Montefiore Hospital in North Philadelphia was my next stop. Here there was career mobility. Montefiore was like Mercy Lite. In this way, it was a homecoming of sorts, and like any homecoming, it was a temporary return to the nest to celebrate what was, to visit the comfortable haunts—old lovers and friends who used to fit before I molted into this new skin.

There were several similarities to my residency experience at Mercy Hospital in the South Bronx. Montefiore had a volume of more than 95,000 patients a year, and Mercy had more than 145,000. At Mercy, I had been a chief resident. In the Montefiore health care system, I was one of the assistant medical directors. Because I was hired to move into the director position at one of the hospital’s suburban locations, I was setting meeting agendas, writing protocols for treating high-risk medical conditions (such as acute stroke and heart attack), assisting in provider evaluations for staff, and sending out my own emails on blood cultures and medication documentation.

Prior to starting the position, I hadn’t fully realized that sending such emails in the role of assistant medical director didn’t make the work feel any more relevant. As I sat at my desk in my new position, with a list of administrative tasks about standard operating procedures, proper documentation in medical records, and risk reduction, I remembered the passion that had brought me to emergency medicine in the first place: sitting with people in crisis and helping them take the first steps toward healing. Mercy Hospital had stoked the fires of this passion and had prepared me well to address the challenges faced by the Montefiore population.

Our mission at Mercy had been to serve the community in a competent and culturally sensitive way, regardless of patients’ ability to pay. It was an especially noble mission, given that the population in the South Bronx was as hardworking as it was poor; in fact, at that time, it was home to the poorest congressional district in the nation. One-third of the patients the hospital treated were entirely uninsured, and many residents didn’t have a primary care physician. So, when the free clinics in the neighborhood were too busy or closed, we were literally their only hope for care.

Suffering from everything from gunshot wounds to malnutrition to stroke, patients lined up for triage at Mercy. Violence in this neighborhood was as regular as leaves falling in October, and its roots lay in battles over money, respect, self-esteem—all fed by deep notions of not having enough, not feeling enough; by geysers of frustration and hurt.

I remembered the moment during residency when I first realized the brambly nature of this violence and these social webs. At that time, the ER at Mercy was divided into sections: Adult Medical, Adult Surgical, Follow-up (for wound checks, suture removals, etc.), and Pediatric. On that particular day during my second year of training, I was working in the pediatric side of the emergency department. The next chart on the rack read, “13 yo male, head trauma.”

I scanned the triage notes: normal vitals, no medical history, a blow to the head. I tapped on the open door and introduced myself to the child, named Gabriel, and the two adults who appeared to be his parents. The boy sat at the side of the stretcher with his hands folded in his lap, his eyes fixed on his interlaced fingers. Behind him, a cartoon of a herd of purple elephants with rising red balloons decorated the wall. Mom stood near the cabinet, arms resting over her purse. Her hands were leathery and her mouth soft. Dad sat in the chair next to the stretcher. His eyes were weary, and an earthy odor emanated from his clothes.

I started by collecting the requisite information: past medical history, vaccination history, medications, allergies to medications, and so on. Then I moved to the matter at hand. The child told me that a classmate, “T,” routinely harassed him at school, picking on him about his appearance and threatening him. T was larger than Gabriel and part of a rough crowd. Gabriel didn’t know if the other boy was in a gang, but T’s crew seemed to be in and out of school as much as juvenile detention.

I asked what had happened, and Gabriel relayed the following story. He had earned good grades on his report card, was helping care for his little sister, and had completed all his chores, so his parents rewarded him with the sneakers he’d wanted for his birthday—popular and pricey shoes, which he proudly wore to school the next day. On his way there, T cornered him in the empty lot next to the school grounds and demanded that he hand over the sneakers. Gabriel refused and continued walking. T followed him, and Gabriel started to run. T then jumped on Gabriel, pulled him to ground, and proceeded to punch him about the head and body. Gabriel tried to defend himself, but the other boy pulled a knife and threatened to kill him, adding that Gabriel was lucky he didn’t have his gun on him that day. Terrified, Gabriel removed his shoes. T picked up the sneakers, spat on Gabriel, cursed, and walked away. After T left, Gabriel ran home shoeless on the hot, cracked pavement of the South Bronx.

He had not passed out, had not experienced nausea or vomiting, and had no abnormal sensation to his skin or any weakness. No neck pain, no difficulty breathing. He had visible swelling and redness on the left side of his face, his shoulders, and chest, and superficial abrasions and cuts to his feet.

What struck me about Gabriel was how quiet he was as he lay down on the stretcher for his examination. What’s remarkable about children is how receptive and resilient their bodies are: They are more likely to bend than to break. Even if a liver tears, oozing hemorrhage from blows to the abdomen, or a blood vessel bursts behind the eye from forceful shaking, nothing is evident on the surface but the beautiful cinnamon skin of their bellies, a regular pulse at their soft wrists, and normal color in their big, bright brown eyes. Kids don’t have the language to name the pain, neither physical nor psychic, nor the resources to address it. Just like adults, children house spiritual pain inside, where it sloshes around vital organs. But in children, the effects of trauma are stickier, shaping the contours of their viscera, the depth their diaphragm respires, the way their heart chambers fill.

“Okay, Mom and Dad, I just have to ask Gabriel a couple of questions alone,” I said, knowing I needed to complete the imperative abuse screen for any child presenting with injuries. Gabriel’s story made sense and sounded credible, but all too often the assailant can turn out to be a family member or another adult the child knows.

After Mom and Dad had left the room, I told Gabriel he could sit up, now that the physical exam was done. Then I pulled a chair up next to him and said, “Gabriel, I am so sorry about what happened. It is terrible and unfair. That shouldn’t happen to anyone.”

Gabriel nodded once and stared down at his thumbs.

“Gabriel, I have to ask you some questions, to make sure you’re safe. Just so you know, everything we speak about is confidential. If it turns out that you’re in physical danger, then that’s when I’ll need to break confidentiality. It’s only because we have to make sure you’re safe. I want you to know that I won’t do anything behind your back. We’ll talk, and I’ll tell you if we are in an area where we have to involve other people in the discussion. Okay?”

“Okay,” he mumbled.

“We ask these questions of all young people, and even all grown-ups, because sometimes people are hurt by people they love, like family members, friends, teachers. Know what I mean?”

“Yeah,” Gabriel replied.

“Who do you live with?”

“My parents and little sister.”

“How old is your sister?”

“She’s seven.”

“Do you like your little sister?”

“Yeah, she’s cool. I mean, she gets on my nerves sometimes, but she’s my sister.”

“Yeah, she has to do that, right?” I said, chuckling a little and meeting Gabriel’s smile. “I hear you take good care of her, don’t you?”

He nodded.

“Do you get along with your mom and dad?” I asked.

“Yeah.”

“Do you feel safe at home?”

“Yeah.”

“Does anyone at home ever hit you? Or threaten you when you get in trouble or something?”

“No. I mean, I be put on punishment if I don’t do what I’m supposed to do sometimes, but nothing like being hit or anything.”

“And how’s school?”

“It’s okay.”

“Do you have a favorite subject?”

“Not really.”

“Do you like going to school?”

“Not really.”

“Why not?”

“So many problems there. Always drama. Always fights.”

“Do you feel safe at school?”

“Nah, but I’ll take care of things.”

“What do you mean?”

“I mean I will take care of things. This won’t happen again.”

“What do you mean?”