Center for Injury Research and Prevention

Trauma-Informed Care Needed for Victims of Violence in the ED

April 4, 2019

Every day, emergency department (ED) doctors and staff like me see children and teens who have been violently injured, from a school brawl to gunshot wounds. By the time they arrive at the ED, these patients have already endured one of the most traumatic experiences of their young lives. The often chaotic environment of the ED only adds to their stress.

Psychological trauma experienced by young patients can affect the care they receive for their physical injuries. Yet, a clinical approach in emergency medicine known as “trauma-informed care” (TIC), is still largely in its infancy. I recently co-authored an article published in the Annals of Emergency Medicine that details how ED staff can implement the four pillars of TIC when treating young patients who have been victims of violence.

In pain, surrounded by strangers in an unfamiliar clinical environment, children and teens may remember previous injuries and ED experiences and/or negative interactions with hospital staff and police. The presence of family, guardians and friends may only add to patients' stress and confusion. Young patients may also be worried about the stigma of violence involving guns and knives and being judged as a “bad” person.

The Four Pillars of TIC

Healthcare professionals provide TIC by taking into consideration how patients’ previous experiences may influence how they perceive and react to medical care. TIC is based on four pillars that promote a culture of empathy and safety for patients:

  1. Knowledge of the effect of trauma
  2. Recognition of the signs and symptoms of trauma
  3. Avoidance of retraumatization
  4. Development of appropriate policies and procedures

In this article, we recommend ways to help alleviate traumatic stress specifically for young patients who have experienced a violent injury:

  • Give the patient a feeling of connection. Assign one team member to stay with the patient and be the main source of communication. Whenever possible, allow parents or guardians to remain with the patient. Offer verbal support such as “I am going to stay and help you with everything you go through here.”
  • Help the patient remain calm. Keep the number of care team members around the patient to a minimum and avoid excess noise and chatter in the area. Encourage the patient to perform slow breathing exercises. Remove potential triggers from the immediate area, such as security guards, which may look like police to an agitated patient who is already worried that he or she may be blamed for whatever happened.
  • Help the patient feel safe. Emphasize that he or she is safe and away from the source and site of the violent injury with statement such as, “You are in the safest place you could be right now.”
  • Help the patient gain a sense of control. Discuss the care plan and, wherever possible, allow the patient to provide input, such as which arm should be used for an IV insertion. Loss of control is a major part of the trauma, and offering choices about care can help ease patient stress.
  • Help the patient communicate. Use language that acknowledges rather than undermines the patient’s defense mechanisms. For example, ask “What happened to you?” instead of “What’s wrong with you?" or even worse, “What did you do to yourself?”
  • Help the patient understand what to expect. Provide positive but realistic statements about the expected treatment outcomes. For example, consider saying “It won’t be easy or fast, but I believe you’ll recover from your injuries,” instead of “You have a long road ahead of you.”
  • Help the patient recover from the trauma. Identify resources, such as case managers and community organizations, which can facilitate recovery after the medical situation is stabilized.

At CHOP, we conduct TIC training through our Violence Prevention Initiative (VPI) to help healthcare providers and staff address young patients’ emotional, as well as physical needs. To date, VPI has trained more than 2,000 CHOP staff members and other professionals in TIC, from physicians to security staff.