During a single week in April, there were 18 driving deaths in Minnesota, most of them involving teens. In at least one crash, the driver was in violation of several of the state’s graduated driver license provisions. Graduated licensing is increasingly popular across the country, and incidents like this are prompting our legislators to tighten them.
One big problem is that each state sets its own licensing standards. And since most states insist on reinventing their own wheel, a patchwork of state standards has been enacted. Some have higher age minimums for obtaining a license. Others limit night driving or number of underage passengers. Most states have addressed phoning and texting while driving.
There is now a push in the US Senate to standardize graduated licensing rules in all states so there is a more even playing field. The proposed legislation would:
- Make getting a driver’s license a 3 step process, including a learner’s permit, a restricted license, and finally an unrestricted license.
- Prohibit nighttime driving without an unrestricted license.
- Prohibit cell phone use without an unrestricted license.
The proposed law makes sense. Accident research has shown that states that adopt a more restrictive licensing policy see a significant reduction in crashes, and a reduction in injury crashes of nearly 40%. Fatal crashes in young drivers was reduced by a whopping 75% in these states!
The major problem with the proposed legislation is that the penalties for states not complying are rather heavy-handed. Such states would face losing some of their federal highway construction funding. Many states would face this issue soon if the law was enacted as it is now written.
Concerned parents should communicate with their legislators and support these efforts to protect their children. More immediately, though, parents need to be involved in the driving decisions of their children. Don’t allow them to drive after dark. Limit the number of passengers they can carry. Require them to use their seatbelts. And make sure they understand the consequences if they choose to break these rules: immediate and non-negotiable loss of driving privileges for a set period of time.
Centers that take care of blunt trauma are familiar with the spectrum on injury that is directly attributable to seat belt use. Although proper restraint significantly decreases mortality and serious head injury, seat belts can cause visceral injury, especially to small bowel.
Lap belt use has been associated with Chance fracture (flexion distraction injury to the lumbar spine) since 1982. The association between seat belts and intra-abdominal injury, especially with an obvious “seat belt sign” was first described in 1987.
Twenty years ago, orthopedic surgeons in Manitoba finally put two and two together and reported a series of 7 cases of Chance fractures. They noted that 6 of the fractures were associated with restraint use. Seat belt sign was also present in 5 of the 6 patients with fractures and three of the six had bowel injuries.
The authors noted that many provinces were mandating seatbelt use at the time, and they predicted that the number of Chance fractures, seat belt signs and hollow viscus injuries would increase. On the positive side, the number of deaths and serious head injuries would be expected to decline.
Although this was a small series, it finally cemented the unusual Chance fracture, seat belt sign, and bowel injury after motor vehicle trauma.
Reference: Pediatric Chance Fractures: Association with Intra-abdominal Injuries and Seatbelt Use. Reid et al. J Trauma 30(4) 384-91, 1990.
This video demonstrates tips, indications and technique for performing needle decompression of the chest for tension pneumothorax.
We’re all aware of the patients that are seen in the ED so frequently that the ER staff know their names, medical histories, and sometimes family members very well. They are the so-called “frequent flyers.” These patients have been characterized as uninsured and on occasion, undesirable.
A recent study analyzed 25 studies done in the last decade detailing the characteristics of these patients. As usual, reality is different that perception.
The study examined data from a variety of sources. The bulk of these studies examined patients being treated at university of public hospitals. Some highlights:
- 1 in 20 ED patients were “frequent fliers”, and they accounted for more than a quarter of all ED visits. Many go on to become a frequent flyer the following year, too.
- Half of frequent flyers presented to multiple EDs
- The majority (60%) were middle-aged and white
- Almost two-thirds had Medicare or Medicaid coverage. Only 15% were uninsured.
- Frequent users were more likely to have seen a primary care physician in the year before their visits. They were also 6 times more likely to have been hospitalized after a visit.
- Use of ambulances was more frequent, and mortality was higher.
- Children were frequent flyers, too. Parents stated that access to a pediatrician was the major factor, but 95% of kids had a primary care provider.
Hopefully, this study will stimulate more scrutiny of this patient group. The research may give some insight into some of the unintended consequences of healthcare reform.
Reference: LaCalle, Rabin. Frequent Users of Emergency Departments: The Myths, the Data, and the Policy Implications. Ann Emerg Med, in press, March 2010.
Nurses have a complementary role with physicians in caring for children with orthopedic injuries. Typically, the child will have been evaluated and had some sort of fracture management implemented. In children, nursing management is easer than in adults since a child is less likely to need an invasive surgical procedure. Many fractures can be dealt with using casts and splints alone.
Here are a few tips for providing the best care for you pediatric patients:
- Ensure adequate splinting / casting. You will have an opportunity to see the child at their usual level of activity. If it appears likely that their activity may defeat the purpose of the cast or splint, inform the surgeon or extender so they can apply a better one.
- Focus on pain control. Nothing aggravates parents more than seeing their child in pain! Make sure acetominophen or ibuprofen is available prn if pain is very mild, or scheduled if more significant. Ensure that mild narcotics are available if pain levels are higher. Remember, stool softeners are mandatory if narcotics are given.
- Monitor compartments frequently. If a cast is used, check the distal part of the extremity for pain, unwillingness to move, numbness or swelling. If any are present, call the physician or extender and expect prompt attention to the problem.
- Always think about the possibility of abuse. Fractures are rarely seen in children under 3, and almost never if less than 1 year old. If you have concerns about the physical findings or parent interactions, let the physician and social workers know immediately.