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[Kevin Whipple for The Trace]

Missouri Under the Gun

The Rookie Surgeon and the 13-Month-Old Gunshot Victim

What it's like to be an ER doctor in the city with America's highest rate of gun violence.

Before coming to St. Louis for her medical residency, Pam Choi, the chief surgery resident at St. Louis Children’s Hospital, can recall treating only one patient who’d been shot — a man who came into the ER while she was on a surgery rotation as a medical student at the University of Rochester. Gun violence was neither part of her personal experience nor an issue she thought about much. She grew up in the Northern New Jersey suburb of Franklin Lakes, one of the safest towns in the state.

Missouri Under The Gun

A collaboration between The Trace and students of the Missouri School of Journalism

It was not long after arriving at St. Louis Children’s Hospital that she began noticing with horror the regularity with which young people were brought into the emergency room with firearm injuries. The incidents soon blurred together in her memory. She can no longer remember the first child gunshot victim she saw. But she may never forget one baby boy.

One night in 2014, Choi was working an overnight shift when her pager buzzed. A tiny patient was headed to the emergency room. “When you see that page come across — ‘13-month old baby, GSW (gunshot wound)’ — your blood just runs cold. You’re like, ‘Oh my God; what should I expect?’” she says.

The infant had been shot as his mother held him in her arms. Only vague details were relayed to Choi as the paramedics rushed the baby across the city, but according to the reports she was getting, the bullets were meant for someone else. The baby was just in the way.

Choi and her team raced to the trauma bay and waited for the ambulance to arrive. She found herself standing very still as she focused on how she would deal with all the possible scenarios.

Would there be cardiac injuries? How much blood loss? 

The younger the patients, the less likely they are to survive traumatic injuries. Was the ambulance taking a long time, or did it just feel that way? Did her team have all the supplies it would need? Were they ready for this? She and her colleagues exchanged only a few words as they waited.

The boy arrived in the ambulance with his mother. As paramedics wheeled him into the emergency room, Choi pulled the mother aside into a quiet conference room and explained where they were taking her son and the operation they would perform there. The boy’s sobbing mother begged Choi to do whatever she and the other doctors could. Choi promised that they would, though experience had already taught her that even in the best of circumstances, outcomes are never guaranteed in the ER.

The infant was chubby and crying loudly. He’d been struck just once, but the single bullet in his small body had done enough damage to threaten his life.  Choi remembers hearing the baby’s cries growing softer as he struggled to breathe. The doctors worked for several hours to stabilize their small patient. Finally, after persistent resuscitation efforts, it became clear that he would survive.

Despite the victory of the boy’s survival, Choi continues to be disturbed by what she witnessed that night. As the boy’s recovery dragged on, she could only think that he didn’t belong there in the hospital. He should be like any other 1-year-old, happily learning and exploring his world.

As one child gunshot victim after another appeared on her operating table, Choi became more frustrated. She wanted to do something about the bigger problem. Her training led her to think about the issue in terms of disease  — the way one might ponder the spread of the flu or HIV. If children were being hurt and killed by particular means, causes could be researched and solutions implemented.

St. Louis Children’s Hospital has one of two Level I trauma centers equipped to treat pediatric gunshot injuries in the St. Louis metro area. Cardinal Glennon Children’s Hospital has the other. During intake, social workers interview patients and their families to determine the circumstances surrounding their injuries. Choi recognized that her facility was uniquely positioned to produce a better understanding of how children in the region become victims of gun violence.

Along with a handful of other researchers, Choi analyzed 398 pediatric gunshot injuries in St. Louis between 2008 and 2013. That rate of young victims was unusually high: A similar study in Detroit covered 10 years and recorded 289 gun injuries in children. A study over nine years in Colorado recorded just 129. The children of greater St. Louis were being shot in the city and in the suburbs. They were targets, bystanders, accidental victims. Slightly fewer than half were in their own homes when they were hit.

The high rates of gun violence in St. Louis have led to numerous intervention attempts by the city government, private organizations, and law enforcement. Programs for at-risk youth abound. Neighborhoods hold regular community forums. In 2014, St. Louis County established a curfew from midnight to 5 a.m. for minors under 17. (Choi’s research showed why the policy would likely be ineffective at stemming the shootings: She found that most gun injuries actually happened outside curfew hours, between 6 p.m. and midnight.)

Despite those efforts, gun violence rates have spiked. In 2007, Missouri legislators repealed a law requiring gun owners to obtain a license before purchasing a gun. In the years afterward, the number of shootings continued to rise, jumping 25 percent through 2010, according to the Johns Hopkins Center for Gun Policy Research. They continued to climb, to 37.7 homicides per 100,000 in 2013; to 50 in 2015; to 59.3 in 2015.

To bring the numbers down, many doctors in St. Louis echo the American Medical Association and the American College of Physicians in approaching gun violence as a public health issue, disentangling research and preventative measures from the partisan politics of gun legislation.

Dr. William Powderly is the director of the Institute for Public Health at Washington University in St. Louis, which launched the Gun Violence Initiative in 2015. To illustrate his organization’s approach, Powderly uses road safety as an analogy. Early on, American drivers had to follow few rules. They could drive with a drink and without a seatbelt, often to deadly ends.

“We had carnage on the roads, and this was clearly recognized as a public health issue,” Powderly says. “And over the next 30, 40 years, we gradually made driving a much safer enterprise in the United States.”

But in Missouri (and across the United States), guns are not like cars. Politics have so thoroughly saturated any discussion about gun safety that some doctors moderate their language to make gun owners more receptive to their ideas.

Dr. Robert Kennedy, a pediatrician who, like Choi, works in the emergency room at St. Louis Children’s Hospital, doesn’t like to use the term “gun control,” for instance. “When you use that language a lot of people tune you out,” he says.

Kennedy has been in the field for about 40 years. Sitting in his house in St. Louis, he clicks through slides of data on child gunshot injuries in St. Louis on his computer — locations, ages, intentional or unintentional — and recounts one tragic story after another. There was the child who thought a family handgun was a squirt-gun; the 12-year-old who didn’t mean to shoot his friend after finding a gun in his grandfather’s bedroom; the father who accidentally shot his infant son while in the car.

In 2013, not long after the Sandy Hook Elementary School shooting, Kennedy wrote an op-ed for the St. Louis Post-Dispatch with fellow St. Louis Children’s Hospital physicians David Jaffe and Martin Keller. In it, the doctors implored readers to support recommendations by a host of medical organizations that wanted to ban assault weapons and high-capacity magazines and end federal restrictions on funding research into gun violence.

But today, Kennedy has stopped looking to legislative solutions to help halt the flow of gunshot victims into his hospital. “I don’t think there is any way to get any legislation passed right now,” he says.

Instead he’s emphasizing simple measures doctors might take, like asking more questions about firearms use and gun violence exposure while documenting patient medical histories. Queries about gun ownership and storage would appear alongside questions such as, “How many alcoholic drinks do you have per week?”

Elsewhere, doctors have found that even such straightforward patient interactions can be vehemently contested. In 2011, Florida passed a law, backed by the National Rifle Association, that barred physicians from asking patients the sorts of gun-related questions that Kennedy believes can prevent firearms injuries and deaths. The 11th Circuit Court of Appeals recently struck down the law, saying it violated doctors’ rights to free speech.

If doctors and public health experts are seeking treatments to what they view as an epidemic, Mary Hennings could be considered a survivor of the disease. The 61-year-old is recovering from her fourth surgery since she was injured by gunfire in 2013.

On a warm evening in March, she moves with difficulty around her daughter’s home in Jennings, a St. Louis suburb. She looks for the right place to sit so as not to irritate her left hip, which was recently replaced. She points to the spot where the bullet entered her leg and then traveled upward. A long, deep scar marks its path.

Hennings was standing in front of her son Michael’s house when she was shot. She was about to head into the city with Michael and a few other family members and friends. But then Michael had to use the bathroom. And then someone else forgot their phone charger. And then Hennings, hurrying to make her appointment, turned to go inside to get it.

Before she could open the door, she found herself falling to the ground, confused. She tried to move but couldn’t. As the pain spread through her leg, she heard more rounds being fired and understood what was happening. She prayed for the shooter to run out of bullets and for the pain to stop. To this day, the case is unsolved.

Hennings’ godson, Anthony, ran to her on the porch. He is so much a part of her family that he calls her Mama. As she bled onto the steps, he ripped off his shirt. “Mama, this is gonna hurt,” he told her as he used the shirt to create a tourniquet. Later, a doctor told Hennings his action had probably saved her life.

This was not the first time Hennings had experienced gun violence. Her son Alvin was shot and killed in 1989 in the St. Louis area. And five months after Hennings herself was shot, her  other son, Michael, was shot to death.

At the kitchen table, Hennings pulls out a scrapbook and points to pictures of Michael. The photos show a handsome man in his 30s who smiles easily back at the camera. Hennings likes to remember doing work around the house with Michael, fighting over who would cut the grass.

Mary Hennings once cut hair for a living. Shortly before he died, Michael told his mom that he was going to barber school, so he could take after her. “Michael was a good guy,” she says, gazing at the photos, occasionally closing her eyes to try to stop the tears.