once, Dad’s parents lost sight of him in a big park. They left, figuring some boys in the park would find their son and bring him home. Luckily, some did.
So, Dad’s emotionally dense. Still, he never hit me. (Thank God: He was so strong that a penny-arcade brass arm-wrestling machine he pinned declared “YOU BELONG IN A ZOO.”) Nor did he ever lay on a hand on my mother. Or yell at her. He adored her. Worked fourteen hours a day in the newsstand for her. And when he lost her to cancer in 2003 after fifty-three years of marriage, suddenly he found himself alone and frightened. As was I, his only child. 
And why not? The most important woman in both of our lives was gone. Mom had been the buffer, a one-woman DMZ who had kept the testosteroned combatants far enough apart that some civil discourse could take place. “Don’t give up, Matty, he’s trying,” she would say on my increasingly infrequent trips home to New York over the last twenty years. I have no doubt she was giving my father the same message regarding me.
The truth was Dad and I spoke a different language. We may have both voiced words of love, hope, and security, but we lacked a Rosetta stone to help us understand them. Publicly, he’d brag to anyone about his son, The Writer. But privately, it was all about the bucks. “How much did you make?” was often followed by, “Y’know, Matty, you’d make a good living as a salesman.”
Dad never read my work; when I handed him my first book, he thumbed through the first few pages and tossed it on from his passenger seat onto the dashboard. “I’m tired, he said. “I’ll look at it later.”
It never occurred to me that my father, my childhood hero, was intimidated by my written words. His own father was illiterate, and he himself, intelligent but negligently educated formally, was more comfortable with the New York Daily News (“New York’s Picture Newspaper”) than some glossy high-falutin’ text, even if it was bylined by his boy. “You’re like your mother…smart,” was all he would say, as he’d put one of my stories aside with nary a glance. I never heard what he was really saying--the way he truly felt about himself. “You’re not like your father. Dumb.”
That I’ve finally learned to see through my father’s words to see the man, and accept the man, and, yes, love the man, and even—whoa!—enjoy being in the man’s presence…well, we’re giving away the end of the tale here, yes? That day in the fall of 2000, when my father fell into my arms and I was thrust into being responsible for someone other than myself for the first time in my life…let’s just say neither of us could have imagined the trip we were destined to take.

***
The continuous thread—and the constant source of tension—in our relationship was our mutual inability to anticipate how the other would react in any given situation. Not to get too psychobabble-y, but when it came to my father, I had the motherlode of expectations about how he should act, this overblown notion of what it meant to be a man. It was the source of nearly all the disappointment and anger I feel towards him. When his accountant suggested he transfer his assets into Mom’s name weeks before undergoing the life-threatening aortic surgery, I expected him to comply. After all, he always made it a point to tell anyone in earshot, “I’d do anything for Clair.”
Yet, his initial reaction? “Well, your mother could die before me.” Never mind that she wasn’t the one about to undergo the operation, he was. And when Mom did get sick with colon cancer in 2001, I expected my father to care for her, the same way she’d cared for him since 1996, when the aneurysm that lead to his eventual surgery was discovered. Within weeks of her first chemo treatments, my father turned to me and said, “Your mother, she’s breaking my balls. She always wants things done for her.”
After Mom’s death in 2003, dad's self-centered behavior things only got worse. A social worker friend of mine calls it the “More-so’s”…as in, when people age and go through serious life traumas, their basic personality become more so. Dad’s already Charlie-centric worldview became cemented through fear, grief, and loneliness. Through that first year following her passing, as he went on about how distraught he was and how angry he was that she died before he did, I was amazed that he never once inquired about how I felt. When I finally asked him why that was so, he meekly replied, “I figured you felt just like me.”
Forced to deal with everything from his finances to his declining health to his newly emergent love life, I tried to treat my father the way I would want to be treated. I expected that he wanted to make the important decisions in his life, and it was my job to put him in the best possible position to make those choices.
How wrong I was. To discover how a couple manages their household, divvies up life’s tasks, organically decides what, and when, and where…these are not things children know. Nor are they written down. (But they should be. Just two columns: This is where your mother called the shotsThis is where your father played Big Daddy. That page alone could save thousands of hours of therapy for the kids once a parent is gone.)
It turned out my father didn’t want to make any decisions at all. Opinions? He had plenty. Especially about the decisions he demanded others (i.e., me) make for him. But as for taking the initiative? As the sign on the Belt Parkway in Brooklyn says, fuggedaboudit. Family friends would call me and say they’d just spoken to my father. It didn’t matter what the question—“When are you selling your house?” “Have you come up with a plan for losing weight” “Have you decided to go for bypass surgery?” “How are you paying the live-in help?”—the answer was invariably the same:
“Ask Matthew, he’s handling it.”
In fact, I took two years off from writing to handle it. From selling the house, to packing the house, to buying the condo in Florida, to moving him to Florida, to moving him back to his brother’s apartment in New York, to getting the cardiologist, to finding the rehab hospital, to finding the permanent live-in aide because he refused to handle certain hygienic issues, to...every day the goddamn phone was ringing with something he expected me to take care of from south of the goddamn Mason-Dixon line (“Mat, I didn’t get the newspaper today. Did you pay the bill?”).
Thousands of hours, thousands of miles, thousands of dollars. Thank you’s? Hardly. Would’ve been my way. Not his. Did he love me? Yes. Did he know how to express that?
No.

***
And so my anger, rage, and yes, at times hatred, grew. It was being fueled by my greatest expectation of all: That my father, in all our dealings, would meet me halfway. Dealing with him was like doing some bizarre mental isometric exercise: I was pushing against a man who could not yield because he was set in stone.
He would ask for help—with his weight, his understandable depression, his aches and pains—and I would provide it, only to watch him sabotage himself at every turn. After a 2005 bypass led to a serious infection, I baby-sat him through twelve grueling weeks of rehab, where after three months of being confined to hospital bed he’d worked his way back from barely being able to sit up to walking down the hall with a walker.
I took him home that day, his promise to the doctor still fresh in my brain—“Yes, I’ll use the walker everywhere”—only to watch him toss it aside the moment he got in the apartment. “I don’t need it,” he said, grabbing at doorknobs to propel himself down the hall.
My frustration exploded the day after his eightieth birthday. I'd flown down to surprise him in Florida on his birthday. I walked into his apartment around 11 a.m.; Gwen, his aide, said he was in his bedroom. I went in, kissed Dad on the forehead, and he opened his eyes. “Hi,” I said. “Happy Birthday.” He looked at me and said, “Hi. I’m having a bad day.” With that, he pointed to a small chair in the corner of the room, bade me to sit down, and went back to sleep. And that’s where he laid for the rest of the day, undressed, unmotivated, unappreciative, just completely….un.
The next day, when he was finally up and around, I lit into him. I started softly but forcefully, and with each deflection on his part (“Not today, I’m not up to it;” “I’m old, what do you want from me?”) I zoomed right past wanting understanding into straight-out venting. My voice soared; my words grew foul.
And my father had a complete meltdown. Tears, trembling, and, most frightening of all, a complete lack of comprehension on his face. It shocked me into a memory, of the time I came home only to find the dog I had just adopted had peed all over my bed. I dragged the dog outside and started screaming at it. The look in its eyes as it cowered said, W-w-w-what have I done??
I never yelled at that dog again. Now, with my father, I was ashamed at what I had done, no matter how much of a “right” I had to do it. I was expecting my father, who never had more than a child’s ability to deal with his own emotions, to somehow “grow up” at age 80. Somehow, between his sobs, I finally got it. There was no compromise to be had. There was no halfway point at which we would ever meet. He could not change.
But I could. 
I won’t lie and say I completely dropped any expectations I had for my father, but I did start seeing the world through his eyes. So many of our fights had occurred because I tried to explain things to him, make him understand why I was making certain decisions. My dad never wanted explanations: He just wanted people to agree with whatever came out of his mouth, no matter how outrageous.
So that’s what I started doing. Agreeing. And a funny thing has happened. The more I’ve stepped away from my own ego, my own need to be right, the better my father and I have gotten along, and the more appreciative my father has become. (And whoever thought I’d live to see the day he'd end many a conversation with, “I love you, baby.”)
I think on some level my dad knows all his talk is just that. I suppose a cynic might say that humoring my father is an act of manipulation. I choose to see it as a conspiracy of kindness, an unspoken acknowledgment between two men who need each other that time is short, so let’s dream big and go out laughing.
And so when my father talks now about all the things he’d like to do—go to Israel, learn to walk better, marry his girlfriend—instead of my pointing out all the speed bumps in those roads—you can’t go to Israel when you can’t even make it across the apartment, you can’t walk well because you’re fifty pounds overweight and won’t shut your mouth, and your girlfriend has only visited you once in the past year—I just nod, smile, and say, “Wouldn’t that be great?”
And you know what? It is.

THE PROTECTORS

(Published in Johns Hopkins Medicine magazine) 
 

THE PROTECTORS

Child Abuse Cases Arrive in the Pediatric Emergency Department with Heartbreaking Frequency. Meet the Medical Team that's First on the Scene...by Mat Edelson




THE PRE-SCHOOLER bouncing around Exam Room 3 of the pediatric emergency room is that iridescent combination of precociousness and politeness uniquely the domain of garrulous 4-year-old girls. “I need to wash my hands,” announces the child, gently peeling a pink butterfly sticker off her tiny right hand. Moments later, washed and dried with two towels (“Two at a time!” she squeals), her beaded, neat cornrows disappear under a window shade. “Look!” exclaims the slightly muffled voice, whose owner is now staring up into the dusk. “The Moon! It looks just like a cookie!”

The observers in the room laugh, but the girl’s mom is not among the smiling. In fact, mom’s not even in the room. She’s 50 feet away, on the other side of electronically secured double doors that she could not breach if she wanted to—and she most certainly does. For while she is known to the little girl as “Momma,” to the two security guards, one police officer, two social workers, crime lab photographer, nurse practitioner and pediatrician who stand between her and her baby, the woman now wears a far more ominous moniker: 

Alleged abuser. 

The allegation is as plain as the inch-long rainbow-colored bruise under the child’s right eye. It was noticed by her teacher earlier in the day, reported to authorities as the law requires, and the child was quickly brought down to Hopkins to have her injury evaluated. And therein lies the question. For while the injury is blazingly apparent, its cause is not. Accident or abuse? The former, claims the mother, who says she wasn’t even present when the child, at her grandmother’s, tripped and fell face-first into the edge of a coffee table. 

Which is exactly the tale the child tells to the specially trained social worker in Exam Room 3, before adding seven words full of both innocence and damnation: 

“That’s what they told me to say.”

The social worker takes a deep breath. “OK, now tell me what
really happened.” 


****
SORTING FACT FROM FICTION and making an informed recommendation is what the Johns Hopkins Child Protection Team headed by Allen Walker is all about. The CPT is first on the scene in the Hopkins pediatric ED, which, by city order, is where Baltimore City police bring all suspected cases of physical child abuse for initial evaluation. 

That alone is a daunting responsibility. According to the Baltimore City Data Collaborative, from 2000 to 2005, the city’s rate of child abuse and neglect ran almost three times higher than the state’s average. For 2005, that meant 11.3 per 1,000 city kids had suffered everything from malnutrition to beating, burnings, and other horrific injuries at the hands of adults. In that same year, more than 30 of each 1,000 city children were removed from their homes by social workers, the vast majority because of suspected neglect or abuse. For children ages 6 to 11, homicide was the third leading cause of death between July, 2001 and May, 2005: For those under 6, it was the second leading cause of death.

A few of the more heinous cases are etched in memory. Two-year-old Bryanna Harris, whose drug-using mother, annoyed by the little girl’s crying, purportedly gave her methadone to hush her up. It killed the toddler. Then there was the case of Emmoney and Emmonea Broadway, the twins delivered at Hopkins, who were found beaten to death a month later.

The fact that city social workers were aware that the mothers in both cases were at high risk for being child abusers isn’t lost on Allen Walker. Throughout the physician’s 30-year career in pediatrics, he’s sought better methods for identifying potential abusers and preventing child abuse.

The soft-spoken Walker practiced in Reno before coming to Hopkins in 1985. For years he’s fought the prevailing American sentiment that how a parent raises a child is not any outside agency’s business, a mindset that he says only furthers the cycle of child abuse by limiting educational opportunities. “You look at some of the Scandinavian countries, mothers get a year off after they deliver to bond with their kids. They get a regular home visitor who teaches them about being a parent,” says Walker. “I don’t think anybody in the United States would seriously think we have either the political will or financial means to do that. Yet that’s the sort of effort that, at least from the medical literature, it’s going to take to prevent this.”

Walker has led the Child Protection Team since its inception here in the 1990s. The concept, he says, is straightforward: “to present a unified voice” of multi-disciplinary expertise. Suspected child abuse cases are fast-tracked through the pediatric ED, where they’re thoroughly evaluated over several hours by a phalanx of expert social workers, nurse practitioners, and physicians. The resulting reports are immediately passed on to the police and city child protective service authorities—all in an effort to keep children safe and potential abusers from slipping through the cracks. 

Prior to the team’s formation, “It was almost impossible to prosecute a physical child abuse case in the city of Baltimore,” says Julie A. Drake, chief of Baltimore City’s Felony Family Violence Division. The reason? While city and state detectives, child protective service workers, and Hopkins’ own physicians often had information that could help determine whether abuse had occurred (or, as importantly, did not), that information often was not shared with the right people or in a timely manner.

Now, a formal agreement between CPT, Drake’s office, the Baltimore City Police Department’s Child-Abuse Unit, and the Department of Child Protective Services has led to more successful prosecutions and cleared cases, often using CPT members as expert witnesses on the stand. “[Dr. Walker] is the most credible medical expert on pediatric trauma and physical child abuse in the state,” says Drake. The CPT team is also involved with many cases in Anne Arundel and Baltimore counties, as children critically injured there are often flown to Hopkins for CPT evaluation. 

In all, officials from these jurisdictions meet with CPT personnel to discuss more than 500 cases annually. It is a triage of a different kind, where diagnoses can set into motion both the wand of caduceus and the wheels of jurisprudence. 

Making those diagnoses is equal parts science and art. Technical advancements in neuro-imaging, MRI, and CT have brought to light many abusive injuries that were once difficult to pinpoint. “Without CT scans, something like a subdural hemotoma (essentially a bruise to the brain)—which is one of the hallmarks of abusive head trauma or Shaken Baby Syndrome—is almost impossible to diagnose,” says Walker. 

These scans have led to new computer and biophysical models that have experts rethinking what once were considered “pathoneumonic,” or absolute, guaranteed signs that a child had been physically abused. “What people said 10 years ago as being tried and true abuse is absolutely wrong,” says another member of the CPT team, pediatrician Mitchell Goldstein. He uses spiral femur fractures as an example. “The thought was that you had to grab and twist the leg to get that fracture,” says Goldstein. “In fact, it’s not an uncommon injury in ambulatory toddlers; they put their foot in a hole, plant and twist, and get that fracture pattern. People had their kids removed from the home and spent time in our jail for our naivete.”

Actually, says Goldstein, “very few injuries say, ‘this is absolute abuse.’” Like an undated black-and-white photo of strangers plucked from a family album, images and scans often raise as many questions as answers. With many plausible explanations for an injury, it’s the art of the interview—and the skill of the interviewer—that often narrows the possibilities. That’s where the work of CPT’s social workers and nurse practitioners comes into play. 

“You have to be careful not to ask leading questions,” says social worker Kathy Kopf. “That’s very important because otherwise [the victims] testimony won’t stand up in court.”

“The goal,” adds nurse practitioner Shawna Mudd, “is to get an injury history from a kid. If I say, ‘Tell me what brought you here today,’ a 7-year-old can go from there,” says Mudd. As an example, she plays out a hypothetical dialogue involving a belt or extension cord, which is the most common abuse object. When a child admits to a beating applied by dad with a belt—and many kids see it as just a normal part of their upbringing—Mudd will seek specifics that hopefully match the physical evidence. “Tell me about the belt,” she’ll say. “How was your dad holding it? What’s the color of it? Who does it belong to? Did anybody see you get hit with the belt? Has it happened before? Are you scared?” 

With younger children—and Kopf says it’s even possible to get tangible leads from barely verbal toddlers—providing a coloring book or toys is often a quick way to get them to feel comfortable enough to talk about their lives, their loves, and their abusers, as they parse out details with little understanding of potential consequences. Older kids and teens often have that understanding—some have been removed from their homes before because of abuse. They sometimes lie about their injuries at first, but generally reconsider when shown or told about the physical evidence that doesn’t match up with their story. 

The social workers never emphasize punitive measures that caregivers could face: The decision whether to place a child in protective custody is made by the city Department of Social Services/Child Protective Services social worker in the ED, after reviewing the CPT’s evidence, interviews, and conclusions. As for arresting the abuser—and under Maryland Law any adult who leaves a mark on a child can be arrested for child abuse—that choice falls to the city’s detectives, again depending to a large degree on CPT’s data.

Instead, the social workers—and the whole CPT team— focus on the child’s immediate safety. It’s the message given to the child and the alleged abuser. “If I were a parent and being questioned, or my child was in a separate room being questioned, I can understand being irate,” says Kopf. “I tell parents, ‘I understand you’re upset, but this isn’t personal. Child abuse does happen, and we just want to make sure your child is safe.’ If they can see the big spectrum, as uncomfortable, as intrusive as it may seem at the time ... nine times out of 10 the parents can be calmed down. 

“But,” she admits, “it’s easier said than done.”

***
Back in the pediatric ED Office just off the nursing station, nurse practitioner Joyce Ordun is studying what amounts to the crime scene on paper. In front of her is the special two-page CPT form assigned to document each case. Ordun, after examining the 4-year-old and interviewing her, has put small marks on the outline of the human body that’s part of each form. Each mark is assigned a number, used to cross-reference and explain each observed lesion in the “assessment” area opposite the drawn body. Each number represents a potential site of abuse.

On this form, Ordun has marked 10 such sites.

In addition to the obvious black eye—mark # 10—there are fresh wounds at the hairline and a tiny slash through the right eyebrow. “Red, up on her forehead, consistent with being hit by something linear, like the side of the belt. These are new,” she notes.

This is not conjecture, but corroboration. After the 4-year- old admitted being coached to lie by her mother, she proceeded to tell the rest of the story, repeating it twice separately to CPT social worker Dawn Walker (no relation to Allen Walker) and later Ordun.

“What did she hit you with?” Ordun had asked.

The little girl, coloring a small Mission to Mars comic book, barely paused to look up.

“She hit me with a belt.”

“Did she hit you with the part that hooks together, or the regular part?”

“The regular part.”

Several marks on the lower body confirm the girl’s comments that she’d been beaten before. Hyper-pigmented (older, still discolored) lesions on the back of her legs are loop-shaped (“from when you fold a belt over,” explains Ordun) and their location rule out an accident or fall as the cause of the markings. “If they were on the front of her legs I wouldn’t worry about them because the kid is [normally] moving forward. But most kids don’t get linear, hyper-pigmented lesions between their legs.” 

“So she was whacked from behind?”

“Yeah,” says Ordun, peering over the paperwork. In the end, the form calls for her to check off one of four boxes. These indicate that the exam reveals physical findings consistent with physical child abuse; findings consistent with neglect; findings unclear or non-specific for physical abuse or neglect; or a history concerning for abuse but physical findings that are non-specific (physical abuse is generally considered an intentional act, while physical neglect—such as poorly nourished children—includes maltreatment due to inattentiveness or ignorance).

Ordun’s choice will send a ripple through both the judicial system and the lives of the girl, her mother, and another family member who now sits in Exam Room 3. Cradled in the arms of the man the little girl calls her father is a 5-month-old girl. The infant is the little girl’s sister: On her cheeks are two quarter-sized abrasions, one under each eye. The mother says her family doctor called the abrasions eczema. Though resting comfortably in the man’s arms, the infant’s size and general condition—a bit disheveled—raises the alarm of another CPT social worker watching from the corridor.

“That baby’s not big,” she says quietly, but her worried eyes clearly rephrase the thought.

That baby’s in trouble

***
Even with all the technical advancements, child abuse remains a frustrating field of work. On one level, the Child Protection Team has made important inroads, especially in the coordination of care. In addition to children who come through the ED, the team is available to anyone who has a pediatric inpatient they suspect has been abused. These account for an estimated one-third of the team’s consults, a service clearly appreciated by faculty and staff.
“We take pressure off the surgeons and social workers,” says CPT social worker Sue Barker. “They can focus on the families. We can, for lack of a better term, do the dirty work.” In a sense, CPT’s presence allows the inpatient units to continue their normal continuity of care for the patient and the family while CPT begins its evaluation. The trust the inpatient team has created with the family remains intact. If CPT determines abuse has occurred, the team works with security and the city’s Child Protective Services division to limit the suspected abuser’s hospital access while the rest of the family and the child receive the social and medical services they need. 

Still, for all the cases, the commitment, the sense that CPT’s efforts, as nurse practitioner Shawna Mudd puts it, “feel like the right thing,” the truth, as she says in her very next breath, is that “we don’t have data or research to show that.” 

In short, while much research literature has been devoted to the downstream effects on victims of child abuse—including increased teen pregnancy and school dropout rates—precious little is known about short-term outcomes following a child abuse diagnosis. This is especially true when it comes to understanding whether medical and educational interventions prevent future episodes of child abuse. While Mitchell Goldstein is documenting whether parents who sign a nursery commitment “not to shake my baby”’ follow through on that pledge, such studies in aggregate are hard to come by. “In terms of where these kids are five years later, in terms of good solid data, we know less about the natural history of child abuse and neglect than most other diseases, because it is such a sensitive subject,” says Walker.
 

Between legal juvenile privacy concerns, poor data keeping by government agencies, and general turf wars by the bureaucracies involved, it’s often hard to uncover a child’s past abuse history, let alone mount research and prevention efforts. While a recent law allows the city’s Child Protective Division to disclose “active” cases, specifics often remain elusive. The consequences of this data chasm can be devastating. Abusive parents often hospital jump, so their child is never seen in the same ED twice. Certain injuries that in isolation appear accidental might be judged differently if a history of repeat occurrence were available. Only it’s usually not. 

Perhaps most frustrating is the realization that, while child abuse is horrific, the abusers often act out of ignorance more than willfulness. “For the most part, there are very few evil people,” says Kathy Kopf, an observation consistently shared by other CPT members. Lack of parenting tools, repeating the discipline they themselves encountered as children...these are often at the heart of an abuser’s actions, especially those parents at wits’ end over their child’s behavior. Kopf recalls a court-ordered physical abuse offenders group she facilitated. After 16 weeks, she concluded their desires were the same as those of most parents: To have their kids stay off drugs and do well in school. The devil was in the details. “Part of it is changing a belief system; that if you hit your child that corrects the behavior. A lot of research [says] it doesn’t work. It just makes a child angry. They’re more likely to abuse a peer at school,” says Kopf. “Also, a lot of parents are religious. They believe in ‘Spare the rod, spoil the child.’ I hear that a lot. ‘The Bible says it’s OK.’”

For now, such educational research and interventions are beyond CPT’s scope, falling instead to the city’s incredibly overworked Child Protective Services division. The team itself operates more on commitment than cash, as Walker and Goldstein are part-time staff and every member of the team has other hospital and ED re- sponsibilities. 

What may improve both the research and staffing situation long term, says Walker, is the recent decision by the American Academy of Pediatrics to create a board-certified child abuse subspecialty. Such a subspecialist “would be in the academic model, seeing patients, evaluating patients, but also having time to pursue research needs in the field,” says Walker. 

What may be more immediately possible is an independent one-stop clinic. “Picture, if you will, a place where Mitch [Goldstein] and I go to work, along with the State’s Attorney, some folks from Protective Services, some Child Abuse detectives, and that’s our office,” says Walker. “We spend our days talking to each other over the coffee machine, coming in from the parking lot. That’s the kind of service model that results in the best deal for kids.” 

In fact, such a model already exists in the Baltimore Child Abuse Center on North Charles Street. Since 2002 the center has been the clearinghouse for suspected sexual abuse cases, with detectives on-site. “This is like working in real time,” says Lt. Thomas Uzarowski, head of the Baltimore City Police Department’s Child Abuse unit. “If in the course of a [medical] inter- view sexual abuse is suspected, they just call down to the first floor, where we
are, and a detective goes up and sits in on an interview. If criminal allegations arise, we roll on it,” says Uzarowski, whose unit also works with the CPT. “The next step is where we evolve to doing physical abuse cases [in a freestanding unit]. It’s just a matter of dollars and cents.”


That those dollars are difficult to find is a bit mystifying to people who spend every day watching a parade of innocent children who’ve been beaten, burned, and literally boiled for something as simple as soiling when they’re not supposed to, or misplacing a T-shirt. Sometimes one can hear a Sisyphean weariness in their voices, at other times utter rage at the cases they absolutely know are child abuse, but medically can’t prove. 

But perhaps the greatest miracle is that overriding all of these emotions is a sense of hope for both parent and child, that the cycle of abuse can be broken and a family can eventually be reunited. “Do I see awful things? Yes. Does it get to me sometimes? Yes,” says Kathy Kopf, who knows that separating a child from a parent should be viewed as a short-term option, not a long-term solution. “But I don’t look at it as doom and gloom. I look at it as an opportunity to get parents through this crisis situation. They made a mistake. For me it’s about what we can do so that it doesn’t happen again.”

***
“WHAT’S GOING ON BACK there?” demands the little girl’s mother in the ED’s waiting room. “They’re not telling us anything!” Social worker Dawn Walker’s face is placid in the face of such emotion—heck, that’s her job—but her internal calculus is whirring, forming an equation that’s rapidly tilting against the mother. The more she talks with the clearly annoyed woman, the greater the number of risk factors for abuse she sees. She’s a young parent. Two young children. She’s not taking this seriously, almost as if it’s a joke. Her story of how the injury occurred doesn’t match the facts. And she’s just asked if the doctors found any additional marks.

“Yes, they’re old, but the doctors did find some marks,” says Walker.

“Whaaat?” sputters the mother. “She doesn’t get abused.” 

Inside the ED office, nurse practitioner Ordun takes one last look over the exam form, checks the box marked “Exam reveals physical findings consistent with physical child abuse,” and offers up her informed opinion of the case.

“Mom,” she says, “is going to jail.”

A few minutes later, a new sound comes from Exam Room 3. It is the sound of a 4-year-old suddenly stripped of her innocence. Sobs so grief-choked that they barely escape her throat. Walker puts her arm around the tiny girl, pulls her close, and attempts to explain the impossible. The CPS social worker has made a decision. For the time being, both sisters will be placed under the care of DSS. The little girl won’t be going home tonight. 

“We want to make sure it’s safe when you go home again,” says Walker, offering comfort to the shattered girl. Walker can see what’s in the girl’s tear-streaked face, the notion that somehow she has brought this upon herself, she is at fault, she has caused this rip in her world. “You have to remember, you didn’t do anything wrong. You did not do anything wrong. Are you going to remember that?” asks Walker. 

Distraught, the little girl seeks relief from the only person who can bring it. The person who created this trauma in the first place. Her abuser. 

“I want my mommmmmy!” she cries. *
Mat Edelson is a frequent contributor to Hopkins Medicine magazine.

(First Published in Johns Hopkins Medicine Magazine Spr/Sum 2008)

SUDDEN IMPACT

SUDDEN IMPACT

Their lives upended in a second, trauma survivors find that regaining their physical health is just one part of recovery. By Mat Edelson



His shoes were right where he had left them.
The left one on the floorboard. The right still on the Hyundai’s gas pedal, which had been mashed to the floor when he passed out—the result of a concussion suffered earlier in the evening in a supposedly minor collision.
 

In a scene reminiscent of what Lawrence “JR” Black Jr. calls “cartoon physics,” his 6-foot, 2-and-a-half-inch frame had been shot out of his shoes at over 100 miles per hour, ripping out the steering column as he exploded through the car’s windshield, his mangled body slamming back to Earth some 90 feet away from the obliterated ve- hicle. The brutal impact after a few seconds of flight shattered 30 bones, tore his femoral artery and lacerated nearly every internal organ.

It was 3 a.m. on February 7, 2009, along an obscure, frozen part of Maryland Route 32.

And 26-year-old JR Black lay dying.

***
When people who have suffered traumatic injuries arrive at a trauma center, surgeons focus exclusively on the myriad physical issues that can kill the patient within minutes.

When looked at from that binary “lived/died” perspective, trauma survivor- ship has improved exponentially through the years—thanks in part to the lessons of war. The information gleaned from treating devastating battlefield injuries as far back as the Civil War has filtered back to civilian surgeons. Advances in technique, equipment, transportation and coordination of care in trauma centers have combined to the point where less than 10 percent of trauma victims who make it to a hospital die from their injuries. 


Numbers like that have some experts now viewing trauma more as a chronic disease than a fatal illness. Or, put another way, the question is moving from, “Can trauma patients survive?” to “Can they thrive post-trauma?” Experts point to cancer, where major clinical and research developments over the last 20 years forced clinicians to re- define what they considered to be “positive” outcomes beyond mortality. In the world of cancer care, quality-of-life issues such as linking up with support groups, finding effective pain management and dealing with psychosocial adjustments are now common clinical conversations, all aimed at helping patients to enjoy productive, fulfilling lives post-treatment. 

That’s a discussion that many trauma surgeons didn’t even realize they needed to have, until a public health researcher and her team spoke up in a voice too familiar and well informed to ignore. 



***
The stars told the young soldier he was still alive.
Just moments before, Ryan Christian Major had, under the cover of Iraqi darkness to avoid snipers, been darting through narrow streets of sand and stone. His platoon’s objective on that November evening in 2006: to eradicate a cell of bomb builders nearby. A small intersection loomed. Major took two steps into it. 

And suddenly he was staring up at the heavens. 

The remotely triggered improvised explosive device tore Major’s right leg from his body, hurling the rest of him over a 6-foot wall and into someone’s yard. Motionless from the neck down, Major never lost consciousness, and even tried to say his good- byes. “Tell my mother and brother that I love them,” Major implored one of his bud- dies, who reacted in a way Major would later say was perfectly appropriate.

The soldier slapped Major’s face.

“Don’t put that on me!” growled his comrade, exhorting the gravely wounded soldier to stay conscious... and alive. “Tell ’em yourself!”

Some four weeks, three continents and several hospitals later, Major would do just that, when he awoke from a drug-induced coma at Walter Reed Army Medical Center. After 19 blood transfusions, he was stabilized and transported stateside, where he soon lost his other leg to an infection. Later, as he became conscious of his surroundings in Ward 68, there came the moment when the neck brace was removed and he could finally lift his head off the pillow. 


What he witnessed shattered him. “It wasn’t the pain that affected me,” Major says. “But seeing the amputation was like a stab to the heart.” 

His legs gone above the knees, he thought of the man he was and despaired over the man he might be. He had defined himself through his body—the challenges it could meet, the sports it could play, the movement in which he gloried. But now? 

“How will I do that without my legs?” wondered Major, his mind asking the same question that hovered, like a shadow, over all the soldiers in Walter Reed facing a similar fate.
And who, if anyone, could show him the way back? 

***
It could be a bad pun or karmic poetry; either way, Johns Hopkins School of Public Health researcher Ellen MacKenzie, PhD, is the first to admit she discovered trauma research quite by accident. 
 
As a student in the 1970s, MacKenzie, a bio- statistician by trade, was studying colleague Susan Baker’s work. Baker, MPH ’68, a professor of Health Policy and Management (HPM) at Hopkins, had developed the Injury Severity Score, or ISS, which would become the standard measurement for predicting injury mortality. MacKenzie wondered if similar scales might predict non-mortality outcomes such as the ability to perform everyday activities. Her advisor, pioneering public health researcher Sam Shapiro, told MacKenzie, “I’m sure there’s a lot of research out there.”

There wasn’t.

Shapiro, an HPM professor, quickly helped her secure a Robert Wood Johnson grant. Of such efforts careers are born, and, in the case of MacKenzie and colleagues, clinical practice changed. MacKenzie spent much of the ’80s burrowing into the world of trauma treatment. Her work focused on quantifying all aspects of trauma care, from the cost of treatment to how pre-existing disease affected the length of hospitalization.

But those findings were the end product of something far more important and lasting. MacKenzie’s true genius was building research partnerships with frontline trauma surgeons and other trauma-oriented physicians—so much so that she spent a sabbatical in 1995 at University of Maryland’s Shock Trauma Center.

“Here I was doing a lot of work in trauma, yet I’m not a clinician, I’m not a survivor, I’m a biostatistician,” says MacKenzie in explaining her choice for the yearlong sabbatical. “And so I wanted to spend time with trauma surgeons to learn what they do, to be closer to them. I went on rounds with them every morning, I sat through surgeries ... I really became part of that family and got ac- cess to a lot of information and got a better feel for their work.” 


MacKenzie realized that the high-pressure, high-volume work of trauma surgeons left them little time for research. They understood the importance of outcomes research but needed a colleague who could find the grants and carry out the work. 

It wasn’t easy—trauma, despite being the fifth leading cause of death, has never had a Lance Armstrong-like celebrity spokesperson to raise awareness and funds. But MacKenzie was motivated. She recognized that trauma surgeons had the power to move the needle, if she could spur them into action. Her opportunity was a study that she and her colleagues called LEAP, as in the Lower Extremity Assessment Project. LEAP was one of the first multicenter trauma studies, featuring 601 patients drawn from eight Level I (highest-level) trauma centers. 

With no existing national consortium for trauma research, MacKenzie needed plenty of charm and persistence to organize some of the country’s top orthopedic surgeons to design and carry out the study. 

LEAP’s ostensible goal was determining whether leg amputation or limb salvage provided the best functional outcomes. But, as MacKenzie notes, “there’s no way you could ethically do a randomized control trial, where some people would get their leg cut off and some wouldn’t, so we had to convince ourselves and others that doing an observational study with trauma centers that handled a lot of both patients would answer the question.”

Working with Carolinas Medical Center trauma surgeon Michael Bosse and orthopedic surgeons from seven other major U.S. trauma centers—as well as her own team led by researchers Melissa McCarthy and Renan Castillo—MacKenzie published initial results in 2002 in the New England Journal of Medicine that shook the world of trauma orthopedics. It turned out that neither group fared well, for reasons that went far beyond their initial injuries and surgical treatment. 


The study, which included asking trauma patients to self-assess how they were faring since their injury, found that barely half returned to work after two years. Some of their explanations for poor outcomes—poor social support networks, low self-confidence to resume life activities, pain and lingering mental health issues including depression, anxiety and post-traumatic stress disorder—could well be addressed in the clinical setting, but had not. The result: needless suffering for trauma victims. 

“We learned that there were elements of the patient’s assessment of the outcome that we weren’t really appreciating well as orthopedic surgeons,” says Andrew Pollak, MD, professor of Orthopaedics at the University of Maryland School of Medicine and Chief of Orthopaedics at the R Adams Cowley Shock Trauma Center. “[We’ve] looked for years at whether the fracture healed as the primary outcome measure. There’s no question it has to heal, otherwise everything else fails. But there’s a lot about patient satisfaction that’s driven by something else”—notably treatment of psychosocial concerns. 

Stephen Wegener, a psychologist in Hopkins’ Physical Medicine and Rehabilitation Department, says LEAP was a case of the right messenger with the right message. He says trauma surgeons might have been less responsive to calls from mental health professionals to ramp up psychological services for trauma victims. Having that missive come instead from a recognized public health researcher deeply familiar with the demands and realities of trauma orthopedics proved far more effective.

Wegener, who began collaborating on several projects with MacKenzie post-LEAP, likens LEAP’s findings to identifying an infectious disease for which an effective treatment already exists. “The results of the study came at a critical time; the Institute of Medicine had just issued its report 
[“Crossing the Quality Chasm”] calling for patient-centered care focusing on the psychosocial needs of patients and families,” he says. “The psychological community had developed cognitive behavioral interventions that have potential benefit for the problems identified in LEAP. And there are interventions on the psychopharmacology side to work with PTSD, depression and pain.”

Ellen MacKenzie and her team had defined the problem. Now they had to deliver solutions.


***
JR Black is healing, and he’s not alone.
 
In the still room, his voice fills the air with a tale of pain and perspective. And ultimately, hope.

Seated around the conference table deep in a corner of University of Maryland’s downtown medical campus are five other trauma survivors. Their faces register recognition, and appreciation as well, as Black discusses his physical travails—the day and a half of surgery after he was helicoptered to Shock Trauma, the fog of the medically induced coma, the shocking realization that every one of his extremities had been broken, the exhausting physical therapy that took his right knee from a virtually useless 28-degree range of motion to a nearly normal 123 degrees. His terrible thirst, unquenched for days because ventilators and liquids simply don’t mix. As he shares his story, heads bob emphatically around the table. They’ve all been there, done that.

“I was ready to jump the guy watering the plants,” recalls one of Black’s young tablemates, whose body was decimated in a motorcycle crash. The line elicits a huge laugh from everyone including Black, but the room quickly turns somber again as he hits upon a universal truth for the assembled.

“I had some dark times after I got out of the hospital,” says Black. “They don’t tell you the easy part is when you’re in the hospital. When I got out and was home, you have a lot of time alone with your thoughts and your ‘new’ body, looking different, covered in scars. There’s something that plays on your mind. It’s hard to have open wounds for such a long time. You feel like a leper.”

For Black and the others around the table, sharing and overcoming those feelings is part of what the Trauma Survivors Network (TSN), which organized the meeting, is all about. MacKenzie’s team helped the American Trauma Society (ATS) develop and launch TSN in 2006. From 2006 to 2009, MacKenzie was ATS president.

A CDC grant is allowing MacKenzie to evaluate TSN’s implementation at the Shock Trauma Center. At its core, TSN con- nects survivors and their families with those who’ve suffered a similar fate, providing support along with resources so trauma victims can rebuild their lives.
 

 A vital aspect of TSN is called “NextSteps.” The self-management program grew from a similar amputee-targeted program called PALS (for Promoting Amputee Life Skills) that MacKenzie developed with Wegener. The programs share a belief that patients are the central players in their re- covery, which can be enhanced by learning self-management skills. LEAP found that greater self-confidence is a major predictor of good outcomes; PALS and NextSteps are designed to teach participants how to take charge of their lives and their recovery.


A randomized trial showed that the eight-week PALS self-management program—which educates patients about their condition and allows them to track their symptoms and progress—reduced depression and improved function and outlook for those who received the training, with an important caveat: timing. “We found that people who were less than a year out from losing their limb did significantly better than those who started the program much later,” says MacKenzie, now the Fred and Julie Soper Professor and Chair of the Department of Health Policy and Management. 

PALS made MacKenzie realize that in order to reach patients with all kinds of support information in a timely manner, she needed a nationwide network. Getting trauma centers around the country to buy in and implement TSN could be that vehicle, an attempt to reach out and pull together trauma centers large and small, so they could promote and offer earlier psychosocial interventions. For patients, TSN may serve as a bridge to long-term recovery. Many say they’re too drugged and disoriented while in
acute care to even comprehend what support services they’ll need, and those who go on to inpatient rehab (just 30 percent of all trauma victims) generally aren’t offered routine psychological services.

“At [the rehab hospital] that was never addressed; all the talk was about physical rehab, ‘you’re going to see the PT, you’re going to see the OT,” says 44-year-old Mike Mutchler, who, along with his stepdaughter and fiancée, was severely injured in a head-on crash in June 2009, which required more than 15 surgeries. 

“I was at enough of a level of consciousness when I was there that it would have been extremely helpful,” says Mutchler. “I’d go so far as to say I wouldn’t even make it an option; I’d require that a psychiatrist come down to talk with a patient, even if it’s just for five minutes, to determine what type of help you might need. Because everyone who goes through this needs something.”

The Trauma Survivors Network may be that first step. MacKenzie’s team is now studying its impact on outcomes, especially TSN’s use of support groups, self-management programs and peer counseling. MacKenzie’s PhD student, Anna Bradford, says those data are vital. As a social worker, Bradford established and ran a trauma support and peer visitation group at Inova Fairfax Hospital for 15 years. Called “Rebuild,” it was a TSN-like precursor, and part of Bradford’s efforts included selling other area hospitals on incorporating the program.

“My gut said everything I saw was making a difference, but I didn’t have any data at all,” says Bradford. “So I’d go around to these various hospitals, tell them about the support work, and they’d say, ‘Oh, what a cool program. Tell me a little bit more about the research.’ And I’d go, ‘Excuse me?’ That’s why I went back to school, and that’s where Ellen comes in.”

Bradford is hoping the data will bear out what survivors like JR Black already know—that the opportunity to join with others in the trauma community will further healing. At the very least, says Black, such support could keep others from making the same seat-of-the-pants mistakes he made during his recovery—such as suddenly stopping his narcotic pain meds because of the side effects. 

“I had been home a few months, and I decided I was going to stop ‘cold turkey’ and not tell anybody. Just sticking the medications in a tissue and hiding it in the recliner I was in because I couldn’t sleep in a bed then,” says Black, who was recovering at his parents’ Hagerstown home. “That was the worst month and a half of my life. It was July, 90 degrees out, and I was sweating, then freezing, and depressed, constant mood changes, no one to talk to. It was nighttime and I couldn’t sleep, and the nerve pain was tingling so bad it kept me awake, screaming in the middle of the night.” 

Despite the agony, Black, unaware that weaning himself slowly from the meds was the correct option, refused to relent. “I felt like [going back on pain meds] would start the side effects all over again. I just wanted to get back to ‘normal’ again. What I didn’t know at the time was that what I was doing could have killed me easily.” 

Experiences like these gave Black, a longtime professional musician, the desire to become a volunteer recovery coach, someone who could reach out and counsel newly injured trauma victims. That’s a desire shared by everyone sitting around the table with Black. They’re all taking part in TSN’s volunteer peer-to-peer training, their freshly minted ID badges a symbol that Shock Trauma values the input these survivors will soon be giving to its patients. 

Black has already sensed the good that can come out of sharing something so awful. Sitting across from him is 19-year-old Nicole Lawrence, a Penn State student who nearly lost her life last November when the car she was riding in with four other students was struck by a speeding vehicle near woman from the car; Lawrence was pinned in the car for nearly a half hour, all the time tending to her unconscious friend who lay at her side. That friend would later die, and Lawrence struggles to this day over why she somehow survived, despite being seated directly at the point of impact. Black visited Lawrence while she was in Shock Trauma. Looking her in the eye now, he tells the room, “I did go see Nicole in November. I remember you had a really good attitude. I remember thinking when I saw her, she’s going to be fine. She was really upbeat when I saw her. You can tell the people that are going to be fine within a couple of minutes of talking to them.” 


He was right: Despite her ongoing struggles with PTSD and reconstructive surgeries, Lawrence returned to Penn State in just over two months. “Here were doctors telling me eight weeks before that I might not make it, and here I was eight weeks later in class,” she tells Black and the others with tears in her eyes. “That was a miracle.” 

It’s those little miracles that have given Black faith—both in himself and others. In the 18 months since his wreck, he’s worked his way from wheelchair, to walker, to cane, to a 28-year-old’s familiar “What, me worry?” gait. Along the way, a bevy of supportive medical professionals have changed his world view. “When you go through trauma, so many people have to help you to get you
back to where you are. Countless numbers,” he tells the group. “Before this happened to me, I was doing music, maybe it was the type of people you deal with in the entertainment business, but you get so cynical and bitter that everyone’s in it for themselves. I had no faith in people. But after this, I saw there really were good people, all the doctors and nurses and therapists. I wanted to be like that.” 

In the TSN peer program that MacKenzie helped develop, Black has found his outlet, a way to bond with others and take fear out of an incredibly frightful journey. While music will always be a part of his life—he continues as a songwriter, even penning a few songs relating to his accident—he’s thinking about a career of helping others thrive after trauma, perhaps as a recovery coach or a social worker. “This is like a first step for me,” he says. “I would really have liked to have someone who had been through everything helping me to know what to expect. It’s an awesome idea.” 

***
Ryan Major is thriving as well, though he’s had to climb his own personal Everest to get to where he is now. The four years since he first arrived at Walter Reed have been nothing short of a rebirth, a gradual reawakening of self-confidence that there can be a worth- while life even after the worst trauma. 

Like JR Black, Ryan Major found comfort in those he could identify with, in his case fellow soldier amputees who moved forward with their lives. It wasn’t so much their words as their deeds that inspired him. A fish in the water before his injuries, Major resisted a Walter Reed therapist’s attempts to get him into a pool. 

“I was like, ‘I can’t do it.’ I couldn’t believe, in my situation, that I would be able to swim again,” says Major, who lives with his mother in Silver Spring, Maryland. The therapist then introduced him to “Jack,” whose name has been changed to protect his privacy. Jack had also lost both his legs above the knees in Iraq. Now an Ironman-style triathlete, Jack displayed fluid movements in the water that astonished Major. “I saw him in the pool and he looked fantastic. I figured that, if he had been in the same situation I was in and could do it, then why don’t I just give it a shot? What the therapist told me, that I could swim, and which I totally denied... Jack showed me that they were right.” 

The military’s long history in dealing with and closely following soldiers throughout their recovery is an area of great interest for MacKenzie’s team. That close follow-through is often missing in civilian treatment, where patients move quickly from highly structured acute care facilities to the
home setting, frequently without getting proper physical and psychosocial rehabilitation. MacKenzie’s team will examine the effectiveness of rehabilitation in both the ci- vilian and military settings as part of a new cooperative agreement with the Department of Defense (DoD). 

Last September, they received a $18.4 million grant from DoD to establish the Major Extremity Trauma Research Consortium (METRC) and address pressing issues in the initial care of patients with serious limb injuries. An additional $43.5 million award has been recommended for funding this fall. It will be used to expand METRC and address other priority topics in acute care and rehabilitation of trauma patients injured at home or in combat. 

METRC will conduct research at more than 24 civilian trauma centers, as well as the four military treatment centers caring for the majority of service members injured in the line of duty, says MacKenzie. The data will be coordinated through and analyzed by MacKenzie’s group, which is also helping to design the clinical studies.

“The initial studies include randomized control trials looking at promoting fracture healing and preventing major complications like deep infection and compartment syndrome [severe muscle swelling],” she says. “We will also be looking at long-term rehab issues. We’re proposing a trauma collaborative care intervention, a multimodal approach that addresses the needs of trauma patients as they transition back to the home and community. The intervention combines the TSN’s services, including NextSteps, adds training providers to promote TSN use, and makes available a ‘recovery coach’ who advocates for the patient and links them to services after they leave the trauma center.” 

MacKenzie’s colleague from the LEAP study, Michael Bosse, chairs the consortium. A retired U.S. Navy captain, Bosse, the director of Orthopedic Clinical Research at Charlotte’s Carolinas Medical Center, notes that the cost of the research is high, but small compared to the economic loss from severe trauma injuries. 

“Look at the disability rates; you take a guy in his 20s who gets a severe leg fracture. You don’t achieve maximum outcome because you don’t know what the gaps are, psychosocially or physiologically. So for the next 40 or 50 years the patient is disabled and on the public’s payroll because we failed to do as much as we could up front,” says the veteran trauma surgeon. “Those are the tremendous opportunities here regarding care of these patients.” 

“It’s a very exciting moment for this field,” agrees Renan Castillo, PhD ’08, MS, an HPM assistant professor and MacKenzie’s deputy director on the project. “These studies are going to, hopefully, answer big questions. It’s not unreasonable to speculate that the METRC studies, like the LEAP study, that was designed to answer one question but ended up providing data for a number of other questions, will lay the foundation for additional studies. Ellen has shown she can bring the clinicians together, and has already successfully built networks like METRC. When you think of Ellen, you think of someone who can get it done.” 

That’s the kind of mindset a soldier like Ryan Major can appreciate. One day removed from his first kayaking expedition on the Potomac, he’s a man in motion. The knowledge and care of his clinicians and therapists have him in a new pair of short prostheses without knee joints (“stubbies,” he laughs), and if he adjusts well to them, the next step is... a real step, in full-length prosthetic legs.

Mentally, he says he’s already adjusted. and when asked if he’s in a good mindset, his youthful voice is strong and unwavering. “Most definitely. I chose to push forward and get on with my life. I’m a young guy with a lot to live for—family, friends and things I dream of doing.”

(Published in Johns Hopkins Public Health Magazine, Fall 2010)