Injuries & Violence :
Injuries remain the most important cause of loss of
potential years of life before age 65. Homicide and motor vehicle accidents are
a major cause of injury-related deaths among young adults, and accidental falls
are the most common cause of injury-related death in the elderly. Other causes
of injury-related deaths include suicide and accidental exposure to smoke, fire,
and flames.
Although there has been a steady decline in motor vehicle
accident deaths per miles driven, road traffic injuries remain the tenth leading
cause of death and the ninth leading cause of the burden of disease. Although
seat belt use protects against serious injury and death in motor vehicle
accidents, at least one-fourth of adults and one-third of teenagers do not use
seat belts routinely. Air bags are protective for adults but not for small
children.
Each year in the United States, more than 500,000 people
are nonfatally injured while riding bicycles. The rate of helmet use by
bicyclists and motorcyclists is significantly increased in states with helmet
laws. Young men appear most likely to resist wearing helmets. Clinicians should
try to educate their patients about seat belts, safety helmets, the risks of
using cellular telephones while driving, drinking and driving—or using other
intoxicants or long-acting benzodiazepines and then driving—and the risks of
having guns in the home.
Long-term alcohol abuse adversely affects outcome from
trauma and increases the risk of readmission for new trauma. Alcohol and illicit
drug use are associated with an increased risk of violent death. There is a
causal link between alcohol intoxication and injury due to assault. Harm
reduction can be achieved through practical measures, such as using plastic
glasses and bottles in licensed premises; controlling prices of drinks; and
targeted policing based on police, accident, and emergency data.
Males aged 16–35 are at especially high risk for serious
injury and death from accidents and violence, with blacks and Latinos at
greatest risk. For 16- and 17-year-old drivers, the risk of fatal crashes
increases with the number of passengers. Deaths from firearms have reached
epidemic levels in the United States and will soon surpass the number of deaths
from motor vehicle accidents. Having a gun in the home increases the likelihood
of homicide nearly threefold and of suicide fivefold. In 2002, an estimated
877,000 individuals successfully committed suicide. Educating physicians to
recognize and treat depression as well as restricting access to lethal methods
have been found to reduce suicide rates.
In elderly patients, the risk of hip fracture when falling
can be reduced by as much as 80% by wearing hip protectors, but only about half
of patients use them regularly. Oral vitamin D supplementation with 700–800
international units/d appears to reduce the risk of hip and other nonvertebral
fractures in both ambulatory and institutionalized elderly persons, but 400
international units/d is not sufficient for fracture prevention.
Finally, clinicians have a critical role in detection,
prevention, and management of physical or sexual abuse—in particular, routine
assessment of women for risk of domestic violence. In a trial, the 12-month
prevalence of intimate partner violence ranged from 4% to 18% depending on the
screening method, instrument, and health care setting. Rates of current domestic
violence on exit questionnaire were 21% in suburban emergency department and 26%
in urban emergency department settings. Inclusion of a single question about
domestic violence in the medical history—"At any time, has a partner ever hit
you, kicked you, or otherwise physically hurt you?"—can increase identification
of this common problem. Another screen consists of three questions: (1) "Have
you ever been hit, kicked, punched, or otherwise hurt by someone within the past
year? If so, by whom?" (2) "Do you feel safe in your current relationship?" (3)
"Is there a partner from a previous relationship who is making you feel unsafe
now?" Women seem to prefer written, self-completed screening questionnaires to
face-to-face questioning. Alternatively, computer prompts to clinicians may
serve as useful reminders to inquiry. Assessment for abuse and offering of
referrals to community resources creates potential to interrupt and prevent
recurrence of domestic violence and associated trauma. Screening patients in
emergency departments for intimate partner violence appears to have no adverse
effects related to screening and may lead to increased patient contact with
community resources.