The shocking truth about road trauma

Key text

Road crash fatalities are something we hear a lot about – newsreaders give us the road toll almost as often as the cricket score. Less talked about are the survivors: yet for every death on the roads another eleven people are injured badly enough to need hospital treatment. The shocking truth about road trauma is that recovery from these injuries can take years, and the pain may never go away. Trauma is the hidden tragedy of the road.

The word 'trauma' is especially appropriate to describe the injuries inflicted by road crashes. The medical profession uses it for any bodily injury or wound, but more literally it means 'a powerful shock that may have long-lasting effects' – an apt description for the sudden violence of a road crash.

Types of injuries

There is almost no limit to the type of injury that might be inflicted in a road crash: from ruptured spleens to severed limbs, broken skulls and fractured ribs. Often, a single individual will suffer several traumas. One example among thousands: the Melbourne Age recently reported the injuries received by a woman involved in a collision in rural Victoria: fractured hip and femur, lacerations to her face, arms and legs, stabbing wound to the throat, broken index finger, puncture wound below her elbow, and a 'de-gloving' injury to her hand (in which the skin had been peeled back when it hit something hard).

Another example: a West Australian motorcyclist, the victim of a driving error by another road user, struck an electricity pole head-on; he was in a coma for two weeks and will be in a wheelchair for life, brain-damaged and paralysed below the neck.

Spinal injury is perhaps the most feared of all injuries. According to a recent report by the Australian Institute of Health and Welfare, 50 per cent of the 261 spinal-cord injuries recorded in Australia from July 1999 to June 2000 were caused by road crashes: 31 per cent of victims were occupants of motor vehicles and 19 per cent were motorcyclists, pedestrians or cyclists. Of the vehicle occupants, more than 66 per cent suffered injuries to the cervical (upper) segments of the spine, resulting in tetraplegia, the impairment or loss of movement in the arms, trunk, legs and pelvic organs.

Trauma care

The best way to reduce the number of people hospitalised is to decrease the number of road crashes, but an effective system of trauma care is also essential. This must be quick and effective – unnecessary delays or errors in medical treatment can be fatal.

One of the tasks of ambulance paramedics when they arrive at a crash site is to assess the extent of injuries to victims and decide where they should be sent and by what means of transport. Those with severe injuries might not survive a long road trip, but local hospitals might not be equipped to treat them effectively; a helicopter may be needed to transport the victim to a more appropriate hospital. Once the victim is in the hospital, a nurse conducts what is known as triage – a preliminary assessment of the patient to determine the urgency with which he or she must receive treatment. Australian hospitals use the Australasian Triage Scale for this purpose.

The Australasian Triage Scale

Related site: Guidelines for the implementation of the Australian Triage Scale Presents the general principles of triage and gives explanations of the different triage categories. (Australasian College for Emergency Medicine)

Triage category	Maximum waiting time
1	patient requires immediate treatment
2	patient should be treated within ten minutes
3	patient should be treated within 30 minutes
4	patient should be treated within 60 minutes
5	patient should be treated within 120 minutes

Primary survey of the trauma patient

When a severely injured road trauma patient arrives at the emergency department, the medical team carries out what is called the primary survey, which is based on the ABCDE system.

• First, the airway (A) is checked for blockages: if necessary, a tube is inserted into the trachea to bypass difficult-to-remove blockages.

• Next, breathing (B) is assessed: is the patient experiencing any difficulties breathing? Breathing can be assisted by using a mask, or a machine called a ventilator. A punctured lung is treated by draining air from the chest.

• Third comes circulation and haemorrhage control (C): pressure bandages might be applied to control major bleeding; the patient's blood type is determined and transfusions made if necessary.

• D is for disability: the neurological status of the patient is assessed – awake and alert, responding to voices or pain, or unresponsive.

• Finally, E is for exposure: the patient's clothes are removed (usually by cutting) so that injuries are not missed in the assessment; the ambient air temperature is controlled to ensure the patient doesn't become hypothermic.

Secondary survey

The primary survey is followed by a secondary survey. This includes a complete physical examination and usually involves a range of tests, such as X-rays, CT scans, angiograms, focused abdominal sonography for trauma (FAST) and blood tests. One of the procedures performed in the secondary survey is called the log roll. This is the controlled turning of the patient to allow a detailed examination of the back of the head, neck and legs, and of the back, buttocks and rectum. The patient's ABCDE is continually monitored during this secondary phase.

After the emergency department

Some road trauma patients can be discharged from the hospital soon after treatment, but most require further care such as surgery or admission to an intensive care unit. Treatment and rehabilitation of severe injuries can take months or even years.

Trauma care in Australia

Australia's trauma care is of a generally high quality, but there's still plenty of room for improvement: one 6-year study estimated that improved diagnosis of road trauma victims might have saved 30 or more lives each year in Victoria alone.

Road trauma care is often particularly inadequate in rural areas. There are several reasons for this:

• rural crashes often involve higher speeds and are therefore more severe;

• the time taken for emergency services to be notified and to reach the crash scene is usually longer than in urban areas;

• rural ambulances are less well equipped to deal with road trauma, reducing the standard of care that can be administered at the crash site and during transportation; and

• rural hospitals are often less well equipped to deal with major road crashes, which may include several people with severe injuries.

The National Road Safety Strategy for the period 2001–2010 makes several recommendations for improving road trauma care. These include:

• installing emergency alert systems in cars to automatically notify emergency services of the location and severity of the crash;

• adopting common procedures for treatment to streamline the transfer of patients from rural to major hospitals;

• improving the number and training of doctors, paramedics and other emergency services personnel in the early management of severe trauma; and

• increasing the level of first-aid training among the general public.

Preventing road trauma

Related site: Designing road vehicles for pedestrian protection Discusses changes in car design to reduce pedestrian injuries in a pedestrian-vehicle crash. (British Medical Association, UK)

Improving car safety will also help. Seatbelts, airbags and other car-design features have increased the safety of car occupants and reduced the severity of the injuries, but more can be done. Car and safety-equipment manufacturers are continually trying to improve safety – for example, pedestrians hit by cars often receive severe head injuries when they collide with the car's bonnet. One European car-safety company is developing a rear-opening bonnet that pops up in collisions with pedestrians to reduce this risk.

In addition to improved car safety, other measures to help prevent road trauma include improvements in roads (eg, black spot programs), tougher enforcement directed at drink-driving and speeding, and educational programs for new and existing drivers.

Inevitably, though, people will continue to be hurt on Australian roads. When you next hear the lament of an ambulance siren, know that a system of care is going into action. Paramedics and rescue workers are rushing to the scene, and a team of doctors is standing by. But no matter how quick and efficient the system is, it can't fix broken backs, or damaged brains, and it can't take away the pain, although it might numb it a little. The sound of the siren is the start of something that may not have an end.

Related Nova topics

• Death-defying designs for car safety
• Fatal impact – the physics of speeding cars
• Alcohol and cars – a volatile mix
• A fair cop! Accurate breath analysis and speed detection
• Bitumen battles – the phenomenon of road rage

Activities

• Novice driver safety (Australian Transport Safety Bureau)
  • Crashes – describes the three most common crash types for young drivers then suggests practice ideas to help beginning drivers avoid these kinds of crashes.
  • Driving situations – each of the following driving situations is described, followed by a series of questions.
    • Intersection collisions
    • Driving for the conditions
    • Overtaking
    • Rear end collisions
    • Driving at night

• Student projects on road safety (Australian College of Road Safety)
  • Questions and answers – six questions and answers relating to road safety issues.

• New South Wales Higher School Certificate Online (Charles Sturt University, Australia)
  These activities focus on road and traffic-related injuries. Students are given relevant information (eg, a graph or a case study) for each of the following topics and asked to consider and analyse it:
  • Road and traffic-related injuries
  • The nature of the problem
  • Extent of the problem
  • Social determinants
  • Risk factors
  • Groups at risk
  • Speeding

• Roads and Traffic Authority, NSW (Australia)
  • Build your hazard perception skills – five interactive modules that use graphical animations to demonstrate the main concepts of hazard perception ('How close is safe?', 'Stopping distances', 'Safe gaps when turning', 'Safe gaps at intersections' and 'Scanning for hazards'). Instructions for using the modules are available.
    (Note: You will need to have a Version 4 or above Flash PlayerTM installed to view these modules.)

• Driver competency standards (Road Safety, Western Australia)
  • Manage crisis – provides suggestions on how to avoid a crash and describes the correct action to take after a crash.

• Newton's Apple (USA)
  • Airbags and collisions – students design ways to cushion an egg to protect it from impact.
  • Broken bones – students learn how to splint a fractured limb.

Further reading

Useful sites

Reports how unsafe road traffic systems are a serious threat to public health and development.
http://www.who.int/world-health-day/2004/infomaterials/world_report/en/

Australian Broadcasting Corporation

• Kids and road injuries (Health Matters, 8 June 2006)
  Summarises the behaviour of children of different ages in relation to road safety.
  http://www.abc.net.au/health/thepulse/s1658136.htm

• Trauma/spinal injuries/physiotherapy before major joint surgery (The Health Report, 5 April 2004)
  Discusses what can be done to reduce the number of traffic deaths and injuries and how we can effectively deal with trauma.
  http://www.abc.net.au/rn/talks/8.30/helthrpt/stories/s1078599.htm

Road safety (Australian Transport Safety Bureau)

Provides a range of information about many aspects of road safety.
http://www.atsb.gov.au/road/safety.aspx

The National Road Safety Strategy 2001-2010 (Australian Transport Council)

Presents a national framework for road safety initiatives. The target of the strategy is to reduce the annual number of road fatalities per 100,000 population by 40 per cent.
http://www.atcouncil.gov.au/documents/pubs/strategy.pdf

Motoring Directions (Australian Automobile Association)

A magazine covering topics of interest to motorists. For example, articles in a recent issue included 'Road safety – changing attitudes' and 'Building safer cars'. Each issue is available in PDF format.
http://www.aaa.asn.au/publications/directions.php

Crash safety (Safe Drive Training, Australia)

A chatty coverage of safe driving, crash statistics, new vehicle safety systems and the importance of loading your car safely.
http://www.sdt.com.au/safedrive-directory-CRASHSAFETY.htm

ANCAP crash tests (NRMA, Australia)

The Australian New Car Assessment Program (ANCAP) carries out crash tests to compare how well cars protect drivers and passengers in serious front and side crashes. From this page, you can check results of crash tests on a particular make and model of car, or look at a category of car (eg, small cars, 4WDs).
http://www.mynrma.com.au/ancap_1.asp

Primary and secondary data sources for the study of road crashes in Australia (Edith Cowan University, Australia)

Documents the variety and relative usefulness of road crash databases, and suggests ways the databases could be improved.
http://www.business.ecu.edu.au/schools/afe/wps/papers/wp002mg.htm

2001 Road Safety Conference papers (Monash University, Australia)

• Australia's National Crash In-depth Study progress report
  Presents results of a study looking at vehicle crash performance and occupant injuries.
  http://www.monash.edu.au/oce/roadsafety/abstracts_and_papers/075/ANCIS_report.pdf

• Achieving the national strategy target
  Discusses the challenge in reducing road fatalities by 40 per cent by 2010 and reviews methods being pursued in Europe.
  http://www.monash.edu.au/oce/roadsafety/abstracts_and_papers/015/Vision_zero.pdf

• Vision Zero requires five star road safety system
  Discusses the ramifications of achieving zero fatality on our roads and the changes in attitude, advances in technology and massive investments that will be required.
  http://www.monash.edu.au/oce/roadsafety/abstracts_and_papers/135/LWrs2001revised.pdf

• Emergency Response Equipment Receptacles (ERER)
  Describes a project to place five large stainless steel containers containing emergency response equipment (ERER) along a thousand kilometres of the Eyre Highway to support victims of road crashes.
  http://www.monash.edu.au/oce/roadsafety/abstracts_and_papers/052/Melbourne - ERER final paperip.pdf

Glossary

angiogram. An X-ray visualisation of blood vessels showing their condition. To be able to see blood vessels in an X-ray image, the vessels are injected with dye.

black spot. A term used to refer to a section of road that is regarded as a high-risk location for car crashes. Black spot programs are designed to reduce the crash risk in these areas by improving the physical conditions or management (eg, building roundabouts, improving lighting). For more information see Black spot program (Department of Transport and Regional Services, Australia).

blood type. Refers to any one of the various types (or groups) into which our blood is classified. Blood types are based on differences in molecules (proteins and carbohydrates) on the surface of red blood cells. For transfusions, the blood type of the donor and the recipient must match. For more information see Blood types – what are they? (Australian Red Cross), and Blood groups, blood typing and blood transfusions (Nobelprize.org, Sweden).

CT scans. A series of X-ray images of the body. The body is X-rayed from many directions and the results are analysed by a computer. The computer generates images of cross-sections (slices) of the body. CT scans show details of the shape and location of soft tissues, as well as bones and blood. Other names for this technique are computerised tomography, CAT scan and computerised axial tomography. For more information see CAT scans (University of Colorado at Boulder, USA).

electromagnetic radiation. Electromagnetic radiation is simply energy which travels through space at about 300,000 kilometres per second – the speed of light. We imagine radiation moving like a wave. The distance between two adjacent wave crests is called a wavelength. The shorter the wavelength, the more energetic the radiation is said to be. Also, the shorter the wavelength, the greater the frequency of the radiation. Other than wavelength, frequency and energy there is no difference between a radio wave, an X-ray and the colour green. They all possess the same physical nature. For more information see Back to Basics: Electromagnetic radiation (Australian Academy of Science) and Electromagnetic Spectrum (NASA Goddard Space Flight Center, USA).

Focused Abdominal Sonography for Trauma (FAST). An ultrasound examination of the abdomen to determine if there is fluid present in body cavities. FAST can detect haemorrhaging and helps medical staff to decide what further procedures are necessary. (Some experts use FAST to stand for Focused Assessment Sonography for Trauma.)

ultrasound. The use of sound waves with frequencies above the range of normal hearing to examine structures inside the body. For more information see How ultrasound works (How Stuff Works, USA).

X-ray. An image produced by sending a beam of X-rays (very high energy electromagnetic radiation) through the body. Different tissues in the body have different densities and absorb and deflect the X-rays differently. A camera records on photographic film the varying levels of X-rays that have passed through the body. For more information see What are X-rays? (MCG Health System, USA) and How X-rays work (How Stuff Works, USA).