CHAPTER 5 THE ROLE OF TRAUMA PREVENTION IN REDUCING INTERPERSONAL VIOLENCE

The issue of interpersonal violence as a public health problem gained a significant national spotlight through a workshop in October 1985 convened by the Surgeon General of the United States to address the problem.¹ A challenge went out to health care providers, administrators, and the public at large to consider violence as a public health problem, and to seek its causes and most effective treatment. In the ensuing 2 years, more Americans died from gunshot wounds than during the entire 8-½ years of war in Vietnam. By 1994, intentional injury was the 10th leading cause of death in America (20,000 per year) and the leading cause of premature mortality.²

The specter of violence has become increasingly prominent in the lives of American children and is one of our most pressing public health problems. Teenagers are more likely to die of gunshot wounds than all “natural” diseases combined. Furthermore, the physical and emotional consequences of nonfatal violence to children who are victims, witnesses, and perpetrators are staggering. Brain, spinal cord, and other debilitating injuries from interpersonal violence consume substantial health care resources through hospital readmissions and lifelong disability. Indeed, intentional injury is frequently referred to as a “chronic recurrent disease.” An interesting phenomenon began to occur in the mid-1990s. Most major cities, and the United States overall, saw a gradual decrease in the rates of homicide and violent assault. Sadly, this trend was matched by the observation that the victims of violent assaults and penetrating injuries were becoming younger.

This chapter will describe the potential role of a trauma center in violence prevention, through the story of an urban, universityaffiliated, Level I trauma center in an impoverished area.

UNDERSTANDING THE PROBLEM

Although the American College of Surgeons requires that a Level I trauma center be actively involved in injury control, the trauma surgeon dealing with resuscitation, operative intervention, and postoperative critical care requires guidance from a vast array of professionals to understand and prevent injuries due to interpersonal violence.³ In 1991, Rosenburg and Mercy wrote, “Professionals from sociology, criminology, economics, law, public policy, psychology, anthropology, and public health must work together to understand the cause and solution” to the problem of intentional injuries. Intervention against intentional injuries requires consideration of the perpetrators, the victims, the assaulting weapons, and the environment and the circumstances of the event.

William Haddon devised an injury control approach, by considering factors related to trauma in three phases. These phases—pre-event, injury event, and post-event—were the basis for the development of the Haddon Matrix, which also considers the factors involved, such as the host, vehicle, and environment. In the parlance of Haddon Matrix, the experience of the trauma center at Johns Hopkins demonstrates that true injury prevention deals with factors in the pre-event phase.

IMPACT OF ENHANCED TRAUMA COMMITMENT ON PATIENT OUTCOMES

The result of several studies from the Division of Trauma at Johns Hopkins Hospital suggested the importance of violence prevention as the avenue for additional improvement in trauma patient outcome. It began with a study showing that, while the implementation of a multidisciplinary trauma program resulted in significant improvement in patient outcomes, no improvement was seen among patients with gunshot wounds, the majority of whom were youths (ages 15–24).⁴ This observation was explained by a disturbing pattern showing an increasing prevalence of gunshot-wound patients arriving “in extremis” or dead on arrival (DOA) from multiple gunshot wounds to the head and/or chest. While 99% of patients leaving the emergency department (ED) alive ultimately survived their hospital visit, the ever-growing incidence of patients who are DOA suggests that the “glass ceiling” is being approached in terms of benefits in patient outcomes to be gained from in-hospital performance improvement endeavors. In 2005, 61 of the 88 trauma deaths (69%) seen at Johns Hopkins Hospital were declared dead in the ED in an average 6 minutes after arrival. Of the remaining 27 patients, 14 were declared dead in the intensive care unit from devastating brain injuries. This suggests that in an entire calendar year, at an urban, university-affiliated Level I trauma center, only 13 of 88 patients who died (15%) were even theoretically salvageable. This is perhaps the most compelling argument suggesting that further incremental improvement in injury outcomes are likely to be realized from prevention activities in the prehospital arena.

A second study involved a geographic analysis showing that the majority of trauma patients admitted to Johns Hopkins Hospital came from a 5-mile radius, incorporating some of Maryland’s most impoverished neighborhoods, and confirmed the previously described predominance of youths (ages 15–24) among gunshot wound patients.⁵ These data led to the conclusion that the injury prevention program should take the form of violence prevention activities for at-risk youths.

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