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Vital records in the development of injury control research
CONCEPTS, COMPONENTS & CONFIGURATIONS injury, research
Vital Records in the Development of Injury Control Research
Most of the resources of the emergency physician are devoted to persons already injured, with little emphasis on prevention. Analyses of state and local injury statistics are necessary to identify local prevention needs in order to set program priorities. We discuss an example, an analysis of statewide injury fatalities identified through the Illinois Vital Records database. The overall death rate for injuries in Illinois was lower than that found for the United States. However, the need for research on several high-risk age groups for certain injuries was identified. Most notably, the homicide rate for those 15 to 24 years old was 140% of the national rate. Other specific nonwhite age groups were overrepresented in poisoning, fire, and firearm deaths, while specific white age groups were overrepresented in suicide, fall, and drowning deaths. The research regarding the etiologies, of these injuries and the formulation and evaluation of prevention strategies based on this research m u s t be interdisciplinary. The emergency physician is in a unique position to serve as a m e m b e r of such an interdisciplinary injury control team, but currently there is little emphasis on or training for this role. [Holden JA, Lumpkin JR, Richards MS: Vital records in the development of injury control research. Ann Emerg Med March 1989;18:286-292.]
Janet A Holden, PhD* John R Lumpkin, MD, FACEE MPHt Margaret S Richards, MPH* Chicago, Illinois From the University of Illinois at Chicago, School of Public Health,* and the Illinois Department of Public Health,t Chicago. Received for publication April 18, 1988. Revision received August 15, 1988. Accepted for publication November 4, 1988. Address for reprints: Janet A Holden, PhD, University of Illinois at Chicago, School of Public Health m/c 922, Box 6998, Chicago, Illinois 60680.
INTRODUCTION John M c K i n l a y relates a story of a p h y s i c i a n trying to explain the dil e m m a s of the m o d e r n practice of medicine. "You know," he said, "sometimes it feels like this. There I am standing by the shore of a swiftly flowing river and I hear the cry of a drowning man. So I jump into the river, and put my arms around him, pull him to shore, apply artificial respiration. Just when he begins to breathe, there is another cry for help. So back I jump into the river, reach him, pull him to shore, apply artificial respiration, and then just as he begins to breathe, another cry for help. So back in the river again, reaching, pulling, applying, breathing, and then another yell. Again and again without end, goes the sequence. You know, I am so busy jumping in, pulling them to shore, applying artificial respiration, that I have no time to see who in the hell is upstream pushing them all in/'] This analogy is appropriate for the p h y s i c i a n caring for the injured patient. M o s t resources of the e m e r g e n c y p h y s i c i a n are devoted to caring for those already injured w i t h only m i n i m a l resources devoted to the investigation of " w h o is p u s h i n g t h e m in." A lesson can be learned from the progress m a d e in chronic disease control. M o r t a l i t y due to cardiovascular disease has d e c l i n e d s i g n i f i c a n t l y t h r o u g h s u c c e s s f u l i n t e r v e n t i o n programs. Both the need for, and the efficacy of, these programs have been d e m o n s t r a t e d b y e p i d e m i o l o g i c research. 2 H o w e v e r , w i t h s o m e exceptions, a the h e a l t h care c o m m u n i t y has m a d e o n l y m o d e r a t e h e a d w a y in defining e t i o l o g i e s of i n j u r y and d e v e l o p i n g p r e v e n t i o n strategies. T h e emergency p h y s i c i a n is in a u n i q u e p o s i t i o n to serve as an injury prevention expert. T h e need for e m e r g e n c y p h y s i c i a n s to play such a role has become increasingly recognized. 4-6 T h e first step in identifying etiologic factors is to delineate the n a t u r e and e x t e n t of injury w i t h i n t h e defined area. T h e characterization of injury on the n a t i o n a l level has had i m p o r t a n t i m p l i c a t i o n s for h i g h w a y and consumer product safety b u t is i n a d e q u a t e for control of other types of inju-
18:3 March 1989
Annals of Emergency Medicine
286/91
VITAL RECORDS Holden, Lumpkin & Richards
ries. Injuries that result from locally s i g n i f i c a n t risk f a c t o r s (eg, agricultural injuries) can only be prevented by local programs designed to decrease those risks. Death rates for some injury categories vary by a factor of ten or more among states with unique socioeconomic, demographic, and urban characteristics. 3,7 There is a limited amount of centrally located descriptive data on injury in Illinois. To address the problem of injury specific to Illinois, some of the broad categories of injury were examined using state vital records from 1981 through 1984. Deaths from injury are a small but important fraction of all injuries. 3 While morbidity data would give a more complete picture of the risk of injury in the state, there are no statewide databases that record morbidity such that the population at risk can be identified. Without a definition of a population at risk, true rates cannot be determined and risk cannot be assessed. The immediate objective of this study was to characterize the impact of selected broad categories of fatal injury on the Illinois p o p u l a t i o n using vital records and, where possible, to compare the magnitude of injury in Illinois with the magnitude of injury nationwide. However, a second objective was to demonstrate the use of an already existing and readily available database as a research tool in an area rarely examined by emergency physicians.
METHODS The terms "trauma" and "injury" are used interchangeably to mean damage to body tissue caused by acute exposure to energy, such as thermal, chemical, or electrical, or the kinetic exchange resulting from a fall, crash, or intentional blow. A second type of injury results from interference with the normal exchange of energy in the body, such as oxygen utilization in drowning. 3 The further subdivision of injury into unintentional or intentional has been used to distinguish "accidents" from homicide and suicide. The practical and philosophical debates concerning the use of these constructs are discussed elsewhere.g,8, 9 In our study, homicide and suicide are referred to by name, and the collective term "injuries" is used to refer to nonhomicide and nonsuicide injuries. 92/287
TABLE 1. Classification of injuries according to ICD-9CM E codes Injury
E Code Range
Motor vehicle*
810.0-825.9
Fall Drowning Fire and explosion
880.0-888.9 910.0-910.9 890.0-899.9
Poisoningt Ingestion of food or object (choking)
850.0-869.9 911.0-912.9
Mechanical suffocation
913.0-913.9
Firearm Suicide
922.0-922.9 " 950.0-959.9
Homicide¢ 960.0-978.9 *Includes collisions with pedestrians, trains, and property as well as noncollision events (eg, running off the road). tlncludes solids, liquids, and gases, and drug overdose. :~lncludes legal intervention.
Statewide summaries of underlying cause of death due to injury were obtained from the Illinois Vital Records Database maintained by the Illinois Department of Public Health. This database uses the International Classifications of Diseases - - 9th Revision Clinical Modification (ICD-9CM) categorization of both cause of death and related etiologic faetors. 1° The records are compiled from all death certificates, ensuring that the population at risk can be equated to the p o p u l a t i o n of the state. The data were sorted by fourdigit ICD-9CM E codes by five-year age, gender, and race groups. The categories of injury, along with their c o r r e s p o n d i n g I C D - 9 C M E code range, are shown (Table I). Broad categories were used to obtain sufficient numbers for analysis; thus, rates for individual four-digit E codes could not be calculated. Potentially productive years of life lost (PPYLL) were calculated using the m e t h o d of Haenszel and Perloff. 11,1~ This derived variable measures the difference between 70 years of age and age at death, weighted to reflect the fact that children do not contribute to the economy before the age of 15 and many 65- to 69-yearolds are still economically productive. Information on PPYLL for all injuries as well as for other causes of death was calculated to demonstrate the magnitude of injury as a premature cause of death. The summary statistics are shown Annals of Emergency Medicine
(Table 2, Figures 1 through 8). The rates for Illinois (Table 2) and the percentages (Figure 1) were calculated using data from Vital Statistics, Illinois. 13 The denominators for the calculation of rates for the noneensus years were obtained from the Division of Health Information and Evaluation, Illinois Department of Public Health. Visual displays of the impact of selected injuries on Illinois for the years 1981 through 1984 are shown (Figures 3 through 8). To generate these figures, the average number of deaths over the four-year period for each injury in each demographic category were calculated. All rates were calculated with a hand calculator and the graphs were produced on a personal computer with the Supercalc ® program. The national death rates (Table 2), obtained from the National Safety Council, 14 are not adjusted for race.
RESULTS The average percentage of the total number of deaths per year and of the PPYLL due to the leading causes of d e a t h for 1981 t h r o u g h 1984 are shown (Figure 1). The disparity between the percentage of deaths and the percentage of PPYLL has been demonstrated on a national level; 3,15 injury has consistently outdistanced heart disease and cancer by at least a factor of two as a cause of premature death. The results for Illinois are not as dramatic, where the total percentage of PPYLL (18% due to uninten18:3 March 1989
TABLE 2. Comparisons of Illinois and US death rates per 100,000 population due to injury
for selected high-risk groups*
Type of Injury Age (yr), Gender
Deaths/100,000 Highest Rate Group
United States TM (1982)
Illinois (1981-1984 Average)
Motor vehicle 15-24, men
56.3
42.9
White men
Fall 7 5 + , both sexes
65.7
54.6
White men
Choking 1 and under, boys 75 +, men
7.2 13.5
7.5 14.4
Black men and boys
Fire 7 5 + , men
11.7
11.6
Black men
Drowning 1-4, both sexes 15-24, men
4.8 7.5
4.8 7.5
White boys Black men
Suffocation 1 and under, boys
5.2
5.2
Black boys
Firearm 15-24, men
2.3
2.3
White men
Homicide 15-24, men
20.9
29.4
Black men
Total unintentional Injuryt
40.6
33.7
*None of these rates are adjusted for race: where a differential is pronounced, the prominent group is labeled at the right. l-Unadjusted for age, sex, or race.
tional injury, 8% due to homicide, and 5% due to suicide) is slightly higher but essentially equal to the p e r c e n t a g e due to h e a r t disease or cancer. One reason for this discrepancy is that m a n y of the national statistics are presented using potential years of life lost (PYLL), which measures the difference between 65 years of age and age of death instead of 70 years. Death rates in Illinois by race and gender confirm m a n y of the nationally d o c u m e n t e d trends 3,8,'a (Figure 9.). W h i t e m e n are o v e r r e p r e s e n t e d a m o n g m o t o r vehicle fatalities and suicides; n o n w h i t e m e n experience excess deaths from homicides, poisonings, fires, and drownings. T h e homicide rate for n o n w h i t e m e n is the m o s t alarming. Chicago alone is responsible for 79% of these deaths. N o n w h i t e m e n a n d w o m e n fare worse in both the homicide and fire categories. W o m e n appear to be at lower risk than their male counterparts for m o s t injuries. While an overview of the injury is18:3 March 1989
sues specific to Illinois can be obtained (Figure 2), information at such an aggregate level is not useful for identifying specific problems. W h e n data for each injury are stratified over age (Figures 3 through 8), it is possible to see which age groups contribute m o s t heavily to the observed race and gender trends. The homicide rate for nonwhite m e n reflects extremely high rates in the 15- to 24-year-old and 25- to 44-year-old age groups (Figure 3). The numbers decline with age, but even at 75 years of age the rates for n o n w h i t e m e n are nearly ten times those of their white cohort. T h e a g e - a d j u s t e d r a t e s (Figure 4) show the clear predominance of 15to 24-year-old m e n in m o t o r vehicle crashes followed by 75-year-old and older white men. We could not determine whether the high rates for elderly white m e n represent pedestrian deaths because the definition of motor vehicle crashes is broad. While a great deal of attention has b e e n f o c u s e d r e c e n t l y on t e e n a g e "suicide clusters, ''16 our data demonAnnals of EmergencyMedicine
strate that elderly white m e n have the highest rate of suicide (Figure 5). The importance of the teenage fatalities s h o u l d n o t be u n d e r p l a y e d , however, as t h e y represent greater premature loss. Further, the lower fatality rates in the younger group m a y well only represent fewer successful suicide attempts. N o n w h i t e w o m e n c o n s i s t e n t l y experience the l o w e s t rates of suicide. Consistent with national figures, 14 our data indicate that the young and the old have the highest risk of dying in fires (Figure 6). N o n w h i t e infants and toddlers and nonwhites over age 75 are at the highest risk in this category. A l m o s t all of the deaths due to falls (Figure 7) o c c u r in e l d e r l y whites. Explanations for the impact of race on death after age 75 from this cause are the subject of debate. 17 N o n w h i t e s of all age groups also have excessive death rates due to poisoning (Figure 8); the person m o s t likely to die from poisoning is the 25- to 44-year-old n o n w h i t e m a n . 288/93
VITAL R E C O R D S Holden, Lumpkin & Richards
80.
[] [] [] []
60D % Average deaths/yr % Average PPYLL/yr
While men and boys While women and girls Nonwhite men and boys Nonwhite women and girls
40-
0
r
3
0
.~-
,~
~
E
~
~
~
u~ E
~
~
8
E
2
150
[] [] [] []
White men and boys White women and girls Nonwhite men and boys Nonwhite women and girls
100
[] [] D []
401
Wh]le men and boys While women and gids Nonwhite men and boys Nonwhite women and gids
oo o oo
2050
I
i
i
i
i
J
~ 3
v
&
&
FIGURE 1. Leading causes of death
and potentially productive years of life lost, Illinois, 1981-1984. F I G U R E 2. Average i n j u r y death rates, Illinois, 1981-1984. FIGURE 3. Average homicide death rates, Illinois, 1981-1984. F I G U R E 4. Average motor vehicle
death rates, Illinois, I981-1984.
These data corroborate the n a t i o n a l decline in childhood poisoning deaths. 2 However, the reluctance of physicians to classify a death as suicide is should be k e p t in mind. The n u m b e r of deaths due to choking, m e c h a n i c a l suffocation, d r o w n ing, and firearm-related injury are too s m a l l for t h e c a l c u l a t i o n of s t a b l e rates; these are not illustrated. However, the data do show that the very 94/289
,2,
~
i
+
V
young (less than 1 year old) and the o l d (75 y e a r s and older) h a v e t h e highest rates of death due to choking. In all age groups, n o n w h i t e s have a higher death rate due to this type of injury. T h e d r o w n i n g rate is h i g h e r for m a l e i n f a n t s a n d for b o y s a n d m e n 5 to 75 years old than for women; rates for n o n w h i t e s are higher t h a n for w h i t e s in these age categories. N o n w h i t e 15- to 2 4 - y e a r - o l d m e n have the highest rate of death due to drowning, f o l l o w e d by nonw h i t e infants. Yet in the toddler age group, w h i t e s have the highest rate. We have no explanation for this phen o m e n o n , but it is w o r t h y of further study. Of the 137 deaths due to m e c h a n i cal s u f f o c a t i o n d u r i n g t h e f o u r - y e a r period, 29 (21.2%) were a m o n g those less t h a n 1 year old and an additional 13 (9.5%) were a m o n g those from 1 to 4 years of age. T h e rates for nonw h i t e s are higher in these age categoAnnals of Emergency Medicine
ries; a l t h o u g h no s i g n i f i c a n t differences are seen overall by gender, the r a t e for w h i t e f e m a l e t o d d l e r s is h i g h e r t h a n t h a t of m a l e t o d d l e r s . Such rates m u s t be u s e d w i t h caut i o n due to t h e s m a l l n u m b e r s involved. While white men and all n o n w h i t e s in t h e 15- to 24-year-old age group die from firearm injuries at the highest rates (53 of 130 total such deaths, or 41.0%), t h e n o n w h i t e fem a l e toddler death rate surpassed all other race or gender categories. Additional years of data are needed to det e r m i n e the v a l i d i t y of this finding. On the whole, Illinois compares quite favorably with national death rates in o v e r a l l u n i n t e n t i o n a l injuries, m o t o r vehicle crashes, and falls (Table 2). Rates for all other categories are essentially equal to the nat i o n a l rates, w i t h t h e e x c e p t i o n of homicide. T h e 15- to 24-year-old unadjusted h o m i c i d e rate is 140% of the n a t i o n a l rate. 18:3 March 1989
50
40
White men and boys
White men and boys
[ ] White women and girls [ ] Nonwhite men and boys
t~ White women and girls [~ Nonwhite men and boys
[ ] Nonwhite women and girls
[ ] Nonwhite women and girls
§ 30
20
10
i !, I
+
6
!0-
80-
White men and boys White women and girls Nonwhite men and boys [ ] White men and boys t~ White women and girls [ ] Nonwhite men and boys
60-
Nonwhite women and girls
~] Nonwhite women and girls 0 -
40.
20-
I
i
-*
i
i
i
i
i
~
~
~
~
+
v
DISCUSSION
Injury in Illinois In t e r m s of s t r i c t e p i d e m i o l o g i c a l research m e t h o d s , t h e r e are several l i m i t a t i o n s of our analysis. However, it does d e m o n s t r a t e the usefulness of the vital records database m a i n t a i n e d in each state. O u r results serve as an example of the w e a l t h of possible research p r o b l e m s that can be identified for further investigation. A n exa m p l e of a m o r e refined analysis t h a t d e m o n s t r a t e d significant differences in county-level m o t o r vehicle-related fatalities using data already collected for a n o t h e r p u r p o s e is p r e s e n t e d b y Baker et al. 19 M o s t of our discussion focuses on the r e a s o n s for t h e l a c k of i n j u r y control research by e m e r g e n c y physicians and t h e p o t e n t i a l b e n e f i t s of such r e s e a r c h for e m e r g e n c y m e d i cine as a speciality. The finding t h a t Illinois compares favorably w i t h the U n i t e d States in 18:3 M a r c h 1989
LO
K V
~
t e r m s of the lower overall death rate is e n c o u r a g i n g b u t d i f f i c u l t to explain. Specific low-risk groups were i d e n t i f i e d . Efforts to d e t e r m i n e t h e reasons for the relatively low rates of s o m e groups are as i m p o r t a n t as inv e s t i g a t i o n s of t h e v u l n e r a b i l i t y of h i g h - r i s k g r o u p s . 2° F o r e x a m p l e , black w o m e n were found to experience suicide rates c o n s i s t e n t l y lower t h a n those of all other race or gender groupings. P s y c h o s o c i a l c h a r a c t e r i s tics of this low-risk group m i g h t suggest n e w approaches to intervention. The effects of race, gender, and age on certain d e a t h rates w i t h i n Illinois w e r e c l e a r l y i d e n t i f i e d as a r e a s in need of further study. Issues such as t h e o v e r r e p r e s e n t a t i o n of s p e c i f i c n o n w h i t e age g r o u p s in h o m i c i d e , p o i s o n i n g , fire, a n d f i r e a r m - r e l a t e d d e a t h s a n d of s p e c i f i c w h i t e age groups in suicide, fall, and drowning deaths were m e n t i o n e d . For example, while childhood poisoning fatalities Annals of Emergency Medicine
~
~6
K
8
F I G U R E 5. Average suicide death rates, Illinois, 1981-1984. FIGURE 6. Average fire death rates,
Illinois, 1981-1984. FIGURE 7. Average fall death rates,
Illinois, 1981-1984. FIGURE 8. Average poisoning death
rates, Illinois, 1981-1984.
h a v e decreased s u b s t a n t i a l l y in t h e U n i t e d States, 2 the m a j o r i t y of such deaths occurring in Illinois are in the n o n w h i t e population. T h e reason for this difference requires further study. W o m e n in Illinois appear to be at l o w e r r i s k t h a n m e n for a l m o s t all injuries. However, f u r t h e r r e s e a r c h on t i m e s p e n t in p o t e n t i a l l y hazardous activities is indicated. A n increase in m o t o r vehicle- and occupation-related injuries to w o m e n can be 290/95
VITAL RECORDS Holden, Lumpkin & Richards
expected as their driving and employm e n t p a t t e r n s change. R e s e a r c h on h o w to b e s t p r e v e n t such i n c r e a s e s and h o w to c o u n t e r a c t t h e i r accept a n c e as an u n a v o i d a b l e price of a n e w l i f e s t y l e s t i l l r e m a i n s to be done.
The Emergency Physician as an Injury-Control Professional One m e t h o d by w h i c h e m e r g e n c y m e d i c i n e has a c h i e v e d its goal of bec o m i n g a s p e c i a l t y is by i n c r e a s i n g the q u a n t i t y and quality of research by practitioners. ~1 T h e need for ongoing research as w e l l as m e t h o d s by w h i c h r e s e a r c h s k i l l s c a n be successfully taught to m e d i c a l students and emergency medicine residents have been demonstrated.2~, 23 T h e s e educational endeavors e m p h a s i z e the i m p o r t a n c e of clinical and h e a l t h serv i c e s research. H o w e v e r , t h e develo p m e n t of epidemiologic and statistical skills required for investigation of preinjury event circumstances, the d i s t r i b u t i o n of i n j u r y e v e n t s in t h e c o m m u n i t y , and t h e f o r m u l a t i o n and evaluation of prevention programs is crucial. H e a l t h professionals are k e y to any progress in i n j u r y - r e d u c t i o n efforts. T h e y are in p o s i t i o n s to u n d e r s t a n d t h e n a t u r e of t h e injuries, to f r a m e solutions, and to i m p l e m e n t , w i t h i n limits, these solutions. However, to successfully initiate, i m p l e m e n t , and e v a l u a t e t h e r e s e a r c h and t h e program efforts needed to achieve longlasting changes, t h e y m u s t f u n c t i o n as an i n t e r d i s c i p l i n a r y team. T h e effect of t h e l a c k of t r a i n i n g for t h e m e m b e r s of such a t e a m on injurycontrol efforts has been noted.a, ~4 A crucial c o m p o n e n t in t h e f a i l u r e to t r a i n s u c h a p r o f e s s i o n a l is t h e absence of courses and m a t e r i a l s on injury p r e v e n t i o n in t h e c u r r i c u l a of medical and other health professional schools. ~s T h e t i m e is ripe for a change, as the public has b e c o m e increasingly aware of the m a g n i t u d e of the injury p r o b l e m and appears receptive to advice and leadership from those in t h e h e a l t h professions. W h i l e t h e need for e m e r g e n c y physicians to increase their p a r t i c i p a t i o n as h e a l t h educators on the n a t u r e of true e m e r g e n c i e s 26 and on t h e m i t igation of injury due to m o t o r vehicle crashes 27 has been noted, the role of the e m e r g e n c y p h y s i c i a n as a m e m ber of the injury-control professional t e a m has n o t b e e n explored. Emer96/291
gency medicine residency training does n o t p r e p a r e e m e r g e n c y p h y s i cians to recognize p a t t e r n s of injury in the c o m m u n i t y and to be part of the i n v e s t i g a t i o n of these patterns. T h e T a s k Force on t h e L e n g t h of T r a i n i n g in E m e r g e n c y M e d i c i n e of the A m e r i c a n College of Emergency Physicians recommends that the a m o u n t of lecture and discussion to be spent on the role of the e m e r g e n c y p h y s i c i a n in all aspects of p r e v e n t i o n should be 0.5 hours out of a threeyear program. 28 N o reading, demons t r a t i o n s , or p a t i e n t i n t e r a c t i o n are r e c o m m e n d e d . T h e need for teaching the principles of p r e v e n t i o n has been recognized; 4 however, this need has y e t to be t r a n s l a t e d i n t o s p e c i f i c guidelines. M o r e t h a n 20 years ago, t h e National Research Council published the s t u d y A c c i d e n t a l D e a t h a n d D i s ability: The Neglected Disease of M o d e r n S o c i e t y . 29 By p l a c i n g i n j u r y
in a d i s e a s e f r a m e w o r k , t h i s s t u d y provided the i m p e t u s for the developm e n t of t o d a y ' s e m e r g e n c y m e d i c a l services s y s t e m . T h e efficacy of an e m e r g e n c y m e d i c a l services s y s t e m in t h e p r e v e n t i o n of t h e n e e d l e s s d e a t h s of t r a u m a v i c t i m s has been d e m o n s t r a t e d . 3° H o w e v e r , i n j u r y is still the leading cause of death for US c i t i z e n s in t h e i r p r o d u c t i v e years. Lack of progress in the p r e v e n t i o n of injury-causing events led to a second major report by t h e Council, I n j u r y in America: A Continuing Public H e a l t h P r o b l e m . 3 T h e absence of an
e m e r g e n c y p h y s i c i a n on t h e e x p e r t p a n e l t h a t p r e p a r e d this r e p o r t is a distressing c o m m e n t on the lack of recognition of the role of e m e r g e n c y m e d i c i n e in injury control. This report provided the current i m p e t u s in injury-control training, research, and program development, spearheaded at the n a t i o n a l level by the Centers for Disease Control. 3I T h e need for e m e r g e n c y m e d i c i n e p a r t i c i p a t i o n at a l l l e v e l s of t h i s " n e w " a c t i v i t y should be self-evident.
SUMMARY W h i l e n a t i o n a l statistics are useful for setting n a t i o n a l goals and priorit i e s for r e s e a r c h a n d i n t e r v e n t i o n , the c o m p i l a t i o n and analysis of state and local statistics for injury are crucial to i d e n t i f y local issues. Such a c o m p i l a t i o n for s t a t e w i d e i n j u r y fatalities identified several areas of pot e n t i a l research. T h e p o t e n t i a l role of Annals of Emergency Medicine
e m e r g e n c y p h y s i c i a n s in delineating, investigating, and developing prevention strategies for injuries specific to their c o m m u n i t i e s is evident, b u t a r e v i e w of the l i t e r a t u r e s h o w s t h a t c u r r e n t l y t h e r e is i n s u f f i c i e n t e m phasis and training for this role. Participation by emergency physicians in all levels of injury-control p o l i c y decisions will provide unique and v a l u a b l e i n p u t to t h e i n j u r y - c o n t r o l process.
REFERENCES 1. Zola IK: Helping - - Does it matter? The problems and prospects of mutual aid groups, in McKinlay JB: A case for refocusing upstream: The political economy of illness, in Conrad P, Kern R (eds): The Sociology of Health and Illness. New York, St Martin's Press, 1981, p 613-628. 2. Prevention "84/'85. Washington, DC, Office of Disease Prevention and Health Promotion, Public Health Service, USDHHS, 1985, p 474-512. 3. National Research Council Committee on Trauma Research: Injury in America: A Continuing Public Health Problem. Washington, DC, National Academy Press, 1985. 4. Hargarten S, Sanders AB: Injury prevention in medical school curriculums (letter). Ann Emerg Med 1986;15:226. 5. WolffB: Emergencymedical services, trauma care systems, and injury prevention. Public Health Rep 1987;102:629-630. 6. Resolution on Injury Control. Adopted by American College of Emergency Physicians Board of Directors, Dallas, Texas, September 18, 1986. 7. BergerLR: Childhood injuries. Public Health Rep 1985;100:572-574. 8. Baker SP, O'Neal B, Karpf RS: The Injury Fact Book. Lexington, Massachusetts, Lexington Books, 1984. 9. Robertson LS: Injuries: Causes, Control Strategies, and Public Policy. Lexington, Massachusetts, Lexington Books, 1983. 10. Centers for Disease Control: CDC Injury Surveillance Guidance Draft Document to State and Local Health Departments. Atlanta,
Georgia, CDC, February 19, 1986. 11. Haenszei W: A standardized rate for mortality defined in units of lost years of life. Am J Public Health 1950;40:17-26. 12. Perloff LD, LeBailly SA, Kletke PR, et al: Premature death in the United States; years of life lost and health priorities. J Public Health Policy 1984;5:167-I84. 13. Illinois Department of Public Health: Vital Statistics Illinois 1981 (through 1984). Springfield, Illinois, IDPH, 1983-1986. 14. National Safety Council: Accident Facts 1984. Chicago, NSC, 1985. 15. Centers for Disease Control: Estimated years of potential life lost before age 65, and cause-specific mortality, by cause of death - United States, I984 and 1985. MMWR 1987;36: 814-815, 36:447. 16. ShafferD: Strategies for prevention of youth 18:3 March 1989
suicide. Public Health Rep 1987;102:611-613. 17. Waller JA (ed): Falls, in Waller JA: Injury Control: A Guide to the Causes and Prevention of Trauma. Lexington, Massachusetts, Lexington Books, 1985, p 321-330. 18. Waller JA: Some questions about numbers, in Waller JA (ed): Injury Control: A Guide to the Causes and Prevention of Trauma. Lexington, Massachusetts, Lexington Books, 1985, p 65-78. 19. Baker SP, Whitfield RA, O'Neill B: Geographic variations in mortality from motor vehicle crashes. N Engl J Med 1987;316:1384-1387. 20. Fife D: Workshop on injury risk groups and determinants. Public Health Rep 1985;100: 568-569. 2I. Gold IW, Podolsky S, Kuhn M, et al: A review of research methodology in an emergency medicine journal. Ann Emerg Med 1983;12: 769-773.
18:3 March 1989
22. Gold IW, Jayne HA: Development and evaluation of a one-month research track in emergency medicine for medical students. Ann Emerg Med 1987;16:686-688. 23. Jones J, Dougherty J, Cannon L, et al: Teaching research in the emergency medicine curriculum. Ann Emerg Med 1987;16:347-353. 24. Waller JA (ed): Injury control and the health professional: Preparation for the future, in Injury Control: A Guide to the Causes and Prevention of Trauma. Lexington, Massachusetts, Lexington Books, 1985, p 525-530. 25. Holden JA, Christoffel T: Preparing and presen.ting an introductory course on motor vehicle injury. Public Health Rep 1988;103:153-161. 26. Back BJ: Emergency medicine in the community (editorial). Ann Emerg Med 1984;13:544. 27. National Highway Transportation Safety Administration: Protecting Our Own, Community Child Passenger Safety Programs. Washing-
Annals of Emergency Medicine
ton, DC, US Department of Transportation, DOT/OST/P-34/85-050, 1986. 28. Task Force on the Length of Training in Emergency Medicine: Final report, in Gallery ME: Curriculum Development in Graduate Medical Education: A Practical Approach. Dallas, Texas, American College of Emergency Physicians, 1984. 29. National Research Council, National Academy of Science: Accidental Death and Disability: The Neglected Disease of Modern Society. Washington, DC, National Academy Press, 1966. 30. Cales RH, T r u n k e y DD: P r e v e n t a b l e trauma deaths: A review of trauma care systems development. JAMA 1985;254:1059-1063. 31. Roseburg ML, Fenley MA (compilers(: 1987 Conference on Injury in America: A summary. Public Health Rep 1987;102(special section): 577-676.
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Vital Records in the Development of Injury Control Research
Most of the resources of the emergency physician are devoted to persons already injured, with little emphasis on prevention. Analyses of state and local injury statistics are necessary to identify local prevention needs in order to set program priorities. We discuss an example, an analysis of statewide injury fatalities identified through the Illinois Vital Records database. The overall death rate for injuries in Illinois was lower than that found for the United States. However, the need for research on several high-risk age groups for certain injuries was identified. Most notably, the homicide rate for those 15 to 24 years old was 140% of the national rate. Other specific nonwhite age groups were overrepresented in poisoning, fire, and firearm deaths, while specific white age groups were overrepresented in suicide, fall, and drowning deaths. The research regarding the etiologies, of these injuries and the formulation and evaluation of prevention strategies based on this research m u s t be interdisciplinary. The emergency physician is in a unique position to serve as a m e m b e r of such an interdisciplinary injury control team, but currently there is little emphasis on or training for this role. [Holden JA, Lumpkin JR, Richards MS: Vital records in the development of injury control research. Ann Emerg Med March 1989;18:286-292.]
Janet A Holden, PhD* John R Lumpkin, MD, FACEE MPHt Margaret S Richards, MPH* Chicago, Illinois From the University of Illinois at Chicago, School of Public Health,* and the Illinois Department of Public Health,t Chicago. Received for publication April 18, 1988. Revision received August 15, 1988. Accepted for publication November 4, 1988. Address for reprints: Janet A Holden, PhD, University of Illinois at Chicago, School of Public Health m/c 922, Box 6998, Chicago, Illinois 60680.
INTRODUCTION John M c K i n l a y relates a story of a p h y s i c i a n trying to explain the dil e m m a s of the m o d e r n practice of medicine. "You know," he said, "sometimes it feels like this. There I am standing by the shore of a swiftly flowing river and I hear the cry of a drowning man. So I jump into the river, and put my arms around him, pull him to shore, apply artificial respiration. Just when he begins to breathe, there is another cry for help. So back I jump into the river, reach him, pull him to shore, apply artificial respiration, and then just as he begins to breathe, another cry for help. So back in the river again, reaching, pulling, applying, breathing, and then another yell. Again and again without end, goes the sequence. You know, I am so busy jumping in, pulling them to shore, applying artificial respiration, that I have no time to see who in the hell is upstream pushing them all in/'] This analogy is appropriate for the p h y s i c i a n caring for the injured patient. M o s t resources of the e m e r g e n c y p h y s i c i a n are devoted to caring for those already injured w i t h only m i n i m a l resources devoted to the investigation of " w h o is p u s h i n g t h e m in." A lesson can be learned from the progress m a d e in chronic disease control. M o r t a l i t y due to cardiovascular disease has d e c l i n e d s i g n i f i c a n t l y t h r o u g h s u c c e s s f u l i n t e r v e n t i o n programs. Both the need for, and the efficacy of, these programs have been d e m o n s t r a t e d b y e p i d e m i o l o g i c research. 2 H o w e v e r , w i t h s o m e exceptions, a the h e a l t h care c o m m u n i t y has m a d e o n l y m o d e r a t e h e a d w a y in defining e t i o l o g i e s of i n j u r y and d e v e l o p i n g p r e v e n t i o n strategies. T h e emergency p h y s i c i a n is in a u n i q u e p o s i t i o n to serve as an injury prevention expert. T h e need for e m e r g e n c y p h y s i c i a n s to play such a role has become increasingly recognized. 4-6 T h e first step in identifying etiologic factors is to delineate the n a t u r e and e x t e n t of injury w i t h i n t h e defined area. T h e characterization of injury on the n a t i o n a l level has had i m p o r t a n t i m p l i c a t i o n s for h i g h w a y and consumer product safety b u t is i n a d e q u a t e for control of other types of inju-
18:3 March 1989
Annals of Emergency Medicine
286/91
VITAL RECORDS Holden, Lumpkin & Richards
ries. Injuries that result from locally s i g n i f i c a n t risk f a c t o r s (eg, agricultural injuries) can only be prevented by local programs designed to decrease those risks. Death rates for some injury categories vary by a factor of ten or more among states with unique socioeconomic, demographic, and urban characteristics. 3,7 There is a limited amount of centrally located descriptive data on injury in Illinois. To address the problem of injury specific to Illinois, some of the broad categories of injury were examined using state vital records from 1981 through 1984. Deaths from injury are a small but important fraction of all injuries. 3 While morbidity data would give a more complete picture of the risk of injury in the state, there are no statewide databases that record morbidity such that the population at risk can be identified. Without a definition of a population at risk, true rates cannot be determined and risk cannot be assessed. The immediate objective of this study was to characterize the impact of selected broad categories of fatal injury on the Illinois p o p u l a t i o n using vital records and, where possible, to compare the magnitude of injury in Illinois with the magnitude of injury nationwide. However, a second objective was to demonstrate the use of an already existing and readily available database as a research tool in an area rarely examined by emergency physicians.
METHODS The terms "trauma" and "injury" are used interchangeably to mean damage to body tissue caused by acute exposure to energy, such as thermal, chemical, or electrical, or the kinetic exchange resulting from a fall, crash, or intentional blow. A second type of injury results from interference with the normal exchange of energy in the body, such as oxygen utilization in drowning. 3 The further subdivision of injury into unintentional or intentional has been used to distinguish "accidents" from homicide and suicide. The practical and philosophical debates concerning the use of these constructs are discussed elsewhere.g,8, 9 In our study, homicide and suicide are referred to by name, and the collective term "injuries" is used to refer to nonhomicide and nonsuicide injuries. 92/287
TABLE 1. Classification of injuries according to ICD-9CM E codes Injury
E Code Range
Motor vehicle*
810.0-825.9
Fall Drowning Fire and explosion
880.0-888.9 910.0-910.9 890.0-899.9
Poisoningt Ingestion of food or object (choking)
850.0-869.9 911.0-912.9
Mechanical suffocation
913.0-913.9
Firearm Suicide
922.0-922.9 " 950.0-959.9
Homicide¢ 960.0-978.9 *Includes collisions with pedestrians, trains, and property as well as noncollision events (eg, running off the road). tlncludes solids, liquids, and gases, and drug overdose. :~lncludes legal intervention.
Statewide summaries of underlying cause of death due to injury were obtained from the Illinois Vital Records Database maintained by the Illinois Department of Public Health. This database uses the International Classifications of Diseases - - 9th Revision Clinical Modification (ICD-9CM) categorization of both cause of death and related etiologic faetors. 1° The records are compiled from all death certificates, ensuring that the population at risk can be equated to the p o p u l a t i o n of the state. The data were sorted by fourdigit ICD-9CM E codes by five-year age, gender, and race groups. The categories of injury, along with their c o r r e s p o n d i n g I C D - 9 C M E code range, are shown (Table I). Broad categories were used to obtain sufficient numbers for analysis; thus, rates for individual four-digit E codes could not be calculated. Potentially productive years of life lost (PPYLL) were calculated using the m e t h o d of Haenszel and Perloff. 11,1~ This derived variable measures the difference between 70 years of age and age at death, weighted to reflect the fact that children do not contribute to the economy before the age of 15 and many 65- to 69-yearolds are still economically productive. Information on PPYLL for all injuries as well as for other causes of death was calculated to demonstrate the magnitude of injury as a premature cause of death. The summary statistics are shown Annals of Emergency Medicine
(Table 2, Figures 1 through 8). The rates for Illinois (Table 2) and the percentages (Figure 1) were calculated using data from Vital Statistics, Illinois. 13 The denominators for the calculation of rates for the noneensus years were obtained from the Division of Health Information and Evaluation, Illinois Department of Public Health. Visual displays of the impact of selected injuries on Illinois for the years 1981 through 1984 are shown (Figures 3 through 8). To generate these figures, the average number of deaths over the four-year period for each injury in each demographic category were calculated. All rates were calculated with a hand calculator and the graphs were produced on a personal computer with the Supercalc ® program. The national death rates (Table 2), obtained from the National Safety Council, 14 are not adjusted for race.
RESULTS The average percentage of the total number of deaths per year and of the PPYLL due to the leading causes of d e a t h for 1981 t h r o u g h 1984 are shown (Figure 1). The disparity between the percentage of deaths and the percentage of PPYLL has been demonstrated on a national level; 3,15 injury has consistently outdistanced heart disease and cancer by at least a factor of two as a cause of premature death. The results for Illinois are not as dramatic, where the total percentage of PPYLL (18% due to uninten18:3 March 1989
TABLE 2. Comparisons of Illinois and US death rates per 100,000 population due to injury
for selected high-risk groups*
Type of Injury Age (yr), Gender
Deaths/100,000 Highest Rate Group
United States TM (1982)
Illinois (1981-1984 Average)
Motor vehicle 15-24, men
56.3
42.9
White men
Fall 7 5 + , both sexes
65.7
54.6
White men
Choking 1 and under, boys 75 +, men
7.2 13.5
7.5 14.4
Black men and boys
Fire 7 5 + , men
11.7
11.6
Black men
Drowning 1-4, both sexes 15-24, men
4.8 7.5
4.8 7.5
White boys Black men
Suffocation 1 and under, boys
5.2
5.2
Black boys
Firearm 15-24, men
2.3
2.3
White men
Homicide 15-24, men
20.9
29.4
Black men
Total unintentional Injuryt
40.6
33.7
*None of these rates are adjusted for race: where a differential is pronounced, the prominent group is labeled at the right. l-Unadjusted for age, sex, or race.
tional injury, 8% due to homicide, and 5% due to suicide) is slightly higher but essentially equal to the p e r c e n t a g e due to h e a r t disease or cancer. One reason for this discrepancy is that m a n y of the national statistics are presented using potential years of life lost (PYLL), which measures the difference between 65 years of age and age of death instead of 70 years. Death rates in Illinois by race and gender confirm m a n y of the nationally d o c u m e n t e d trends 3,8,'a (Figure 9.). W h i t e m e n are o v e r r e p r e s e n t e d a m o n g m o t o r vehicle fatalities and suicides; n o n w h i t e m e n experience excess deaths from homicides, poisonings, fires, and drownings. T h e homicide rate for n o n w h i t e m e n is the m o s t alarming. Chicago alone is responsible for 79% of these deaths. N o n w h i t e m e n a n d w o m e n fare worse in both the homicide and fire categories. W o m e n appear to be at lower risk than their male counterparts for m o s t injuries. While an overview of the injury is18:3 March 1989
sues specific to Illinois can be obtained (Figure 2), information at such an aggregate level is not useful for identifying specific problems. W h e n data for each injury are stratified over age (Figures 3 through 8), it is possible to see which age groups contribute m o s t heavily to the observed race and gender trends. The homicide rate for nonwhite m e n reflects extremely high rates in the 15- to 24-year-old and 25- to 44-year-old age groups (Figure 3). The numbers decline with age, but even at 75 years of age the rates for n o n w h i t e m e n are nearly ten times those of their white cohort. T h e a g e - a d j u s t e d r a t e s (Figure 4) show the clear predominance of 15to 24-year-old m e n in m o t o r vehicle crashes followed by 75-year-old and older white men. We could not determine whether the high rates for elderly white m e n represent pedestrian deaths because the definition of motor vehicle crashes is broad. While a great deal of attention has b e e n f o c u s e d r e c e n t l y on t e e n a g e "suicide clusters, ''16 our data demonAnnals of EmergencyMedicine
strate that elderly white m e n have the highest rate of suicide (Figure 5). The importance of the teenage fatalities s h o u l d n o t be u n d e r p l a y e d , however, as t h e y represent greater premature loss. Further, the lower fatality rates in the younger group m a y well only represent fewer successful suicide attempts. N o n w h i t e w o m e n c o n s i s t e n t l y experience the l o w e s t rates of suicide. Consistent with national figures, 14 our data indicate that the young and the old have the highest risk of dying in fires (Figure 6). N o n w h i t e infants and toddlers and nonwhites over age 75 are at the highest risk in this category. A l m o s t all of the deaths due to falls (Figure 7) o c c u r in e l d e r l y whites. Explanations for the impact of race on death after age 75 from this cause are the subject of debate. 17 N o n w h i t e s of all age groups also have excessive death rates due to poisoning (Figure 8); the person m o s t likely to die from poisoning is the 25- to 44-year-old n o n w h i t e m a n . 288/93
VITAL R E C O R D S Holden, Lumpkin & Richards
80.
[] [] [] []
60D % Average deaths/yr % Average PPYLL/yr
While men and boys While women and girls Nonwhite men and boys Nonwhite women and girls
40-
0
r
3
0
.~-
,~
~
E
~
~
~
u~ E
~
~
8
E
2
150
[] [] [] []
White men and boys White women and girls Nonwhite men and boys Nonwhite women and girls
100
[] [] D []
401
Wh]le men and boys While women and gids Nonwhite men and boys Nonwhite women and gids
oo o oo
2050
I
i
i
i
i
J
~ 3
v
&
&
FIGURE 1. Leading causes of death
and potentially productive years of life lost, Illinois, 1981-1984. F I G U R E 2. Average i n j u r y death rates, Illinois, 1981-1984. FIGURE 3. Average homicide death rates, Illinois, 1981-1984. F I G U R E 4. Average motor vehicle
death rates, Illinois, I981-1984.
These data corroborate the n a t i o n a l decline in childhood poisoning deaths. 2 However, the reluctance of physicians to classify a death as suicide is should be k e p t in mind. The n u m b e r of deaths due to choking, m e c h a n i c a l suffocation, d r o w n ing, and firearm-related injury are too s m a l l for t h e c a l c u l a t i o n of s t a b l e rates; these are not illustrated. However, the data do show that the very 94/289
,2,
~
i
+
V
young (less than 1 year old) and the o l d (75 y e a r s and older) h a v e t h e highest rates of death due to choking. In all age groups, n o n w h i t e s have a higher death rate due to this type of injury. T h e d r o w n i n g rate is h i g h e r for m a l e i n f a n t s a n d for b o y s a n d m e n 5 to 75 years old than for women; rates for n o n w h i t e s are higher t h a n for w h i t e s in these age categories. N o n w h i t e 15- to 2 4 - y e a r - o l d m e n have the highest rate of death due to drowning, f o l l o w e d by nonw h i t e infants. Yet in the toddler age group, w h i t e s have the highest rate. We have no explanation for this phen o m e n o n , but it is w o r t h y of further study. Of the 137 deaths due to m e c h a n i cal s u f f o c a t i o n d u r i n g t h e f o u r - y e a r period, 29 (21.2%) were a m o n g those less t h a n 1 year old and an additional 13 (9.5%) were a m o n g those from 1 to 4 years of age. T h e rates for nonw h i t e s are higher in these age categoAnnals of Emergency Medicine
ries; a l t h o u g h no s i g n i f i c a n t differences are seen overall by gender, the r a t e for w h i t e f e m a l e t o d d l e r s is h i g h e r t h a n t h a t of m a l e t o d d l e r s . Such rates m u s t be u s e d w i t h caut i o n due to t h e s m a l l n u m b e r s involved. While white men and all n o n w h i t e s in t h e 15- to 24-year-old age group die from firearm injuries at the highest rates (53 of 130 total such deaths, or 41.0%), t h e n o n w h i t e fem a l e toddler death rate surpassed all other race or gender categories. Additional years of data are needed to det e r m i n e the v a l i d i t y of this finding. On the whole, Illinois compares quite favorably with national death rates in o v e r a l l u n i n t e n t i o n a l injuries, m o t o r vehicle crashes, and falls (Table 2). Rates for all other categories are essentially equal to the nat i o n a l rates, w i t h t h e e x c e p t i o n of homicide. T h e 15- to 24-year-old unadjusted h o m i c i d e rate is 140% of the n a t i o n a l rate. 18:3 March 1989
50
40
White men and boys
White men and boys
[ ] White women and girls [ ] Nonwhite men and boys
t~ White women and girls [~ Nonwhite men and boys
[ ] Nonwhite women and girls
[ ] Nonwhite women and girls
§ 30
20
10
i !, I
+
6
!0-
80-
White men and boys White women and girls Nonwhite men and boys [ ] White men and boys t~ White women and girls [ ] Nonwhite men and boys
60-
Nonwhite women and girls
~] Nonwhite women and girls 0 -
40.
20-
I
i
-*
i
i
i
i
i
~
~
~
~
+
v
DISCUSSION
Injury in Illinois In t e r m s of s t r i c t e p i d e m i o l o g i c a l research m e t h o d s , t h e r e are several l i m i t a t i o n s of our analysis. However, it does d e m o n s t r a t e the usefulness of the vital records database m a i n t a i n e d in each state. O u r results serve as an example of the w e a l t h of possible research p r o b l e m s that can be identified for further investigation. A n exa m p l e of a m o r e refined analysis t h a t d e m o n s t r a t e d significant differences in county-level m o t o r vehicle-related fatalities using data already collected for a n o t h e r p u r p o s e is p r e s e n t e d b y Baker et al. 19 M o s t of our discussion focuses on the r e a s o n s for t h e l a c k of i n j u r y control research by e m e r g e n c y physicians and t h e p o t e n t i a l b e n e f i t s of such r e s e a r c h for e m e r g e n c y m e d i cine as a speciality. The finding t h a t Illinois compares favorably w i t h the U n i t e d States in 18:3 M a r c h 1989
LO
K V
~
t e r m s of the lower overall death rate is e n c o u r a g i n g b u t d i f f i c u l t to explain. Specific low-risk groups were i d e n t i f i e d . Efforts to d e t e r m i n e t h e reasons for the relatively low rates of s o m e groups are as i m p o r t a n t as inv e s t i g a t i o n s of t h e v u l n e r a b i l i t y of h i g h - r i s k g r o u p s . 2° F o r e x a m p l e , black w o m e n were found to experience suicide rates c o n s i s t e n t l y lower t h a n those of all other race or gender groupings. P s y c h o s o c i a l c h a r a c t e r i s tics of this low-risk group m i g h t suggest n e w approaches to intervention. The effects of race, gender, and age on certain d e a t h rates w i t h i n Illinois w e r e c l e a r l y i d e n t i f i e d as a r e a s in need of further study. Issues such as t h e o v e r r e p r e s e n t a t i o n of s p e c i f i c n o n w h i t e age g r o u p s in h o m i c i d e , p o i s o n i n g , fire, a n d f i r e a r m - r e l a t e d d e a t h s a n d of s p e c i f i c w h i t e age groups in suicide, fall, and drowning deaths were m e n t i o n e d . For example, while childhood poisoning fatalities Annals of Emergency Medicine
~
~6
K
8
F I G U R E 5. Average suicide death rates, Illinois, 1981-1984. FIGURE 6. Average fire death rates,
Illinois, 1981-1984. FIGURE 7. Average fall death rates,
Illinois, 1981-1984. FIGURE 8. Average poisoning death
rates, Illinois, 1981-1984.
h a v e decreased s u b s t a n t i a l l y in t h e U n i t e d States, 2 the m a j o r i t y of such deaths occurring in Illinois are in the n o n w h i t e population. T h e reason for this difference requires further study. W o m e n in Illinois appear to be at l o w e r r i s k t h a n m e n for a l m o s t all injuries. However, f u r t h e r r e s e a r c h on t i m e s p e n t in p o t e n t i a l l y hazardous activities is indicated. A n increase in m o t o r vehicle- and occupation-related injuries to w o m e n can be 290/95
VITAL RECORDS Holden, Lumpkin & Richards
expected as their driving and employm e n t p a t t e r n s change. R e s e a r c h on h o w to b e s t p r e v e n t such i n c r e a s e s and h o w to c o u n t e r a c t t h e i r accept a n c e as an u n a v o i d a b l e price of a n e w l i f e s t y l e s t i l l r e m a i n s to be done.
The Emergency Physician as an Injury-Control Professional One m e t h o d by w h i c h e m e r g e n c y m e d i c i n e has a c h i e v e d its goal of bec o m i n g a s p e c i a l t y is by i n c r e a s i n g the q u a n t i t y and quality of research by practitioners. ~1 T h e need for ongoing research as w e l l as m e t h o d s by w h i c h r e s e a r c h s k i l l s c a n be successfully taught to m e d i c a l students and emergency medicine residents have been demonstrated.2~, 23 T h e s e educational endeavors e m p h a s i z e the i m p o r t a n c e of clinical and h e a l t h serv i c e s research. H o w e v e r , t h e develo p m e n t of epidemiologic and statistical skills required for investigation of preinjury event circumstances, the d i s t r i b u t i o n of i n j u r y e v e n t s in t h e c o m m u n i t y , and t h e f o r m u l a t i o n and evaluation of prevention programs is crucial. H e a l t h professionals are k e y to any progress in i n j u r y - r e d u c t i o n efforts. T h e y are in p o s i t i o n s to u n d e r s t a n d t h e n a t u r e of t h e injuries, to f r a m e solutions, and to i m p l e m e n t , w i t h i n limits, these solutions. However, to successfully initiate, i m p l e m e n t , and e v a l u a t e t h e r e s e a r c h and t h e program efforts needed to achieve longlasting changes, t h e y m u s t f u n c t i o n as an i n t e r d i s c i p l i n a r y team. T h e effect of t h e l a c k of t r a i n i n g for t h e m e m b e r s of such a t e a m on injurycontrol efforts has been noted.a, ~4 A crucial c o m p o n e n t in t h e f a i l u r e to t r a i n s u c h a p r o f e s s i o n a l is t h e absence of courses and m a t e r i a l s on injury p r e v e n t i o n in t h e c u r r i c u l a of medical and other health professional schools. ~s T h e t i m e is ripe for a change, as the public has b e c o m e increasingly aware of the m a g n i t u d e of the injury p r o b l e m and appears receptive to advice and leadership from those in t h e h e a l t h professions. W h i l e t h e need for e m e r g e n c y physicians to increase their p a r t i c i p a t i o n as h e a l t h educators on the n a t u r e of true e m e r g e n c i e s 26 and on t h e m i t igation of injury due to m o t o r vehicle crashes 27 has been noted, the role of the e m e r g e n c y p h y s i c i a n as a m e m ber of the injury-control professional t e a m has n o t b e e n explored. Emer96/291
gency medicine residency training does n o t p r e p a r e e m e r g e n c y p h y s i cians to recognize p a t t e r n s of injury in the c o m m u n i t y and to be part of the i n v e s t i g a t i o n of these patterns. T h e T a s k Force on t h e L e n g t h of T r a i n i n g in E m e r g e n c y M e d i c i n e of the A m e r i c a n College of Emergency Physicians recommends that the a m o u n t of lecture and discussion to be spent on the role of the e m e r g e n c y p h y s i c i a n in all aspects of p r e v e n t i o n should be 0.5 hours out of a threeyear program. 28 N o reading, demons t r a t i o n s , or p a t i e n t i n t e r a c t i o n are r e c o m m e n d e d . T h e need for teaching the principles of p r e v e n t i o n has been recognized; 4 however, this need has y e t to be t r a n s l a t e d i n t o s p e c i f i c guidelines. M o r e t h a n 20 years ago, t h e National Research Council published the s t u d y A c c i d e n t a l D e a t h a n d D i s ability: The Neglected Disease of M o d e r n S o c i e t y . 29 By p l a c i n g i n j u r y
in a d i s e a s e f r a m e w o r k , t h i s s t u d y provided the i m p e t u s for the developm e n t of t o d a y ' s e m e r g e n c y m e d i c a l services s y s t e m . T h e efficacy of an e m e r g e n c y m e d i c a l services s y s t e m in t h e p r e v e n t i o n of t h e n e e d l e s s d e a t h s of t r a u m a v i c t i m s has been d e m o n s t r a t e d . 3° H o w e v e r , i n j u r y is still the leading cause of death for US c i t i z e n s in t h e i r p r o d u c t i v e years. Lack of progress in the p r e v e n t i o n of injury-causing events led to a second major report by t h e Council, I n j u r y in America: A Continuing Public H e a l t h P r o b l e m . 3 T h e absence of an
e m e r g e n c y p h y s i c i a n on t h e e x p e r t p a n e l t h a t p r e p a r e d this r e p o r t is a distressing c o m m e n t on the lack of recognition of the role of e m e r g e n c y m e d i c i n e in injury control. This report provided the current i m p e t u s in injury-control training, research, and program development, spearheaded at the n a t i o n a l level by the Centers for Disease Control. 3I T h e need for e m e r g e n c y m e d i c i n e p a r t i c i p a t i o n at a l l l e v e l s of t h i s " n e w " a c t i v i t y should be self-evident.
SUMMARY W h i l e n a t i o n a l statistics are useful for setting n a t i o n a l goals and priorit i e s for r e s e a r c h a n d i n t e r v e n t i o n , the c o m p i l a t i o n and analysis of state and local statistics for injury are crucial to i d e n t i f y local issues. Such a c o m p i l a t i o n for s t a t e w i d e i n j u r y fatalities identified several areas of pot e n t i a l research. T h e p o t e n t i a l role of Annals of Emergency Medicine
e m e r g e n c y p h y s i c i a n s in delineating, investigating, and developing prevention strategies for injuries specific to their c o m m u n i t i e s is evident, b u t a r e v i e w of the l i t e r a t u r e s h o w s t h a t c u r r e n t l y t h e r e is i n s u f f i c i e n t e m phasis and training for this role. Participation by emergency physicians in all levels of injury-control p o l i c y decisions will provide unique and v a l u a b l e i n p u t to t h e i n j u r y - c o n t r o l process.
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22. Gold IW, Jayne HA: Development and evaluation of a one-month research track in emergency medicine for medical students. Ann Emerg Med 1987;16:686-688. 23. Jones J, Dougherty J, Cannon L, et al: Teaching research in the emergency medicine curriculum. Ann Emerg Med 1987;16:347-353. 24. Waller JA (ed): Injury control and the health professional: Preparation for the future, in Injury Control: A Guide to the Causes and Prevention of Trauma. Lexington, Massachusetts, Lexington Books, 1985, p 525-530. 25. Holden JA, Christoffel T: Preparing and presen.ting an introductory course on motor vehicle injury. Public Health Rep 1988;103:153-161. 26. Back BJ: Emergency medicine in the community (editorial). Ann Emerg Med 1984;13:544. 27. National Highway Transportation Safety Administration: Protecting Our Own, Community Child Passenger Safety Programs. Washing-
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