The trauma of gun violence; Dr. Edward E. Cornwell III, trauma chief at Johns Hopkins Hospital, describes gunshot wounds as "more and more a juvenile disease."

A .357 MAGNUM handgun can fire a bullet with a muzzle velocity of 1,500 foot pounds. Baffled by muzzle velocity and foot pounds? Well, consider this: That bullet has enough energy to bore through the trunk of a big, boxy Lincoln Towncar and continue through the back seat and the front seat and kill the driver. It's an awesome weapon, and it's just one of many types of high-powered handguns that can be found on Baltimore's streets, all too often, in the hands of teen-age drug dealers.

So what happens when the human body meets the gun industry's deadliest creations? It's not pretty. Ask Dr. "Eddie" Cornwell, the trauma chief at Johns Hopkins Hospital. During the 16 years he has been a trauma surgeon, Cornwell has saved his share of gunshot-wound victims, and he has watched many others go to the medical examiner for autopsies.


Now, as a board member of Baltimore's Police Athletic League, Cornwell is on a mission to save kids before they wind up on the operating table. Periodically, he visits a PAL after-school center in East Baltimore and gives a slide presentation showing ghastly bullet wounds. During his "Rap with Doc" sessions with boys from 11 to 17, he talks about the harsh realities of gun violence. To drive home his point, he arranges for the boys to visit the hospital to meet gunshot victims and to look at the hideous holes in their bodies. It's Cornwell's version of "Scared Straight."

Edward E. Cornwell III, 43, realizes that only a quirk of fate separates him from the African-American youths he is trying to save. He says his parents made the difference. His father was a surgeon on the faculty at Howard University Medical Center, and his mother was a school teacher before she became a Realtor.


Cornwell graduated from Sidwell Friends School in Washington in 1974 and moved on to Brown University and the Howard University School of Medicine. Next came an internship and residency in general surgery at Los Angeles County General Hospital, followed by a fellowship at Maryland Shock Trauma Center in Baltimore. He moved on to faculty positions at Howard and L.A. County General before Hopkins recruited him to head its adult trauma unit about two years ago.

Cornwell has strong opinions about gun violence. Recently, he shared his thoughts with Perspective Editor Mike Adams.

How many gunshot wounds does Hopkins treat annually?

It's been slowly increasing. We had about 365 in 1997, about 380-some in 1998 and 390 last year. Baltimore actually stands out a bit, apart from the national trend. From the early to the late 1990s, in Boston, New York Los Angeles, Miami, Washington, the numbers of penetrating trauma, gunshot wounds and stabbings, have gone down. Baltimore is different, and I don't have a complete explanation for it. But, in the neighborhood around Hopkins, about 80 percent of the crime is centered around trying to obtain or sell illegal drugs.

While the good news is, nationally, the gunshot wound rate is down, the bad news is that we have more kids in school who are entering what's called their "crime-prone" years. And these kids have spent more hours watching violence on television, are more likely to see violence in their immediate surroundings, and are less likely to have a nonviolent role model in the home and have more access to guns than any generation in American history.

Basically, [street] crime in America has become the domain of males from 14 to 34. And in many cities, like Los Angeles, where I was before I came here, we see 35 to 40 percent of our gunshot wounds happening to people 21 years old or younger. It's becoming more and more a juvenile disease.

How would you describe the typical gunshot wound victim treated here at Hopkins based on age, race and economic background?

Simply put, young black males. The typical patient would be in his late teens or early 20s, someone from the surrounding neighborhoood. As I said before, in 1999, we had about 390 gunshot cases, and those patients from the narrow age of 15 to 20 years old represent close to 60 percent of our gunshot wounds and close to two-thirds of all of our deaths.


What's the societal cost of these gunshot cases? Who's paying the bill?

You and I are paying the bill. The taxpayers are paying the bill. That's the sad truth throughout the country. To be a Level 1 Trauma Center as we are, we need to be open, ready and available 24 hours a day. That means the lights are on, the CAT scan is ready, the operating room is ready to go, the blood bank is available, people are in-house who are specialists in certain areas and prepared to take care of these patients whether they show up or not. And then, when the patients show up, they may or may not be able to pay. Many of my patients are Male X, Male Y, Male P, for hours before we even know a name.

I saw a patient in clinic yesterday who I operated on in September. He came here with multiple abdominal gunshot wounds at about 4: 30 on a Saturday morning. He had so many injuries to his abdomen that reconstructing things took almost 13 hours. Three shifts of people, probably 25 professionals were involved in his care. Myself and the chief resident, who was operating, were the only two who were with the kid from the time he came in until the time he was tucked away in the intensive care unit. And his name was Male X; nobody even knew his name.

Regardless of who you are, you get the best that we have [at Hopkins], whether you're the President of the United States or Male X. But, at the end of the day, that hit is frequently taken by the hospital, and they transport those charges to those who are insured.

What impact does treating large numbers of uninsured patients have on medical facilities?

L.A. County Hospital, where I was in 1995, was threatened to the point where it nearly closed, the largest hospital in the largest county in the country. President Clinton himself delivered a Medicare waiver to save that hospital. It was important for us at that hospital to make people understand it was not just a hospital for what some call them -- illegal immigrants, gang members, drug addicts.


By the time I left there, more than 50 percent of the patients came from working families that just didn't have health insurance. If we allow people to think it's a problem of them, then we'll never get to the bottom of the problem.

The relationship for trauma care in Maryland is rather unique in the sense that third party [health care industry] reimbursement for the hospitals, not for the professionals, is better than in most states. In many states, trauma centers are not fighting to stay open, they simply opt to close.

What do you think could be done about this epidemic of gun violence?

It's complicated, so the solutations are going to be complicated. I think, No. 1, we have to talk about true prevention, and those of us in the medical profession, specifically in the trauma surgical arena, need to think about prevention the way our colleagues think about prevention.

If we take a patient who has been shot, and we quickly get them to the emergency room and stop the bleeding and get them through the intensive care and get them home, we consider that a save, a positive case. Now, in the process of doing that, it's been a learning experience for residents and students. The patient may have had injuries that are of academic interest, so the victim becomes part of our series on abdominal gunshot wounds, and we write it up and we present it at meetings to our colleagues. If the patient does well without complications, we consider that a success. Then we send that patient right back to the same setting. Think about that. How much sense does it make?

Imagine my colleagues in surgical oncology saying we're going to do a cancer prevention project. We're going to wait for a patient to develop prostate cancer with metastatic disease to his bones, then we're going to do radical surgery to remove the prostate and the surrounding tissue, then we're going to give him follow-up with chemotherepy and other therepy for his metastatic disease, then, after we do all of that, spend hundreds of thousands of dollars, we're going to do an annual rectal exam and do PSAs [a blood test for prostate cancer] every year, because we don't want it to recur. You wouldn't call that true prevention.


When you start talking about stopping violence, you get into all the things that we as Americans have a tough time talking about: race, access to health care, crime and punishment, prisons, gun control. What issue has more sensitive buzz words involved than violence prevention in America?

What's your definition of prevention?

I was at a hospital [L.A. County General] that was losing hundreds of thousands of dollars on trauma alone in just a few months. It would have been hard to walk up to a hospital administrator and say we need more counselors to follow up and go into the family dynamics of the victims. And even when that happens, it is not true prevention. Nor is it prevention to become aware of this 18-year-old kid with all the psycho-sociological dysfunction that has to happen for him to wind up in front of a gun. Prevention has got to be identifying kids at risk and intervening before they become victims or perpetrators.

We, the trauma surgeons, need to join forces with social scientists and public health professionals so we can address these at-risk kids.

How do you reach these kids?

My own intervention is showing them the most graphic, gory slides that I can.


In Los Angeles, I was involved in something called the Youth Impact Program. The judges at the juvenile court, when they had first-time nonviolent offenders showing up in court with tattoos and shaved heads and baggy pants, all the insignias of gang involvement, they'd say, "OK, you're going to this Youth Impact Program," which was run by the Los Angeles Police Department. The kids had to spend 100 hours there over four months. They could go home at the end of the day, so this kept them out of jail. The police would bring us, the trauma surgeons, in, and we'd show the gory slides of kids who looked like them. Instead of telling them, "Don't, don't, don't," we'd take them to see a kid who was in the ICU with a gunshot wound to the neck who would never move again.

How did you become involved with Baltimore's Police Athletic League?

When I got here, I was trying to get a handle on this city, and [former Police Commissioner Thomas Frazier] put me on the board, and I adopted a center, Fort Worthington, about 10 minutes from the hospital.

The officers there are my heroes. These kids look up to those officers. They have surveys that show that 96 percent of the kids feel safe in those places. It's a sad fact that you're not going to find a survey of many public schools in America where 96 percent of the kids say they feel safe -- especially when you turn on the news and hear about a 6-year-old being shot in a Michigan school.

The Police Athletic League is different than the Youth Impact Program in Los Angeles. The kids here are doing something positive just by being in the center, whereas they had to do something negative to be in the program in Los Angeles.

Have you brought any of the kids to Hopkins?


I brought them to the hospital and showed them that 13-hour case. He was in the hospital for two months, and it was the result of drug-related violence. The kids came to bedside, and he talked to them. And I think that's effective.

Did you get the sense that it made an impact on them?

Yeah, it made an impact. I showed them this one patient who had an open wound. After big operations, these things swell up so big that you can't get the abdomen closed, so we treat these open wounds, and we sew in grafts and the tissue starts to heal, and something called granulation tissue starts to grow in. And to me, a surgeon, this pink tissue looks great. But if I took you bedside, you'd look at it and say, "Ugh."

So, I took these 11- and 12-year-olds and showed them that. Then I showed them another guy I had. He was hit by a shotgun blast in a crack house. He had holes in his back so large that I could scoop out of the buckshot. His wounds had healed and looked beautiful to me, but the kids started running out of the room.

The guy turned to them and said, "Say no to drugs, kids." It was dramatic. I took them in, I had 15 in a group, I took them in five or six at a time. In the second and third groups, some of them said, "That's OK, I don't want to go in," by that time the kids from the first group started telling them what they were seeing.

What about gun control as a preventative measure?


We talk about it every four years when there's an election and people tend to demagogue the issue. The problem is we leave it to politicians. There is a consensus that some people should not have guns, but that consensus has not translated into law. I will readily admit to you as a trauma surgeon, I'm afraid of guns, afraid of them because of what I see all the time.

I don't think someone who is a legitimate sportsman feels the same way. So I need to see what their lifestyle is like, they need to see what I see, and somewhere in between we need to find a happy medium, as we do with cars. We don't let just anyone drive cars.

But I think one of the great myths is this issue of Second Amendment rights. There's no more tried concept, the lawyers tell me, in the history of American jurisprudence. Over 20,000 times, various laws restricting or regulating gun ownership have been challenged, and not once in the history of this country have they been struck down on the basis of Second Amendment rights. So, we don't need to debate that. Being able to maintain a well-armed militia doesn't mean that 6-year-olds get to take guns to school.

Does the high number of gunshot wounds overshadow other acts of violence such as beatings and stabbings that often go unreported by the news media because they don't result in fatalities?

Yes, the deaths are the tip of the iceberg. A young woman admitted to a trauma service in America, in this hospital or any other hospital, is more likely than anything else to be a victim of domestic violence, usually from an intimate partner -- one of the great under-reported crimes in America. You play the odds. A young woman died; who is my first suspect? The intimate partner. And one thing I don't undetrstand: You know when the great peak of this occurs? During pregnancy. It's incredible how common it is.

Over the years, have their been any cases that really touched you?


Hundreds. The most recent was yesterday. A 47-year-old woman is in her car, and her car is hit and her passenger is killed, and she turns out to have what turn out of be lethal injuries. She came in 2: 30 Sunday morning. I was on call. She went to neurosurgery, then she came back, and each step of the way, I was explaining to the family where we were, the grim prognosis associated with that as she progressed to brain death, explaining that there is no neurologic activity in brain death.

I just hate that part of the job. I like most of what I do, but walking into that room and talking to families, there is no right way to do that. You feel terrible. ...

And I'm touched every time I go into the room and there is a young kid who is dead. I don't care if a kid is running drugs out of his mother's house, when they are killed and you tell the mother, they still didn't think it would happen. One of the more common things I hear is, "He was a good kid, he fell into the wrong crowd." It's kind of funny, but in 16 years, I haven't heard anyone say, "You know, Doc, you know all those kids who were running with the wrong crowd? My kid was the wrong crowd."