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Emergency intervention

Dr. Carolyn Snider is leading a research project that could help stem the tide of violence on Winnipeg's mean streets

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Winnipeg Health Region
Wave, September / October 2013

John sits slumped over on the edge of a bed inside the Health Sciences Centre Emergency Department.

One eye is blackened and swollen shut. Scrapes and cuts cover his hands, arms and face. An X-ray has been ordered to determine whether his left arm is fractured.

Just a few hours earlier, the man, just barely 18, was walking down a street in the city's core when he was attacked by several youths intent on settling a score. Police found him lying on a street corner and brought him to Emergency.

In short order, the medical team gets to work. The good news is the X-ray shows his arm is not broken. Within a few hours, he is cleaned, sutured, bandaged and ready to go.

John is not a real person. But he does represent the reality of many young people who pass through the doors of Winnipeg's busiest hospital.

Last year alone, more than 1,000 young people were treated for injuries resulting from violence. Some come into Emergency beaten, others arrive stabbed, sometimes shot, and barely alive.

But perhaps the most troubling statistic is this one: As many as 20 per cent of these young people, mostly from Winnipeg's most economically disadvantaged communities, will be back in the Emergency Department within a year.

For Emergency physician Dr. Carolyn Snider, this simple fact means injuries from violence are not just a crime best left to law enforcement to deal with. Rather, they are like a chronic disease, one that has been ignored far too long.

"We know in Winnipeg that approximately 20 per cent of youth who are injured by violence will be back in our Emergency Department at HSC with another injury due to violence within a year," says Snider. "If that same number was quoted for stroke or heart attacks - or many of the other medical conditions that we treat in our Emergency Departments - people would be in an uproar."

But there is no uproar. Instead, young people come into the Emergency Department, receive treatment, and disappear into the night.

"We essentially treat 'em and street 'em," says Snider, who is also an assistant professor in the Department of Emergency Medicine at the University of Manitoba's Faculty of Medicine. "And then we see a lot of these youth back in our ED with another injury."

This approach to care - a standard that is adhered to in Emergency Departments across the country - has long troubled Snider, as it does many of her colleagues in the field of Emergency Medicine. Rather than just "treating and streeting" these young people, she believes more can be done to prevent the chronic problem of recurring injuries through violence. And now, she is getting a chance to put her theory to the test.

Snider recently received funding to develop and test a new intervention program designed to reduce injuries from violence. The research project, which officially kicks off at the Health Sciences Centre this fall, is called the WrapAround Care for Youth Injured by Violence: A Pilot Randomized Control Trial. It will test and evaluate the Emergency Department Violence Intervention Program (ED-VIP), which was specially designed for the research project.

Under the initiative, young people treated in Emergency for injuries due to violence will be met by a support worker in the department. These support workers will have "lived experience" (grew up in the community, had experience with violence themselves or have worked extensively with youth affected by violence). In addition to a support worker, those participating in the ED-VIP will also have access to a social worker who will help them navigate the many resources they will need to address the various factors that put them at risk for future violence.

The program - the first of its kind in Canada - is rooted in the idea that injuries from violence, like chronic diseases, have underlying causes. Address the root causes of violence, and chances are you can reduce the risk of injuries.

Snider's innovative project is a prime example of how the Faculty of Medicine is using its research programs to drive change in the delivery of health care.

Traditionally, Emergency medical teams have focused on treating a patient's physical wounds. But Snider says it only makes sense for Emergency staff to become more involved. "We have an obligation as medical professionals to practice preventive medicine," she says. Moreover, Emergency staff members are frequently the only medical professionals these youth will meet and often have some insights into why the young people are there in the first place.

For example, they know that some violence-related injuries are gang-related, but not always. A good number are simply the unfortunate circumstances of being in the proverbial wrong place at the wrong time. Staff members also know that it may only be a matter of time before they see the same young people come back, only the next time they may be in worse shape, possibly clinging to life.

Born and raised in Ontario, Snider first started thinking about the issue of injuries from violence while working in hospitals that served some of the rougher communities in Toronto. "It simply didn't make sense to me that we were putting a bandage around the sutures and sending them on their way," she says.

In researching the issue, she discovered that some cities facing the same problem in the United States had successfully adopted programs that addressed the root causes of the problem - fractured families, a lack of safe housing, high unemployment, few educational opportunities and widespread poverty.

She concluded that a program based on the U.S. model, one involving health-care, social and community support workers, could work in Canada. Then, two years ago, she was recruited to Winnipeg. And it didn't take her long to realize this city's need for such a program was even greater than Toronto's.

"I was a physician at Sunnybrook and St. Michael's in Toronto - the two trauma centres in the city - so I saw lots of youth who were injured by violence," she says. "I can tell you that my epiphany here was that the need in Winnipeg was beyond anything I experienced in Toronto because it was so concentrated in the city's core and affected so many young people."

Snider took the first step toward achieving her goal of launching such a program last summer. She cobbled together enough funding to launch a small-scale study to determine the viability of doing a larger research project that would examine the effectiveness of an intervention program.

"It's what I call proof of concept work, meaning we're just trying to figure out how this could work," says Snider.

For this particular study, Snider hired Heather Woodward to act as the support worker. A social worker by training with experience working with at-risk youth, Woodward's job was to meet with those coming through Emergency with injuries. Among other things, she would ask how they were getting home, where they were staying and even whether they needed some clothes.

"A lot of these kids come in bloodied and don't have clothes to wear home," says Snider. "We're hoping to provide them with a bit more of an appropriate way to facilitate their exit from the Emergency than sending them out on the street with nothing at all."

Woodward would also try to arrange for a follow-up meeting. During the follow-ups, Woodward would inquire as to what the young person in question needed, and then assist him or her to find the right resources - be it housing, drug counselling, getting back into school or help finding work.

"I was the jack of all trades," says Woodward. "I would try to be everything from mentor to crisis worker to cultural and support resource person."

During the eight-month proof of concept study, Woodward met with dozens of individuals - about three to four a week. Many were not at that point in their lives to seek further help, so they declined to participate in the study. But others did. Over the course of the initial study, Woodward worked with 10 young people - five of which she's still actively assisting in the community.

"We've had some successes," Snider says. "We have one participant, whose baby was originally in care, and is now back in her care. She is now going to a job training program. Another has received drug counselling and is back helping to support his young family."

Snider hopes to build on this initial success with the more in-depth pilot program this fall. If it is successful, the program could lay the groundwork for a new national standard of care for young people who suffer injuries from violence.

As a controlled study, the research project aims to involve 180 youth and young adults between the ages of 14 and 24. Half will receive initial treatment and ongoing interventions through the help of a support worker and a social worker. The other 90 - the control group - will receive typical care in the Emergency Department and will be contacted after one year to see if they are interested in the intervention. "In reality, right now we don't have the resources to help all of the youth eligible for our program. However, it was important to us that our control group eventually be offered the intervention," says Snider. "This will help us understand how best to recruit patients, and issues like safety, adherence and fidelity so we can see if a larger trial is feasible. "Hopefully, in about one-and-a-half years we will apply for funding for a main trial - where we expect to enrol more than 600 youth with a similar structure as this pilot, but it will look at effectiveness outcomes."

With $900,000 in funding so far from the Canadian Institutes of Health Research and the Manitoba Institute of Child Health, the pilot project will be able to hire five part-time support workers and two social workers who can provide additional resources in instances when problems are related to a youth's family life.

A major component of the study will involve using multiple sources of statistical and health data to compare those receiving ongoing support aimed at preventing further violence to those who are not receiving any care beyond the hospital.

"One of the main ways we will be following youth is through health research data from the (U of M Faculty of Medicine's) Manitoba Centre for Health Policy," Snider says, referring to the fact that Manitoba has one of the most comprehensive health population data-bases in North America. "That's one of the big reasons why we think we can be successful at doing research with these youth. In some ways, that's what is so good about doing research here in Manitoba."

The research team will have access to anonymized health data of youth enrolled in the program, revealing how many times they visit Emergency for injuries due to violence, for substance abuse and for mental health problems. With this database, Snider says they hope to measure the impact of social determinants of health like education and housing. Even a youth's interaction with the justice system will be tracked.

But beyond the number-crunching, the ultimate goal is much more tangible. In addition, to proving that some form of preventive care is needed and that it could provide long-term benefits for at-risk youth and young adults, Snider says she hopes the model will change individual lives, engaging one person at a time in much the same way that Woodward had been doing during the proof of concept study.

As Woodward explains, her role in that study was to be available via telephone and to respond to calls about youth coming into hospital who were injured by violence. In the early days, she'd usually get a phone call from a social worker on call at the hospital. Eventually, an e-mail system was set up to alert her once Emergency staff encountered a youth who had obvious signs of being injured by violence - beaten up, stabbed or even shot.

"When I think about this project and the typical people we'd see, it's a young person sitting alone, bleeding, bruised and injured. It could be their head, a leg, their body - it could be anywhere."

Some of these young people may have been accompanied by friends and family on the odd occasion, but most were alone and often in desperate situations. "Some of these people were brought to the hospital via ambulance or police escort, or they themselves thought it was serious enough to seek medical attention," she says.

A lot of young people in Winnipeg don't seek medical attention unless it's the last resort. Woodward says she has heard stories of youth putting their broken fingers back in place or re-adjusting their nose on their own because they didn't want to go to the hospital. "Usually the hospital isn't the first place they want to be."

But once they are in Emergency, quite often there's a unique window of opportunity to reach out. "For a lot of the younger guys, it's a real teachable, scary moment to be in the hospital," Snider says.

Even the most hardened gang members shed the mediafed stereotypes. "Some of the most polite patients are the young guys that have been injured by violence," Snider says. "Once you start talking to them and showing them that you respect them, it becomes very clear that these kids don't want to be in this position."

And their needs can be quite complex once they've left the Emergency Department. Those with gang affiliations who want to leave the lifestyle behind often need to find a new place to live. "I think a lot of the public think that youth make a conscious choice to be part of a gang," she says. "Unfortunately, for a lot of these kids, joining a gang may have felt like the safest option at the time. For others, close family members were involved and, gradually, they were too."

By no means is gang affiliation black and white either. "A lot of people are early gang-involved, high-risk of being gang-involved or peripherally gang-involved," she says. "It's a very complex spectrum."

And those who choose to leave are at even higher risk of injury. "There is a risk when you decide to leave a gang of being beaten up as part of a gang exit because you can be privy to things that are only known to the gang," she says. "We've done a lot of thinking about how best to keep a youth who chooses to exit from a gang safe."

A large component of developing an enhanced care model is trying to meet youth where they live - not so much geographically, but psychologically and emotionally.

"What is very clear is that the person who comes to this youth at the bedside has to have either significant experience working with youth affected by violence or may themselves have ‘lived experience,' meaning they've been involved in gangs or violence when they were younger and have since turned their lives around," Snider says. "There's very much a role model, mentoring aspect to the support worker role."

Once a patient agrees to participate, he or she will be given a basic mobile phone and plan, thanks to a partnership with Rogers, Snider says. "They can text back and forth with the support worker," she says. "We'll also be using it for research follow-up purposes, so once a month we will ask if they have safe housing, or are attending school or working."

More than anything, the research project will employ a community-based approach to provide ongoing support. Snider says while their injuries are acute and need immediate treatment, the long-term harm is often a deeper problem, its roots embedded in much larger social problems.

In the past, social determinants of health, such as housing and poverty, were largely ignored when it came to medical care for injuries caused by violence. But research in the U.S. - which has the highest injury by violence rates in the developed world - has shed new light on how to address the problem.

"Violence is now looked at as a public health problem," Snider says.

Chicago-based epidemiologist Gary Slutkin is a pioneer in this field. He has conducted groundbreaking research and helped spearhead innovative and effective programs aimed at stemming the tide of violence in some of America's most violence-plagued neighbourhoods, including Chicago's South Side.

As the founder and Director of Cure Violence, he advocates taking a harm reduction approach to violence, making it a health problem as much as it is one of law and order.

Among the programs promoted by his organization is a community-based approach that was captured in an award-winning documentary The Interrupters. It features former gang members and respected members in violence-plagued neighbourhoods engaging in dialogue with those most likely to cause and to be harmed by violence.

While Slutkin's program is rooted in the community, there is also a hospital-based component to it. "He really speaks to this idea that violence is a chronic condition and a public health issue, and that's really where my whole frame of reference is regarding this problem as well," says Snider.

The Winnipeg ED-VIP project at HSC aims to tap into the resources already available in the community. "There are so many wonderful grassroots organizations making big differences in the lives of these youths," says Snider. Among them are several Aboriginal youth programs, including: Ka Ni Kanichihk, which offers cultural reclamation for the gang-involved youth of Aboriginal heritage; Spence Neighbourhood Association, which provides extensive gangprevention programs for youth in their neighbourhood; New Directions, which provides gang-prevention programming for newcomer youth; and Gang Awareness for Parents, which works with parents who are concerned about their children becoming gang-involved. All of these programs are key partners in the ED-VIP.

"Although we don't track the ethnicity of our patients, we know that a large majority of youth injured by violence are Aboriginal or newcomer youth," says Snider. "The cultural component can't be emphasized enough. Youth must be provided with the opportunity to learn about, participate, and eventually lead in their own communities," she says. "It is these opportunities that provide the empowerment youth need to eventually making healthier life choices."

And because her funding is limited, it's essential that the ED-VIP team work hand-in-hand with other programs in the community. Already, Snider has been laying the groundwork to build bridges that simply didn't exist between community organizations and health care.

"I've become involved with an organization called the Gang Action Interagency Network - or GAIN," she says. "It brings agencies dedicated to gang prevention together on a monthly basis to sit down and talk and plan new initiatives, so a lot of member organizations from GAIN have helped this research get off the ground."

Up until her involvement, no stakeholder from the medical community had ever been involved with GAIN. It's just one of many steps Snider says she hopes will lead to changes in the medical culture regarding violence - something that can't come soon enough.

"That fact that we just treat 'em and street 'em, is despicable in my mind," she says. It's more than a health-care problem. It's an issue of social justice. "There's such a disparity about how we treat heart and stroke disease (also preventable) compared to violence because it affects a different social class," she says. "Let's be honest. If this (injuries from violence) affected a lot of middle-class suburbanites, this would not be an issue. We would not be looking for dollars to do the research."

But the fact is Snider has found funding for the study, and only after it has run its course will she know whether the ED-VIP concept should be the model of care here and across the country.

"Maybe this isn't the best way to spend our money," she says. "That's why it's important to test it, because if this doesn't work, then we need to find something that does work. But if we can show that it works, it's likely we can find big cost savings, not just for our healthcare system, but across all three levels of government. And more importantly, we can help youth make important, positive changes in their lives."

Joel Schlesinger is a Winnipeg writer.

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