Before and After the Trauma Bay: The Prevention of ViolentInjury Among Youth
Rebecca Cunningham, MDLynda Knox, PhDJoel Fein, MD, MPHStephanie Harrison, MPH, PhDKeri Frisch, MSMaureen Walton, MPH, PhDRochelle Dicker, MDDeane Calhoun, MAMarla Becker, MPHStephen W. Hargarten, MD,MPH
From the Departments of Emergency Medicine and the UM Injury Research Center (Cunningham,Harrison), School of Public Health (Cunningham), and Psychiatry (Walton), University of MichiganMedical Center, Ann Arbor, MI; the Department of Family Medicine, Keck School of Medicine,University of Southern California, Los Angeles, CA (Knox); the Department of Pediatrics andEmergency Medicine, University of Pennsylvania School of Medicine and Emergency Department atThe Children’s Hospital of Philadelphia, Philadelphia, PA (Fein); Department of Emergency Medicineand the Injury Research Center, Injury Research Center, Medical College of Wisconsin, Milwaukee,WI (Frisch, Hargarten); the Department of Surgery, University of California and San FranciscoGeneral Hospital, San Francisco, CA (Dicker); and Youth ALIVE!, Oakland, CA (Calhoun, Becker).
Despite a decline in the incidence of homicide in recent years, the United States retains the highest youthhomicide rate among the 26 wealthiest nations. Homicide is the second leading cause of death overall and theleading cause of death for male blacks aged 15 to 24 years. High rates of health care recidivism for violentinjury, along with increasing research that demonstrates the effectiveness of violence prevention strategies inother arenas, dictate that physicians recognize violence as a complex preventable health problem andimplement violence prevention activities into current practice rather than relegating violence prevention to thecriminal justice arena. The emergency department (ED) and trauma center settings in many ways are uniquelypositioned for this role. Exposure to ﬁrearm violence doubles the probability that a youth will commit violencewithin 2 years, and research shows that retaliatory injury risk among violent youth victims is 88 times higherthan among those who were never exposed to violence. This article reviews the potential role of the ED in theprevention of youth violence, as well as the growing number of ED- and hospital-based violence preventionprograms already in place. [Ann Emerg Med. 2009;53:490-500.]
0196-0644/$-see front matterCopyright
2008 by the American College of Emergency Physicians.doi:10.1016/j.annemergmed.2008.11.014
In the United States, violence is the leading cause of death formale blacks aged 15 to 25 years and the second leading cause of death for all youths aged 15 to 25 years regardless of race orethnicity. In 2006, almost a million youths ages 15 to 24 yearsreceived medical care for nonfatal violent injuries. As many as40% of violently injured youths return to the emergency department (ED) in the future with violence-related injuries,and as many as 20% are victims of homicide within 5 years of admission. As with other forms of violence, including elderabuse, child abuse, and domestic violence, the ED is uniquely positioned to intervene to reduce rates of violent reinjury anddeath in these vulnerable youths. ED clinicians can identify andassess violently injured youths for risk of violent reinjury andperpetration of retaliatory violence; provide counseling andlinked referrals to resources that may help reduce risk of futureviolence; and advocate for policies and programs that reducerisk for violence and violent reinjury. This article reviews recentresearch on youth violence and its prevention, discusses 3actions ED providers can take to aid in reducing violent reinjury and homicide among young patients, and identiﬁes areas forfuture research. A list of resources for providers interested inintegrating clinical preventive services in their patient care plansis also provided.Youth violence, which includes acts such as aggravatedassault, robbery, rape, and homicide, is a signiﬁcant publichealth problem in the United States. In 2006, more than766,000 youths ages 15 to 24 years received medical care fornonfatal violent injuries, of which 9% required hospitalization.
Repeated visits among this injured cohort are common: studiesindicate that readmission rates for youths treated in the ED forviolent injuries are as high as 44% for injury caused by anotherassault, and some studies ﬁnd a subsequent homicide rate of 20% among the subset whose index visit required admission totrauma service.
In 2005, more than 5,000 youths ages 15 to490
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