Public rescue tube deployment in Hawaii: protective association with rescuer drownings.

OBJECTIVE: To describe the association between public rescue tube (PRT) flotation devices and fatal rescuer drownings in Kauai, Hawaii. METHODS: We reviewed Hawaii death certificate data from 1993 to 2017, sometimes supplemented with autopsy and emergency medical service reports, to identify fatal rescuer drownings. Incidents were analysed in relation to the initial 2008 deployment of PRT. RESULTS: Over the 25-year period, only 13% (228) of the 1750 identified drownings occurred in Kauai, but nearly half (46%, or 13) of the 28 rescuer deaths occurred there. However, only 1 of the 13 rescuer deaths in Kauai occurred after the 2008 deployment of PRT. The state-wide proportion of rescuer deaths in Kauai decreased significantly from 60% (12 of 20) from 1993 to 2007 to 13% (1 of 8) from 2008 to 2017. There were no apparent changes in the proportions of rescuer drownings in the other three counties of the state, where PRTs were essentially non-existent. CONCLUSION: Despite valid concerns, we found no fatal rescuer drownings related to PRT use after their 2008 introduction in the county of Kauai. Instead, we observed a reduction in the number of rescuer drownings, and in their proportion of total drownings in association with the deployment of PRT. The findings of this study have the potential to directly impact ocean and other open water environment-related fatal drowning prevention policy and practice.

Decrease in injuries from fireworks in Hawaii: associations with a county policy to limit access.

OBJECTIVE: To examine trends in fireworks-related injuries (FRI) before and after enactment of an ordinance to limit access in the City and County of Honolulu (the island of Oahu). METHODS: Surveillance of FRI treated in all emergency departments in the state, for 18 new year's periods (31 December through 1 January) from 2004 to 2021. Prelaw (2004 to 2011) and postlaw (2012 to 2021) number of FRI were compared, by patient age and county. RESULTS: The average annual number of FRI for all ages decreased significantly in Oahu, from 74 during the prelaw period to 27 during the postlaw period (p<0.01), but not in the remaining neighbour islands (p=0.07). Decreases were particularly evident for Oahu paediatric patients (under 18 years), among whom FRI declined from 42 to 10 per year (p<0.01). FRI were approximately halved for older Oahu patients and neighbour island paediatric patients. CONCLUSIONS: Legislation requiring permits for a specified number and type of fireworks, and limiting access to persons 18 years and older was associated with significant decreases in FRI in the City and County of Honolulu.

Unique Epidemiology of Spinal Cord Injury in Hawai'i: Wave-related Incidents.

Spinal cord injury remains one of the most devastating forms of traumatic injury. The purpose of this study was to characterize the clinical characteristics of spinal cord injury patients and the geographic location where the injury occurred in the state of Hawai'i. Spinal cord injury cases from 2009-2017 were identified using the State Trauma Registry, which included demographics, mechanism of injury, and outcomes. In 1170 spinal cord injury cases, the second most frequent etiology was an ocean-wave related incident. Over half of wave related spinal cord injury occurred on ten beaches on four islands. Compared to other mechanisms, patients with wave related spinal cord injury were significantly less likely to be Hawai'i residents (15%), screen positive for alcohol (4%), or have an injury in the lower thoracic or lumbar region (4%). These patients were also less likely to die (1%) and more likely to be discharged to home (66%). Wave related incidents are a major cause of spinal cord injury in Hawai'i, disproportionately affecting visitors. Education focused toward middle-aged male visitors at beaches with moderate to severe shorebreak may reduce the incidence of injury.

Rural Level III centers in an inclusive trauma system reduce the need for interfacility transfer.

BACKGROUND: Development of Level III trauma centers in a regionalized system facilitates early stabilization and prompt transfer to a higher level center. The resources to care for patients at Level III centers could also reduce the burden of interfacility transfers. We hypothesized that the development and designation of Level III centers in an inclusive trauma system resulted in lower rates of transfer, with no increase in morbidity or mortality among the non-transferred patients. METHODS: State trauma registry data from January 2009 through September 2015 were examined from five rural hospitals that transfer patients to our highest (Level II) trauma center and resource hospital. These five rural hospitals began receiving state support in 2010 to develop their trauma programs and were subsequently verified and designated Level III centers (three in 2011, two in 2013). Multivariate logistic regression was used to examine the adjusted odds of patient transfers and adverse outcomes, while controlling for age, gender, penetrating mechanism, presence of a traumatic brain injury, arrival by ambulance, and category of Injury Severity Score. The study period was divided into "Before" Level III center designation (2009-2010) and "After" (2011-2015). RESULTS: 7,481 patient records were reviewed. There was a decrease in the proportion of patients who were transferred After (1,281/5,737) compared to Before (516/1,744) periods (22% vs. 30%, respectively). After controlling for the various covariates, the odds of patient transfer were reduced by 32% (p < 0.0001) during the After period. Among non-transferred patients, there were no significant increases in adjusted odds of mortality, or hospitalizations of seven days or more, Before versus After. CONCLUSIONS: Development of rural Level III trauma centers in a regionalized system can significantly reduce the need for transfer to a remote, higher level trauma center. This may benefit the patient, family, and trauma system, with no adverse effect upon patient outcome. LEVEL OF EVIDENCE: Epidemiological, level III.

Motor vehicle crash fatalaties and undercompensated care associated with legalization of marijuana.

BACKGROUND: Half of the US states have legalized medical cannabis (marijuana), some allow recreational use. The economic and public health effects of these policies are still being evaluated. We hypothesized that cannabis legalization was associated with an increase in the proportion of motor vehicle crash fatalities involving cannabis-positive drivers, and that cannabis use is associated with high-risk behavior and poor insurance status. METHODS: Hawaii legalized cannabis in 2000. Fatality Analysis Reporting System data were analyzed before (1993-2000) and after (2001-2015) legalization. The presence of cannabis (THC), methamphetamine, and alcohol in fatally injured drivers was compared. Data from the state's highest level trauma center were reviewed for THC status from 1997 to 2013. State Trauma Registry data from 2011 to 2015 were reviewed to evaluate association between cannabis, helmet/seatbelt use, and payor mix. RESULTS: THC positivity among driver fatalities increased since legalization, with a threefold increase from 1993-2000 to 2001-2015. Methamphetamine, which has remained illegal, and alcohol positivity were not significantly different before versus after 2000. THC-positive fatalities were younger, and more likely, single-vehicle accidents, nighttime crashes, and speeding. They were less likely to have used a seatbelt or helmet. THC positivity among all injured patients tested at our highest level trauma center increased from 11% before to 20% after legalization. From 2011 to 2015, THC-positive patients were significantly less likely to wear a seatbelt or helmet (33% vs 56%). They were twice as likely to have Medicaid insurance (28% vs 14%). CONCLUSION: Since the legalization of cannabis, THC positivity among MVC fatalities has tripled statewide, and THC positivity among patients presenting to the highest level trauma center has doubled. THC-positive patients are less likely to use protective devices and more likely to rely on publically funded medical insurance. These findings have implications nationally and underscore the need for further research and policy development to address the public health effects and the costs of cannabis-related trauma. LEVEL OF EVIDENCE: Prognostic, level III.

Impact of Helmet Use on Injury and Financial Burden of Motorcycle and Moped Crashes in Hawai'i: Analysis of a Linked Statewide Database.

Helmet use reduces injury severity, disability, hospital length of stay, and hospital charges in motorcycle riders. The public absorbs billions of dollars annually in hospital charges for unhelmeted, uninsured motorcycle riders. We sought to quantify, on a statewide level, the healthcare burden of unhelmeted motorcycle and moped riders. We examined 1,965 emergency medical service (EMS) reports from motorcycle and moped crashes in Hawai'i between 2007-2009. EMS records were linked to hospital medical records to assess associations between vehicle type, helmet use, medical charges, diagnoses, and final disposition. Unhelmeted riders of either type of vehicle suffered more head injuries, especially skull fractures (adjusted odds ratio (OR) of 4.48, P < .001, compared to helmeted riders). Motorcyclists without helmets were nearly three times more likely to die (adjusted OR 2.85, P = .001). Average medical charges were almost 50% higher for unhelmeted motorcycle and moped riders, with a significant (P = .006) difference between helmeted ($27,176) and unhelmeted ($40,217) motorcycle riders. Unhelmeted riders were twice as likely to self-pay (19.3%, versus 9.8% of helmeted riders), and more likely to have Medicaid or a similar income-qualifying insurance plan (13.5% versus 5.0%, respectively). Protective associations with helmet use are stronger among motorcyclists than moped riders, suggesting the protective effect is augmented in higher speed crashes. The public financial burden is higher from unhelmeted riders who sustain more severe injuries and are less likely to be insured.

Helmet use among motorcycle and moped riders injured in Hawaii: Final medical dispositions from a linked database.

BACKGROUND: Reports regarding helmets in motorcycle crashes have been limited by the lack of data across the spectrum of injury outcomes, generally excluding low-severity injuries that do not require further medical treatment. We hypothesized that the protective effect of helmets may be underestimated in studies that focused only on patients who arrive at a trauma center and that it may differ depending on whether the crash involved a motorcycle or moped. METHODS: The emergency medical service reports of 2,553 crash patients treated from 2007 to 2009 were linked to police crash reports, hospital billing data, death certificates, and the Fatal Analysis Reporting System for a more complete description of the crashes throughout the state. RESULTS: The number of unhelmeted riders (n = 1,674) was nearly double those who were helmeted (n = 879). Multivariate logistic regression models estimated 45% greater odds of a hospital admission (vs. no hospital treatment or a discharge from the emergency department setting) among unhelmeted riders, compared with helmeted riders. Unhelmeted riders also had an adjusted odds of a fatal injury that was more than double that of helmeted riders (odds ratio, 2.71; 95% confidence interval, 1.68-4.46). Stratified analyses showed that these protective associations between helmet use and medical disposition were apparent only among motorcyclists. CONCLUSION: The magnitude of the protective associations between helmets and medical outcomes was generally greater than that reported by other studies. Motorcyclists seem to benefit from helmet use more than moped riders. This data could be used to promote helmet use through education and public policy. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III.

Surfing injuries.

The purpose of this study was to describe the relative frequency, pattern, and mechanism of surfing injuries. Descriptive data of surfing injuries was collected by using a Web site-based interactive multiple choice survey. Data was collected from May 1998 to August 1999. Completed surveys were obtained from 1,348 individuals reporting 1,237 acute injuries and 477 chronic injuries. Lacerations accounted for 42% of all acute injuries, contusions 13%, sprains/strains 12%, and fractures 8%. Thirty-seven percent of acute injuries were to the lower extremity, and 37% to the head and neck. Fifty-five percent of injuries resulted from contact with ones own board, 12% from another surfer's board, and 17% from the sea floor. Sixty-seven percent of acute surfing injuries are caused by board contact. Older surfers, more expert surfers, and those surfing large waves have a higher relative risk for significant injury. Equipment modifications are suggested that may decrease the risk for injury.

Dietary intake changes associated with post-cyclone food aid in Western Samoa.

This study examines dietary intake responses to a food aid program in Western Samoa, which consisted primarily of rice and flour supplements. Using a semi-quantitative food frequency questionnaire, intake estimates were made for 147 Samoans (72 men, 75 women), 5 months before and 8 months after a tropical cyclone. Study participants were from urban Apia (n = 34) and three rural, more traditional villages (n = 113). For the total sample, consumption of rice and pancakes more than doubled, and the contribution of these foods to total carbohydrate and kilocalorie intake increased approximately three-fold (p < 0.0001, for paired t-tests). Significant decreases were noted for the nutrient contribution from breadfruit and coconut products. These dietary changes were significantly less in the urban sub-sample. These results indicate the food aid may have accelerated an existing modernizing trend in the diet of Samoans. The nutritional and economic implications are discussed within the context of Western Samoa.

Population change in adult obesity and blood lipids in American Samoa from 1976-1978 to 1990.

Obesity in American Samoan adults in 1990 was compared to that in 1976-1978 to evaluate population changes concomitant with modernization. Body weight, stature, the body mass index (BMI), and two skinfolds were measured in 1990 in 830 males and females 25-74 years old, and were compared to corresponding data from 1976 and 1978 for 1,621 adults. Mean BMI and skinfold thicknesses increased markedly from 1976-1978 to 1990 in males at all ages. Mean BMI for 45-54 year old males was approximately 3.6 kg/m2 higher (P < 0.0001) in 1990 than in 1976-1978, but was only 0.6 kg/m2 higher in females of the same age. The prevalence of overweight increased significantly from 66% in 1976-1978 to 85% in 1990 (P < 0.001) in 35-44 year old males, but remained about the same, 91%, in females of that age. Similar sex differences in temporal change were found in skinfolds. Fasting serum total and high density lipoprotein (HDL) cholesterol and triglycerides were obtained for a random subsample of 67 males 40-49 years old and were compared to lipid levels in a 1978 sample of American Samoan males of similar age and residence. Both total and HDL cholesterol were significantly different between 1978 and 1990, 178 vs. 205 mg/dl (P < 0.02), and 43 vs. 37 mg/dl (P < 0.01), respectively. Triglycerides were higher in 1990 than in 1978, 169 vs. 128 mg/dl. The results suggest that obesity and adiposity increased more over 12-14 years among adult males than among females, who in 1976-1978 were already massively overweight. © 1993 Wiley-Liss, Inc.