When Equality Is Not Equity: The Ethics of Access to Trauma Care: A Surgical Perspective.

OBJECTIVE: The purpose of this surgical perspective is to describe the trauma care needs of the South Side of Chicago and the creation of an adult trauma center at the University of Chicago Medicine and associated hospital-based violence intervention program. BACKGROUND: Traumatic injury is a leading cause of death and disability in the United States. Disparities across the continuum of trauma care exist, which are often rooted in the social determinants of health. Trauma center distribution is critical to timely treatment and should be based on the trauma needs of the area. The previous trauma ecosystem of Chicago was incongruent with the concentration of violent injuries on the south and west sides of the city, leading to a fallacy of distributive justice. METHODS: A descriptive analysis of community partners, trauma program leadership, trauma surgeons, and the violence intervention program director was performed. RESULTS: The UCM trauma center opened in May 2018 and has since been one of the busiest trauma centers in the country, with a 40% penetrating trauma rate. There have been significant reductions in patient transport time on the South Side up to 8.9 minutes ( P <0.001). The violence intervention program employs credible messengers with lived experience representing the community and has engaged over 8000 patients since 2018, developing both community-based and medical-legal partnerships. CONCLUSIONS: The persistent efforts of the community and key stakeholders led to a system change that improved trauma care for the South Side of Chicago.

State-Level Analysis of Intimate Partner Violence, Abortion Access, and Peripartum Homicide: Call for Screening and Violence Interventions for Pregnant Patients.

BACKGROUND: Despite representing 4% of the global population, the US has the fifth highest number of intentional homicides in the world. Peripartum people represent a unique and vulnerable subset of homicide victims. This study aimed to understand the risk factors for peripartum homicide. STUDY DESIGN: We used data from the 2018 to 2020 National Violent Death Reporting System to compare homicide rates of peripartum and nonperipartum people capable of becoming pregnant (12 to 50 years of age). Peripartum was defined as currently pregnant or within 1-year postpartum. We additionally compared state-level peripartum homicide rates between states categorized as restrictive, neutral, or protective of abortion. Pearson's chi-square and Wilcoxon rank-sum tests were used. RESULTS: There were 496 peripartum compared with 8,644 nonperipartum homicide victims. The peripartum group was younger (27.4 ± 71 vs 33.0 ± 9.6, p < 0.001). Intimate partner violence causing the homicide was more common in the peripartum group (39.9% vs 26.4%, p < 0.001). Firearms were used in 63.4% of homicides among the peripartum group compared with 49.5% in the comparison (p < 0.001). A significant difference was observed in peripartum homicide between states based on policies regarding abortion access (protective 0.37, neutral 0.45, restrictive 0.64; p < 0.01); the same trend was not seen with male homicides. CONCLUSIONS: Compared with nonperipartum peers, peripartum people are at increased risk for homicide due to intimate partner violence, specifically due to firearm violence. Increasing rates of peripartum homicide occur in states with policies that are restrictive to abortion access. There is a dire need for universal screening and interventions for peripartum patients. Research and policies to reduce violence against pregnant people must also consider the important role that abortion access plays in protecting safety.

Trauma surgical skill sustainment at the University of Chicago AMEDD Military-Civilian Trauma Team Training Site: an observation report.

Background: The Army Medical Department (AMEDD) Military-Civilian Trauma Team Training (AMCT3) Program was developed to enhance the trauma competency and capability of the medical force by embedding providers at busy civilian trauma centers. Few reports have been published on the outcomes of this program since its implementation. Methods: The medical and billing records for the two AMCT3 embedded trauma surgeons at the single medical center were retrospectively reviewed for care provided during August 2021 through July 2022. Abstracted data included tasks met under the Army's Individual Critical Task List (ICTL) for general surgeons. The Knowledge, Skills, and Abilities (KSA) score was estimated based on previously reported point values for procedures. To assess for successful integration of the embedded surgeons, data were also abstracted for two newly hired civilian trauma surgeons. Results: The annual clinical activity for the first AMCT3 surgeon included 444 trauma evaluations and 185 operative cases. The operative cases included 80 laparotomies, 15 thoracotomies, and 15 vascular exposures. The operative volume resulted in a KSA score of 21 998 points. The annual clinical activity for the second AMCT3 surgeon included 424 trauma evaluations and 194 operative cases. The operative cases included 92 laparotomies, 8 thoracotomies, and 25 vascular exposures. The operative volume resulted in a KSA score of 22 799 points. The first civilian surgeon's annual clinical activity included 453 trauma evaluations and 151 operative cases, resulting in a KSA score of 16 738 points. The second civilian surgeon's annual clinical activity included 206 trauma evaluations and 96 operative cases, resulting in a KSA score of 11 156 points. Conclusion: The AMCT3 partnership at this single center greatly exceeds the minimum deployment readiness metrics established in the ICTLs and KSAs for deploying general surgeons. The AMEDD experience provided a deployment-relevant case mix with an emphasis on complex vascular injury repairs.

Survivor's remorse.

ABSTRACT: In urban, large metropolitan trauma centers, we are accustomed to seeing the most gruesome morbidity and mortality in medicine. By far, the most devastating morbidity and mortality to observe are those inflicted on one human being to another. Gun violence is pervasive in this industrialized country, and it impacts us all. Staff, residents, and faculty in trauma centers bear the brunt of this trauma, second only to the families and communities that suffer the loss of loved ones. This burden is especially heavy for health care workers who share the same ethnic background of those who are disproportionately affected by interpersonal gun violence. Survivors of gun violence exist on a spectrum of chronic illness that ranges in physical and mental morbidity and social disruption in loss of wages and capabilities. This disease not only infects those wounded or killed but also transmits through communities and generations. Urban violence exists because of historic and systematic racism. It continues to persist because racism creates inequities in the quality of education, housing, and investment in urban environments, exacerbated by residential segregation. For two providers, a trainee and a faculty member of African descent, conscious of the determinants that create gun violence, it is overwhelming. We, as health care providers, must tell our stories and the stories of those whose voices are not empowered. We can hope that, by sharing these experiences, we stimulate action and change by raising the moral consciousness of those unaware of the tragedies we witness every day.

Social Vulnerability and Firearm Violence: Geospatial Analysis of 5 US Cities.

BACKGROUND: Firearm violence is now endemic to certain US neighborhoods. Understanding factors that impact a neighborhood's susceptibility to firearm violence is crucial for prevention. Using a nationally standardized measure to characterize community-level firearm violence risk has not been broadly studied but could enhance prevention efforts. Thus, we sought to examine the association between firearm violence and the social, structural, and geospatial determinants of health, as defined by the Social Vulnerability Index (SVI). STUDY DESIGN: In this cross-sectional study, we merged 2018 SVI data on census tract with shooting incidents between 2015 and 2021 from Baltimore, Chicago, Los Angeles, New York City, and Philadelphia. We used negative binomial regression to associate the SVI with shooting incidents per 1,000 people in a census tract. Moran's I statistics and spatial lag models were used for geospatial analysis. RESULTS: We evaluated 71,296 shooting incidents across 4,415 census tracts. Fifty-five percent of shootings occurred in 9.4% of census tracts. In all cities combined, a decile rise in SVI resulted in a 37% increase in shooting incidents (p < 0.001). A similar relationship existed in each city: 30% increase in Baltimore (p < 0.001), 50% in Chicago (p < 0.001), 28% in Los Angeles (p < 0.001), 34% in New York City (p < 0.001), and 41% in Philadelphia (p < 0.001). Shootings were highly clustered within the most vulnerable neighborhoods. CONCLUSIONS: In 5 major US cities, firearm violence was concentrated in neighborhoods with high social vulnerability. A tool such as the SVI could be used to inform prevention efforts by directing resources to communities most in need and identifying factors on which to focus these programs and policies.

Capacity Assessment in Emergency Surgery.

AbstractInformed consent is a necessary component of the ethical practice of surgery. Ideally, consent is performed in a setting conducive to a robust patient-provider conversation, with careful consideration of risks, benefits, and outcomes. For patients with medical or surgical emergencies, navigating the consent process can be complicated and requires both careful and expedited assessment of decision-making capacity. We present a recent case in which a patient in need of emergency care refused intervention, requiring urgent capacity assessment and a modification to usual care.

A novel machine-learning tool to identify community risk for firearm violence: The Firearm Violence Vulnerability Index.

BACKGROUND: Firearm violence in the United States is a public health crisis, but accessing accurate firearm assault data to inform prevention strategies is a challenge. Vulnerability indices have been used in other fields to better characterize and identify at-risk populations during crises, but no tool currently exists to predict where rates of firearm violence are highest. We sought to develop and validate a novel machine-learning algorithm, the Firearm Violence Vulnerability Index (FVVI), to forecast community risk for shooting incidents, fill data gaps, and enhance prevention efforts. METHODS: Open-access 2015 to 2022 fatal and nonfatal shooting incident data from Baltimore, Boston, Chicago, Cincinnati, Los Angeles, New York City, Philadelphia, and Rochester were merged on census tract with 30 population characteristics derived from the 2020 American Community Survey. The data set was split into training (80%) and validation (20%) sets; Chicago data were withheld for an unseen test set. XGBoost, a decision tree-based machine-learning algorithm, was used to construct the FVVI model, which predicts shooting incident rates within urban census tracts. RESULTS: A total of 64,909 shooting incidents in 3,962 census tracts were used to build the model; 14,898 shooting incidents in 766 census tracts were in the test set. Historical third grade math scores and having a parent jailed during childhood were population characteristics exhibiting the greatest impact on FVVI's decision making. The model had strong predictive power in the test set, with a goodness of fit ( D2 ) of 0.77. CONCLUSION: The Firearm Violence Vulnerability Index accurately predicts firearm violence in urban communities at a granular geographic level based solely on population characteristics. The Firearm Violence Vulnerability Index can fill gaps in currently available firearm violence data while helping to geographically target and identify social or environmental areas of focus for prevention programs. Dissemination of this standardized risk tool could also enhance firearm violence research and resource allocation. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

Social Vulnerability Index is strongly associated with urban pediatric firearm violence: An analysis of five major US cities.

BACKGROUND: Firearm-related injury in children is a public health crisis. The Social Vulnerability Index (SVI) identifies communities at risk for adverse effects due to natural or human-caused crises. We sought to determine if SVI was associated with pediatric firearm-related injury and thus could assist in prevention planning. METHODS: The Centers for Disease Control and Prevention's 2018 SVI data were merged on census tract with 2015 to 2022 open-access shooting incident data in children 19 years or younger from Baltimore, Chicago, Los Angeles, New York City, and Philadelphia. Regression analyses were performed to uncover associations between firearm violence, SVI, SVI themes, and social factors at the census tract level. RESULTS: Of 11,654 shooting incidents involving children, 52% occurred in just 6.7% of census tracts, which were on average in the highest quartile of SVI. A decile increase in SVI was associated with a 45% increase in pediatric firearm-related injury in all cities combined (incidence rate ratio, 1.45; 95% confidence interval, 1.41-1.49; p < 0.001). A similar relationship was found in each city: 30% in Baltimore, 51% in Chicago, 29% in Los Angeles, 37% in New York City, and 35% in Philadelphia (all p < 0.001). Socioeconomic status and household composition were SVI themes positively associated with shootings in children, as well as the social factors below poverty, lacking a high school diploma, civilian with a disability, single-parent household, minority, and no vehicle access. Living in areas with multi-unit structures, populations 17 years or younger, and speaking English less than well were negatively associated. CONCLUSION: Geospatial disparities exist in pediatric firearm-related injury and are significantly associated with neighborhood vulnerability. We demonstrate a strong association between SVI and pediatric shooting incidents in multiple major US cities. Social Vulnerability Index can help identify social and structural factors, as well as geographic areas, to assist in developing meaningful and targeted intervention and prevention efforts. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

Strengthening Doctor-Patient Relationships Through Hospital-Based Violence Interventions.

PROBLEM: Violence in Chicago has been persistently high in low-income communities of color. Recent attention has focused on how structural inequities weaken protective factors that help keep communities healthy and safe. Spikes in community violence seen in Chicago since the COVID-19 pandemic further expose the lack of social service, health care, economic, and political safety nets in low-income communities and the apparent dearth of faith in those systems. APPROACH: The authors contend that a comprehensive, collaborative approach to violence prevention that prioritizes treatment and community partnerships is needed to address social determinants of health and structural characteristics that often provide the context for interpersonal violence. One strategy to address decreasing faith in systems like hospitals is foregrounding frontline paraprofessional prevention workers who possess cultural capital based on their experiences navigating interpersonal and structural violence. Hospital-based violence intervention programs help professionalize these prevention workers by providing a framework for patient-centered crisis intervention and assertive case management. The authors describe how the Violence Recovery Program (VRP), a multidisciplinary hospital-based violence intervention model, leverages the cultural capital of credible messengers to use teachable moments to promote trauma-informed care to violently injured patients, assess their immediate risk for reinjury and retaliation, and connect them to wrap-around services to help aid comprehensive recovery. OUTCOMES: Violence recovery specialists have engaged over 6,000 victims of violence since the program's launch in 2018. Three-quarters of patients expressed social determinants of health needs. Over the past year, specialists have connected over one-third of engaged patients to mental health referrals and community-based social services. NEXT STEPS: High violence rates in Chicago limited case management opportunities in the emergency room. In fall 2022, the VRP began to establish collaborative agreements with community-based street outreach programs and medical-legal partnerships to address structural determinants of health.

Review Paper on Penetrating Brain Injury: Ethical Quandaries in the Trauma Bay and Beyond.

OBJECTIVE: The aim of this review was to review the ethical and multidisciplinary clinical challenges facing trauma surgeons when resuscitating patients presenting with penetrating brain injury (PBI) and multicavitary trauma. BACKGROUND: While there is a significant gap in the literature on managing PBI in patients presenting with multisystem trauma, recent data demonstrate that resuscitation and prognostic features for such patients remains poorly described, with trauma guidelines out of date in this field. METHODS: We reviewed a combination of recent multidisciplinary evidence-informed guidelines for PBI and coupled this with expert opinion from trauma, neurosurgery, neurocritical care, pediatric and transplant surgery, surgical ethics and importantly our community partners. RESULTS: Traditional prognostic signs utilized in traumatic brain injury may not be applicable to PBI with a multidisciplinary team approach suggested on a case-by-case basis. Even with no role for neurosurgical intervention, neurocritical care, and neurointerventional support may be warranted, in parallel to multicavitary operative intervention. Special considerations should be afforded for pediatric PBI. Ethical considerations center on providing the patient with the best chance of survival. Consideration of organ donation should be considered as part of the continuum of patient, proxy and family-centric support and care. Community input is crucial in guiding decision making or protocol establishment on an institutional level. CONCLUSIONS: Support of the patient after multicavitary PBI can be complex and is best addressed in a multidisciplinary fashion with extensive community involvement.

COVID-19 Among African Americans: An Action Plan for Mitigating Disparities.

As the COVID-19 pandemic has unfolded across the United States, troubling disparities in mortality have emerged between different racial groups, particularly African Americans and Whites. Media reports, a growing body of COVID-19-related literature, and long-standing knowledge of structural racism and its myriad effects on the African American community provide important lenses for understanding and addressing these disparities.However, troubling gaps in knowledge remain, as does a need to act. Using the best available evidence, we present risk- and place-based recommendations for how to effectively address these disparities in the areas of data collection, COVID-19 exposure and testing, health systems collaboration, human capital repurposing, and scarce resource allocation.Our recommendations are supported by an analysis of relevant bioethical principles and public health practices. Additionally, we provide information on the efforts of Chicago, Illinois' mayoral Racial Equity Rapid Response Team to reduce these disparities in a major urban US setting.

The Ethics and Politics of Gun Violence Research.

Gun violence is an epidemic that affects hundreds of thousands of Americans each year. Despite gun violence being disproportionately more lethal than other leading causes of trauma, there is a dearth of research being carried out on its root causes and prevention strategies. For the past 20 years, lobbying and politics have interfered with the forward progress of gun violence research. Physicians have a history of producing actionable public-health change and have an ethical obligation to fight for the research that will benefit their patients.

Coagulopathy as a Surrogate of Severity of Injury in Penetrating Brain Injury.

Penetrating brain injury (PBI) is the most devastating type of traumatic brain injury. Development of coagulopathy in the acute setting of PBI, though common, remains of unclear significance as does its reversal. The aim of this study is to investigate the relationship between coagulopathy and clinical presentation, radiographical features, and outcome in civilian patients with PBI. Eighty-nine adult patients with PBI at a Level I trauma center in Chicago, Illinois who survived acute resuscitation and with available coagulation profile were analyzed. Coagulopathy was defined as international normalized ratio [INR] >1.3, platelet count <100,000 /µL, or partial thromboplastin time >37 sec. Median age (interquartile range; IQR) of our cohort was 27 (21-35) years, and 74 (83%) were male. The intent was assault in 74 cases (83%). The mechanism of PBI was gunshot wound in all patients. Forty patients (45%) were coagulopathic at presentation. In a multiple regression model, coagulopathy was associated with lower Glasgow Coma Scale (GCS)-Motor score (odds ratio [OR], 0.67; confidence interval [CI], 0.48-0.94; p = 0.02) and transfusion of blood products (OR, 3.91; CI, 1.2-12.5; p = 0.02). Effacement of basal cisterns was the only significant radiographical features associated with coagulopathy (OR, 3.34; CI, 1.08-10.37; p = 0.04). Mortality was found to be significantly more common in coagulopathic patients (73% vs. 25%; p < 0.001). However, in our limited sample, reversal of coagulopathy at 24 h was not associated with a statistically significant improvement in outcome. The triad of coagulopathy, low post-resuscitation GCS, and radiographical effacement of basal cisterns identify a particularly ominous phenotype of PBI. The role, and potential reversal of, coagulopathy in this group warrants further investigation.