ViolenceThink back to your last shift. How many of you saw someone whose chief complaint was “assault”? What did you do for the patient? If you’re like most of us, you ruled out acute life-threatening injuries, sighed loudly (especially if the person had been in the ED before for other fight-related injuries), and dispo’ed. But do you ever wonder if you should do more? Or why?

Peer Violence: A Definition

In the public health world, folks divide interpersonal violence into one of a few major categories. There is intimate partner violence (aka “domestic violence” or “dating violence”). There is family violence (elder abuse, child abuse). There is community violence (i.e., war). And there is peer violence, which we define as violence between two or more people who are:

  1. Not related or romantically involved
  2. Peers (more or less)
  3. Not part of a war

Why Should We Care?

Peer violence is common [CDC statistics]. There are almost 2 million ED visits a year for assault. Homicide is the second leading cause of death for young Americans (age 5-44) and the leading cause of death for African American youths (age 10-24). And, depending on where you work, 40-70% of youths seen in the ED for any reason would report that they have been in a physical fight in the past year.

One fights predicts more fights.1 We know this anecdotally, but the statistics backs us up! 40% of youths who present with an assault-related injury will be back with another. And 20% of youths who are admitted for penetrating trauma will end up dying within 5 years.

Fights have enormous long-term consequences. They not only cause immediate disability and high medical resource use (an average of $24,000 per assault-related hospitalization), but they also lead to a cascade of downstream morbidity: mental health problems, substance abuse, lost productivity, and chronic disease.

So what can we do? Screen, Intervene, and Refer

If you’re really motivated, you can develop a local hospital-based violence intervention program, or address the social determinants of health that cause violence in the first place. But for a quick and easy way to decrease recidivism (similar to “SBIRT” techniques advocated for alcohol/smoking/substance abuse), try these 3 steps:

Screen Shot 2013-11-03 at 11.56.39 PM


  1. Southern California Academic Center of Excellence on Youth Violence Prevention’s Reinjury Prevention for Youth Presenting with Violence-Related Injuries: A Training Curriculum for Trauma Centers
  2. National Network of Hospital-Based Violence Intervention Programs (NNHVIP) website

Cunningham R, Knox L, Fein J, et al. Before and after the trauma bay: the prevention of violent injury among youth. Ann Emerg Med. 2009;53(4):490-500. [PubMed]
Megan L. Ranney, MD MPH

Megan L. Ranney, MD MPH

ALiEM Featured Contributor
Assistant Professor of Emergency Medicine
Alpert Medical School, Brown University
Injury Prevention Center of Rhode Island Hospital
Megan L. Ranney, MD MPH

Latest posts by Megan L. Ranney, MD MPH (see all)