a special program of the National Emergency Medicine Association (NEMA) 

Transcripts: 544-3 to 544-5

Week: 544.3 Guest: Dr. Carnell Cooper, Surgeon, R. Adams Cowley Shock Trauma, Baltimore Topic: Study on repeat patients hospitalized by violence, Part One of Three Producer/Host: Steve Girard

NEMA: What if you landed in your local trauma center twice in two years? You'd probably say it was a bad coincidence. For some, being patched back together at a trauma center is something else entirely...a pattern. We're talking with Dr. Carnell Cooper, a surgeon at the Cowley Shock Trauma Center in Baltimore...part of a team that put together a study aimed at establishing reasons behind a pattern of serious medical treatments. Dr. Cooper, what planted the seed for this study...

COOPER: Repeat victims of violence, in various studies done across the country, may vary from as little as ten percent of the populations of the patients that we as much as 45 % of the patients that we're seeing. We're talking about just trauma patients. So, for all the patients that present to us for reasons like gunshot wounds, or car accidents, or falls, or many as ten to forty five percent of these patients may be repeat victims of violence. And we became interested in this problem because we see a lot of patients who have been here before, and after a while, you begin to say, "well why is it we keep seeing the same people over and over again"? And we tried to figure out why...more importantly, "how could we stop this revolving door"? And that's why we undertook this study, to say, "let's figure out what the demographics are, what their characteristics are, and maybe by finding out what their characteristics are, we can then try to figure, "how can we intervene"? What kind of preventive things can we get started...and that's how we sort came around with this idea.

NEMA: What was the first step?

COOPER: Well, the first thing I did was I sought help. I'm not an epidemiologist, so I immediately went to one of my colleagues, Paul Stolley, who actually had interest in this...and he's actually head of epidemiology and preventive medicine, and he actually did a lot of, the majority actually, of the groundwork, in terms of getting all these exact parameters of how to approach this study, set up. And once we had done that, it was a matter of trying to find money to support it, and that, of course, took the longest amount of time to really achieve. But it was, one of the things that we, at a university are obligated to, is not just to see patients come in with their injuries, put them back together and then send them out...because obviously, if they're coming back again, we're not doing a very good job. And so, we sat down and we began to figure out how to attack this problem. Our institution...the University of Maryland Shock Trauma Center, actually coined the phrase that's actually used across the country and the world right now, called, "the golden hour"....meaning that when patients get injured, you have that, within that one hour period around the injury, you have an opportunity to save them. In that hour of time is critical, in terms of getting them here, and getting them taken care of. Well, we felt the same way about these injured patients. When someone gets injured, it is the one opportunity in which they sit back and go, "Wow"...especially young kids. "All of the sudden, I'm injured, I almost died"! This may be the time when we can say, "you're mortal", and this is the time that they are a little bit scared and you could intervene and say, "Here's the things in your lifestyle that put you at risk, and here are the things you've gotta change". And so, when we went about designing the study, that was the thing that was on our minds. Here is a golden opportunity to intervene, and stop the cycle.

NEMA: Dr. Carnell Cooper of Adams Cowley Shock Trauma Center...more on the findings and results of the study coming in our next program. It's pretty good news... I'm Steve Girard.


Week: 544.4 Guest: Dr. Carnell Cooper, Surgeon, R. Adams Cowley Shock Trauma, Baltimore Topic: Factors that result in repeat violent trauma, Part Two of Three Producer/Host: Steve Girard

NEMA: We've been talking with Dr. Carnell Cooper, a surgeon at Baltimore's Adams Cowley Shock Trauma Center... about an interventional study surrounding a group of repeat victims of violent trauma. Dr. Cooper, when your group looked at the questionnaires and the interview questions, what was on the list of problems which may lead a person to repeat trauma...?

COOPER: We think unemployment is an important factor, and it's something that has been found in studies done with this population, some of the populations studied in other regions in the past. And we think that the fact that these patients have no income, or are in a very low income bracket, it predisposes them, it limits their ability to get out of the situation they're in. They're forced to stay in the same neighborhood they're in, they are forced to seek other resources, they can't often get the sort of drug rehab care they may need to kick their we think that plays a major role.

NEMA: And I guess a major part of the study was to gauge how that affects the rest of terms of costs to the health care system....

COOPER: Absolutely, in our population, our patients....the average costs of these patients was almost 45 thousand dollars per admission. So, they are a, most of them in our study, had no medical insurance at fact, 77% of the males, and 64% of the females that were the cases, had no insurance, which means we, the citizens of the state of Maryland, essentially pay for this bill. Also of interest is that the average...on average, the much as 70 % of these patients, had spent an average of 27 months in jail, again something the citizens actually pay for. So, if we can impact on they're lifestyle, get them employed, help them get their diploma, then break them out of this cycle, we may not only impact on the way they are affecting our health care system, but also we may impact on the way they're affecting our penal system.

NEMA: Some surprises during the process...?

COOPER: Well, it was interesting because many of our patients were surprised that anyone even cared enough to be interested in the things that we asked them: about their lifestyle, what were the events surrounding the shooting, did they have an education, etc... They were very surprised that anyone was even interested in that particular part of their lifestyle.

NEMA: Dr. Carnell Cooper of Baltimore's Shock Trauma Center. More on trying to make a difference to those leading troubled our next program. I'm Steve Girard.


Week: 544.5 Guest: Dr. Carnell Cooper, Surgeon, R.Adams Cowley Shock Trauma, Baltimore Topic: Altering economics to prevent repeat violent trauma, Part Three of Three Producer/Host: Steve Girard

NEMA: We've been talking with Dr. Carnell Cooper of Baltimore's Cowley Shock Trauma Center, about a small, interventional study of the repeat victims of violence. You say the prominent ingredient in putting a person back into a trauma center for a second or third time seems to be unemployment...hard economic conditions. And you believe that there is a Golden Hour", when you have a patient's attention, that intervention can be most effective in breaking the cycle. What were you able to say during that "golden hour"....and how did the program of intervention in this study help did the cases turn out?

COOPER: Again, emphasizing how we as a system are sort of...we take these patients in who are gunshot, with stab wounds, whatever...we put them back together and we send them out, without ever trying to attack the other underlying problems which may have brought them there in the first place. And we, as a system, aren't equipped to do that, so it's not surprising that we don't. So the first thing that we were surprised about was the number of people who received our program questionnaire warmly, and were surprised anyone was interested. And then, the second thing that was surprising - no one said, gee whiz, this is all garbage, and I'm not interested in helping out. So, they were the first two things we were surprised about. Our intervention, which was a pilot study that was actually initiated by a physician named Cuthbert Sitkins, along with Dr. Stolley, was a job employment intervention process. And what we did was along with...the state health and mental hygiene department, it was a combined effort. These patients were given employment at some of the state offices...a lot were menial jobs, cleaning, putting away equipment, many basic kinds of jobs. And what we did was help patients do things like fill out job applications, we helped them prepare for their job with a social worker who followed them along, who helped them answer questions...things like, "How am I supposed to dress for this job"?..."What do I do if a problem comes up between me and a fellow employee"?..."What do I do if I have a problem communicating to my boss"? Those kinds of issues. And, essentially, once we got these folks into their jobs, none of them ended up in the two year follow up that we did, coming back to our facility as a victim of repeat trauma. And that was one of the goals of the individual process, was to try to cut this cycle of coming back to our hospital. So we accomplished one of our goals in our intervention process. No one came back. The second goal, for those folks who could not complete a diploma, was to get a GED...we weren't as successful for that as we liked...but a large percentage of them did accomplish that goal as well.

NEMA: So, what's the next step?

COOPER: First up, we are trying to publish this data, right now, because once it's published, it means that we have a wider disbursement of it. I recently presented some of the data at the American Association for Surgery of Trauma meeting in Houston...which is the largest meeting of trauma surgeons across the country, that's held every year.We are continuing to look for funding to see if we can, once again, embark upon this same study, but with a wider group of patients.

NEMA: Doctors, administrators and nurses all played a role in making the Shock Trauma Center study on repeat victims of violence real, human terms. Our thanks to Dr. Carnell Cooper...I'm Steve Girard.