Motorcycle casualties sustained during Daytona Beach Bike Week 2000: lessons learned

STUDY OBJECTIVE: In March 2000, an estimated 500,000 people attended an annual motorcycle rally in Daytona Beach, FL, where approximately 64,000 residents live year-round. The media reported 15 deaths during this 10-day event. To more comprehensively assess the extent of trauma and need for emergency medical care, we investigated all motorcycle crashes, regardless of outcome. METHODS: Motorcycle-related crash data from local medical examiner, hospital, emergency medical services (EMS), and police sources were linked. Frequencies of crashes, injuries, hospitalizations, and deaths were determined, and EMS use data were analyzed. RESULTS: During Bike Week 2000, 570 people were involved in 281 motorcycle-related crashes. Two hundred thirty (40%) people were injured, of which 147 (64%) sought treatment in emergency departments, 72 (31%) were hospitalized, and 11 (5%) died. In crashes between motorcycles and passenger cars, individuals exposed as motorcycle occupants were 8.7 times more likely to be injured than car occupants (95% confidence limit 1.7, 15.7). Of 205 EMS dispatches for motorcycle-related crashes, two thirds resulted in transport to an ED. Data needed to assess known risk factors (eg, alcohol use, speed, lack of helmet use) were not routinely ascertained at either the crash site or ED. CONCLUSION: Although fatalities first called attention to the problem, nonfatal injuries outnumbered deaths 20:1. The manpower resources of civil service and health resources could become overwhelmed or exhausted in circumstances in which many people are injured or killed throughout a relatively long period. The situation deserves future study. Better risk factor surveillance is needed to help prevent crashes.     

Factors associated with severity of motorcycle injuries among young adult riders

Study objective: A cohort of 4,729 junior college students in Taiwan was studied to determine risk factors for increased severity of motorcycle injuries. Methods: Crash characteristics were collected by using self-administered questionnaires soon after a student was involved in a motorcycle crash. The proportional odds model with generalized estimating equations, with correlated ordinal responses for collisions categorized into not injured, mildly injured, and severely injured categories, was used to determine the odds of injury severity. Results: A total of 1,889 motorcycle crashes involving 1,284 persons occurred over a 20-month period from November 1994 to June 1996. There were 1,339 noninjuries, 474 mild injuries, and 76 severe injuries. The adjusted odds ratio (OR) of rural to urban roads having a greater level of injury severity was 1.64. Compared with noncollisions, collisions with a moving car (adjusted OR=1.76), a parked car (adjusted OR 1.90), or another stationary object (adjusted OR=2.31) increased the odds for a greater level of injury severity. Riders using Sanyang (adjusted OR=1.63) and Yamaha (adjusted OR=1.39) motorcycles had greater odds of being involved in a crash with a greater level of injury compared with those riding Kymco motorcycles. Darkness (adjusted OR=1.65) and greater speeds (adjusted OR=1.63 to 4.69) also increased the odds of greater injury severity. Conclusion: At the time of motorcycle crashes, factors such as being on rural roads, collisions with a heavier object, some motorcycle makes, darkness, and greater speeds increased the severity of motorcycle injuries among these young adult riders. [Ann Emerg Med. 2003;41:783-791.]     

A prospective study of the impact of helmet usage on motorcycle trauma.

STUDY OBJECTIVE: To determine the effect of the use of a motorcycle helmet on reducing the mortality, morbidity, and health care costs resulting from motorcycle crashes. DESIGN: A prospective, multicenter study of all eligible motorcycle crash victims. SETTING: The emergency departments of eight medical centers across the state of Illinois, including representatives from urban, rural, teaching, and community facilities. TYPE OF PARTICIPANTS: All motorcycle crash victims presenting less than 24 hours after injury for whom helmet information was known. Data were collected from April 1 through October 31, 1988. MEASUREMENTS AND MAIN RESULTS: Fifty-eight of 398 patients (14.6%) were helmeted, and 340 (85.4%) were not. The nonhelmeted patients had higher Injury Severity Scores (11.9 vs 7.02), sustained head/neck injuries more frequently (41.7 vs 24.1%), and had lower Glasgow Coma Scores (13.73 vs 14.51). Twenty-five of the 26 fatalities were nonhelmeted patients. By logistic regression, the lack of helmet use was found to be a major risk factor for increased severity of injury. A 23% increase in health care costs was demonstrated for nonhelmeted patients (average charges $7,208 vs $5,852). CONCLUSION: Helmet use may reduce the overall severity of injury and the incidence of head injuries resulting from motorcycle crashes. A trend toward higher health care costs was demonstrated in the nonhelmeted patients.     

Air Bag Safety

Study objective: To describe injuries associated with deployment of air bag passive-restraint systems in use in the United States.Design: Retrospective review of data collected by the National Highway Traffic Safety Administration (NHTSA) from 1980 to 1994. Participants: Occupants of air bag-equipped vehicles who were involved in crashes on US roads. Results: Of 618 reported occupant injuries related to air bag deployment, an overwhelming majority were classified as minor (96.1%). Most occupants sustained abrasions, contusions, and lacerations. The face (42.0%), wrist (16.8%), forearm (16.3%) and chest (9.6%) were the most frequently injured body areas. Conclusion: Most injuries related to air bag deployment are minor and must be viewed in the context of the potentially life-threatening injuries they prevent. [Antosia RE, Partridge RA, Virk AS: Air bag safety. Ann Emerg Med June 1995;25:794-798.]     

Factors associated with severity of motorcycle injuries among young adult riders

STUDY OBJECTIVE: A cohort of 4,729 junior college students in Taiwan was studied to determine risk factors for increased severity of motorcycle injuries. METHODS: Crash characteristics were collected by using self-administered questionnaires soon after a student was involved in a motorcycle crash. The proportional odds model with generalized estimating equations, with correlated ordinal responses for collisions categorized into not injured, mildly injured, and severely injured categories, was used to determine the odds of injury severity. RESULTS: A total of 1,889 motorcycle crashes involving 1,284 persons occurred over a 20-month period from November 1994 to June 1996. There were 1,339 noninjuries, 474 mild injuries, and 76 severe injuries. The adjusted odds ratio (OR) of rural to urban roads having a greater level of injury severity was 1.64. Compared with noncollisions, collisions with a moving car (adjusted OR=1.76), a parked car (adjusted OR 1.90), or another stationary object (adjusted OR=2.31) increased the odds for a greater level of injury severity. Riders using Sanyang (adjusted OR=1.63) and Yamaha (adjusted OR=1.39) motorcycles had greater odds of being involved in a crash with a greater level of injury compared with those riding Kymco motorcycles. Darkness (adjusted OR=1.65) and greater speeds (adjusted OR=1.63 to 4.69) also increased the odds of greater injury severity. CONCLUSION: At the time of motorcycle crashes, factors such as being on rural roads, collisions with a heavier object, some motorcycle makes, darkness, and greater speeds increased the severity of motorcycle injuries among these young adult riders.     

Prospective Countywide Evaluation of the Effects of Motor Vehicle Safety Device Use on Hospital Resource Use and Injury Severity

Study objective: We evaluated the efficacy of safety devices (seat belts and air bags) on hospital resource use and injury severity while controlling for variables known to affect outcome of motor vehicle crashes. Methods: We conducted a prospective observational study of motor vehicle crash victims who were transported to the hospital in a suburban-rural county with a population of 1.4 million. Out-of-hospital providers recorded patient demographic characteristics, mechanism of injury (based on American College of Surgeons criteria), and use of seat belts or air bags. Hospital charts were reviewed for hospital admission, length of hospital stay, ICU stay, surgery, major nonorthopedic surgery or death, and severe injury (Injury Severity Score > 15). Results: The study group comprised 1,446 motor vehicle crash victims. Median age was 30 years, 47% were male, and 69% used safety devices. The use of safety devices reduced the likelihood of hospital admission (adjusted odds ratio [OR], .67; 95% confidence interval [CI], .46 to .98), surgery (adjusted OR, .52; 95% CI, .27 to 1.01), major surgery or death (adjusted OR, .14; 95% CI, .04 to .52), and severe injuries (adjusted OR of Injury Severity Score > 15, .39; 95% CI, .19 to .83). Conclusion: The use of safety devices is associated with decreased hospital resource use and less severe injuries for victims of motor vehicle crashes who are transported to the hospital by emergency medical services providers, even after adjustment for many other variables known to affect the outcome of motor vehicle crashes. Continued efforts to promote safety device use are warranted. [Henry MC, Hollander JE, Alicandro JM, Cassara G, O'Malley S, Thode HC Jr: Prospective countywide evaluation of the effects of motor vehicle safety device use on hospital resource use and injury severity. Ann Emerg Med December 1996;28:627-634.]     

Motorcycle crash injuries and costs: effect of a reenacted comprehensive helmet use law.

STUDY OBJECTIVES: To document the effect of a reenacted comprehensive helmet use law on injuries and fatalities. DESIGN: Retrospective before-and-after analysis. SETTING: Two urban counties representing 40% of Nebraska's population. PARTICIPANTS: Six hundred seventy-one patients reported as injured to the Nebraska Department of Roads in the period from one year before through one year after the reenactment on January 1, 1989. RESULTS: The helmet use law was temporally associated with a 26% decrease in the reported rate of motorcycle crashes in Nebraska compared with five other midwestern states. There were sharp declines in the number (and rates) of reported injured, hospital transports, hospital admissions, severe nonhead injuries, severe head injuries, and deaths. Serious head injuries (Abbreviated Injury Score, 3 or higher) decreased 22%. The percentage of injured motorcyclists with serious head injuries was significantly lower among the helmeted motorcyclists (5%) than among the unhelmeted cyclists (14%) for the two years combined. CONCLUSION: The reenactment of a helmet use law resulted in fewer crashes, fatalities, and severe head injuries.     

A population-based study of motorcycle injury and costs.

STUDY OBJECTIVE: To provide a population-based injury and cost profile for motorcycle injury in Connecticut. DESIGN: Population-based retrospective epidemiologic review of Connecticut death certificates, hospital discharge data, and police accident reports. RESULTS: Connecticut death certificates identified 112 deaths from motorcycle injuries for an annual death rate of 1.2 per 100,000 persons. Death rates were highest among 20- to 24-year-old men. Nonhelmeted motorcyclists were 3.4-fold more likely to die than were helmeted riders (P less than .05). An estimated 2,361 motorcycle-related hospital discharges resulted in an annual hospitalization rate of 24.7 per 100,000 persons. Head, neck, and spinal injuries accounted for 22% of all injuries. Total costs exceeded $29 million; 29% of hospitalized patients were uninsured, and 42% of the cost was not reimbursed to the hospitals. CONCLUSION: Motorcycle injuries contribute significantly to Connecticut's mortality, morbidity, and medical costs. Our study suggests that a uniform helmet law would save an estimated ten lives and prevent more than 90 nonfatal injuries in Connecticut each year at a cost savings to the state of $5.1 million. These data are crucial in advocating re-enactment of motorcycle helmet laws.     

Against all advice: an analysis of out-of-hospital refusals of care

STUDY OBJECTIVE: We examine the characteristics of patients involved in out-of-hospital emergency medical services (EMS) incidents that result in refusal of care and determine the rates of subsequent EMS, emergency department (ED), and inpatient care, as well as death within 7 days. METHODS: Utah statewide EMS data identifying refusals of care were probabilistically linked to Utah statewide ED, inpatient, and death certificate data within 7 days of the initial EMS refusals for 1996 to 1998. Refusals were defined as incidents in which field treatment or transport was refused and did not include incidents in which EMS providers deemed care or transport unnecessary. RESULTS: Of 277244 EMS incidents, 14109 (5.1%) resulted in refusals of care. For all age groups, motor vehicle crash dispatches resulted in the highest rate of refusal of care, ranging from 8.0% to 11.7%. Slightly more than 3% of patients involved in a refusal of care incident had a subsequent EMS dispatch within a week. One fifth of the patients involved in EMS refusals of care had a subsequent ED visit. Less than 2% of the EMS refusal patients were hospitalized; hospitalization was highest among children younger than 3 years and adults older than 64 years. Twenty-five adults died within a week of refusing EMS care, of whom 19 (76.0%) were older than 64 years. CONCLUSION: Refusal of care incidents are a small segment of all EMS incidents. They arise from a variety of situations, and the risk for missed intervention may be minimal.     

Occupational Blood Contact Among Prehospital Providers

Study objective: To assess the nature and frequency of blood contact (BC) among emergency medical service (EMS) workers.Design: During an 8-month period, we interviewed EMS workers returning from emergency transport calls on a sample of shifts. We simultaneously conducted an HIV seroprevalence survey among EMS-transported patients at receiving hospitals served by these workers. Setting: Three US cities with high AIDS incidence. Participants: EMS workers. Results: During 165 shifts, 2,472 patients were attended. Sixty-two BCs (1 needlestick and 61 skin contacts) were reported. Individual EMS workers had a mean of 1.25 BCs, including .02 percutaneous exposures, per 100 patients attended. The estimated annual frequency of BC for an EMS worker at the study sites was 12.3, including .2 percutaneous exposures. For 93.5% of the BCs, the HIV serostatus of the source patients was unknown to the EMS worker. HIV seroprevalences among EMS-transported patients at the three receiving hospital emergency departments were 8.3, 7.7, and 4.1 per 100 patients; the highest rates were among male patients 15 to 44 years old who presented with pneumonia. Conclusion: EMS personnel regularly experience BCs, most of which are skin contacts. Because the HIV serostatus of the patient is usually unknown, EMS workers should practice universal precautions. Postexposure management should include a mechanism for voluntary HIV counseling and testing of the patient after transport and transmittal of the results to the EMS. [Marcus R, Srivastava PU, Bell DM, McKibben PS, Culver DH, Mendelson MH, Zalenski RJ, Kelen GD: Occupational blood contact among prehospital providers. Ann Emerg Med June 1995;25:776-779.]     

Use of out-of-hospital variables to predict severity of injury in pediatric patients involved in motor vehicle crashes

STUDY OBJECTIVE: We sought to create a clinical decision rule, on the basis of variables available to out-of-hospital personnel, that could be used to accurately predict severe injury in pediatric patients involved in motor vehicle crashes as occupants. METHODS: We analyzed the National Automotive Sampling System database, a national probability sample, using pediatric patients up to 15 years old (occupants only) involved in motor vehicle crashes from January 1993 to December 1999. The National Automotive Sampling System database includes patients from regions throughout the country, weighted to represent a nationwide sample. Twelve out-of-hospital variables were used in classification and regression tree analysis to create a decision rule separating children with severe injuries (Injury Severity Score [ISS] > or =16) from those with minor injuries (ISS < 16). Misclassification costs and complexity parameters were selected to yield a decision tree with appropriate sensitivity and specificity for the identification of severely injured patients, while also being simple and practical for out-of-hospital use. Probability weights were used throughout the analysis to account for the sampling design and sampling weights. RESULTS: Using a sample size of 8,392 children, we constructed a decision rule using 3 out-of-hospital variables (Glasgow Coma Scale score, passenger space intrusion > or =6 in [> or =15 cm], and restraint use) to predict those patients with an ISS of 16 or more. Internal cross-validation was used to determine the sensitivity and specificity, yielding values of 92% and 73%, respectively, for the prediction of patients with an ISS of 16 or more. CONCLUSION: Out-of-hospital variables available to field personnel could be used to effectively triage pediatric motor vehicle crash patients using the decision rule developed here. Prospective trials would be needed to test this decision rule in actual use.     

Risk factors for motor vehicle crashes in older women

BACKGROUND: Motor vehicle crash and fatality rates are higher per mile driven for elderly drivers, with an exponential increase above age 75. Identifying elderly drivers who are at risk for automobile crashes may help direct interventions to reduce their high rate of injuries and deaths. METHODS: Subjects were 1416 women aged 65 to 84 enrolled in the Portland, Ore. site of the Study of Osteoporotic Fractures. Motor vehicle crash information for the years 1986-1995 for each participant was obtained from the Oregon State Department of Transportation. Items from questionnaires, interviews, and physical examinations were tested prospectively for associations with the occurrence of motor vehicle crashes. RESULTS: About one third of participants (415 of 1416) had a motor vehicle crash during a mean follow-up time of 5.7 years. After adjustment for age and weekly driving mileage, risk factors significantly associated with motor vehicle crashes were a fall in the previous year [hazard ratio (HR) 1.53, 95% confidence interval (CI) 1.26-1.86], a greater orthostatic systolic blood pressure drop (HR 1.11 per 12.5 mm Hg, 95% CI 1.01-1.22), and increased foot reaction time (HR 1.10 per 0.06 second, 95% CI 1.00-1.22). Other neuromuscular tests, functional status, medical diagnoses, vision tests, and cognitive tests did not predict motor vehicle crashes in this study population. CONCLUSIONS: This prospective study with extended follow-up of a large cohort of elderly women has identified crash risk factors that can be measured in the clinical setting. Further study is needed to determine if interventions aimed at these risk factors can decrease the risk of motor vehicle crashes.     

Effect of Adenosine on the Management of Supraventricular Tachycardia by Urban Paramedics

Study objective: To determine the effect of the addition of adenosine, as a standing-order medication, on the prehospital management of supraventricular tachycardia (SVT) in a large urban emergency medical services (EMS) system. Design: Prospective observational case series with historical controls. Setting: Large urban municipal EMS system staffed by paramedics and emergency medical technicians trained to operate automatic or semiautomatic defibrillators (EMT-Ds). Participants: We observed a consecutive sample of prehospital patients who presented with an initial ECG rhythm of SVT, as interpreted by the treating paramedics, between July 1 and December 31, 1993. We used patients from the same 6-month period in 1992 as our control group. Indications for treatment were chest pain, evidence of myocardial ischemia, or shock. Adenosine had been introduced as a first-line medication to be used under standing orders in cases of unstable SVT before a physician was contacted for medical control options. Results: We studied 239 cases and 228 controls. Acceptable call reports with pretreatment and posttreatment ECGs were available for 140 (59%) of the study cases and 104 (46%) of the controls. The two groups were similar in terms of age, sex, and initial vital signs. In the control group, 75 patients had indications for treatment, and 16 were treated (21%). In the study group, 127 had indications for treatment and 103 (81.1%) were treated (odds ratio, 15.83; 95% confidence interval, 7.38-34.4). Conclusion: The introduction of adenosine as a standing-order medication into an urban EMS system increased the proportion of patients who received advanced life support treatment. Paramedics were able to accurately diagnose and begin treatment of SVT with adenosine without direct medical supervision. [Lozano M Jr, McIntosh BA, Giordano LM: Effect of adenosine on the management of supraventricular tachycardia by urban paramedics. Ann Emerg Med December 1995;26:691-696.]     

Rural trauma care: a study of trauma care in a rural emergency medical services region

Motor vehicle-related trauma deaths in a 21-county rural emergency medical services (EMS) system are reviewed. Injury severity scores (ISS) and Glasgow coma scores (GCS) were recorded to provide baseline data for future comparison as the system progresses. The majority of deaths (67%) were related to CNS injuries. ISS in this series was similar to data reported from Orange County, California. The average GCS for all patients in this series was 5, indicating the high prevalence and severity of head injuries in motor vehicle deaths. Patients treated only in community hospitals had a low average ISS of 28.5. Those transferred from community hospitals to the regional tertiary care center had an average ISS of 36.2. Those admitted directly to the tertiary center had an ISS of 38.9. The data suggest that the rural trauma system might improve if there were training programs that promote recognition of significant injury, more aggressive resuscitation, and expeditious transfer of the injured patients.     

Motorcycle fatalities in New Mexico: the association of helmet nonuse with alcohol intoxication.

STUDY OBJECTIVE: To determine the relationship among helmet use, alcohol use, and ethnicity in people killed on motorcycles. DESIGN: Retrospective review of all motorcycle fatalities in New Mexico from 1984 through 1988. SETTING: Office of the Medical Investigator, State of New Mexico. TYPE OF PARTICIPANTS: All decedents of motorcycle crashes in New Mexico from 1984 through 1988. INTERVENTIONS: Review of all autopsies, medical investigator reports, traffic fatality reports, and toxicological studies on fatally injured motorcyclists. RESULTS: Nine of the helmeted drivers (18%) were legally intoxicated compared with 67 of the nonhelmeted drivers (51%) (chi 2 = 15.7, P less than .0001); 42 of the white nonHispanic decedents (37%), ten of Hispanic decedents (12%), and none of the Native-American decedents were wearing helmets. The head and neck region was the most severely injured body region in 42 of the nonhelmeted cases (84%) and in eight of the helmeted cases (50%) (Fisher's exact test, P less than .02). CONCLUSION: There is an association between nonuse of helmets and alcohol intoxication in fatally injured motorcyclists in New Mexico. Strategies for preventing motorcycle fatalities should address alcohol abuse and ethnicity in conjunction with helmet use.     

VESAS: A Solution to Seasonal Fluctuations in Emergency Department Census

Study objective: To design and implement a plan for emergency department staffing and additional space to reduce waiting time and the rate of patients leaving without being seen during the viral epidemic season. Methods: The study was conducted in the ED of a tertiary care children’s hospital. We compared 24,657 children who presented for care between November 1996 and March 1997 (VESAS plan enacted) with 24,012 children who presented for care during the same period in the preceding year. VESAS (Viral Epidemic Supplemental Attending and Staff), an additional team of personnel, was on call for the viral epidemic season and was called to work if the hourly ED census that day was 25% or more of the past year’s average hourly patient volume. Extra examination rooms were made available in space contiguous to the ED. Interval data, “left without being seen” rates, and ED census were monitored and compared with the previous year’s data. Results: The VESAS team was used for 32% of the days during the 4-month intervention period. The left-without-being-seen rate was reduced by 37% (95% confidence interval, 33% to 41%). The average time from arrival to consultation with a physician was decreased by 15 minutes (95% confidence interval, –10 to –20) for all patients. Waiting times were most markedly reduced for less acutely ill or injured patients, although a modest decrease was also observed in patients with more severe illnesses or injuries (–10 minutes). The percentage of lesser-severity patients seen in an urgent care area was increased from 35% to 51%. Conclusion: VESAS, a plan for providing space and personnel to handle an increased volume of patients that can be activated on the basis of hourly census data, was successful as judged by waiting times and percentage of patients who left without being seen. [Shaw KN, Lavelle JM: VESAS: A solution to seasonal fluctuations in emergency department census. Ann Emerg Med December 1998;32:698-702.]     

Emergency Department Presentation and Misdiagnosis of Imported Falciparum Malaria

Study objective: To review the travel history, clinical presentation, laboratory findings, diagnostic accuracy, management, and outcome of the largest reported series of emergency department patients with imported falciparum malaria in the United States. Methods: This is a retrospective case series at a large, inner-city medical center in Los Angeles. Twenty cases of falciparum malaria with initial medical evaluation in the ED were identified from the period 1979 through 1993. Results: Fifteen male and 5 female patients were identified, with an age range of 5 to 55 years. All had a recent history (within 2 months) of international travel in regions endemic for malaria. Most (85%) were recent immigrants or expatriates returning from a recent visit to their native country. The most common documented symptoms were fever (100%), chills (65%), vomiting (60%), anorexia (45%), and headache (45%). Tachycardia (85%) and hyperpyrexia (>39°C) (65%) were the most common presenting signs. Malaria was considered in the ED diagnoses in only 12 cases (60%). The specification of falciparum (malignant) malaria was established in only 2 cases (10%). Hepatitis and gastroenteritis were the most common misdiagnoses. Only four patients received antimalarial medication in the ED. There were no deaths, and complications were limited to thrombocytopenia and anemia. Two patients required transfusion. Conclusion: Imported falciparum malaria presenting to EDs in the United States is frequently misdiagnosed. Emergency physicians improve their ability to diagnose falciparum malaria by obtaining a thorough travel history on all patients with clinical features suggesting an infectious origin and considering this diagnosis in any patient with a history of travel to or migration from malaria-endemic areas. [Kyriacou DN, Spira AM, Talan DA, Mabey DCW: Emergency department presentation and misdiagnosis of imported falciparum malaria. Ann Emerg Med June 1996;27:696-699.]