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Open Access Publications from the University of California

Volume 12, Issue 3, 2011

Volume 12 Issue 3 2011

Injury Control and Response

Adoption of the 2006 Field Triage Decision Scheme for Injured Patients

Background: When emergency medical services (EMS) providers respond to the scene of an injury, they must decide where to transport the injured patients for further evaluation and treatment. This is done through a process known as “field triage”, whereby a patient’s injuries are matched to the most appropriate hospital. In 2005-2006 the National Expert Panel on Field Triage, convened by the Centers for Disease Control and Prevention and the National Highway Traffic Safety Administration, revised the 1999 American College of Surgeons Committee on Trauma Field Triage Decision Scheme. This revision, the 2006 Field Triage Decision Scheme, was published in 2006.

Methods: State Public Health departments’ and EMS’ external websites were evaluated to ascertain the current status of implementation of the 2006 Field Triage Decision Scheme.

Results: Information regarding field triage was located for 41 states. In nine states no information regarding field triage was available on their websites. Of the 41 states where information was located, seven were classified as “full adopters” of the 2006 Field Triage Decision Scheme; nine were considered “partial adopters”; 17 states were found to be using a full version or modification of the 1999 Field Triage Decision Scheme; and eight states were considered to be using a different protocol or scheme for field triage.

Conclusion: Many states have adopted the 2006 Decision Scheme (full or partial). Further investigation is needed to determine the reasons why some states do not adopt the guidelines. [West J Emerg Med. 2011;12(3):275-283.]

Suburban Poverty: Barriers to Services and Injury Prevention among Marginalized Women Who Use Methamphetamine

Objective: This paper aims to identify the needed healthcare and social services barriers for women living in suburban communities who are using or have used methamphetamine. Drug users are vulnerable to injury, violence and transmission of infectious diseases, and having access to healthcare has been shown to positively influence prevention and intervention among this population. Yet little is known regarding the social context of suburban drug users, their risks behaviors, and their access to healthcare.

Methods: The data collection involved participant observation in the field, face-to-face interviews and focus groups. Audio-recorded in-depth life histories, drug use histories, and resource needs were collected from 31 suburban women who were former or current users of methamphetamine. The majority was drawn from marginalized communities and highly vulnerable to risk for injury and violence. We provided these women with healthcare and social service information and conducted follow-up interviews to identify barriers to these services.

Results: Barriers included (1) restrictions imposed by the services and (2) limitations inherent in the women’s social, economic, or legal situations. We found that the barriers increased the women’s risk for further injury, violence and transmission of infectious diseases. Women who could not access needed healthcare and social resources typically used street drugs that were accessible and affordable to self-medicate their untreated emotional and physical pain.

Conclusion: Our findings add to the literature

on how healthcare and social services are related to injury prevention. Social service providers in the suburbs were often indifferent to the needs of drug-using women. For these women, health services were accessed primarily at emergency departments (ED). To break the cycle of continued drug use, violence and injury, we suggest that ED staff be trained to perform substance abuse assessments and provide immediate referral to detoxification and treatment facilities. Policy change is needed for EDs to provide the care and linkages to treatment that can prevent future injuries and the spread of infectious diseases. [West J Emerg Med. 2011;12(3):284-292.]


Injury Secondary to Antiretroviral Agents: A Retrospective Analysis of a Regional Poison Center Database

Introduction: Poisoning is an increasingly important cause of injury in the United States. In 2009 poison centers received 2,479,355 exposure reports, underscoring the role of poison centers in intentional and unintentional injury prevention. Antiretroviral (ARV) agents are commonly prescribed drugs known to cause toxicity, yet the frequency of these incidents is unknown. The objectives of this study were to quantify the number of reported cases of toxicity secondary to ARV agents at a regional poison center, and to describe the circumstances and clinical manifestations of these poisonings.

Methods: We conducted a retrospective review of poison center records between December 1, 2001, and January 7, 2010.

Results: One hundred sixty-two exposures to ARV agents were reported to the poison center, of which 30% were intentional and 70% were unintentional. Three patients developed major toxicity and no deaths occurred. The remaining patients developed moderate and minor effects as defined by poison center guidelines.

Conclusion: ARV drug toxicity appears to be infrequently reported to the poison center. Fatal and major toxicities are uncommon, and intentional overdoses are associated with a more serious toxicity. Educational efforts should encourage clinicians to report toxicities related to the use of ARV agents to poison centers in order to better study this problem. [West J Emerg Med. 2011;12(3):293-295.]

Intentional Ethylene Glycol Poisoning Increase after Media Coverage of Antifreeze Murders

Background: The media can have a profound impact on human behavior. A sensational murder by ethylene glycol (EG) poisoning occurred in our state. The regional media provided extensive coverage of the murder. We undertook this investigation to evaluate our incidence of EG poisoning during the timeframe of before the first report linking a death to ethylene glycol to shortly after the first murder trial.

Methods: Descriptive statistics and linear regression were used to describe and analyze the number of EG cases over time. A search of the leading regional newspaper’s archives established the media coverage timeline.

Result: Between 2000 and 2004, our poison center (PC) handled a steady volume of unintentional exposures to EG [range: 105–123 per year, standard deviation (SD)=7.22]. EG exposures thought to be suicidal in intent increased from 12 cases in 2000 to 121 cases in 2004. In the 19 months prior to the first media report of this story, our PC handled a mean of 1 EG case with suicidal intent per month [range: 0–2, SD=.69]. In the month after the first media report, our PC handled 5 EG cases with suicidal intent. When media coverage was most intense (2004), our PC received a mean of 10 EG suicidal-intent calls per month [range: 5–17, SD=3.55]. Although uncommon, reports of malicious EG poisonings also increased during this same period from 2 in 2000 to 14 in 2004.

Conclusion: Media coverage of stories involving poisonings may result in copycat events, applicable to both self-poisonings and concern for malicious poisonings. Poison centers should be aware of this phenomenon, pay attention to local media and plan accordingly if a poisoning event receives significant media coverage. The media should be more sensitive to the content of their coverage and avoid providing “how to” poisoning information. [West J Emerg Med. 2011;12(3):296-299.]

Suicide Fads: Frequency and Characteristics of Hydrogen Sulfide Suicides in the United States

Objective: To assess the frequency of hydrogen sulfide (H2S) suicides and describe the characteristics of victims in the United States (U.S.) since the technique became common in Japan in 2007.

Methods: To ascertain the frequency of intentional H2S related deaths in the U.S. prior to the start of the Japanese trend in 2007, we searched the multiple-cause-of-death data from the National Vital Statistics System. To collect as much information about the victims as possible, we sent an email to the National Association of Medical Examiners (NAME) listserv asking for their cooperation in identifying cases of H2S suicide. To identify cases that were not voluntarily reported by medical examiners but were reported by the media, we conducted Google searches using the search terms: “hydrogen sulfide suicide,” “H2S suicide,” “detergent suicide,” “chemical suicide,” and “suicide fad.” We obtained all available autopsy reports and abstracted information, including the site of the incident, the presence of a note warning others about the toxic gas and the demographic characteristics of the victims. We contacted medical examiners who potentially had custody of the cases that were identified through media reports and requested autopsies of these victims. When unable to obtain the autopsies, we gathered information from the media reports.

Results: Forty-five deaths from H2S exposure occurred in the U.S. from 1999 to 2007, all unintentional. Responses from the NAME listserv yielded autopsy reports for 11 victims, and Google searches revealed an additional 19 H2S suicides in the U.S. since 2008. Overall (n=30), two cases were identified during 2008, 10 in 2009, and 18 in 2010. The majority of victims were white males, less than 30-years-old, left a warning note, and were found in cars. There were five reports of injuries to first responders, but no secondary fatalities.

Conclusion: H2S suicides are increasing in the U.S., and their incidence is probably underestimated by public health officials and physicians. First responders are at risk when assessing these victims due to the severe toxicity of the gas. Emergency providers must be aware of H2S suicides to educate others and care for the rare survivor. [West J Emerg Med. 2011;12(3):300-304.]

Youth Violence

Pre-Teen Alcohol Use as a Risk Factor for Victimization and Perpetration of Bullying among Middle and High School Students in Georgia

Objective: We examined the association between pre-teen alcohol use initiation and the victimization and perpetration of bullying among middle and high school students in Georgia.

Methods: We computed analyses using data from the 2006 Georgia Student Health Survey (N=175,311) of students in grades 6, 8, 10 and 12. The current analyses were limited to students in grades 8, 10 and 12 (n=122,434). We used multilogistic regression analyses to determine the associations between early alcohol use and reports of both victimization and perpetration of bullying, perpetration only, victimization only, and neither victimization or perpetration, while controlling for demographic characteristics, other substance use, peer drinking and weapon carrying.

Results: Pre-teen alcohol use initiation was significantly associated with both bullying perpetration and victimization relative to non drinkers in bivariate analyses (OR=3.20 95%CI:3.03-3.39). The association was also significant between pre-teen alcohol use initiation and perpetration and victimization of bullying in analyses adjusted for confounders (Adj.OR=1.74; 95%CI:1.61-1.89). Overall, findings were similar for boys and girls.

Conclusion: Pre-teen alcohol use initiation is an important risk factor for both the perpetration and victimization of bullying among boys and girls in Georgia. Increased efforts to delay and reduce early alcohol use through clinical interventions, education and policies may also positively impact other health risk behaviors, including bullying. [West J Emerg Med. 2011;12(3):305-309.]

Associations between Electronic Media Use and Involvement in Violence, Alcohol and Drug Use among United States High School Students

Objective: We identified associations between time spent watching television and time spent playing video or computer games or using computers and involvement in interpersonal violence, alcohol and drug use in a nationally representative sample of United States high school students.

Methods: We analyzed data from the 2007 national Youth Risk Behavior Survey. Exposure variables were time spent watching television and time spent playing computer or video games or using computers (hereafter denoted as “computer/video game use”) on an average school day; outcome variables included multiple measures assessing involvement in violence and alcohol or drug use. Chi-square tests were used to identify statistically significant associations between each exposure variable and each of the outcome variables. We used logistic regression to obtain crude odds ratios for outcome variables with a significant chi-square p-value and to obtain adjusted odds ratios controlling for sex, race, and grade in school.

Results: Overall, 35.4% (95% CI=33.1%-37.7%) of students reported frequent television (TV) use and 24.9% (95% CI=22.9%-27.0%) reported frequent computer/video game use. A number of risk behaviors, including involvement in physical fights and initiation of alcohol use before age 13, were significantly associated with frequent TV use or frequent computer/video game use, even after controlling for sex, race/ethnicity and grade.

Conclusion: Findings highlight the need for additional research to better understand the mechanisms by which electronic media exposure and health-risk behaviors are associated and for the development of strategies that seek to understand how the content and context (e.g., watching with peers, having computer in common area) of media use influence risk behaviors among youth. [West J Emerg Med. 2011;12(3):310-315.]

A Case Study with an Identified Bully: Policy and Practice Implications

Objective: Bullying is a serious public health problem that may include verbal or physical injury as well as social isolation or exclusion. As a result, research is needed to establish a database for policies and interventions designed to prevent bullying and its negative effects. This paper presented a case study that contributed to the literature by describing an intervention for bullies that has implications for research, practice and related policies regarding bullying.

Methods: An individualized intervention for an identified bully was implemented using the Participatory Culture-Specific Intervention Model (PCSIM; Nastasi, Moore, & Varjas, 2004) with a seventh-grade middle school student. Ecological and culture-specific perspectives were used to develop and implement the intervention that included psychoeducational sessions with the student and consultation with the parent and school personnel. A mixed methods intervention design was used with the following informants: the target student, the mother of the student, a teacher and the school counselor. Qualitative data included semi-structured interviews with the parent, teacher and student, narrative classroom observations and evaluation/feedback forms filled out by the student and interventionist. Quantitative data included the following quantitative surveys (i.e., Child Posttraumatic Stress Reaction Index [CPTS-RI] and the Behavior Assessment Scale for Children, 2nd Edition). Both qualitative and quantitative data were used to evaluate the acceptability, integrity and efficacy of this intervention.

Results: The process of intervention design, implementation and evaluation are described through an illustrative case study. Qualitative and quantitative findings indicated a decrease in internalizing, externalizing and bullying behaviors as reported by the teacher and the mother, and a high degree of acceptability and treatment integrity as reported by multiple stakeholders.

Conclusion: This case study provided important contributions by describing an intervention that is targeted to specific needs of the bully by designing culture specific interventions and working with the student’s unique environmental contexts. Additional contributions included the use of mixed methods to document acceptability, integrity and efficacy of an intervention with documented positive effects in these areas. In addition, implications for policy and practice related to the treatment of students identified as bullies and future research needs are discussed. [West J Emerg Med 2011; XX(X)XX-XX].

Intimate Partner and Sexual Violence

Dyadic Characteristics and Intimate Partner Violence among Men Who Have Sex with Men

Objective: Although the research community has begun to recognize intimate partner violence (IPV) as an important issue in same-sex relationships, there has been a lack of attention to characteristics of these relationships that may be associated with IPV. In particular, there has been a lack of attention paid to the associations between dyadic characteristics and IPV in same-sex relationships. This paper examined associations between dyadic characteristics, including relationship satisfaction, communal coping and efficacy, and perpetrating and experiencing IPV among a sample of United States men who have sex with men (MSM). Methods: We collected data via an online survey with 528 MSM, who were greater than 18 years of age and reported at least one male sex partner in the last 12 months. The analysis examined dyadic factors associated with reporting of experiencing and perpetrating emotional violence, physical violence, and sexual violence. Results: The prevalence of violence in the sample ranged from nine percent reporting perpetrating sexual violence to 33% of men reporting experiencing emotional violence. MSM who reported greater satisfaction with their relationship or who reported a higher degree of concordance with their partner on lifestyle choices were less likely to report experiencing or perpetrating emotional violence. MSM who perceived a stigma to being in a male same-sex couple were less likely to report experiencing or perpetrating sexual violence. Conclusion: The results presented here demonstrate high levels of IPV among MSM and that dyadic characteristics are associated with the occurrence of IPV. Understanding relationship characteristics associated with increased IPV among same-sex male couples can contribute to the development of more accurate IPV screening tools, and more sensitively and appropriately designed intervention messages. [West J Emerg Med. 2011;12(3):324-332.]

Rape Victimization and High Risk Sexual Behaviors: A Longitudinal Study of African-American Adolescent Females

Objectives: African-American women are affected by disproportionately high rates of violence and sexually transmitted infections (STI)/human immunodeficiency virus (HIV) infection. It is imperative to address the intersection of these two urgent public health issues, particularly as these affect African-American adolescent girls. This study assessed the prevalence of rape victimization (RV) among a sample of African-American adolescent females and examined the extent to which participants with a history of RV engage in STI/HIV associated risk behaviors over a 12-month time period.

Methods: Three hundred sixty-seven African-American adolescent females ages 15-21, seeking sexual health services at three local teenager-oriented community health agencies in an urban area of the Southeastern United States, participated in this study. Participants were asked to complete an audio computer-assisted self-interview (ACASI) at baseline, six- and 12-month follow-up. We assessed sociodemographics, history of RV and sexual practices. At baseline, participants indicating they had experienced forced sex were classified as having a history of RV.

Results: Twenty-five percent of participants reported a history of RV at baseline. At six- and 12-months, victims of RV had significantly lower proportions of condom-protected sex (p=.008), higher frequency of sex while intoxicated (p=.005), more inconsistent condom use (p=.008), less condom use at last sex (p=.017), and more sex partners (p=.0001) than non-RV victims. Over the 12-month follow-up period, of those who did not report RV at baseline, 9.5% reported that they too had experienced RV at some point during the 12-month time frame.

Conclusion: African-American adolescent females who experience RV are engaging in more risky sexual behaviors over time than non-RV girls, thereby placing themselves at higher risk for contracting STIs. In light of the results from this unique longitudinal study, we discuss considerations for policies and guidelines targeting healthcare, law enforcement and educational and community settings. The complexities of RV screening in healthcare settings are examined as is the need for tighter collaboration between healthcare providers and law enforcement. Finally, we consider the role of prevention and intervention programs in increasing awareness about RV as well as serving as an additional safe environment for screening and referral. [West J Emerg Med. 2011;12(3):333-342.]

Intimate Partner Violence and Sexual Risk-taking among Men Who Have Sex with Men in South Africa

Objective: A growing body of literature suggests that men who have sex with men (MSM) represent a high risk group for human immunodeficiency virus (HIV) infection in Africa, but are often overlooked in the development of HIV interventions and programming. Little attention has been paid to the presence of intimate partner violence (IPV) among MSM in African settings. This paper examines reporting of IPV among a sample of predominantly white, gay internet-recruited MSM in South Africa and examines associations between IPV and sexual risk-taking.

Methods: Internet-using MSM were recruited through selective placement of banner advertisements on Eligibility criteria were over 18-years-old, residence in South Africa and self-reporting of recent male-male sexual behavior. There were 777 eligible respondents, of which 521 MSM with complete data are included in the final analysis. Ninety percent of the sample reported a White/ European race, and 96% self-identified as gay.

Results: The prevalence of IPV, both experienced and perpetrated, was relatively high, with 8% of men reporting having experienced recent physical IPV and 4.5% of men reporting recent experiences of sexual IPV. Approximately 4.5% of MSM reported recently perpetrating physical IPV, while the reporting of perpetration of recent sexual IPV was much lower at 0.45%. Reporting of experiencing and perpetration of physical IPV was significantly associated with race, level of education and reporting recent unprotected anal sex. Reporting of experiencing recent sexual IPV was significantly associated with reported experiences of homophobia.

Conclusion: There is a limited amount of data on IPV within same-sex relationships in South Africa, and the results presented here suggest that the prevalence of IPV within this White/European and gay population is cause for concern. Collection of IPV data through surveys administered via social networking sites is feasible and represents a way of reaching otherwise marginalized population groups in IPV research; although in this instance Black Africans and MSM who did not identify as gay were severely under-represented. [West J Emerg Med. 2011;12(3):343-347.]

Treatment, Services and Follow-up for Victims of Family Violence in Health Clinics in Maputo, Mozambique

Background: Family violence (FV) is a global health problem that not only impacts the victim, but the family unit, local community and society at large.

Objective: To quantitatively and qualitatively evaluate the treatment and follow up provided to victims of violence amongst immediate and extended family units who presented to three health centers in Mozambique for care following violence.

Methods: We conducted a verbally-administered survey to self-disclosed victims of FV who presented to one of three health units, each at a different level of service, in Mozambique for treatment of their injuries. Data were entered into SPSS (SPSS, version 13.0) and analyzed for frequencies. Qualitative short answer data were transcribed during the interview, coded and analyzed prior to translation by the principal investigator.

Results: One thousand two hundred and six assault victims presented for care during the eight-week study period, of which 216 disclosed the relationship of the assailant, including 92 who were victims of FV. Almost all patients (90%) waited less than one hour to be seen, with most patients (67%) waiting less than 30 minutes. Most patients did not require laboratory or radiographic diagnostics at the primary (70%) and secondary (93%) health facilities, while 44% of patients received a radiograph at the tertiary care center. Among all three hospitals, only 10% were transferred to a higher level of care, 14% were not given any form of follow up or referral information, while 13% required a specialist evaluation. No victims were referred for psychological follow-up or support. Qualitative data revealed that some patients did not disclose violence as the etiology, because they believed the physician was unable to address or treat the violence-related issues and/or had limited time to discuss.

Conclusion: Healthcare services for treating the physical injuries of victims of FV were timely and rarely required advanced levels of medical care, but there were no psychological services or follow-up referrals for violence victims. The healthcare environment at all three surveyed health centers in Mozambique does not encourage disclosure or self-report of FV. Policies and strategies need to be implemented to encourage patient disclosure of FV and provide more health system-initiated victim resources. [West J Emerg Med. 2011;12(3):348-353.]

Elder Maltreatment

Elder Financial Exploitation: Implications for Future Policy and Research in Elder Mistreatment

Recent advances in the understanding of elder mistreatment have demonstrated that financial exploitation tends to be one of the most common forms of mistreatment affecting older populations. Agencies such as the World Bank and World Health Organization show significant concern regarding financial exploitation and its connection to physical and emotional injury to victims. The World Bank uses the term “financial violence” as a means of generally describing the harm caused to an individual as a result of financial exploitation or abuse. The proportion of financial exploitation in relation to other forms of elder mistreatment is defined in our research. We discuss the potential impact of elder financial exploitation on victims as well as explore the implications for future research and policy development focused on financial aspects of elder mistreatment and call for further study in the concept of financial exploitation as a violent act. [West J Emerg Med. 2011;12(3):354-356.]

A Survey of Georgia Adult Protective Service Staff: Implications for Older Adult Injury Prevention and Policy

Background: The aging population is a rapidly growing demographic. Isolation and limited autonomy render many of the elderly vulnerable to abuse, neglect and exploitation. As the population grows, so does the need for Adult Protective Services (APS). This study was conducted to examine current knowledge of older adult protection laws in Georgia among APS staff and to identify training opportunities to better prepare the APS workforce in case detection and intervention.

Methods: The Georgia State University Institute of Public Health faculty developed a primary survey in partnership with the Georgia Division of Aging Services’ leadership to identify key training priority issues for APS caseworkers and investigators. A 47-item electronic questionnaire was delivered to all APS employees via work-issued email accounts. We conducted descriptive analyses, t-tests and chi-square analyses to determine APS employees’ baseline knowledge of Georgia’s elder abuse policies, laws and practices, as well as examine associations of age, ethnicity, and educational attainment with knowledge. We used a p-value of 0.05 and 95% confidence intervals to determine statistical significance of analyses performed.

Result: Ninety-two out of 175 APS staff responded to the survey (53% response rate). The majority of respondents were Caucasian (56%) women (92%). For over half the survey items, paired sample t-tests revealed significant differences between what APS staff reported as known and what APS staff members indicated they needed to know more about in terms of elder abuse and current policies. Chi-square tests revealed that non-Caucasians significantly preferred video conferencing as a training format (44% compared to 18%), [χ2(1) = 7.102, p < .008], whereas Caucasians preferred asynchronous online learning formats (55% compared to 28%) [χ2(1) =5.951, p < .015].

Conclusion: Results from this study provide the Georgia Division of Aging with insight into specific policy areas that are not well understood by APS staff. Soliciting input from intended trainees allows public health educators to tailor and improve training sessions. Trainee input may result in optimization of policy implementation, which may result in greater injury prevention and protection of older adults vulnerable to abuse, neglect and exploitation. [West J Emerg Med. 2011;12(3):357-364.]