Joseph L. Wright

The teen driver

Motor vehicle–related injuries to adolescents continue to be of paramount importance to society. Since the original policy statement on the teenaged driver was published in 1996, there have been substantial changes in many state laws and much new research on this topic. There is a need to provide pediatricians with up-to-date information and materials to facilitate appropriate counseling and anticipatory guidance. This statement describes why teenagers are at greater risk of motor vehicle–related injuries, suggests topics suitable for office-based counseling, describes innovative programs, and proposes preventive interventions for pediatricians, parents, legislators, educators, and other child advocates.

Sports Injuries: An Important Cause of Morbidity in Urban Youth

Introduction. Sports injuries account for substantial morbidity and medical cost. To direct intervention, a population-based study of the causes and types of sports injuries was undertaken. Method. An injury surveillance system was established at all trauma center hospitals that treat residents 10 to 19 years old in the District of Columbia and the Chief Medical Examiners Office. Medical record abstractions were completed for those seen in an emergency department, admitted to the hospital, or who died from injury June 1996 through June 1998. Findings. Seventeen percent (n = 2563) of all injuries occurred while participating in 1 of 6 sports (baseball/softball, basketball, biking, football, skating, and soccer) resulting in an event-based injury rate of 25.0 per 1000 adolescents or 25.0/1000 population year. Rates were higher in males for all sports. The most common mechanisms were falls (E880–888) and being struck by or against objects (E916–918). Hospitalization was required in 2% of visits and there were no deaths. Of those requiring hospitalization, 51% involved other persons, 12% were equipment-related, and 8% involved poor field/surface conditions. Of all baseball injuries, 55% involved ball or bat impact often of the head. Basketball injuries included several injuries from striking against the basketball pole or rim or being struck by a falling pole or backboard. Biking injuries requiring admission included 2 straddle injuries onto the bike center bar and collision with motor vehicles. Of all football injuries, 48 (7%) involved being struck by an opponents helmet and 63 (9%) involved inappropriate field conditions including falls on or against concrete, glass, or fixed objects. In soccer there were 4 goal post injuries and a large proportion of intracranial injuries. There were 51 probable or clear assaults during sports and an additional 30 to 41 injuries from baseball bat assaults. Conclusions. Many sports including noncontact sports involved injuries of the head suggesting the need for improved head protection. Injuries involving collisions with others and assaults point to the need for supervision and enforcement of safety rules. The 16% of sports injury visits and 20% of hospitalizations related to equipment and environmental factors suggest that at least this proportion of injury may be amenable to preventive strategies. Design change may be warranted for prevention of equipment-related injuries. The many injuries involving inappropriate sports settings suggest the need for and use of available and safe locations for sports.

An Evidence-based Guideline for Prehospital Analgesia in Trauma

Abstract Background. The management of acute traumatic pain is a crucial component of prehospital care and yet the assessment and administration of analgesia is highly variable, frequently suboptimal, and often determined by consensus-based regional protocols. Objective. To develop an evidence-based guideline (EBG) for the clinical management of acute traumatic pain in adults and children by advanced life support (ALS) providers in the prehospital setting. Methods. We recruited a multi-stakeholder panel with expertise in acute pain management, guideline development, health informatics, and emergency medical services (EMS) outcomes research. Representatives of the National Highway Traffic Safety Administration (sponsoring agency) and a major childrens research center (investigative team) also contributed to the process. The panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to guide the process of question formulation, evidence retrieval, appraisal/synthesis, and formulation of recommendations. The process also adhered to the National Prehospital Evidence-Based Guideline (EBG) model process approved by the Federal Interagency Council for EMS and the National EMS Advisory Council. Results. Four strong and three weak recommendations emerged from the process; two of the strong recommendations were linked to high- and moderate-quality evidence, respectively. The panel recommended that all patients be considered candidates for analgesia, regardless of transport interval, and that opioid medications should be considered for patients in moderate to severe pain. The panel also recommended that all patients should be reassessed at frequent intervals using a standardized pain scale and that patients should be re-dosed if pain persists. The panel suggested the use of specific age-appropriate pain scales. Conclusion. GRADE methodology was used to develop an evidence-based guideline for prehospital analgesia in trauma. The panel issued four strong recommendations regarding patient assessment and narcotic medication dosing. Future research should define optimal approaches for implementation of the guideline as well as the impact of the protocol on safety and effectiveness metrics.

Effectiveness of a mentor-implemented, violence prevention intervention for assault-injured youths presenting to the emergency department: results of a randomized trial.

OBJECTIVE. The goal was to assess the impact of a mentor-implemented, violence prevention intervention in reducing aggression, fighting, and reinjury among assault-injured youths. METHODS. In a randomized, controlled trial performed in the emergency departments of 2 large urban hospitals, 10- to 15-year-old youths who presented with peer assault injuries were recruited and randomly assigned to intervention and comparison groups. In the intervention group, youths received a mentor, who implemented a 6-session problem-solving curriculum, and parents received 3 home visits with a health educator, to discuss family needs and to facilitate service use and parental monitoring. The comparison group received a list of community resources, with 2 follow-up telephone calls to facilitate service use. Youths and parents were interviewed at baseline and at 6 months, for assessment of attitudes about violence, risk factors, fighting, and repeat injury. RESULTS. A total of 227 families were recruited, with 23% refusing participation and 4% providing partial interview completion. A total of 166 families were enrolled, with 87 assigned to the intervention group and 79 to the comparison group; 118 (71%) completed both youth and parent follow-up interviews, and 113 had usable data. The intervention and comparison groups were not significantly different at baseline with respect to demographic features or risk factors, except for increased knife-carrying and fewer deviant peers in the intervention group. After adjustment for baseline differences, there was a trend toward significant program effects, including reduced misdemeanor activity and youth-reported aggression scores and increased youth self-efficacy. Program impact was associated with the number of intervention sessions received. CONCLUSIONS. A community-based, mentor-implemented program with assault-injured youths who presented to the emergency department trended in the direction of decreased violence, with reduced misdemeanors and increased self-efficacy.

Characterizing the teachable moment: is an emergency department visit a teachable moment for intervention among assault-injured youth and their parents?

Objectives: Injury interventions often invoke the teachable moment (TM); however, there is scant empirical research examining this construct with violent injuries. We sought to operationalize the TM construct and to determine whether an emergency department (ED) visit was a TM for intervention among assault-injured adolescents and their parents. Setting and Participants: One hundred sixty-eight youth (age, 10-15 years) and their parents presenting to the ED with interpersonal assault injuries at 2 urban medical centers. Methods and Analysis: Data were collected using ED record abstraction and interviews. Interview questions assessed perceived injury severity, perceived susceptibility, and preventability/ability to avoid future conflict. Data were examined by age, sex, weapon involvement, and time elapsed between injury and interview. Factor analysis was used to identify the components of the TM construct, and a TM index was created for youth and parents. Results: Youth and parents found their trip to the ED moderately stressful, although parents perceived more stress than youth. Older youth (13-15 years old) and the parents of younger youth (10-12 years old) were most likely to see their injuries as preventable. The parent TM index was positively correlated with parent-reported aggression (r = 0.16, P < 0.03); the youths TM index scores were associated with the time elapsed since the event (r = −0.16, P = 0.03). Conclusions: This study provides preliminary support for the TM after assault injuries. The TM index may be a first step toward an assessment that can differentiate individuals who are amenable to violence prevention intervention from those who are not.

Point-of-care ultrasonography by pediatric emergency medicine physicians

Emergency physicians have used point-of-care ultrasonography since the 1990s. Pediatric emergency medicine physicians have more recently adopted this technology. Point-of-care ultrasonography is used for various scenarios, particularly the evaluation of soft tissue infections or blunt abdominal trauma and procedural guidance. To date, there are no published statements from national organizations specifically for pediatric emergency physicians describing the incorporation of point-of-care ultrasonography into their practice. This document outlines how pediatric emergency departments may establish a formal point-of-care ultrasonography program. This task includes appointing leaders with expertise in point-of-care ultrasonography, effectively training and credentialing physicians in the department, and providing ongoing quality assurance reviews.

Data Elements for Emergency Department Systems, Release 1.0 (DEEDS): A Summary Report

See editorial, p 274. Variations in the way that data are entered in emergency department record systems impede the use of ED records for direct patient care and deter their reuse for many other legitimate purposes. To foster more uniform ED data, the Centers for Disease Control and Preventions National Center for Injury Prevention and Control is coordinating a public-private partnership that has developed recommended specifications for many observations, actions, instructions, conclusions, and identifiers that are entered in ED records. The partnerships initial product, Data Elements for Emergency Department Systems, Release 1.0 (DEEDS), is intended for use by individuals and organizations responsible for ED record systems. If the recommended specifications are widely adopted, then problems-such as data incompatibility and high costs of collecting, linking, and using data-can be substantially reduced. The collaborative effort that led to DEEDS, Release 1.0 sets a precedent for future review and revision of the initial recommendations. [DEEDS Writing Committee: Data Elements for Emergency Department Systems, Release 1.0 (DEEDS): A summary report. Ann Emerg Med February 1998;31:264-273.].

Urban youths’ perspectives on violence and the necessity of fighting

Objectives: To assess youth perceptions of the causes and consequences of violence generally, the causes and consequences of fighting specifically, and to determine how best to approach fighting in the context of violence prevention activities. Methods: Thirteen structured focus group interviews with youths from three high violence urban settings: a large, urban high school, a training center for disadvantaged youths, and a school for adjudicated youths. Participants were 120 urban, predominately African-American youths and young adults ages 14–22 years (mean: 17.2 years). Seven focus groups were conducted with females, and six with males. Results: Adolescents identified the causes of violence on multiple levels including: individual, family, interpersonal, and community level factors. Most youths (89%) had been in a physical fight. Participants felt that fighting was not “right”, but identified situations in which it was necessary. Specifically, fighting was used as a problem solving tool, and could prevent escalation of violence. Youths felt that the adults in their lives, including physicians, were generally ill equipped to give advice about violence, as adults’ experiences were so removed from their own. Participants looked to experienced role models to offer problem solving and harm reduction strategies. Youths were open to receiving anticipatory guidance about violence and fighting from primary care physicians they felt comfortable with, and who showed respect for their experiences. Conclusions: Interventions that include blanket admonitions against fighting should be reassessed in light of youth perceptions that fighting plays a complex role in both inciting and preventing more serious violence.

Randomized Trial of a Case Management Program for Assault-Injured Youth : Impact on Service Utilization and Risk for Reinjury

Objectives: The purposes of this study were to (1) assess receptiveness of families to violence prevention interventions initiated after an assault injury and (2) assess the effectiveness of a case management program on increasing service utilization and reducing risk factors for reinjury among assault-injured youth presenting to the emergency department. Design/Methods: A randomized controlled trial of youth, aged 12 to 17 years, presenting to a large urban hospital with peer assault injury was conducted. Youth and parents were interviewed at baseline and 6 months to measure service utilization, risk behavior, attitudes about violence, mental health, and injury history. Intervention: Intervention families received case management services by telephone or in person during 4 months by a counselor who discussed sequelae of assault injury and assessed family needs and facilitated service use. Controls received a list of community resources. Results: Eighty-eight families were enrolled; 50 (57%) completed both youth and parent follow-up interviews. Intervention and control groups were not significantly different at baseline on demographics, service utilization, and risk factors. Fighting was common in both groups. Most parents and youth identified service needs at baseline, with recreational programs, educational services, mentoring, and counseling as most frequently desired. There was no significant program effect on service utilization or risk factors for injury. Although intervention families were satisfied with case management services, there was no significant increase in service utilization compared with controls. Conclusions: Youth and parents were receptive to this violence prevention intervention initiated after an emergency department visit. This pilot case management program, however, did not increase service utilization or significantly reduce risk factors for injury. More intensive violence prevention strategies are needed to address the needs of assault-injured youths and their families.

Prevention of public health risks linked to bullying: a need for a whole community approach

Bullying is a very toxic psychosocial stressor associated with serious health problems and death, affecting both the victims and the bullies. This form of abuse or maltreatment occurs around the world and along the lifespan. Health professionals have the unique responsibility of promoting the development of community initiatives for the prevention of bullying and related health problems. This effort must include ongoing programs with elements of primary, secondary, and tertiary prevention. These programs should be supported and monitored by a public health policy with a strategy aimed at developing a whole community awareness about bullying and the related health risks, prohibiting bullying, and developing emotionally and physically safe environments in schools and workplace settings. Public health policy should mandate the monitoring, detection, and reporting of bullying incidents; provide guidance for school intervention; and offer guidelines for medical consultation.