Article 1
Injury characteristics of the Pulse Nightclub shooting: Lessons for mass casualty incident preparation. Smith CP, Cheatham ML, Safcsak K, Emrani H, Ibrahim JA, Gregg M, Eubanks WS, Lube MW, Havron WS, Levy MS. J Trauma Acute Care Surg. 2020 Mar;88(3):372-378.
At the EAST 2020 meeting, the Injury Prevention Committee, per usual, spent Tuesday volunteering at a local high school, putting on an injury prevention program. On the bus from the resort to the school, we passed a grim makeshift memorial: the Pulse nightclub. I cannot speak for the entire committee, but I can say that my thoughts went to a visualization: what would I do if I were the trauma surgeon in charge that night.
This retrospective descriptive study identifies the injury patterns seen in the 102 victims, 40 of which are mortalities, in the Pulse nightclub shooting, as abstracted by the 6 co-authors. Medical records and autopsy reports were reviewed. Patients who survived were transported either to the Level 1 trauma center or to community hospitals. There were several relevant findings. Head injuries were uniformly fatal and neurosurgical intervention was not required. Those who died had an average of 4 bullet injuries, compared to 2 in survivors. Those who died were significantly more likely to be injured in the head, chest or abdomen than survivors, who were more likely to be injured in the extremities. Operations required immediately included laparotomy, vascular injuries, orthopedic injuries and hand injuries.
The purpose of this review was to inform mass casualty preparation in other centers. As expected, the extremely short transport distance from the Pulse nightclub to Orlando Regional Medical Center had a positive impact on survival, as victims were able to receive resuscitation and hemorrhage control in a timely fashion. Documentation was poor, particularly regarding prehospital transport as the systems were overwhelmed. Engagement of all hospital systems was crucial: emergency department physicians for resuscitation, subspecialty surgical services, interventional radiology. Non-surgical specialties were vital to clear available hospital beds and assume care of non-acute patients. Coordination between the Level 1 trauma center, nearby community hospitals and emergency services was of paramount importance. Staff were brought from surrounding hospitals to staff operating rooms and other services. Central Florida regularly has disaster drills that include all of these agencies and all involved parties felt that the execution of these interdisciplinary drills significantly improved the care offered during the actual event. The authors strongly recommend similar mass casualty drills be implemented in other trauma systems, as the propensity for mass casualty events seems to be rising.
Article 2
Protective effects of helmets on bicycle-related injuries in elderly individuals. Kim T, Jung KY, Kim K, Yoon H, Hwang SY, Shin TG, Sim MS, Jo IJ, Cha WC. Inj. Prev. 2019 Oct;25(5):407-413.
The benefits of physical activity for our aging population is not in doubt, but with increased activity comes increased risk of injury. The authors note that bicycle injuries have increased nationally in Korea in the context of a government bicycling-promotion program which included publicity, education, and bicycle infrastructure. Bicycle helmets are widely recommended to prevent head injury associated with bicycle crashes, but as the authors point out, the bulk of education and regulation of helmets has focused on young people. In this paper, Kim et al. investigate the role of bicycle helmet wearing in reducing risk of traumatic brain injury among bicyclists age over 65.
This was a retrospective analysis of data from 8 emergency departments, 2011-2016. Patients presenting with bicycle-related injuries were divided into ages 20-64 and ages ≥ 65. The primary outcome was TBI. There were 7,181 patients included, 1,253 age ≥ 65. Another 558 were excluded for unknown helmet use. Only 6% of older adults wore helmets vs. 19% of younger adults. TBI was present in 5.9% of helmeted young adults and 7.9% of nonhelmeted young adults, and in 4.9% of helmeted older adults and 14.% of nonhelmeted older adults. These differences remained significant in multivariable analysis: helmet use as associated with lower odds of TBI (OR 0.72, 95% CI 0.55-0.93), and the effect was more pronounced in older adults. Other key risk factors were crashes involving a motor vehicle, crashes on roadways, and patient comorbidities.
Strengths of this study include a robust assessment of crash factors and setting. However, this study must be interpreted in the context of an unknown denominator. There may be many cyclists excluded from the study because though they crashed, they did not need to seek care, in part because their helmets successfully prevented an injury. It is not clear why helmets were more protective in older adults. This could relate to alterations of older cyclists other protective reflexes, to direct effect of the helmet itself, or to unmeasured confounding. As the population ages, it is critical to continue to promote physical activity for older adults, but injury prevention efforts must adapt in concert. Future work remains to educate older bicyclists about helmet use, and to make helmets accessible to this population.
Article 3
Plight of the Distracted Pedestrian: A Research Synthesis and Meta-Analysis of Mobile Phone Use on Crossing Behavior. Simmons SA, Caird JK, Ta A, Sterzer F, Hagel, B. Inj. Prev. 2020 Apr;26(2):170-176.
Pedestrian deaths remain a large public health problem, with the overall number of pedestrian deaths continuing to increase. Mobile phones add complexity to pedestrian safety, with mobile phones able to be used by pedestrians in route. Distracted pedestrians are known to be a common problem, with mobile phone use accounting for approximately 2,000,000 injuries to pedestrians. Many studies have been undertaken on how mobile phone use affects pedestrians, but the true influence of mobile phones on pedestrian actions still remains unclear. This manuscript is a meta-analysis that sought to discern the influence of mobile phones on pedestrian behavior.
The meta-analysis included both experimental studies and observational studies. A comparison between usual behavior and mobile phone influenced behavior was needed for inclusion. Aspects of pedestrian behavior assessed included the following: initiation duration (duration prior to beginning walking), missed opportunities (possible crossing events missed by pedestrians), crossing duration (time crossing requires), looking left and right (use of head turning before beginning crossing), and hits and close calls (pedestrian crashes and near pedestrian crashes with cars).
33 studies were included in this manuscript. The experimental studies and observational studies were examined separately. Texting/phone browsing was associated with initiation duration (r=0.32), looking left and right (r=-0.43), and hits and close calls (r=0.34). Talking was associated with initiation duration (r=0.25), missed opportunities (r=0.17) and hits and close calls (r=0.17). Music listening was not associated with any of the pedestrian behaviors. Qualitative analysis of multiple pedestrian behaviors in observational studies revealed that pedestrians distracted by mobile phones did not as often look at vehicles while crossing.
The authors noted that texting/browsing require pedestrians to frequently interact with their mobile phones, and as would be anticipated was the most influential pedestrian behavior on looking side to side for street crossing as well as near misses or actual pedestrian crashes. Whether the texting/browsing associated decrease in looking side to side, talking on the phone, or listening to music translates to more frequent pedestrian crashes is unknown. The authors concluded that texting was the most influential of the distracted behaviors, but that further research is required to establish a causal link between distracted pedestrian behaviors and occurrence of pedestrian accidents. Suggested potential injury prevention interventions for mobile phone distracted pedestrians included: phone alerts, specified walking lanes, ticketing behaviors, and padding structures.
