 On behalf of the Plain Center and the University of Chicago Trauma Center, I welcome you to the 12th lecture in our series on ethical issues in violence, trauma, and trauma surgery. It's my pleasure today to introduce our two speakers, Dr. Kimberly Joseph and Reverend Carol Rees. Kimberly Joseph is a retired physician who worked for many years in the Division of Trauma and Burns at the John H. Stroger Hospital of Cook County. Dr. Joseph received her MD from Columbia University College of Physicians and Surgeons in New York, did her residency in general surgery at the University of Illinois College of Medicine. Here in Chicago, and completed a fellowship in surgical and critical care at Stroger Hospital. Dr. Joseph cared for patients at Cook County's trauma program beginning in 1993. Reverend Carol Rees is chaplain at Stroger Hospital and a licensed clinical social worker. Reverend Rees also is a co-principal investigator and program director of Healing Her People Chicago. You may remember that the clinical director of Healing Her People, Rad Stibach, gave a lecture in this series about two weeks ago on the programs that is Healing Her People programs work to facilitate trauma recovery in children and adolescents injured by violence. Reverend Rees came to Stroger in 1986 when she was working at the Southern Baptist Convention. Until 2002, Reverend Rees was the executive director of the AIDS Pastoral Care Network. And in 2005, she returned to Stroger. And in 2010, became staff chaplain at Stroger. Dr. Joseph and Reverend Rees' talk today is entitled, as you see it behind me, crime and notary. When is it our moral duty to do more for our trauma patients in need? Please join me in giving a warm welcome. Thank you. So thanks, everybody, for coming. Carol and I are very honored to be here. We want to thank the McLean Center and Dr. Sigler for inviting us to come and speak with you all today. I need to do a shout out before I get started. Abner, Nympha, and Mary Lou, please stand up. Abner, Nympha, and Mary Lou are three of our very dedicated trauma nurses at county. And even though this is going for publication, at least I'll speak for myself, maybe not for Carol, but you're going to hear me refer to it as county. I have never, except when I had to speak for the media, called it Stroger. So I apologize in advance. We're going to be talking about county. I would like this to be somewhat interactive. Carol and I are going to tag team this a bit. We're going to ask some questions, not with the idea that there are right answers, but just to kind of get people thinking of some things. So the first thing I want to ask, which I think all of you are probably better versed in this type of thing than I am, in your opinion, what's the difference between morals and ethics? Moral is a general in everything. Ethic mostly is related to the conduct. What's good, what's not? What is right, what's not? What is justice, what is not? But the moral is in general moralities of almost everything like that, but often it's mixed together. One means something and means the other. OK, so I'm going to just repeat in case people didn't hear. He was talking about morals, sort of being a larger concept. Morality, ethics, and problem, what's right or wrong. So I think the conduct, as I've always understood, ethics, I agree with you. It's really something that is externally put on us in some way about how we should behave, what's appropriate conduct. Whereas morality, a lot of people to argue morality is something that is bigger and perhaps also more internal. But I would say probably also societal. And that's part of what we're going to be talking about today. And my next question before we really get started, which I don't want an answer to, is for you individually in something in your life, is there anything that you consider to be a moral imperative? OK, if I don't trip and there's a couple of trauma centers, a couple of trauma surgeons here. So first off, we don't have any disclosures. What Carol and I are going to do is take you through some cases, but also take you through kind of the journey that we went through when we first asked to consider doing this. And one of the things that when we were trying to put this together, and we talked about this a little bit a couple of hours ago, is that the words have meaning. The language is important. And one of the things that Carol and I, I won't say discovered, but maybe rediscovered, was that we, a bit of it, is that we needed to go back and actually look at the language about what we do and figure out, number one, are we doing it? But number two, where does it come from? And by looking at where it came from, that also helped inform our answering, are we actually doing it? So our understanding of what cure actually means, what care actually means, what hurt actually means. Where does that word come from? What does it actually mean? What healing actually means, both the current use and also where it comes from. So we'll start with a case that I had many years ago titled Why Jeevan Bodderdock. So this is a guy who came in by report, jumped in front of a train in a suicide attempt. He was unstable on arrival. We ended up having to intubate him, all the things that we would normally do for an unstable trauma patient. His left leg was essentially near amputated. We completed that actually in what you would call your emergency department. We call it our trauma resuscitation area. He also had a very mangled left arm. We took him to the operating room, finished the amputation on his left leg, also did some repairs, muscle, debriefments, and things to his left arm. We get him through this process and resuscitate him, medically what we would consider to be successfully. We get him extubated. And the first thing he asked me when he woke up, we had him, took the tube out. First thing he asked me is, why did you even bother, Doc? Why did you even bother? By this time, we've had him for a few days, he knew that he'd lost his left leg. His left arm was essentially not able to be used. He couldn't use it. There was so much nerve damage. What do I do now? So if you had known that the patient wished to die when he arrived, now think ethically and morally, going back to what you're saying, did we actually do the right thing by this patient? If you would have known beforehand that the intent of this patient was to end his life, did we do the right thing? And I'm asking not because I expect that there is a right answer to this, but I'd just like to know what you think. I do. And I'm very patient. I am very patient. I've been an ATLS instructor for 20-plus years. I can wait you out. The basic premise by which we perform emergent treatment for patients who can't give us consent is that we presume that it would prefer to live and die. Yes. We presume to retain function rather than lose function of a limb or organ system. And you're basically suggesting if we don't have that presumption, can we still treat? Yes. Immersely. That's what I'm asking. And so I suppose using that framework, we have to say no, at least, or at least that we have to find some different framework in which to understand our presumption of the imposition of our treatment of the patient. OK. And I think that's absolutely legitimate. There's somebody behind you who's going shaking his head. So tell me what you're thinking. OK? OK. What if you knew that the reason that he did not want to go on living is that he had Huntington's, Korea, and he was going to, he knew he was going to die in a matter of a couple of years anyway, horribly, that there wasn't going to be any treatment? Would that change the way you're thinking about it? OK. I still think that I think it's more complicated to think, well, if he has a terminal disease and he wants to die fine, you know, I think it's an easy way out for us to not treat underlying depression and not treat underlying psychedelics. OK, and we're going to come back to that. Go ahead. So I'm not a physician. I'm looking at this from a patient's point of view at my own particular point of view. I very strongly believe in a right to die in an individual's right to make that decision. And I would say, if it were me, I would say the same thing as the patient had said. However, I've also seen studies that say that perhaps the majority of patients and a majority of patients who are saved from suicide are thankful for it because it's an impulsive decision and they wish they could take it back. So assuming that the physician has no way of knowing what this person's real feelings and real intentions were, I reluctantly have to say, yes, you did the right thing. OK. And I went through, yeah, well, and I have to say, I went through, in my mind, feeling pretty sure that this was intentional just based on the description that was given to me at the scene. And still made the decision of, well, for some of the things you talked about, was this something that if we had another chance at it, could we treat him? Could we have him feel a little bit different, not knowing the medical history? And ended up with this decision that I made, knowing that probably this was an intentional act. So let me take it one step further. You can see the second question up there. What if he had said, not whether or not treat me or don't treat me, but don't intubate me? I've seen people in my family, and they've been on life support. I don't ever want to be in life support. He's decisional. He's awake, and he can tell you, I don't want to be intubated. It's Bill, right? Yes. And again, I think that's legit, too. If you're saying his blood pressure's low, does he really understand what's going on? We use that argument a lot in people who we kind of suspect may actually be decisional, but we don't want to do what they want us to do. So we say, well, his blood pressure's low. He doesn't really understand what's going on. So the reason that I'm presenting this is because really, if you look at then what goes on to happen to him is that he has no real nerve function in his left arm. His left leg has now been amputated. We get him an electric wheelchair. It lasts for maybe two months. It breaks down. The insurance won't replace it. He's unemployed. He has chronic pain. He has difficulty now in all of his relationships. He's intermittently homeless. I follow him for about two years and then lose track of him. I don't know what happened to him. So I did find sort of at the end of this road asking myself, did I behave ethically in this case, which in some ways, for me, was an easier answer, but then asking myself, did I behave morally in this case, which was a harder answer for me. So I'm not going to read through all these things because this is really your area of expertise. For a lot of you, what are the domains of medical ethics, at least modern domains? And I would say that we did our best to do no harm. We really did not recognize his autonomy because we I won't say we. I'll say I did not think he was capable of being decisional and at first, when I first saw him, I acted in what I thought was a patient's best interest. We're going to get back to that also. Tried to treat him with respect, but again, there were circumstances that led to that not happening. The bigger question to me really is a moral question. Did we cure him? And that's when you have to go back and start looking at what's the origin of the word cure. So if we look at it from relief of a disease or something that we fixed, something that cures a particular medical problem, then yes, we cured him. But what do you think is the actual origin of the word cure? I heard wellness. Say it again. Cure is heart. It's heart. Cure is heart, sort of. C-U-R. It has like cardiac cure, OK? So it's interesting because when we were looking this up, one of the things that we found was that the Latin root of the word cure has to do with soul. So if you think of the old word for a priest, curates. It actually has to do with treating the soul. And I would argue that in this area, we failed miserably. That we didn't ever completely address the cure for him and the care of his spirit, the care of his soul. I think back on him a lot about what I would have done differently, and we'll hopefully have a chance to talk a little bit about that. And this idea of looking after somebody, and we'll talk in a second about care, Carol's going to talk more about healing. But we were entrusted not just with his body. We were entrusted with him, with his person, with his soul. And I will, I call this a failure on my part, that I wasn't able to somehow help his soul. Now, some are sitting back there, and I have to admit I do periodically, just to get through my day, say, well, there's a limit to what you can do. And yes, that's true. I would like us, by the end of the time that we have together, to push that limit a little bit further back, and not use that as a crutch, and start thinking in terms of what are the things that we should be doing, whether you see this guy or not, to make sure that you are able to treat his soul. What are the things that we have to do? And for me, that's a moral question. That's not an ethical question. How about the origins of the word care? Did we care for him? Yeah, I think by some definitions, we did care for him. You can see some of the more modern definitions up there. But one of the most modern definitions is that the provision of what is necessary for the health, welfare, maintenance, well-being, and protection of someone or something. And again, I would argue that in this case, we failed to care for him. Not just individually for me as a physician, but there's some place upstream in this patient's course where we, as a profession, fail to provide care for this patient, fail to provide what was necessary for his well-being. And we'll talk more about that. These are some of the other definitions, but the one I really want to focus on, because we're gonna keep coming back to it, is this first one, the provision of what is necessary. Go ahead. Yes. So I probably would have done the exact same thing in terms of my medical treatment of him, and notice that I am not using the word care. That's deliberate. I would do the same medical treatment for him. The care of this patient actually needed to start before I saw him. And part of what we have to define for ourselves is what are we doing to care for people that we are responsible for, and we are now medically, as healthcare providers, as ethicists, we are responsible for the people who require healthcare in this country. And if that's our definition, then our notion of what care is changes. It's not just the medical treatment. It's what are we doing to make sure that patients have access to the kinds of resources that will prevent this from happening? And we're going to push into that. I don't want to take up too much time because I want to make sure Carol also has time to talk about her case. Exactly. So what I think has changed to some degree is my degree of agitation, disruptiveness, whatever the word is you want to use now, whatever the current word is about making sure that this guy didn't have to jump in front of a train to get care, to get care, not treatment to get care. And that's what we're going to be talking more about what's the moral, for us, for me, the moral imperative. So even if we pass the ethics test, and even if my treatment of him would have been the same, one of the things that Carol and I did as part of this journey, looking to see what are we doing with regard to cure the soul part of this and care what is necessary to maintain well-being, to maintain health. That's a bigger issue that I would argue is a moral issue, not an ethical issue. And this is basically what I just said. So we are, Carol and I, as part of this journey that we are on continue to be on, but really as part of putting this together, looking at what else do we need to do if we're going to reclaim the word cure as the care of souls, if we're gonna reclaim that, what do we have to do to make sure that that happens for our patients? And it has to happen upstream, but I'm gonna now turn it over to Carol. Well, I think the other thing that we're doing is trying to have us all kind of look at this language that we use a little bit more in depth and a little bit more broadly. Because if you go back to some of these slides, the connecting cure with the healing of a disease wasn't the original meaning of the word. It happened in English speaking countries as they began to, in the 14th century, they began to connect those two things. So it was probably healthcare professionals. Well, it happened because in the 14th and 15th century, there were things that could be cured. But if you think back, there were a lot of things that just could be cured. The only thing you could offer was spiritual support, right? And then we get to a point where there are things that, quote, could be cured. And that's the word now morphs into something different. And it's not that the new meaning is not legitimate. It's just that we've lost to some degree the old. And my argument and Carol's argument is that we've got to now put them back together. Great. So this is our second case study. In, at Stroger Hospital, I should use county, shouldn't I? We should be consistent. I've been talking to the press a little bit more frequently than you, so I've retrained myself. We've had the privilege of working with a lot of young people. And I find these kids, mostly young boys, quite amazing. And I want to introduce you to two of them, Jonathan and David, who are cousins. Jonathan is outgoing, always looking for an invitation to perform. David is shy but thoughtful. The two of them are inseparable and share kind, sweet interdependence. They lived just a block away from each other and they were both shot in separate incidents near where they lived. When our team of outpatient trauma intervention specialists first met the boys, they were both struggling with the physical and emotional complications of their injuries because it was just, we encountered them just after they had been injured. Neither of them was in school, neither had a job. They were both often hungry and looking a little bit disheveled. David used copious amounts of marijuana to cope with his PTSD symptoms. And I mean copious amounts, smoking up to 13 times a day. Jonathan immersed himself in rap music, writing lyrics and looking for places to record and perform. But during the spring and summer, we were able to help both boys and begin to deal with their PTSD symptoms and find support with a group of boys and girls who understood their struggles. And they began to blossom. They both got summer jobs. We were able to convince, control, drag, then both back to school. During the summer, neither had been in school for more than a year. And when the first day of school hit, David was sober and they were ready to roll. About three weeks into school received a call that there had been a fire at Jonathan's house. Eight people were asleep in the house, including both Jonathan and David. The only way out of their second floor apartment was to jump from the bedroom window. Everyone was panicky and not thinking or seeing clearly because of the smoke and the fire. David jumped first to encourage and to help catch the others. Now Jonathan's family is homeless, living with friends and relatives. Their already tenuous financial situation had become dire. But the most difficult thing they had to deal with during that period of time was that Jonathan's little sister, Brianna, died in the fire. She did not make it to the window to jump to safety and no one was able to find her in the house. The boys felt guilty and responsible. They should have been able to get her out of the house. They both told us after Brianna's death that she was the one person in their family who told them how proud she was that they were going back to school. It made her happy to see them doing something good for themselves. The boys said very frequently we have to finish school. We have to make something of our lives. Brianna believed in us. And while they have found strength in remembering Brianna in this way, both Jonathan and David remain in a very dangerous place, both physically and emotionally. They were shot. They lived in the same neighborhood where they were shot and worry every day about their safety and the safety of their families and friends. They went to sleep in the one place they felt safe and woke up to a house on fire. And the only person who really believed in them, a little girl, died. In the year or so since the events that I described, several other things have happened to these young men, now young men. Both of them have become serious artists blowing glass in our project fire program that I know Brad spoke to you about a couple of weeks ago. Both of them are peer leaders in our program. They help facilitate support groups and their trainers for the Healing Herp People program and our trauma-informed care training programs that maybe some of you guys have participated here at UFC. A couple of not so good things have happened. David was shot in an incident in which his uncle was murdered and died in their home. They were shot on the front porch of their house. Jonathan, while he's remained not unreinjured, well, that's an inelegant way to say that, but while he hasn't been injured again, he's had a couple of close calls with the police. He was arrested because he was sitting outside the home of a white woman who called 911 because she didn't know who that was sitting in the car outside of her house. And then on a second occasion a few weeks later he was roused out of the car by the police because he was again sitting in his car and was in a neighborhood where he didn't belong. Trauma teams care for people with physical injuries who've been knocked about and very often treated unjustly. We talk a lot about injury in our profession and talk about it in terms of often in terms of the physical harm or damage that's done to someone. But the other origin of this word, if you look at kind of the more archaic uses of it is that this is a wrong or an injustice or something that has done harm to someone which isn't necessarily related to a physical injury. And the word for hurt comes from an old French word, herder or to knock. So I wanna, it did evolve into a metaphor for wound and harm but I think what we wanna talk about for a little bit with you guys is that the young people that we serve primarily in our unit are young people as I said before who have been knocked about and treated unjustly. So I wanna talk a little bit about the broader context of our work. Trauma is a disease of young men primarily. 50% of the deaths among men of, young men of all diseases, I mean of all ages are due to unintentional injuries. You guys probably know these things. You may or may not know that the leading cause of death of young black men in the same age range is homicide. And you can see where homicide shows up even under as the second and third leading causes of death in younger black males. And then suicide and then heart disease. I mean kind of a twisted sense of reality sometimes but I think about this. You know you survive homicide up to age 34 and then oh you're gonna die of a heart attack. So we'll talk a little bit about the context in which health outcomes for young people are way more challenging than we would like to see. We were here last, a couple of weeks ago, I was here last when Brad talked about adverse childhood experiences. This is another context in which we are working with our young people. Adverse childhood experiences look like this. Physical and sexual abuse, emotional abuse and neglect, parental separation, incarcerated household members. A lot of our young people deal with these adverse childhood experiences. 70% of our kids have had three or more of these adverse childhood experiences and 21% have had five or more. One of the things I think we may not have talked about a couple of weeks ago is the impact of race and institutional racism in this country and the legacy of slavery. So there are a group of people working on these things who talk about racing aces that a lot of our kids have experienced the adverse childhood exposures that we talked about that I just talked about, but for many of them below, I mean, that's just the tip of the iceberg for a lot of our kids that just by being young and African-American in this country, you have, before you're even born, experienced trauma. Another thing that our kids deal with is a cycle of violence, past trauma. Within five years, 45% of our patients are re-injured just by being shot puts you at higher risk of being shot again and 20% are dead if this is without any intervention at all. The other thing that our kids deal with on a day-to-day basis, you heard that in the story embedded in the story of Jonathan and David, but these kids hear gunshots, they've been jumped, they've seen the stabbing, they've had family members who've been murdered. So this is the group of questions that we typically ask our kids to assess what their violence exposure has been. Anyone wanna venture a guess as to how many, on average, how many of these community violence exposures our kids have had? This is a list of 14, come on, some of that. 10, 12, it's not quite that bad. Seven, 0.7, almost eight. I mean, I don't know what happened to you when you were growing up, but those kinds of experiences were not part of my life. And I don't know if I would still be standing, if I would be standing here today at all. I'd like to think that I would be that hopeful and resilient and there'd been people in my life who would have picked me up and carried me through, but I don't know. And for those who have screened positive for PTSD among our patients, I mean, among our clients at County and Comer, eight, almost nine types of community violence. Prevalence of PTSD symptoms is very, very high. If you just take a look at this seven, almost eight percent of the general population you would expect to find, I just saw you. Hey, Carlos. Eight percent in the general population would screen positive for PTSD symptoms among our pediatric adolescent patients, almost 48%, so almost half of them screen positive. For those who had witnessed the homicide, 100% of them screen positive. And some data that I think Brad has been collecting would, the latest data that he reported, I think last week is that 65, upwards of 65% of our kids suffer from PTSD symptoms. Yeah. One of the things that gets lost as we're going through this is that you can get shot and you're not going to have 100% necessarily have screen positive for PTSD, but it can really get achieved. And that goes back to what we're talking about, right, the cure and the care. It's not that you didn't have the physical injury, it's that you've seen someone else. You had it happen. So your perspective now has to change about where is our moral responsibility. Why, thanks. Thank you. Thank you. Yeah. I think that was an awesome question. Whoa. A slide or so ago when you said that you were sharing with us that these children or young people had these various experiences, and you said, I'm going to paraphrase but that like you had not had that in your mind. I guess I, so as I think about the moral and ethics of that, I mean of the conversation, I go back to what relevance do you think you sharing making that comment has to the overall conversation about this? And I'm not saying yet one way or other. I guess I'm thinking that it made me think certain things but I want to be clear as to what your intention was because I feel like I wasn't sure and I couldn't keep going through the slides with you because I felt like that must have meant something because you said it, but I don't know what it means. Sure, what it meant for me when I said it is I don't know that I would have been able to be a healthy whole human being and still standing here today and being able to survive all of these types of exposure to violence. I don't know if I would have been able to cope with all of that. And so what I'm, for me, what I'm talking about when I, I guess the subtext that I didn't say is that these kids are incredibly strong, incredibly tough and incredibly resilient. They make connections with their families, with their friends that somehow sustain them through this. I want to say to you that even though these kids look like that, these microstressers are having an impact on their lives. And I think could be wrong, but that's why the same group you're looking at, flipping them 10, 15 years out and there's all this heart. Yeah, absolutely. Because what we know from Dr. Nelson's work at Rush, was that the same group of people have a really high rate of miscarriages and multiple miscarriages because of all of these systemic microstressers that the society continues to tell us these people are resilient. These people are not resilient. These people can, I mean, and I'm just, this is my opinion, but it appears that there is so much water that goes over that says these people are resilient, they do what you, you know, they can make these, and they can, yes, yes, yes, but I cannot leave that piece of the conversation without saying that there are extensive microstressers that are happening to these people, us people, whoever we are, that are real. Absolutely. These other, so I don't want you, I guess I'm challenging you not to celebrate that resilience, but to also acknowledge that in creating this strata of experiences for people that there is not just this violent downside, but there is this downside that they are carrying these generational stressors that are impacting us as a society, generation after generation after generation. Right, and that's what these slides were about. That, I mean, even just the list of adverse childhood experiences that in this study from several years ago, those stressors led to social, emotional, cognitive impairment, health risk behaviors, early death, and this even, it's even worse here. Maybe we didn't spend enough time here, but the history of slavery and structural racism, white supremacy, all of that. I mean, I was just, I keep having to look up this word allostatic load, but that's just the wear and tear on your body, right? Just from being born black in this country. It's interesting because what I'm hearing you challenge us on is actually the use of the word resilience, and that's good, because that's part of what we are trying to work through all the time is the meaning of the word, and what is it being used correctly? And I don't know. I think we want to, as you said, celebrate whatever is being used correctly, we want to, as you said, celebrate whatever it is that gets these kids far enough along that hopefully they get to Carol and to her team and Brad so that we can maybe change, interrupt that cycle. But you're actually right. If you read the original ACEs study, these were physical, you know, Kaiser Permanente population, right? And we saw that these types of exposures led them to physical problems, asthma, diabetes, heart problems. And then take this now where people have these additional exposures, and I would then challenge all of us, if resilience is not the correct word, what is the word that we want to use here? And maybe we want to use a different word. Well, I mean, I think resilience is not a bad word, but I think the problem with it is the whole idea that it normalizes what has happened in this population of people they can survive. And it's part of the social structure of the way that... So I think there is resilience, but it's undermined by the idea that this is the way it is. And that's the end of it. It's not, as you said earlier, it's not an ending, it's actually a process. And then what do we do with that? Well, that's part of the moral challenge then is going to be what is the resilience of the word that we use, is there a better word? And what do we do with that? It's a context, though. Well, and I think what we're talking about is in a different slide. I mean, part of the reason that we've been working on these hospital-based violence intervention programs is that you do something here while they're in the hospital. We make a connection. We offer some support, some intervention that's pretty intensive and as long-term as it's necessary. The young men I talked about before we've been working with, what, Brad, for three years. So they weren't resilient in and of... Well, they might have been resilient in and of themselves, but they're in a much different place than they might have been had they been left to their own devices and left to the continual exposure to trauma that their family has experienced. And maybe talking about... One of the things that struck me... I'm familiar with the case, but one of the things that really struck me at the time was that their first call was to Carol when this happened. Their first call was to get in touch with their electronic intervention specialists. And that was, to me, a building of... or capitalizing on whatever resilience they've been able to develop. Is it the right word? I don't know. But now I've got to think about that. Right. Well, and we... You here and then Brad... It's wonderful that you see the thing the way you see it. But suppose you were omnipotent person. You had everything in the tip of your finger that you could do. How would you cure this? Because we talk about cure. How do you cure it? So I'm going to defer that till the end because I think... She's going to defer that to me. It's like, oh, thank God. Thank God. But I think it's a good question. We got this question earlier today. Yeah. I'm going to change it a little bit. How do you operationalize what we're talking about? Right? That's the thing that we are asking you to do. And I do want to say that again because I do want to kind of try and put this together and say, here are some suggestions about things that I would say based on moral imperative, we must do. But they'll be my ideas and the challenge will be to have everybody start thinking about this. What are the... What goes to the first, second question? What is your moral imperative? If you were... If you have a look at the whole picture, how are you going to operationalize it? What's your moral imperative? So Brad... Brad. I think we have three questions. Yeah, one, two, three. Yeah. I didn't get your name, sorry. Just back to this resilience point which I think is really helpful for a particular reason. Yeah. It's very hard to communicate, especially to people who haven't had to deal with the things that our kids are dealing with, what they go through. But sometimes the result of that is the only thing that people see is the violence or the trauma. The same way, if we talk about the resilience and it erases the impact of what's been done to them by us, which is why we want to erase it, right? And then, we're really doing them a great disservice. So how do we go both ways at the same time, right? How do we talk about the resilience people who don't acknowledge and are not eliciting the rage, the grief, the pain, everything that they've had to overcome to make it to the point that they're at? So that was just my comment. I think we could spend far more time in this discussion than we would take any other time. I have a question here, and then... I'm just wondering, if the word republic in any healing were right here on a variety of treatment, resilience? Yeah. And I would, if it's a combination of the two, so capitalizing on whatever your inner resources are and then saying it is more imperative that there have to be extra resources. Well, if the definition of resilience is you use only your inner resources, none of us are, right? There's nothing that I have overcome and recovered from in my own life experience that I've done by myself. So if that's the definition, the working definition, then we absolutely need to excise that in our language altogether, because that really is not at all what happens. I'm going to throw up a suggestion about survivor. And I'm going to use the analogy of military combatants. When they're in a combat environment, they're surviving, and they develop tactics and habits that enhance their ability to survive an environment. And when they return, many times, they call themselves survivors of this environment. So if they're injured, they go back to the same environment and still out there on the streets trying to survive. And so I'll just throw it out. So they're not really survivors yet until they get out of that? If they're not going back to the same environment, it's the same as if you're wounded, you know, you go to the combatant station to fetch you up and you go back to the fob and you still have risk for mortar or cyber-round. So I want to ask Dr. Siegler a question. We had sort of embedded conversation throughout the presentation, rather than stopping at five and then having a conversation. Is that okay to keep going that way? Yeah, and you guys have to tell us what it is. Okay. I know what time it is. We won't be here that long. So are most of you from Chicago? No? A lot of people. Okay, well this, in the blue and white areas are the city and the city limits. The dots represent homicides in the city. So what do you, and these two little, I mean the circles, yeah, the dots are homicides. The two red dots are roughly county and UCM. This was within a year. I think this was data from 2016. Commentary on the map as you're looking at it. What do you notice? About 11% of trauma, each one of them, equal homicide and suicide is equal, each 11% of all trauma. The only thing is that suicide is more serious because people shoot from close. So then, and they usually put it in their mouth or put it in their head, close or resistant, it's gone. So most of the suicide dies completely. But it's equally each 11% of trauma. All trauma. And for some trauma, but when you stratify for race and age, it's extremely more, yeah, it's very different. What else do you notice? A lot of dots. A lot of dots. Yeah, so what about here and here? Chicagoans, what are these neighborhoods? And what else do we know about those parts of the city? Yeah, primarily these are, our city is extremely segregated. These are mostly parts of the city where black and brown people live. It's also, you know, high rates of poverty, poor housing stock, food deserts. Some of the, I have taken some of our young men home after a group meeting and there's not a grocery store anywhere to be found within, you know, many, many, many blocks of where they live. There are few businesses, few jobs, the schools tend to be underfunded and underperforming even if they're Chicago public schools. All Chicago public schools are not the same. Transportation in and out of these parts of the city is difficult. And then of course, this community violence piece. So again, this is another just sort of visual way to think about the stressors that people live within this community. I didn't get to update this slide, but I was at a meeting over the weekend with a bunch of healthcare executives. You were at that meeting. Do you remember what they said about the life expectancy here in the loop? 85 years of age. So this is our hospital. It's just right out the Congress Expressway West. You get to about right here in the Garfield Park neighborhood. What's the life expectancy? Huh? No, what's the average life expectancy? How long? 69. There's a, so you go five miles west. Do the math. And to your point earlier, the stressors are there of all of these things. So, you know, if I had a magic wand, there'd be a lot of things. I kind of hate putting this slide up here, but you mentioned the military a little bit ago. One of the things I think we've been discovering with many of our young people is that they have for many years of their life been in situations where they've done things or been forced to do things that violate their moral code or their ethics. And they feel bad about it. And they feel like they don't deserve to be alive in this world. And that definition, they can no longer be regarded as decent human beings. Well, this is one of the areas that particularly for me as an Episcopal priest, I get really concerned about because that's, you know, that's a matter of who you are in the depths of your soul and your sense of who you are as a human being that has been damaged. Yeah, so I just said that. Injury and hurt, I mean, with these two boys that we talked about, you know, I think we did all of the ethical things right with them. But I don't know that we've significantly addressed their sense of injury and justice and the ways in which they've been knocked around in the world. Trauma people, are any of you guys in this? No, maybe not. We believe that with the right intervention at the right time we can save a life. And that's why we're doing this program in here at Comer and at County to try to intervene at some point to promote healing. And I'm going to kind of go through these quickly because I know Kim is going to talk a little bit more about it. But again, healing has been conflated, I think, in our minds with and not inappropriately with disease. But it also has talked that healing refers to restoring to wholeness or health or to an undamaged state. We are not going to restore ourselves to our undamaged states. It's an aspirational thing. But I think healing can happen for because I've seen it with our kids. I think we can hopefully restore some sense of wholeness, help these young people restore wholeness to try to ensure that they're not hurt more. And that takes, that's going to be a long term project. And then their restore sense of these are human beings as holy and whole individuals. And again, what do we do? So to be respectful of people's time, I'm not going to go through the third case. We're going to kind of go to the end because I know that people have lives. Do they want to get to? Yeah, that's fine. So let's turn the lights up again and see if we can sort of answer the question that you asked. So I'm going to skip ahead to go through all of this. This was something that was actually written in response to a set of incidents that happened about patients who came in who were obese and this idea that somehow they were at fault for what was happening to them and what was our responsibility. And the first responsibility was to care. And I would argue that the first responsibility was to care, to cure, to try to prevent or ameliorate injury, to heal. That all of those things were together. And the question is then how do we operationalize that? How do we, I'm not omnipotent, but what do I do? So my moral imperative that I'm going to share with you is that we have a set, we have a group of people who are systemically disadvantaged with regard to their health. And it is my moral imperative to change that and that I think it's not an ethical issue, it is a moral issue. So what does that look like for me right now? For a variety of reasons, one of which is sort of has to do with current politics. I have been in the face of more legislators in the past 12 months than I have been since I was 18 years old. That is part of my moral imperative and the thing that I'm talking to people about and I'm saying to them, here's my experience, use it. I can tell you from firsthand experience, this is what this looks like. My moral imperative when I talk to these people is we have got to look at mental health and treat it in the same way that we treat issues of defense, issues of national security. And that this has to be routine. This is not separate from what I do as a trauma surgeon. This is part of what I do as a trauma surgeon and it is your responsibility to make sure that I am able to do that. Now, ingrained in that moral imperative, we were talking about sort of what happens in a hospital or in an institution. Ingrained in that moral imperative is that you have to have a recognition that this isn't going to happen tomorrow. But I believe I'm morally responsible knowing what I know to make sure that it doesn't ever get dropped, that it is in somebody's face all the time. That's one moral imperative I have. Another moral imperative that I actually decided years ago and that I feel like I've had some success with is to make sure that everybody that I train has some part of my moral imperative. So in other words, everybody that I train since 1993 has been trained to look at things other than setting the fracture. So you get screened for child abuse, you get screened for domestic violence, you get screened for substance abuse. One thing that we only recently were doing is asking questions now about what are your community violence exposures and making sure that you get to those resources. That's another part of my moral imperative. It's not about ethics, it's not about the conduct of how I conduct myself as a physician. This is my moral imperative. Part of my moral imperative is to, and this I have not done well at all, is to force the conversation about societal racism. One of my mentors from DC, there's no such thing as race. You'll recognize, yes. Yeah, Dr. Callender. There's no such thing as race. But it's the term that is used and it's the only term that people are going to recognize. And we have to force that conversation, whether it be in regard to immigration or healthcare, which to me are linked. That I have not done. And that's something that, operationally, that's something that is my next part of the moral imperative for me. And I guess what I would say is the challenge that I would like to issue, and that I think Carol hopefully also would like to issue to all of you. I was your boss. So yeah, so yeah. She has no choice. But to actually ask yourself that question, with regard, we're all here because we're in healthcare. What's your moral imperative? What is the thing that not ethically, morally, you feel you have to do in order to treat care, cure, heal the people that you are seeing? The treat is easy actually. The treat, we've got tons of textbooks that tell us how to do the treat. The care, the cure and the heal, I think are the hard parts. And we, that's our moral imperative. That's what I would like all of you to find to figure out for yourself what is the thing that you feel you have to do morally to get your patients healed. To do with resilience is the wrong word. To figure out what is that thing that we capitalize on that's intrinsic and then bring in the extrinsic factors in order to get people to heal. And that's going to be a different thing I think for every person. But it's a question that we both think you have to ask yourself. Because the moral injustice here, the injury here is that there is this group of people who have these exposures, who are systemically disadvantaged and systemically not healthy because we're just treating them. And we're not caring or curing or healing them. And let me turn this back over to you so you can. I'll just say one thing real quick. I'll stand close to you. Okay. So, I'm actually, I'm going to give this to you. This looks weird right? Yeah. That didn't mean to make it weird. But one of the things that I wanted to say about to follow up on what Kim was saying is that for me, inherent in the language that I use around healing and health and whole and holy is the belief that people do have, and we all have intrinsic within ourselves resources to do that. And we also, most of us have external factors that make that very difficult, if not sometimes impossible to do. And part of the conversation about cure and cure of souls, when I talk to my bishop about where I work, he asks me, where's your cure? My cure, my place where I do my work and care for people is the hospital. But that's the language that we use in my profession. And I would hope that part of what Kim and I hoped to get out of the day to day is just push us a little bit to think about the language that we use, how it's connected to our own values and belief systems and our own sense of who we are as moral human beings and let that drive what we do in healthcare settings where we work. And then this is sort of the second to last slide. This is really what we're challenging people to do. And as I said, it's going to be different. It's going to be different for each of you, which is good. That's how it should be. And we'll stop and we'll answer questions.