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Adult Pedestrian Traffic Trauma in Cape Town with Special Reference to the Role of Alcohol

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Adult Pedestrian Traffic Trauma in Cape Town with Special Reference to the Role of Alcohol ADULT PEDESTRIAN TRAFFIC TRAUMA IN CAPE TOWN WITH SPECIAL REFERENCE TO THE ROLE OF ALCOHOL Town Margaret Mary Peden BSc NursingCape (UCT), Diploma in Intensive Nursing Science Cum Laude (GSH), BSc Med Hons of(Epi) Cum Laude (Stell) University Thesis presented for the degree of DOCTOR OF PHILOSOPHY Faculty of Medicine Department of Surgery UNIVERSITY OF CAPE TOWN January 1997 The copyright of this thesis vests in the author. No quotation from it or information derived from it is to be published without full acknowledgement of the source. The thesis is to be used for private study or non- commercial research purposes only. Published by the University of Cape Town (UCT) in terms of the non-exclusive license granted to UCT by the author. University of Cape Town ADULT PEDESTRIAN TRAFFIC TRAUMA IN CAPE TOWN WITH SPECIAL REFERENCE TO THE ROLE OF ALCOHOL Margaret Mary Peden DECLARATION I, Margaret Mary Peden, hereby declare that the work on which this thesis is based is my original work (except where acknowledgements indicate otherwise) and that neither the whole work nor any part of it has been, is being, or is to be submitted for another degree in this or any other University. I empower the University to reproduce for the purpose of research either the whole or any portion of the contents in any manner whatsoever. I acknowledge, with thanks, the guidance of my supervisors. Signature removed SIGNATURE DATE DEDICATED to All Trauma Nurses at Groote Schuur Hospital Their dedication and commitment to the care of injured patients has been an inspiration to the researcher. ii ACKNOWLEDGEMENTS It is impossible to acknowledge every person who has made a contribution to this study, but I extend my sincere thanks to them all. Special thanks are due to: • Dr Johan van der Spuy, Head of the MRC National Trauma Research Programme, my boss, supervisor and mentor extraordinary, who had enough faith in me to believe that I could do justice to a topic so close to his heart; • Professor Rosemarie Hickman, Head of Surgical Research, UCT for co­ supervising this thesis; • Professor John Knottenbelt, former Head of the Trauma Unit, Groote Schuur Hospital, for his supervision of this thesis prior to his departure to England and his continued support and assistance via e-mail subsequently; • my colleagues (past and present) at the National Trauma Research Programme: Anneke du Toit, Malinda Steenkamp, Nolubabalu Sidzumo, Anthea van Blerk and Dr Blanche de Wet. Special thanks to Naeema Abrahams who was always willing to assist with data capture when the unit was busy; • members of the Cape Town City Traffic Department, particularly Mr Frank Davies and Wouter Smit; • Mr Bjorn van Oordt, Mrs Myrtle van Vuuren and the librarians at the Directorate of Traffic Safety; • the Medical Superintendent of Groote Schuur Hospital and staff members of the Trauma Unit, Trauma Admission Ward and Surgical and Respiratory Intensive Care Units, particularly Lena Scheepers, Hawa Christians, Dr Peter Bautz, Dr Ravi Oodit, Nicki Fouche and Yvonne Rabe; • all the clerks in Trauma Unit who conscientiously bleeped me every time a pedestrian presented; • Nelmarie du Toit and Shehaan Hendricks at the Child Accident Prevention Foundation of South Africa; iii • the 1993 intake of Carinus Nursing College Trauma Students who assisted with some data capture; • Dr Dirk van Schalkwyk, Dr Carl Lombard, Dr Debbie Bradshaw and Ilse Stander for statistical advice; • Professor Deon Knobel, Dr Zip Scholtz and Dr Len Lerer at the Department of Forensic Medicine, UCT; • Mr Morris Stokol and staff at the Chemical Forensic Laboratory, Department of Health; • Dr Carolyn Fowler for encouraging e-mails from the USA; • Professor J.P. van Niekerk, Karen Morris and Gill Goldberg at Medical School, UCT and Jane Hutchings at the Doctoral Degrees Board, UCT, for their patience and assistance; • the patients who formed the study population; • Sue Blyth for editing the manuscript and for unwavering encouragement; • Thea and Nicholas Marais for patiently checking references, page numbers and tables with me and for general support throughout the years • Dave Marais for his computer assistance and advice; • all my friends, especially Ann Tilney for support, understanding and practical assistance; • my mother, brother and sister for love, support and encouragement, albeit from afar. FINANCIAL SUPPORT This project was funded by a "Request for Proposals" grant from the Medical Research Council. The opinions expressed in this thesis are those of the researcher and do not necessarily represent those of the Medical Research Council. iv ABSTRACT ADULT PEDESTRIAN TRAFFIC TRAUMA IN CAPE TOWN WITH SPECIAL REFERENCE TO THE ROLE OF ALCOHOL Margaret Mary Peden National Trauma Research Programme, Medical Research Council PO Box 19070, Tygerberg, 7505 January 1997 This research is a prospective, descriptive survey of adult pedestrian injuries in Cape Town. It profiles 'at risk' pedestrians and describes their injuries, injury severity and outcome. The role which alcohol plays in these collisions is threaded through the thesis. Since no study of this nature has been done in South Africa, it provides baseline data on the epidemiology, alcohol-relatedness, clinical presentation and prevention of adult pedestrian collisions in the metropole. Data were collected prospectively on all injured pedestrians who presented consecutively, within six hours of being injured, to the Trauma Unit of Groote Schuur Hospital over a nine week period in 1993. Data were also gathered retrospectively from the state mortuary on all pedestrians who died before reaching hospital during the same time period. A total of 227 patients were included in the study. Data gathered included demographics, physiological response to injury, anatomical nature and severity of injuries as well as progress and outcome. Injuries were assessed and scored using the Abbreviated Injury Score ( 1990 revision) and the New Injury Severity Score. Alcohol consumption was assessed using four measures, viz. self-evaluation, clinical assessment, breath alcohol analysis and blood alcohol concentration (SAC). Data were analysed using SAS version 6. The study recorded a very high incidence of alcohol intoxication among injured pedestrians in Cape Town. This is highly suggestive of a causal link. One hundred and forty-one patients (62.1%) were found to have positive BACs; more than 40% had BACs in excess of 0.20 g/100ml. SAC positive pedestrians were found to have more severe injuries, to require longer hospitalisation periods and to need more complex management. They consequently cost more to treat than their sober counterparts. The comparison between the four methods of alcohol assessment revealed that self-evaluation and clinical assessment were poor screening tools. Breath alcohol analysis, using a Lion Alcolmeter S-D2, had a high degree of accuracy when compared to the SAC, which remains the 'gold standard'. It is therefore recommended that all traffic trauma patients be subjected to breath analysis. The study also generated recommendations for the prevention of pedestrian collisions. These address pre-crash, crash and post-crash factors. Control of drunken driving and walking, as well as road safety education, particularly to pedestrians, are key issues. However, there remains a need for improved road engineering and better monitoring of the roadworthiness of vehicles. This thesis highlights the severity of alcohol-related pedestrian injuries and the importance of preventative strategies. V GLOSSARY The following abbreviations have been used throughout this thesis, both in text as well as figures and tables. ABS Anti-lock Braking System Al Anatomic Index AIDS Acquired Immune Deficiency Syndrome AIS Abbreviated Injury Scale AIS 90 Abbreviated Injury Scale, 1990 Revision ANC African National Congress AOD Alcohol and Other Drugs APACHEII Acute Physiology and Chronic Health Evaluation II ASCOT A Severity Characterization of Trauma ATLS Advanced Trauma Life Support AUDIT Alcohol Use Disorder Test BAC Blood Alcohol Concentration BAC +ve Positive Blood Alcohol Concentration, i.e. ~0.01 g/100ml BAC-ve Zero Blood Alcohol Concentration BrAC Breath Alcohol Concentration BP Blood Pressure CAGE Alcohol use scale CAIS Condensed Abbreviated Injury Scale CDT Carbohydrate-deficient transferrin CERSA Centre for Epidemiological Research in Southern Africa Cl Confidence Interval CMS Cape Metropolitan Study CRAMS CRAMS Scale CRIS Comprehensive Injury Scale CSIR The Council for Scientific and Industrial Research CT Computerised Tomography DALY Disability Adjusted Life Years DEF DEFinitive Methodology Df Degrees of freedom DOA Dead on arrival DSM-IV Diagnostic Statistical Manual of Mental Disorders, Forth Edition DT Delirium Tremens DTS Directorate of Traffic Safety ED Emergency Department FCI Functional Capacity Index g/100 ml grams per 100 millilitre GCS Glasgow Coma Scale GGT Gamma-glutamyltransferase GSH Groote Schuur Hospital HICDA-8 Hospital International Classification of Diseases, 8th Revision HPT Haemopneumothorax ICU Intensive Care Unit vi ICD International Classification of Diseases ICD-10 International Classification of Diseases, 10th Edition IIS Injury Impairment Scale IQR Inter-quartile range ISS Injury Severity Score km/hr Kilometre per hour LDV Light delivery vehicle or 'Bakkie' MAIS Maximum Abbreviated Injury Scale MAST Michigan Alcohol Screening Test MCV Mean Corpuscular Volume METRO Medical Emergency Transport and Rescue Organisation MISS Modified Injury Severity Scale MRC Medical
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