Tag Archives: mortality

General

What Is The Cost of the “Personal Freedom” Not To Wear A Motorcycle Helmet?

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The Highway Safety Act of 1966 led to a mandate that all states adopt universal helmet laws for all motorcycle riders or risk the loss of federal highway funds. By 1975, all but 3 states had enacted these laws. However, Congress then did an about-face and eliminated the helmet law requirement for receiving the funds. Many states then revisited their laws, and some repealed them. As of now, 20 states (and D.C.) have inclusive helmet laws, 27 have conditional laws, and 3 (IL, IA, NH) have no helmet requirements.

Croce and his group in Memphis looked at the impact of helmet use in motorcyclists using the National Trauma Data Bank from 2002-2007. They found:

  • Helmet use was higher in states with helmet laws (90%), vs conditional laws (61%), vs no laws (53%)
  • Helmeted riders had less severe injuries in nearly all brain and skull trauma. Glasgow Coma Scale and Injury Severity Scores were significantly lower.
  • Cervical spine fractures were less frequent in helmeted patients (3.9% vs 5.9%)
  • Hospital and ICU stays were shorter for riders who wore helmets
  • Mortality was significantly lower in helmeted motorcyclists (3.8% vs 6.7%)
  • Significantly more helmeted riders were insured

Advocacy groups continue to try to repeal or weaken helmet laws, generally based on a 1986 report (ref 2) which stated that helmets decrease peripheral vision and hearing, increase the number of cervical injuries, and have no impact on mortality. Frequently, proponents of helmet law repeal also claim that the laws infringe on personal freedom.

Helmets do decrease peripheral vision by 20 degrees, but research and a DOT report have shown that this has no impact on motorcycle safety or impact rates (refs 3,4). Helmets have been shown to have no impact on hearing at low speeds, and all riders (with or without helmets) have decreased hearing at higher speeds. Helmets do not diminish or enhance hearing at any given speed (ref 4). A number of studies, including this one, have shown that cervical injuries are less frequent in riders who survive the crash.

The insurance and hospital utilization information in this paper is most interesting. Unhelmeted riders have more significant injuries, are more likely to stay in the hospital and ICU longer, and are much less likely to have insurance to pay for it. And this is for the survivors! Deaths create an even greater societal burden, with lost lifetime earnings, tax revenues and other adverse economic effects.

Courts have repeatedly upheld mandatory helmet laws under the Constitution when challenged. A federal court once responded to one of these challenges with this quote: 

“From the moment of injury, society picks the person up off the highway, delivers him to a municipal hospital and municipal doctors; provides him with unemployment compensation if, after recovery, he cannot replace his lost job; and, if the injury causes permanent disability, may assume responsibility for his and his family’s subsistence. We do not understand a state of mind that permits plaintiff to think that only he himself is concerned.”

For a list of current helmet law status by state, click here.

References:

  1. Impact of motorcycle helmets and state laws on society’s burden. J Trauma 250(3):390-394, 2009.
  2. The effect of motorcycle helmet use on the probability of fatality and the severity of head and neck injuries: a latent variable framework. Evaluation Review 10:335-375, 1986.
  3. Motorcycle helmets – medical costs and the law. J Trauma 30:1189-1199, 1990.
  4. The effects of motorcycle helmets upon seeing and hearing. NHTSA Report number DOT HS 808-399, 1994.
General

Personal Decisions are the Leading Cause of Death

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A relatively obscure research paper published in late 2008 by Ralph Keeney at Duke University makes this startling claim: over half of the people who died in this country in the year 2000 did so because of their own personal decisions! If you look at current mortality statistics, the top four causes of death from year to year are heart disease, cancer, stroke and injury. We naturally look at this and think that these people had a heart attack or discovered a cancer or crashed their car. What these statistics fail to show is how the people really ended up with these conditions.

Keeney’s paper looked beyond what was written on the death certificate and looked at how frequently personal choices caused these conditions. For example, smoking leads to heart disease, cancer, stroke, and high blood pressure, to name a few. Being overweight leads to heart disease, diabetes, high blood pressure, and many others. Inappropriate use of alcohol can lead to cancer, liver disease and a tendency to get into accidents.

The top causes of death were analyzed, looking at the percentage that could be caused by personal decisions such as smoking, diet, exercise, and use of alcohol or other drugs. A personal decision was defined as a situation where the individual could make a choice between two or more readily available alternatives (for example, smoking and not smoking) and that they had control over this choice. These choices are not necessarily easy to make because habits, social pressure, or genetic predisposition can make some alternatives hard to select.

Keeney found that about 55% of deaths in 2000 were caused by personal decisions. This compares to about 5% in the year 1900. This is due to the fact that the majority of the causes of death in 1900 were due to infectious diseases, and there were no antibiotics at the time to treat them.

What this paper shows us is that the need for high quality prevention activities is even greater that we thought, and that we may not be focusing on the right areas.Trauma centers habitually direct their prevention programs toward car seats, diving injuries, red light running, falls prevention and others. What we really need to focus on is personal choice, and teaching people how to make the right decisions. For trauma prevention, alcohol-related programs will probably give the greatest result since it is involved in so many of the top causes of death, even causes not related to trauma.

Trauma centers need to scrutinize their own prevention programs, and look critically at ways they can teach wise choices. It may be necessary to chage the focus of existing programs, or move to new programs that find ways to influence personal decision making. That way, trauma centers can have a hand not only in preventing certain types of injuries, but in directly decreasing the overall death rate as well.

Reference: Keeney RL. Operations Research 56:6, 1335-1347, 2008.

General

Lack of EMS Documentation is Associated With Increased Mortality

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EMS policy and the trauma center verification process requires that all trauma patients delivered to a trauma center must have a copy of the EMS run sheet. Two parameters that are commonly used to monitor performance improvement (PI) in EMS are:

  • accurate record of scene physiology (SBP, HR, RR, GCS)
  • request by on-scene BLS for ALS assistance

The study looked at the impact of those criteria on patient survival. A total of 4744 patients from the National Trauma Data Bank were analyzed.

Physiologic data: About 28% had at least one missing physiologic data point, with respiratory rate being most commonly missed. They found that the mortality in the group with missing data was over twice as high (10.3%) as it was in the group with complete date (4.5%).

BLS call for ALS assistance: This assist was called for in 17% of cases. These cases were less likely to involve penetrating injuries and more likely to involve car or motorcycle crashes. Injury Severity Score was the same. Eventual patient mortality was the same for BLS calling ALS and ALS response alone.

So why does failure to record physiologic data translate into higher mortality? The initial response may be that the patient was sicker, and so they needed more intense care during transport with less time to record vitals. However, the researchers controlled for this and found it was not a factor. Other issues that may be a factor are EMS training and proficiency, leadership at the scene and enroute, and available staff and resources, among other things.

The researchers speculate that documentation might be a good global measure of appropriate or inappropriate prehospital care that rolls all of these possible factors into one easily identifiable audit filter. They recommend that this be used to focus performance improvement efforts and hopefully improve survival.

I recommend that the results of this study be taken to heart and used to help persuade EMS programs to get religious about recording complete vital signs and leaving the run sheet at the trauma center every time a patient is delivered. Documentation should be evaluated regularly, and all cases with any missing vital signs should be reviewed closely. Trauma Center PI programs should work with EMS to analyze this data and look for the patterns that increase mortality.

Reference: Lack of Emergency Medical Services documentation is associated with poor patient outcomes: a validation of audit filters for prehospital trauma care. Journal of the American College of Surgeons, 210(2):220-227, 2010.