One late afternoon while evaluating a patient to be admitted to the inpatient service from the pediatric emergency department (ED), a trauma notification was announced: “16 [years old] level I, GSW to chest, no pulses, ETA 5 minutes.”

I made my way to the pediatric trauma bay to offer my help, given my dual role as director of the pediatric inpatient service and medical director of our institution’s hospital-based community violence prevention program. However, on opening the trauma bay curtain, it became evident that my help was not required. I was greeted with a somber stare and nod by the ED attending physician on duty, who looked up to the clock on the wall and said, “Time of death, 4:45 pm.”

I walked out of the trauma bay and bumped into a tearful man wearing blue jeans and a yellow sweater splattered with paint who asked, “How is my son?”

The recitation of the events previously transpired then began, and the man in painted clothes reached nervously for his phone to call his wife: “Come to the hospital; Joshua was hurt.”

Soon thereafter came a wave of family and friends washing ashore to the trauma bay, staring at Joshua’s face, hoping for that infectious responsive smile they so fondly knew.

One hour later, a woman arrived wearing no shoes and only a pair of white socks stained with a mix of soil and autumn leaves: “I can’t stop shaking since my husband called me.”

She held her hands close to her chest, staring deeply into the curtain behind me, reluctant to walk through a gateway into a reality she was not ready to accept. It did not take long for her to confirm what she already knew.

After a couple of minutes, she emerged from behind the curtains: “We are ready to go, Doctor. Thank you for everything you did for my son.”

I nodded back and stood there as they walked away holding hands, the father’s jeans splattered with paint and the mother’s white dirt-stained socks painting a permanent portrait of the unimaginable in my mind. I wondered what they would call Joshua’s mother back in their neighborhood. When a woman loses a husband, she is called a widow. When a child loses a parent, they are deemed an orphan. But when a mother loses a child. . .there is just no name for that.

A lot of the attention of violent trauma is directed at mass shootings, defined as any incident with ≥4 victims, which account for <2% of shootings in the United States.1  Ninety-eight percent of shootings in the United States involve <4 victims, the majority of whom are young black and Hispanic men. The incidence of firearm-related homicide is highest among black (31.4 per 100 000) and Hispanic (8.1 per 100 000) men <24 years and is lowest among white Non-Hispanic men (1.6 per 100 000) of the same age.2  The majority of stories related to gun violence manifest themselves in the form of the narrative that brought Joshua to our pediatric ED in the Bronx. New York City, like many other major cities in the United States, has experienced record lows in homicides, dropping below 300 homicides per year for 2 consecutive years for the first time in over 50 years.3  However, what remains unchanged is that the majority of those victims continue to be young black and Hispanic men, whose lives lost leave devastating long-lasting impacts. Their stories, along with the stories of the parents, families, and friends that they leave behind, are lost amid the normalcy that comes with accepting such tragedy as an everyday unavoidable reality.

Five days after Joshua’s presentation to our ED, I joined a gathering in the courtyard of a public housing complex comprising local residents, politicians, community and religious leaders, and the network of outreach workers that work for our hospital’s community violence prevention program. Once the crowd gathered and other speeches from local leaders had reverberated throughout the autumn air, I was handed the megaphone and spoke:

People think bullets have no names, but they are engraved with more than the names of those whose lives they take away. They are engraved with the names of fathers, mothers, brothers, sisters, and friends. The effect of one bullet ricochets throughout communities. What we are doing today is changing the words etched onto those bullets to instead say “never again.”

This community must not continue to bury its children. Let us gather here again, every day if need be, to celebrate life and not to commemorate its loss.

The crowd marched through the public housing complex chanting, “Whose streets are these? Our streets” and “We’re better together,” with signs raised in the air that read “Stand Up to Violence” and “Don’t Shoot: Children at Play.” Heads emerged from the top-floor windows of the surrounding brick buildings, and people began joining the chant. The crowd marched past building entrances blocked by collections of candles, pictures, basketballs, and messages that read, “We miss you.”

I stood there scanning the crowd and surroundings for glimpses of Joshua’s parents but instead found myself gazing toward the bench where a group of teenagers sat and imagined Joshua’s mother walking past them, hopelessly looking amid the crowd for a glimpse of her son’s infectious smile and then closing her eyes as she walked past them, hoping to hear his laughter amid the jokes. I imagined what the young men on the bench would say or do when his mother walked by. I imagine they would do the same to her as they did to me as I looked at them then before departing, greet her with a simple nod, signaling an acknowledgment of their shared loss.

The effects of violent trauma extend far beyond the individual hospital victims we encounter. It is estimated that violent trauma results in 62 billion dollars in cost, comprising primarily health care costs and lost future productivity.4  What this number does not encompass is the subsequent retaliatory shootings that occur, resulting in a cycle of violence that incurs additional victims and subsequent immeasurable costs. Additionally, the mental health effects on direct family members, friends, and community members cannot be valued with a dollar amount. The effect of adverse childhood events, chronic stress, and allostatic load on overall health outcomes is well documented and is an indirect effect of untreated violent trauma exposure.5,6 

As the summer months come to a close with its accompanying expected increase in violent trauma in urban communities, we as physicians must look at individual patients presenting to our trauma bays as distal outcomes of an intricate network of upstream preventable causal factors of disease. We must embrace a public health approach composed of primary-, secondary-, and tertiary-based prevention methods to treat violence like the disease that it is in communities with high prevalence. Pediatric and adult trauma centers are epicenters for violent trauma, where victims can be treated for their acute injuries while also being provided with resources to prevent retaliation and reinjury. This can be achieved by incorporating evidence-based methods, such as the one implemented in our hospital, in which outreach workers from the patient’s communities can provide mentorship, conflict resolution strategies, and lifestyle alternatives to mitigate the persistent cycle of violence. Unfortunately, in Joshua’s presentation there was no personal intervention possible, but even in his death there existed an opportunity to intervene. After his death, outreach workers from our hospital’s community violence prevention program were able to identify and mediate the active conflict resulting in Joshua’s death. Since that conflict mediation over 3 years ago, there have been 0 shooting victims presenting to our trauma bays from his old neighborhood. This is testament to the fact that when you treat violence like a disease and take active steps to evaluate its etiology and prevent it, the disease spread can be halted.

These types of initiatives require the collaborative efforts and support of local and state legislatures, community leaders, and interdepartmental support from within a hospital system. Cooperation between different sectors of public service can be challenging but is achievable if all are united with the common goal of preventing cases like Joshua’s. It is only after such collaborative efforts lead to fruitful results of treatment and prevention of violent trauma that we as physicians can look mothers and fathers like Joshua’s confidently in the eye and truthfully say, “I am sorry, but there is nothing more we could have done for your son.”

Dr Romo conceptualized and designed the Hospital Pediatrics Perspective piece, drafted the initial manuscript, and approved the final manuscript as submitted.

FUNDING: No external funding.

1
Metzl
JM
,
MacLeish
KT
.
Mental illness, mass shootings, and the politics of American firearms
.
Am J Public Health
.
2015
;
105
(
2
):
240
249
2
Centers for Disease Control and Prevention
.
WISQARS fatal injury reports, 1999-2010, for national, regional, and states (restricted). Available at: https://webappa.cdc.gov/cgi-bin/broker.exe?_PROGRAM=wisqars.DataRestriction.sas&_SERVICE=v8prod&mprint=nomprint&agreeCheck=ON. Accessed April 23, 2019
3
Police Department, City of New York
.
CompStat report covering the week 8/26/2019 through 9/1/2019. Available at: https://www1.nyc.gov/assets/nypd/downloads/pdf/crime_statistics/cs-en-us-city.pdf. Accessed May 1, 2019
4
Centers for Disease Control and Prevention
.
Web-based Injury Statistics Query and Reporting System (WISQARS). Available at: www.cdc.gov/injury/wisqars. Accessed May 3, 2019
5
Geronimus
AT
,
Hicken
M
,
Keene
D
,
Bound
J
.
“Weathering” and age patterns of allostatic load scores among blacks and whites in the United States
.
Am J Public Health
.
2006
;
96
(
5
):
826
833
6
Jackson
JS
,
Knight
KM
,
Rafferty
JA
.
Race and unhealthy behaviors: chronic stress, the HPA axis, and physical and mental health disparities over the life course
.
Am J Public Health
.
2009
;
99
(
12
):
1
7

Competing Interests

POTENTIAL CONFLICT OF INTEREST: The author has indicated he has no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The author has indicated he has no financial relationships relevant to this article to disclose.