Stephen W. Hargarten

Overseas fatalities of United States citizen travelers: An analysis of deaths related to international travel

STUDY OBJECTIVE Studies of travel-related mortality and morbidity have been limited to nonfatal events. Causes of travel-related mortality may differ significantly from morbidity and thus have different prevention strategies. DESIGN We examined the overseas fatalities of US citizen travelers for the years 1975 and 1984. The death certificates were abstracted; all deaths under age 60 and a 20% sample of deaths 60 and older were examined. SETTING AND TYPE OF PARTICIPANTS All overseas travel fatalities of US citizens were examined excluding those occurring in Canada. INTERVENTIONS None. RESULTS Cardiovascular events (including myocardial infarctions and cerebrovascular accidents) and injuries accounted for 49% and 25% of the overseas deaths of US citizen travelers, respectively. Infectious diseases other than pneumonia accounted for only 1% of the deaths. Eighty percent of injury deaths occurred outside of hospitals. Injury death rates for male travelers were greater than US age-specific death rates. CONCLUSIONS Greater emphasis on the prevention of fatal events, especially those resulting from injury, must be given by physicians and other individuals and organizations who advise travelers. Further studies are needed to explore the issues of preventable injury deaths, emergency medical services, and overseas travel.

Obesity and Risk for Death Due to Motor Vehicle Crashes

OBJECTIVES We examined the role of body mass index (BMI) and other factors in driver deaths within 30 days after motor vehicle crashes. METHODS We collected data for 22 107 drivers aged 16 years and older who were involved in motor vehicle crashes from the Crashworthiness Data System of the National Automotive Sampling System (1997-2001). We used logistic regression and adjusted for confounding factors to analyze associations between BMI and driver fatality and the associations between BMI and gender, age, seatbelt use, type of collision, airbag deployment, and change in velocity during a crash. RESULTS The fatality rate was 0.87% (95% confidence interval [CI]=0.50, 1.24) among men and 0.43% (95% CI=0.31, 0.56) among women involved as drivers in motor vehicle crashes. Risk for death increased significantly at both ends of the BMI continuum among men but not among women (P<.05). The association between BMI and male fatality increased significantly with a change in velocity and was modified by the type of collision, but it did not differ by age, seatbelt use, or airbag deployment. CONCLUSIONS The increased risk for death due to motor vehicle crashes among obese men may have important implications for traffic safety and motor vehicle design.

Before and after the trauma bay: the prevention of violent injury among youth.

Despite a decline in the incidence of homicide in recent years, the United States retains the highest youth homicide rate among the 26 wealthiest nations. Homicide is the second leading cause of death overall and the leading cause of death for male blacks aged 15 to 24 years. High rates of health care recidivism for violent injury, along with increasing research that demonstrates the effectiveness of violence prevention strategies in other arenas, dictate that physicians recognize violence as a complex preventable health problem and implement violence prevention activities into current practice rather than relegating violence prevention to the criminal justice arena. The emergency department (ED) and trauma center settings in many ways are uniquely positioned for this role. Exposure to firearm violence doubles the probability that a youth will commit violence within 2 years, and research shows that retaliatory injury risk among violent youth victims is 88 times higher than among those who were never exposed to violence. This article reviews the potential role of the ED in the prevention of youth violence, as well as the growing number of ED- and hospital-based violence prevention programs already in place.

Workplace Violence in Emergency Medicine: Current Knowledge and Future Directions

BACKGROUND Workplace violence (WPV) has increasingly become commonplace in the United States (US), and particularly in the health care setting. Assaults are the third leading cause of occupational injury-related deaths for all US workers. Among all health care settings, Emergency Departments (EDs) have been identified specifically as high-risk settings for WPV. OBJECTIVE This article reviews recent epidemiology and research on ED WPV and prevention; discusses practical actions and resources that ED providers and management can utilize to reduce WPV in their ED; and identifies areas for future research. A list of resources for the prevention of WPV is also provided. DISCUSSION ED staff faces substantially elevated risks of physical assaults compared to other health care settings. As with other forms of violence including elder abuse, child abuse, and domestic violence, WPV in the ED is a preventable public health problem that needs urgent and comprehensive attention. ED clinicians and ED leadership can: 1) obtain hospital commitment to reduce ED WPV; 2) obtain a work-site-specific analysis of their ED; 3) employ site-specific violence prevention interventions at the individual and institutional level; and 4) advocate for policies and programs that reduce risk for ED WPV. CONCLUSION Violence against ED health care workers is a real problem with significant implications to the victims, patients, and departments/institutions. ED WPV needs to be addressed urgently by stakeholders through continued research on effective interventions specific to Emergency Medicine. Coordination, cooperation, and active commitment to the development of such interventions are critical.

Incidence of sports and recreation related injuries resulting in hospitalization in Wisconsin in 2000

Objective: To describe the incidence and patterns of sports and recreation related injuries resulting in inpatient hospitalization in Wisconsin. Although much sports and recreation related injury research has focused on the emergency department setting, little is known about the scope or characteristics of more severe sports injuries resulting in hospitalization. Setting: The Wisconsin Bureau of Health Information (BHI) maintains hospital inpatient discharge data through a statewide mandatory reporting system. The database contains demographic and health information on all patients hospitalized in acute care non-federal hospitals in Wisconsin. Methods: The authors developed a classification scheme based on the International Classification of Diseases External cause of injury code (E code) to identify hospitalizations for sports and recreation related injuries from the BHI data files (2000). Due to the uncertainty within E codes in specifying sports and recreation related injuries, the authors used Bayesian analysis to model the incidence of these types of injuries. Results: There were 1714 (95% credible interval 1499 to 2022) sports and recreation-related injury hospitalizations in Wisconsin in 2000 (32.0 per 100 000 population). The most common mechanisms of injury were being struck by/against an object in sports (6.4 per 100 000 population) and pedal cycle riding (6.2 per 100 000). Ten to 19 year olds had the highest rate of sports and recreation related injury hospitalization (65.3 per 100 000 population), and males overall had a rate four times higher than females. Conclusions: Over 1700 sports and recreation related injuries occurred in Wisconsin in 2000 that were treated during an inpatient hospitalization. Sports and recreation activities result in a substantial number of serious, as well as minor injuries. Prevention efforts aimed at reducing injuries while continuing to promote participation in physical activity for all ages are critical.

Injury Deaths of US Citizens Abroad: New Data Source, Old Travel Problem

BACKGROUND Global travel continues to increase, including among US citizens. The global burden of injuries and violence, accounting for approximately 5 million deaths worldwide in 2000, is also growing. Travelers often experience heightened risk for this biosocial disease burden. This study seeks to further describe and improve our understanding of the variable risk of travel-related injury and death. METHODS Information on US civilian citizen deaths from injury while abroad was obtained from the US Department of State Web site. This information was categorized into regional and causal groupings. The groupings were compared to each other and to injury deaths among citizens in their native countries. RESULTS From 2004 to 2006, there were 2,361 deaths of US citizens overseas due to injury. Of these US citizen injury deaths, 50.4% occurred in the Americas region. Almost 40% (37.8%) of US citizen injury deaths in the low- to middle-income Americas were due to vehicle crashes compared to about half that (18.9%) (proportional mortality ratio [PMR] = 1.72, 95% confidence interval [CI] 1.59-1.62) for low- to middle-income Americas citizen injury deaths. Similar differences between US citizen injury death abroad and the in-country distributions were also found for vehicle crashes in Europe (35.9% vs 16.5%, PMR = 2.17, 95% CI 1.78-2.64; p < 0.0005), for drowning deaths in the Americas (13.1% vs 4.6%, PMR = 2.67, 95% CI 2.29-3.11) and many island nations (63.5% vs 3.5%, PMR = 11.38, 95% CI 8.17-15.84), and for homicides in the low- to middle-income European countries (16.9% vs 10.5%, PMR = 1.52, 95% CI .90-2.57). CONCLUSIONS US citizens should be aware of regional variation of injury deaths in foreign countries, especially for motor vehicle crashes, drowning, and violence. Improved knowledge of regional variations of injury death and risk for travelers can further inform travelers and the development of evidence-based prevention programs and policies. The State Department Web site is a new data source that furthers our understanding of this challenging travel-related health issue.

Emergency airway management in hanging victims

STUDY OBJECTIVE To determine the incidence, demographics, clinical indicators of survival, and frequency of cervical-spine fractures to define appropriate emergency airway management in hanging victims. DESIGN Medical examiner records, paramedic reports, and emergency department and hospital medical records were reviewed retrospectively for the period January 1, 1978, to January 1, 1990. SETTING Urban paramedic system with nine receiving hospitals. PARTICIPANTS A total of 160,724 medical examiner and paramedic records were reviewed to identify a total study population of 306 hanging victims. One hundred eighty-two victims (59%) were found dead at the scene, and the emergency medical system was not notified. An additional 57 (19%) were seen by paramedics and declared dead at the scene. Sixty-seven (22%) were treated and transported to nine receiving EDs; 39 of these 67 received oral or nasal endotracheal intubation. RESULTS The incidence of hanging was 0.19% of all medical examiner cases and paramedic runs during the 12-year study. Those hanging victims who survived to receive paramedic transport and treatment by physicians were typically male and attempted suicidal hanging in a public place (most frequently jail) with available bedding or clothes. No hanging victim treated and transported by paramedics had documentation of cervical-spine or spinal cord injury. CONCLUSION In nonjudicial hanging victims seen by paramedics and transported to an ED, cervical-spine injury is rare. Cerebral hypoxia rather than spinal cord injury is the probable cause of death and should be the primary concern in treatment of this patient population. Following external stabilization of the neck, nasal or oral endotracheal intubation is appropriate emergency airway management in hanging victims.

Predictive value of psychological screening in acute hand injuries

Difficulties in adjustment frequently accompany severe hand injuries. The purpose of this study was to determine whether presurgical screening could predict long-term adjustment problems. One hundred thirteen patients with severe hand injuries completed a presurgical questionnaire evaluating flashbacks, avoidance, and causal factors pertaining to the injury. Patients were evaluated by a psychologist within 5 days after surgery and again 6 months later. Flashbacks initially occurred with equal frequency in occupationally and nonoccupationally injured groups. At 6-month follow-up 50% of the occupationally injured patients and 25% of the nonoccupationally injured patients had flashbacks. Avoidance of the activity at which patients were injured was also assessed. Among occupationally injured patients, 52% initially reported no avoidance compared with 17% at follow-up. Patients with nonoccupational injuries showed more initial avoidance (68%), with slightly less at follow-up (61%). Of the occupationally injured patients, 46% initially reported personal error or fatigue as the cause of their injury, but only 6% reported this as the cause at follow-up; it is interesting that at 6-month follow-up 81% of this group reported machine failure or lack of safeguards. Among nonoccupationally injured patients, 71% reported personal error as the cause of injury presurgically and 66% at 6-month follow-up. Presurgical screening appears to be a valid means of identifying persons at risk of ongoing adjustment problems after hand injury. A screening interview can easily be conducted in less than 5 minutes.

Cancer presentation in the emergency department: A failure of primary care

Emergency departments are intended to be the location of entry into the health care system for patients with acute problems, such as injuries and myocardial infarctions. In contrast, cancer should optimally be detected during periodic health examinations, either through screening procedures or by early detection from signs and symptoms which prompt a routine visit to a primary care physician. This study was undertaken to describe patients who present to an emergency department with urgent symptoms and signs, are hospitalized, and subsequently diagnosed with cancer (ED group). One hundred twenty-nine patients were retrospectively studied. When compared with patients diagnosed in a primary care setting (tumor registry patients), the ED group was significantly older, more often male, had a significantly lower survival rate, and more frequent metastatic disease at diagnosis (P less than .001). The ED group accounted for 5.3% of the new tumor registry patients for the study years. Only 3.1% of the ED group had no insurance, and 21% reported no personal physician. Strategies are needed for patients and physicians to reduce the number of late-diagnosed cancer cases presenting in emergency departments.

Death after discharge from the emergency department

STUDY OBJECTIVE To determine the rate and cause of death of patients who were evaluated in the emergency department and discharged and how the cause of death related to the ED visit. DESIGN Retrospective chart review of medical examiner cases from July 1, 1990, to June 30, 1991. SETTING Urban county served by 13 hospital EDs with 383,416 visits in 1991. Eighty-five percent of these patients were discharged. PARTICIPANTS Medical examiner cases of patients who had been evaluated and released from an ED within 8 days prior to death. RESULTS Forty-two of the 2,665 medical examiner cases met inclusion criteria. Death was classified as expected or unexpected based on the patients clinical status at the time of discharge, and directly related or not directly related to the ED visit, based on review of all records and the cause of death as listed on the death certificate. Six deaths (14%) were considered expected and directly related. Three deaths (7%) were considered expected and not directly related. Twenty-four deaths (57%) were considered unexpected and not directly related. Nine deaths (21%) were considered unexpected and directly related; the most common cause was ruptured aortic aneurysm, occurring in three of these nine cases. The death rate was 13 per 100,000 discharged patients. CONCLUSION Death after discharge from the ED is uncommon. The most common cause of unexpected, directly related death is ruptured aortic aneurysm.