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.

IN-HOSPITAL PREVENTION: SHORTCOMINGS

A third project sought to duplicate the experience with alcohol- and drug-abuse intervention described at other centers among predominantly blunt trauma populations.⁶ Given the recognized comorbid incidence of alcohol and substance abuse among perpetrators and victims of interpersonal violence, a project was undertaken that sought to analyze introspection and readiness to change among young patients (ages 15–24) surviving an injury and demonstrating a positive toxicology screen. In contrast to other reports in the literature, this project demonstrated a depressingly low incidence of “readiness to change,” and an even lower incidence in accessing available counseling services. This study suggests a major shortcoming of an in-hospital violence prevention program: The potential beneficiaries are random and are based on the trajectory of a bullet, rather than the presence of psychosocial risk factors.

EFFECTIVENESS OF A VIOLENCE PREVENTION PROGRAM

Baltimore is one of the most appropriate cities in America in which to pursue initiatives in youth violence prevention. It is the nation’s 13th largest city, and the largest American city that did not enjoy the decrease in violence seen nationally in the mid-1990s. Baltimore ranks at or near the top of the nation in the following high-risk indicators: (1) rate of births to unwed teenage mothers, (2) episodes of assault and suspension among students in Baltimore City Elementary Schools (K–5), (3) dropout rate for Baltimore City Public High Schools (76% for black males), and (4) juvenile arrest rate for murder.

A project was undertaken evaluating the effectiveness of a violence-prevention initiative geared toward changing attitudes about interpersonal conflict among at-risk youths from a previously described catchment area.⁷ Participants were given a package survey of six previously validated scales, both preintervention and postintervention, to assess their attitudes about interpersonal conflicts. This package included the following scales:

After parental consent and the youths’ consent, the children were administered the survey package as a preintervention test at their Police Athletic League (PAL) center. They were then brought to the hospital in groups on a day convenient for the officer at the PAL center to accompany them. The tour included video and slide presentations that graphically depicted the results of gun violence, followed by open discussions. The children would be given T-shirts on completion of their tour and their postintervention tests. Among the first 90 participants in the program, there was statistically significant reduction in the Beliefs Supporting Aggression scale, and a trend toward reduction in the Likelihood of Violence scale. This suggested a multidisciplinary violence-prevention program can produce short-term improvement in beliefs supporting aggression among at-risk youth.

CULTURE OF VIOLENCE

One might expect that this chapter would close with a description of a study of 90 young people demonstrating short-term improvements in attitudes toward conflict and aggression. However, recent visits by the authors to the executive offices of media production companies have emphasized the dominance of an American culture that glamorizes violence. Images that sensationalize violent acts reach millions of young people every day, while the previously described outreach program reached only 90 kids over 1 year. Accordingly, it was decided to incorporate an approach that seeks to reach influential adults (journalists, TV/radio personalities, politicians, athletes, and entertainers) with a graphic message that describes the tragic consequences of trivializing interpersonal injuries.

A group has been formed to pursue the production of a professionally made educational video and/or public service announcement, titled “Hype vs Reality.” The purpose of this project is to demonstrate the dramatic distinction between the glamorized concept of violence repeatedly offered by the entertainment media and the stark reality of violence in America as seen in EDs and trauma centers across the country.

With this effort, we join the growing cadre of surgeons and other physicians and public health professionals who have resolved to extend the sphere of their influence beyond the hospital and university walls, and interact with a larger audience beyond our typical professional societies and scientific publications. The process of changing a culture of violence will require a sustained generational effort from multiple disciplines, much as it took decades to reverse the notion among young people that cigarette smoking or casual cocaine use is “cool.”