Pulse
Plan of Action
Physicians are working with the City of Minneapolis to keep kids from becoming repeat victims of violence.
Emergency physician Dave Dvorak, M.D., would like to make sure no kids show up in a Minneapolis emergency room injured or dying as a result of violence. So outside of his work at Fairview Southdale Hospital, Dvorak mentors a 10-year-old boy who is being raised by his great-grandmother in North Minneapolis, a part of town troubled by poverty and gang activity. He’s also working with the City of Minneapolis on a project designed to prevent kids who come to emergency departments with violence-related injuries from again showing up shot, stabbed, or worse.
“Rather than the traditional model of ‘treat and street,’ where the physical injuries are attended to, we’re trying to create an intervention program that will meet their other needs and reduce their risk of re-injury or retaliation,” he says.
Dvorak’s work is part of the Blueprint for Action, a citywide initiative that treats youth violence as a preventable public health concern. The initiative was started in response to a spike in the rate of violent crime among young people in 2006 (the rate has since fallen). According to city statistics, homicide was the leading cause of death among residents ages 15 to 24 between 2003 and 2006, with nearly 80 young people dying at the hands of others during that period. In addition, more than 6,100 Minneapolis youths were either admitted to hospitals or seen in ERs for assault-related injuries during the same period.
Dvorak notes that the effects of youth violence are costly not only in terms of lives and lost opportunities but also in terms of dollars.
The blueprint, which was launched in January 2008, takes a broad view of violence prevention, says Gretchen Musicant, commissioner of the Minneapolis Department of Health and Family Support. Its strategies are to connect kids with trusted adults or supportive services, intervene at the first sign of trouble, get kids back on track if they do get in trouble, and reduce the emphasis on violence in movies, television, music, and video games.
“Injuries that are caused by violence are preventable,” Musicant says. “We are not born with genes that say we’re going to get shot. By bringing a public health approach to youth violence instead of just a criminal justice approach, we’re able to integrate a lot of components that have to do with youth development—a sense of future, hopefulness, connection to the community, connection to other adults.”
Protocol for Prevention
Musicant says their idea for taking this approach grew out of the work of Debra Prothrow-Stith, M.D., a Boston physician who defined youth violence as a public health concern and developed a prevention plan for that city in the 1990s that led to a marked decrease in juvenile homicide. Musicant and other Minneapolis leaders met with Prothrow-Stith to learn about the Boston model, which involved government, law enforcement, educators, religious organizations, businesses, civic groups, and the health care community.
“It seemed only natural that we think about the role of hospitals, especially the trauma hospitals,” Musicant says. “They see the immediate impact of violence in our community.” Meetings between Minneapolis Mayor R.T. Rybak and representatives from area hospitals led to an effort by Dvorak, who is working toward a master’s degree in public health, Christine Kletti, M.D., an emergency physician at Hennepin County Medical Center, and Maribeth Woitas, R.N., director of emergency services at North Memorial Medical Center, to create a standardized protocol for ER staff who encounter a youth who has been a victim of violence. “The ER is a very logical point of intervention,” Dvorak says. “These kids have pretty much self-selected as being at risk by virtue of the fact that they’ve ended up in the ER shot or stabbed.”
According to Dvorak, the way it works is that ER physicians or nurses will identify youths between the ages of 8 and 22 who are victims of violent injury that is not self-inflicted and notify a hospital social worker. The social worker will then assess the young person’s need for conflict resolution or anger management training; chemical dependency treatment; mental health counseling; or help with leaving a gang, connecting with family, earning a GED, obtaining job training, or developing skills to parent their own children. The social worker will then match the youth with organizations that can help get their lives on track and reduce their chances of being a repeat victim or perpetrator.
“This is really a spin-off of other types of intervention programs that exist already,” he says, explaining that ERs already have protocols for victims of sexual assault, domestic violence, and child abuse.
Dvorak and his colleagues will first implement the protocol at North Memorial and HCMC, both of which are trauma centers, and eventually make it available to other hospitals.
Will It Work?
So far, few studies have been done of emergency room-based violence-prevention initiatives. One in Baltimore found that young violence victims who were exposed to a similar intervention were less likely to be arrested for and convicted of a violent crime than those who were not. Another in the Baltimore/D.C. area showed that young victims who were paired with a mentor after their visit to the ER committed fewer misdemeanors and showed less aggression than those who did not get paired with a mentor. And a third found that young violence victims at an Oakland, California, ER who were matched with a peer role model were less likely to be arrested for any offense than youths who were not. Despite these positive findings, Dvorak cautions that the studies are preliminary and the numbers small.
But to physicians who work with at-risk youths, such efforts are worth trying. Michele Van Vranken, M.D., an adolescent medicine physician at the Teen Age Medical Service (TAMS) clinic at Children’s Hospitals and Clinics in Minneapolis’ Phillips neighborhood, says intervening in the ER following a crisis can be a turning point. “Emotions are very high. Folks who may be tough or have a wall up could realize that they could have died at that particular moment, and that could be a motivator for change,” she says. “It’s also a time that brings a lot of their social support together—family and friends. If they’re all together in that same space, getting them resources to help them move through this together is likely to be more successful than just trying to do it with one individual.”
She says the ER can be a place where counselors can diffuse tensions between victims and the people who injured them and prevent retaliation. “It’s a chance to prevent that tit for tat that keeps going and going and going.”
Both she and Dvorak acknowledge that intervening in the ER is only part of the solution to the problem of youth violence. But they believe doctors can make a difference just by asking questions and letting patients know that violence is not a normal part of life. “Doctors once didn’t believe that asking about smoking could make a difference [in getting people to quit], but we’ve found it does,” Van Vranken says. Asking youths about violence could have the same effect. “We have to believe it matters.”—Kim Kiser