Prevention Of Injuries & Violence

Injuries remain the most important cause of loss of potential years of life before age 65. Road traffic injuries, selfinflicted injuries, falls, and interpersonal violence are the major sources of injuries. Injuries affect mostly older women and young men, often causing long-term disability. Although there has been a steady decline in motor vehicle accident deaths per miles driven, road traffic injuries remain the tenth leading cause of death and the ninth leading cause of the burden of disease. Although seat belt use protects against serious injury and death in motor vehicle accidents, at least one-fourth of adults and one third of teenagers do not use seat belts routinely.
Air bags are protective for adults but not for small children. Each year in the United States, more than 500,000 people are nonfatally injured while riding bicycles. The rate of helmet use by bicyclists and motorcyclists is significantly increased in states with helmet laws. By the end of 2000, bicycle helmet use in 15 communities monitored by the CDC’s National Center for Injury Prevention and Control had risen from 40% to 55%, exceeding the Healthy People 2000 goal. Young men appear most likely to resist wearing helmets. Clinicians should try to educate their patients about seat belts, safety helmets, the risks of using cellular telephones while driving, drinking and driving—or using other intoxicants or long-acting benzodiazepines and then driving—and the risks of having guns in the home.
Long-term alcohol abuse adversely affects outcome from trauma and increases the risk of readmission for new trauma. Alcohol and illicit drug use are associated with an increased risk of violent death. There is a causal link between alcohol intoxication and injury due to assault.
Harm reduction can be achieved through practical measures, such as using plastic glasses and bottles in licensed premises; controlling prices of drinks; and targeted policing based on police, accident, and emergency data.
Males aged 16–35 are at especially high risk for seriousinjury and death from accidents and violence, with blacks and Latinos at greatest risk. For 16- and 17-year-old drivers, the risk of fatal crashes increases with the number of passengers. Deaths from firearms have reached epidemic levels in the United States and will soon surpass the number of deaths from motor vehicle accidents. Having a gun in the home increases the likelihood of homicide nearly threefold and of suicide fivefold. In 2002, an estimated 877,000 individuals successfully committed suicide.
Educating physicians to recognize and treat depression as well as restricting access to lethal methods have been found to reduce suicide rates. In elderly patients, the risk of hip fracture when falling can be reduced by as much as 80% by wearing hip protectors, but only about half of patients use them regularly. Oral vitamin D supplementation with 700–800 IU/d appears to reduce the risk of hip and other nonvertebral fractures in both ambulatory and institutionalized elderly persons, but 400 IU/d is not sufficient for fracture prevention.
Finally, clinicians have a critical role in detection, prevention, and management of physical or sexual abuse in particular, routine assessment of women for risk of domestic violence. In a trial, the 12-month prevalence of intimate partner violence ranged from 4% to 18% depending on the screening method, instrument, and health care setting. Rates of current domestic violence on exit questionnaire were 21% in suburban emergency department and 26% in urban emergency department settings. Inclusion of a single question about domestic violence in the medical history—“At any time, has a partner ever hit you, kicked you, or otherwise physically hurt you?”—can increase identification of this common problem. Another screen consists of three questions: (1) “Have you ever been hit, kicked, punched, or otherwise hurt by someone within
the past year? If so, by whom?” (2) “Do you feel safe in your current relationship?” (3) “Is there a partner from a previous relationship who is making you feel unsafe now?”
Women seem to prefer written, self-completed screening questionnaires to face-to-face questioning. Alternatively, computer prompts to clinicians may serve as useful reminders to inquiry. Assessment for abuse and offering of referrals to community resources creates potential to interrupt and prevent recurrence of domestic violence and associated trauma.
Physical and psychological abuse, exploitation, andneglect of older adults are serious underrecognized problems. Clues to elder mistreatment include the patient’s appearance, recurrent urgent-care visits, missed appointments, suspicious physical findings, and implausible explanations for injuries.