We need a wake-up call

A study reviewing the causes of major trauma in Alberta over the last decade finds that most cases were largely preventable-and only further proves that we need to hold each other accountable in order to see a change.

Jessica McKee was formerly the provincial trauma epidemiologist at the School of Public Health's Injury Prevention Centre when she published the paper online at BioMed Central earlier this year-she is now the Clinical Director at Innovative Trauma Care Inc. and continues to look for solutions to assist trauma surgeons. The paper was co-authored with Sandy Widder, an associate professor in the Department of Surgery in the Faculty of Medicine & Dentistry and director of Trauma Services at the University of Alberta Hospital, who further collaborated with the University of Calgary to gather data.

Health care centres like the University of Alberta Hospital use an intake form that checks a patient's blood alcohol content following a major trauma incident. McKee and Widder wanted to examine that registry to determine how significant alcohol was over the past ten years.

"I wanted to see how we're doing as a whole and hopefully identify opportunities for injury prevention," McKee says. "Because if the biggest cause of trauma is preventable and you can decrease those rates, you decrease a major burden on the health care system."

Ultimately they found that almost 40 per cent of all major trauma cases were alcohol-related, and that 82 per cent of those found to be intoxicated had a blood alcohol content (BAC) well over the legal driving limit. While drunk-driving incidents do count for some major trauma (25.4 percent), the fact is that the true scope of injuries caused by alcohol use is far larger than what is being captured.

"We found that we are not screening as many people as we could or should when they enter the Emergency Room," Widder says. "This could be because of age or stereotype, but in truth everyone should have their blood alcohol levels drawn."

McKee points out that the data gathered for this study only included major trauma. The average injury severity score (ISS) for this study was 21-in these cases the patient was severely hurt and had injured two or more body systems. But if a patient, for example, broke both of their arms and legs in an alcohol-related accident, their ISS score would only be 9-and hasn't been included in this study.

"Think about any long weekend," she goes on. "Think about how many bar fight victims take up emergency beds. Think about the incidents where a patient may not have required a hospital admission, but they required an ambulance. There are those who go to their regular doctor or a medicentre for treatment. And, of course, there are the domestic violence cases that alcohol contributes to as well."

"When you add it up, these preventable injuries cause a huge burden on our medical system and are costing us billions of dollars per year."

"The prevalence of alcohol use, despite all of our messaging, is still a province-wide issue," adds Widder. "Having a positive alcohol level is associated with violence, with other drug and substance use and abuse. We need to focus on all of these issues with intervention and not just have a very limited view of the problem."

Accessibility to alcohol is a contributing factor to these results; besides numerous bars and restaurants, retail liquor stores are essentially open from 11 a.m. to 2 a.m. every day of the week. Just this past April, Edmonton's City Council voted to allow more liquor stores in the suburbs, bypassing a weakly-enforced rule where liquor stores couldn't operate within 500 metres of each other.

There are strategies to educate patients about their drinking. Audits-a voluntary questionnaire conducted in hospitals-can serve as an eye-opening moment for patients who had no idea what their BAC was at the time of their injury. The study found that of those who positively screened for alcohol use, nearly 40 per cent had a BAC more than double the legal driving limit (the legal limit is 17.4 mmol/L; 38 per cent had BAC of over 39.4 mmol/L).

"We as a society don't know what drinking means, or what being drunk looks like," McKee says. "If you order a nine-ounce glass of wine, that counts as two standard drinks. If you have three of those glasses in one night, you are technically binge drinking-but most of us don't see it that way."

"We know that there are vulnerable populations out there," says Widder. "We also know that people who arrive intoxicated are often repeat offenders" (In fact, when data was pulled for the study, some patients appeared in the registry multiple times). "In order to be best able to offer interventions to these people, we need to know who needs the help."

"Unfortunately we don't have adequate resources for those people who want and need help. We do have a social worker who works very closely with members of the trauma team and does offer some basic interventions, but in terms of ongoing outpatient interventions, this is something that we cannot sustain as a trauma service."

Health care workers have the opportunity to provide the patient with support and resources like Alcoholics Anonymous as a way to help during the audit process. But more often than not, trauma surgeons will mend their patients, only to have them return to the streets and highways without treating the underlying issue of their alcohol abuse.

"Complete government control or prohibition is not necessarily the answer, but we do need programs that teach us strategies to deal with drinking," McKee explains. "It's not necessarily about teaching them right or wrong and putting a moral connotation to it. It's about providing them the facts and making sure they are informed so they can make the best decisions. If we learn this young enough and if we can take the 'magic' out of drinking, then we should be able create a shift that lowers the risk of these events."

Widder sums up the entire issue perfectly: "Trauma is actually the one disease that is curable, if we focused on injury prevention."