Rex Ziak

A baby falls down the stairs in her walker. A woman dies in a crash caused by drinking driver. A teenager suffers serious burns to his hands and face after playing with fireworks. A couple drowns after their boat capsizes with no life vests on board. These incidents are often dismissed as "accidents." Correcting these misperceptions is part of the mission of the Harborview Injury Prevention and Research Center (HIPRC). In 1985, the National Academy of Sciences issued a report that described injuries as the "most important public health problem facing our nation today". That same year the HIPRC was formed as one of the first centers in the nation specifically devoted to research on and prevention of injuries.

The centers goal is to decrease morbidity and mortality caused by trauma. Our work addresses the injury problem in our own community and region and contributes to the science of injury control. We adddress unintentional injuries (such as Motor vehicle trauma and drowning) and intentional injuries (such is homicide, suicide, and assault) to persons of ill ages.

 HIPRC activities include etiologic epidemiological research, acute care of trauma patients in the emergency department and intensive care unit, rehabilitation in the hospital and home, studying biomechanics to examine the causes and treatments of injury, and translating our research findings into recommendations that make sense to the lay public in the hope we will save lives. The promotion of bicycle helmets, a campaign to ban baby walkers in the United States, and advocacy for increasing the minimum age requirements for Washington's infant seat restraint laws are some of our efforts most apparent to the public, but we do much more.

Alcohol is a factor in many situations involving traumatic injuries. Half of all injured patients admitted to Harborview Medical Center have recently been drinking and nearly one-third are acutely intoxicated. Alcohol abuse is a major public health problem and the most common contributor to trauma . Studies of the acute care of trauma patients should not ignore the effect of alcohol. Researchers at the HIPRC prospectively studied the association between alcohol abuse and response to treatment for trauma. Patients with chronic abuse have higher rates of mortality, complications, and infections, and, most significantly, are more likely to be readmitted for subsequent trauma . As a result, Harborview is the first trauma center in the world to make alcohol intervention a routine part of trauma care.

When successful trauma care ends, rehabilitation often begins. As more patients survive serious injuries, new challenges arise is they seek the most independent and self-sufficient lives possible. Our rehabilitation work has focused extensively on children who suffered traumatic brain injury (TBI). In the first longitudinal cohort study in the country, the center followed children With TBI and a group of noninjured children for more than three years. The results demonstrated that children who suffered mild TBI (90% of all head-injured children) recovered rapidly and showed few long-term, injury-related problems in learning, behavior, or social skills. However, children with moderate and severe TBI had persisting deficits in many areas. We also examined the economic impact of TBI in children. The most common source of this trauma, motor vehicle crashes, was also the most costly These findings reaffirm the need for legislative, educational, and environmental changes to improve motor vehicle safety, and thus to save lives and dollars.

Our epidemiological research, led by the faculty of the School of Public Health, has addressed the problem of firearms and the associated risk of injury and death. We consider the association to be much like that of studies linking smoking and cancer 20 years ago. When public health advocates first became involved, little changed; but two decades and several hundred studies later, much has changed. We believe that we can make a similar impact in the area of violent death - and that it is time public health professionals take the lead. We need to continue to conduct research to evaluate the effect of various regulations and interventions on firearm injuries and to use this information to inform the debate about gun control.

Our work investigating medical conditions and motor vehicle collisions in older adults found that physicians' advice is extremely influential in an older person's decision about whether to keep driving. More important, however, was the finding that few medical conditions - with the exceptions of diabetes and hearing loss - are associated with an increase in the risk of collisions.

The study of biomechanics is a relatively new addition in the field of injury control. We need to understand the mechanics of injury if we hope to improve the care of patients or design more effective prevention strategies. Our engineers are working with epidemiologists to investigate falls in the elderly HIPRC epidemiologists have examined such issues as the risk factors for and cost of falls. One risk factor identified was shoes. Biomechanics experts are studying the stability of different types of shoes and characteristics such as their stiffness and friction with the walking surface. We believe that a major prevention campaign will emanate from this collaboration.

This multidisciplinary approach is the essence of our work in injury control. We have collaborated with the Center for Health Studies, Group Health Cooperative of Puget Sound, to develop Group Health as a small population laboratory for injury research, including studies on bicycle helmets, older drivers, and domestic violence. Other collaborators include the Washington State Department of Health, the Seattle-King County Department of Health, the Seattle Police Department, the Washington Traffic Safety Commission, and the Seattle and King County Engineering Departments, among others.

Most importantly, our collaborative and interdisciplinary effort marshals a vast array of expertise, experience, and enthusiasm to reduce injury - the most common cause of death and disability for more than half of the human life span. A decade ago injury was the nation's "neglected" disease. The contributions of those in public health have altered that status. Our initial work has led to increased awareness of this significant problem and to reductions in mortality and morbidity We have begun to realize what can and should be done.

Recommended Reading

Baker SP, O'Neill B, Ginsburg MJ, Li G: The Injury Fact Book. New York: Oxford University Press, 2nd ed., 1992.

Chang DC, Tencer AF, Triece B, et al: Geometric changes in the cervical canal during impact. Spine 1993; 19:1(55-172.

Grossman DC, Milligan BC, Deyo RA: Risk factors for suicide attempts among Navajo adolescents. Am J Public Health 1991; 81:870-4.

Jaffe KM, Fay GC, Polissar NL, et al: Severity of pediatric traumatic brain injury and neurobehavioral recovery at one year: A cohort study. Arch Phys Med Rehabil 1993; 74:587-595.

Jurkovich GJ, Rivara FP, Gurney JG, et at: The effect of acute alcohol intoxication and chronic alcohol abuse on outcome from trauma. JAMA 1993; 270:51-56.

Koepsell TD, Wolf ME, McCloskey L, et at: Medical conditions and motor vehicle collision injuries in older adults. J Am Geriatric Soc 1994; 42:695-700.

National Academy of Sciences. Injury in America. Washington, DC: National Academy Press, 1985.

Sloan JH, Kellermann AL, Reay DT, et at: Handgun regulations, crime, assaults and homicide: A tale of two cities. N Engl J Med 1988; 319:1256-1262.

Thompson RS, Rivara FP, Thompson DC: A case control study of the effectiveness of bicycle safety helmets. N Engl J Med 1989; 320:1361-1367.

Authors

Lisa W. Rogers was director of public information for the Harborview Injury and Prevention Research Center until fall 1995.

Frederick P. Rivara, M.D., M.PH., is director of the Harborview Injury Prevention and Research Center, and the George Atkins Professor of Pediatrics and adjunct professor of epidemiology at the University of Washington.

David C. Grossman, M.D., M.PH., is co-director of the Harborview Injury Prevention and Research Center, and assistant professor of pediatrics and adjunct assistant professor of health services at the University of Washington. 

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