Emotional and Physical Healing in the Emergency Room

February 19, 2013 | Dr. Thea James, Assistant Dean, Office of Diversity and Multicultural Affairs at Boston University School of Medicine

Hospital and emergency room personnel encounter children exposed to violence daily in their work.

Hospital and emergency room personnel encounter children exposed to violence daily in their work. The Defending Childhood Task Force recognized the critical importance of these first-line workers in its report, including the recommendation “Develop and provide trauma-informed care in all hospital-based trauma centers and emergency departments for all children exposed to violence.” The task force goes on to recommend that “Hospital-based counseling and prevention programs should be established in all hospital emergency departments—especially those that provide services to victims of violence—including victims of gang violence. Professionals and other staff in emergency medical services should be trained to identify and engage children who have been exposed to violence or to prolonged, extreme psychological trauma.”

In today’s guest blog, task force member Dr. Thea James describes how a trauma-informed, “upstream” approach called the Violence Intervention Advocacy Program has been used to prevent and treat children’s exposure to violence in Boston, where she lives and works.

Even before I entered medical school, I wanted to be an emergency medicine physician. I loved the notion of having multiple opportunities on any given day to meet a stranger and make a difference in his or her life.

I was unaware, however, that medical school does not teach students how to handle unnatural life events. We are not prepared for lonely walks from the trauma room to the waiting room to tell a family their child is dead. No syllabus holds the answer to the question asked by a critically ill 4-, 15-, or 18-year-old lying on a gurney: “Am I going to die?”―not to mention how you feel when that child does die. Alas, medical school also does not teach us to recognize our own trauma in these unnatural scenarios, nor its potential subsequent effects and manifestations. 

Standing over lifeless and near-lifeless bodies in the trauma room caused me to wonder what led to that moment. I found some answers in tattoos on those bodies: “Living is hard, dying is easy”; “Born to be hated, dying to be loved”; and “Death is nothing, but to live defeated is to die every day.” I realized that while these deaths were shocking to me, they were not so surprising to these young people; indeed, their tattoos seemed to indicate their expectations that violence would enter, and perhaps end, their lives.

After an epidemic of these unnatural events―the deaths of young people who should have had long lives ahead of them―my emergency department was given the privilege of developing an intervention.

The Violence Intervention Advocacy Program (VIAP) is an emergency department‒based program that helps guide victims of community violence through recovery from physical and emotional trauma. Using a trauma-informed model of care, VIAP empowers clients and families and facilitates recovery by providing services and opportunities that bring hope and healing to victims and their families. VIAP offers mental health and family support services and assistance with housing, food safety, education, life skills training, and employment readiness. In turn, this guidance helps strengthen others who are affected by violence and contributes to building safer and healthier communities.

The program is activated when a victim of violence lands in our emergency department (ED) trauma room for treatment. Our case managers contact victims of violence the same day or next day (if they come in at night) at their bedside in the ED, on the ward, or by phone if they are discharged during program off hours.

At the same time, mental health clinicians from the hospital community response team evaluate and provide services for these victims at their bedsides on the wards and continue home services post-discharge if necessary. They also provide mental health services for younger siblings and parents.

Our case managers follow these patients, who become their clients. Each case manager becomes the most important element to a client’s success—the one person the client can depend on, rely on, and call 24/7. Case managers develop rapport with their clients to establish trust, screen for retaliation and safety, monitor mental health status, engage in reflection, get to know their social situations and family members, and talk with family members. Gradually, the case manager completes a needs assessment for each patient, screening for housing, food, education, and employment needs and providing support, life skills training, employment readiness, and dependability. The case manager walks each client and his/her family through the healing process for as long as it takes.

The program provides insight into the lives of a subset of injured young patients―those who are most “at risk” for violent events. Through assessment and experience, we have begun to understand how their life journeys culminate in violent injury. We have learned about their challenges and barriers to recovery.

For some, challenges begin in the hospital, where they may be stigmatized by the nature of their injuries and by those who are there to help them heal. Due to a lack of knowledge about trauma and its manifestations, hospital personnel can inadvertently re-traumatize these young victims of violence, re-inscribing their expectations of disrespect and hurt.

The greatest lesson I have learned about youth violence and this population of vulnerable young souls is that they are “hurt people hurting people.” We must provide support and guidance to all who are affected―victims and their families―to break the painful cycle of violence in their lives and provide them with new opportunities to become healthy, happy, and productive citizens.

I have also found that the most important element to a successful intervention is having a caring, responsible, and trauma-informed adult in the life of a victim—one who will advocate for and accompany the victim on the journey to recovery. This trend is growing through the work of the National Network of Hospital-Based Violence Intervention Programs, of which I am proud to be a part.

My experience as a member of the Attorney General’s Defending Childhood Task Force affirmed and provided context for what I see daily when working with young victims of violence and their families. Each task force member’s area of expertise represented something I have witnessed and learned about from our young clients: prenatal challenges; multigenerational familial and community trauma (poverty, etc.); unidentified clues in behavioral health; missed opportunities for screening, recognition, and intervention in all manner of problems; children lacking a sense of security or belonging and their attraction to gangs to seek it; lack of national awareness; the public feeling community violence does not affect them; and a criminal justice system that inadvertently perpetuates cycles of violence by creating barriers to positive outcomes. 

What I gained, and hope others will gain, from the task force’s report is context for how and why our children and young people are exposed to violence and how we can help. I know from experience that many potential points of prevention and intervention exist in a child’s life. The task force’s report provides a roadmap for the powerful impact we all can make.

Thea James, MD, is an associate professor of emergency medicine at Boston Medical Center and Boston University School of Medicine and immediate past president of the Medical-Dental Staff at Boston Medical Center. She also is the director of the Boston Medical Center Massachusetts Violence Intervention Advocacy Program. Dr. James is a founding member of the National Network of Hospital-Based Violence Intervention Programs (NNHVIP). She serves on the steering committee and the research group of NNHVIP.

Dr. James is an assistant dean for the Office of Diversity and Multicultural Affairs and a member of the Admissions Committee at Boston University School of Medicine. For many years, Dr. James has traveled to Haiti with teams of emergency medicine residents. In 2006, she and a colleague co-founded a nonprofit organization called Unified for Global Healing, and for the past 3 years this multidisciplinary team has worked in Ghana, West Africa, India, and Haiti.

To watch videos of the Defending Childhood Task Force hearings, visit NCCD’s task force page. For more information on the Defending Childhood Task Force and Initiative, visit the Department of Justice’s task force website.