Deborah Friedman has served as Director of Trauma at the Montreal Children’s Hospital Trauma Centre, McGill University Health Centre, since 2000. In 2011, she was appointed Director of the hospital’s Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP), a Public Health Agency of Canada initiative. She is an Associate Professor in the Departments of Pediatrics and Pediatric Surgery in the Faculty of Medicine and Health Sciences at McGill University.
Debbie, how did you find you way into the injury prevention field? What attracted you?
I’ve been in the field for more than three decades. My background is in physiotherapy and I’ve done a degree in international health management. I started working clinically in neurotrauma and neurosurgery, primarily with patients with head injuries and spinal cord injuries. In the ’80s, I was given the opportunity to develop what turned out to be the first neurotrauma program in Quebec and then a model used for elsewhere in Canada. As a clinician, I worked in trauma, and injury prevention was certainly an area that I found interesting. Right from the onset, I took it on to develop a co-ordinated interprofessional approach to neurotrauma for head injuries and spinal cord injuries. I felt, how do you do trauma without doing injury prevention? Because seeing the things that you see, the two of them need to be partners.
For years I developed the neurotrauma program and developed a whole team, as well as started doing outreach as part of it to get out important messages, focusing on key injuries we were seeing. We developed strategies to advocate for changes and connect with others who were starting to come out in the injury prevention field so that our voice would be strong and heard, and people would be sensitized to some of the issues. A lot of the work was really through trauma, and I also partnered with other people. The Canadian Hospitals Injury Reporting Program (CHIRPP) was an important, strong player at the Montreal Children’s Hospital because of the value this data set provided on the number of people who died or were injured, but also context around their injuries.
At the same time, I felt that what was happening in neurotrauma needed to happen in all of trauma. So, in 2000, I took on the position of Trauma Director and put neurotrauma, trauma and everything under the same umbrella. Keeping with all the accreditation standards, we started to develop a burn trauma program, a mild traumatic brain injury program, a trauma team leader program, and an injury prevention program. I worked closely with CHIRPP, led by Dr. Barry Pless. In 2011 when Dr. Pless retired, I was asked to take on the directorship of CHIRPP. That was a pivotal moment for me because I put everything under the whole trauma umbrella, so there was always good communication. As much as we collaborated, it was still two separate areas of the hospital: in order to be able to do injury prevention properly, I needed to be able to know what was going on in trauma in real time.
What have been the biggest changes you’ve seen since you started?
In the mid ’90s, the whole Quebec trauma system was looked at: partly because we had a 52-per-cent mortality rate, it required a whole reorganization of how we do trauma care, having level one, level two, and level three centres, and bringing in the pre-hospital system. We also had accreditation standards formally implemented. All of that started to grow including things such as teaching and training, and research and injury prevention. And of course, clinical care. For me, it was always a partnership. Injury prevention was never separate from trauma care. The good thing is that the mortality rate in Quebec went from 52 per cent to the current 5 per cent. Still too high but to me, but that’s a significant improvement following years of work we’ve all done to enhance patient care and processes and develop partnerships.
In the late ’90s, I realized that, while I consider myself a pioneer in the field of concussion, we’d been focusing so much on neurotrauma and mostly moderate and severe, but there’s this whole other entity of patients with concussions who don’t fit into that category. We can’t just be accepting that this is a right of passage, to get a concussion when you’re playing sports. Certainly, support from the professional sports world was not there. Concussion was being minimized and that was part of what drew my attention to go out there and say, “hey, we’re seeing this issue. These kids are really suffering. What are we doing?”. Around 2002, I remember going out with an alert about the rise of concussion in minor hockey injuries; nobody was very happy with me, including the Quebec hockey Association. I think I even made it to Don Cherry’s corner, where he made some comment, “… that lady, what does she know about concussions?” I figured it was a badge of a sort of wear. With my clinical work, my teaching, my research, I felt we needed to develop more of a program in that area and then to encompass clinical care, and also to study what we were doing and see if the approach we were using for concussion management was right. Concussion was a new field and it’s gone through so much transformation in the last 25 years, so the whole approach is very different. We created a living lab within our concussion program so that we would ask questions, study them and then change what we’re doing clinically. And I feel like we’ve made valuable contributions over the years in that area.
I’ve been fortunate, working across trauma and injury prevention. In our department, we have research, we have clinicians, we have CHIRPP, and we have injury prevention all sitting within the same space. We’ve developed a trauma system of care. It’s not a program. It’s not a department. It’s a system of care. There are probably 35 different departments, services and divisions involved in our trauma system. Injury prevention is a standing item on every quality improvement meeting, on every trauma committee meeting, and is included in every executive committee meeting. It’s a standing item because it has to be.
One of the one of the other changes that I’ve seen, certainly since COVID, is related to suicide and violence. I used to go to conferences in the United States and they’d be talking about gun violence and stabbing and assaults. I used to think, this is horrible and I’m so grateful that we live where we are and we’re not seeing this the same way. Since COVID, the landscape has changed and the number of mental-health-related traumas we’re seeing has increased; the amount of violence, assault, stabbing, gunshot is very different than we used to deal with. There’s this whole other world emerging. As well, bullying and bullying amplified by social media are influencing these new levels of violence.
Why did you stay in the injury prevention field?
Throughout my trauma and injury prevention journey I had a lot of support from the Montreal Children’s Hospital leadership and the Montreal Children’s Hospital Foundation, which was and is greatly appreciated and needed.
It’s been an amazing ride and I’ve had so many incredible opportunities in teaching, research, and in partnerships within the community. We’ve tried to be leaders in the field, in the clinical sense, but also in the injury prevention sense, because we see the reality firsthand, and we see the devastation and tragedy. Take something like pool drowning. It doesn’t need to happen. The problem is, how do we get the enforcement of by-laws that would prevent this, such as four-sided fencing around pools in backyards?
I love what I do. I have a passion for the work. I’ve been so fortunate to work with incredible people, been able to build a dynamic team of people who are so dedicated and hardworking. They excel at patient care and family support, they make injury prevention messaging something positive and proactive.
What do you feel have been some of the successes in injury prevention?
I think what we accomplished by building concussion care and prevention programs is a big stand out: making sure that the research and clinical fields are working close together, reflecting what we really need. We created that living lab within the concussion clinic and developed an interprofessional approach to care, which really meets the multifaceted and sometimes complex needs of patients and families. We’ve been able to get the kids involved too, with giving the prevention messages. It’s been gratifying seeing hockey organizations eventually adopt concussion education materials and our efforts to inform and educate the public, policymakers and coaches and teachers finally being embraced.
I love to teach. I’ve enjoyed the research we did. I love to develop different clinical programs and to have the privilege of working with so many wonderful people over the years. I’ve combined the whole clinical academic research prevention into a package where one impacts the other. I’m a real advocate of CHIRPP because it’s honestly the most reliable data we have an injury prevention, so bringing CHIRPP under the trauma umbrella was a real highlight because I really feel that it allowed us to do things in real time and to have a handle on what was going on in our trauma population.
Other successes are the early reporting on cannabis-related pediatric injuries, drowning prevention campaigns, work on baby walker bans, soccer net anchoring, trampoline safety and summer camp safety.
I always feel good when a lot of the materials we developed are used within the network and by others asking permission if they can use our content. We participated in many task forces within the ministry and within l’Institut national de santé publique du Québec (INSPQ). They tap into our expertise so that we can have protocols that apply to the population.
How do you feel about the future of the injury prevention field?
Teaching medical students about injury prevention, I find many of them are quite keen and I’ve had a lot of them reaching out. Could we be involved in your outreach activities? Could we do it? And not just the medical students, but other health professions, such as nursing and occupational therapy. When I was at McGill, we did a few initiatives that involved all the different schools that were in the faculty of medicine and health sciences, to try to get them all on board and working together. I find people are much more open to talking about injury prevention.
But it’s also frustrating that even when we do get something such as legislation passed, the enforcement piece of it becomes challenging. So, the results we are aiming for don’t happen and we are still seeing devastating injuries. Even being able to show the proportion of injuries isn’t convincing enough. People just accept it as part of life. It’s better, but not yet where it needs to be. We need society to realize that most injuries don’t need to happen. For example, we had some good responses a couple of years ago during COVID, when we found that tobogganing was one of the sports that kids could do. But not all hills are made for tobogganing, and a lot of the municipalities followed our regulations. We followed up with them and they actually enforced it, made sure that they were open areas, had separate lanes, didn’t have the kids crossing in front of each other, had warning signs when the conditions were too icy. So that gives me hope. All we need is a little bit of a glimpse of success and that keeps us energized.
I worry again with social media, with all the TikTok challenges and stuff because we’ve seen some horrible tragedies. I’m concerned, you know, you feel like, OK, we got this taken care of now. What’s next? The next thing emerges from a whole different direction. We have to be on our toes, track things carefully, work together as communities and with partnerships. We can’t do it alone. We need buy-in from everyone. And I think it’s important for all of us working in the field make sure we stay connected and join forces.
If you could wave a magic wand and change one thing for injury prevention, what would it be?
I’d like to see policymakers working closely with injury prevention and trauma so that we’re actually able to impact change. Having a Canadian national vision and national position statements for things such as ATVs and e-scooters which we know are emerging trends, will allow us to put our heads together and work collaboratively toward a goal. These are things where we can really affect change and are tangible. There’s tremendous work that’s been done at Parachute, but it would be great if the sector had more support for this national work. I’d like to see all the trauma centres combine their trauma programs so that they are able to have real data in real time; so that we’re able to tap into everybody’s numbers because sometimes that’s not so easy to do.
Preventing injuries are a solution to the frontline issues impacting our emergency departments, hospital admissions and the rest of the healthcare system. Twenty-five per cent of the volume in busy emergency departments are trauma-related. Preventing these injuries could make an impact.
I’m also very concerned about the trends we’re seeing with violence and with the impact of social media. I’d like to see constraints because I don’t think it’s going in a good direction.
Most importantly, I’d like more people to recognize that injuries are not random accidents. Many are preventable. Every injury prevented changes not just one life, but an entire family and community. When an injury happens, it doesn’t just affect the child. It affects the family. It affects the community. It affects everybody around them. It’s truly devastating and traumatic. And there are areas that we really can change things to have permanent lasting effects.
I feel fortunate to, and privileged to, have been let into people’s lives during some of the most difficult periods, to be able to train generations of healthcare professionals,and to be able to work with so many wonderful people.