Violence As Seen In Hospitals

The mere mention of the word [violence] conjures up images of war, street crime, child abuse, domestic abuse, drive by shootings, serial killings among others. We are, on a daily basis, confronted with newspaper head lines and television news lead stories of some of the most horrific violent events imaginable.

As an Emergency Physician working in a trauma hospital center located in New York City, I see the victims, (and sometimes perpetrators) of violent acts daily. Harlem Hospital is a 500-bed municipal facility located in central Harlem. Harlem Hospital is a designated trauma and burn center. This essentially means that significantly traumatized victims are preferentially brought to our hospital even if it means bypassing closer hospitals which are not equipped to manage these patients.

The treatment of victims of violence is a very challenging and expensive business. Treatment begins in the prehospital setting with the Emergency Medical Services (now under the auspices of the Fire Department in N.Y.C.) and continues into the hospital. The "Trauma Center" has a number of multidisciplinary teams of medical rehabilitation and social service personnel who are dedicated to the resuscitation, treatment and recovery of the trauma victim. These teams include the Emergency Department personnel, the trauma (Surgical) team and a variety of specialist, (e.g. orthopedics, neurosurgeons, pediatric surgeons), who are readily available to treat these patients 24 hours every day. The Trauma Center must also have a number of support services in place at all times.

Victims of trauma more often than not, require a great number of laboratory and radiologic tests. These tests include routine tests such as blood counts, blood electrolytes, urinanalysis and toxicologic studies. X-rays are almost always needed and special studies such as C.A.T. scans are also required for many of these patients (especially those who have sustained head trauma). The cost of treatment of a single victim of violence can easily tally well into the hundreds of thousands of dollars. It is also a fact that many of these patients do not have insurance to cover the cost of treatment and rehabilitation.

A high percentage, (greater than 80%), of victims of interpersonal violence, know the perpetrator. Domestic violence, a greatly under-reported crime, is literally epidemic in the inner city and nationwide. As part of our routine patient assessment, our staff is required to ask patients if they have been hurt by someone known to them. This is particularly important if they present with an injury or illness that could be the result of domestic violence or neglect. In the vast majority of cases, violence is perpetuated on women by their husbands or "significant others".

When medical treatment is completed and admission to the hospital is not required, we will not discharge the patient from the hospital until we are convinced that she has a safe environment to return to. These patients are also strongly encouraged and given guidance as to how to press charges and utilize the legal system to assure their safety.

A disturbing trend over the last several years has been the tremendous increase in cases of elderly abuse. This, like other forms of domestic violence is largely an under-reported crime. Elderly abuse is defined as any form of physical violence, mental cruelty, neglect, sexual abuse or financial exploitation of a person 60 years and older. I recall treating an elderly lady several years ago, who presented to the O.R. with a burn to her hand. She was accompanied by her granddaughter, (a woman in her twenties), who lived with her and "took care" of her. I was struck by inconsistencies in the history as to how the burn occurred. The granddaughter stated that the patient had spilled hot tea on her hand, however, the burn involved all of the fingers, palm and back of the hand. The patient was not saying much while her granddaughter was in the treatment room. When she was asked to leave, (which she did extremely reluctantly), the true story emerged.

The granddaughter was a crack cocaine addict who had been pilfering off the grandmother's money to supply herself with drugs. When the grandmother tried to put a stop to this by direct depositing her checks, the granddaughter decided to punish her by forcibly submerging her hand into a sink filled with scalding water. The authorities were notified and the granddaughter arrested. There were several features of this case which raised "red flags" as to the possibility of abuse. Many of these features are often commonly seen in child abuse cases and other forms of domestic abuse.

We may see injuries that are not consistent with the history given by the patient or caretaker. Injuries seen in areas where people generally do not hurt themselves, (e.g. throat, face, inner thigh, abdomen or genitals), also raise the possibility of abuse. An extremely anxious or conversely withdrawn, timid or unresponsive patient, especially in the presence of the caretaker, greatly raise our level of suspicion. There are certain telltale burns and fractures which almost exclusively occur as a result of an assault. These are always difficult and unpleasant cases to deal with. However, missing the real cause of their injuries, may result in further assaults and possibly death.

Several landmark studies have shown that higher than expected death rates in the inner city are largely due to violence, homicide and accidents. Other significant factors include alcohol use, drug and other substance abuse. My personal experiences as an Emergency Physician substantiate the veracity of these studies and also demonstrate how many of these factors interrelate.

Greater than 50% of the trauma victims who present to my Emergency Department are intoxicated with alcohol or have a positive toxicology screen for illicit drugs. It is common for us to receive two or more "drug related" shootings or stabbings to our hospital daily. Cocaine and particularly phencyclidine intoxicated individuals are prone to violent episodes directed towards others and towards themselves. Innumerable alcohol intoxicated individuals hurt others and themselves primary as a result of accidents.

The association of wrenching poverty, generalized despondency, inadequate education, dissolution of the traditional family unit, prevalent drug/alcohol abuse and a breakdown of moral standards, all, in my opinion, contribute to the epidemic of violence that we continue to see daily. As Emergency and Trauma physicians we are most often put in the position of trying to put the pieces of broken bodies and lives together after the damage has been done. Clearly, some trauma is unpredictable and can't be prevented. Interpersonal violence is, however, one hundred percent preventable with proper interventions. Solutions are not cheap or easy however. Poverty, education and family disruptions must be addressed aggressively. Clearly, money must be invested to help correct many of these community and social problems. Other issues, however, can be addressed without great investments of money.

We all need to learn, apply and teach principles of conflict resolution. This has to be initiated in our own homes and also taught in schools, community centers, churches and any other places where young people gather. People also need to be taught skills which would improve their chances for success in the home and work place. Good behavior, respect for one another and patience needs to be modeled by all of us. I personally participate in a variety of conferences and forums where I can relate some of my experiences as an emergency physician and comment on the consequences that certain behaviors reap.

I am not seeking to put myself out of business as an emergency physician. However, you will find that Emergency Department personnel would generally be quite happy to see a lot less of human tragedy which occurs daily as a consequence of interpersonal violence. All of us are members of God's family. If one of us is hurt the entire family suffers. Let's all begin to take steps to turn things around.

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