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Cofactors of alcohol-related trauma at a rural trauma center
Cofactors of Alcohol-Related Trauma at a Rural Trauma Center RAYMOND N. ANKNEY, BA,* JAMES VIZZA, PsYD,I JAMES A. COIL, MD,II STANLEY KUREK, DO,* RICHARD DEFREHN, BSW,$ HOLLY SHOMO, RN§ To analyze the cofactors of alcohol-related trauma at a rural, Level II trauma center, 127 admitted trauma patients were interviewed about psychological problems, social factors, and medical histories. Patients were divided into two groups, blood alcohol content (BAC) positive and BAC negative, for analysis. Seventy-one patients (56%) were BAC negative; 56 (44%) were BAG positive. Forty-three of the 82 males (52%) had positive BAC tests, compared with 13 of the 45 females (29%) (P = .01). Fifty-one of the 56 BAC-positive patients (91%) were aged 21 to 50 years, compared with 29 of the 71 BAC.negative patients (41%) (P = .0001). Ten of the 12 patients (83%) who were recently unemployed were BAC positive, compared with 46 of the 115 patients (40%) who were not recently unemployed (P = .004). Eleven of the 12 patients (92%) with positive drug screens were BAC positive, compared with 45 of the 115 patients (39%) with negative drug screens (P = .0005). These results show that there are important cofactors of alcohol-related trauma in rural areas. (Am J Emerg Med 1998;16:228-231. Copyright © 1998 by W.B. Saunders Company) Alcohol continues to play a major role in traumatic injuries. The National Institutes of Health estimates that 64% to 70% of homicides, 75% of stabbings, 69% of beatings, and 56% of assaults involve alcohol. 1 Alcohol is involved in 40% of motor-vehicle crashes. 2 However, limited research has been done on alcohol-related trauma in rural areas. The purpose of this study was to determine the psychological, social, and medical cofactors of alcoholrelated trauma at a rural, Level II trauma center.
METHODS The trauma center studied covers a 10,000-square-mile area of the northeast United States. Approximately 90% of the trauma population has sustained blunt vehicular trauma. The median family income for the largest county in the coverage area is $26,455 (Census Bureau). Fourteen percent of the county's residents live below the poverty level, and 30% of the population receives medical assistance and Aid to Families with Dependent From the *Department of Surgery, the tDepartment of Behavioral Medicine, the 1:Department of Social Services, and the §Department of Psychiatry, Conemaugh's Memorial Medical Center, Johnstown, PA; and the IIDepartment of Surgery, St. Vincent's Medical Center, Staten Island, NY. Manuscript received July 26, 1996, returned August 16, 1996; revision received December 30, 1996, accepted January 5, 1997. Supported by the Conemaugh Research Foundation. Presented in part at the Pennsylvania Committee on Trauma meeting, November 9, 1994, Hershey, PA. Address reprint requests to Mr Ankney, Department of Surgery, Conemaugh's Memorial Medical Center, 1086 Franklin St, Johnstown, PA 15905. Key Words:Blood alcohol content, trauma patients, rural. Copyright © 1998 by W.B. Saunders Company 0735-6757/98/1603-000358.00/0 228
Children. The county's population is 97% Caucasian, 2% African American, and 1% Hispanic. One hundred twenty-seven consecutive trauma patients were interviewed about psychological problems, social factors, and medical histories by two consult liaison nurses and three social service workers. A trauma patient was defined as any person admitted through the emergency department following a trauma alert or code. Interviews were conducted in the patient's hospital room while he or she was receiving inpatient care. Family members also participated in the study, and information was collected from the medical records. Table 1 shows the variables that were analyzed. The trauma patients were divided into two groups for analysis: blood alcohol content (BAC) positive and BAC negative. Any alcohol detected on a blood screen placed the person in the BAC-positive category. The BAC-negative population served as the control group and helped to identify the cofactors of alcohol-related trauma. Student's t tests and X2 analyses were used to compare the groups. P values < .05 were considered statistically significant. The hospital routinely draws a BAC screen for all trauma patients. Informed consent was obtained from patients, and the study's protocol was approved by the hospital's Institutional Review Board.
RESULTS One hundred twenty-seven consecutive trauma patients were enrolled into the study from October 6, 1992, through February 22, 1993. Seventy-one patients (56%) were BAC negative, whereas 56 patients (44%) were BAC positive (range, .01 to .32 mg/dL). Eighty-two patients were male (65%), and 45 patients were female (35%). The mean age of the study population was 35.2 years (range 6 to 84 years). Males were much more likely to be BAC positive than females. Forty-three of the 82 males (52%) had positive BAC tests, compared with 13 of the 45 females (29%) (P = .01). Age was also a cofactor of alcohol-related trauma. Fifty-one of the 56 BAC-positive patients (91%) were aged 21 to 50 years, compared with 29 of the 71 BAC-negative patients (41%) (P = .0001). Table 2 demonstrates that vocational-educational issues may play a role in alcohol-related trauma in rural areas. In particular, recent unemployment and recent changes in job status were significantly higher among the BAC-positive population. None of the study's interpersonal variables reached statistical significance; however, this may have been because of the small numbers in some of the groups. For example, 12 of the 19 patients (63%) who reported significant personal changes (ie, divorce) were BAC positive, compared with 44
ANKNEY ET AL • COFACTORS OF ALCOHOL-RELATED TRAUMA
229
TABLE2. Vocational-Educational Variables
TABLE 1. Data Collection Form
Variable
Yes (% BAC+)
No (% BAC+)
P Value
Recent change in job status Recent change in job condition Significant event at work Other event at work Recent unemployment Change in educational status
20 (65%) 5 (60%) 1 (0%) 29 (34%) 12 (83%) 5 (40%)
107 (4o%) 122 (43%) 126 (44%) 98 (47%) 115 (40%) 122 (44%)
.04 NS NS NS .004 NS
Trauma Profile Name
Age
1. Vocational~Education Recent change in job status Recent change in job condition Significant event at work Other event at work Unemployed
Sex _ _
Recent change in educational status Recent change in educational condition Significant event at school Other event at school
2. Interpersonal Significant change (ie, divorce) Recent conflict Problems with parent/ child
Death (relative or friend) Abuse Other
3. Substance Use Alcohol screen positive Drug screen positive 4. Financial Recent change in status Bankruptcy/foreclosure 5. Legal Arrest Trial/hearing
Sentencing Charges filed
6. Mental Health History~Past Counseling Inpatient Outpatient 7. Educational Level Elementary (1-6) intermediate (7-8) High school (9-12) 8. Health Recent injury Past injury Recent diagnosis
College Graduate
opiates, benzodiazepines, amphetamines, cocaine, and cannabis. Eleven of the 12 patients (92%) with positive drug screens were BAC positive, compared with 45 of the 115 patients (39%) with negative drug screens (P = .0005). Furthermore, financial and legal variables seemed to be cofactors for alcohol-related trauma. In particular, all four patients (100%) who recently had had criminal charges filed against them were BAC positive, compared with 52 of the 123 patients (42%) who had not had charges filed (P = .02). Table 3 lists the financial and legal variables. The mental health and medical histories of the trauma patients were also evaluated (Tables 4 and 5). Inpatient treatment at a psychiatric facility or a psychiatric unit (inpatient mental counseling) and history of major injury requiting emergency department treatment (previous traumatic injury) were the strongest cofactors of alcohol-related trauma among these variables. DISCUSSION
Recent medical procedure Chronic condition Medications
9. Hobbies~Interests~Activities (list three) 10. Emotional State Prior to Injury Depression Anxiety Other
NOTE: "Yes" is the number of patients who reported a recent change in job status, a recent change in job condition, etc; "No" is the number of patients who did not have a recent change in job status, a recent change in job condition, etc; % BAC+ is the percentage of patients who are blood-alcohol-content positive. Statistical analyses were then performed to determine whether patients with these vocationaleducational variables were more likely to be BAC positive than patients without these variables.
Anger Guilt
11. History of Major Traumatic Injuries
There are several limitations to this study. In particular, there was some selection bias because of the study's two exclusion criteria: patient death before an interview could be conducted, ie, on scene, and cognitive deficits preventing patients from completing interviews. Also, a few patients refused to answer all of the questions. Finally, although BAC was measured for all patients on admission, times from injury to drawing of blood in the hospital varied, possibly allowing some patients to clear the alcohol. However, our data suggest that there are differences in the TABLE3. Financial and Legal Variables
12. Describe Events Prior to the Accident (24 hours)
of the 108 patients (41%) without significant personal changes (P = .07). A positive drug screen (the presence of any drug that had not been prescribed for the patient or used in the prehospital emergency process) was highly predictive of a trauma patient's BAC status. There were positive screens for
Variable
Yes (% BAC+)
No (% BAC+)
P Value
Recent change in financial status Bankruptcy/foreclosure Recent arrest Recent trial Recent criminal sentencing Criminal charges filed
19 (63%) 1 (100%) 3 (100%) 6 (67%) 2 (100%) 4 (100%)
108 (41%) 126 (44%) 124 (43%) 121 (43%) 125 (43%) 123 (42%)
NS* NS .05 NS NS .02
*Recent change in financial status had a probability value of .07, just missing statistical significance.
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AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 16, Number 3 • May 1998
TABLE4. Mental Health and Emotional State Before Injury Variable
Yes (% BAC+)
No (% BAC+)
P Value
Inpatient mental counseling Outpatient mental counseling Depression Anxiety Anger Guilt Other emotion
8 (88%) 18 (39%) 20 (60%) 11 (55%) 9 (67%) 2 (50%) 51 (43%)
119 (41%) 109 (45%) 107 (41%) 116 (43%) 118 (42%) 125 (44%) 76 (45%)
.01 NS NS NS NS NS NS
psychological profiles, social factors, and medical histories of the BAC-positive and BAC-negative populations at a rural trauma center. Male gender, patients aged 21 to 50 years, recent change in job status, recent unemployment, positive drug screens, inpatient mental counseling, recent arrests, criminal charges filed, and old traumatic injuries were all statistically more frequent in the BAC-positive group. Six other variables, significant personal changes (P = .07), changes in financial status (P = .07), other interpersonal problems (P = .11), recent criminal sentencing (P = .11), depression (P = .12), and recent conflicts (P = .13), approached statistical significance. A larger study population would have allowed us to determine whether these six variables are important cofactors for alcohol-related trauma in rural areas. Finally, chronic pain was the only variable that was statistically greater in the BAC-negative population than in the BAC-positive population. We have no explanation for this finding. Perhaps chronic pain is a distraction during driving. Our results complement a 1995 study by Brotman et aP and a 1993 study by Poole et al. 4 Brotman et al found that the typical rural trauma patient is a young adult male with a high school education. Driving while impaired is commonplace in this primarily blue-collar patient population. About half of rural trauma patients earned less than $13,000, 45% were married, and 68% were male. 3 Poole et al identified five risk factors for admitted rural trauma patients: younger age, male gender, racial minority, previous hospitalization for injury, and a greater proportion of prior trauma admissions within the past 5 years. 4 The literature reports some important demographic differences between our rural trauma patients and urban trauma patients. Urban trauma is mostly from penetrating injuries and is violence related, while rural trauma is more likely to TABLE5. Medical History Variable
Yes (% BAC+)
No (% BAC+)
P Value
Recent injury Past injury Recent diagnosis Recent medical procedure Chronic pain Medication use Previous traumatic injury
12 (58%) 25 (48%) 10 (50%) 5 (20%) 26 (27%) 26 (50%) 22 (64%)
115 (43%) 102 (43%) 117 (44%) 122 (45%) 101 (49%) 101 (43%) 105 (40%)
NS NS NS NS .05" NS .04
*Chronic pain was the only variable that was statistically more frequent in the BAC-negative population.
be from blunt injury and not to be violence related. Violence is one of the leading causes of death, particularly for black men and women aged 15 to 23 years, in inner cities in the United States. Researchers at St. Vincent Medical Center report that between 1990 and 1994, the number of penetrating trauma patients under the age of 21 increased 83%. 5 Moreover, a study of the victims of violence showed that 83% were injured by gunshots. Another 11% were stabbed. 6 Sims et al 7 followed 263 consecutive survivors of violent trauma in Detroit over 5 years. Seventy-six percent were unemployed, and 164 abused alcohol and drugs. Eighty-five percent were male. Overall, 142 of the 263 patients committed crimes, and 81 patients were victims of major crimes (robbery, rape, murder, assault). Although the average patient age was 32 years, there was a 20% 5-year mortality rate. 7 Cesare et al 8 report that 80% of penetrating trauma victims in Hartford were male, and 78% were single. Fifty-four percent were black, and blacks outnumbered whites and Hispanics by a 2:1 ratio. Fifty-four percent were unemployed, and 35% tested positive for illegal drugs. The mean age was 31 years. Twenty percent of victims of personal violence were repeat patients. 8 Rivara et al 9 noted that males, minorities, unemployed persons, and Medicaid patients were at greater risk of readmission for trauma in Seattle. Regardless of whether traumatic incidents occur in rural or urban areas, we believe that health-care providers should place greater emphasis on identifying alcoholic patients and referring them for treatment. ~° Trauma centers and emergency departments should play key roles in this effort. 11A2 Nilssen 13 estimated that 30% to 70% of hospital patients have harmful levels of alcohol use. About half of hospital and trauma admissions involve alcohol use. 13 Few patients receive in-hospital counseling regarding the harmful effects of drinking, with even fewer understanding the significant effects of alcohol on driving performance. 1416 In fact, one study of 346 trauma patients injured in motor-vehicle crashes found that not one patient was referred for alcohol evaluation and treatment. 17 Moreover, some research suggests that rural trauma centers, which are primarily level II and level III, do a poorer job of alcohol screening than urban centers. Soderstrom et a118 found that an alcohol testing policy on admission was in place at 72% of level I, 56.9% of level II, and 47.4% of level III and unspecified centers. In a recta-analysis, Bien et a119 found eight studies that tested brief interventions for alcoholism in health-care settings against untreated controls. Seven studies showed significant reductions in alcohol use and related problems from the brief interventions. Bien concludes, "Perhaps the best promise of brief motivation counseling, however, is as a low-cost intervention that can be applied to large populations within the confines of ongoing service delivery systems. The results from this substantial body of clinical trials are remarkably consistent across cultures: brief intervention yields outcomes significantly better than no treatment, and often comparable to more extensive treatment." 19 Gentilello et al20 reported that a standard outpatient intervention to encourage inpatient alcoholic trauma patients into treatment was successful. Seventeen of 19 patients
ANKNEY ET AL • COFACTORS OF ALCOHOL-RELATED TRAUMA
(89%) accepted treatment and went to a 28-day inpatient facility. Gentilello et al believe that 80% to 90% of trauma patients can be induced to treatment, with 50% of patients achieving sobriety. Trauma centers, he says, should use counselors familiar with the Social Network Integration (SNI) technique. During an SNI, it may be possible to overwhelm the alcoholic's defenses and send the person for prompt treatment. 2° The statistical significance of the factors identified in our study suggests that there were biopsychosocial differences between the BAC-positive and the BAC-negative groups. We cannot conclude or even speculate on cause and effect. We can say that the BAC-positive group was more likely than the control group to have had various biopsychosocial issues that needed to be addressed. This conclusion is not dependent on identification of the BAC-positive group as alcoholics. Consequently, this group might well benefit from counseling interventions to address not only alcohol use but also the various cofactors. We also conclude: (1) there seem to be demographic differences between urban and rural trauma patients; (2) there are indicators that psychological problems, social factors, and medical conditions serve as cofactors of alcoholrelated trauma at a rural trauma center; (3) larger studies are needed to identify additional cofactors of alcohol-related trauma in rural areas; (4) the cofactors of alcohol-related trauma can alert health professionals to possible alcoholdependent patients; and (5) it is important that rural trauma centers and emergency departments place greater emphasis on referring alcohol-dependent patients to treatment.
REFERENCES 1. Haberman PW, Natarajan G: Trends in alcoholism and narcotics abuse from medical examiner data. J Stud Alcohol 1986;47:316321 2. Williams AF, Wells JK: Factors associated with high blood alcohol concentrations among fatally injured drivers in the United States, 1991. Arlington, VA, Insurance Institute for Highway Safety, January 1993
231
3. Brotman S, Indeck MC, Leonard D, et al: The study of the relationship between lifestyle characteristic self-reported drinking patterns and trauma. Am Surg 1995;61:975-979 4. Poole GV, Griswold JA, Thaggard K, et al: Trauma is a recurrent disease. Surgery 1993; 113:608-611 5. Wilson N: An education in violence. Health Progress 1996;77: 37-42 6. Hume SK: Teaching nonviolence in the innercity. Health Progress 1996;77:34-36 7. Sims DW, Bivins BA, Obeid FN, et al: Urban trauma: A chronic recurrent disease. J Trauma 1989;29:940-947 8. Cesare J, Morgan AS, Fetice PR, et al: Characteristics of blunt and personal violent injuries. J Trauma 1990;30:176-182 9. Rivara FP, Koepsell TD, Jurkovich GJ, et al: The effects of alcohol abuse on readmission for trauma. JAMA 1993;270:19621964 10. Chang G, Astrachan BM: The emergency department surveillance of alcohol intoxication after motor vehicle accidents. JAMA 1988;260:2533-2536 11. Madden C, Cole TB: Emergency intervention to break the cycle of drunken driving and recurrent injury. Ann Emerg Med 1995;26:177-179 12. Rutherford WH: The responsibility of emergency medicine towards the prevention of road accidents. Arch Emerg Med 1986;3: 163-176 13. Nilssen O: TheTromso study: Identification of and a controlled intervention on a population of early-stage risk drinkers. Prev Med 1991 ;20:518-528 14. Conigrave KM, Burns FH, Reznik RB, et al: Problem drinking in emergency department patients: the scope for early intervention. Med J Aust 1991;154:801-805 15. Kamerow DB, Pincus HA, Macdonald Dl:Alcohol abuse, other drug abuse, and mental disorders in medical practice. JAMA 1986;255: 2054-2057 16. Naranjo CA, Bremner KE: Behavioural correlates of alcohol intoxication. Addiction 1993;88:31-41 17. Gentilello LM, Donovan DM, Dunn CW, et al: Alcohol interventions in trauma centers. JAMA 1995;274:1043-1048 18. Soderstrom CA, Dailey JT, Kerns TJ: Alcohol and other drugs: An assessment of testing and clinical practices in U.S. trauma centers. J Trauma 1994;36:68-73 19. Bien TH, Miller WR, Tonigan JS: Brief interventions for alcohol problems: A review. Addiction 1993;88:315-336 20. Gentilello LM, Duggan P, Drummond D, et al: Major injury as a unique opportunity to initiate treatment in the alcoholic. Am J Surg 1988;156:558-561
METHODS The trauma center studied covers a 10,000-square-mile area of the northeast United States. Approximately 90% of the trauma population has sustained blunt vehicular trauma. The median family income for the largest county in the coverage area is $26,455 (Census Bureau). Fourteen percent of the county's residents live below the poverty level, and 30% of the population receives medical assistance and Aid to Families with Dependent From the *Department of Surgery, the tDepartment of Behavioral Medicine, the 1:Department of Social Services, and the §Department of Psychiatry, Conemaugh's Memorial Medical Center, Johnstown, PA; and the IIDepartment of Surgery, St. Vincent's Medical Center, Staten Island, NY. Manuscript received July 26, 1996, returned August 16, 1996; revision received December 30, 1996, accepted January 5, 1997. Supported by the Conemaugh Research Foundation. Presented in part at the Pennsylvania Committee on Trauma meeting, November 9, 1994, Hershey, PA. Address reprint requests to Mr Ankney, Department of Surgery, Conemaugh's Memorial Medical Center, 1086 Franklin St, Johnstown, PA 15905. Key Words:Blood alcohol content, trauma patients, rural. Copyright © 1998 by W.B. Saunders Company 0735-6757/98/1603-000358.00/0 228
Children. The county's population is 97% Caucasian, 2% African American, and 1% Hispanic. One hundred twenty-seven consecutive trauma patients were interviewed about psychological problems, social factors, and medical histories by two consult liaison nurses and three social service workers. A trauma patient was defined as any person admitted through the emergency department following a trauma alert or code. Interviews were conducted in the patient's hospital room while he or she was receiving inpatient care. Family members also participated in the study, and information was collected from the medical records. Table 1 shows the variables that were analyzed. The trauma patients were divided into two groups for analysis: blood alcohol content (BAC) positive and BAC negative. Any alcohol detected on a blood screen placed the person in the BAC-positive category. The BAC-negative population served as the control group and helped to identify the cofactors of alcohol-related trauma. Student's t tests and X2 analyses were used to compare the groups. P values < .05 were considered statistically significant. The hospital routinely draws a BAC screen for all trauma patients. Informed consent was obtained from patients, and the study's protocol was approved by the hospital's Institutional Review Board.
RESULTS One hundred twenty-seven consecutive trauma patients were enrolled into the study from October 6, 1992, through February 22, 1993. Seventy-one patients (56%) were BAC negative, whereas 56 patients (44%) were BAC positive (range, .01 to .32 mg/dL). Eighty-two patients were male (65%), and 45 patients were female (35%). The mean age of the study population was 35.2 years (range 6 to 84 years). Males were much more likely to be BAC positive than females. Forty-three of the 82 males (52%) had positive BAC tests, compared with 13 of the 45 females (29%) (P = .01). Age was also a cofactor of alcohol-related trauma. Fifty-one of the 56 BAC-positive patients (91%) were aged 21 to 50 years, compared with 29 of the 71 BAC-negative patients (41%) (P = .0001). Table 2 demonstrates that vocational-educational issues may play a role in alcohol-related trauma in rural areas. In particular, recent unemployment and recent changes in job status were significantly higher among the BAC-positive population. None of the study's interpersonal variables reached statistical significance; however, this may have been because of the small numbers in some of the groups. For example, 12 of the 19 patients (63%) who reported significant personal changes (ie, divorce) were BAC positive, compared with 44
ANKNEY ET AL • COFACTORS OF ALCOHOL-RELATED TRAUMA
229
TABLE2. Vocational-Educational Variables
TABLE 1. Data Collection Form
Variable
Yes (% BAC+)
No (% BAC+)
P Value
Recent change in job status Recent change in job condition Significant event at work Other event at work Recent unemployment Change in educational status
20 (65%) 5 (60%) 1 (0%) 29 (34%) 12 (83%) 5 (40%)
107 (4o%) 122 (43%) 126 (44%) 98 (47%) 115 (40%) 122 (44%)
.04 NS NS NS .004 NS
Trauma Profile Name
Age
1. Vocational~Education Recent change in job status Recent change in job condition Significant event at work Other event at work Unemployed
Sex _ _
Recent change in educational status Recent change in educational condition Significant event at school Other event at school
2. Interpersonal Significant change (ie, divorce) Recent conflict Problems with parent/ child
Death (relative or friend) Abuse Other
3. Substance Use Alcohol screen positive Drug screen positive 4. Financial Recent change in status Bankruptcy/foreclosure 5. Legal Arrest Trial/hearing
Sentencing Charges filed
6. Mental Health History~Past Counseling Inpatient Outpatient 7. Educational Level Elementary (1-6) intermediate (7-8) High school (9-12) 8. Health Recent injury Past injury Recent diagnosis
College Graduate
opiates, benzodiazepines, amphetamines, cocaine, and cannabis. Eleven of the 12 patients (92%) with positive drug screens were BAC positive, compared with 45 of the 115 patients (39%) with negative drug screens (P = .0005). Furthermore, financial and legal variables seemed to be cofactors for alcohol-related trauma. In particular, all four patients (100%) who recently had had criminal charges filed against them were BAC positive, compared with 52 of the 123 patients (42%) who had not had charges filed (P = .02). Table 3 lists the financial and legal variables. The mental health and medical histories of the trauma patients were also evaluated (Tables 4 and 5). Inpatient treatment at a psychiatric facility or a psychiatric unit (inpatient mental counseling) and history of major injury requiting emergency department treatment (previous traumatic injury) were the strongest cofactors of alcohol-related trauma among these variables. DISCUSSION
Recent medical procedure Chronic condition Medications
9. Hobbies~Interests~Activities (list three) 10. Emotional State Prior to Injury Depression Anxiety Other
NOTE: "Yes" is the number of patients who reported a recent change in job status, a recent change in job condition, etc; "No" is the number of patients who did not have a recent change in job status, a recent change in job condition, etc; % BAC+ is the percentage of patients who are blood-alcohol-content positive. Statistical analyses were then performed to determine whether patients with these vocationaleducational variables were more likely to be BAC positive than patients without these variables.
Anger Guilt
11. History of Major Traumatic Injuries
There are several limitations to this study. In particular, there was some selection bias because of the study's two exclusion criteria: patient death before an interview could be conducted, ie, on scene, and cognitive deficits preventing patients from completing interviews. Also, a few patients refused to answer all of the questions. Finally, although BAC was measured for all patients on admission, times from injury to drawing of blood in the hospital varied, possibly allowing some patients to clear the alcohol. However, our data suggest that there are differences in the TABLE3. Financial and Legal Variables
12. Describe Events Prior to the Accident (24 hours)
of the 108 patients (41%) without significant personal changes (P = .07). A positive drug screen (the presence of any drug that had not been prescribed for the patient or used in the prehospital emergency process) was highly predictive of a trauma patient's BAC status. There were positive screens for
Variable
Yes (% BAC+)
No (% BAC+)
P Value
Recent change in financial status Bankruptcy/foreclosure Recent arrest Recent trial Recent criminal sentencing Criminal charges filed
19 (63%) 1 (100%) 3 (100%) 6 (67%) 2 (100%) 4 (100%)
108 (41%) 126 (44%) 124 (43%) 121 (43%) 125 (43%) 123 (42%)
NS* NS .05 NS NS .02
*Recent change in financial status had a probability value of .07, just missing statistical significance.
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AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 16, Number 3 • May 1998
TABLE4. Mental Health and Emotional State Before Injury Variable
Yes (% BAC+)
No (% BAC+)
P Value
Inpatient mental counseling Outpatient mental counseling Depression Anxiety Anger Guilt Other emotion
8 (88%) 18 (39%) 20 (60%) 11 (55%) 9 (67%) 2 (50%) 51 (43%)
119 (41%) 109 (45%) 107 (41%) 116 (43%) 118 (42%) 125 (44%) 76 (45%)
.01 NS NS NS NS NS NS
psychological profiles, social factors, and medical histories of the BAC-positive and BAC-negative populations at a rural trauma center. Male gender, patients aged 21 to 50 years, recent change in job status, recent unemployment, positive drug screens, inpatient mental counseling, recent arrests, criminal charges filed, and old traumatic injuries were all statistically more frequent in the BAC-positive group. Six other variables, significant personal changes (P = .07), changes in financial status (P = .07), other interpersonal problems (P = .11), recent criminal sentencing (P = .11), depression (P = .12), and recent conflicts (P = .13), approached statistical significance. A larger study population would have allowed us to determine whether these six variables are important cofactors for alcohol-related trauma in rural areas. Finally, chronic pain was the only variable that was statistically greater in the BAC-negative population than in the BAC-positive population. We have no explanation for this finding. Perhaps chronic pain is a distraction during driving. Our results complement a 1995 study by Brotman et aP and a 1993 study by Poole et al. 4 Brotman et al found that the typical rural trauma patient is a young adult male with a high school education. Driving while impaired is commonplace in this primarily blue-collar patient population. About half of rural trauma patients earned less than $13,000, 45% were married, and 68% were male. 3 Poole et al identified five risk factors for admitted rural trauma patients: younger age, male gender, racial minority, previous hospitalization for injury, and a greater proportion of prior trauma admissions within the past 5 years. 4 The literature reports some important demographic differences between our rural trauma patients and urban trauma patients. Urban trauma is mostly from penetrating injuries and is violence related, while rural trauma is more likely to TABLE5. Medical History Variable
Yes (% BAC+)
No (% BAC+)
P Value
Recent injury Past injury Recent diagnosis Recent medical procedure Chronic pain Medication use Previous traumatic injury
12 (58%) 25 (48%) 10 (50%) 5 (20%) 26 (27%) 26 (50%) 22 (64%)
115 (43%) 102 (43%) 117 (44%) 122 (45%) 101 (49%) 101 (43%) 105 (40%)
NS NS NS NS .05" NS .04
*Chronic pain was the only variable that was statistically more frequent in the BAC-negative population.
be from blunt injury and not to be violence related. Violence is one of the leading causes of death, particularly for black men and women aged 15 to 23 years, in inner cities in the United States. Researchers at St. Vincent Medical Center report that between 1990 and 1994, the number of penetrating trauma patients under the age of 21 increased 83%. 5 Moreover, a study of the victims of violence showed that 83% were injured by gunshots. Another 11% were stabbed. 6 Sims et al 7 followed 263 consecutive survivors of violent trauma in Detroit over 5 years. Seventy-six percent were unemployed, and 164 abused alcohol and drugs. Eighty-five percent were male. Overall, 142 of the 263 patients committed crimes, and 81 patients were victims of major crimes (robbery, rape, murder, assault). Although the average patient age was 32 years, there was a 20% 5-year mortality rate. 7 Cesare et al 8 report that 80% of penetrating trauma victims in Hartford were male, and 78% were single. Fifty-four percent were black, and blacks outnumbered whites and Hispanics by a 2:1 ratio. Fifty-four percent were unemployed, and 35% tested positive for illegal drugs. The mean age was 31 years. Twenty percent of victims of personal violence were repeat patients. 8 Rivara et al 9 noted that males, minorities, unemployed persons, and Medicaid patients were at greater risk of readmission for trauma in Seattle. Regardless of whether traumatic incidents occur in rural or urban areas, we believe that health-care providers should place greater emphasis on identifying alcoholic patients and referring them for treatment. ~° Trauma centers and emergency departments should play key roles in this effort. 11A2 Nilssen 13 estimated that 30% to 70% of hospital patients have harmful levels of alcohol use. About half of hospital and trauma admissions involve alcohol use. 13 Few patients receive in-hospital counseling regarding the harmful effects of drinking, with even fewer understanding the significant effects of alcohol on driving performance. 1416 In fact, one study of 346 trauma patients injured in motor-vehicle crashes found that not one patient was referred for alcohol evaluation and treatment. 17 Moreover, some research suggests that rural trauma centers, which are primarily level II and level III, do a poorer job of alcohol screening than urban centers. Soderstrom et a118 found that an alcohol testing policy on admission was in place at 72% of level I, 56.9% of level II, and 47.4% of level III and unspecified centers. In a recta-analysis, Bien et a119 found eight studies that tested brief interventions for alcoholism in health-care settings against untreated controls. Seven studies showed significant reductions in alcohol use and related problems from the brief interventions. Bien concludes, "Perhaps the best promise of brief motivation counseling, however, is as a low-cost intervention that can be applied to large populations within the confines of ongoing service delivery systems. The results from this substantial body of clinical trials are remarkably consistent across cultures: brief intervention yields outcomes significantly better than no treatment, and often comparable to more extensive treatment." 19 Gentilello et al20 reported that a standard outpatient intervention to encourage inpatient alcoholic trauma patients into treatment was successful. Seventeen of 19 patients
ANKNEY ET AL • COFACTORS OF ALCOHOL-RELATED TRAUMA
(89%) accepted treatment and went to a 28-day inpatient facility. Gentilello et al believe that 80% to 90% of trauma patients can be induced to treatment, with 50% of patients achieving sobriety. Trauma centers, he says, should use counselors familiar with the Social Network Integration (SNI) technique. During an SNI, it may be possible to overwhelm the alcoholic's defenses and send the person for prompt treatment. 2° The statistical significance of the factors identified in our study suggests that there were biopsychosocial differences between the BAC-positive and the BAC-negative groups. We cannot conclude or even speculate on cause and effect. We can say that the BAC-positive group was more likely than the control group to have had various biopsychosocial issues that needed to be addressed. This conclusion is not dependent on identification of the BAC-positive group as alcoholics. Consequently, this group might well benefit from counseling interventions to address not only alcohol use but also the various cofactors. We also conclude: (1) there seem to be demographic differences between urban and rural trauma patients; (2) there are indicators that psychological problems, social factors, and medical conditions serve as cofactors of alcoholrelated trauma at a rural trauma center; (3) larger studies are needed to identify additional cofactors of alcohol-related trauma in rural areas; (4) the cofactors of alcohol-related trauma can alert health professionals to possible alcoholdependent patients; and (5) it is important that rural trauma centers and emergency departments place greater emphasis on referring alcohol-dependent patients to treatment.
REFERENCES 1. Haberman PW, Natarajan G: Trends in alcoholism and narcotics abuse from medical examiner data. J Stud Alcohol 1986;47:316321 2. Williams AF, Wells JK: Factors associated with high blood alcohol concentrations among fatally injured drivers in the United States, 1991. Arlington, VA, Insurance Institute for Highway Safety, January 1993
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3. Brotman S, Indeck MC, Leonard D, et al: The study of the relationship between lifestyle characteristic self-reported drinking patterns and trauma. Am Surg 1995;61:975-979 4. Poole GV, Griswold JA, Thaggard K, et al: Trauma is a recurrent disease. Surgery 1993; 113:608-611 5. Wilson N: An education in violence. Health Progress 1996;77: 37-42 6. Hume SK: Teaching nonviolence in the innercity. Health Progress 1996;77:34-36 7. Sims DW, Bivins BA, Obeid FN, et al: Urban trauma: A chronic recurrent disease. J Trauma 1989;29:940-947 8. Cesare J, Morgan AS, Fetice PR, et al: Characteristics of blunt and personal violent injuries. J Trauma 1990;30:176-182 9. Rivara FP, Koepsell TD, Jurkovich GJ, et al: The effects of alcohol abuse on readmission for trauma. JAMA 1993;270:19621964 10. Chang G, Astrachan BM: The emergency department surveillance of alcohol intoxication after motor vehicle accidents. JAMA 1988;260:2533-2536 11. Madden C, Cole TB: Emergency intervention to break the cycle of drunken driving and recurrent injury. Ann Emerg Med 1995;26:177-179 12. Rutherford WH: The responsibility of emergency medicine towards the prevention of road accidents. Arch Emerg Med 1986;3: 163-176 13. Nilssen O: TheTromso study: Identification of and a controlled intervention on a population of early-stage risk drinkers. Prev Med 1991 ;20:518-528 14. Conigrave KM, Burns FH, Reznik RB, et al: Problem drinking in emergency department patients: the scope for early intervention. Med J Aust 1991;154:801-805 15. Kamerow DB, Pincus HA, Macdonald Dl:Alcohol abuse, other drug abuse, and mental disorders in medical practice. JAMA 1986;255: 2054-2057 16. Naranjo CA, Bremner KE: Behavioural correlates of alcohol intoxication. Addiction 1993;88:31-41 17. Gentilello LM, Donovan DM, Dunn CW, et al: Alcohol interventions in trauma centers. JAMA 1995;274:1043-1048 18. Soderstrom CA, Dailey JT, Kerns TJ: Alcohol and other drugs: An assessment of testing and clinical practices in U.S. trauma centers. J Trauma 1994;36:68-73 19. Bien TH, Miller WR, Tonigan JS: Brief interventions for alcohol problems: A review. Addiction 1993;88:315-336 20. Gentilello LM, Duggan P, Drummond D, et al: Major injury as a unique opportunity to initiate treatment in the alcoholic. Am J Surg 1988;156:558-561