It takes more than a stitch to heal a bullet wound.
With the creation and launch this summer of the St. Louis Area Hospital-Based Violence Intervention Program (STL-HVIP), a citywide network of hospital-based intervention and ongoing support, the St. Louis medical community is taking a significant step to help patients heal from acts of violence.
With 205 murders in 2017 — about 20 more than those tallied in recent years, and 94 percent attributable to firearms — St. Louis is experiencing an epidemic of gun violence. Homicide is the No. 1 cause of death for black males ages 15 to 44. There are many more who survive episodes of violence only to live in its shadow. In general, for every seven people injured by firearms in the United States, six survive. While loss of life is the most tragic outcome, those who survive such incidents live their lives with the weight and complications of often-terrible injuries. This is an enormous burden, disproportionately carried in St. Louis by its black community.
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The anatomy of violence is brutal. As a trauma surgeon, I have tried to stop the bleeding as patients died and their mothers cried. The despair of the moment is as vast as the ocean. There is no pill, no surgery, no bandage for those deep, deep wounds. When a person is traumatized by violence, the fear centers in the brain are broken. Instead of safe memories, victims relive the events and are at high risk of developing post-traumatic stress disorder. This can lead to hypervigilance and, in turn, behaviors that are aggressive and violent. Educational and vocational efforts are interrupted. Families and communities grieve and wage war. Substance abuse with alcohol and opiate pain killers increases.
Research shows that once violence touches a person’s life, he or she is more likely to become a repeat victim or a perpetrator of violence, each time with a greater chance of dying. This reality seeps into communities where violence is concentrated, affecting the lives and well-being of every citizen. As the late Professor Norman White attested, many St. Louis citizens are “living in risk,” surrounded by circumstances and internalized personal histories that allow violence to flourish. He described this “inescapable truth” as the source of toxic stress within the individual.
This stress, in turn, creates higher levels of hormones and adrenalin, even during sleep. While it may be convenient to regard behavioral violence as a simple personal choice, the circumstances that give rise to that violence both for the victim and the perpetrator are fed by the same vicious cycle of stress and injury.
It is therefore impossible to treat and prevent violent injury without addressing the social and emotional vulnerabilities each patient carries. When patients survive traumatic violence, hope is arrested when that risk returns. How can this pattern be disrupted?
Fueled by the Washington University Gun Violence Initiative and innumerable committed medical providers, the STL-HVIP is taking an unprecedented step forward in meeting the complex, needs of traumatized St. Louis citizens. In this initiative, patients admitted to the hospital for treatment of violent injuries will be given the opportunity to receive services addressing social, economic, psychological, legal and personal injuries. The support provided by trained counselors will continue for several months, helping victims stabilize, truly heal and become less likely to be involved in violence again.
Unlike similar programs in urban hospitals in the United States, this program is based on cooperation between all of the trauma centers in St. Louis, representing a unique opportunity to treat and better understand the effects of violence on the individual and community at the same time.
Violence is a disease that can be treated completely, within the individual and within the community. This initiative moves the physicians, nurses and care providers of all kinds closer to being able to understand, treat and prevent violence, allowing true healing to occur long after the stitches have come out.
Dr. Laurie Punch is an assistant professor of surgery at the School of Medicine at Washington University.
