Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter.
Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.
OCR for page 129
15. Unintentional Injuries
The harm, disability, and death resulting from injury
can be reduced by coordinated community prevention
and control measures and individual awareness of risk
factors for injurer, according to many testifiers. (#368;
#378)
Injuries are not accidents or random events. They
are predictable and therefore preventable. Injury
prevention can be effective, but there are many
players, and little direction," states Patricia West of
the Colorado Department of Health. (~368)
Frederick Rivara, Director of the Harborview Injury
Prevention and Research Center in Seattle, believes
that "injurer control is coming of age, and will have a
significant impact on the morbidity and mortality due
to trauma in the coming decade." (#334) Steven
Macdonald of the University of Washington quotes
the 1985 National Academy of Sciences report Injury
in Amenca, which states that ninjury is the principal
public health problem in America today.
Macdonald echoes this view and calls for a concerted
local, state, and national approach: "Linking injury
epidemiology and health policy is the key." (~322)
Over the past decade, adds Rivara, the increasing
attention paid to controlling injury has allowed this
attitude of preventability to take root. It is likely that
aggressive goals in injury control can be set and
reached by the year 2000. (~334J Forty-eight
testifiers addressed unintentional injuries and sug-
gested objectives to reduce injury from motor vehicle
accidents, falls, fires, poisoning, drowning, and
violence.
The Year 2000 Health Objectives distinguish
between intentional and unintentional injuries.
Speakers gave specific objectives for each category and
outlined many prevention strategies. For a few
testifiers, separation of the two categories in the Year
2000 Health Objectives is problematic. Not only is
the intentionality of many injuries hard to assess, says
Macdonald, but if trends and prevention measures are
to be reliable, injury reporting must include all
injuries, regardless of cause. (#322)
Because of the nature of much of the testimony
and many of the suggested prevention strategies, this
chapter presents injury prevention goals popularly
grouped under Unintentional" injuries. Chapter 16
deals with injury prevention as it relates to violence,
homicide, suicide, child abuse, and so on, which come
under the heading of ~intentional" injury in the Year
2000 Health Objectives outline. Disabling injuries,
especially as they affect children and teens, are seen
by many witnesses as deserving special attention, as
are implementation problems related to manpower
and organization and to surveillance and data collec-
tion.
MOTOR VEHICLE INJURIES
The American Automobile Association (AAA) reports
that 44,241 people died nationwide in 1984, from
motor vehicle crashes. Of these fatalities, about half
were alcohol related.2 ¢~008) Trauma from motor
vehicle crashes is the fourth leading cause of death in
the United States, the leading cause of death for ages
5 to 34, and the second leading cause of death for
ages 1 to 4. The vehicular-crash-related death rate
for a 15-year-old male is many times that of polio at
its worst. (~011) In terms of potential years of life
lost, motor vehicle fatalities rate above both cancer
and heart disease.
To reduce the number of motor vehicle deaths,
says Karen Tarrant of the Michigan Department of
State Police, the problem must be seen as an impor-
tant public health priority. (~425) Traffic injuries
are more than just a "highway safety problem," echoes
James Saalberg of the CUNA Mutual Insurance
Group, and individuals must be encouraged to think
of them as a health problem. (~190)
According to Tarrant, prevention and control of
motor vehicle accidents involve five components:
drinking and driving, proper restraint, speed, roadway
design, and vehicle design. Of these five, drinking
and driving, proper restraint, and compliance with
speed limits reflect individual attitudes. Although law
enforcement agencies can take measures to increase
compliance with traffic rules, health promotion efforts
in the community are necessary to bring about
significant and long-lasting reductions in injury rates.
Such programs should teach the importance of
"buckling up," not driving after or while drinking, and
obeying speed limits. (~425) Robert Haggerty of the
William T. Grant Foundation reports that driver
competence (or incompetence) is also a factor in
some motor vehicle accidents, (e.g., older drivers with
vision or hearing deficiencies) and should be
Unintentional Injuries 129
OCR for page 130
addressed through both increased compliance and
health promotion efforts. (#784J
Richard Austin, chairman of the Michigan State
Safety Commission, adds that education on traffic
safety has to indude personal decisions about interact-
ing with other vehicles as pedestrians, bicyclists, or
drivers. (#011) Such education Is especially impor-
tant for children. As pedestrians and bicycle riders,
many children do not have a proper understanding of
how a car operates or how long it takes to stop.
(#058) For five to nine year olds, pedestrian and
bicycle injury is the most important cause of trauma
that leads to death.3 (#334J
Education, however, is not sufficient by itself to
reduce fatalities from motor vehicle crashes. David
Sleet of San Diego State University says that failure
to use seat restraints may be the single most impor-
tant preventable risk factor for motor vehicle trauma.
This trend must be countered and reversed through
policy and legislation, as well as through health
promotion and incentives. "With 100 percent safety
belt use in front seats, an additional 10,000 lives could
have been saved and 120,000 injuries prevented in
1986," he says. (#285) Leo Gossett of the Texas
Department of Public Safety also sees the proper use
of occupant restraints as The most identifiable and
measurable factor" in the reduction of motor vehicle
injures and deaths. (#296)
State and local police should enforce seat belt use
and be strict with alcohol-related offenses. According
to Gab Trietsch of the Texas Department of High-
ways and Public Transportation, public awareness
programs coordinated with a law enforcement pro-
gram, including new safety belt and driving-while-
into~ncated (DWI) laws, have contributed to a decline
in traffic deaths to a 10-year low in Texas. (#563)
Health professionals also should be involved in the
effort to increase seat belt use and to strengthen
legislation requiring such use at all times. (#190)
The successful implementation of laws in all 50
states and the District of Columbia requiring the use
:3f child safety seats is a notable victory, achieved
through the efforts of state and local traffic enforce-
ment agencies, health professionals, organizations, and
communities. Joseph Hill of the Detroit Department
of Health, however, reports that the number of
injuries to infants and small children Is still unaccept-
ably high due to lack of compliance and incorrect use
of the seats. Continuing public awareness campaigns
are still of vital importance. (#404)
One method of increasing compliance with child
safety seat use, says Sleet, is to require that all
130 Healthy People 2000: Citizens Chart the Course
newborns leave the hospital in child safety seats.
(~285) Auto insurance companies also could offer
free child safety seats to policy holders who have
children. According to Saalberg, League General
Insurance Company of Michigan offers such a pro-
gram to its policy holders. Begun in 1979, this
program is now available in live states and has
distributed 17,000 seats. A four-year evaluation of
this program showed increased restraint use and a
substantial drop in injuries.4 (~190J
Mandatory helmet laws for motorcyclists in all
states were encouraged. (~296)
Enforcement of speed limits is another component
of traffic safety, cited by Trietsch as one factor (along
with safety belt and DWI laws) in the success of the
Texas program. He underlines the role of police
training and coordination between state and local
levels in bringing about compliance. f#563J
To help provide safer conditions for all who use
the roadways, an effective management system must
be in place, according to the Highway User's Federa-
tion. A comprehensive management system would
include road upkeep, pavement improvement, roadside
obstacle removal, and pedestrian and bicycle access.
(~517J
Finally, vehicle manufacturers themselves have a
role to play. According to the Highway User's
Federation, improved technology is making cars more
crash resistant. Manufacturer changes include brake
enhancement, side impact protection, use of on-board
electronics, improved vehicle stability, and automatic
restraints. Laboratory testing and field experimenta-
tion on better restraint systems are occurring, which
include "improved belt designs, passive belts, air bag
applications, and electronic accident avoidance tech-
nology.n (~51 7)
OTHER CAUSES OF INJURY
Beyond automobile accidents, witnesses identified falls,
fires, and drownings as key preventable causes of
Injury.
Falls
Children and elderly adults have the highest risk of
death or injury due to falling, according to William
King and colleagues of the Children's Hospital of
Alabama. (~266) To reduce injury and mortality
from falls, Michael Oliva of Aurora, Colorado urges
funding for fall prevention programs for older people.
Providers of health care should recognize, he says,
OCR for page 131
that many falls are not unexpected events.
For example, you can identity those who have a
high risk of falling when they get up at night to
use the bathroom. They may have had prior
falls, and their disabilities and medications may
increase their risk of falling. Fall prevention in
the elderly is closely related to their health
problems and it should be included in their plan
of care. (#378)
Fires
Residential fires took 3,900 lives in 1984. This makes
fires the second leading cause of death in the home
after falls.5 From a public health perspective, a
critical intervention to reduce residential fires is the
installation of smoke detectors in all homes. Rivara
says that smoke detectors should be installed in all
households, but particularly in the households of the
poor. fit is the poor who are at greatest risk of fire
deaths, he says, "particularly poor children." (~334)
West writes, HI would like to see legislation at the
national level, but also state legislation that says that
all new housing will have smoke detectors built in.
But I think that any housing units that receive federal
funding-and this is, specifically, low income
housing~lso should have smoke detectors in theme
(#368J
Rivara points out that approximately one-half of
residential fires are started by cigarettes.6 Thus,
development of a self-extinguishing cigarette would be
an effective countermeasure. (~334J Sleet indicates
that cigarette lighters in the hands of children cause
between 120 and 200 childhood deaths annually,
primarily to children under five years of age.7 He
stresses the need for federal standards to require that
all cigarette and novelty lighters be child proof.
(#285)
Poisoning
Poison control centers can reduce the number of
emergency room visits made by poison victims. These
centers should be set up regionally, says Lewis
Schwarz of Morristown Memorial Hospital in New
Jersey, and should be reachable through a standard
toll-free number, publicized nationally. By keeping a
data base on the many and frequently updated drugs
and products on today's market, poison control
centers can offer up-to-date information over the
telephone. By monitoring calls nationally, they also
will be able to provide data for analysis of use and
misuse patterns. (~446) The use of child-proof caps
for medicines and household products has also proved
to be a successful passive prevention technique,
according to Haggerty. (#784)
Drowning
In 1983, over 5,000 persons died from drowning.
More than half of the persons were under 25,8 and
82.4 percent of those drowned were male.9 To pursue
the goal of no more than 1.5 drowning deaths per
100,000 people, Rivara encourages the use of multiple
strategies and more studies; for example, "it is not
known whether toddler and child swim classes are ~
positive or a negative risk factor for drowning." He
also points out that "interventions for pool drownings
may not be applicable to those occurring in natural
bodies of water." (~334J
DISABLING INJURIES
Most injuries are nonfatal, according to Macdonald,
but some severely disabling injuries are "perceived as
worse than death." Of the eight 1990 objectives
dealing with accident prevention and injury control,
only one measures nonfatal injuries, and that is "based
on unreliable data. Macdonald calls for the year
2000 objectives to measure the incidence of severe
injuries, the prevalence of disability, and the rates of
disability days. (~322) Samuel Stover of the Univer-
sity of Alabama at Birmingham refers to "this epidem-
ic of injuries with permanent disabilities and con-
cludes that "we really don't pay much attention to
them.n (~674) In 1983, for instance, nearly 8,000
children age 15 or under died from injuries sustained
in accidents,~° and many more were permanently
disabled, according to Martin Eichelberger of the
Children's Hospital National Medical Center. (#058)
Injuries to the spinal cord, head, or brain are
especially disabling. Approximately 8,000 new cases
of spinal cord injury occur yearly, and these are
concentrated in the late-teen, young-adult age group.
There is a lack of information on the effects of
immediate treatment and rehabilitation on patients
with spinal cord and head injuries, says Stover, and
more applied research is critical to increase the
rehabilitation rates of these patients. (~674)
Even mild or moderate head injury victims ex-
perience significant cognitive, emotional, and social
disabilities, according to Thomas Boll of the Univer-
sity of Alabama Hospital. As yet, no systematic
Unintentional Injuries 131
OCR for page 132
program exists in the United States for the diagnosis
and treatment of noncatastrophic brain injury. The
importance of primary prevention, however, is mani-
fest, says Boll: many head injuries in childhood could
be prevented if children always used restraint devices
in vehicles, including school buses. (#264)
Several speakers were concerned with reaching
children through injury prevention education. Jill
Floberg of Olympia Physical Therapy SeIvice writes:
I often stand and wonder at how today's youth
survive to adulthood with an apparent false
sense of invincibility. High-tech toys with high-
tech risks and the viewing of unreal responses to
injury in various media, lead to an expectation
that no matter what happens, someone can fix
it.
An important intervention, Floberg says, is to assess
the Recklessness profile of 6 to 15 year olds. Col-
lecting such information could help to design effective
educational efforts in the schools on personal protec-
tion. (~317) Eichelberger sees a need for
nationwide education efforts on the preventability of
childhood injury. "Instill a conviction among
Americans," he says, "that most childhood accidents
can be prevented-and that this country has a respon-
sibility to take the steps necessary to prevent them.n
(~058)
IMPLEMENTATION
Manpower and Organization
The sweep of environmental and control factors
involved in injuries, and the necessary crosscutting
strategies that must be undertaken to curb them,
mandate a combination of local and statewide preven-
tion efforts with individual and professional awareness
efforts. Public health approaches, with an emphasis
on social marketing and broad-based collaboration,
are appropriate for implementing injury prevention,
according to West. Collaboration between different
groups reduces fragmentation of effort and increases
use of the same message throughout a community.
(#368)
Law enforcement officers, public health officials,
and health professionals all have roles to play in
~ . . .. . . . . .
enforcing or puollclzlng Injury prevention measures
and in educating the public on individual risk factors.
Trietsch underscores the usefulness of interdisciplinary
"teams" in the Texas effort to reduce traffic injury
132 Healthy People 2000: Citizens Chart the Course
rates. For example, the Texas Department of High-
ways and Public Transportation provides funds directly
to the Texas Department of Health for the promotion
of safety belts, child safety seats, and DWI reductions.
In return, the Department of Health "activates its
extensive network of health professionals, clinics, and
outreach programs to provide training, education, and
materials where needed. (#563) According to
Saalberg, health professionals also are invaluable in
identifying, treating, and controlling those who suffer
from alcoholism and problem drinking; expanding the
availability of emergency medical services; and making
further advances in trauma treatment. !~190;
West strongly urges the development of statewide
programs for injury control, which could serve as
umbrella organizations for the activities of different
sectors of society. The minimum criteria for a
statewide injury prevention and control program are
1. establishment of a statewide plan for injury
prevention and control that encompasses (a) technical
assistance to communities; (b) surveillance and data
collection; (c) a broad-based coalition; and (d) a
comprehensive focus that includes prehospital and
acute care, as well as rehabilitation;
2. maintenance of statewide poison control ser-
vices;
3. enforcement of existing legislation;
4. development of other legislative/regulatory
approaches as needed; and
5. integration of injury prevention and control
content into the education and training of a variety of
populations, including health care providers and the
media. (i¢368)
Roughly 50 percent of injury deaths are im-
mediate," says Macdonald. Of the remaining 50
percent, 30 percent occur within the first four hours
after injury. This presents a compelling need to
provide quality prehospital emergency services and
trauma care as an important tertiary prevention
strategy. (i'329) Many testifiers supported
Macdonakl's argument, claiming that the quality and
immediacy of intervention can determine mortality
rates. f#257)
Surveillance and Data Collection
It is essential to ongoing injury control to have a
statistical data base capable of producing comprehen-
sive and reliable injury information. ('tot 9) To
establish and improve information collection for such
data bases, speakers unanimously encouraged a more
standard format of injury reporting and a regional
OCR for page 133
collection system for this information. Currently, says
the National Safety Council, "knowledge in this field
is characterized by proliferating and redundant efforts
in some areas and near absolute neglect in others."
(~019)
One step in making reporting procedures more
standard would be to have hospitals, emergency
medical service units, trauma centers, and police
reports record the same types of information with the
same or similar coding schemes. (#322) Several
witnesses called for the use of the ICD-9 External
Cause of Injury codes, or E-codes, to identify risk
factors from the physical environment. Without such
coding, "head injuries from motor vehicle crashes
cannot be distinguished from those due to falls,"
points out Rivara; with them, however, "the existing
systems would serve as a feasible and extremely useful
surveillance tool for injuries requiring medical care."
(#334) Currently, only four states (Maryland, New
REFERENCES
York, Pennsylvania, and Virginia) require hospitals to
use E-codes. However, even the use of E-codes may
not be enough, according to Macdonald, because they
"do not allow for identification of risk factors that are
behavioral (such as alcohol use or seatbelt non-use)
or those from the social environment (such as occupa-
tional or recreational settings)." He advocates the
incorporation of an "activity code" into the fifth digit
of the ICD-10 version of the E-oodes as a further
refinement of the system. (#322) Schwarz's recom-
mendation for regional poison information centers
with a national 800 number is another example of
how to collect the necessary data. (~446) Testifiers
believe that having such information and control
measures in place and available through a central
organization, at either a state or a national level,
could significantly increase the opportunities for large-
scale prevention measures.
1. National Research Council, Committee on Trauma Research: Injury in America: A Continuing Public Health
Problem. Washington, D.C.: National Academy Press, 1985
2. U.S. Department of Transportation, National Highway Traffic Safety Administration: Fatal Accident
Reporting System, 1988. A Review of Information on Fatal Traffic Crashes in the United States in 1988 (DOT
Publication No. HS 807 507), 1989
3. Fingerhut LA, Kleinman JC, Malloy MH, et al.: Injury fatalities among young children. Public Health Rep
103(4):399-405, 1988
4. Saalberg JH: Second Evaluation of the League General Insurance Company Child Safety Seat Distribution
Program. U.S. Department of Transportation, National Highway Traffic Safety Administration, 1985
5. National Safety Council: Accident Facts, 1985 Edition. Chicago, 1985
6. Baker SP, O'Neill B. Karpf RS: The Injury Fact Book. Lexington, Ma.: Lexington Books, 1984
7. Ibid.
8. U.S. Department of Health and Human Services: Disease Prevention/Health Promotion: The Facts. Palo
Alto, Cal: Bull Publishing Company, 1988
9. National Safety Council: op cit., reference 5
10. National SafeW Council: Accident Facts, 1986 Edition. Chicago, 1986
11. Young JS, Burns PE, Bower AM, et al.: Spinal Cord Injury Statistics: Experience of the Regional Spinal
Cord Injury Systems. Phoenix: Good Samaritan Medical Center, 1982
Unintentional Injuries 133
OCR for page 134
TESTIFIERS CITED IN CHAPTER 15
008 Anderson, Dave; American Automobile Association
011 Austin, Richard; Michigan Department of State Police
019 Benjamin, George; National Safety Council
058 Eichelberger, Martin; Children's Hospital National Medical Center (Washington, D.C.)
190 Saalberg, James; CUNA Mutual Insurance Group
257 Johnston, Carden; American Academy of Pediatrics
264 Boll, Thomas; University of Alabama at Birmingham
266 King, William; Kohaut, Edward C.; Johnston, F. Carden, et al.; The Children's Hospital of Alabama
285 Sleet, David; San Diego State University
296 Gossett, Leo; Texas Department of Public Safety
317 Floberg, Jill; Olympia Physical Therapy Service
322 Macdonald, Steven; University of Washington
334 Rivara, Frederick; Harborview Injury Prevention and Research Center (Seattle)
368 West, M. Patricia; Colorado Department of Health
378 Oliva, Michael; Aurora, Colorado
404 Hill, Joseph; Detroit Department of Health
425 Tarrant, Karen; Michigan Department of State Police
446 Schwarz, Lewis; Morristown Memorial Hospital (New Jersey)
517 Livingston, Charles; Highway Users Federation
563 Trietsch, Gary; Texas Department of Highways and Public Transportation
674 Stover, Samuel; University of Alabama at Birmingham
784 Haggerty, Robert; William T. Grant Foundation (New York)
134 Healthy People 20(70: Citizens Chart the Course
Representative terms from entire chapter:
injury prevention
