It’s 2:00 A.M. on a Saturday morning when police spot the limp body of a man lying in a park in downtown Seattle. Initially they assume he is a street person “sleeping one off”, but further investigation reveals that he has been assaulted and cannot move. Emergency units are called and he is rushed to the nearest trauma unit.
After extensive examination, it is found that the man has been struck with a blunt object and has sustained a high-level spinal cord injury that will leave him paralyzed from the neck down. Later, authorities learn that the victim is homeless, has no family, and has a long history of alcoholism. He does not remember the attack, and the assailant is never found.
A teenage boy is rushed to the trauma unit after being shot numerous times, at close range, in a gang-related incident. He is on life support, unable to breathe on his own, with a C-2 level incomplete spinal cord injury. The gang unit of the Seattle Police Department determines that the patient is still in danger, even in the hospital, and posts police guards at his bedside to protect him from gang members who might want to “finish him off”. Later, when the patient is able to speak, he refuses to cooperate with police or name his assailant, fearing retaliation.
A 45-year-old woman breaks off a relationship with a man whom she has been dating for a short time. He begins harassing and stalking her. She contacts the police, obtains a restraining order, and changes her phone number, but the harassment continues. One morning the man waits outside her home and follows her to work, where he shoots her from his car and then speeds away from the scene. The bullet injures the woman’s spine, resulting in complete Paraplegia. Her attacker remains at large for several months before being apprehended out of state, tried, and sentenced to 30 years in prison.
Ten years ago, scenarios like these were unusual in most parts of the country. In 1984, the majority of spinal cord injuries (SCIs) in the United States were caused by Motor vehicle accidents, followed by falls and sporting or recreational activities. However, trauma centers across the country are receiving and treating cases resulting from violence at an alarmingly increased rate.
According to a fact sheet published in March by the University of Alabama National Spinal Cord Injury Statistical Center in Birmingham, AL, acts of violence — primarily gunshot wounds — account for 25.1% of the SCI cases that have been reported nationally since 1990. That percentage has increased steadily since 1973, while that of injuries caused by motor vehicle accidents and sporting activities has declined. Injury prevention efforts, such as seat belt laws and improved protective gear for sports activities, have probably contributed to this trend, but the number of injuries resulting from violent acts is increasing as well.
On a local level, the Northwest Regional Spinal Cord Injury Center (NWRSCIS) has been collecting data on SCI since September 1990. During that period, the incidence of SCI due to violence among NWRSCIS patients has only been 11.6%, significantly lower than the national average, but it has been increasing steadily from year to year.
The etiology of injury can have a major impact on how well an individual progresses through his or her hospitalization, Rehabilitation, and transition to home or other discharge destination. If the assailant responsible for the injury is still at large, it can be difficult for the patient to focus on recovery and rehabilitation. Many of these patients try to delay discharge from the hospital, fearing for their life or the life of a family member.
Some patients disabled by acts of violence pose problems for rehabilitation staff because of antisocial behavior, substance abuse and lack of family support systems. The man who was found assaulted in a downtown Seattle park had no home and no family members to assist with Discharge Planning. He was going through alcohol withdrawal during his rehabilitation and was difficult for staff to deal with. He was ultimately discharged to a nursing home, where he remained only a short time before choosing to return to the street because the nursing home would not allow him to leave the facility to drink with his street buddies.
The man is an aggressive and verbally abusive panhandler and is well known to Seattle City Police officers who patrol the downtown area. However, he is considered mentally competent, and continues to refuse nursing home placement. His life on the street precludes preventive health care, resulting in numerous and costly visits to the emergency room.
When someone is injured in a gang-related incident, such as the teenage boy described above, the potential effects on recovery and rehabilitation are extensive. Along with the physical and psychological issues faced by all persons who sustain SCI, there are legal concerns, personal safety issues, fear of non-acceptance by the gang, and fear for the safety of family members. Beneath their tough exteriors, many young gang members are basically still children, and lack the social skills to express their need for control and respect. It is a real challenge for the medical staff to meet the conflicting needs of these patients.
The role of medical professionals working with SCI patients injured through acts of violence is seldom straightforward or by-the-book. Each situation is unique and may involve unusual demands and even some element of danger. When two city police officers are posted at the bedside of a teenager in the intensive care unit, any staff member would be naive to think that there was not some degree of risk involved in working with that patient. Recently, a young man with SCI who had been shot in a gang-related incident had to be transferred from one rehabilitation facility to another across town after he was confronted in the hospital by a rival gang member who threatened to kill him.
In the case of the woman whose assailant was still at large during her hospitalization and rehabilitation, a picture of the assailant was posted at the nursing station and staff members were asked to be alert to the possibility that he might try to enter the unit. This policing role was never taught or even considered in nursing school.
As a social worker in the field of SCI rehabilitation, I have seen my role change significantly over the past ten years. In 1984, most of my work was with the patients themselves, their families, and funding and support agencies. Today, I also find myself involved with the officers, detectives, and gang units of the various police departments serving our catchment area.
Unfortunately, the statistics seem to indicate that the number of people sustaining SCI due to violence will continue to escalate. While our news media, leaders and politicians seek to explain this trend and find a way to reverse it, health care professionals working with patients who sustain SCI through acts of violence will need to remain flexible and supportive, and not lose sight of the fact that these injuries have distinct and complex psychosocial aspects that must be addressed.