Chapter

9

Traffic safety andmedicine
Kazuhiko Kibayashi
Professor, Department of Legal Medicine, School of Medicine, Tokyo Women’s Medical University

Takashi Moriya
Professor, Emergency Department, Saitama Medical Center, Jichi Medical University

Masaya Takahashi
Senior Researcher, National Institute of Occupational Safety and Health, Japan

9.1

Traffic accident casualty statistics

Traffic accident casualty statistics issued by the Japanese National Police Agency (NPA) are for on-road
accidents as defined by the Road Traffic Act that resulted in fatality within 24 h of the accident. This statistic is the conventional reference when discussing traffic accident fatalities. Beginning in 1993, to better grasp the number of deaths occurring after that 24-h window and to allow for easier international
comparisons, separate statistics that additionally include deaths occurring between 24 h and 30 days following an accident have also been calculated. NPA statistics for injury from traffic accidents classify
injuries requiring treatment for less than 30 days as minor injuries, and those requiring 30 days or moreof treatment as serious injuries. General injury statistics report a combination of both minor and serious
injuries. In contrast, demographic statistics tally all persons dying within 1 year of a traffic accident,
regardless of the site of the accident. Note that regardless of the period following the accident, medicallyspeaking, all deaths due to involvement in modes of transportation are considered traffic accident
deaths.
Nationwide statistics for 24-h traffic fatalities since 1989 peaked at 11,452 in 1992, and then fell for
13 consecutive years to 9,943 fatalities in 1996, 7,768 in 2003, 4,968 in 2009, and 4,373 in 2013. Fatalities
between 24 h and 30 days folPersons
lowing a traffic accident were
1,176 in 2003, 863 in 2009, and
779 in 2013, this being a similar
reduction to the 24-h traffic
fatalities, being equal to 10–20%
the number of fatalities within
24 h of accidents for that same
year (Fig. 1). The number of traffic accident-related injuries also
fell over 9 consecutive years to

9,000
8,000
7,000
6,000
5,000

Death within 30 days

4,000

Death within 24 h

3,000
2,000
1,000
0

2004

2005

2006

2007

2008

2009

2010

2011

2012

Figure 1. Traffic fatalities

2013

Year

90｜Theory

781,494 in 2013, withapproximately 6% of
injuries being serious
injuries and requiring over 30 days oftreatment (Fig. 2).
This reduction
in casualties is theresult of severale f for t s , i n clu d i ng
legal efforts such as
strengthening laws
against drunk driv-

Persons
1,200,000
1,000,000
800,000
600,000

Injured

400,000

Seriously injured

200,000
0

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Year

Figure 2. Injuries due to traffic accidents
Persons
3,500

ing and making seat3,000
belt usage manda2,500
tory, the development
15 or less2,000
of accident-resistant
16–29
road environments,
30–49
1,500
50–64
automobile struc1,000
65 and abovetural developments,
500
improvements in0public transportation
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Year
Figure 3. Traffic fatalities by age (death within 24 h)facilities and medical
rescue systems, andcomprehensive accident prevention measures such as traffic safety education. Viewing casualty statistics
by age, the ratio of fatalities and injuries among the elderly is relatively high, and the amount of reduction experienced among all age groups was smallest among the elderly; the rate of elderly fatalities isapproximately 6.6 times that of other age groups, and the rate of serious injury is approximately 3 times
as high (Fig. 3).1)
While the number of traffic accident-related fatalities has reduced for all age groups, the ratio ofelderly fatalities overall is increasing since the reduction rate for elderly fatalities is small. To address thisissue, since June 2009 persons aged 75 years or older wishing to renew their driver’s license must
undergo a cognitive function test, and must furthermore undergo a driving course designed for theelderly. Other traffic accident-prevention measures targeting elderly pedestrians will likely be particularly needed.2)

Chapter 9: Traffic safety and medicine｜91

9.2

Damage due to traffic accidents

One feature of personal injury due toautomobiles is that even when injury
externally seems to be minor, internal
damage can be quite severe. Automobile
accident-related fatalities are categorized
into deaths of pedestrians, drivers, andpassengers, and other possible categorizations are for fatalities by motorcyclists
and bicyclists. Each group has characteristic injuries (Table 1).
Injuries to pedestrians are categorized as those occurring due to the initial

Table 1. Traffic accident damage by riding position in terms of
mechanism of injury
1. Pedestrians
Injury due to bumper, hood, windshield
Injury due to being run over (tire marks, abrasion) or dragged
Primary injuries: Injury due to initial impact
Secondary injuries: Injury due to being flung up and colliding
with the vehicle
Tertiary injuries: Injury due to impact with the ground
2. Drivers
Injury due to steering wheels, seatbelts, and air bags
Injury due to dashboards, windshields
Cervical spine injury (whiplash)Lower extremity injury or pelvic fracture due to legs being
extended to depress brake at impact
Injury due to being ejected from vehicle

impact (primary injuries), those due tobeing flung up and subsequently colliding
3. Passengers
Injury due to steering wheels, seatbelts, and air bagswith the vehicle (secondary injuries), andInjury due to dashboards, windshields
those due to impact with the ground (terCervical spine injury (whiplash)
Injury due to being ejected from vehicle
tiary injuries). Pedestrian injuries arehighly dependent on the automobile’s
form and its speed at the time of impact.
For standard passenger vehicles, pedestrian impact with the front bumper will result in lower extremity
injuries at approximately bumper height, but in the case of hoodless cab-type vehicles, primary injuries
will occur in the chest and lumbar regions. Such correspondence between primary injury locations andvehicle collision sites are vital to vehicle identification in hit-and-run accidents. In the case of low-speed(around 20 km/h) accidents, pedestrians are thrown in front of or to the side of vehicles. In the case of
mid-speed (20–60 km/h) accidents, pedestrians tend to be flung up onto the hood or windshield. In
high-speed (60–100 km/h) accidents, pedestrians are flung over the vehicle, and subsequently impact
with the ground. In low-speed accidents where pedestrians are thrown in front of the vehicle, in somecases the pedestrian will be run over by the same vehicle, and when hit by cars at high speed, pedestrians will often sustain severe head injuries due to the subsequent impact with the ground.3) Brain damage
is a very severe injury frequently seen in traffic accidents, and diagnosis and pathology of brain damage
are important issues related to saving the lives of accident victims (Fig. 4).4)
Damage to drivers and passengers occurs when the vehicle collides with other vehicles or roadsidestructures, and resulting in contusions from being hit by objects from within the vehicle. The same canoccur when vehicles roll over or when passengers are ejected from the vehicle. When the steering wheel
impacts the driver’s chest or abdomen, cardiac rupture and other serious injuries can occur. Seatbelts
prevent the head and chest from impacting the windshield and steering wheel, and furthermore prevent
ejection from the vehicle, which can result in serious injury. The usage or non-usage of seatbelts is an

92｜Theory

Extremities Other
2% 1%
Lumbar6%
Abdomen
7%
Chest
22%

Whole
body
6%

important predictor of injury severity. Seatbelt usage isrequired even when airbags are present; rapidly inflating airbags can cause serious contusions to the chest and abdomen if
seatbelts are not worn.
Extent of damage is quantified to objectively study traffic accident damage. In 1971 the U.S. Association for the

Head or face
51%

Advancement of Automotive Medicine created the Abbreviated Injury Scale (AIS) and performed research such as comparisons of treatment prognosis between multiple facilities,
the relationship between collision speed and damage, and dif-Neck
5%
Figure 4. Fatalities by injury site
(2013; death within 30 days; 5,152 persons)

ferences in damage when seatbelts were or were not worn. The
AIS divides the body into seven areas (body surface, head,neck, chest, abdomen and pelvic organs, spine, and extremi-ties), and assigns scores to each area based on damage according to 6 severity levels (1: minor; 2: moderate; 3: serious; 4:
severe; 5: critical; 6: fatal). The largest score is also called maximum AIS. There is also the injury severity
score (ISS), a severity evaluation method for multiple trauma that is calculated based on the AIS. In theISS, the body is divided into six areas (head and neck, face, chest, abdomen, extremities and pelvic
organs, and body surface), and assigns an AIS score of 1–5 to each injury. The ISS score is calculated bytaking the maximal score from each area, and summing the squares of the top three AIS scores. Accordingly, the maximum value is 75. Alternatively, if any single location has an AIS score of 6, the ISS score is
automatically calculated as 75. The ISS score represents severity well and is correlated with death rates,
particularly in the case of multiple trauma patients. Analysis of mechanism of injury through analysis ofthree factors in traffic accidents—personal injury, accident vehicle, and scene of the accident—provides
fundamental data for ensuring the safety of persons, vehicles, and road environments to prevent theoccurrence of accidents (active safety) and reduces damage to passengers and pedestrians following
accidents (passive safety).

9.3

Emergency medical care

9.3.1 Regional characteristics and the importance of immediacy in emergency medicine
Emergency medical care is the keystone of medicine, and is considered by all citizens to be the last bastion in the medicine for care of unexpected acute pathology.
Acute pathology is characterized by progress, regardless of differences in the degree of onset. A
sudden headache may indicate subarachnoid hemorrhage. Chest pain may indicate acute myocardial
infarction. A fall from a high location will likely lead to severe injuries caused by high-energy trauma.
All of these cases require rapid transport to a hospital. Brain aneurysm rupture, which is known to be acause of subarachnoid hemorrhage, has a high probability of fatality due to a second rupture on theChapter 9: Traffic safety and medicine｜93

same day of onset. Acute myocardial infarction can easily lead to a form of arrhythmia called ventricularfibrillation within 4 h of onset. High-energy trauma is highly likely to result in severe injury, and failure
to determine a course of treatment by performing a diagnosis of the injury within 1 h of occurrence has
a statistically significant increase in likelihood of death.5)
Maintaining an emergency care supply system that provides an “anytime, anywhere, anyone” levelof care for such acute pathology is extremely important but at the same time very difficult. In Japan, differences in treatment outcomes for severe trauma have been reported by region and facility. To address
this, Japan Trauma Care and Research developed a course called Japan Advanced Trauma Evaluation
and Care (JATECTM) to demonstrate a protocol for trauma care, and is working toward its implementation through off-the-job participation throughout the country. The JATEC course was originally centered on doctors, but given the importance of team medical care, it was later extended to include nurses.
Year after year, the course has been confirmed to contribute to substantial improvement of death rates
due to trauma.6)
The status of emergency medical care takes on a different meaning between large and small cities.
In many hospitals in large cities there are many specialists capable of providing leading-edge treatment,
but for example in Tokyo, there have been unfortunate incidents of death believed to have been due torefusal of hospitals to admit patients or delays in transporting patients between hospitals. In contrast,
hospitals in smaller cities often concentrate the role of emergency care for an entire region in one location, requiring them to admit patients with both minor and severe injuries, which presents the danger oflosing the ability to function as a hospital. Setting aside the issue of which problem is easier to solve,
given this situation it is necessary to consider the significance of the existence of emergency care within
the framework of the community. Such problems must thus be solved through the combined efforts of
the local hospitals, emergency services, fire brigades, police departments, and governments of each individual region.7)
9.3.2 Current status and problems related to time for emergency medical careTime is of the essence for reducing death and sequela in emergency care, so it is necessary that ambulances reach emergency patients as quickly as possible, that hospital selection is rapidly performed, andthat the time to arrival at the hospital is as short as possible. Nationwide data, however, indicates that thetime to reach patients and the time required for hospital admittance continue to lengthen (Fig. 5). Multiple factors related to these increased delays have been identified at ambulance dispatch points, scenesof injury, and at hospitals, and measures have been taken to address each, but currently, effective solutions have not yet been found.
The Tokyo Fire Department has experienced an increase in the number of ambulance dispatch
incidents, and so has increased its number of emergency crews to meet with increased regional populations and demands for appropriate emergency care (Fig. 6). Nonetheless, the number of dispatches per
ambulance crew has not decreased; indeed, the number has increased from 1,488 in 1963 to 3,183 in
2013. There are a number of factors behind this increase, including increased reliance on ambulances for
relatively minor situations, increased emergency service requests from the elderly, changes in disease94｜Theory

trends, increased elderly
population, and physiological characteristics ofthe elderly. These trends
are similar across Japan,
and due to the increased
elderly population, about
40% of emergency patient transport is now forpatients aged 70 years orolder.
Changes in bloodpressure or state of con-

Minutes
45
40
35
30
25

Time from alert
to arrival on site

20

Time from alert
to hospital admission

15
10
5
0

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Year

Figure 5. Trends in arrival time and time to hospital admission
1000s of requests
800

sciousness in the elderly, 700
which can rapidly wors- 600
en due to the effects of 500
medication or difficulty 400
Emergency carerequests
in maintaining homeo- 300
stasis, can in many cases 200
b e a l l e v i at e d s i mp l y 100
0through body position
1963 1968 1973 1978 1983 1988 1993 1998 2003 2008 2013 Yearadjustments or observaFigure 6. Trends in number of emergency care requests in Tokyo
tion over time. In manycases, the situation improves during the wait for an ambulance to arrive, but the ambulance will often be used for transport toa hospital for examination, just in case. Unlike exogenous disease, inferring the prognostics of endogenous disease is considered difficult,3) and this difference is even more pronounced in the elderly. With
the goal of better optimizing ambulance usage, in 2007 the Tokyo Fire Department became the first inJapan to offer a telephone-based triage service for the general public, aiding in the determination ofwhether pathologies are sufficiently acute to warrant requesting emergency services. This service, called“#7119,”8) helped to lower the number of emergency requests in 2008, but by 2013, numbers were again
increasing. This illustrates the difficulty of restraining the number of incidents, given that emergency
medical care is viewed as an administrative service.

9.4

Driving and healthOperating an automobile requires skillful judgment and operation on the part of drivers. It is thus inappropriate to drive while impaired due to the influence of fatigue, illness, alcohol, or drugs.

Chapter 9: Traffic safety and medicine｜95

Illnesses that can affect automobile operation can be broadly classified into two types: chronic illness that is likely to hinder vehicle operation, and acute illness that can cause sudden death of the driver.
The Japanese Road Traffic Act and other enforcement orders classify illnesses that can hinder vehicle
operation as follows: 1) Schizophrenia with symptoms of hallucinations (excluding individuals that do
not exhibit symptoms that prevent any one of the abilities required for safe vehicle operation, such as
perception, prediction, decision-making, and operational control); 2) Epilepsy (excluding individuals inwhom there is no risk of seizure recurrence, those in whom seizure recurrence does not result in movement disorders or impaired consciousness, and those in whom seizure recurrence occurs only during
sleep); 3) Recurrent syncope (defined as disease that results in disturbance of consciousness due to transient ischemia of the whole brain, for which there is a possibility that episodes may recur); 4) Hypoglycemia unawareness (excluding individuals who are able to artificially modulate blood sugar); 5) Manic
depression (including mania and depression, but excluding individuals that do not exhibit symptoms
that prevent any one of the abilities required for safe vehicle operation, such as perception, prediction,
decision-making, and operational control); 6) Sleep disorders with symptoms of severe drowsiness; 7)
Other illnesses that involve symptoms that prevent any one of the abilities required for safe vehicle operation, such as perception, prediction, decision-making, and operational control; and 8) Dementia.
These illnesses can hinder vehicle operation present a risk of injury to others, and thus acquisition
and renewal of driver’s licenses is restricted for affected persons. Operation of automobiles by persons
with chronic disease that causes episodes of impaired consciousness can result in the occurrence of serious accidents. Therefore, the Road Traffic Law establishes that 1) persons acquiring or renewing driver’s
licenses are required to respond to a questionnaire related to symptoms of certain diseases, 2) physicians
who have diagnosed persons as having certain diseases that they feel may increase their chances of being
involved in a serious accident may elect to submit forms stating such, and 3) persons suspected of having certain diseases can immediately have their driver’s license provisionally revoked.9)
Sudden death is defined as the unexpected death of an otherwise healthy individual within 24 h ofonset of an endogenous disease, and is most commonly due to cardiovascular disease such as myocardial infarction, cardiomyopathy, aortic aneurysm rupture, aortic dissection, cerebral aneurysm rupture,and hypertensive cerebral hemorrhage. Such disease can sometimes occur suddenly while driving, butwhile they can result in death of the driver, in most cases the driver is able to retain sufficient functioning to stop the car by the side of the road after onset, and thus they rarely result in the death of passengers or pedestrians. There are, however, cases in which sudden onset results in driver incapacitation,
thus leading to a fatal traffic accident. Early diagnosis of underlying disease during standard healthexaminations and rapid treatment are therefore important for preventing sudden death while driving,which is classified as death by disease instead of by traffic accident. In cases where sudden death whiledriving is suspected, the cause of death is investigated, because distinguishing between such causes andlack of attention is important for elucidation of the cause of the accident and the dignity of the deceased.
Because alcohol impairs judgment and hinders vehicle operation, and can thus lead to traffic accidents, driving under the influence of alcohol is prohibited. In Japan, drunk driving is defined as operating an automobile with a blood alcohol concentration of 0.3 mg/mL or more, or with a breath alcohol

96｜Theory

Table 2. Relation between blood/breath alcohol concentration and drunkenness
Blood
Blood
BreathDrunkenness
concentration concentration concentration(mg/mL)(%)(mg/L)
Stage 0:
0.1–0.5
0.01–0.05
0.05–0.25 Euphoria: Feeling slightly intoxicatedStage 1:
0.5–1.0
0.05–0.1
0.25–0.5 Mild drunkenness: Mild cognitive disturbanceStage 2:
1.0–1.5
0.1–0.15
0.5–0.75 Light drunkenness: Cheerfulness, talkativeness, excitement
Moderate drunkenness: Lowered decision-making, lowered ability
Stage 3:
1.5–2.5
0.15–0.25
0.75–1.25
to walk
Stage 4:
2.5–3.5
0.25–0.35
1.25–1.75 Strong drunkenness: Slurred speech, clouded consciousness
Stage 5:
3.5–4.5
0.35–0.45
1.75–2.25 Stupor: Loss of consciousness, hypothermia
Stage 6:
4.5–
0.45–
2.25–
Coma: Cardiac dysfunction, respiratory paralysis, death

concentration of 0.15 mg/L or more (breath alcohol concentration is taken as approximately 1/2000 thatof blood alcohol concentration). In contrast, driving under the influence of alcohol is defined as driving
in a situation where alcohol consumption may prevent normal automobile operation, regardless of bloodor breath alcohol concentration. The relation between drunkenness and the degree of blood or breath
alcohol concentration is important for determination of driving ability at the time of an accident (Table2). Blood alcohol levels peak 1–2 h following consumption, then exhibit a gradual, linear decline as alcohol is metabolized. Maximum blood concentration increases with the amount of alcohol consumption,
but the rate at which alcohol can be metabolized is fixed (a decrease of 0.16 mg/mL per hour), so large
amounts of alcohol consumption will result in residual blood alcohol persisting over an extended time.
It is therefore sometimes the case that one believes oneself sober the morning after heavy drinking, but
in fact residual blood alcohol results in driving under the influence of alcohol. Note that in cases of hitand-run accidents where alcohol concentrations could not be measured at the time of the accident, concentrations can be still estimated according to a mathematical equation, based on the amount of alcohol
consumed or alcohol concentrations at a later time.10)
Other substances frequently abused in Japan, such as solvents, stimulants, and narcotics, can also
act on the brain to lower decision-making abilities and prevent normal driving, and there have been
accidents where solvents and stimulants have led to traffic accidents. There has been an increase in theabuse of dangerous drugs, and in the future it will likely be necessary to develop tests to screen for theuse of illegal drugs, such as stimulants and dangerous drugs, by drivers involved in traffic accidents.
Thorough implementation of such screenings would likely have a deterrent effect on driving while under
the influence of illegal drugs, which can result in fatal traffic accidents.

9.5

Traffic safety and sleep

9.5.1 Two major factors pertaining to sleep and safe driving
Safe driving requires appropriate perception, decision-making, and control, three operational abilities

Chapter 9: Traffic safety and medicine｜97that are disturbed by drowsiness. Good sleep is essential to preventing drowsiness.11), 12), 13)
A good understanding of accidents due to drowsiness calls for some fundamental backgroundknowledge. Among other things, there are two major sleep-related factors that have an effect. One is thehuman body’s circadian (internal) clock.14) The circadian clock functions to regulate daily rhythms
through various bodily functions such as temperature and hormone control, and its effects on operational ability increase from morning until night. The effects then decrease to a minimum in the earlymorning, after which they begin to rise again (Fig. 7A).
The other factor is the duration of time spent awake.15), 16) Operational ability worsens as the time ofcontinual wakefulness increases (Fig. 7B). Shortening the period of continual wakefulness by sleeping or
napping can thus inhibit worsening of operational ability.
Interaction occurs between the effects of the circadian clock and time spent awake, which determines the actual level of operational ability. As an example, Fig. 7C shows the results of an experimentin which response time was measured after 36 h of being continually awake (participants were asked topress a button as quickly as possible after viewing a light, or other visual stimulation).17) Pressing a button in response to visual stimuli corresponds well to extremely fundamental driving skills, such as braking when seeing a red signal or using the steering wheel to avoid a stopped car. This data makes it easy
to see that driving from late night to early morning or for long periods of time makes accidents more
likely.
Change due to circadian rhythmWorse

10 16 22→4

10 16 22

Change due to time awake

10 16 22

10 16 22

10 16 22B

4

10 16 22 (time of day)
20

C

＋

15

＝

10
5

←

Better0

6 12 18 24 30 36

0

6 12 18

24 30 360

6 12 18

Response errors (times)

Operational ability

A

4

Change due to combination of A and B

0
24 30 36 (Time awake [h])Figure 7. Effects of circadian rhythmicity and time awake on operational ability
The vertical axis represents the number of errors (lapses) in a reaction time test; C: Dots and black lines show measured values, gray lines are fitted according to A
and B

In addition to the circadian clock and time spent awake, the amount and quality of sleep before
driving are also closely related to safety. Not only sleep deprivation before automobile operation, butalso chronically short sleep, increases the risk of traffic accidents. 18), 19) Lowered quality of sleep often
occurs due to environmental conditions such as noise or high temperature,20) work- or family-related
stress,21) disorders such as insomnia or sleep-related breathing disorders,22) or other illnesses including
depression or back pain.23) Such sleep quality-related problems increase the likelihood of traffic accidents.24), 25) Furthermore, the use of medications that can result in drowsiness should be avoided whendriving.26)

98｜Theory

Sleep-related problems may lead to traffic violations that can then cause motor vehicle crashes.
Short sleep duration has been found to increase the frequency of driver inattention,27) and a group of
sleep apnea patients was shown to commit more stopping violations than did a control group.28)
9.5.2 Significance of sleep in traffic safety measures
Traffic safety can be ensured using several approaches. As described above, sleep and sleep-related problems have a large effect on drivers, and thus there is a critical need for establishing effective measures toimprove drivers’ sleep by sharing knowledge regarding proper sleep among drivers and their families
and employers, and also by developing workplace-based and other organizational programs for adequate
sleep.29)

References
1) Traffic Bureau, National Police Agency. 2014. Heisei 25 nen chu no kotsu jiko no hassei jokyo [Traffic accident situation 2013].
(in Japanese)2) Kibayashi, K., R. Shimada, and K. Nakao. 2013. “Temporal and Regional Variations in Accidental Deaths of Elderly People
in Japan.” Medicine, Science and the Law 53: 172–176.
3) Payne-James, J., R. Jones, S. B. Karch, and J. Manlove. 2011. Simpson’s Forensic Medicine. 13th ed. Hodder Arnold.
4) Kibayashi, K., R. Shimada, K. Nakao, and A. Ro. 2012. “Analysis of pituitary lesions in fatal closed head injury.” American
Journal of Forensic Medicine and Pathology 33: 206–210.
5) Cowley, R. A., F. Hudson, E. Scanian, W. Gill, R. J. Lally, W. Long, and A.O. Kuhn. 1973. “An economical and proved helicopter program for transporting the emergency critically ill and injured patient in Maryland.” Journal of Trauma 13, 12:1029–1038.
6) Hondo, K., A. Shiraishi, S. Fujie, D. Saitoh, and Y. Otomo. “In-hospital trauma mortality has decreased in japan possibly due
to trauma education.” Journal of the American College of Surgeons 217, 5: 850–857.
7) Moriya, T., and K. Tanjoh. 2009. “Current status of emergency medical services and role of prehospital care.” IATSS Review
Vol. 34, No. 3: 260–269. (in Japanese)
8) Sakurai, A., N. Morimura, M. Takeda, K. Miura, N. Kiyotake, T. Shiahara, and T. Aruga. 2014. “A retrospective quality assessment of the 7119 call triage system in Tokyo: telephone triage for non-ambulance cases.” Journal of Telemedicine and Telecare. http://doi.org/10.1177/1357633X14536347.
9) Kibayashi, K., and H. Shojo. 2002. “Incipient Alzheimer’s disease as the underlying cause of a motor vehicle crash.” Medicine,
Science and the Law 42: 233–236.
10) Kibayashi, K, T. Sumida, H. Shojo, and M. Hanada. 2007. “Dementing diseases among elderly persons who suffered fatal
accidents: a forensic autopsy study.” American Journal of Forensic Medicine and Pathology 28: 73–79.
11) Mitler, M. M., M. A. Carskadon, C. A. Czeisler, W. C. Dement, D. F. Dinges, and R. C. Graeber. 1988. “Catastrophes, sleep,and public policy: consensus report.” Sleep Vol. 11, No. 1: 100–109.
12) Åkerstedt, T. 2000. “Consensus statement: fatigue and accidents in transport operations.” Journal of Sleep Research Vol. 9, No.
4: 395.
13) Folkard, S., D. A. Lombardi, and P. T. Tucker. 2005. “Shiftwork: safety, sleepiness and sleep.” Industrial Health Vol. 43, No. 1:
20–23.
14) Golombek, D. A., and R. E. Rosenstein. 2010. “Physiology of circadian entrainment.” Physiological Reviews Vol. 90, No. 3:
1063–1102.
15) Cajochen, C., S. B. Khalsa, J. K. Wyatt, C. A. Czeisler, and D. J. Dijk. 1999. “EEG and ocular correlates of circadian melatoninphase and human performance decrements during sleep loss.” American Journal of Physiology Vol. 277, No. 3 Pt. 2:
R640–649.
16) Dawson, D., and K. Reid. 1997. “Fatigue, alcohol and performance impairment.” Nature Vol. 388, No. 6639: 235.
17) Van Dongen, H. P., A. M. Bender, and D. F. Dinges. 2012. “Systematic individual differences in sleep homeostatic and circadian rhythm contributions to neurobehavioral impairment during sleep deprivation.” Accident Analysis & Prevention Vol. 45
Suppl.: 11–16.

Chapter 9: Traffic safety and medicine｜9918) Dawson, D., and K. McCulloch. 2005. “Managing fatigue: it’s about sleep.” Sleep Medicine Reviews Vol. 9, No. 5: 365–380.
19) Dorrian, J., M. Sweeney, and D. Dawson. 2011 “Modeling fatigue-related truck accidents: Prior sleep duration, recency andcontinuity.” Sleep and Biological Rhythms Vol. 9, No. 1: 3–11.
20) Kayaba, M., T. Ihara, H. Kusaka, S. Iizuka, K. Miyamoto, and Y. Honda. 2014. “Association between sleep and residential
environments in the summertime in Japan.” Sleep Medicine Vol. 15, No. 5: 556–564.
21) Takahashi, M., K. Iwasaki, T. Sasaki, T. Kubo, I. Mori, and Y. Otsuka. 2012. “Sleep, fatigue, recovery, and depression after
change in work time control: a one-year follow-up study.” Journal of Occupational and Environmental Medicine Vol. 54, No.
9: 1078–1085.
22) Rosekind, M. R., and Gregory K. B. 2010. “Insomnia risks and costs: health, safety, and quality of life.” American Journal ofManaged Care Vol. 16, No. 8: 617–626.
23) Finan, P. H., and M. T. Smith. 2013. “The comorbidity of insomnia, chronic pain, and depression: Dopamine as a putative
mechanism.” Sleep Medicine Reviews Vol. 17, No. 3: 173–183.
24) Léger, D., V. Bayon, M. M. Ohayon, P. Philip, P. Ement, A. Metlaine, M. Chennaoui, and B. Faraut. 2014. “Insomnia and accidents: cross-sectional study (EQUINOX) on sleep-related home, work and car accidents in 5293 subjects with insomnia
from 10 countries.” Journal of Sleep Research Vol. 23, No. 2: 143–152.
25) Tregear, S., J. Reston, K. Schoelles, and B. Phillips. 2009. “Obstructive sleep apnea and risk of motor vehicle crash: systematic
review and meta-analysis.” Journal of Clinical Sleep Medicine Vol. 5, No. 6: 573–581.
26) Hetland, A., and D. B. Carr. 2014. “Medications and impaired driving.” Annals of Pharmacotherapy Vol. 48, No. 4: 494–506.
27) Anderson, C., and J. A. Horne. 2013. “Driving drowsy also worsens driver distraction.” Sleep Medicine Vol. 14, No. 5:
466–468.
28) Vakulin, A., P. G. Catcheside, C. J. Van Den Heuvel, N. A. Antic, R. D. McEvoy, and S. D. Baulk. 2011. “Increased rate of traffic law infringements during on-road metropolitan driving in obstructive sleep apnea patients.” Sleep and Biological Rhythms
Vol. 9, No. 3: 144–149.
29) Takahashi, M. 2012. “Prioritizing sleep for healthy work schedules.” Journal of Physiological Anthropology Vol. 31, No. 1: 1–8.
Recommended Reading
1) Bloomberg, H., B. Svennblad, K. Michaelsson, L. Byberg, J. Johansson, and R. Gedeborg. “Prehospital trauma life support
training of ambulance caregives and the outcomes of traffic-injury victims in Sweden.” Journal of the American College ofSurgeons 217, 6: 1010–1019.e2.
2) Czeisler, C. A. 2013. “Perspective: casting light on sleep deficiency.” Nature Vol. 497, No. 7450: 13.
3) Takahashi, M. 2014. “Assisting shift workers through sleep and circadian research.” Sleep and Biological Rhythms Vol. 12 (2):85–95. http://doi.org/10.1111/sbr.12065.
4) Williamson, A., R. Friswell, J. Olivier, and R. Grzebieta. 2014. “Are drivers aware of sleepiness and increasing crash risk whiledriving?” Accident Analysis & Prevention 70: 225–234. http://doi.org/10.1016/j.aap.2014.04.007.
5) Ayas, N., R. Skomro, A. Blackman, K. Curren, M. Fitzpatrick, J. Fleetham, C. George, T. Hakemi, P. Hanly, C. Li, et al. 2014.
“Obstructive sleep apnea and driving: A Canadian Thoracic Society and Canadian Sleep Society position paper.” CanadianRespiratory Journal Vol. 21, No. 2: 114–123.
6) Strohl, K. P., D. B. Brown, N. Collop, C. George, R. Grunstein, F. Han, L. Kline, A. Malhotra, A. Pack, B. Phillips, et al. 2013.
“An official American Thoracic Society Clinical Practice Guideline: sleep apnea, sleepiness, and driving risk in noncommercial drivers. An update of a 1994 Statement.” American Journal of Respiratory and Critical Care Medicine Vol. 187, No. 11:
1259–1266.
Practical application projects for reference
Addressing issues associated with prehospital emergency transportation: 176–179
Dissemination and promotion of screening for sleep disorders: 180–183