Trauma and Injury Prevention Section Newsletter - September 2006, Vol 10, #2
Letter from the Chair
Mark Sochor, MD, MS
Hope everyone is enjoying the summer months. Soon it will be fall and time for another Scientific Assembly. Mark your calendars as our section meeting is on Tuesday October 17 at 1:30-3:00 pm in room 279 of the Morial Convention Center. I look forward to seeing you there to help us elect new officers and make critical decisions as they relate to the section.
The work we do is vitally important, as injury is an epidemic that must be defeated. I was reminded of this fact by one of my patients. This woman had decided to try and end her life. She drove to the shopping mall with two of her five children to purchase some clothes at a department store. She had left work early that day to run some family errands. Once she arrived at the department store she parked her full size suburban and the children got out. Once the kids were out the mother said she wanted to get a closer spot in the parking lot and told the kids to meet her up front.
She proceeded to drive to the back of the building and drove the suburban through the back of the store and into the main support beam of the building. She totaled the suburban, but did not receive a scratch on her body. She arrived to me catatonic in a c-collar and backboard. I scanned her stem to stern, but could not find an injury. She was then off to mental health after being cleared of any life threatening injury.
After my shift it occurred to me how far automobiles have come in terms of injury prevention. Wouldn’t it be great to have those kinds of results with hand guns, poisonings, child abuse, etc? How powerful would it be to have a gun that would not take a life if put to the temple or abdomen? Even if the operator’s intent was to harm themselves, they would not be able to do so. Pills when ingested in large quantities would detect the amount present and not release themselves and prevent an overdose from occurring.
Automobiles continue to be the most dangerous product for persons aged 4-34 years of age, but great strides have been made over the past 50 years toward making driving safer. This took little steps in the right directions and constantly moving forward and pushing the technology envelope. It also took devoted scientists and health professionals to bring this epidemic to the attention of the general public. I think it is a good example of what can be accomplished when determined people concentrate on a certain injury issue or cause.
Although trauma funding is lacking this fiscal year, we need to keep the pressure on to have the funding reinstated and to continue our projects moving forward. YOU and I are the professionals who will make the little steps toward making injury, violence, and trauma less of an epidemic. A timely example of the work of our section and the Trauma Care and Injury Control Committee is ACEP’s participation in the Coalition for Fire-Safe Cigarettes. This potentially will save hundreds of people, if not thousands, from being injured or killed each year. There is not one solution, but several that must be pursued. Keep up the good work, and I look forward to seeing you at Scientific Assembly.
Back to Top
Letter from the Chair-elect
An Opportunity to Pursue Motorcycle Helmet Laws Again?
Ernest E. Sullivent, III, MD
When I think of primary injury prevention, the first three items that pop into my mind are seat belts, children’s car seats, and motorcycle helmets. In recent years, we have made tremendous progress on the first two. Regarding the latter… well, we’re still working on the helmet issue. Mandatory motorcycle helmet laws have been an unusual and glaring example of policy going in the wrong direction, as some states with existing laws are actually repealing them.
Perhaps we now have an opportunity to turn the tide. Today’s 24-hour news cycle allows us the unique opportunity to use well publicized events to our advantage. Such an event recently took place when last year’s victorious Super Bowl quarterback, Ben Roethlisberger of the Pittsburgh Steelers, crashed his motorcycle while not wearing a helmet. While his injuries were not life-threatening, he did suffer fractures of his mandible, maxilla, nose, and multiple teeth. He also sustained a 9 inch occipital scalp laceration. Four surgeons operated for 7 hours to repair his extensive injuries. Had he been wearing a helmet, he would have walked away with only extremity abrasions.
Prior to his accident, Roethlisberger had proudly and publicly stated that he didn’t wear a helmet when riding. In referring to the recently repealed motorcycle helmet law in Pennsylvania, he was recorded saying, if the state didn’t think helmets were necessary, he didn’t think he needed one. I wonder how the state legislators in Pennsylvania (particularly those from Pittsburgh) feel about their vote now. Although mandatory motorcycle helmet laws are almost universal in first world countries throughout the world, state laws control helmet use in the United States. Four states do not have mandatory helmet laws (CO, IA, IL, NH) and twenty-six others only require helmets for younger riders. Only twenty states in the US have mandatory laws for all riders. One of the latter states, Michigan, just passed a bill on June 7th to repeal its helmet laws for adult riders - the Governor is expected to veto this bill.
Most reasonable people, and especially those who work in emergency departments, do not understand why anyone would not wear a helmet while riding a motorcycle. I am a third-generation motorcyclist (I retired after residency), and while I was among the majority of motorcyclists who always wore a helmet, I do have some insight. Motorcyclists pride themselves as being individualists and tend to resist government interventions that trespass on their "rights." They will state there is no replacement for the wind rushing through their hair. They also point to decreased peripheral vision and hearing ability with a helmet. Hard though it is to believe, they will also claim that the helmets increase the likelihood of cervical injuries. Their claims and reasons are endless. One thing you can be sure of, however, is that the "helmet choice" proponents are very passionate about this issue and will not give up the fight.
The basic problem for us is that these proponents are much more organized and politically savvy than those supporting mandatory helmet laws. Their lobbying efforts have been extremely effective, and they are a formidable force, as I witnessed while in Texas in 1998. Their recent successes in repealing universal helmet laws (Arkansas, Florida, Kentucky, Texas, Michigan) has only emboldened them, and no state with such laws is safe. We must not only fight for universal helmet laws in states without them, but must also be vigilant in all states that may be vulnerable to repeal efforts.
My dream is that after Mr. Roethlisberger recovers from his injuries, he will decide to do public service announcements advocating helmet laws, or at the very least helmet use. This is not inconceivable, given that the NFL is very active and supportive of community activities. In fact, this presents a tremendous opportunity. However, it is not likely. Perhaps, however, this highly publicized incident involving one of the nation’s most popular sports figures has many people at least re-thinking this issue. I certainly haven’t heard a single person comment that he was better off without a helmet that day.
The pursuit of instituting or retaining universal helmet laws will be an on-going battle at the state level. Despite having all the facts on our side, the lobbying power of the other side puts us at a great disadvantage. We must stay in this fight for the long haul, and work for the day when motorcycle helmets become mandatory in all 50 states.
Back to Top
Meet the TIPS Board Liaison, Dr. David Sklar
David Sklar, MD, FACEP, has a long history of interest and involvement in the area of trauma and injury prevention. He is currently serving as the chairman of the Department of Emergency Medicine at the University of New Mexico, and was a pioneer in advocating injury prevention training for EMTs, EM residents, and practicing emergency physicians. His research has focused on intimate partner violence, homicide, suicide, pedestrian injuries, and motor vehicle injuries. He oversees a grant on pedestrian safety in New Mexico that involves the development of community advocacy groups. He also manages a grant involving intimate partner death review teams, which work with the law enforcement community, lawyers, social workers, psychiatrists and others, to identify possible areas of prevention based upon the detailed review of intimate partner violence deaths. Additionally, Dr Sklar has worked on data-driven legislative changes in all-terrain vehicle safety training for children. He first became interested in injury prevention when he became a victim of pedestrian injury during his residency training while out jogging. Dr. Sklar is looking forward to the Trauma and Injury Prevention Section meeting at Scientific Assembly.
Back to Top
Project: "Brief Intervention to Increase Safety Belt Use Among Emergency Department Patients"
Funding Source: CDC/National Center for Injury Prevention and Control (1 R49 CE000681-01)
PI: William G. Fernandez, MD, MPH
The investigators propose a study to test the utility of a brief intervention targeted at improving safety belt use (SBU) among emergency department (ED) patients identified as at-risk for serious injury. A total of 1,363 ED patients at Boston Medical Center will be screened during a 3-month period. The research coordinator and research associates will systematically sample ED patients, and ask them for permission to complete a brief screening form on health and safety issues. Upon obtaining verbal consent from registered ED patients, research associates will have participants complete a brief, self-administered, written screening form. Once completed, patients who give an answer less than "always" wear safety belt, on an SBU screening question-the Global Measure of SBU (GM-SBU)-will be asked to participate in an intervention to promote health and safety among ED patients. A full informed consent process will then be conducted, and those who choose to enroll will sign IRB-approved consent forms as well as a HIPPA release form; be reimbursed for their time; and complete an intake form. Participants will be randomized into one of two groups: an intervention group that will receive a brief motivational intervention (ie, the brief negotiated interview) to increase seat belt use, and a control group that will receive no intervention. Research staff will contact participants for a follow-up phone survey at 3- and 6-month intervals to determine if individuals randomized to the Intervention group had a statistically higher self-reported prevalence of seat belt use than those in the control group who received only usual care.
Back to Top
Alcohol and Other Drug Problems Among Hospitalized Trauma Patients
Daniel W. Hungerford and Larry M Gentilello, Editors
Journal of Trauma, Volume 59, Number 3, September 2005 Supplement
(Submitted by Ernest Sullivent, MD)
CDC’s Injury Center initiated collaboration among 12 organizations including 9 federal agencies that contributed about $200,000 to organize and present this 2½ day conference in March 2003.
The conference featured five half-day sessions, each comprising presentations by national leaders in trauma surgery and one to two hours of plenary discussion. The audience was composed of an interdisciplinary mix of leaders including trauma surgeons, other medical practitioners, alcohol researchers, psychologists, psychiatrists, epidemiologists, and federal agency representatives.
The supplement includes papers, detailed summaries of discussion sessions, and recommendations to improve identification and treatment of trauma center patients with alcohol and drug problems. This special issue also:
- Explains the need for intervention programs
- Introduces the conceptual bases underlying intervention methods
- Presents evidence about the efficacy of interventions
- Describes the opportunities in trauma centers for interventions
- Lists the benefits and challenges of incorporating interventions into routine trauma care
- Offers tips for implementing interventions
The journal supplement has been mailed to about 4,500 subscribers worldwide. In addition, the Robert Wood Johnson Foundation’s program, "Innovators Combating Substance Abuse" at Johns Hopkins Medical School has ordered 1,000 copies to distribute. The National Center for Injury Prevention and Control (NCIPC) has 4,000 print copies to distribute and free PDF files of all the articles that are available via the NCIPC website (www.cdc.gov/ncipc). The supplement is also being widely promoted among partners and trade media.
Trauma Center Certification Criteria
In 2005, the American College of Surgeons Committee on Trauma (ACS-COT) adopted a criterion deficiency that will require
- level I and II trauma centers to "have a mechanism to identify patients who are problem drinkers' and
- level II trauma centers to "have the capability to provide an intervention for patients identified as problem drinkers."
Five federal agencies—CDC, NIAAA, NIDA, and SAMHSA—have provided $700,000 over two years to research the impact of insurance laws that discourage screening for alcohol or drug intoxication in medical care settings. These laws present a formidable barrier to efforts in identifying and helping patients with alcohol and drug problems.
Training for Implementation
Three federal agencies—NHTSA, SAMHSA, and CDC—are currently collaborating in a multi-year project with the ACS-COT to develop training materials and provide training to screen and provide brief interventions in trauma centers.
AHRQ: Agency for Healthcare Research and Quality
AAST: American Association for the Surgery of Trauma
CMS: Centers for Medicaid and Medicare Services
HRSA: Health Resources and Services Administration • Join Together
NCIPC: National Center for Injury Prevention and Control
NHTSA: National Highway Traffic Safety Administration
NIAAA: National Institute on Alcohol Abuse and Alcoholism
NIDA: National Institute on Drug Abuse
ONDCP: Office of National Drug Control Policy
RWJF: Robert Wood Johnson Foundation
SAMHSA: Substance Abuse and Mental Health Services Administration.
Back to Top
Screening for Our Safety
Michelle McMahon-Downer, MD
The Injury Prevention Center at Rhode Island Hospital has recently completed a research project called Screening for Our Safety (SOS). This project was designed to educate Rhode Island emergency department physicians on accepted methods for screening, counseling, and referring patients with alcohol use disorders. For several years now, Rhode Island has had the highest percentage of motor vehicle crash deaths due to alcohol in the country. Thus, it seemed imperative to address this problem with emergency medicine physicians who treat patients with alcohol use disorders every day.
Since a single alcohol-related emergency department (ED) visit can be a strong predictor of continued problem drinking, alcohol-impaired driving, and possible early death, and since an injury may be an important motivator to reduce drinking, a visit to the ED can present a life-saving opportunity for intervention leading to treatment and prevention of future injuries. To take advantage of this opportunity, ED physicians must screen injured patients for alcohol abuse, refer such patients for treatment, and, if appropriate and allowed in their state, report the results. However, frequently this does not occur due to lack of awareness and education about alcohol and its relationship with injuries and unfamiliarity with screening tools and avenues for reporting patients with alcohol problems.
SOS aimed to close this gap through an on-line program that educates ED resident physicians and attending physicians about:
- Alcohol abuse and its relationship with injuries,
- Screening tools for detecting alcohol and drug abuse,
- RI’s state law permitting reporting of unfit drivers to the Department of Motor Vehicles’ Medical Review Board, and
- Information on Brief Motivational Intervention and referral resources for Alcohol Use Disorders.
All ACEP members in the state of Rhode Island were invited to partake in the SOS study. Through pre- and post-tests and follow-up sessions, we assessed baseline knowledge and behavior and ascertained whether the SOS curriculum proved effective in altering attitudes and practices regarding alcohol and injuries, screening of patients for alcohol use disorders, and reporting and referral of patients with alcohol use disorders. We also analyzed the number of DMV reports submitted by physicians before and after the introduction of the SOS curriculum. Results of this study will be published in a peer-reviewed journal shortly.
Back to Top
Fentanyl-Related Overdoses Among Illicit Drug Users
Ernest Sullivent, MD
Emergency physicians and EMS personnel should be aware that the Centers for Disease Control and Prevention (CDC) has received increasing reports of fentanyl-related overdoses among intravenous drug users in several states.
Recent reports indicate the occurrence of this problem in Chicago, Detroit, and Philadelphia/Camden starting in late 2005. Chicago had at least 40 deaths with confirmed fentanyl exposure between September 2005 and March 20, 2006. Additional deaths are suspected, but have not been confirmed toxicologically. During the same September to April time period, approximately 100 overdose deaths involving fentanyl were reported in Detroit. A few cases have been reported in Harrisburg, PA, Maryland, and Delaware. Philadelphia and the neighboring Camden (New Jersey) area have experienced at least 10 confirmed deaths and additional possible deaths during April and May.
Fentanyl is a prescription opioid analgesic that is roughly 50 times more potent than heroin. Fentanyl is used in the health care setting as an analgesic and anesthetic, and is available in an injectable form (Sublimaze®), a transdermal patch (Duragesic®), and a transmucosal "lollipop" (Actiq®). Fentanyl can also be produced in clandestine laboratories and then mixed with or substituted for heroin or cocaine without the knowledge of the drug user. Similar to other opiates, its use results in respiratory and CNS depression. Because of its potency, use of fentanyl-laced drugs is more likely to result in an overdose and respiratory arrest. Patients with fentanyl overdose may require increased amounts of naloxone. Routine opiate toxicology screens will not detect fentanyl.
Law enforcement agencies are actively involved in multiple jurisdictions attempting to track the fentanyl back to the producers – the fentanyl may be coming from one or more clandestine laboratories yet to be identified. Police recently seized fentanyl-laced heroin bags in Philadelphia and Camden and closed a fentanyl lab in Mexico. Overdoses of illicit drugs should be reported to local law enforcement. Unexplained increases in the incidence of drug overdoses in a community, especially in the northeastern United States, should also be reported to law enforcement.
Back to Top
Model Communities: Linking EMS and Public Health
Ernest Sullivent, MD
The Centers for Disease Control and Prevention (CDC) has selected seven communities as models of how emergency medical services can work with other safety and public health agencies in times of disaster. As part of CDC’s TIIDE Project (Terrorism Injuries: Information, Dissemination and Exchange), model communities identify where relationships between the emergency care community and public health are established and operate at levels that effectively respond to events that may cause large numbers of injuries.
Constructed around the interrelated activities of partnership building, learning lessons from previous terrorist events, and disseminating information, the TIIDE Project was established to address the urgent need to develop and exchange information about injuries from terrorism. That information includes community strategies to improve public safety, public health, clinical managements, and health care system preparedness in the event of mass casualty incidents.
Twenty communities from across the nation submitted applications. Applications were reviewed by a panel of representatives from the TIIDE Project and the National Center for Injury Prevention and Control, Division of Injury Response. The selected communities are:
- Clark County Health District, Las Vegas, Nevada
- Erie County, New York
- Livingston County, New York
- Monroe County, New York
- Louisville, Kentucky
- Boston, Massachusetts
- Eau Claire County, Wisconsin
Each of the communities listed above has been successful in strengthening the relationship and collaboration between public health and the emergency care community to improve routine operations and preparedness for the citizens of their communities. Many of these communities shared common features. Some of these include:
- Strong medical oversight in both public health and emergency care;
- A desire and an effort to educate both emergency care and public health providers about each others’ role;
- Recognition of the role of and a commitment toward the development of and maintenance of long term relationships between key leadership through regular meetings, teambuilding exercises, and planning;
- Bringing community stakeholders (businesses, clinics, universities, etc.) into the planning process;
- Creating disaster plans that were developed locally, involve public health and emergency care, and that are drilled repeatedly; and
- Aggressively pursuing and securing funding.
E-mail questions and comments about CDC’s TIIDE Project to your staff liaison Barbara Marone at firstname.lastname@example.org.
Back to Top
It's Grant Application Time!
The application process for the 2006-2007 Section Grant Program is now underway. Sections seeking funding through the Section Grant Program must first submit a brief Letter of Intent describing their proposal by January 12, 2007. For more information on the Section Grant Program, please visit us online.
The 2006 – 2007 Chapter Grant Program is also accepting applications. Letters of Intent are due at the ACEP headquarters by January 5, 2007. For additional information on the Chapter Grant Program, please visit us online.
Back to Top
This publication is designed to promote communication among emergency physicians of a basic informational nature only. While ACEP provides the support necessary for these newsletters to be produced, the content is provided by volunteers and is in no way an official ACEP communication. ACEP makes no representations as to the content of this newsletter and does not necessarily endorse the specific content or positions contained therein. ACEP does not purport to provide medical, legal, business, or any other professional guidance in this publication. If expert assistance is needed, the services of a competent professional should be sought. ACEP expressly disclaims all liability in respect to the content, positions, or actions taken or not taken based on any or all the contents of this newsletter.