In 1989, Eugene Richards published the visual chronicle of scenes from the Denver Country Hospital Emergency Department. Anyone who has worked in an emergency department (ED) would recognize the grainy photos that put on display the gruesome injuries that people incur as a result of senseless violence.
Let’s face it — in addition to unscheduled primary care and geriatric medicine, much of what we manage in the ED is trauma. My wife has pointed out that when an emergency doctor is having an interesting, productive, and intellectually engaging day at work, it means someone else is having an extremely bad day. And over these past months on the reservation, I have noticed a stunning amount of trauma as a result of violence, many of which involve family members and a majority that are complicated by drugs, alcohol, or both. These experiences have left me questioning what might be causing such a stunning disregard for human life in our tiny part of the world.
For example, in one recent week during three separate night shifts, our ED cared for a limb-threatening gunshot wound, a bowel-eviscerating stab wound, five assault and batteries, and a homicide victim who died after a gunshot wound to the chest. At the same scene where the last patient was found and brought into the ED, another person was killed as a result of a gunshot wound to the head. In addition, I evaluated a sexual assault victim of intimate partner violence and a victim of elder abuse that absolutely broke my heart.
The Navajo Nation covers a land area of roughly 27,000 square miles, about the same size of West Virginia, with a population of about 180,000. An FBI report in 2013 found that the homicide rate per capita on the rez outpaced that of places like Boston and Seattle, major metropolitan areas that have significantly higher population density. The per capita homicide rate here is four times the national average. And even more concerning is that it seems to be affecting native children and adolescents to a much high degree, as reports show that American Indian and Alaska Native (AIAN) children suffer disproportionately from abuse and violence that result in rates of post-traumatic stress disorder that are similar to those seen in service members returning from war. Here kids are twice as likely to die before the age of 24 when compared to all other races in the U.S. Tucked back amidst the red rocks, spiritual mesas, and sacred peaks is one of the most dangerous places to grow up in America.
The causes of such trauma and violence are difficult to pin down, but likely result from a confluence of factors including systemic issues arising from complex and contrived jurisdictional tribal laws, an underfunded and understaffed law enforcement force, severe poverty and unemployment, undertreated and undiagnosed mental health conditions, the proliferation of illegal drug-use and alcohol abuse, and the proliferations of gang activity and broken families, due to many of the same issues above
It seems there is a desperation and loneliness which seems to have led to a staggering disregard for the traditional values of Native people — those of community, family, love, generosity, and harmony.
As an emergency department physician who sees the traumatic aftermath but who has individual patient encounters that are episodic and transactional, I was left wondering what is my profession’s role in injury and trauma prevention. It is vital and should be incorporated into every setting where we care for acutely injured patients. As emergency physicians on the front lines, we should be at the vanguard of trauma and injury prevention, and control and educate ourselves of the science and evidence-based practices of trauma and injury prevention.
But where to start?
The Center for Disease Control and Prevention is a good resource, and have outlined a systems-based approach to injury prevention. And we, as emergency medicine physicians, can recognize and flag important signals of homicide or suicide clusters, in addition to being effective screeners for intimate partner violence, child and elder abuse, and unsafe social environments for our patients. Once high-risk individuals are identified, a community-wide agency network is needed to provide needed support. Perhaps we could partner with national organizations or trauma centers to engage in population and public health research that could help determine which interventions are the most effective and sustainable.
As a profession, our duty to our patients is to always keep them safe and show them how much we care. Much more than dispensers of medical knowledge and remedies we are advocates, protectors, and promoters of wellness.
What do you think could strengthen our Native communities and help keep them safe from violence? Please share and thank you for your efforts!