AUTHORS: Michael J. Murray, M.D., Ph.D. et al
ASA Monitor 01 2018, Vol.82, 40-43.
Morbidity and mortality caused by intentional and unintentional trauma, as well as injuries such as intentional and accidental ingestions, are major public health problems worldwide, resulting in billions of dollars of avoidable medical expense as well as critical lost productivity. In addition to being the third-leading cause of death overall, traumatic injury is the leading cause of death in individuals younger than 46 years; therefore, it results in more years of life lost, more disability-adjusted life years (DALYs) for survivors and more resulting financial cost than from any other cause.
Much has been written about the anesthetic management of patients who have sustained traumatic injury, but relatively little has been published in the anesthesia literature about injury prevention. The members of the ASA Committee on Trauma and Emergency Preparedness (COTEP) are of the opinion that if we are serious about improving outcomes from traumatic injury, we as physician anesthesiologists need to also be more engaged in the ongoing national discussions on injury prevention. Even more important, we need to educate our patients on injury prevention when opportunities to do so present themselves. The Centers for Disease Control and Prevention (CDC) reports that in 2014, the latest year for which statistics were available for this article, there were 199,752 deaths from accidental injury, of which 135,928 were unintentional, 42,826 were suicides, and 15,872 were homicides; for 4,597 deaths, the mechanism was undetermined. The CDC also reports that whereas the number of deaths from non-communicable diseases such as cardiac disease, cancer and stroke has significantly decreased, the number of deaths from accidental injury increased 23 percent in 2014! In addition, death from traumatic injury due to violence (homicides, terrorism) is also increasing at an alarming rate. As members of a specialty involved in so many phases of trauma care, physician anesthesiologists must be more willing to be involved and to address these important public health issues.
One must keep these numbers in perspective. In 2005, for example, one study estimated that there were far more preventable deaths from other causes than from accidental injury. Approximately 467,000 deaths were thought to be secondary to hypertension and cigarette smoking, for both of which there are effective interventions. Obesity, lack of physical activity, and high salt intake were each estimated to account for more than 100,000 deaths annually. Alcohol-induced deaths accounted for more than 30,000 deaths. However, there are already programs in place to address these public health issues, and ASA has taken a position in the past, for example, on tobacco smoking, and most of us counsel our patients who are current smokers on the importance of seeking help to discontinue smoking.
The causes of accidental and traumatic deaths vary by exposure to risk (correlated to age). Therefore, when educating patients, we need to know and succinctly target our audience. The primary cause of death in older adults is from accidental falls – from ladders, on slippery floors, and over throw rugs and items left on the floor. In younger adults (age 18-25), the greatest number of accidental deaths is from motor vehicle crashes, many caused by inexperienced drivers allowing distractions (cellphone texting, music, other passengers, etc.) to affect their safe driving. Too often, alcohol or substance abuse may also be implicated in driver impairment; these factors are also a contributing factor in both homicides and suicides. For adults overall, intentional and accidental drug overdoses, the majority involving prescription drugs, are the leading cause of preventable death; the number of deaths from opioid overdose has received great attention of late, having been called a “national crisis.” As physician anesthesiologists and experts in the management of pain, we have an obligation not only to educate our patients but also to influence our outpatient prescribing colleagues through opioid avoidance options (regional anesthesia, non-opioid adjuncts, reasonable prescribing amounts, etc.).
“In addition, death from traumatic injury due to violence (homicides, terrorism) is also increasing at an alarming rate. As members of a specialty involved in so many phases of trauma care, physician anesthesiologists must be more willing to be involved and to address these important public health issues.”
In terms of preventable deaths from injuries, the CDC ranks poisonings and suicides as the number-one and number-two causes of death. While these issues are very important, from the perspective of the trauma anesthesiologist working in an E.R., O.R. or ICU, blunt trauma (from motor vehicle crashes and falls) and penetrating trauma (from gunshots and stabbings) are the treatable injuries with which we are most familiar. Furthermore, we believe that such injuries are a major public health problem that require more awareness on our part. At a minimum, we should educate our patients when possible; we do so now during the preoperative visit if we have a patient who is a current cigarette smoker.
For example, when approaching a young patient in the preoperative area who is on a cellphone, how difficult is it to make the statement, “I hope you don’t text and drive”? Or if attending to an older patient before surgery, how difficult is it to remind them that they need to make their homes as fall-proof as possible? Or if there is an indication that family members hunt (e.g., the clothes they are wearing), how much time does it take to remind them of the basic tenets of gun safety? While these interventions may appear trivial, and do little to affect morbidity and mortality rates, they reinforce public safety messages that are being widely disseminated. In addition, our comments reinforce the idea that we as patient advocates are concerned about their welfare in the O.R., and that we are equally concerned about their welfare even when they are not under our care.
Deaths from gunshot wounds or stabbings are highly dramatic, and are often captured and politicized in the media within the context of debates on gun control, racial tensions, immigration and terrorism. Violent attacks (gun and knife trauma) are among the top five causes of death from preventable injury, and several national medical groups have weighed in on both the public health and political aspects of the debate through policy statements and various forms of advocacy. COTEP members see both sides of the political debate and recognize that if ASA is not at the table when these issues are discussed nationally, we run the risk of our voices not being heard in the debate on preventable injury and deaths from violence.
In conclusion, we as physician anesthesiologists should take the necessary steps to protect ourselves and our families, to prevent avoidable injury whenever possible and to take steps to educate our patients on this very important public health issue. Finally, many of the members of COTEP are of the opinion that the time has come for ASA to consider joining the national discussion on injury prevention strategies. Adequate care of such injuries depends largely upon us, and we should be a willing and vocal partner in finding solutions to the problem of preventable injury.
The views expressed herein are those of the authors and do not represent official policy of the U.S. Department of Defense or the Department of the Navy.