Commentary: Moving Forward by Looking Behind You
Article Outline
[Kahn C. Commentary: moving forward by looking behind you. Ann Emerg Med. 2009;54:604-605.]
I cannot see a fatally injured child in my trauma center without feeling my small share of the terrible grief that child's parents are just starting to discover. No matter what the mechanism, no matter how unintentional the injury, I always find myself in a group of emergency department and trauma staff trying to cope with a deceptively simple question: how could this happen?
After several years of dealing with the consequences of injuries, many emergency physicians start to wonder how they, just one person afloat in a sea of injured victims, can truly start to make a difference. Rather than merely rearranging the deck chairs on the Titanic, as a colleague of mine is fond of saying, perhaps the answer is in preventing that crash in the first place.
The recent NHTSA report on motor vehicle backing crashes gives us some insight into an area in which improvement can definitely be made. An estimated 292 persons are killed every year in back-over crashes, a third of them children younger than 5 years, and about 18,000 people are injured in this manner.1 The report gives us several opportunities to help change these statistics.
There is a clear association between age and injury. Children younger than 5 years, although only 7% of the population and 8% of the total injuries, represented 35% of the fatalities in back-over crashes occurring from 2002 to 2007 in the United States. Surprisingly, another group was also overrepresented: persons older than 70 years make up 9% of the population but 26% of the fatalities in this group (and 18% of the injuries). A brief literature review shows several articles related to child back-over injuries but not a single one on older adults. Now that NHTSA has discovered this information, we have a chance to do something about it.
Another significant finding of the report is the location of these incidents. The highest single location for fatal back-overs was in driveways (24% of deaths). This is not surprising to people who study back-over injuries because it has been reported consistently for more than 4 decades.2, 3, 4, 5, 6 What might be surprising is just how preventable these incidents can be. In fact, just the absence of a physical separation of the driveway from a children's play area is associated with a population attributable risk of 50% (95% confidence interval 24.7% to 75.3%).7 In other words, putting a fence between every driveway and children's play area would halve the number of pediatric back-over fatalities. This should also not be surprising because a similar finding was made in work to prevent pediatric drownings; putting a completely enclosing fence around a swimming pool cuts the risk of drowning by about 75%.8
It is often assumed that larger vehicles such as sport utility vehicles present a higher risk of back-over incidents. The report does show that sport utility vehicles and pickups are overrepresented in injuries and even more so in fatalities. However, it is dangerous to assume that driving a smaller vehicle will prevent a back-over. A widely used test for visibility is placing a standard 28-inch target (such as a traffic cone) behind the vehicle and then moving it farther and farther from the vehicle until the top of it just becomes visible to the driver. The NHTSA Special Crash Investigation team reconstructed several of the back-overs studied in this report; the appendix describes one case with a typical non–sport utility vehicle passenger vehicle in which the 28-inch target was not visible until it was about 35 feet behind the car. These blind zones become larger with drivers shorter than 5 feet 8 inches or if the seats are lowered. Although the average toddler is taller than 28 inches, it is easy to miss seeing a child who is sitting on the ground playing or bending over to pick up a toy. Clearly, any vehicle can be involved in back-over incidents.
As one might expect, a large number of victims are run over by a relative. In fact, 40% of backed-over victims in a subset of crashes that received extra investigation were related to the driver. It is not hard to imagine a child running outside to say one last goodbye to Mommy or Daddy, not paying attention to the moving vehicle. It is also not hard to imagine that driver looking at something inside the passenger compartment while the child runs outside and then putting the car into reverse, with tragic consequences.
Fortunately, there is some good news in this field. Congress passed the Cameron Gulbransen Kids Transportation Safety Act of 2007, which mandated study of several aspects of pediatric nontraffic motor vehicle injuries. The NiTS system (the basis for this NHTSA report) was created partially in response to this legislation and has already resulted in new data that can be used to better understand back-over injuries. Further, technology to improve rear-visibility blind zones is starting to appear in passenger vehicles, such as rear-view cameras and detectors that sound an alarm if an object is behind a vehicle. Organizations such as Safe Kids' Spot the Tot program and Kids and Cars are working hard to sound the drumbeat of child vehicular safety. One can only hope that the next report on back-overs will describe significant improvement in eliminating back-over injuries and fatalities.
In the meantime, there are several simple steps that every driver can take to avoid a back-over crash:
Emergency physicians have the opportunity to prevent injuries and improve public health with every shift they work. I personally find that some of the best teachable moments come between the phrases “Good news; this is just a really bad cold!” and “Antibiotics won't help your child,” when I am certain to have a parent's attention. Although it is difficult to cover every risk with every patient, it is easy to pick one or two topics for the shift—back-over prevention, swimming pool safety, safety belt use, helmet wearing, and smoke detector checks are just a few of the nearly limitless possibilities—and ask about them with every patient. You may never know whose life you have saved with that information, but protecting parents from the horror of burying their child is worth the effort to give it. We do not have to ask, “How could this happen?” We know how many injuries happen, and it is time we renew our efforts to keep them from happening.
References
- . Fatalities and Injuries in Motor Vehicle Backing Crashes. Washington, DC: US Dept of Transportation, National Highway Traffic Safety Administration; 2008;Publication No. DOT HS 811 144
- . Differences in child pedestrian injury events by location. Pediatrics. 1994;93:284–288
- Driveway motor vehicle injuries in children: a prospective review of injury circumstances. Med J Aust. 2006;184:311
- . Deaths due to car driveway accidents. IMJ Ill Med J. 1964;126:688
- . Driveway-related motor vehicle injuries in the paediatric population: a preventable tragedy. N Z Med J. 2002;115:U148
- Driveway crush injuries in young children: a highly lethal, devastating, and potentially preventable event. J Pediatr Surg. 1998;33:1712–1715
- . Driveway-related child pedestrian injuries: a case-control study. Pediatrics. 1995;95:405–408
- . Pool fencing for preventing drowning in children. Cochrane Database Syst Rev. 2000;(2):CD001047
Section editors: Mary Pat McKay, MD, MPH; Todd Thoma, MD; Christopher Kahn, MD, MPH; Catherine S. Gotschall, ScD
PII: S0196-0644(09)01432-2
doi:10.1016/j.annemergmed.2009.08.007
© 2009 Published by Elsevier Inc.
