180

Injury Control

Injury and Disability Prevention and
  Alcohol-Related Crashes

      Julian A. Waller, M.D., M.P.H.
Depa&rmnt of Medicine, University of Vermont, Burlington, Vermont

This chapter is built around four assumptions. First, contrary to the general impres-
sion of the public, and even of many working in the field of highway safety, about 80
percent of the people fatally injured in alcohol-related crashes are individuals who
themselves had been drinking and are either drivers, impaired passengers of alcohol-
impaired drivers, or impaired pedestrians (Waller 1985). About two-thirds of injuries in
alcohol-related highway crashes also involve such individuals.

The image of the innocent victim who is run down by a drunken driver who escapes
all injury himself has great emotional impact but only limited support from the real world.
We have a responsibility to be fully aware that injury to the innocent is not the largest
aspect of the problem.

Second, the tendency over the years has been to see issues involving alcohol and injury
primarily as a safety problem, rather than a public health concern. As work over the past
two decades has shown, reinforced by the recent National Academy of Sciences report
I+lryirr America, injury is the primary cause of lost productive years of life in the United
States, and alcohol abuse is an important contributor to that toll (National Research
Council Committee on Trauma Research 1985).

A very substantial proportion-probably a majority- of persons who get into trouble
with alcohol on the highway are not typical social drinkers, but rather problem drinkers
or alcoholics. The safety issue is only part of a much larger public health problem.

In looking at the safety aspect, we must constantly be aware of this broader perspec-
tive. For example, an important effect of increasing the age for alcohol consumption to
21 was the reduction in the highway crash toll among teenagers. But, although at least
some short-term data suggest otherwise (Vingilii and Smart 1981), it may be that the
most important long-term result of such legislation will be to reduce a wide range of
alcohol-related problems among teenagers and the onslaught of teenage and young adult
alcoholics that we began to see when the drinking age was lowered to 18.

Third, during the late 196Os, Dr. William Haddon developed a matrix of highway crash
analysis in which human, vehicular, and environmental factors interact during the
precrash, crash, and postcrash phases to determine the occurrence, initial severity, and
ultimate outcome of these events. He subsequently described generic interventions
relevant to these phases in his brilliant paper, "On the Escape of Tigers" (Haddon 1970).
In talking about injury prevention and amelioration, this chapter utilizes Haddon's basic
approach, with an awareness of all three types of factors across all three phases of crash
events.

Finally, this review is clearly not alone in discussing components of Haddon's nine
cells. Therefore, this examination is quite selective, focusing on aspects that will not be
considered by others or that will be considered in a different context.


INJURY CONTROL                                                          181

Behavioral Issues in the Precrash Phase

How do we alter behavior to prevent the occurrence of crashes? All the other panels
are concerned with one or another aspect of this area. This chapter focuses particularly
on three aspects. One is the characteristics of the populations we are trying to reach.

As data expand, it is becoming increasingly clear that many people begin to be
impaired at blood alcohol concentrations (BACs) below 0.05 gm/dl. But the data about
who gets into trouble are equally clear. Over three-quarters of alcohol-related fatalities,
and almost as high a proportion of alcohol-related injury crashes, involve drivers or
pedestrians with BACs of 0.10 gm/dl or higher. Usually the BAC is much higher,
averaging 0.16 gm/dl (NHTSA 1986).

My own work and that of others has focused on two groups of heavy drinkers, namely,
teenage and young adult males, and problem drinkers and alcoholics. A new group
causing increasing concern is teenage and young adult females who are drinking more
and driving more, at least in part as aspects of their new independence (Fell 1987).

This discussion, however, focuses on a different issue, namely, the interdependence
of lifestyle components. Studies show that those teenagers most likely to drive after
drinking are also the ones most likely not to use seatbelts, to drive recklessly, to have less
exercise, to prefer more fat in their diet, to have had premarital sexual experience, and
to have done so without benefit of contraceptives (Jessor 1987; Maron et al. 1986). We
know that heavy drinkers tend also to be heavy smokers, a fact not lost on the tobacco
and alcohol beverage manufacturers, which often are divisions of single companies and
thus are able to consolidate marketing strategies. A recent study by the Internal Revenue
Service shows that individuals most likely to cheat seriously on their taxes are also more
likely to be taking chances in other aspects of their lives, including speeding, drunken
driving, adultery, and risky investments and sports (Goleman 1988).

This is precisely why it is so important to take a broader public health viewpoint.
Specific behavioral interventions often show at least partial success. But such interven-
tions all tend to bog down on the fact that they have minimal effect on those hard core
segments of the population that are most `overrepresented in whatever behavioral aspect
they are trying to change.

The problem, simply stated, is that we are just beginning to learn which behaviors
interact, and how, so as to create that entity we called lifestyle. We know relatively little
about how lifestyles are either transmitted or altered between generations or within
generations, and whether it is possible to alter selectively one aspect of lifestyle, even if
it creates dissonance with other aspects. Frankly, we need such information if we are to
do more than simply nibble around the edges of behavioral modification. Alcohol-
related behavior is far too intimately and intricately tied to other life beliefs and behaviors
to permit us to expect success with simplistic approaches to modifying behavior, espe-
cially as it relates only to the activity of driving.

The foregoing and subsequent comments may sound like a plea for more research,
and on one level they are. But the ultimate goal is to achieve intervention programs that
work. In addition to basic research, we need to try out interventions in such a way that
they can be adequately evaluated to answer the following questions, among others
(Wailer 1980).

o  Does the program alter behavior, morbidity, or mortality overall? Are any other
activities or events going on in the community that may explain any changes
observed? For example, the rise of activities by MADD, SADD, RID, and other
groups concerned with alcohol and highway safety coincided with the end of
the baby boom, and it appears that at least a part of the reduction in alcohol-
related crashes can be attributed to the reduction in young males, rather than


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BACKGROUND PAPERS

to specific anti-alcohol activities. This is not a criticism of the activities per se,
but rather of the method of determining effect.             . .

o Is the programmore or less successful with some segments of the population,
or under some circumstances, than with others?

.  What proportion of the total problem do-those segments account for?

.  What factors seem to explain the population or circumstance differences? Are
the factors intrinsic to the population or &cum- stances itself, to the way the
intervention was carried out, or to both?

o  Can the program be modified in a way more likely to reach the hard to reach,
for example, by addressing more specifically those unique aspects of knowledge,
attitudes, and practices that make them a more difficult target?

a  Given the availability of other nonbehavioral options for injury control, is the
cost-effectiveness of the program sufficient to warrant its continuation, or are
other options preferable?

The methods for answering these questions must be built into the initial design of the
intervention rather than being tacked on as an afterthought. This requires early involve-
ment of someone with skills and knowledge in process and outcome components of
program evaluation. It has been said that knowledge without action is futile; but action
without knowledge is fatal. We need sound use of both.

The third concern is about alcohol-impaired pedestrians, who account for 7 percent
of all alcohol-related highway fatalities (NHTSA 1986) but a substantially higher propor-
tion of those in urban areas. Most attention in the efforts to reduce the alcohol-related
highway tolI has been paid to the impaired driver, as indeed it should. But we must not
overlook the pedestrian. Efforts to educate people about alcohol-related risks should
also mention the risks to this group of road users.

An excellent study by Blomberg et al. (1979) in New Orleans showed that, unfor-
tunately, it is not possible to identify high-risk locations where impaired pedestrians are
more likely to be found. Nonetheless, some efforts aimed at high-risk populations may
be of use, Efforts to provide alcohol in controlled settings on campuses, for example,
may reduce the likelihood that college students will travel as either drivers or pedestrians
after becoming impaired off campus. But apparently no evaluation of such activities has
taken place. Clearly, more needs to be done in both the research and program areas.

Vehicular Issues in the Precrash Phase

There is a tendency to assign ail responsibility for a crash to the driver or the
pedestrian if alcohol is present. But, as Patricia Wailer cogently notes (Haight et al.
1976).

The fact that the human error involved in accidents is frequently related to
information failure (including recognition errors) strongly suggests that the
demands of the driving situation are more than the driver can handle. There
is considerable need to recognize that the human being varies in his perfor-
mance and that on the whole it can be assumed that he probably does about
as well as he can be expected to, given the circumstances. Accident inves-
tigations should be conducted in which the human element is taken as a given
and the vehicle and environment are analyzed to determine the extent to
which they need to be modified so that the human can function satisfactorily.
Thus, simply because a vehicle is performing up to the manufacturer's
standards does not mean that the vehicle performance is satisfactory. Per-
haps the manufacturer's standards need to be modified and the vehicle
performance enhanced. Simply because the roadway signing meets the
criteria set down in a highway design handbook does not mean that the


INJURY CONTROL                                                       183

signing is adequate. The criteria often used call for signs that can be readily
viewed by drivers with 20/30 vision. Furthermore, the standards must be met
only by the signs when they are new. Most highway signs remain iu place for
years, and many legally licensed drivers cannot meet a vision criterion of
20/30. Under such circumstances, when the driver fails to read the sign in
time to make a decision, is it a driver failure? Most humari factors experts
would not agree, yet accident causation studiespersist inperpetuatingthemyth
that dnvers are somehow supposed to be able to compensate under any
conditions for. the shortcomings (legalizedfaikres?) of the vehicles and driving
environment. (p. 48-49)

Ample evidence exists that vehicle design or other characteristics contribute to the
occurrence of highway crashes.

a

Perhaps the most obvious example involves the motorcycle, which combines
special problems with stability and handling, reduced conspicuousness so that   . .
other drivers are less able to avoid it and, once in a crash, reduced survivability
for the occupants. Recent work from California and New York indicates that
special training and licensing requirements for motorcycle drivers are inade-
quate to compensate for these problems (Insurance Institute for Highway
Safety). In 1986, fully 54 percent of motorcycle fatalities had been drinking
(NHTSA 1986), but whether the unique features of the motorcycle exacerbate
the effects of the alcohol impairment is not known. In other words, if a driver
has a crash at a given BAC it is not known to what extent the vehicle handling
characteristics versus the driver's handling capabilities contribute to the crash.

o  One modification of motorcycle design that has aided crash avoidance has been
linking the ignition switch to lights so that motorcycles always operate with their
lights on during the daytime, thus increasing their visibility. The addition of
reflectors to bicycles also improves the nighttime visibility of these vehicles, thus
giving a car driver impaired by alcohol additional time to react.

o Issues of vehicle handling characteristics also are relevant to the crashes of
certain utility vehicles that have. a propensity to roll over in crashes (Reinfurt et
al. 1982). When faced with the rollover data, persons representing the automo-
tive industry on a related lawsuit countered that the overrepresentation of
rollovers did not reflect the vehicle characteristics per se, but rather the sorts
of people who drive these vehicles, for example, the fact that such vehicles are
often driven by the young.' As seen in figure 1, the propensity to rollover is
associated with age. Both the young driver and the "older" driver are at higher
risk of rollover in crashes for two of the three models examined. If the issue were
solely driver characteristics, one would expect to see overrepresentation only
of young drivers, but not of those who have reached the "senile" years of 35 or
  older!

o  But it is also known that the automotive industry- as does any industry- tries
to target its buying audience by selective placement and design of advertise-
ments to highlight vehicle characteristics that are likely to attract certain buyers.
It is unlikely that many 45-year-old business executives drove around during the
1960s and 1970s in VW bugs, or currently use pickup trucks as their transpor-
tation of choice. It is equally unlikely that many 19-year-old laborers ?? college
students are in the market for a Mercedes or Volvo or Lincoln Continental, and
advertisements for these vehicles that appear to be aimed at these audiences
are seldom, if ever, seen.

o  How does all this relate to alcohol? A study from the General Motors research
staff shows a strong correlation between "Youth Sport," "High Sport," "Sixties

1

Comments about the Reinfurt et al. paper by Kent Joscelyn and others during post-presentation question
and answer period at AAAM meeting, 1982.


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BACKGROUND PAPERS

%

40 -

30 -

64 Jeep CJ-5

10 -

+-----I, Ford Bronco

A.. . . . . . . . A  Chev.  Blazer

- All Utility
          Vehicles

.   I      I      I      I            I
   <20     20-24   25-29    30-34             >34

                                 DRIVER AGE

Figure 1. Utility vehicle rollover percentages by driver age for single vehicle
     crashes.

Generation," and "Wild West/Cool Bravado" vehicles and likelihood of involve-
ment or death in an alcohol-related crash, and either negative or no association
for "Sedate, Self-restrained" or "Domestic Economy" vehicles (Angell and Von
Buseck 1985). The authors of this research were not able to divulge which
vehicles lit into such categories. The question, of course, is to what extent do
handling characteristics of the vehicles involved make driving easier, more
difficult, or have no effect for drivers with alcohol in their systems?

o  Issues related to braking provide an additional vehicular example. Recent
improvements of braking systems in more expensive vehicle models through the
use of computers are aimed at a longstanding problem of brakes that lock up
and permit the vehicle to skid. In considering the anticipation or early iden-
tification of a skid situation, Olsen (1978) has noted that suspension systems in
many U.S. vehicles are sufficiently "soft" so the driver may realize he is begin-
ning to skid when there is barely time, or it is already too late, to make an
appropriate response.

o  Given the fact that alcohol alters perception, judgment, and slows response


INJURY CONTROL

185

time, "soft" suspension and standard brake systems can only add to the demands
of the driving task for a person who is already impaired. The recent installation
of elevated rear brake lights is an important improvement to quickly alert drivers
to potential danger and should especially benefit those with modest impairment
by alcohol.

o  Side and rear view vision systems have been faulted in many vehicles, especially
trucks, and in 1972 an estimated 900,000 crashes per year were attributed to
inadequate vision on trucks, with 500,000 of those believed to result from poor
but correctable mirror design (Reiss et al, 1972). Alcohol severely affects vision,
including narrowing of visual fields. Inadequacies of vehicle vision systems,
therefore, are likely to be even more of a problem for the alcohol-impaired
driver than for the average driver.

o  Trucks present their own set of difficulties. In 1986, almost 5,100 medium or
heavy trucks (over 10,000 lbs) were involved in crashes, in which 4,881 persons
died. Only 16 percent of the fatalities were truck occupants (NHTSA 1986).   '
Crash rates for trucks exceed those of other vehicles on all types of roads,
including freeways, and when trucks account for 25 percent of traffic volume on
an expressway system, a 3-percent increase in truck traftic produces a 23-per-
cent increase in crash frequency per mile (U.S. Bureau of Public Roads 1963).
Overwhelmingly, such crashes are more serious because the energy loadings are
  greater.

o  Other drivers find it particularly difficult to maneuver in the presence of large
trucks, not only because they are behemoths, but because they often are
traveling faster or slower than the traffic flow, may be poorly visible at night,
create aerodynamic turbulence and, in bad weather, may obscure the vision of
other drivers by splashing their windshields. Each of these characteristics adds
to the alcohol impairments of the driver. Therefore, the very presence of more
trucks on the roads quite likely exacerbates the problem of alcohol-related
crashes. Add to this the safety effects of deregulation and of increases in truck
size and double trailers that have been approved at the Federal level and it is
clear why we have a serious problem.

Roadway Issues in the Preinjury Phase

The earlier quote by Patricia Waller is relevant to issues of highway design and
construction as well as to vehicles. It is not enough to know that individuals crashed
because they were impaired by alcohol, The question also is, if they were so impaired,
why did they crash where they did and not at an earlier location along their path? The
answer often is that only at this location did the driving task become too demanding.

Much is already known about the types of roadway characteristics that increase
demands on the driver and are associated with more crashes. In addition, some recent
work has pinpointed the interreration between some of these factors and alcohol
impairment. Here are a few examples.

0  Several studies done for the Insurance Institute for Highway Safety pinpointed
roadway characteristics that are overrepresented in single vehicle crashes. One
study in Georgia showed that such crashes are most likely to occur at or near
curves of greater than 6 degrees, especially if associated with grades of 2 percent
or more (Wright and Robertson 1976). These data, however, are not specific to
drivers using alcohol, and it is reasonable to assume - but currently not known
- that a person with a BAC of 0.10 gm/dl might be at greater risk at somewhat
less demanding locations, e.g., curves of 4 degrees or greater with or without an
associated grade.

o  Presumably, the higher the BAC the less demanding the roadway that will prove


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BACKGROUND PAPERS

excessive. However, since the Georgia study examined single vehicle crashes,
which commonly involve alcohol, it may also be that unimpaired individuals tend
not to crash until the road is much more demanding and, in fact, the combination
of a 6-degree curve and 2-percent grade is a good measure of the point at which
the demand becomes too great for the typical driver impaired by alcohol. This
can only be determined, however, by a BAC-specific analysis of crash
environment.

o  Increasing the speed with which a traffic light changes from green to red is
associated with an increase in intersection crashes, whereas slowing the change
cycle reduces the crash rate (Zador et al. 1985). A change of 20 percent, from
lo-percent slower than that recommended in traffic management manuals to
lo-percent faster, is associated with a fourfold difference in crash rate. Again,
impaired drivers are uniquely likely to be affected by such changes because they
have slower reaction times, especially for situations that involve making choices.

a  A report from the National Transportation Safety Board (1980) identified the
State of Utah as having two to three times as many crashes per day of wet
weather as do the surrounding States. It does not seem reasonable to assume
that Utah has more careless or alcohol-impaired drivers than these other States.
In fact, given its large Mormon population, one would anticipate less alcohol
use. The difference appears to be attributable to the Utah roads, which are built
with a dense aggregate so that water doesn't drain off readily and vehicles can
hydroplane easily.

While this situation has been documented for Utah, it is not known how often
such differences in roadway construction contribute in extremely subtle ways to
the occurrence of crashes, or to those involving alcohol. Police investigations
simply take the roadway construction as an immutable fact and, if drivers skid,
they assume it must have been something they did wrong, rather than consider-
ing the possibility that something may also have been wrong with the way the
road was built.

o  Two cases provide information about the effect of roadway characteristics on
drivers at different BACs. One study indicated that drivers at BACs of 0.05
gm/dl, and, to a lesser extent at 0.10 gm/dl, are less likely to wander off the sides
of roads or across the center line if the painted stripes are 6 or 8 inches wide
instead of the usual four inches (Nedas et al. 1982). Test areas of roadway with
wider side and center stripes had significantly fewer crashes than did standard
  roads.

o  Other work shows that putting reflectors on signs or on pedestrians permits
drivers with moderate BACs to recognize these features from a further distance
(Hazlett and Allen 1969). Since the inadequacies of road sign placement, size,
readability, and information presented have been well documented, such
greater visibility and consequently longer time for the impaired driver to react
can only be helpful (Tamburri 1969). Studies of wrong-way driving by alcohol-
impaired drivers about 20 years ago identified problems of poor signage and
inadequate separation of some on- and off-ramps on freeways and resulted in
important and successful corrective actions (Alcohol and Highway Safety 1968).

The Missing Link in Alcohol-Related
Crash Avoidance Research

Excellent information has existed for at least the past two decades about the relative
risk of crashing that a driver faces at given BACs (Jones and Joscelyn 1978; Haight et al.
1976). Information is also available about the crash contribution, and sometimes even
the relative crash risk, of certain vehicular or roadway characteristics. What is not known
is how the three sets of data interact. To date, no study has specifically examined the


INJURY CONTROL                                                       187

interaction of alcohol, roadway, and vehicular characteristics in crashes without making
the methodologic error of assuming that the roadway and vehicular aspects were
functioning optimally if they were working as designed and constructed. The fact that
they may have been designed or constructed so as to increase crash risk has been
considered irrelevant by prior researchers.

Again quoting Patricia Wailer on this issue (Haight et al. 1976),

It is a serious error to consider the vehicle and environment as noncon-
tributory simply because they meet the currently established standards. Most
drivers also meet the currently established standards. After all, driver licens-
ing programs exist precisely to see that this is the case. Critics may quickly
point out that our licensing standards are not adequate, but cannot the same
criticism be made with equal validity of the standards concerning vehicles
and roadways? Why are these standards somehow sacrosanct while the
standards used to license drivers are so readily the object of criticism? If the
driver in a crash holds a valid license, then the argument can be made that
he, too, has met existing standards and can be held no more culpable than
the inadequate signing that is nonetheless legal. (p. 31)

Such unnecessary additions to the demands on the driver or the pedestrian, of course,
create a problem not only for the person impaired by alcohol, but also for the elderly,
those just learning to drive, persons unfamiliar with the specific road, and all the rest of
us at times when traffic is particularly heavy, weather is bad, or when, for whatever
reason, we happen to be functioning at less than our personal optimum capacity. If the
goal is truly the prevention of crashes, rather than simply the excoriation of those who
consume alcohol, we will look to all possible options in crash prevention, especially if
they have the wider benefits described above.

Human Issues During the Crash Phase

A common axiom says, "Drunks don't get hurt when they fall because they are so
relaxed." Unfortunately, this assumption not only is inaccurate; it is the exact opposite
of what occurs. Both laboratory and epidemiologic evidence has been growing rapidly
documenting that, especially at lower levels of kinetic impact, persons who have con-
sumed alcohol are more likely to be injured, to have severe injury, to die, and to die
before definitive treatment can be brought to bear (Waller 1985). The reason is that
alcohol adversely affects both the internal function of individual cells and the functioning
of organ systems to make it easier for them to become injured and more difficult for them
to respond properly to injuries that do occur. Clearly, this myth of invulnerability for
alcohol-impaired persons needs to be dispelled.

Vehicular Issues During the Crash Phase

The past two decades have seen considerable attention to, and correction of, vehicular
components that increase crash severity. Examples include laws requiring seatbelt use
and the move toward wider availability of airbags, collapsible steering columns designed
to absorb damaging kinetic energy before it reaches the driver's chest, development of
high-penetration windshields, dashboard construction that is less hazardous on impact,
removal of pedestrian-spearing hood ornaments and tail tins, and attempts to alter the
front design of vehicles to reduce pedestrian damage on impact.

Some major hiatuses still exist, however. Attempts to reduce the effects of side
impacts on vehicle occupants are as yet unsuccessful. Most States have not reinstated
laws requiring use of helmets by motorcyclists, despite the documented savings of life,
limb, and money that accompanied initial passage of such laws and the loss of such
savings where these laws were repealed.


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BACKGROUND PAPERS

Unfortunately, with both helmet and seatbelt laws, among those least likely to obey
the law are persons under the influence of alcohol (e.g., Jessor 1987; Maron et al. 1986).
Research has shown that excessive nonuse of seatbelts is to be found as often among
persons entering bars as among those leaving and, therefore, greater nonuse is not an
acute effect of the alcohol per se but rather appears to reflect underlying lifestyle issues
(Preusser et al. 1986). Despite this relatively greater tendency toward nonuse, however,
persons using alcohol more often wear helmets and seatbelts where the law rquires them
than where use is voluntary, indicating that this high-risk group may be harder to reach,
but not impossible to reach.

Another major hiatus is the faihue to improve truck de&n or construction to reduce
crash severity. It has been known for years, for example, that sides and rear ends of trucks
can be constructed to prevent underride by automobiles during crashes and, conse-
quently, to avoid decapitation of automobile occupants. But the trucking industry, to
date, has successfully avoided regulations that would require this small addition to truck
weight (Minahan and O'Day 1977). The industry may have gained, but public safety has
lost. In similar fashion, energy-absorbing features universally found in automobiles are
often not required by NHTSA in pickup trucks or various recreational vehicles, which
are probably the vehicles preferred by high-risk young, heavy-drinking males.

Roadway Issues During the Crash Phase

The past two decades have seen both substantial progress and continuing problems
in roadway safety. Energy-absorbing construction of guardrails, bridges, and under-
passes, and of light- and sign-posts has become far more common, especially on primary
roads built for higher speeds. These changes reflect the decades-old data indicating that
such design and construction reduce crash severity. Little of this, however, has been
applied to secondary roads, and in many places trees, rock outcroppings, and telephone
poles remain - or in some cases continue to be planted or placed- dangerously close to
the roadway, even for roads that have posted speed limits of 50 mph or higher.

One continuing problem is that even the best energy-absorbing devices that were
designed for one generation of vehicles may be inappropriate for subsequent generations
of vehicles that might follow during the expected lifetime of these devices. For example,
devices built to deal effectively with crashes of the large and mid-size cars that preceded
the 1973 oil embargo are no longer adequate for the large population of compact and
subcompact automobiles, especially as these share the roadways with more and larger
trucks.

Again, the Missing Link

Alcohol increases injury severity, especially at lower rates of energy exchange. AU the
vehicular and roadway research and designs for alteration of energy transfer to date have
been based on a presumption of normal tissue response. It is not known to what extent,
if at all, assumptions need to be altered in considering the reduction of injury for
alcohol-impaired persons or, as well, for the elderly, rather than just for unimpaired
young individuals.

Issues During the Postcrash Phase

Only hvo issues during the postcrash phase are considered, namely, the acute manage-
ment of injured persons who have consumed alcohol, and the application of rehabilita-
tion concepts. Treatment of underlying alcoholism postinjury is also an extremely
important issue, but it is being considered by another panel.

Before turning to alcohol-specific issues of acute management, a brief comment
should be made about the general status of trauma care systems in the United States.


INJURY CONTROL

189

Over the past two and a half decades, substantial improvements have occurred in the
trauma care system. Modified hearses and police cars to transport the injured have been
replaced by modular, well-equipped ambulances. The SO-hour or beyond emergency
medical technician (EMT) training has replaced the &hour standard Red Cross course.
Ambulance-to-hospital radio communication has become commonplace. Emergency
department nurses and many physicians are being trained in advanced life support, and
the whole specialty of emergency medicine has developed.

What is still missing is the widespread regionalization of such improvements, espe-
cially as they involve cooperation between ambulance services, between ambulances and
hospitals and, most assuredly, between hospitals themselves. A tremendous economic
power struggle is taking place in many States concerned with designating specific
hospitals as trauma centers because they are better equipped and better staffed, while
neighboring hospitals perceive them as likely to "steal" lucrative cases. Until we see a
system of regionalization of trauma care in every State of the Nation, instead of the
current spotty distribution of such systems, we will not be able to say that this Nation's
acute care system is beginning to be adequate.

We turn now to alcohol-specific issues in acute care. As long ago as 1928, Bogen
documented the need to determine whether a person had consumed alcohol in order to
provide effective emergency care. It is becoming increasingly apparent that the com-
petent physician must determine if the individual is likely, not only to be acutely under
the influence of alcohol, but also to be an alcoholic.

Acutely alcohol-impaired patients are more likely to have cardiac arrhythmia that
may be lie-threatening either at the crash site or shortly after arrival in the emergency
department. They may have greater respiratory distress both because of the acute effects
of alcohol and because they are likely to be smokers. Alcohol may cause severe hypoten-
sion. The presence of alcohol may, on the one hand, cause serious masking of symptoms
of intra-abdominal injuries because of clouded sensorium and, on the other hand, result
in overdiagnosis of the severity of head injury because alcohol-related altered conscious-
ness is confused with trauma-related effects.

If patients are alcoholics, their wounds are more likely to become infected, because
alcohol depresses immune response. But, at the same time, sudden fever may not be a
sign of infection, but rather of impending delirium tremens, which carries a 25-percent
mortality rate.

Many physicians have been concerned about their legal liability if they do a blood
alcohol determination without specific patient approval. It is becoming increasingly
obvious, however, for all of the above reasons, that the physician who does not obtain a
BAC for clinical management is courting a suit for malpractice if problems occur that
might have been foreseeable had the BAC been known.

Lastly, attention must be turned to the subject of rehabilitation. The whole field of
rehabilitation medicine developed as a result of the progressively higher survival rates
of severely injured soldiers that was achieved during World War II and the Korean
Conflict. The years since have seen tremendous advances in basic research in this field
as well as in the design and development of new techniques, skills, equipment, and
prostheses and the formation of rehabilitation teams.

Unfortunately, as was pointed out in the National Research Council (1985) report,
Zujury in America, much of what is known is not being applied. Patients may not be
referred to a physiatrist, or the referral may be sufficiently delayed so that disability is
unnecessarily prolonged or may even have become permanent. Complete rehabilitation
centers are few and far between, and many physicians do not know how to access them.
This is especially true for the services needed for severe head injury, which is a more
common outcome in the presence of alcohol. The plea of this chapter, therefore, is not
so much for new research, but rather for the wider application of what is already ~IIOWLL


190

BACKGROUND PAPERS

Summary

Alcohol contributes not only to the occurrence of crashes but also to the initial severity
of injuries, problems in treatment, and ultimate outcome. The exact relationship of
alcohol use and abuse and other lifestyle issues is just beginning to be examined, and the
dearth of knowledge remains an important obstacle to achieving behavioral change for
drivers and pedestrians who drink.

Characteristics of the vehicle'and the road environment also contribute to crash
occurrence and crash severity. Because littIe research, either qualitative or quantitative,
has examined the interaction of vehicular and road environment characteristics in
crashes at various blood alcohol concentrations, the exact relationship remains conjec-
ture, and potential improvements in injury and disability prevention may be missed.
Specifically, the following are recommended:

.  Research needs to be carried out and the results used to intervene in the
interaction between alcohol use practices and other aspects of lifestyle.

o Persons knowledgable in evaluation concepts and methods must be utilized
early in the design of intervention programs, and evaluation should be an
integral part of all such programs.

0  Research should be undertaken into the interaction between different BACs,
vehicle handling characteristics, and aspects of road design, construction, and
maintenance to determine which vehicular and roadway aspects exacerbate the
effects of impairment caused by BACs below 0.10 gm/dl, and to set vehicle and
road standards that will take this knowledge into consideration. Similar re-
search is needed to determine quantitatively the relation between BAC and
vehicle and roadway features relevant to injury severity, and to apply such
knowledge for injury reduction standards.

0 Motorcycle helmet laws need to be reinstated in those States where they were
  rescinded..

0  Federal crash and injury prevention standards currently applicable to
automobiles should be extended to pickup trucks and recreational xhicles.
Rear and side guards on trucks should be mandated to prevent other vehicles
from underriding medium and large trucks in two-vehicle crashes.

0 All necessary steps must be undertaken, including legislation if nxzary, to
ensure that regionalization of adequate trauma systems is achiexd throughout
  the Nation.

o Physicians must be educated through hospital quality assurance m and
other means about the need to determine BAC and to screen for &&ism as
part of the proper management of the trauma patient. Sii -onal
methods should be used to get physicians to seek prompt and Lzpriate
assistance for the rehabilitative aspects of trauma care.

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