- Email: [email protected]
Injuries in a 1-Day Recreational Cycling Tour: Bike New York
INJURY PREVENTION/ORIGINAL CONTRIBUTION
Injuries in a 1-Day Recreational Cycling Tour: Bike New York From the Department of Emergency Medicine, St Luke’s–Roosevelt Hospital Center and Columbia University College of Physicians and Surgeons, New York, NY,* the Division of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX,‡ and the Department of Emergency Medicine, Massachusetts General Hospital, and Channing Laboratory, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA.§ Received for publication March 20, 1998. Revision received July 13, 1998. Accepted for publication July 22, 1998. Presented at the American College of Emergency Physicians Research Forum, San Francisco, CA, October 1997. Dr Camargo is supported by grant No. HL-03533 from the National Institutes of Health, Bethesda, MD. Reprints not available from authors. Copyright © 1999 by the American College of Emergency Physicians. 0196-0644/99/$8.00 + 0 47/1/94663
Stephen D Emond, MD* Paul Tayoun, MD* John P Bedolla, MD‡ Carlos A Camargo, Jr, MD, DrPH§
Study objective: To describe injuries during a 1-day urban cycling tour. Methods: During the May 1996 “Bike New York” tour, we monitored EMS calls to identify injuries in a cohort of helmeted cyclists shielded from traffic. We collected demographic information from entry records, injury data from ambulance call reports, and follow-up on transported patients from telephone interviews with emergency physicians. Data were summarized using proportions, relative risks (RRs), 95% confidence intervals (CIs), and χ2 test. Results: Approximately 28,000 cyclists participated, of which 23,502 (84%) were officially registered. Sixty-eight percent of registered bicyclists were male, and 92% were between 18 and 55 years old. Of the 140 EMS calls made during the tour, 136 (97%) involved participants; this yielded an injury incidence of 5 per 1,000 riders, or 12 to 13 per 100,000 person-miles. Injury was more common among younger cyclists (RR=1.4 for age ≤35 years versus age >35 years; 95% CI, 1.0 to 2.0; P<.05), and possibly women (RR=1.3; 95% CI, .9 to 1.8; P=.11). Injuries were mostly minor, but there were 7 concussions and 6 clavicle fractures; none of the 140 injuries was fatal. Thirty-eight calls resulted in ED transport, and 5 of these patients were admitted. Although EMS units were evenly distributed along the route, most EMS calls occurred in only 3 of the 7 zones (P<.001). Conclusion: Injuries during the largest 1-day US cycling tour were uncommon. More data are needed to determine the relative importance of injury risk factors. Data collection during mass events may help guide distribution of EMS personnel. [Emond SD, Tayoun P, Bedolla JP, Camargo CA Jr: Injuries in a 1day recreational cycling tour: Bike New York. Ann Emerg Med January 1999;33:56-61.]
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INTRODUCTION
As recreational bicycling has grown in popularity in the United States, large organized cycling tours, ranging from 1-day tours to transcontinental rides, have emerged. Injuries related to cycling tours have likely increased, but their precise epidemiology has not been determined. 1-3 Although surveillance data provide population-based estimates of cycling injury incidence,4-6 most research has been based on registries of patients presenting to EDs7-14 or on registries maintained by cycle tour organizers.1-3 The first approach identifies only the more seriously injured patients and provides no data on injury incidence, whereas the second is usually limited by the small number of bicyclists in a given tour. Regardless, injured cyclists tend to be younger and male; the most serious injuries involve unhelmeted cyclists or motor vehicle contact. Few of these studies describe outcomes of injured bicyclists. To better describe patterns of injury associated with organized recreational cycling, we studied the largest 1-day cycling tour in the United States. Because the ride involved mandatory helmet use and was isolated from motor traffic, we expected that few serious injuries would occur, and that head injuries would be particularly uncommon. Furthermore, we expected that injured cyclists would more likely be young men.
sible for calls in a given zone, and the EMS command officer was in charge of all zone officers. A patient tracking unit with a radio-computer link to EMS units was stationed at the reunion center at the finish area. As disposition and transportation occurred, the patient tracking unit received and relayed information to 2 volunteer tour physicians (JPB, PT) in charge of data collection, patient follow-up, and tracking. The tour physicians called the receiving hospitals and determined from treating physicians the nature of the transported patients’ injuries, tests being performed, and final disposition (eg, admitted or disFigure 1.
Bike New York tour route.
M AT E R I A L S A N D M E T H O D S
”Bike New York: The Great Five Boro Bike Tour” is the largest 1-day mass cycling tour in the United States. First organized in 1957, the tour is an annual fund-raising event sponsored by Hostelling International–American Youth Hostels and the New York City Department of Transportation. EMS personnel and emergency physicians provide medical support and routinely collect injury data; however, these data had not previously been examined in detail. The institutional review board at St Luke’s– Roosevelt Hospital Center considered study of these data to be exempt from review. The 19th annual tour took place on May 5, 1996. Its 42-mile course began in lower Manhattan and continued through all 5 boroughs, finishing in Staten Island (Figure 1). Tour participants were separated from traffic by barriers and New York City Police Department, EMS, and civilian personnel. All registered bicyclists were required to wear helmets and registration vests. Civilian marshals stationed along the tour route at approximately 1/4- mile intervals acted as first-responders and triggered the EMS system whenever an injury was observed or reported. A similar number of EMS units was stationed along each of seven 6mile “zones” on the route. Each zone officer was respon-
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charged). This information was communicated to patients’ emergency contacts. We collected demographic information from entry records, injury data from ambulance call reports, and followup data on transported patients from telephone interview records. The patient information included the ambulance call record (ACR) diagnosis, age, gender, zone in which the injury occurred, and disposition (eg, refused medical assistance [RMA] or hospital where patient was transported). Diagnoses of RMA patients were based on ACR diagnoses and confirmed by interviews with EMS crews. Disposition data were available for all transported patients. Data analysis was performed with Stata 5.0 software (StataCorp, College Station, TX). Data are presented as proportions with 95% confidence intervals (CIs) when appropriate. The association between demographic factors and injury was examined by χ 2 tests, then summarized with relative risks (RRs) and 95% confidence intervals (CIs). Because the registration data provided to the investigators contained no unique participant identifiers, multivariate modeling was not possible. All P values are 2-sided, with values of P<.05 considered statistically significant. R E S U LT S
A total of 23,502 bicyclists registered for the tour: 20,428 by mail, 1,023 by walk-in, and 2,051 on the day of the tour. Starting line and finish line number counts identified approximately 4,500 others who either began the tour unregistered or joined the tour en route, for an approximate total of 28,000 bicyclists. Race organizers estimated that Table 1.
Characteristics of registered bicyclists (n=23,502) and individuals that triggered an EMS call (n=140).
22,500 registered bicyclists and 3,000 others rode the entire 42 miles, which translated to at least 1,071,000 person-miles ridden during the tour. If the remaining 2,500 bicyclists had completed the full distance, the total would be 1,176,000 person-miles. Data from registration information were available for 91% of registered bibicyclists. Gender was available for 21,317 (91%) of registered bibicyclists, of whom 68% were male. Birth dates were recorded for 21,885 (98%) of registered bibicyclists, of whom 92% were between 18 and 55 years old (Table 1). During the tour, 140 calls were made to EMS. One hundred thirty-six (97%) involved tour participants, for a reported injury incidence of 5 injuries per 1,000 bicyclists (95% CI, 4% to 6%). Given the uncertainty about the total number of miles ridden by tour participants, this represents between 12 injuries per 100,000 person-miles (95% CI, 10% to 14%) and 13 injuries per 100,000 person-miles (95% CI, 11% to 15%). The 4 nonbicyclist injuries involved 2 police officers and 2 bystanders; none were transported. Most injuries were minor. Some patients may have sustained more than 1 injury, but only the major diagnosis in the field was reported (Table 2). Soft tissue injuries of the extremities (ie, contusions, hematomas, and abrasions) were most frequent. Patients with diagnoses of “blunt trauma” had injuries that were not otherwise specified and included some concussions. There were no deaths. Injury was more common among younger bicyclists (RRs =1.4 for age ≤ 35 years versus age > 35years; 95% CI, 1.0 to 2.0; P < .05). While more EMS calls were triggered for injuries among male bicyclists (87 of 140, or 62%), there was a trend toward greater risk of injury among women (RRs = 1.3 for women versus men; 95% CI, .9 to 1.8; P =.11). Table 2.
Primary injuries triggering an EMS call (n=140). Characteristic Age (y) <18 18–25 26–35 36–45 46–55 56–65 >65 No data Gender Male Female No data
5 8
Registered Bicyclists No. (%)
EMS Calls No. (%)
Injury
No. (%) 63 (45) 32 (23) 21 (15) 10 (7) 4 (3) 4 (3) 3 (2) 2 (1) 1 (<1)
977 (5) 2,099 (10) 9,806 (45) 5,464 (25) 2,677 (12) 676 (3) 186 (1) 1,617
7 (5) 19 (14) 68 (46) 22 (18) 13 (9) 6 (4) 5 (4) 0
Soft tissue injury* Abrasion Blunt trauma† Fracture Dislocation Laceration Musculoskeletal pain Dizziness or presyncope Acute asthma
14,568 (68) 6,749 (32) 2,185
87 (62) 53 (38) 0
*
Category includes simple contusions and hematomas. Category includes concussions (head injury with loss of consciousness).
†
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Of the 140 patients seen by EMS crews, 102 were designated RMA (typically because of perceived low acuity injury, such as an abrasion), but may have received primary first aid from the EMS crew. Thirty-eight (27%) of the 140 calls resulted in transport to hospitals. Two of the 4 injured nonbicyclists were transported. Thirty-three patients were treated and released, and 5 were admitted. All 33 patients w e r e triaged but 6 walked-out or left against medical advice before formal physician evaluation. Three of these patients had ACR diagnosis of soft tissue injury, and 3 had blunt trauma. The remaining 27 discharged patients had various soft tissue and orthopedic injuries; some had more than 1 injury (Table 3). Only 7 patients suffered concussions, defined as “head injury with loss of consciousness,” yielding an incidence of .3 per 1,000 bicyclists (95% CI, .1 to .5). Clavicle fracture was the most common orthopedic injury. The patient who received operative care for the open finger fracture had 1 of the 6 clavicle fractures. There were few acute medical problems. EMS calls were not evenly distributed across the seven 6-mile zones (P < .001), with most calls occurring in zones 4, 6, and 7 (Figure 2). Most calls were related to injury events on steep downhill gradients. Injuries in Zone 4 most often occurred on the downhill portion of the Queensboro Bridge. Zone 6 comprised the highest point on the tour, the top of the Gowanus Expressway overpass, which led to a steep downhill gradient complicated by construction at the end of the hill. Zone 7 included the descent off the VerrazanoNarrows Bridge with a 90-degree turn onto the finish area. Zone 6 had the largest number of EMS calls (39) and ED transports (17). DISCUSSION
Recreational bicycling is promoted as a healthful means to physical fitness. It is not, however, without hazard. Overall, the Consumer Product Safety Commission estimates there are 880 bicycle-related injuries per 100,000 bicyclists each year.15 A 1985 survey indicated that 46% of 492 active adult urban bicyclists had been involved in a bicycle injury event and 9% had injuries resulting in hospital admission 9 ; soft tissue injuries predominated. Thompson et al4 reported an overall injury rate of 163 per 100,000 and a head injury rate of 42 per 100,000 in a Seattle health maintenance organization. Although most bicyclist injuries are minor, the National Center for Injury Control and Prevention reported 783 pedal cyclist traffic-related deaths in 1995, for an age-adjusted rate of .3 deaths per 100,000 bicyclists.6 Most deaths are due to head injuries, which are markedly less common with helmet use.16-18
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Injury rates in 1-day recreational cycling tours have not been previously reported. In the current study, we calculated an overall injury incidence of 5 per 1,000 Bike New York riders, or 12 to 13 per 100,000 person-miles. Serious injuries were uncommon in this urban cycling tour. Because we found no comparative data from 1-day cycling tours in a MEDLINE review of injury surveillance and bicycling, we reviewed reports of ED bicycle-injury registries to ascertain patterns of injuries and risk factors for more seriously injured bicyclists.7-14 ED registries consistently describe a marked male predominance and low frequency of helmet use (typically ≤ 10%); most injuries occur from bicycle-traffic incidents or falls from bicycles. More than one third incur neurologic injury, often severe. Twenty percent to 60% of patients present with fractures, usually of the upper extremity. In a retrospective study of bicycle injury event-related hospital admissions or deaths in the 1989 Oregon Injury registry, Frank et al7 reported helmet use in only 4% of patients; 69% of injured bicyclists were male. Adults accounted for 40% of the injuries but 67% of deaths, usually from neurological injuries. Ninety-three percent of the deaths and 34% of all injuries involved bicycle versus automobile crashes. A Scandinavian study attributed more than half of acute injuries to bicyclist error, motor vehicle contact, and road defects.19 Another study of urban bicyclist injuries reported frequency of injury event mechanisms, the most frequent of which were being struck by motor vehicle, falling from a bicycle, or being struck by a bicycle; 11% of injured patients were pedestrians. 12 A larger review of injuries identified motor vehicle crash, self-reported speed over 15 miles per hour, and age younger than 6 years or more than 39 years as risk factors
Table 3.
Injuries of transported bicyclists (n=38) according to ED disposition. Disposition Treated in ED and released Isolated contusion/abrasion Nonoperative fracture* Concussion Uncomplicated laceration Acromioclavicular separation Admitted overnight to hospital Operative fracture† Concussion (admit for observation) Complicated facial laceration with dental trauma Chest pain with ECG changes
No.
8 8 6 4 2 2 1 1 1
*
Category includes 5 clavicle fractures and 1 scaphoid fracture. Category includes 1 bimalleolar ankle fracture and 1 open finger fracture.
†
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for serious acute injuries.20 In another registry study, alcohol consumption was a risk factor for greater injury severity, longer hospitalization, and higher health care costs. 21 Injury data also are available from some organized cycling tours, particularly from longer tours. For instance, of 2,069 participants in the 4,200-mile transcontinental 1976 Bikecentennial tour, 308 bicyclists had 399 injury events, for an injury rate of 8 per 100,000 person-miles. Most injuries were minor, and overuse injuries, such as hand numbness and knee pain, were common. Injured bicyclists were more likely to be young and unmarried. Bicycle malfunction, adverse road conditions, and downhill gradients contributed to injury events.1 In the 460-mile, 8-day 1983 Arizona tour, 7 of the 132 participants suffered minor traumatic injuries, and 2 sustained fall-related fractures for an injury rate of 14 per 100,000 person-miles. Overuse injuries (eg, buttock pain, knee problems, neck-shoulder pain) were common. Acute injuries were more common in bicyclists with no prior riding experience. 2 A more complete study was done on the 339-mile, 6-day 1994 Cycle Across Maryland tour. Two thirds of the 1,638 participants were male. Eighty-five bicyclists sustained acute traumatic injuries (15/100,000 person-miles), 76 had overuse injuries (14/100,000 person-miles), and 37 suffered other medical problems (7/100,000 person-miles).
Figure 2.
EMS calls and patient disposition by zone. Dark bar denotes EMS calls; light bar denotes patient transports to ED.
Risk factors for injury included no prior touring experience and a history of racing.3 A recent study of the 547-mile, 8-day 1996 “California AIDSRide 3” identified 25,379 patient encounters, with 509 triaged as requiring physician examination. Fifty-seven (11%) of these had soft tissue injuries, and 46 (9%) had orthopedic injuries; 158 (31%) involved heat-related illnesses. Fifty-five (11%) of the 509 required ED transport, and 7 (13%) of these were admitted. There were no deaths.22 Organized tours invariably have mandatory safety helmet policies and use other strategies to protect participants from traffic, including high-visibility vests, intersection warnings for bicyclists and motorists, and roving tour support vehicles. Bike New York used barriers, police officers, and civilian personnel to separate bicyclists from motor traffic. Eliminating the 2 most important injury risk factors undoubtedly accounts for much of the difference between tour-related injuries and ED bicycle-related injuries in general. In particular, head injury incidence was low and the extent of injury minor. We attributed this to mandatory helmet use. Information on optimal EMS and medical staffing of mass events is limited, but reviews stress preplanning and tight coordination of services, with levels of staffing and staff expertise determined by location (urban versus rural), participant and spectator density, and environmental fac-
No. of Patients 40 35 30 25 20 15 10 5 0 1
6 0
2
3
4 Zone
5
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tors. 23-25 Ideally, road and other conditions should determine where civilian monitors and medical staff are deployed along the tour route. Tour organizers often place civilian monitors to warn bicyclists of upcoming terrain and road hazards.3 For instance, steep downhill gradients lead to increased breaking times, and in a crowdedtour, may cause the lead bicyclists to fall or halt for congestion, catching rear bicyclists unaware, thereby resulting in a pileup. Most EMS calls occurred in the second half of the Bike New York tour, along downhill stretches with terrain or road hazards. Unfortunately, data on injury mechanism were unavailable (eg, from patient or bystander reports or from detailed ACRs), and we were unable to determine whether this late surge in calls was related to road/terrain hazards, bicyclist fatigue, risky behaviors, or some combination of factors. Regardless, placing more EMS units in areas where more injuries occur may result in more efficient use of limited resources. Pretour and posttour surveys and detailed injury reports could help elucidate these issues, allow tour planners to offer more detailed pretour advice to participants, and hopefully to help prevent even the few injuries that occur. We recognize the limitations of this study. Regarding injury incidence, all EMS calls did not result in transported patients, and not all patients transported to hospitals were formally evaluated; we assume these patients had mild injuries. Other acute or late injuries may have occurred, with patients presenting for ED care on their own. That there were more than 20 hospital EDs along the tour route proved to be a logistical impediment to identifying these additional injuries. Because injuries provoking EMS calls during the tour were largely minor, however, we suspect we identified most of the serious tour-related injuries. In addition to lacking details on injury mechanism and circumstances, our dataset had minimal information on characteristics of patients versus nonpatients, including training status, prior long-distance cycling experience, and alcohol consumption on the day of the tour. We were, consequently, unable to determine the impact of these previously reported risk factors. Finally, there were too few serious injuries to allow us to assess risk factors for serious injuries alone. In summary, injuries during the largest 1-day recreational cycling tour in the United States were uncommon. Most injuries that occurred were minor, suggesting that mandating helmet use and shielding bicyclists from motor traffic may be effective means of injury prevention. More data are needed to determine the relative importance of bicyclists’ age, gender, and other injury risk factors. Future studies should include detailed, standardized injury-event and follow-up questionnaires. The uneven distribution of EMS
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calls suggests a better way to distribute EMS personnel during future events. Increased collaboration between tour planners and emergency medicine researchers could help make Bike New York, and other large recreational cycling tours, even safer. REFERENCES 1. Weiss B: Nontraumatic injuries in amateur long distance bicyclists. Am J Sports Med 1985;13:187-192. 2. Kulund D, Brubaker C: Injuries in the Bikecentennial Tour. Physician Sports Med 1978;6:75-78. 3. Dannenberg A, Needle S, Mullady D, et al: Predictors of injury among 1638 riders in a recreational long-distance bicycle tour: Cycle Across Maryland. Am J Sports Med 1996;24:747-753. 4. Thompson DC, Thompson RS, Rivara FP: Incidence of bicycle-related injury in a defined population. Am J Public Health 1991;80:1388-1390. 5. Simpson A, Minerio J: Prevention of bicycle accidents. Injury 1992;23:171-173. 6. Internet/World Wide Web URL: http://www.cdc.gov/ncipc/osp/us9592/mvpctr.htm [accessed 1/19/98]. 7. Frank E, Frankel P, Mullins RJ, et al: Injuries resulting from bicycle collisions. Acad Emerg Med 1995;2:200-203. 8. Ballham A, Absoud E, Kotecha M, et al: A study of bicycle accidents. Injury: Br J Accident Surg 1985;16:405-408. 9. Kiburz D, Jacobs R, Reckling F, et al: Bicycle accidents and injuries among adult bicyclists. Am J Sports Med 1986;14:416-419. 10. Yelon JA, Harrigan N, Evans JT: Bicycle trauma: A five-year experience. Am Surg 1995;61:202-205. 11. Hems T, Simpson H: Prevention of hand injuries in cycle accidents. J Trauma 1992;32:683-685. 12. Tucci J, Barone J: A study of urban bicycling accidents. Am J Sports Med 1988;16:181-184. 13. Rivara FR, Maier RV, Mueller BA, et al: Evaluation of potentially preventable deaths among pedestrians and bicyclist fatalities. JAMA 1989;261:566-570. 14. Lofthouse G: Bicycling injuries: Traumatic injuries to the extremities and thorax. Clin Sports Med 1994;13:113-135. 15. Tinsworth DK, Polen C, Cassidy S: Bicycle-related injuries: Injury, hazard, and risk patterns, in Rogers GB, Tinsworth DK, Polen C, et al (eds): Bicycle Use and Hazard Patterns in the United States. Washington DC: US Consumer Product Safety Commission, June 1994. 16. Thompson RS, Rivara FP, Thompson DC: A case-control study of the effectiveness of bicycle safety helmets. N Engl J Med 1989;320:1361-1367. 17. Maimaris C, Summers C, Browing C, et al: Injury patterns in cyclist attending an accident and emergency department: A comparison of helmet wearers and non-wearers. BMJ 1994;308:15371540. 18. Thompson DC, Nunn ME, Thompson RS, et al: Effectiveness of bicycle safety helmets in preventing serious facial injury. JAMA 1996;276:1974-1975. 19. Nyberg P, Bjornstig U, Bygren LO: Road characteristics and bicycle accidents. Scand J Soc Med 1996;24:293-301. 20. Rivara FP, Thompson DC, Thompson RS: Epidemiology of bicycle injuries and risk factors for serious injury. Inj Prev 1997;3:110-114. 21. Friedman LJ, Rodi SW, Kreuger MA, et al: Medical care at the California AIDS Ride 3: Experiences in event medicine. Ann Emerg Med 1998;31:219-223. 22. Spaite D, Criss E, Weist D, et al: A prospective investigation of the impact of alcohol consumption on helmet use, injury severity, medical resource utilization, and health care cost in bicycle related trauma. J Trauma 1995;38:287-290. 23. Montalto N, Janas T: Medical coverage of recreational cycling events: participation of local EMS squads and advanced planning. Clin Sports Med 1994;13:249-258. 24. Sanders AB, Criss E, Steckl P, et al: An analysis of medical care at mass gatherings. Ann Emerg Med 1986;15:515-519. 25. Ault MJ, Lawrence SM: Providing medical coverage for amateur athletic events. Your Patient and Fitness 1996;10:23-30.
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Injuries in a 1-Day Recreational Cycling Tour: Bike New York From the Department of Emergency Medicine, St Luke’s–Roosevelt Hospital Center and Columbia University College of Physicians and Surgeons, New York, NY,* the Division of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX,‡ and the Department of Emergency Medicine, Massachusetts General Hospital, and Channing Laboratory, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA.§ Received for publication March 20, 1998. Revision received July 13, 1998. Accepted for publication July 22, 1998. Presented at the American College of Emergency Physicians Research Forum, San Francisco, CA, October 1997. Dr Camargo is supported by grant No. HL-03533 from the National Institutes of Health, Bethesda, MD. Reprints not available from authors. Copyright © 1999 by the American College of Emergency Physicians. 0196-0644/99/$8.00 + 0 47/1/94663
Stephen D Emond, MD* Paul Tayoun, MD* John P Bedolla, MD‡ Carlos A Camargo, Jr, MD, DrPH§
Study objective: To describe injuries during a 1-day urban cycling tour. Methods: During the May 1996 “Bike New York” tour, we monitored EMS calls to identify injuries in a cohort of helmeted cyclists shielded from traffic. We collected demographic information from entry records, injury data from ambulance call reports, and follow-up on transported patients from telephone interviews with emergency physicians. Data were summarized using proportions, relative risks (RRs), 95% confidence intervals (CIs), and χ2 test. Results: Approximately 28,000 cyclists participated, of which 23,502 (84%) were officially registered. Sixty-eight percent of registered bicyclists were male, and 92% were between 18 and 55 years old. Of the 140 EMS calls made during the tour, 136 (97%) involved participants; this yielded an injury incidence of 5 per 1,000 riders, or 12 to 13 per 100,000 person-miles. Injury was more common among younger cyclists (RR=1.4 for age ≤35 years versus age >35 years; 95% CI, 1.0 to 2.0; P<.05), and possibly women (RR=1.3; 95% CI, .9 to 1.8; P=.11). Injuries were mostly minor, but there were 7 concussions and 6 clavicle fractures; none of the 140 injuries was fatal. Thirty-eight calls resulted in ED transport, and 5 of these patients were admitted. Although EMS units were evenly distributed along the route, most EMS calls occurred in only 3 of the 7 zones (P<.001). Conclusion: Injuries during the largest 1-day US cycling tour were uncommon. More data are needed to determine the relative importance of injury risk factors. Data collection during mass events may help guide distribution of EMS personnel. [Emond SD, Tayoun P, Bedolla JP, Camargo CA Jr: Injuries in a 1day recreational cycling tour: Bike New York. Ann Emerg Med January 1999;33:56-61.]
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INTRODUCTION
As recreational bicycling has grown in popularity in the United States, large organized cycling tours, ranging from 1-day tours to transcontinental rides, have emerged. Injuries related to cycling tours have likely increased, but their precise epidemiology has not been determined. 1-3 Although surveillance data provide population-based estimates of cycling injury incidence,4-6 most research has been based on registries of patients presenting to EDs7-14 or on registries maintained by cycle tour organizers.1-3 The first approach identifies only the more seriously injured patients and provides no data on injury incidence, whereas the second is usually limited by the small number of bicyclists in a given tour. Regardless, injured cyclists tend to be younger and male; the most serious injuries involve unhelmeted cyclists or motor vehicle contact. Few of these studies describe outcomes of injured bicyclists. To better describe patterns of injury associated with organized recreational cycling, we studied the largest 1-day cycling tour in the United States. Because the ride involved mandatory helmet use and was isolated from motor traffic, we expected that few serious injuries would occur, and that head injuries would be particularly uncommon. Furthermore, we expected that injured cyclists would more likely be young men.
sible for calls in a given zone, and the EMS command officer was in charge of all zone officers. A patient tracking unit with a radio-computer link to EMS units was stationed at the reunion center at the finish area. As disposition and transportation occurred, the patient tracking unit received and relayed information to 2 volunteer tour physicians (JPB, PT) in charge of data collection, patient follow-up, and tracking. The tour physicians called the receiving hospitals and determined from treating physicians the nature of the transported patients’ injuries, tests being performed, and final disposition (eg, admitted or disFigure 1.
Bike New York tour route.
M AT E R I A L S A N D M E T H O D S
”Bike New York: The Great Five Boro Bike Tour” is the largest 1-day mass cycling tour in the United States. First organized in 1957, the tour is an annual fund-raising event sponsored by Hostelling International–American Youth Hostels and the New York City Department of Transportation. EMS personnel and emergency physicians provide medical support and routinely collect injury data; however, these data had not previously been examined in detail. The institutional review board at St Luke’s– Roosevelt Hospital Center considered study of these data to be exempt from review. The 19th annual tour took place on May 5, 1996. Its 42-mile course began in lower Manhattan and continued through all 5 boroughs, finishing in Staten Island (Figure 1). Tour participants were separated from traffic by barriers and New York City Police Department, EMS, and civilian personnel. All registered bicyclists were required to wear helmets and registration vests. Civilian marshals stationed along the tour route at approximately 1/4- mile intervals acted as first-responders and triggered the EMS system whenever an injury was observed or reported. A similar number of EMS units was stationed along each of seven 6mile “zones” on the route. Each zone officer was respon-
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charged). This information was communicated to patients’ emergency contacts. We collected demographic information from entry records, injury data from ambulance call reports, and followup data on transported patients from telephone interview records. The patient information included the ambulance call record (ACR) diagnosis, age, gender, zone in which the injury occurred, and disposition (eg, refused medical assistance [RMA] or hospital where patient was transported). Diagnoses of RMA patients were based on ACR diagnoses and confirmed by interviews with EMS crews. Disposition data were available for all transported patients. Data analysis was performed with Stata 5.0 software (StataCorp, College Station, TX). Data are presented as proportions with 95% confidence intervals (CIs) when appropriate. The association between demographic factors and injury was examined by χ 2 tests, then summarized with relative risks (RRs) and 95% confidence intervals (CIs). Because the registration data provided to the investigators contained no unique participant identifiers, multivariate modeling was not possible. All P values are 2-sided, with values of P<.05 considered statistically significant. R E S U LT S
A total of 23,502 bicyclists registered for the tour: 20,428 by mail, 1,023 by walk-in, and 2,051 on the day of the tour. Starting line and finish line number counts identified approximately 4,500 others who either began the tour unregistered or joined the tour en route, for an approximate total of 28,000 bicyclists. Race organizers estimated that Table 1.
Characteristics of registered bicyclists (n=23,502) and individuals that triggered an EMS call (n=140).
22,500 registered bicyclists and 3,000 others rode the entire 42 miles, which translated to at least 1,071,000 person-miles ridden during the tour. If the remaining 2,500 bicyclists had completed the full distance, the total would be 1,176,000 person-miles. Data from registration information were available for 91% of registered bibicyclists. Gender was available for 21,317 (91%) of registered bibicyclists, of whom 68% were male. Birth dates were recorded for 21,885 (98%) of registered bibicyclists, of whom 92% were between 18 and 55 years old (Table 1). During the tour, 140 calls were made to EMS. One hundred thirty-six (97%) involved tour participants, for a reported injury incidence of 5 injuries per 1,000 bicyclists (95% CI, 4% to 6%). Given the uncertainty about the total number of miles ridden by tour participants, this represents between 12 injuries per 100,000 person-miles (95% CI, 10% to 14%) and 13 injuries per 100,000 person-miles (95% CI, 11% to 15%). The 4 nonbicyclist injuries involved 2 police officers and 2 bystanders; none were transported. Most injuries were minor. Some patients may have sustained more than 1 injury, but only the major diagnosis in the field was reported (Table 2). Soft tissue injuries of the extremities (ie, contusions, hematomas, and abrasions) were most frequent. Patients with diagnoses of “blunt trauma” had injuries that were not otherwise specified and included some concussions. There were no deaths. Injury was more common among younger bicyclists (RRs =1.4 for age ≤ 35 years versus age > 35years; 95% CI, 1.0 to 2.0; P < .05). While more EMS calls were triggered for injuries among male bicyclists (87 of 140, or 62%), there was a trend toward greater risk of injury among women (RRs = 1.3 for women versus men; 95% CI, .9 to 1.8; P =.11). Table 2.
Primary injuries triggering an EMS call (n=140). Characteristic Age (y) <18 18–25 26–35 36–45 46–55 56–65 >65 No data Gender Male Female No data
5 8
Registered Bicyclists No. (%)
EMS Calls No. (%)
Injury
No. (%) 63 (45) 32 (23) 21 (15) 10 (7) 4 (3) 4 (3) 3 (2) 2 (1) 1 (<1)
977 (5) 2,099 (10) 9,806 (45) 5,464 (25) 2,677 (12) 676 (3) 186 (1) 1,617
7 (5) 19 (14) 68 (46) 22 (18) 13 (9) 6 (4) 5 (4) 0
Soft tissue injury* Abrasion Blunt trauma† Fracture Dislocation Laceration Musculoskeletal pain Dizziness or presyncope Acute asthma
14,568 (68) 6,749 (32) 2,185
87 (62) 53 (38) 0
*
Category includes simple contusions and hematomas. Category includes concussions (head injury with loss of consciousness).
†
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Of the 140 patients seen by EMS crews, 102 were designated RMA (typically because of perceived low acuity injury, such as an abrasion), but may have received primary first aid from the EMS crew. Thirty-eight (27%) of the 140 calls resulted in transport to hospitals. Two of the 4 injured nonbicyclists were transported. Thirty-three patients were treated and released, and 5 were admitted. All 33 patients w e r e triaged but 6 walked-out or left against medical advice before formal physician evaluation. Three of these patients had ACR diagnosis of soft tissue injury, and 3 had blunt trauma. The remaining 27 discharged patients had various soft tissue and orthopedic injuries; some had more than 1 injury (Table 3). Only 7 patients suffered concussions, defined as “head injury with loss of consciousness,” yielding an incidence of .3 per 1,000 bicyclists (95% CI, .1 to .5). Clavicle fracture was the most common orthopedic injury. The patient who received operative care for the open finger fracture had 1 of the 6 clavicle fractures. There were few acute medical problems. EMS calls were not evenly distributed across the seven 6-mile zones (P < .001), with most calls occurring in zones 4, 6, and 7 (Figure 2). Most calls were related to injury events on steep downhill gradients. Injuries in Zone 4 most often occurred on the downhill portion of the Queensboro Bridge. Zone 6 comprised the highest point on the tour, the top of the Gowanus Expressway overpass, which led to a steep downhill gradient complicated by construction at the end of the hill. Zone 7 included the descent off the VerrazanoNarrows Bridge with a 90-degree turn onto the finish area. Zone 6 had the largest number of EMS calls (39) and ED transports (17). DISCUSSION
Recreational bicycling is promoted as a healthful means to physical fitness. It is not, however, without hazard. Overall, the Consumer Product Safety Commission estimates there are 880 bicycle-related injuries per 100,000 bicyclists each year.15 A 1985 survey indicated that 46% of 492 active adult urban bicyclists had been involved in a bicycle injury event and 9% had injuries resulting in hospital admission 9 ; soft tissue injuries predominated. Thompson et al4 reported an overall injury rate of 163 per 100,000 and a head injury rate of 42 per 100,000 in a Seattle health maintenance organization. Although most bicyclist injuries are minor, the National Center for Injury Control and Prevention reported 783 pedal cyclist traffic-related deaths in 1995, for an age-adjusted rate of .3 deaths per 100,000 bicyclists.6 Most deaths are due to head injuries, which are markedly less common with helmet use.16-18
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Injury rates in 1-day recreational cycling tours have not been previously reported. In the current study, we calculated an overall injury incidence of 5 per 1,000 Bike New York riders, or 12 to 13 per 100,000 person-miles. Serious injuries were uncommon in this urban cycling tour. Because we found no comparative data from 1-day cycling tours in a MEDLINE review of injury surveillance and bicycling, we reviewed reports of ED bicycle-injury registries to ascertain patterns of injuries and risk factors for more seriously injured bicyclists.7-14 ED registries consistently describe a marked male predominance and low frequency of helmet use (typically ≤ 10%); most injuries occur from bicycle-traffic incidents or falls from bicycles. More than one third incur neurologic injury, often severe. Twenty percent to 60% of patients present with fractures, usually of the upper extremity. In a retrospective study of bicycle injury event-related hospital admissions or deaths in the 1989 Oregon Injury registry, Frank et al7 reported helmet use in only 4% of patients; 69% of injured bicyclists were male. Adults accounted for 40% of the injuries but 67% of deaths, usually from neurological injuries. Ninety-three percent of the deaths and 34% of all injuries involved bicycle versus automobile crashes. A Scandinavian study attributed more than half of acute injuries to bicyclist error, motor vehicle contact, and road defects.19 Another study of urban bicyclist injuries reported frequency of injury event mechanisms, the most frequent of which were being struck by motor vehicle, falling from a bicycle, or being struck by a bicycle; 11% of injured patients were pedestrians. 12 A larger review of injuries identified motor vehicle crash, self-reported speed over 15 miles per hour, and age younger than 6 years or more than 39 years as risk factors
Table 3.
Injuries of transported bicyclists (n=38) according to ED disposition. Disposition Treated in ED and released Isolated contusion/abrasion Nonoperative fracture* Concussion Uncomplicated laceration Acromioclavicular separation Admitted overnight to hospital Operative fracture† Concussion (admit for observation) Complicated facial laceration with dental trauma Chest pain with ECG changes
No.
8 8 6 4 2 2 1 1 1
*
Category includes 5 clavicle fractures and 1 scaphoid fracture. Category includes 1 bimalleolar ankle fracture and 1 open finger fracture.
†
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NEW YORK CYCLING TOUR Emond et al
for serious acute injuries.20 In another registry study, alcohol consumption was a risk factor for greater injury severity, longer hospitalization, and higher health care costs. 21 Injury data also are available from some organized cycling tours, particularly from longer tours. For instance, of 2,069 participants in the 4,200-mile transcontinental 1976 Bikecentennial tour, 308 bicyclists had 399 injury events, for an injury rate of 8 per 100,000 person-miles. Most injuries were minor, and overuse injuries, such as hand numbness and knee pain, were common. Injured bicyclists were more likely to be young and unmarried. Bicycle malfunction, adverse road conditions, and downhill gradients contributed to injury events.1 In the 460-mile, 8-day 1983 Arizona tour, 7 of the 132 participants suffered minor traumatic injuries, and 2 sustained fall-related fractures for an injury rate of 14 per 100,000 person-miles. Overuse injuries (eg, buttock pain, knee problems, neck-shoulder pain) were common. Acute injuries were more common in bicyclists with no prior riding experience. 2 A more complete study was done on the 339-mile, 6-day 1994 Cycle Across Maryland tour. Two thirds of the 1,638 participants were male. Eighty-five bicyclists sustained acute traumatic injuries (15/100,000 person-miles), 76 had overuse injuries (14/100,000 person-miles), and 37 suffered other medical problems (7/100,000 person-miles).
Figure 2.
EMS calls and patient disposition by zone. Dark bar denotes EMS calls; light bar denotes patient transports to ED.
Risk factors for injury included no prior touring experience and a history of racing.3 A recent study of the 547-mile, 8-day 1996 “California AIDSRide 3” identified 25,379 patient encounters, with 509 triaged as requiring physician examination. Fifty-seven (11%) of these had soft tissue injuries, and 46 (9%) had orthopedic injuries; 158 (31%) involved heat-related illnesses. Fifty-five (11%) of the 509 required ED transport, and 7 (13%) of these were admitted. There were no deaths.22 Organized tours invariably have mandatory safety helmet policies and use other strategies to protect participants from traffic, including high-visibility vests, intersection warnings for bicyclists and motorists, and roving tour support vehicles. Bike New York used barriers, police officers, and civilian personnel to separate bicyclists from motor traffic. Eliminating the 2 most important injury risk factors undoubtedly accounts for much of the difference between tour-related injuries and ED bicycle-related injuries in general. In particular, head injury incidence was low and the extent of injury minor. We attributed this to mandatory helmet use. Information on optimal EMS and medical staffing of mass events is limited, but reviews stress preplanning and tight coordination of services, with levels of staffing and staff expertise determined by location (urban versus rural), participant and spectator density, and environmental fac-
No. of Patients 40 35 30 25 20 15 10 5 0 1
6 0
2
3
4 Zone
5
6
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tors. 23-25 Ideally, road and other conditions should determine where civilian monitors and medical staff are deployed along the tour route. Tour organizers often place civilian monitors to warn bicyclists of upcoming terrain and road hazards.3 For instance, steep downhill gradients lead to increased breaking times, and in a crowdedtour, may cause the lead bicyclists to fall or halt for congestion, catching rear bicyclists unaware, thereby resulting in a pileup. Most EMS calls occurred in the second half of the Bike New York tour, along downhill stretches with terrain or road hazards. Unfortunately, data on injury mechanism were unavailable (eg, from patient or bystander reports or from detailed ACRs), and we were unable to determine whether this late surge in calls was related to road/terrain hazards, bicyclist fatigue, risky behaviors, or some combination of factors. Regardless, placing more EMS units in areas where more injuries occur may result in more efficient use of limited resources. Pretour and posttour surveys and detailed injury reports could help elucidate these issues, allow tour planners to offer more detailed pretour advice to participants, and hopefully to help prevent even the few injuries that occur. We recognize the limitations of this study. Regarding injury incidence, all EMS calls did not result in transported patients, and not all patients transported to hospitals were formally evaluated; we assume these patients had mild injuries. Other acute or late injuries may have occurred, with patients presenting for ED care on their own. That there were more than 20 hospital EDs along the tour route proved to be a logistical impediment to identifying these additional injuries. Because injuries provoking EMS calls during the tour were largely minor, however, we suspect we identified most of the serious tour-related injuries. In addition to lacking details on injury mechanism and circumstances, our dataset had minimal information on characteristics of patients versus nonpatients, including training status, prior long-distance cycling experience, and alcohol consumption on the day of the tour. We were, consequently, unable to determine the impact of these previously reported risk factors. Finally, there were too few serious injuries to allow us to assess risk factors for serious injuries alone. In summary, injuries during the largest 1-day recreational cycling tour in the United States were uncommon. Most injuries that occurred were minor, suggesting that mandating helmet use and shielding bicyclists from motor traffic may be effective means of injury prevention. More data are needed to determine the relative importance of bicyclists’ age, gender, and other injury risk factors. Future studies should include detailed, standardized injury-event and follow-up questionnaires. The uneven distribution of EMS
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calls suggests a better way to distribute EMS personnel during future events. Increased collaboration between tour planners and emergency medicine researchers could help make Bike New York, and other large recreational cycling tours, even safer. REFERENCES 1. Weiss B: Nontraumatic injuries in amateur long distance bicyclists. Am J Sports Med 1985;13:187-192. 2. Kulund D, Brubaker C: Injuries in the Bikecentennial Tour. Physician Sports Med 1978;6:75-78. 3. Dannenberg A, Needle S, Mullady D, et al: Predictors of injury among 1638 riders in a recreational long-distance bicycle tour: Cycle Across Maryland. Am J Sports Med 1996;24:747-753. 4. Thompson DC, Thompson RS, Rivara FP: Incidence of bicycle-related injury in a defined population. Am J Public Health 1991;80:1388-1390. 5. Simpson A, Minerio J: Prevention of bicycle accidents. Injury 1992;23:171-173. 6. Internet/World Wide Web URL: http://www.cdc.gov/ncipc/osp/us9592/mvpctr.htm [accessed 1/19/98]. 7. Frank E, Frankel P, Mullins RJ, et al: Injuries resulting from bicycle collisions. Acad Emerg Med 1995;2:200-203. 8. Ballham A, Absoud E, Kotecha M, et al: A study of bicycle accidents. Injury: Br J Accident Surg 1985;16:405-408. 9. Kiburz D, Jacobs R, Reckling F, et al: Bicycle accidents and injuries among adult bicyclists. Am J Sports Med 1986;14:416-419. 10. Yelon JA, Harrigan N, Evans JT: Bicycle trauma: A five-year experience. Am Surg 1995;61:202-205. 11. Hems T, Simpson H: Prevention of hand injuries in cycle accidents. J Trauma 1992;32:683-685. 12. Tucci J, Barone J: A study of urban bicycling accidents. Am J Sports Med 1988;16:181-184. 13. Rivara FR, Maier RV, Mueller BA, et al: Evaluation of potentially preventable deaths among pedestrians and bicyclist fatalities. JAMA 1989;261:566-570. 14. Lofthouse G: Bicycling injuries: Traumatic injuries to the extremities and thorax. Clin Sports Med 1994;13:113-135. 15. Tinsworth DK, Polen C, Cassidy S: Bicycle-related injuries: Injury, hazard, and risk patterns, in Rogers GB, Tinsworth DK, Polen C, et al (eds): Bicycle Use and Hazard Patterns in the United States. Washington DC: US Consumer Product Safety Commission, June 1994. 16. Thompson RS, Rivara FP, Thompson DC: A case-control study of the effectiveness of bicycle safety helmets. N Engl J Med 1989;320:1361-1367. 17. Maimaris C, Summers C, Browing C, et al: Injury patterns in cyclist attending an accident and emergency department: A comparison of helmet wearers and non-wearers. BMJ 1994;308:15371540. 18. Thompson DC, Nunn ME, Thompson RS, et al: Effectiveness of bicycle safety helmets in preventing serious facial injury. JAMA 1996;276:1974-1975. 19. Nyberg P, Bjornstig U, Bygren LO: Road characteristics and bicycle accidents. Scand J Soc Med 1996;24:293-301. 20. Rivara FP, Thompson DC, Thompson RS: Epidemiology of bicycle injuries and risk factors for serious injury. Inj Prev 1997;3:110-114. 21. Friedman LJ, Rodi SW, Kreuger MA, et al: Medical care at the California AIDS Ride 3: Experiences in event medicine. Ann Emerg Med 1998;31:219-223. 22. Spaite D, Criss E, Weist D, et al: A prospective investigation of the impact of alcohol consumption on helmet use, injury severity, medical resource utilization, and health care cost in bicycle related trauma. J Trauma 1995;38:287-290. 23. Montalto N, Janas T: Medical coverage of recreational cycling events: participation of local EMS squads and advanced planning. Clin Sports Med 1994;13:249-258. 24. Sanders AB, Criss E, Steckl P, et al: An analysis of medical care at mass gatherings. Ann Emerg Med 1986;15:515-519. 25. Ault MJ, Lawrence SM: Providing medical coverage for amateur athletic events. Your Patient and Fitness 1996;10:23-30.
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