Is injury prevention the responsibility of the emergency physician? To the emergency medicine establishment, the answer is clear. In policy statements, editorials, and reviews, emergency health care providers have repeatedly been called to join the injury prevention effort.1-11 But medicine abounds with recommended practices that individual physicians do not follow because of disagreement, uncertainty, or perceived impracticality. For the practicing emergency physician, taking time to acquire new knowledge, to form new habits, and to use them in the busy acute care setting requires much more than a call to action. It requires confidence that the effort is worth it as well as the tools to do the job.
In 1998, the American College of Emergency Physicians (ACEP) wrote in a policy statement that "emergency physicians are ideally situated and have the responsibility to affect the health of the public by educating them on injury prevention issues," and that "emergency physicians should incorporate injury control into their practices" in both clinical and educational settings.12 The Emergency Medical Services for Children (EMSC) program, a broad federal effort aimed at improving the emergency care of children nationwide, has also emphasized injury prevention as vital to every step in the EMSC continuum.13 The latest Institute of Medicine (IOM) report on emergency care in the United States has further underscored the importance of this approach.14 These high-level statements, among others, voice a sentiment that has been growing in emergency medicine for years: emergency physicians are uniquely positioned and qualified to play a prominent role in injury prevention. This sentiment arose from the recognition that expert trauma care alone cannot slow the injury epidemic that kills more children and young adults in the United States than any other cause. Emergency physicians, "standing at the interface between prevention and treatment" with a specialist's knowledge of injury, are poised to make a contribution to injury prevention no one else can make.
In recent years, the sentiment has grown far beyond policy statements and recommendations. At an institutional level, the effort to incorporate injury prevention into emergency medicine has affected residency curricula, departmental policies, and research initiatives around the country. Numerous emergency departments have become active in interventions and data collection for surveillance and program evaluation. But despite these developments, at an individual level, the call to join the injury prevention movement still causes ambivalence, or even surprise, in many emergency physicians.
The conclusion that emergency physicians are ideally situated to practice injury prevention is not intuitive to everyone. Even when shown the logic, skeptical providers still doubt that preventive activities belong in the acute care setting. Their sense of purpose or mission might not extend beyond the treatment of acute health problems. Others agree with the injury prevention effort in emergency medicine and want to participate but see no practical way to do it. Hectic, overcrowded emergency departments can seem an unlikely place to effectively educate patients and families, and busy work schedules make provider involvement in efforts outside the clinical setting difficult. And even when these hurdles are overcome, an essential question remains: which injury prevention strategies work? Both skeptics and believers need to know what evidence supports the assertion that injury prevention is the responsibility of the emergency physician - the skeptics so they might better understand the call to participate and the believers so their work might be more effective.
A five-year-old boy arrives in the ED by ambulance from the scene of a motor vehicle crash. He was a back-seat passenger wearing a lap belt in a car that struck another car head-on. Both cars were traveling approximately 50 miles per hour. His seven-year-old brother, also wearing a lap belt, was pronounced dead at the scene. His parents, who were belted in the front seat, suffered minor injuries and are being treated at another ED nearby.
The boy arrives tachycardic and in mild respiratory distress, with diminished breath sounds on the left, a linear ecchymotic area across the upper abdomen, and midline tenderness over the lumbar spine. Laboratory evaluation reveals a hemoglobin of 6.8 g/dL and hematuria on urinalysis. His chest x-ray is consistent with traumatic diaphragmatic hernia with the stomach bubble visible in the left chest, mediastinal shift to the right, and a pneumothorax on the left. Lumbar and thoracic spine radiographs show compression fractures of the first and second lumbar vertebrae.
"All the hallmarks of â seat belt syndrome," the trauma surgeon points out to you. "We've got to teach parents that it's not enough just to buckle their kids up," he says, frustrated, as he heads to the operating room to explore and repair the boy's internal injuries. You wonder what to say to the boy's parents. Did they know that a booster seat might have prevented these injuries and might have saved their other son's life? Maybe they think this was just an unlucky accident - awful, but unavoidable. Is this the right time to counsel them? Whose job is it to teach or ask families about safety? When is there time for injury revention when the waiting room is full? And even if there was time, what works? Discouraged, you pick up another chart and read about your next patient: a two-year-old girl with a facial scald from coffee left on the edge of a kitchen counter…
Taken as a whole, the literature on injury prevention practices from multiple settings is robust, with a number of well-studied safety devices and strategies included in evidence-based best practices (Table 1).15 The subset of the literature addressing injury prevention in the emergency department has grown rapidly in recent years, but remains limited in important aspects. Descriptive epidemiology and risk factor identification have been studied longest and best, with numerous observational and crosssectional studies focused on defining the injury problem and those at risk. These studies provide a foundation of injury data from populations in a variety of settings and describe the role of injury surveillance based in the emergency department.16 Fewer studies have evaluated interventions; of those, the quality is variable. Due to the difficulty in measuring the ultimate outcome of interest - change in injury rate or severity - investigators have relied on more proximate outcomes to judge an intervention's value. Many have used pre- and post-tests around education or follow-up surveys after distribution of safety devices. They have explored the acceptability of an intervention to families and providers or have measured the attitudes, knowledge, and self-reported changes in behavior believed to influence injury risk. Some have measured self-reported injury occurrence. Self-reporting is vulnerable to social acceptability and acquiescence biases, and its validity for injury prevention behaviors is variable.17-20 As with all studies, the accuracy of conclusions depends on the study design and the causal claims of the investigators, which need to be examined carefully. The association of the measured outcome with the ultimate outcome in question (injury rate, injury severity, mortality from injury, costs of injury) should be well-established.
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.
To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study, will be included in bold type following the reference, where available.