Treated injuries in northern Vermont.

OBJECTIVES: To study characteristics of injury events and injuries requiring treatment in a Vermont population. METHOD: A one year 30% prospective sample was studied of persons from 22 communities who received first physician care for injury at the Medical Center Hospital of Vermont. RESULTS: Modal injuries were-superficial involving skin only among children below age 10, overexertion injuries among 10-59 year olds, and fractures among older persons. Among interviewed males ages 20-59, 31% of injuries were work related. Among females 26% were work related. Examining hospitalized cases only would have overemphasized falls, chemical injuries, leg fractures, transportation and nursing home injuries, and undercounted overexertion injuries, especially to the back, arm fractures, and injuries during recreation, work and home activities. Most common products/materials in use when injured were recreational equipment (24%) and motor vehicles (9%). Those most often causing injury were ground (20%) and home structures/construction materials (17%). No product was involved in 39% of injury event initiation and 15% of injury causation. CONCLUSION: In order to adequately reflect the distribution of treated injuries in the community by anatomical area, age, and event type studies must examine both emergency department and hospitalized cases and use a data collection system capable of recording several parameters to describe injury events and products/materials involved.

The Injury Impairment Scale as a measure of disability.

Scores on the Injury Impairment Scale (IIS) were compared with reported disability for work or school, household activities, and activities of daily living during the first 18 months after injury for 2,194 persons treated in an emergency department or hospitalized for their injuries. Persons whose most severe injury was more life-threatening or who had larger numbers of injuries more often had higher IIS scores for their most life-threatening injury than did persons with fewer or less life-threatening injuries. Hospitalized patients had higher IIS injuries more often than did emergency department patients. As IIS increased, duration of disability also increased. However, many high IIS patients either reported no disability or disability of only short duration, suggesting only limited association between disability and IIS as it is currently designed.

Treatment charges, payment sources, and disability from alcohol-related trauma.

We examined treatment charges and who paid them and disability for work, school, household activities, and activities of daily living according to identified use of alcohol before injury among 2,416 patients age 15 years or older from 22 northwestern Vermont communities. Over 90% received emergency department treatment only. Among patients reported to have consumed this drug mean hospital and physician charges, respectively, were $2,482 and $565; 31.7% did not pay any portion of their hospital bills, and 27.8% of their total bills were unpaid. Among patients not known to have consumed alcohol, mean hospital and physician charges were $601 and $158, respectively; 10.7% made no payments and 11.3% of their bills were unpaid. Bills of alcohol users more often were paid by Medicaid and less often by Workmen's Compensation or commercial insurance than were those of patients without alcohol. Users also were less likely than the nonalcohol group to pay physicians' bills for hospital care. Alcohol users experienced longer postinjury disability than did persons not known to have been drinking.

Emergency department care and hospitalization as predictors of disability.

Duration of complete and partial disability for work, school, and home activities and activities of daily living during the first 18 months after injury were compared for 2,043 emergency department (ED) patients and 151 hospitalized patients from 22 northwestern Vermont communities who received their initial medical care for injury at the Medical Center Hospital of Vermont and were subsequently interviewed. Larger proportions of hospitalized patients than ED patients had any disability or prolonged disability. During almost all time frames, and even among patients who still had ongoing disability at 18 months, the majority of persons with disability had required ED treatment only. These data suggest that, based on disability, ED patients should not necessarily be considered to have merely minor injuries.

Trauma center-related biases in injury research.

OBJECTIVES: Most studies from trauma centers analyze and present combined data on patients from their surrounding communities and patients referred for specialized services from service areas of other hospitals. Information is needed about the effect of combining data from the two groups on conclusions about injury in the community. METHOD: All injured patients seen in a trauma center emergency department of 30% of days over one year were studied concerning referral status, age, sex, type of activity when injured, injury type and severity, hospitalization, and prior medical history. RESULTS: Combining data for both groups suggested an older, more medically impaired population, with more severe injuries, more frequent hospitalization, more serious head and spine injuries, fewer extremity fractures, and fewer household-related and more transportation-related injuries than were actually occurring in the community. CONCLUSIONS: Data from local and out-of-area referred patients at trauma centers should be analyzed and presented separately in studies from this source if an accurate representation is to be provided of the role of injury in the population at large of the community.

Characteristics, costs, and effects of violence in Vermont.

Study of the distribution, characteristics, costs and effects involving 125 assaults, 22 attempted suicides (plus 5 completed out-of-hospital suicides), and 49 injuries of questionable intent was carried out among local area patients treated in a hospital serving 22 communities (150,000 population) in northern Vermont. Patients referred from the service areas of other hospitals were specifically excluded in order to provide a picture of injuries from violence in the community, rather than of injuries treated at the hospital. The percentages hospitalized were assault, 5%; attempted suicide, 50%; and unknown intent, 6%. Most assault injuries were to the head or upper extremity administered by fist; suicide attempts most often were by medication or a sharp instrument to arms, while injuries of unknown intent usually resulted from smashing a hand against a building structure. Alcohol use was noted for 26%, 38%, and 23% of patients aged 15 years or older in the three respective categories. Average hospital charges (excluding physicians' bills) for the three respective injury events were $420, $2639, and $388. Only 2% of hospital bills were paid by patients or their families, 25% were paid by commercial insurance, 19% by government sources, and 54% remained unpaid. One eighth of physicians' bills for hospital and followup care were paid by patients or their families, and about 60% were still unpaid a year after billing. Among assault patients who could be contacted for followup and who had been employed or in school previously, 27% had no disability for work or school and the remainder averaged 18 days of complete plus partial disability.

Characteristics, hospital charges, and effects of road transportation injuries in Vermont.

We studied 470 crash- and noncrash-related road transportation injuries to vehicle occupants, bicyclists, and pedestrians seen at a trauma center in Vermont. Among primary care patients, crash and noncrash groups had similar AIS and average disability at one year. Hospitalized patients had longer disability, but a majority of overall disability days and ongoing disability was found among nonhospitalized patients. Seventy-four percent of hospital bills were paid by insurance, 16% by government, 3% by self, with 7% unpaid. Limiting the sample only to hospitalized patients, or including referred patients, markedly affected--but in different ways--distributions of event type, body area injured, charges, and other characteristics.

Reflections on a half century of injury control.

Using both historical analysis and personal reminiscence, this article describes the development of injury control activities since about 1940, focusing particular attention on the rise and fall of the Public Health Service's Division of Accident Prevention. By the 1940s and 1950s, modest but useful efforts in injury control research and programming had been made. The 1960s and early 1970s then saw an explosion of new concepts, programs, and enthusiasm, but much of this soon dissipated. Since 1985 there has been a renaissance of interest and effort, and the development of a new cadre of injury control professionals. This progress is threatened, however, by both old and new problems.

A scheme for describing injury events.

OBJECTIVE: To develop a data collection system that provides a more comprehensive picture of the components of the preinjury and injury phases of injury events than is usually available in medical records. METHOD: Based on a scheme originally designed for study of occupational injuries among off-shore petroleum drilling workers, eight data areas were designated and lists of categories were developed to permit applicability to a general injury surveillance program. Medical records for 1600 injured patients treated at the Medical Center Hospital of Vermont were reviewed to determine current frequency of recording such information. RESULTS: A scheme for injury surveillance was designed that included location of the event, general and specific activities at time of injury, work relationship, nature of the event, animal or person contact, products or materials being used and those causing injury, and energy type and mechanism. CONCLUSION: An acceptable scheme has been developed that can be used for general surveillance, or modified to focus in greater detail on specific environments, products, or event types.

Potential availability of transplantable organs and tissues in fatalities from injury and nontraumatic intracranial hemorrhage.

Study of all Vermont and urban Rhode Island trauma fatalities for 1987, and all fatalities in these states from nontraumatic intracranial hemorrhage for 1986 and 1987, identified few potential donors for asystole-sensitive organs, such as heart, lungs, liver, pancreas, and kidneys. It is estimated that nationally there is a maximum potential of about 5000 cadavers per year from these two sources that meet screening criteria for age, duration of survival after event, brain death, and absence of organ damage or important disease. This would yield up to 5000 hearts, livers, and pancreases, perhaps 5-6000 lungs, and up to 10,000 kidneys. However, for tissues that have longer postdeath viability it is estimated that annually at least 60,000 eyes, 22,000 heart valve sets, 29,000 donations of 2 or more long bones per cadaver, and 36,000 skin donations are potentially available from these sources.

Injuries to farmers and farm families in a dairy state.

This study examined injuries among farmers and farm family treated at two rural Vermont hospitals. Most involved dairy farming and woodlot activities. Livestock accounted for 38% of injuries among dairy farmers. Other injuries involved a variety of events, including equipment repair and use, haying, chemicals and biologicals, falls, and contacts with fixed objects. Half of woodlot injuries involved chainsaws. On average, livestock-related injuries resulted in 21.5 days of disability for work during the first 6 months after injury, whereas those not involving livestock averaged 16.2 days of disability. On dairy farms 14% of farming injuries were to family members, and at least a third of all injuries to farm family members were work related. Insurance coverage for medical care was sparse for all rural persons treated for injury, especially for woodlot operators.

Potential availability of transplantable organs according to factors associated with type of injury event.

Potential availability of transplantable organs from different types of injury fatalities was studied. Factors examined included target organ damage or disease, age of potential donor, duration of survival before circulatory arrest, and universal rejection factors such as sepsis, HIV infection, or systemic malignancy. Motor vehicle fatalities yielded the greatest proportion of potentially viable organs. Delay in discovery and universal rejection factors were important exclusionary issues for fatalities from suicide, homicide, and non-motor vehicle unintentional injury. There was no difference in organ damage or in duration of survival with higher speeds in fatal crashes, suggesting that states with 65 mph speed limits--and consequently higher death rates--may have greater potential availability of donatable organs than do those with 55 mph maximum. The increase in deaths at higher speeds, however, vastly outweighs the benefits of any possible increase in the potential for donor organs.

Research and other issues concerning effects of medical conditions on elderly drivers.

Most research on medical impairment to driving has been limited by the inability to define some conditions, inadequate sample selection, poor definition of excessive crash risk, ignoring of comorbid conditions or human-environmental interactions, and failure to examine the interaction of aging and medical conditions. Driver screening procedures are both crude and inadequately related to data or theory. Recommendations are presented to improve research and screening programs.

Hearing loss prevalence and management in nursing home residents.

OBJECTIVES: To determine the prevalence and management of hearing loss and hearing handicap among non-demented nursing home residents. DESIGN: Descriptive study of total population of two nursing homes. PARTICIPANTS: All 121 eligible residents. SETTINGS: Two nursing homes. MINI OUTCOME MEASURES: Audiometry, questionnaires of nurses and subjects regarding perceived hearing handicap, and documentation in medical records of hearing loss. RESULTS: 77% had at least a mild (greater than or equal to 26 dB Hearing Level) hearing loss in the better ear, and 51% had a moderate to severe loss (greater than or equal to 41 dB HL). Self-assessments of hearing handicap by residents, together with audiometric findings and expressed interest in a hearing aid, were more useful guides for aural rehabilitation needs than were nurses' assessments of residents' handicaps. Medical records failed to identify 48% of residents with moderate to severe hearing losses. Fifty-eight percent of residents with severe hearing loss currently had hearing aids, and 38% more would like to have an aid. CONCLUSIONS: Residents should have hearing evaluations with documentation of results on admission and periodically under the direction of a nurse trained as a hearing specialist. Environmental modifications of the NH plus use of hearing aids can improve hearing.

Management issues for trauma patients with alcohol.

An estimated 20-25% of patients treated in emergency departments or as inpatients for trauma have been drinking and most of them have BACs of 0.10 gm/dL (22 mmol/L) or higher. Many are problem drinkers or alcoholics, smokers, and also abuse other drugs. Both acute ingestion and chronic abuse of alcohol increase the frequency and severity of injury, and may complicate patient management by mimicking head trauma, masking intra-abdominal injury, causing circulatory collapse, reducing immune response, altering hepatic metabolism, or causing delirium tremens. Proper management of a trauma patient with alcohol includes BAC determination, careful history taking for alcoholism with referral for further evaluation or treatment when indicated, and determination whether other drugs are also being misused. Failure to do these may put a physician at legal risk both for improper care of the patient and for exposing others to injury if the patient crashes after being discharged from the emergency department while still impaired by alcohol.

Teaching about substance abuse in medical school.

Physicians often fail to diagnose and treat (or treat properly) alcoholism and other chemical dependence in patients. This failure may result from inadequate training, a sense of futility about effectiveness of treatment, belief that this is a social problem rather than disease or denial because the physician him/herself is from a family with substance abuse. A survey of 81 first year medical students identified six (7%) with past or present patterns suggesting abuse of alcohol or other drugs, five (6%) reporting both personal and immediate family abuse patterns, and 25 (31%) who reported such patterns in parents, grandparents or siblings. Students who are adult children of alcoholics (ACOAs) often need emotional support while learning about alcoholism and its treatment. Medical school training about substance abuse must take these needs into consideration and provide services approved by, but insulated from, the dean's office to help students cope with effects of personal or family substance abuse.