It's 1:57 a.m. on a warm Saturday night in Winnipeg. Dr. Carolyn Snider is barely two hours into her shift as an emergency room physician at the Health Sciences Centre, Manitoba's primary trauma hospital, but has already treated and released two 16-year-old teenagers with lacerations resulting from a violent disagreement at a house party.
Her current patients, a 19-year-old man and 22-year-old woman, are waiting for treatment in adjoining rooms. The young man will need 14 stitches from being hit over the head with an empty liquor bottle after refusing the 22-year-old's request for a cigarette. His alleged attacker suffered a broken arm and fractured cheek bone when the victim's friends jumped in to retaliate. The two had just met that night in a downtown bar.
Although the above scenario is hypothetical, it's unfortunately all too representative of a typical summer night in emergency departments (EDs) across Canada. According to Snider, who has worked in EDs in Toronto and Winnipeg, injuries due to intentional assaults are the number one reason that youth aged 12 to 24 years visit an ED. They're also the leading cause of hospitalization among men aged 20 to 24.
"Injury is a chronic, recurring condition," says Snider. "Not only does it affect mostly young people, but right now the standard of care in many hospitals is to stitch them up and send them on their way without attempting to treat the root causes."
Unsatisfied with the status quo, Snider turned to her colleagues in the U.S. to see how a hospital-based violence intervention program might work in Canada. After extensive community consultation with clinicians, nurses, social workers, community youth workers and former gang members, the Emergency Department Violence Intervention Program (EDVIP) was created as a pilot research project to address some of the underlying reasons young people get caught up in a cycle of injury and violence.
Funded by the Canadian Institutes of Health Research, EDVIP is the only randomized control study of its kind in North America that is designed to directly assess the effectiveness of reducing repeat intentional injury among youth injured by violence by providing care both in the hospital and in the community for approximately one year starting at the time of the initial injury.
Heather Woodward is the organization's social worker and leads the EDVIP intervention team. She explains how the program works.
"Wraparound care involves meeting the youth at their bedside at the time of the injury and providing them the opportunity to work with a support worker to address any areas in their life that the youth identifies as putting them at risk of future violence," she says.
Woodward goes on to explain that there are a number of key components that make this intervention program successful. The first is that the support workers are people with whom the youth feel comfortable and can identify. The EDVIP intervention team currently has five support workers (three men and two women) who either have experience with violence or extensive experience working with youth affected by violence.
Second, it's important that the youth are met right at the bedside in the ED to take advantage of the 'teachable moment.'
"Research has shown that youth who have been injured by violence are often in a reflective and receptive state of mind," says Snider, who now serves as medical director and principal investigator for the program. "This makes the hospital emergency department the ideal setting for initiating an intervention."
The third key component is that the youth themselves are the ones who decide what may have been the contributing factors that put them at risk of violent injury.
"It's not the support worker's job to 'fix' the youth, but rather to walk with them on their journey of healing," says Woodward. Among the more commonly cited risk factors are problems with addictions, a lack of safe housing, and involvement with the criminal justice system.
Snider remembers clearly the moment that she realized not enough was being done to treat the root causes of youth violence. A young man who she treated months prior for a laceration was back in her trauma room at Sunnybrook Hospital in Toronto. She remembers wondering if there was something she could have done at his initial visit that might have helped prevent his return.
Snider went on to learn that this young man's situation was not an isolated incident; in fact, approximately 20 per cent of youth who are injured by violence will return to the emergency department with another injury within the next year.
Rick Linden, professor of Criminology at the University of Manitoba and member of the EDVIP Advisory Board, is an internationally renowned expert on young offenders. He explains that the same circumstances that often give rise to young peoples' involvement in criminal activity also leave them susceptible to becoming victims of assault.
"There is a very strong relationship between being a violent offender and serious victimization among young offenders," says Linden. "These youth come from similar backgrounds. Typically they are marginalized youth from poor families. They frequently share common lifestyles that put them at risk of victimization, and they are often involved in gangs. Whether an individual becomes a victim or an offender at any given time may be a matter of timing, luck or strength and these circumstances may change the next time around."
In fact, over the past decade in Canada, about one quarter of homicide victims and almost half of those accused were youth between the ages of 14 and 24. In Manitoba, the province with one of the highest homicide rates, more than one third of homicides in the past six years involved youth.
Snider recently completed her own analysis of youth who were injured or killed by violence in Manitoba spanning 2004 to 2011. She discovered that youth are more than four times more likely to be the victim of a serious injury or homicide if they had previously been charged with a criminal offence — even after controlling for other factors such as gender, income, education, involvement with Child and Family Services and prior visits to the ED for assault injuries.
"It quickly became clear during the pilot stage of our study that we needed support and input from the justice and law enforcement sectors," Dr. Snider explains. As a result, a new partnership with the Winnipeg Police Service was formed.
S/Sgt. Bob Chrismas of the Winnipeg Police Service serves as a liaison between the police and the EDVIP team. He explains how programs such as EDVIP are part of "the new economics of policing."
"EDVIP is an excellent example of this type of proactive, intervention-based approach. The Winnipeg Police Service has adopted crime prevention through social development as its crime prevention approach, and therefore has fully embraced the EDVIP as a partner and supports it as a great example of social innovation and collaboration."
Chrismas says the program and its team are having a positive impact.
"I have been moved by the team's compassion and dedication to community and to the individual clients; their devotion is clearly behind their outstanding successes after the first year. They are truly changing the lives of violence-affected youth. I believe this model will be adopted by emergency departments in hospitals across Canada."
Although the program is still in its pilot stage and won't have any concrete results to report for another year, Snider says the program's participants have made great strides.
"Many [youth] are back in school or have full-time jobs. Some are volunteering their time at ceremonies and helping to deliver furniture and household items in the community. Most of our youth are now safely housed. A lot of the youth who are Aboriginal have been introduced — or re-introduced — to their culture and ceremony and are participating in and learning about sweat lodges, sun dances and pow wows. Most importantly, we clearly see a number of our youth developing independence and taking responsibility for their own lives."
As the many community partners that work closely with EDVIP know, even small achievements can make huge differences in the lives of the young people served by this program.