Anatomy of Gun Violence: Contextualized Curriculum to Train Surgical Residents in Both Technical and Non-Technical Skills in the Management of Gun Violence. Onufer EJ, Andrade E, Cullinan DR, Kramer J, Leonard J, Stewart M, Vallar K, Wise PE, Klingensmith ME, Punch LJ. J Am Coll Surg. 2020 Dec;231(6):628-637.e7.
Firearm-related injury continues to be a major contributor to traumatic injury in the United States. Management of such injuries involve both an understanding of the operative skills as well as the social and psychological aspects of trauma informed care and breaking the cycle of violence. This study is a proof of concept attempting to evaluate if such an expanded view of trauma care can be taught.
The authors present a review of their “Anatomy of Gun Violence” curriculum offered from 2017-2019 to 60 surgical residents. The curriculum involves operative sills training including Bleeding Control training session, a Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) training session, and the Surgery for Abdominal-thoracic ViolencE (SAVE) simulation lab. In addition, trainees received several hours of didactic surgical lectures and mock oral sessions. To facilitate a more comprehensive understanding of the impact of firearm-related injury, trainees watched a film highlighting a survivor then had the opportunity to have an interactive discussion with a patient about their experience. Objective knowledge performance and 5-point qualitative Likert scale of satisfaction were measured. An improvement in overall didactic knowledge surrounding firearm-related injury was seen. After the SAVE lab, there was a 9% increase in overall operative trauma knowledge (p<0.05). Numerous new procedural skills were introduced during the curriculum. Trainees noted that they wanted more simulation time and additional information on firearm safety, policy, and advocacy. Many residents stated that the survivor session affected their view of victims of firearm-related injuries. Overall satisfaction of the curriculum was 4.92 and 4.77 out of 5 in 2017-2018 and 2018-2019, respectively.
While the study is limited as a single-center survey-based study, the novel approach to expanding beyond purely surgical interventions should be applauded. Given the call for improved trauma informed care education, training, and implementation, this article is quite timely. Surgical trainees should be learning about not only the physical impacts of violence, but also the psychological impact of trauma from adverse childhood events to acute physical injury. Trying to reach trainees during their formative years may help combat compassion fatigue and maintain their view of the humanity behind the injury. Comprehensive trauma care and recovery must include physical, emotional, and social support. This is particularly important for trainee in urban settings that see a disproportionate level of interpersonal violence. The authors point out appropriately that trainees will end up in a wide variety of specialties after completing residency. It is essential to remember that the tools of empathy and compassion transcend all of medicine, and we should embrace any opportunity to practice them.
Evaluation of a population health strategy to reduce distracted driving: Examining all “Es” of injury prevention. Stewart TC, Edwards J, Penney A, Gilliland J, Clark A, Haidar T, Batey B, Pfeffer A, Fraser DD, Merritt NH, Parry NG. J Trauma Acute Care Surg. 2021 Mar 1;90(3):535-543.
Cell phone use while driving (CPWD) is a major cause of distraction-induced driving errors and contributes to the injuries and deaths associated with motor vehicle collisions (MVCs). A multi-dimensional approach to injury prevention is vital to increase awareness and change attitudes regarding CPWD and reduce morbidity and mortality from MVCs. This study evaluated one such multi-faceted population health strategy targeting CPWD in London, Canada.
The authors describe the injury prevention campaign for CPWD and the mixed methods used to evaluate its effectiveness. The development of the CPWD campaign was based on local epidemiologic data and adolescent focus groups. The campaign, targeted to 16-44 year old, incorporated the five “E’s” of injury prevention (epidemiology, education, environment, enforcement, and evaluation) and focused on personal stories and consequences of CPWD. The educational messages were dispersed through a variety of methods including social media via an AdTube campaign, billboards and transit shelter advertisements, movie theater trailers, high school video contests and education material distributed by police, educators and practitioners. The campaign was enforced by local and regional police. The prevention strategy also incorporated geospatial targeting to determine the most effective billboard placement and to identify the most appropriate intersections for police enforcement of the campaign. Annual distracted driving offense statistics were recorded, interrupted time series analyses with autoregressive integrated moving average (ARIMA) modeling were performed on annual distracted driving tickets and warnings, and data were compared preintervention (2011-2014) to postintervention (2015-2019). A population health telephone survey was also conducted to evaluate the public awareness of the campaign via random-digit dialing in the city of London and the surrounding area. Social media analytics and a survey for movie-goers were also utilized to evaluate those aspects of the campaign. The social media AdTube campaign had a >10% view rate with most views coming from computers and mobile devices. Their survey of movie-goers viewing the trailer found 61% of respondents used handheld CPWD (14% all of the time) with 80% reporting the trailer made them think twice about future CPWD. The stakeholder survey and spatial analysis targeted the advertisements in areas close to high schools, universities, near intersections with previous MVCs, high traffic volumes, and population density. The telephone survey demonstrated that 41% of the respondents were aware of the CPWD campaign. Police enforcement campaign blitzes resulted in 160 tickets for CPWD. There was a statistically significant decrease in distracted driving citations annually (p = 0.001) postintervention.
Distracted driving is a major public health problem. This study addresses distracted driving and injury prevention through public health strategies specifically related to CPWD, a significant factor in the morbidity and mortality associated with MVCs. While the study has some limitations, particularly with its use of self-reported surveys with inherent bias and the lack of long-term objective outcomes especially in regard to the road safety strategy, the authors take a comprehensive, mixed methods approach to determine the effectiveness of their multi-faceted, public health strategy to combat CPWD. In doing so, they demonstrate a novel, effective approach that can be replicated in other regions to effectively address CPWD and limit injuries and death from MVCs.
Identifying participants for inclusion in hospital-based violence intervention: An analysis of 18 years of urban firearm recidivism. Bonne S, Tufariello A, Coles Z, Hohl B, Ostermann M, Boxer P, Sloan-Power E, Gusmano M, Glass NE, Kunac A, Livingston D. J Trauma Acute Care Surg. 2020 Jul;89(1):68-73.
Gun related violence is a major cause of death and disability in the United States with long lasting effects both in individual communities as well as nationwide. Identifying patients who are high risk for recidivism is an important factor in initiation of hospital based violence intervention programs. The purpose of this study was to evaluate demographics and possible predictable characteristics for possible gun violence recidivism and how to apply preventative resources to high risk populations.
The authors present a seventeen year retrospective review at their Level I trauma center of gunshot wound victims tracking for recidivism while at the same time cross referencing countrywide murder trends. Patients presenting from 2000-2017 were merged with publicly available murder data in the catchment area of the trauma center. Murder victims were matched to the trauma databank to identify recidivism. In addition, further analysis was done to compare demographic and quantifiable situation features of future recidivism to non-recidivism. There were 9,699 cases reviewed with a total of 9,159 total victims. The overall in hospital mortality rate was 14.7%. Future recidivism were likely to peak in the late teens and mid-twenties, more likely to be black (94%) or Hispanic (4%), and male (98.8%) (p<0.05). One hundred and thirty- three (25.9%) recidivists were “early” and had a second gunshot wound within a year of the first vs. 143 (27.8%) were late having a gunshot wound 5 years later. Compared to total prehospital and in hospital mortality rate of 14.7% for the first gunshot, the mortality rate increased substantially with each subsequent event. Overall cost was much higher for the second hospitalization $63,650 in 2016 (adjusted dollars) vs. $69,938 (p<0.05).
While this may be a single institutional experience, the results of the study do translate to changes which can be tracked into other communities and nationally. Gunshot wound victims are best and most easily identified at the time of their first incident and the risk multiplies exponentially would appropriate hospital and community based interventions. Hospital based injury prevention implementation is crucial in not only identifying initial victims but following them into the community for widespread interventions on a local level. These hospital based intervention programs would serve to economic and social benefit to communities.
Dusk to Dawn: Evaluating the effect of a hospital-based youth violence prevention program on youths' perception of risk. Snyder KB, Farrens A, Raposo-Hadley A, Tibbits M, Burt J, Bauman ZM, Evans CH. J Trauma Acute Care Surg. 2020 Jul;89(1):140-144.
Interpersonal violence and mortality discriminately affect youths with homicide is the third leading cause of death for people age 10–24, particularly those from ethnic minorities. American College of Surgeon verified Level 1 trauma centers are required to have injury prevention programs in an attempt to combat traumatic morbidity and mortality. This is often done through the use of Hospital-Based Violence Injury Prevention programs (HVIPs). This article describes the University of Nebraska Medical Center’s HVIP called the Dusk to Dawn (D2D). The program focuses on social cognitive framework around interpersonal violence. Participants follow the life of a young man involved in a violent event and personalizes the experience. The authors hypothesized that the D2D program would alter perceptions of violence, improve conflict resolution skills, with the hope of reducing risk of injury.
Participants were referred to the program through a variety of paths. In total, 108 of the 213 participants fully completed the program and surveys. Of these, 61.1% participated in the program at the hospital, while the 38.9% completed the program while in juvenile detention. Participants were asked to complete pretest and posttest surveys. Participants were asked about any previous gang affiliation and exposure to violence either personally or within their close circle. They were also asked about personal involvement with violent behavior. They were also asked about the satisfaction with the D2D program on a Likert scale. Finally, they were asked to assess risk factors for violent injury. The majority of participants were from I think minorities with the largest population being African-American. Approximately three quarters lives at home with her parents. About 80% had completed high school while the others had middle school educations. Approximately one third of participants had prior arrest records. Approximately one quarter had been in a gang and have been injured by violence. Over half reported that a friend of family had died as a result of violence. About 30% have been violent in the past month with 7.5% stating that they carried a knife or gun in the last month. Approximately 60% of participants stated they were satisfied with the D2D program. Of these, 83.3% greater strongly agreed that D2D help them understand violence and would recommend them to others their age. After the intervention there were statistically significant increases in the perception that family was one of the most important personal risk factors for violence. There is a decrease in the perception that school issues were as important. There were increases in perception that violence among peers and substance use were high risk for violent injury.
This social cognitive approach to teaching youth about violent injury has been replicated at other sites and this is an additional example of its success. Previous programs that focus more on consequences have been demonstrated not to have positive influence on youth violence prevention. Youth violence remains a significant public health issue and its prevention must begin early on given that significant risk factors exist early in children's lives. Adverse childhood experiences significantly contribute to violent behavior and risk for violent injury. Well social cognitive program such as this 1 cannot erase adverse childhood experiences they can help the youth who have already experience them understand and reframe their thinking around violence and injury. While social cognitive program such as this one cannot erase adverse childhood experiences they can help the youth who have already experience them understand and reframe their thinking around violence and injury. But much still needs to be done in terms of reducing these risk factors, this article exemplifies a good example of social cognitive education in an attempt to medicate violent response and injury.