Repeat Victims of Violence in an Urban Trauma Center

Article excerpt

Repeat victims of violence are overwhelming urban trauma centers, yet little is written about them in the medical literature. This study combined medical record and survey data to study urban trauma recidivism among patients presenting at the Emergency Department [ED] of St. Elizabeth Hospital in Youngstown, Ohio during a 4-year period. Two-fifths of urban trauma patients were repeat victims. Repeat victims were more likely to be poor African-American males, have substance abuse and mental health problems, and live in neighborhoods where violence is pervasive. Most have no health insurance. Demographic characteristics were less important in explaining recidivism than were the circumstances surrounding violent behaviors. ED physicians must be trained to take into account a wide variety of environmental, personal, and circumstantial factors in treating and managing urban trauma patients. This may require reforms in health care financing.

Urban trauma is among the most hotly debated topics in emergency medical care (Eastman, 1992; Fleming, Sterling-Scott, Carabella, & Williams, 1992; Koop & Lundberg, 1992; Trunkey, 1990). Two studies (Morrissey, Byrd, & Deitch, 1991; Sims, Bivins, Obeid, Horst, Sorensen, & Faith, 1989) conclude that urban trauma should be viewed as a chronic disease: between 33 and 44 % of victims presenting at trauma centers have been victims before, often in the recent past. Other studies (DeMuth, 1989; Sims, et al., 1989) report less recidivism?one in 20?among urban trauma patients. All studies agree that urban trauma is much more likely to affect primarily young, male African-Americans who are poor, less educated, engage in criminal behavior, and abuse alcohol or drugs (National Research Council, 1993). Most repeat victims need expensive treatments, not covered by public or private insurance. Trauma systems may be jeopardized by repeat victims of violence (Hinds, Gleadhill, & Humphreys, 1990; Sims et al., 1989).

But a great deal is yet to be learned about repeat victims of violence (Morrissey et al., 1991; Sims et al., 1989; Smith, Fry, Morabito, & Organ, 1992). Studies have focused on patients from major academic medical centers (De Muth, 1989; Hinds et al., 1990); penetrating wounds or fatalities; demographic characteristics (Morrissey et al., 1991; Sims et al., 1989; Smith et al., 1992); simple bivariate analyses; and medical records (Morrissey et al., 1991; Sims et al., 1989; Smith et al., 1992). Studies have not asked about the circumstances accompanying violent behaviors.

This study compares repeat and one-time surviving adult victims of violence admitted to St. Elizabeth Hospital Medical Center in Youngstown, Ohio through its trauma center from July 1989 to June 1993. The study utilizes medical records and survey research to describe differences between repeaters and one-time victims. The study searches for patient management and prevention implications, first by replicating and extending existing studies, then by expanding them to include more on circumstances surrounding violent behavior.

METHODS

Background

St. Elizabeth Hospital Medical Center is a 660-bed regional, tertiary-care, teaching hospital with residency programs in radiology, surgery, internal medicine, family medicine, and dentistry, and a school of nursing. It is the only Level I-equivalent trauma center in a sixcounty region.

Youngstown, Ohio's metropolitan area includes about 250,000 inhabitants; the city itself has a population of 90,000. One fifth of the U.S. population lives in metro areas of similar size. Socioeconomic studies show Youngstown to be a typical Midwestern industrial area, like Flint, MI, Gary, IN, Akron, OH, and Erie, PA (Shanahan, 1988).

Urban Violence Defined

Urban violence was an occurrence of any ICD-9 "E-code" on the primary, secondary, tertiary, fourth, or fifth diagnoses from a patient's medical record. ICD-9 codes E950-E959, representing suicide and self-inflicted injuries, were excluded, as were spouse or child abuse and rape. …