Commentary: Pedestrians: Truly Vulnerable Road Users
Article Outline
[McKay MP. Commentary: pedestrians: truly vulnerable road users. Ann Emerg Med. 2009;53:825-826.]
In my practice of emergency medicine, there have been some cases that continue to haunt me. One was a 25-year-old woman who was struck by a bus while walking to work one morning; she was apparently crossing the street in a crosswalk. This was the case that taught me the true meaning of the distinction between being “run into” and “run over”; the wheels of the bus crushed her pelvis, chest, and head. It was obvious at the intersection that she was fatally injured, but mass hysteria at the scene (which occurred at a busy location in the middle of rush hour) led emergency medical services to bring her to us. She had bilateral complex leg fractures, a crushed unstable pelvis, a crushed chest, and gray matter leaking from open skull fractures. Her face was flattened. Like the cartoon character Road Runner, she had been “pancaked,” but unlike the cartoon, she wasn't going to bounce back.
As you may imagine, we did not continue the “code” for long. The police had kept the victim's identification at the scene, but we had her cellular telephone. That case was the first time I used the cellular information to find the family: I called the contact labeled “Dad” and told him his daughter had been hit and seriously injured. When he arrived, I had to tell him she had not survived. Death notification is never easy, but this one really got to me. He kissed her and then told me about her: how she had finally gotten her life together after a series of setbacks, finally gotten a job, and begun living in her own apartment. Other family members were struggling with physical and mental health issues, but this one daughter had finally put herself together and this outcome was totally unfair.
No matter how “put together” they are, pedestrians are truly vulnerable road users. The unprotected human body simply cannot win in a crash with a 1- or 2-ton passenger vehicle, much less with a bus or tractor-trailer. In the United States, the basic safety design has been to try to separate the pedestrians from the vehicles by building sidewalks and keeping high-speed highways free of pedestrians altogether. Of course, this doesn't always work: there are plenty of roadways without sidewalks that are shared by vehicles and pedestrians, and on some of them the speed limit is quite high.
The public doesn't generally view “pedestrian-struck” patients as a major health issue; there are no marches on Washington trying to bring the problem to light. Perhaps this is because these crashes seem like something caused by an individual's behavior. However, the 4,654 pedestrian fatalities in one calendar year (2007) reported by the NHTSA1 outstrips the current number of American military personnel (4,249 people as of February 25, 2009) killed in Iraq in the 6 years since the invasion began.2 All of the American military personnel are volunteers who signed up for a potentially hazardous job. The pedestrians, on the other hand, are usually just trying to get somewhere.
Although pedestrian fatalities have decreased during the last decade, this is likely an effect of exposure; fewer pedestrians equals fewer pedestrian fatalities. Throughout the next few years, this may change significantly as we as a nation struggle to increase physical activity—particularly walking—to fight the obesity epidemic,3 as gas prices continue to be volatile, and as the public emphasis on addressing global warming by targeting vehicle emissions increases. Heavier vehicle types are associated with an increased risk of pedestrian fatality,4, 5 so the recent decrease in sales of sport utility vehicles may eventually decrease the risk of pedestrian fatality but not pedestrian-struck crashes.
In any pedestrian crash, there are at least 2 people involved: the pedestrian and the driver. I'm quite sure that drivers who hit and kill pedestrians experience significant psychological trauma, no matter how unintentional the event was. For all of us to safely use the road, both pedestrians and drivers have to honor obligations to the other group. Pedestrians have to make themselves as visible as possible, look both ways before entering the roadway, and carefully judge the safety of their position relative to the stopping distance of the vehicle. Drivers must be aware of and respond to the presence of pedestrians. When a pedestrian crash occurs, there must have been a problem of perception: the driver failed to see the pedestrian and perceive the danger in time or with enough room to take evasive action or the pedestrian made choices based on faulty perceptions about vehicle location or speed or inaccurate predictions about the driver's behavior.
It makes some sense then that the biggest risk factors for pedestrian fatality involve difficulty with risk assessment or situations in which perception may be impaired. Overall, male victims experience fatal, unintentional injuries at more than twice the rate of female vctims,6 perhaps because of increased willingness to take risks. This same increase in fatality rate is demonstrated among pedestrian fatalities. According to the report today, older pedestrians (age 70 years and older) seem to be more likely to die when struck (they account for 16% of fatalities but only 6% of injuries); this may be an effect of increased frailty, but perhaps older pedestrians are less able to judge gaps in traffic and therefore more likely to put themselves into higher-risk situations. Fully 67% of all fatal pedestrian crashes occurred during nighttime hours, pointing to decreased visibility in the dark. This problem may combine with the increased risk associated with being intoxicated; 35% of dead pedestrians in 2007 were legally drunk (>0.08 BAC) when they were struck. Finally, more than 77% of all fatalities occurred outside intersections, places where drivers may have lower expectations of pedestrians' presence and be slower to perceive and avoid them.
During the past few years, there appear to be new risks to pedestrians. At any given time, about 6% of US drivers can be observed using a cellular telephone,7 although using a cellular telephone to make a call appears to increase the risk of a crash by about a factor of 4.8 The exact risks of texting are not yet clear but are likely even higher because both hands are usually needed. In addition, the distraction of using the telephone to chat or send text messages appears to affect pedestrians' behaviors, increasing their risk of making unsafe choices about crossing a road. This holds true for both children and adults.9, 10, 11 Thus, new technologies designed to make our lives easier and more interesting may also participate in cutting it short.
What's an emergency physician supposed to do about all this? Obesity is a major health problem in the United State. We're all supposed to be asking our patients to exercise more, and walking is good exercise. This issue, combined with the need to develop a greener outlook on transportation and rising fuel costs, makes me think we will start to see a tipping point at which more and more people choose to use their feet: pedestrian exposure will go up. At the same time, we have some generally predictable risks to pedestrians and more recent increases in those risks associated with new technology. I don't have all the answers, but it seems to me that there are some things we can do—and that we need to be proactive about.
The first, and the one with perhaps the most evidence to support it, is to make screening and brief intervention for alcohol overuse a routine component of ED care.12 Brief interventions are aimed at generally decreasing alcohol use which, in many cases, would limit the risk of being a fatally injured pedestrian. The second thing we can do to address this issue is to attend to our own behavior. With more than 20 years of education apiece, we're supposed to be smart enough to recognize the risks and act appropriately. And with the general prominence of evening shifts to cover the evening bump in ED census, we are often out and about during the riskiest hours of darkness. As pedestrians, this means wear bright clothing at night, cross in the crosswalks, and obey the “don't walk” signal. As drivers, this means keeping a conscious eye out for pedestrians and giving way appropriately. It means that we personally need to try to avoid using cellular telephones to call or text while walking or driving because we recognize the increase in risk.
Finally, improving emergency care and injury control for pedestrians may mean supporting legislation (and funding) aimed at improving pedestrian safety. In many communities, particularly suburban ones, this means supporting local plans to create or upgrade sidewalks and traffic lights. Because darkness seems to impose a special risk, in some locations installing or enhancing roadway lighting may create a big improvement in pedestrian safety. In busy intersections, creating a pedestrian over- or underpass may provide a safety solution and simultaneously improve traffic flow.
Intoxicated pedestrians are clearly at increased risk of serious or fatal injury from a vehicle crash. Because these people primarily pose a physical risk to themselves (unlike intoxicated drivers), it may be easy to fall back on the idea that adults have to make their own choices about their behavior. However, I believe this is a largely unrecognized risk. We can address pedestrian safety by educating our patients (perhaps as part of the brief negotiation process) and asking people to ensure they have a safe way home when and wherever they choose to drink. In our communities, we can help develop safe-ride programs as part of a general traffic safety effort.
Successfully addressing pedestrian safety as an emergency physician could mean supporting legislation to limit the use of cellular telephones and texting devices by both pedestrians and drivers. As useful as these devices are to all of us, there is a time and place for everything, and the roadway isn't the right place for distractions.
If we as a nation take proactive measures, increasing physical activity, addressing obesity, and participating in the “greening” of America should not result in a significant increase in the number of severely or fatally injured pedestrians.
On a personal note, the bottom line is that I never again want to have to find the “in case of emergency” number on someone's phone to tell the next of kin that the patient has been pancaked.
References
- . Traffic safety facts: 2007 data: pedestrians (DOT HS 810 994). http://www-nrd.nhtsa.dot.gov/Pubs/810994.PDFAccessed February 11, 2009
- Icasualties.org Iraq Coalition casualty count. Available at: http://icasualties.org/Iraq/index.aspx Accessed February 25, 2009.
- Using pedometers to increase physical activity and improve health: a systematic review. JAMA. 2007;298:2296–2304
- Pedestrian crashes: higher injury severity and mortality rate for light truck vehicles compared with passenger vehicles. Inj Prev. 2004;10:154–158
- . United States pedestrian fatality rates by vehicle type. Inj Prev. 2005;11:232–236
- . WISQARSTM (Web-based Injury Statistics Query and Reporting System). http://www.cdc.gov/injury/wisqars/index.htmlAccessed February 28, 2009
- . Driver hand-held cellular phone use: a four-year analysis. J Safety Res. 2006;37:261–265
- Role of mobile phones in motor vehicle crashes resulting in hospital attendance: a case-crossover study. BMJ. 2005;331:428–433
- . Effect of cell phone distraction on pediatric pedestrian injury risk. Pedatrics. 2009;123:e179–e185
- . Mobile telephones, distracted attention, and pedestrian safety. Accid Anal Prev. 2008;40:69–75
- . The effects of mobile phone use on pedestrian crossing behaviour at signalized and unsignalized intersections. Accid Anal Prev. 2007;39:197–205
- . The impact of screening, brief intervention, and referral for treatment on emergency department patients' alcohol use. Ann Emerg Med. 2007;50:699–710
Section editors: Mary Pat McKay, MD, MPH; Todd Thoma, MD; Chris Kahn, MD, MPH; Catherine S. Gotschall, ScD
PII: S0196-0644(09)00371-0
doi:10.1016/j.annemergmed.2009.04.003
© 2009 Published by Elsevier Inc.
