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This is to certify that the

thesis entitled

PEDIATRIC AND ADULT BICYCLE INJURIES 0N
MACKINAC ISLAND: A THREE YEAR REVIEW

presented by

Elizabeth Anne Klein

has been accepted towards fulfillment
of the requirements for

Master of Sciencedegree in Nursing

 

    

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to remove this checkout from your record.
TO AVOID FINES return on or before date due.

 

DATE DUE DATE DUE DATE DUE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1M WM“

 

PEDIATRIC AND ADULT BICYCLE INJURIES ON
MACKINAC ISLAND: A THREE YEAR REVIEW

BY
Elizabeth Anne Klein

A THESIS
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE IN NURSING

College of Nursing

1998

ABSTRACT

PEDIATRIC AND ADULT BICYCLE INJURIES ON
MACKINAC ISLAND: A THREE YEAR REVIEW

BY
Elizabeth Anne Klein

The purpose of this study was to examine the occurrence
of bicycle injuries in both the pediatric and adult
populations on Mackinac Island from 1994 through 1996 as it
relates to occurrence, anatomical site and injury severity.
Additional aspects of the study included a look at the
accident site location, along with time of day and day of
week for each incident. All accident reports were reviewed
during this time and this study revealed that adults were
involved in a greater number of accidents, and a greater
percentage of them required Emergency Medical Service
transport to medical care. Injuries sustained by the adult
population tended to be more severe. For both groups the
greatest percentage of injuries were located in the upper
extremity, followed by the face and head. The majority of
accidents occurred, for both groups, from 12 noon to 8 p.m.
and were in high traffic areas. Implications for

establishing safety interventions are discussed.

Copyright by
ELI ZABETH ANNE KLEIN
1998

ACKNOWLEDGMENTS

I wish to thank my thesis committee, Dr. Manfred
Stommel, chair, Dr. Mary Hughes and Patty Peek for their
encouragement and support of this study. I also wish to
thank the College of Osteopathic Medicine at Michigan State
University for inviting me to participate in this study,
with deep appreciation to Dr. Mary Hughes for her continued

support.

iv

TABLE OF

LIST OF TABLES . . . . . . .
LIST OF FIGURES . . . . . . .
INTRODUCTION . . . . . . . .
PROBLEM STATEMENT . . . . . .

CONCEPTUAL FRAMEWORK . . . .
Rationale for Model Use

LITERATURE REVIEW . . . . . .
Injury Patterns . . .

Impact of Safety Equipment

Barriers to Use . . . .
International Studies .
Injury Scales . . . . .

DEFINITION OF TERMS . . . . .

METHODOLOGY . . . . . . . . .
Study Design . . . . . .
Population and Sample .
Human Subjects Approval
Instruments . . . . . .

Data Collection Procedures .

RESULTS 0 O O O O O O O 0

Research Question 1 . .
Research Question 2 . .
Research Question 3 . .
Research Question 4 . .
Research Question 5 . .
Research Question 6 . .

Assumptions . . . . . .

DISCUSSION . . . . . .

Limitations . . . . . .
Future Research . . . .
Implications . . . . . .

CONTENTS

10
13
17
19
20
22

24

27
31
31
32
32
34

35
35
38
41
44
44
46
49

51
53
54
SS

TABLE OF CONTENTS (cont.)

CONCLUSION

LIST OF REFERENCES . . . . .

APPENDICES

Appendix
Appendix
Appendix
Appendix
Appendix
Appendix

A:
B:
C:
D:
E:
F:

Abbreviated Injury Scale

Mackinac Island Injury Survey .

Modified Mackinac Island Injury Survey

Modified Abbreviated Injury Scale .
AIS - 6 Severity Code .

UCRIHS Approval .

vi

58

60

65
71
72
73
74
75

Figure
Figure
Figure
Figure
Figure
Figure

Figure

Figure

1:

2:

LIST OF FIGURES

Pender's Health Promotion Model
Adaptation of Pender's Health Promotion

Anatomical Schemata for Injury Location

Mackinac Island Map .

Pediatric Incident Location .

Adult Incident Location .

Relative Frequencies by Anatomical Site

Age Group . . . .

Relative Frequency of Pediatric ad Adult

Injury Severity .

viii

Model

INTRODUCTION

Bicycle injuries are widespread in the United States as
well as many parts of the world. Mackinac Island is a small
island located off the northern coast of the lower peninsula
of Michigan, where bicycles are the major mode of
transportation and cars as well as other motorized means of
transportation are prohibited. The island is also a very
popular tourist destination which receives visitors from all
over the world who come to see “things as they used to be”
and who often ride a bicycle to tour more remote portions of
the island. This site was chosen because it was thought to
provide a unique environment in which to study a large
population of bicycle riders and related injuries unaffected
by motor vehicles, to determine types, severity and location
of injuries suffered by riders on this island. This resort
area provides a rare Opportunity for studying the effects of
bicycling injuries in the unusually vulnerable tourist
population. This vulnerability appears to be related to
lack of preparation and a false sense of security in a
recreational environment where no formal safety programs

have been instituted to protect the rider. Proper safety

2
equipment may reduce the frequency and severity of injuries
though there may be multiple barriers to the use of this
equipment.
Problem Statement

Bicycles are increasingly being used as a means of
recreational transportation. The nurse practitioner,
therefore, will be called on to treat many of the injuries
resulting from accidents involving bicycles. In addition an
important role of the APN will be to develop and promote
programs that assist individuals and communities in reducing
and preventing bicycle-related injuries. However, an
understanding of injury patterns must precede the
development of such programs. The purpose of this study is
to identify and compare occurrences and severity of bicycle-
related injuries in the pediatric and adult age groups
reported to the Mackinac Island Police Department during the
three year study period, from 1994-1996. Of all the
injuries sustained by bicycle riders, head and upper face
injuries appear to be the most preventable and will be
looked at in detail. In addition, sites of accidents will
be plotted on a map of the island for each age group.
Mackinac Island was chosen as the site of the study because
there are a large number of cyclists and no motorized
vehicles.

Specific questions to be addressed in this study are:
1. Of the bicycle injuries reported, how many occur in the

pediatric and adult age groups?

3

2. Where on Mackinac Island do most accidents occur?

a. Are there significant variations in the number of
accidents across week days?

b. Are there significant variations in accidents by
time of day?

3. What is the frequency and anatomical location of
injuries reported in the pediatric and adult bicycle
rider?

a. What is the severity of these injuries among the
pediatric and adult persons reporting their
bicycle injuries?

Conceptual Framework

Concerning a framework for this study, investigation of

injury patterns in pediatric and adult bicycle riders can

most appropriately be understood in terms of Nola Pender's

Health Promotion Model (Pender, 1996). The Health Promotion

Model (HPM), designed as a competence or approach-oriented

model with a wellness-oriented framework, guides the

Advanced Practice Nurse toward a holistic approach to health

promotion. It was originally proposed as a framework

through which nursing and behavioral science perspectives
were integrated to focus on factors influencing health

behaviors, see Figure 1.

The basis for the HPM derives from the integration of a

number of constructs from the Expectancy-Value Theory and

the Social Cognitive Theory (Pender, 1996). The Expectance-

Value Theory is a model of rational and economic behavior,

Cognitive-Perceptual
Factors

4

Modifying Factors

 

+

 

 

Importance of health
Perceived control of health
Perceived self-efficacy

Definition of health

 

 

 

 

Perceived health status

—

 

 

 

 

Perceived benefits of
health-promotin g behaviors

 

 

 

 

Perceived barriers to health-
promoting behaviors

 

 

Figure 1.

 

 

 

Demographic characteristics
Biologic characteristics
Interpersonal influences

Situational factors

Behavioral factors

 

 

 

Participation in
Health-Promoting
Behaviors

 

 

Likelihood of
engaging in
health-promoting
behaviors

 

f

l
l

 

 

Cues to action

 

 

 

Pender's Health Promotion Model (1996 p. 52).

 

 

5
meaning that it assumes that the individual will persist
with a behavior as long as the outcome has a positive
personal value and, based on present available information,
will bring about a desired outcome. The Social Cognitive
Theory is an interactional model of causation according to
which environmental events, personal factors and behavior,
shaped by both internal forces and external stimuli, and act
as reciprocal determinants of each other (Pender, 1996). A
critical perception of the HPM is that the individual or
community does not use fear or potential threat as a source
for behavior change.

The likelihood of an individual participating in
health-promoting behaviors is influenced by cognitive
perceptual factors. These include an individual's
definition of health significance, and one's perceived
control over it. Current perceived health status
understanding the benefits of and the barriers to health-
promoting behavior, along with the person's perception as to
their ability to carry out these behaviors, all alter the
behavior outcomes. Other influences on the cognitive-
perceptual factors include demographic variables such as age
and sex. Biological characteristics, interpersonal
influences and situations, along with behavioral factors
also act as modifying agents of cognitive-perceptual
factors. Furthermore, cues to action, described as stimuli_
that can trigger health-promoting behavior can originate

from internal or external sources. For the purpose of this

6

study, Pender's HPM will be used with regards to the
Advanced Practice Nurse (APN) implications for practice and
the development of safety interventions that act as external
cues to action that promote health behaviors, see Figure 2.
W

The Health Promotion Model has been used in a variety
of settings to help explain and predict health-promoting
behaviors. Pender, Walker, Sechrist, and Stromborg, (1990),
determined through the use of the HPM that individuals who
reported more health-promoting behaviors viewed health as
high-level wellness rather than the absence of illness, and
also that health was affected by significant others, not by
chance or luck. Additionally, the HPM was determined useful
in both adult and adolescent studies in predicting and
explaining exercise behaviors, (Pender, 1996). According to
Farrand and Cox,(1993), health behavior of children is
influenced by intrinsic motivation, self-esteem, personal
health perception, and adult or parental influences, with
health perception being the single consistent variable
affecting health behavior. Further studies of this model
show great promise, but little research has been done that
examines external cues to action as it relates to the study
in this paper.

Pender's HPM, (1996), is an appropriate model for
studying injury incidence rates because it provides the
Advanced Practice Nurse (APN) with a framework for

understanding health behavior in settings outside the

 

 

DATA INFORMATION

 

 

l

 

 

External Cues to Action

Education
Posters that indicate

proper helmet usage
safe rider practices
dangerous terrain
access to health care
accident reporting

Pamphlets

information given prior to
coming to Island that
encourages helmet usage

safe rider practices
discouragement of alcohol use
while riding

access to health care

accident reporting

 

 

 

Cognitive Perceptual

Factors for Intervention

 

 

 

i

 

 

POSITIVE HEALTH-PROMOTING BEHAVIORS

bicyclists wearing helmets

 

 

Figure 2. Adaptation of Pender's Health Promotion Model

(1995)

 

 

8
individual's everyday environment. Because of the holistic
nature of this model, the APN's understanding of health
behavior as a combination of influences coming from self,
significant others, the community, and the environment is
enhanced. Armed with this knowledge, the APN can develop
and direct programs towards increasing the level of well-
being of the individual, family or community.

Health motivation, a key concept instrumental in
predicting health behavior, is defined as a generalized
state of intent that results in behaviors to improve or
maintain health (Becker, 1974). By combining the concept of
health motivation with health beliefs, defined as attitudes
or thoughts an individual has towards health, the APN is
able to apply the HPM to data collected from empirical
research to promote positive health behavior through
stimulating external cues to action.

As Pender (1996) emphasizes, external cues can come
from a variety of sources; interaction with significant
others, communications from the media and visual input.
Additionally, Pender (1996) states that by expanding the
number and frequency of external cues, health-promoting
behavior is prompted with increased frequency and regularity
of positive health practices. Adapting Fender's HPM
externally generated cues to action can also refer to
information developed and presented to the individual or
community which could directly prompt positive-health

behavior or alter the cognitive perceptual factors that lead

9
to the promotion of these behaviors, see Figure 2. Cues to
action may stimulate behavior change independently or be
used as a foundation to assist the community or individual
in modifying their cognitive-perceptual factors. By
providing the individual or community with data stating
injury potential and prevalence of accidents at particular
sites one is likely to raise the general external cues to
action as it relates to implications for health-promoting
behaviors and awareness about the likelihood and dangers of
physical accidents. These external cues to action provide
the building blocks by which the individual or community can
develop a plan of action to promote health and safety
allowing the bicyclists to take necessary action to ensure a
safer riding experience. This study can be used to increase
the level of awareness especially in individuals unfamiliar
with their surroundings, like visitors in recreational
areas.

The impact of the media should not be overlooked as a
means of increasing the number or frequency external cues.
Provision of health bulletins based on the results of this
study may be a significant means of reaching this objective.
Additionally, the use of visual cues, such as signs posted
at dock sites encouraging helmet use or along pathways
indicating changes in terrain should not be overlooked as
important means of promoting the likelihood of the
individual altering or engaging in health-promoting

behaviors.

10
Literature Review

Accidents in the United States are considered the most
significant cause of morbidity and mortality in children,
accounting for more death than all diseases combined
(Ashbaugh, Macknin, s Medendorp, 1995). Bicycle-related
crashes are a major cause of injury to children, and
researchers note that in a study of 492 active adult
bicyclists approximately 50 percent of adult riders have
been involved in an accident (Kibuz, Jacobs, Reckling, &
Mason, 1986). Though the adult bicyclists may be more
experienced, this same study noted that 58.7 percent stated
that they were at fault at the time of the mishap.
Furthermore, studies have indicated that college students
are nearly as accident prone as children (Kibuz, Jacobs,
Reckling, & Mason, 1986).

Statistics indicate head trauma as one of the most
frequently treated types of bicycle injuries. It has been
noted by Noakes (1995) that few cyclists who have either
suffered or died as a result of these injuries were wearing
adequate helmet protection. Rivara et el. (1994) concluded
that the risk of upper head injury was 2.7- fold higher
among bicyclists not wearing helmets, and the risk for loss
of consciousness was 7.3- fold higher. Rivara further
emphasizes that bicycle helmet use has been associated with
an injury reduction of approximately 80 percent for upper
head and 95 percent for loss of consciousness, reduced

hospitalization and decreased occurrence of both serious and

11
non-serious injuries including skull fracture, concussion,
and soft-tissue injury to the face.

The empirical evidence relevant to the problem under
investigation focuses on the prevalence and severity of
injuries associated with bicycle accidents. The literature
consistently states that in the United States more than
500,000 people are treated annually for injuries sustained
in cycling accidents (Noakes, 1995; Zavoski, Lapidus, Lerer,
& Banco, 1995). The literature does not give estimates as
to the number of bicyclists who crash but do not seek direct
medical assistance for injuries. Bicycling crashes are
considered to be a significant cause of morbidity and
mortality in the United States, (Sacks, Holmgreen, Smith, &
Sosin, 1991). In 1991 Americans owned approximately 105
million bicycles (Rowe, Rowe, & Bota, 1995), but studies did
not indicate how many individuals owned more than one
bicycle. Though the number owned may overestimate the
number of riders at any given time, the literature supports
that an estimated 80 percent of school-age children own
bicycles (Hu, Wesson, Chipman, & Parkin, 1995), and the use
of bicycles, both as a means of transportation and as a
recreational sport, has grown worldwide. However, the
literature is vague as to who fits into the school-age
category and how much variation there is among different
countries. Currently the production of new bikes exceeds
the production of new cars by 3 to 1 (Henderson, 1995),

though most of this is accounted for by China.

12

Traditionally police records were the main source of
information on bicycle-related injuries. A study done by
Cross and Fisher (1977) estimated that 2/3 of all bicycle
accidents did not get reported. Since 1977, the use of
emergency department records combined with police records
has provided a much more accurate picture about the number
and severity of bicycle accident injuries (Stutts,
Williamson, Whitley, & Sheldon, 1990).

Currently each year in the United States, more than
500,000 visits to the Emergency Department are the result of
bicycle mishaps (Weiss, 1994). Injuries sustained range
from minor bruising, cuts and abrasions to more serious,
life-threatening traumas leading to long-term disabilities
(Weiss, 1994). It has been estimated that over 40 percent
of all bicycle accidents are associated with an injury to
the head and face, with most resulting from a simple fall
from a bicycle rather than a collision with a motor vehicle.
However, more than 75 percent of the cyclists fatally
injured die as a result of injuries sustained to the head
and neck associated with a collision with a motor vehicle
(Naokes, 1995). Multiple studies have demonstrated that
bicycle-related deaths resulting from head trauma are almost
always the result of intra-cranial hemorrhage. In addition,
bicyclists are also at risk for serious maxillofacial
injuries including those to soft tissue and bone (Weiss,

1994).

13

W

Trauma patterns seen in the adult bicyclist
predominantly affect soft tissue of the extremities with 9.3
percent of all injuries requiring hospital admissions. Just
as significant is the fact that 27.5 percent of such
accidents result in missed days at work or school (Kiburz,
Jacobs, Reckling, & Mason, 1986). Of all the bicycle-
related deaths reported annually, approximately 50 percent
occur in individuals under 21, (Weiss, 1994), and exceed the
death rate from many other causes receiving much greater
public attention. Weiss further states that the death rate
from childhood bicycle injuries is approximately the same as
that of pre-immunization death rates from the Hemophilus
influenza infection which prompted the establishment of a
major national immunization program. According to Rivara
(1985), if as many children died as the result of football
injuries each year as die from bicycle crashes, there would
be a strong parental outcry requiring modification of the
game. Most studies have focused on trends in bicycle-
related injuries in children, all of which provide
supporting data indicating that the highest injury rates are
generally seen in youths between the ages of 9-15 (Mazurek,
1994; Lofthouse, 1994). Stutts et el. (1990) state in a
report of 649 Emergency Department treated bicyclists, males
were approximately twice as likely as females to sustain
injury of AIS 2 or greater, 22 percent male vs. 12 percent

female (p< 0.01), with adult riders experiencing a greater

14
percent of their injuries in categories greater than or
equal to AIS 2. It is generally well accepted throughout
the literature that there are more male riders than female
riders (Noakes, 1995). When reviewing data of injury rates
from an international perspective it is difficult to
ascertain the number of injuries per 100,000 population
because most studies dealt with injuries and injury types
associated more with cause in certain populations. However
one study done in Ontario, Canada between 1989 and 1991
reported boys, between the ages of 11-12 having the highest
overall injury and head injury rates (HU, Wesson, Chipman, &
Parkin, 1995). All studies have indicated, especially in
countries where aggressive tabulation of bicycle-related
injures are undertaken, the rate of injury to bicyclists has
been increasing (Noakes, 1995).

The trauma registry of the Children's Hospital Medical
Center in Cincinnati, Ohio has made preventing bicycle
injury its current major initiative. It has studied all
pediatric bicycle-related crashes in the state of Ohio from
1991 and 1992, revealing that 419 children were treated for
bicycle-related injuries, with 191 children being
hospitalized for injuries in 1992 alone. The majority of
victims were males between the ages of 5-14 years (Ashbaugh,
Macknin, & Medendorp, 1993). This type of reporting,
consistent with much of the literature that focuses on
injuries in the pediatric population, suggests that males

have the highest accident and injury rates. Males between

15
the ages of 10-14 were also reported as having the highest
mortality (Mazurek, 1994). These results are consistent
with international results indicating boys have a greater
injury rate in comparison to girls (Towner, Jervis, Walsh, &
Green, 1994).

Few studies haven been done, whether in the United
States or abroad, trying to investigate and obtain
information regarding injury patterns for adult bicycle
riders. Injury patterns seen in the adult bicyclists are
predominately soft tissue injuries to the extremities with
9.3 percent of all injuries requiring hospital admissions
(Kiburz, Jacobs, Reckling, & Mason, 1986). In earlier study
done by Kiburz, Jacobs, Reckling, & Mason, (1986), which
looked at crashes involving 492 active adult cyclists who
were members of two Kansas bicycle clubs, 46.3 percent of
the cyclists had had an accident for which about 60 percent
claimed responsibility 34.8 percent of the accidents involve
moderate to severe injuries. For how long the people have
been cycling at any given outing and where they were cycling
may have played a significant role in the injury patterns.
The mean cycling experience of these riders was 10.7 years,
with lone cyclists accounting for approximately 50 percent
of all cycling accidents. A 1989 Oregon study of 311
bicycle-related injuries indicated that, although children
accounted for 60 percent of serious accidents, adults
accounted for 67 percent of fatalities (Frank, Frankel,

Mullins, 8 Taylor, 1994). Investigation of the literature

16
consistently shows riders under 21 years are involved in the

greatest number of cycling accidents, but adult riders over

the age of 21 have the most serious accidents. These

studies do not report the time spent biking by individuals
or their experience riding therefore making it difficult to

compare the two populations. Throughout several years of

studies the highest injury rate is seen in males, and this
trend predominates throughout all age groups (Fife et el.',

1983; Goodwin, Parker, & Dudzik, 1994).

When looking at the type of injury sustained in a
bicycle crash, early studies indicate the majority are

abrasions, lacerations, or contusions. A smaller number of

injuries resulted in fractures, with the smallest number

being reported as concussions. Later investigations reached

Similar conclusions, but went into greater depth describing
and associating anatomical injury sites not only. with
Sever ity but also with relevance to age group and sex. The
reStilts show that in single-injury accidents, the arm and
hand are most frequently involved, followed by the leg,
f°°“:‘—, and ankle. In accidents resulting in multiple-site
inj Dries. it is interesting to note that the arm and hand
°nc€ ‘again are injured most frequently, followed by the knee
and head. Contusions, followed by lacerations and sprains
were the most common injury type noted (Gerberich, Parker, &
Wdzik, 1994).

The literature focuses much attention on head injuries

as being the most important determinant of mortality and

l7

long-term disability in bicycle-related crashes. Noakes
(1995) reports head and face injury rates associated with
bicycle accidents vary worldwide from 31 to 81 percent with
an average of 51 percent. All leading experts agree that
the most common head injury noted was a concussion, which
accounted for about 54 percent of this type of injury. The
next most reported head injury was skull fractures, in about
24 percent of incidents, with intra-cranial hemorrhage seen
in approximately 5 percent (Li, Baker, Fowler, & DiScala,
1995). Head injuries as the resulting from bicycling
accidents have been documented in national and international
studies in part because of the devastating consequences.
This type of injury accounts for upwards of 70 percent of
fatalities and is the most common discharge diagnosis from
hospitals (Zavoski, Lapidus, Lerer, & Banco, 1995).
Furthermore, head injuries were found to be one of the most
easily prevented injuries in both numbers and severity
through the use of a properly worn bicycle helmet.
Thempson, Rivara, & Thompson (1996) state that bicycle
helmets may be effective in decreasing this type of injury
by upwards of 85 percent.
Imnact_9f_Safe£¥_Eaninment

Through the proper use of bicycle safety equipment, the
frequency and severity of bicycle-related injuries could be
reduced. It is estimated that recreational and commuter
riders have a 50 percent chance of injury every year.

Because most fatalities involve injuries to the head, a

18
properly worn bicycle helmet is the most important piece of
protective equipment that a cyclist can wear (Ellis,
Streight, 8 Mellion, 1994).

Properly fitted, well maintained, and correctly worn
personal safety equipment will help decrease the amount and
severity of injuries. The bicycle helmet is designed to
reduce the risk of head injury in bicycle falls and crashes.
As with many sports, equipment designed to prevent injuries
associated with sport-specific conditions will limit its
overall effectiveness. Therefore the use of a football or
motorcycle helmet for bicycling is deemed unwise. The
bicycle helmet reduces the force of impact to the head
during a fall or crash and helps to prevent head cuts and
penetration by sharp objects. It is important that a
bicycle helmet be properly fitted in order to remain in
place during impact (Ellis, Streight, & Mellion, 1994).
Properly worn bicycle helmets are the most readily effective
measure available in reducing bicycle-related head injuries
(Thompson, Rivara, & Thompson, 1996). Bicycle helmets have
been shown in some studies to reduce severe head injuries by
about one-third. However, Henderson (1995) states it could
be estimated in the 45 percent range, going as high as 85
percent in some areas worldwide. Most experts agree that,
regardless of the type of bicycle helmet used in the United
States, it will provide substantial protection against head
injuries and injuries to the upper and middle face of

persons involved in crashes, including those involving motor

19

vehicles. They may, however, have no significant effect on
serious injuries to the lower face, (Thompson, Nunn,
Thompson, 8 Rivara, 1996). The use of protective clothing
such as cycling shorts and padded gloves can reduce injuries
from a scrape in a fall. Other protective equipment
includes the use of eye protection to shield the rider from
flying objects such as stones, bugs, and other wind-born
irritants, along with radiation from the sun. The use of
sunglasses per se are not considered to be appropriate
because of their poor performance during impact, (Thompson,
Nunn, Thompson, & Rivara, 1996).
W

Though there are many pieces of safety equipment the
rider can use, it may not be feasible for the bike rental
shaps to provide them all. Bicycle safety helmets have been
successfully introduced in many countries, including
Australia, Great Britain, Denmark, Sweden, and the United
States. However, there are several barriers to their use
discussed by Seijts, Kok, Bouter, & Klip (1995): first, many
individuals feel helmets to be somewhat uncomfortable,
particularly, that they trap heat and tend to tangle hair.
Secondly, many bikers do not know what to do with the helmet
once they stop cycling, for instance, when shopping or
dining. Third, negative social pressure is exerted on
riders, especially younger riders. In resort areas,
additional barriers include not coming prepared for

bicycling and not knowing how to access safety equipment.

20

By looking at the types and severity of injuries sustained
on Mackinac Island, determination of the most appropriate
safety equipment needed, making this equipment accessible,
and educating the rider on its correct use may then be
undertaken.
Internaticnal.§fudies

Worldwide bicycle utilization has made bicycle-related
injuries a significant area of pediatric and adult trauma.
It is important to note that the primary use of bicycles in
the United States is recreational, whereas in many foreign .
continents the bicycle is the primary mode of transportation
for work as well as pleasure. Motorists are trained at a
young age to watch for cyclists on the roadways in countries
other than the United States. In the review of studies done
in Great Britain, Australia, and the United States, there
are some noted differences in the percentages of injuries
categorized by anatomical site. The trend shows that the
majority of injuries are sustained to the upper extremity
followed by head and face. Injuries to the lower
extremities are then followed by the least-frequent
injuries, those involving the trunk (Ballham, Kotecha, &
Bodiwala, 1985; Gerberich, Parker, & Dudzik, 1994). An
exception to this was noted in a study examining injuries
sustained by off-road bicyclists and competitive riders.
Here 90 percent of all injuries involved the extremities,

(Pfeiffer & Kornisch, 1995).

21

Internationally, head injuries from bicycle-related
crashes consistently account for the most significant injury
types in both children and adult bicycle riders. Australian
studies reveal injuries to bicyclists as a significant cause
of death and personal injury producing short and long-term
disabilities that led to the establishment of strict bicycle
safety rules (Henderson, 1995). Likewise in Ontario,
Canada, safety regulations were implemented because an
estimated 75 percent (n=212) of bicycle-related deaths, from
1986-1991, were the result of head injuries and only 4
percent of those involved wore bicycle helmets at the time
of the crash. Over 32 percent of the victims under the age
of 15 listed human error as a major cause of these
accidents (Rowe, Rowe & Bota, 1995). In the Peoples'
Republic of China, where bicycling is a major means of
transportation, bicycle mishaps constitute the primary cause
of traumatic brain injury in individuals of all ages (Weiss,
1994). Noakes (1995), states that an estimated 1 percent of
all Australian children between the ages of 5 and 14 years
seek medical attention from hospitals and clinics annually
and that 10 percentof United States and Australian visits
to emergency departments are for the treatment of bicycle-
related injuries. Further studies in Sweden suggest that
for all cyclists 700 person-years of work are lost annually

as the result of cycling injuries alone, (Noakes, 1995).

22

W

The first scales designed to rate injury severity were
developed in 1943 for the purpose of studying airplane
crashes, (Committee on Medical Aspects of Automotive Safety,
1971). In 1969 the Abbreviated Injury Scale,(AIS), (see
Appendix A) was introduced and then further refined in 1978-
1979, resulting in the publication of the AIS-80 which has
been used consistently since this time to categorize the
severity of injury from many different sources, such as auto
accidents and plane crashes (Kramer, Barancik, & Thode,
1990). The literature supports the use of the AIS, (see
Appendix A), as a tool for easy documentation of injury
severity, and recognizes the possibility of inconsistencies
because injury categorization is still left up to
professional judgment. The use of injury scaling in
organized medicine was initiated in 1966 through the efforts
of the American Medical Association and its Committee of the
Medical Aspects of Automotive Safety. The AIS is a
numerical scale developed to rate the severity of injuries
and not a system used for the coding of fatalities. In
addition, it does not propose to assess the combined effect
of multiple injuries sustained by any individual
(Petrucelli, States, & Hames, 1991). Baker (1974) quotes
the authors of the AIS as cautioning against adding or
averaging the AIS ratings, claiming that.‘the quantitative
relationship of the AIS codes is not known and is almost

certainly nonlinear“ (Baker, O'Neill, Haddon, & Long, 1974).

23

Further review of the literature supports this observation
and shows that the AIS is not an additive progression scale.
The original 1971 publication of the AIS was revised in
1978-1979, which led to the development of the AIS-80 in
1980. The revisions made in the AIS resulted in very few
changes in the injury codes but rather clarified injury
descriptions and strengthened the overall system.
Currently, the AIS is used by large numbers of crash
investigators all over the world, (Petrucelli, States, &
Hames, 1981), and has been adopted as the official tool used
by all U.S. federally funded crash investigation teams
(MacKenzie, Shapiro, Moody, & Smith, 1984). In studies
where the severity of injury is rated, the AIS has provided
a flexible, logical framework by which categorization is
done quickly and easily (see Appendix A). The categories of
AIS framework are simply laid out, but do require the
judgment of professionals to place the victim in a
particular category. Thus, the degree to which morbidity
and mortality are related hascontinued to remain
conjectural in spite of the medical ease of the scale itself
(Baker, O'Neill, Haddon, & Long, 1974). The studies that
did use the AIS the injury category and injury description
were well defined and readily understood, making reader
comparisons easier, (Baker, O'Neill, Haddon, & Long, 1974).

Most studies discussing bicycle-related injuries do not
specifically discuss rating injury severity, making it

difficult to determine how serious the injuries were.

hrs
of t'
high
of i
bicy
usef

less

24

Larson, (1995) did examine injury severity through the use

of the AIS. By using a Maximum AIS (MAIS), which is the

highest AIS-score in all body regions, the severity and site

of injuries sustained correlated with findings in other

bicycle studies. This study showed that the AIS-system as a

useful tool to describe injuries, which generally tend to be

less severe following bicycle accidents (Larson, 1995).

Definition of Terms

1. Bicycle - a two-wheeled vehicle powered by pedaling.

2. Adult rider - a male or female over the age of 21

years.
3. Pediatric rider - a male or female 21 years of age or
younger.
4. Location of injuries - (see Figure 3).
A. Head — area of skull that is normally covered by

scalp hair.

Face - area of skull not normally covered by scalp
hair, to involve eyes, ears, nose, mouth, chin,
forehead and cheeks.

Neck - area from angle of mandible to the junction
of neck and chest.

Shoulder - area involving glenohumeral joint and
clavicle.

Upper extremity - defined as being distal to
glenohumeral joint to tips of fingers.

Chest.- inferior to clavicle to inferior border of

ribs.

25

 

 

 

 

 

 

 

 

 

//

 

Figure 3.

Anatomical Schemata for Injury Location

26
Abdomen - inferior margins of ribs to iliac crest
and inguinal ligament, to include internal
injuries.
Back - T1 through tip of sacrum.
Groin - genital area from inguinal ligament to
involve genitalia.
Lower extremity - extends from hip to tips of

toes.

Types of injuries documented in police or health clinic

records, including:

I

II

III

IV

VI

VII

VIII

IX

Concussion - closed head injury - a transient loss
of consciousness occurring immediately following a
non-penetrating blunt impact to the head.

Fracture - a complete or incomplete break in the
continuity of a bone.

Laceration - a rough, jagged tear of the skin
tissue.

Contusion - an injury to the subsurface tissue
without the skin being broken.

Abrasion — scraping away of a surface by friction.
Subdural - collection of blood in the subdural
space.

Epistaxis - bloody nose.

Strain - muscle damage secondary to trauma.
Dislocation - displacement of bone from an

articulating joint.

27

X Sprain - injury to a ligament or tendon around a
joint.

XI Separation - displacement of bone from bone at
ligamentous attachments at non-articulating
joints.

XII No injury - accidents occurring in which the rider
received no injury.

XIII Minor cuts and scrapes - injuries occurring in
which no specific body parts are listed in
reports.

Injury severity will be based on a modification of the

Abbreviated Injury Scale as reported in police records,

from 1 to 5, with 1 being the least serious and 5 being

fatal (see Appendix B).

Victim - an individual injured in a bicycling accident,

including the driver of the bicycle, bicycle passenger,

or a pedestrian run into by a bicyclist.

Incident type - bicycle-bicycle, bicycle-horse,

bicycle-pedestrian, or bicycle alone, or other.

Accident and incident will be used inter-changeably in

this study.

Methodology

Mackinac Island is a popular tourist destination

located off the coast of Northern Michigan between Lake

Huron and Lake Michigan (see Figure 4). Mackinac Island has

500-600 permanent residents with an estimated annual tourist

rate well over 1,000,000 visitors per year. The majority of

28

 

Figure 4.

Mackinac Island Map

29

individuals come to Mackinac Island between the months of
May and October. It is estimated that during this time
Mackinac Island receives up to 10,000 visitors per day. An
8-mile road circling the entire island and multiple paved.
trails travel throughout the interior of the hilly island.
One of the unique aspects of this vacation spot is the
ambiance created by the horse-drawn carriages and bicycles
used as the major means of transportation by visitors and
residents alike. There are 3 motorized vehicles on the
island, a police car, an ambulance, and a fire truck.
Travel to Mackinac Island is mainly by ferry from the main
coast of Michigan, though there is an island airstrip.

Bicycles provide the major means of transportation to
sight-seers and help to create an unusual environment in
which to study the prevalence of bicycle-related injuries.
Visitors may choose to bring their own bicycle or rent one
on the island. It has been estimated by the Mackinac Island
Chamber of Commerce that over 150,000 bicycles are rented at
the 4 bicycle rental shops each year, not including the
rental of bikes from the 36 places of lodging. This unique
environment poses its own special set of circumstances that
may act as causative factors for bicycle mishaps inCluding:
1. Often shared routes among horse transports,

pedestrians, and bicyclists;
2. A large number of bicyclists sharing the roadway with

varying degrees of expertise riding rental bikes

unfamiliar to them;

Bic
ins

ric‘

INC
'u'hi
vi:

Off

len-

bi~

an

30

3. Bicycles by themselves offer nothing in the way of
protection to the rider;

4. Many bicyclists often come to Mackinac Island
unprepared for bicycling, including having no safety
gear and inappropriate clothing;

5. Traveling down hills while viewing the scenery rather
than the road;

6. High rates of speed attained by the bicyclists may be
quite significant and lead to severe injury in a crash;
and

7. Rough pavement or gravel road surfaces, and weather
conditions may create a setting in which a mishap can
occur.

Bicycle helmet usage is very low and, in the majority of

instances, bicycle helmets are not readily available to the

riders when they rent their bike.

Bicycle riders on Mackinac Island vary greatly in age
and skill and a large number in not wearing a bicycle helmet
while riding on the island. Mackinac's isolated setting
without the presence of automobiles and high bicycle usage
offers a unique opportunity in which to study bicycle injury
patterns in pediatric and adult riders. However, the very
uniqueness of the setting may make it difficult to
generalize the results to other communities.

The purpose of this study is to determine the number of
bicycle crashes, location of accidents on the island, types

and severity of injuries reported and medical care given

31
with the intention of comparing these results between the
pediatric and adult bicycle-riding population. This
retrospective study will examine all bicycle-related
accident data from police and health clinic records on
Mackinac Island from 1994 through 1996. Major components of
this study are to include the age of the victim, an adult
being over 21 years of age and a pediatric victim 21 years
of age or younger, injury occurrence and documented severity
of injury, as well as crash location on the island.
mm

For this study a retrospective record review of all
police records of bicycle crashes occurring on Mackinac
Island during the years 1994-1996 was done.
Mum:

All bicycle accidents reported to the police and health
department on Mackinac Island were examined, a total of 290
cases from 1994 through 1996. Included in this study will
be anyone who had reported an accident, for example, a
parent reporting an accident involving a child, to the
police department or was treated at the health clinic for
injuries resulting from a bicycle-related accident. This
study is one of a three part study undertaken with Dr. Mary
Hughes, Department of Internal and Emergency Medicine in the
College of Osteopathic Medicine at Michigan State
University. The author of this thesis was involved in data
collection, entry and analysis. A distinction between

individuals in the residential and tourist population was

32

not made. Therefore, anyone involved in a bicycle-related
crash that occurred on Mackinac Island from 1994 through
1996 was included in this study. Although on the surface
the overall estimated incidence of accidents may seem
insignificant, less than .1 percent (290 per approximately
450,000 rentals), these numbers may be misleading. The
average rental time is one hour and therefore this rate (<.1
percent) can not be compared to other studies involving
cyclists who ride on a regular basis many hours a year.
Permission to view the police and health clinic records was
previously obtained by Dr. Hughes from the Mackinac Island
Police Department and the Mackinac Island Medical Clinic.
W1

Human subjects' approval was granted for this project
by Michigan State University and Sparrow Hospital. No
accident victim is individually identified in the study
results. All data collection sheets are maintained in the
personal possession of Dr. Hughes and are not available for
public use.
Instruments

The Abbreviated Injury Scale (1980) was modified for
ease of use during this study and employed in conjunction
with the injury code classification developed and used by
the Mackinac Island Police Department (Appendix D). The
data will reflect only injuries in which a police report was
filed. All cycle accident victims who present to the island

clinic for treatment automatically have a police report

33
generated. Those individuals who felt their accident was
serious enough to report to the police also result in a
police report being generated. Not all minor accidents are
reported to the police or require medical attention, and
therefore the crash totals do not necessarily indicate all
accidents occurring on Mackinac Island during this period of
time.

Two instruments were used to measure and organize data
for this study. The first was a modification of the
Mackinac Island Injury Survey (Appendix B) developed by Dr.
Hughes to obtain and organize data relevant to the number of
tourists, bicyclists, and information associated with a
bicycle accident on the island and bicycle helmet use. The
Mackinac Island Injury Survey was specifically developed for
this study and has not been used in other studies to date.
For the purposes of this project this survey was modified
for ease of handling to include only information that was
necessary to aid in injury comparison between the pediatric
and adult bicycle population. This tool was titled the
Modified Mackinac Island Injury Survey (Appendix C). The
data collected from police and health clinic records was
examined and placed into the appropriate category.

The categories in the Modified Mackinac Island Injury
Survey include date of incident, whether the accident
occurred on a weekday or weekend, island site of accident,
time when the incident occurred, type of accident,

anatomical site of injury and injury severity. Further

34
information regarding the age and gender of the victims,
along with a cross-check of files to see if the accident
victim who did not obtain medical care at the time of
incident reported injury to the health clinic within 24
hours of the accident. To aid in the categorization of
injury severity listed in the records, a space was made
available to document a brief description of injuries, this
information was be used by medical personnel to determine
the most appropriate coding for injury severity.

The second tool used in this study was a modification
of the Abbreviated Injury Scale -.6 severity Code (Appendix
E). This tool titled the Modified Abbreviated Injury Scale
(Appendix D), was modified to correlate injury severity data
from the Mackinac Island Police Department incident sheets
and the AIS scale. Included are injuries from these
categories that required individuals to be transported to
mainland hospitals for treatment. The severity code used by
the Mackinac Island Police Department follows the AIS
categories in reverSe and was adhered to in this study. The
injuries are ranked from 1 through 5, 1 - fatal to 5 - no
injury.

W

The authors went to the Mackinac Island Police
Department and reviewed all records related to bicycle
injury. The records were made available on the premises
from the police department. Data was transferred to the

Mackinac Island Injury Survey. Where injuries were not

35
noted, the survey was then taken to the Mackinac Island
Medical Clinic and a search was made for the victim in their
files. If found, the injuries were then noted on the"
survey. Charts remained on the premises of the clinic at
all times. Data was then coded and entered into the EpiInfo
Statistical Program and transferred to SPSS program for data
analysis.

For the purpose of this study, “adults” will be any
victim greater than the age of 21 years of age and
“pediatric” will be any victim 21 years of age or less, as
defined by the American Academy of Pediatrics. The
determination of age groups was established by Dr. Hughes
and the College of Osteopathic Medicine at Michigan State
University. Totals will be generated to indicate adult and
pediatric victims for the study period. Mean ages and
ranges will be calculated. Gender as a relative percent of
total in age group will also be calculated.

Results

This study examined the records of all accident victims
located at the Mackinac Island Police Department and Health
Clinic (n=290 with 1 undocumented case) from 1994 through
.99..

W

In answer to the first research question, the results
indicate a smaller number of pediatric victims, 43.1 percent
(n=125) compared to 56.6 percent (n=164) adults. The mean

age of a pediatric victim was 12.2 years with a standard

36

deviation of 6.44. The mean age of the adult victim was
41.2 years with a standard deviation of 15.9 years. The
mean age of all victims was 28.7 years with a standard
deviation of 18.94 years (range 1 - 88 years) (See Table 1).

A relative percentage obtained by cross tabulation with
a Pearson chi-square was performed on the totals of accident
victims who did or did not seek medical care at the island
health clinic. Results show a significantly lower
proportion of children (72.8 percent) than adults (85.5
percent), p < .045, seeking medical care at the clinic after
their reported bicycle accident (See Table 2).

In each age group, Emergency Medical Service (EMS)

transport to the clinic and transport off the island for

Table 1.

Wm

 

Age of Person

 

 

 

 

 

 

 

1.0 Mean 12.2000
N y 125
Standard Deviation 6.4458
2.0 Mean 41.4268
N 164
Standard Deviation 15.1908
Total Mean 28.7855
N 289
Standard Deviation 18.9442
=Peds 21 years and less
2=Adults 22 years and greater

 

 

 

 

37

Table 2.

 

Pediatric vs. Adults Clinic Crosstabulation

 

 

 

 

 

 

 

 

Clinic

No Yes Total

Pediatric Age less Count 34 91 125

vs. Adults than 22

% of age group 27.2% 72.8% 100.0%
% within Clinic 56.7% 39.9% 43.3%
% of Total 11.8% 31.5% 43.3%

Age older Count 26 137 164
% of age group 15.9% 83.5% 100.0%
% within Clinic 43.3% 60.1% 56.7%
% of Total 9.0% 47.4% 56.7%

Total Count 60 228 289
% of age group 20.8% 78.9% 100.0%
% within Clinic 100.0% 100.0% 100.0%
% of Total 20.8% 78.9% 100.0%

 

 

Chi-Square Test

 

Pearson Chi- (2-sided)

Square N of ' .045

 

care. Results show that a higher percentage of adult
accident victims used EMS services, 58.3 percent, (95 of 163
injured), compared with 44 percent of pediatric victims, (55
of 125 injured). Results of a Pearson's Chi Square revealed
p of 0.016 indicating that there was a statistically
significant difference in the percentages between pediatric
and adult usage of EMS services. When reviewing the

percentages of victims per age group that were transported

38

off the island for care, results indicated that there was a
greater percent of adult victims, 4.4 percent, (7 of 161
injured with 2 cases undocumented) transported off the
island compared to 2.4 percent of pediatric victims, (3 of
125 injured). Because of the small number of victims a
Fisher's exact was done to test for the significance of
these percentages. These results revealed a p value of
0.375 indicating that the difference between these age-
groups with respect to being transported off the island was
not statistically significant (see Table 3).
W

In answer to the second research question concerning
where most accidents occur, a map indicating location of
incidents was developed to depict the occurrence in each
population separately (See Figures 5 and 6). Each dot on
the map represents one accident. The map relating to

pediatric accident location (Figure 5) indicates a high

Table 3.
WWW

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

l xans XEMS ] xorrrs xorrrs J]
Count % Count % Count % Count %
1 55 44.0 95 58.3 3 2.4 7 4.4
2 70 56.0 68 41.7 121 97.6 153 95.6%
Total 125 100.0 163 100.0 124 100.0 150 100.0
lsggdiatric 2=adults

 

 

Pediatric Incident Location

 

Figure 6

Adult Incident Location

 

39

in

st

qr

Va

41
concentration of incidents around the docks, which is the
downtown region. To a lesser degree a cluster of accidents
is seen at Arch Rock and British Landing. Likewise in the
adult population a large cluster of accidents is seen at the
dock region (Figure 6) followed by Arch Rock and finally
British Landing. No distinctive geographical patterns
specific toe each age group is discernible.
W

A cross tabulation of days of week when accident
occurred with age group (pediatric vs. adult) was done for
289 (99.7 percent) of a total 290 cases over 3 years being
reported, see Table 4. Results show that for the pediatric
population, the lowest number of incidents (8.8 percent)
occurred on Sunday, while the highest percentage, (18.4
percent) Wednesday and Thursday (See Table 5). In the adult
age group the lowest percentage of incidents was on Thursday
(9.8 percent), with Saturday having the highest number of
incidents (33) (See Table 6).

A chi-square frequency test was done on both
populations respectively though these results did not reach
statistical significance. Results for the pediatric age
group revealed a chi-square value of 6.432 and a p value of
.377 (Table 5). Likewise for the adult group a chi-square
value of 17.366 with a p value of .054 was obtained (table

6).

Table .

ll

Pedi
ti.

Age
thar

Age
that

Iota

 

/

Table 4.

42

WW

 

Pediatric vs. Adult Day of Week Crosstabulation

Day of Week

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pediatric Count 11 16 16 23 23 16
vs. Adult
Age less % within 8.8 12.8 12.8 18.4 18.4 12.8 16.0
than 22 Pediatric
vs. Adult
Age Older Count 31 17 18 27 16 22 33
than 21
% within 18.9 10.4 11.0 16.5 9.8 13.4 20.0
Pediatric
vs. Adult
Total Count 42 33 34 SO 39 38 53
% within
Pediatric 14.5 11.4 11.8 17.3 13.5 13.1 18.4
vs. Adult ~
g =—

 

 

 

43
Table 5.

 

  

 

   

Sun Mon Tues Wed Thurs Fri

 

 

Day of Week
Test Statistics
Day of Week
Chi-Square 6.432
df 6
Asymp. Sig. .377

 

 

 

 

Table 6.

WW

 

Percent

     

 

Sun Mon Tues Wed Thurs Fri Sat

 

 

 

Day of Week
Test Statistics
Day of Week
Chi-Square 12.366
df 6
Asymp. Sig. .054

 

 

 

 

higl

hour

the:
l C'
wit.

obs

of
doc

vic

44

WW

Results for accidents by time of day indicated that the
highest rate per hour of accidents occurred between the
hours of 12 noon and 8 pm for both age groups. The
pediatric group reported a rate of 11.38 incidents per hour,
whereas the adult group reported 11.62 incidents per hour.
A Chi-Square test on each group revealed significant results
with a p value of .000 (See Tables 7, 8 and 9). This
observed difference in accident rates among both the
pediatric and adult populations may well be due to sampling
chance.
W

Results for relative frequency and anatomical location
of injury reveal totals of 150 and 255 injuries respectively
documented in the pediatric and adult populations. Some
victims sustained more than one injury during an accident
thus totals reported were greater than the number of
accident reports.

Injury totals documented in the pediatric and adult age
groups were not significantly different from each other.
The highest incidence of injury location occurred in the
upper extremity for both groups, 22.2 percent for the
pediatric group and 24.5 percent for the adult respectively.
However, it is noted that when combining head and face
injuries the percentage for adults is slightly higher (25.7
percent verses 24.5 percent) than those occurring in the

upper extremity. For the pediatric age group the combined

45

Table 7.

 

 

   

Accidents per Hour

    

   

 

\).\ x x 4‘ \ . \\.\\\\

6am to 12 noon 12 noon to 8pm 8pm to 6am

 

 

Time of Day
Test Statistics
PEDS
Chi-Square 95.678
(if 2
Asymp. Sig. .000

 

 

 

 

Table 8.

 

Accidents Per Hour
T

 

       

 

6am to 12 noon 12 noon to 8pm 8pm to 6am

 

 

Test Statistics TflneofDay
ADULT
Chi-Square 51.607
df 2
AsympL4§ig. .000

 

 

 

 

46

Table_9.
WW

 

Time - Population Crosstabulation

 

 

 

 

 

 

Po-ulation ,
1 - .mmmiis ,
Peds Adults Total
Time 6am-12noon Count 21 40 61
% within TIME 34.4 65.6 100.0
8 within POP 17.1 24.8 21.5
12noon-8pm Count 91 93 184
% within TIME 49.5 50.5 100.0
% within POP 74.0 57.8 64.8
8pm-6am Count 11 28 39
% within TIME 28.2 71.8 100.0
% within POP 8.9 17.4 13.7
Total Count 123 161 284
% within TIME 43.3 56.7 100.0
%within POP 100.0 100.0 100.0 1
— —_ ,,

 

 

 

 

 

 

 

head and face rates were higher than upper extremity rates

(28.1 percent verses 22.2 percent).

A smaller difference

was noted between age groups with regards to the least

frequent anatomical location of the injury.

In the

pediatric group, the abdomen sustained the least percentage

of injuries (0 percent), whereas in the adult population the

least percentage was found to be seen equally in the neck,

groin, and abdomen (.4 percent).

The percentage of minor

injuries reported were almost identical, 8.5 percent and 8.3

percent respectively.

Injuries listed as unknown were

again
pedia
(See

stati
siril

rider

sever
ratin-
Of th:
injurj
this ;
pattei
injur:
group
Percei
sligh'
incap.
Pedia
incap.
inlur.
(59.7
reSuli
PQICer

filmOSt

47

again similar with 10 percent being reported in the
pediatric group and 10.8 percent reported in the adult group
(See Figure 7). Again, all observed differences were not
statistically significant, indicating the essential
similarity in injury patterns among pediatric and adult
riders.
W

The sixth research question is concerned with injury
severity. Relative frequency for both age groups was done,
rating injuries from 1 to 5, 1 = fatal and 5 = no injury.
Of the 125 pediatric accidents reported, 114 had documented
injury severity. In the adult group, 164 of 165 cases had
this information documented. Similar injury severity
patterns were seen in both age groups, with category 3
injuries being the most frequently reported. Only the adult
group reported a category 1, fatal injury, with 1 case or .6
percent of adult injuries. The adult group also reported a
slightly higher percentage of category 2 injuries, rated as
incapacitating, 27.4 percent compared to 21.9 percent in the
pediatric population. Category 3 injuries, listed as non-
incapacitating, showed a higher percentage of pediatric
injuries (64.9 percent) when compared to the adult group
(59.7 percent). Category 4, minor injuries, listed similar
results with 6.1 percent of pediatric injuries and 4.8
.Percent of adult. The final category, 5, no injury, held

alluost identical results with 7 percent of pediatric

 

 

Peal-93.0 m=9

ans aimmwv

 

 

4 8
Relative Frequency

 

 

 

 

 

 

 

 

 

 

 

 

 

a s s s s
l
i
t
Figure 7
In Pediatrics

Relative Frequencies by Anatomical Site by Age Group ]lAdults

 

49

accident victims and 7.3 percent of adult crash victims (See
Figure 8).

A Pearson's Chi Square test for significance revealed,
for category 2, a p value of 0.298 (Chi Square = 1.08),
category 3, a p value of 0.384, (Chi Square = .76), category
4, a p value of 0.734, (Chi Square = .11), and category 5 a
p value of 0.924 (Chi Square 8 .01). For all of the injury
categories there is no statistical difference between the
pediatric and adult age groups. When looking at all
categories together, the overall Chi Square was 2.0 with 4
degrees of freedom and a p value of 0.7354. A
crosstabulation was done comparing categories 1 and 2
between the pediatric and adult group as well as categories
3, 4, and 5. In the sample the results showed there to be
an odds ration of 1.388, with a 95 percent confidence
interval of .793 - 2.428, indicating that there was 38.8
percent higher odds of severe injury in adults. Though
these results appear to be significant a p value of .247
was reported indicating that there was no significance (see
Table 10.
Assumptions

This study assumes that police and health care workers
using the injury severity scale have a consistent
understanding of what the categories 1 - 5 encompass. The
data entered by police and health clinic workers on their
reports is treated as accurate assessments of the health

status of the victims with the understanding that the

50

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

0 fifi
c as
g fifi
E IAdult
g ~. IPediau'ic
3
o
I:
Figure 8 - WWW
Table 10.
W
Crosstabulation
I r PEDS ADULTS TOTAL
Severity Code Count 89 118 207
3, 4, and 5 Percentage 78.1 72.0 74.5
Severity Code Count 25 46 71
1 and 2 Percentage 21.9 28.0 25.5
Total Count 114 164 278
Odds Ratio 1.3
lp Value .244
95% CI “mm

 

 

 

51
subjective nature of rating injuries can be encompassed in
the injury severity scale.

Though the AIS was developed in 1960 -1970, and further
adapted in 1979, because of its extensive use throughout the
world it is assumed to be able to rate the severity of
injury accurately.

Discussion

Results showed that a greater number of accidents
reported were in the adult age group and that adults sought
medical care at the island health clinic in greater
percentages as well. Furthermore, a larger percentages of
adult accident victims used EMS transport to the clinic
compared to their younger counterparts. Adults also
required transport off the island in larger numbers,
although there doesn't appear to be a marked difference in
injury severity among the adult population. Multiple
factors may be considered when looking at the difference
between these two populations, including difference in rider
experience, possible alcohol or medication use, and adults
generally weigh more.

As was expected, there were a greater number of
incidents occurring in areas where there was the most
congestion, around the docks, Fort, and Grand Hotel. Both
the British Landing and Arch Rock provided the rider with
challenging terrain and an interesting view and this may
explain why the accident rate is greater in these areas.

The largest percentage of accidents happened between 12 noon

52
and 8 pm as anticipated, with the largest percentage seen in
the pediatric group, 74 percent, compared with 57 percent in
adults. Most visitors do not spend the night on Mackinac
Island therefore boat arrival and departure times may be the
reason why the majority of accidents with children occur
during this time.-

When reviewing results for day of week, adults tended
to have more accidents on weekends and on Wednesday, whereas
the pediatric age group had the highest incident rate during
the middle of the week. Because of the lack of knowledge
regarding the population base, it is difficult to relate
occurrence to actual numbers of adult or pediatric visitors
on a particular day.

The anatomical site of injury revealed the greatest
percentage of injuries sustained in the upper extremity, 22
percent for the pediatric group and 25.5 for the adults.

The second most prevalent injury site was the face with 15.3
percent and 13.2 percent for pediatric and adult bicyclists
respectively. These results are consistent with results
from other Studies.

In analyzing injury severity (see table 9), the results
showed adults sustained a greater percentage of injury in
the most serious categories, 1 and 2, though not
significant, with the percent of pediatric injuries
surpassing them in category 3. There was approximately the
same percentage 7 and 7.3 percent respectively in the no

injury category.

53

When looking at the results from an overall
perspective, trends begin to show. There is a tendency for
there to be a greater number of injuries of adults across
the board, but this study is unable to answer why. This
data does not indicate whether there are simply more adults
than children biking on the island and thus making the
number of injuries higher for the adults. This study did
show, however, that there was a significant health risk to
the tourist population, and these results could be used as
an impetus for developing safety programs that would protect
both visitor and resident.
II 'I l'

The study is limited by the lack of thorough and
consistent documentation of accidents. In the majority of
instances, specific locations were documented but not 100
percent of the time. Other mitigating factors such as
weather conditions, road conditions, victims view of why the
accident occurred, stated use of alcohol, incidence of
helmet use, and experience of the rider all may have played
a role in determining the accuracy of the results. The
documentation of injury severity may have been affected by
the personal interpretation of the police or health
officials reporting the accident. The data only reflects
accidents serious enough to be reported to the police or
those that required treatment at the health clinic. The
data does not include all accidents that may have occurred

during the study period. The lack of information on the

Ir
Se
re

th

54
population base with regards to the number of adult and
pediatric visitors who bicycled on Mackinac Island during
the period of observation limited the ability to make
comparison between age groups. The uniqueness of Mackinac
Island does provide a good environment in which to study
bicycle injuries unaffected by automobiles. However, this
same uniqueness may make it difficult to generalize the
results to other resort communities.

The AIS, though extensively used by itself, has not
been well documented as an effective tool to be adapted to
other injury scales. Though the injury rating used by the
Mackinac Island Police Department is based on the AIS, it
specifically has not been tested for reliability and
validity.

Watch

Further research is needed in other resort communities
to see if the results obtained in this study persist in
other areas. This research should also attempt to include
more information on the population base that could
facilitate age group comparisons. The main focus of this
research project was to look at injury occurrence and to
determine if there was a safety concern on Mackinac Island.
This study did not attempt to answer questions as to why.
In order to effectively develop programs that will promote
safety, these questions need to be answered. Future
research should be aimed at developing an understanding of

the causes of injury and then establishing safety protocols

55
that reduce the occurrence and severity of injury that can
be applied to other tourist communities.
We
For the purpose of this study, Pender's HPM was used

with regards to implications for'the Advanced Practice Nurse
(APN) and the development of safety interventions that
promote health behaviors, see Figure 2. Understanding the
incidence of injury and the source and mechanism of action
provides effective tools for the health care professional to
actively develop and promote health awareness programs for
injury prevention on individual and community levels.
Though all individuals who encounter the safety message will
not be sufficiently motivated to adopt health- behavior,
everyone directly or indirectly will bear the cost in
injuries that could have been prevented (Kellerman &
Martinez, 1996). There is no guarantee that simply adopting
healthy behaviors will eliminate the risk of injury.
Several strategies for the prevention of injury can be
developed after first defining the problem and then
identifying causes and risk factors (Kellerman & Martinez,
1996). Categorizing an identifiable injury in relation to
its severity is essential in order to understand associated
morbidity and mortality rates (Baker, O'Neill, Haddon, &
Long, 1974).

. The data and information gathered, relating to rider
demographics, health care services and accident factors

develop into external cues which can lead directly to

56
positive healthepromoting behaviors or be used as cognitive
perceptual factors for the basis of developing
interventions. The perceived benefits can be enhanced
through safe rider practices, and the development of
educational programs for the bike rental shops with regard
to the magnitude of the problem as well as means of making
positive changes related to bicycle safety. Awareness of
the perceived barriers to these interventions, such as lack
of knowledge regarding risk and proper use of safety
equipment, as well as accessibility, is necessary in order
to establish programs or interventions that will indeed be
used by the community and the individual bike rider on
Mackinac Island. Undocumented data, like helmet usage, can
be a focus of the APN in assisting the police and health
departments to improve information gathering regarding
injury patterns. Improving the forms that are used to
report accidents can be a useful tool in the evaluation of
safety programs instituted.

Injury cause emerges as an important factor when
determining possibility of prevention. Many studies
incorporated causation into their projects and discovered
significant factors that repeatedly presented. Though most
accidents do not involve motor vehicles, most fatalities do,
and as a result, a great deal of information can be found.
Studies consistently found the cyclists were generally at
fault due to their failure to obey traffic laws (Noakes,

1995). Few studies comparing injury causation in the

57
pediatric and adult population were found, but in separate
studies certain trends emerge. The lack of skill, (Noakes,
1995) followed by environmental conditions, (Gilbert &
McCarthy, 1994) were the most prevalent reasons, and though
little research has been done in the tourist community, it
seems as though these trends may well continue (Carey &
Aitken, 1996).

By understanding the benefits as well as the barriers
to health promotion the APN is provided with an excellent
opportunity to act as an educator and advocate for safety on
the individual and community level. The APN can assist the
community in understanding the magnitude of the current
health risks and develop programs that will assist them in
providing a safer environment for their guests. The APN can
assist the community in exploring and developing appropriate
strategies which promote safety of the individual rider.
Through the use of bulletins attached to current advertising
brochures the visitor can be made aware in advance of coming
to Mackinac Island of appropriate action to take in order to
promote their own safety, such as bringing their own bicycle
helmets if they do not wish to rent one on the island.
Assisting the bike rental shops in obtaining proper sizes
and numbers of helmets necessary to meet the needs of the
riders along with teaching the employees proper equipment
fit might be a means of encouraging business participation
in bicycle safety. Once on the island the use of signs

posted at strategic spots along pathways depicting and

58
encouraging correct helmet use along with safe rider
practices could further enhance the safety message. These
signs could further warn the visitor of changes in terrain
as well as dangerous intersections can also be of great
benefit in promoting safety.

Through the role as evaluator the APN can continue to
assist the community on Mackinac Island in identifying what
is and is not effective in terms of safety promotion and
give further voice to the perceived susceptibility of
already identifiable high risk situations. Evaluating the
current means of reporting and tracking accidents on the-
island through police and health clinic forms may be one
means of achieving this goal.

Conclusion

It is hoped that this study has helped define a safety
problem on Mackinac Island as it relates to the safety of
its bicycle riders. Safety issues are one of the many
concerns that a host community has in a highly visited
tourist destination. The information gathered from this
study will be used to assist the community of Mackinac
Island in developing safety programs that will reduce injury
from bicycle accidents and help improve the quality of
information obtained when an accident occurs.

1 It is the responsibility of all members of a community
to not only provide for the safety of its own members, but
also its guests. By continually evaluating risk potential

and through the development and promotion of successful

59
safety programs the most memorable event may be the one that

never occurred, a preventable injury.

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64

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APPENDIX A

ABBREVIATED INJURY SCALE

65

ABBREVIATED INJURY SCALE

 

 

 

Severity Severity Category/Injury Description Police
Code Code
0 No Injury O or D
1 Minor C
General

Aches all over
Minor lacerations, contusions, and abrasions
(first aid - simple closure)
All 1" degree or small 2nd or small 3rd
degree burns

Head and Neck
Cerebral injury with headache; dizziness; no
loss of consciousness
”Whiplash” complaint with no anatomical or
radiological evidence
Abrasions and contusions of ocular apparatus
(lids, conjunctiva, cornea, uveal injuries);
vitreous or retinal hemorrhage
Fracture and dislocation of teeth

Chest

Muscle ache or chest wall stiffness
Abdominal

Muscle ache; seat belt abrasions; etc.
Extremitiee

Minor sprains 8 fractures and/or dislocation
of digits

 

 

 

 

Severity
Code

   

 

66

Severity Category/Injury Description

Moderate

General
Extensive contusions; abrasions: large
lacerations; avulsions (less than 3" wide)
lOt-ZOt body surface 2'“1 or 3“ burns

Head and Neck ‘ -
Cerebral injury with or without skull
fracture, less than 15 minutes
unconsciousness no post-traumatic amnesia
Undisplaced skull or facial bone fractures or
compound fracture of nose
Lacerations of the eye and appendages;
retinal detachment
Disfiguring lacerations
“Whiplash? severe complaints with anatomical
or radiological evidence

Chest
Simple rib or sternal fractures
Major contusions of chest wall without
hemothorax or pneumothorax or respiratory
embarrassment

Abdominal
Major contusions of abdominal wall

Extremities and/or Pelvic Girdle
Compound fractures of digits
Undisplaced long bone or pelvic fractures
Major sprains of major joints

 

Police‘
Code

 

 

 

Severity
Code

 

67

 

Severity Category/Injury Description

Severe (Not Life-Threatening)
General

Extensive contusions: abrasions: large
lacerations involving more that two
extremities, or large avulsions (greater than
3' wide)

20-30t body surface 2° or 3° burns

Mead and Neck

Chest

Cerebral injury with or without skull
fracture, with unconsciousness more than 15
minutes; without severe neurological signs:
brief; post-traumatic amnesia (less than 3
hours)

Displaced closed skull fractures without
unconsciousness or other signs of
intracranial injury

Loss of eye, or avulsion of optic nerve
Displaced facial bone fractures or those with
antral or orbital involvement

Cervical spine fractures without cord damage

Multiple rib fractures without respiratory
embarrassment

Memothorax or pneumothorax

Rupture of diaphragm

Lung contusion

Abdominal

Contusion of abdominal organ
Extraperitoneal bladder rupture
Retroperitoneal hemorrhage

Avulsions of ureter

Laceration of urethra

Thoracic or lumbar spine fractures without
neurological involvement

Extremities and/or Pelvic Girdle

Displaced simple long-bone fractures and/or
multiple hand and foot fractures

Single open long-bone fractures

Pelvic fracture with displacement

Dislocation of major joints

Multiple amputation of digits

Lacerations of the major nerves or vessels of
extremities

 

Police1
Code

 

 

Severity
Code

68

Severity Category/Injury Description

 

Chest

 

Severe (Life-Threatening, Survival Probable)
General

Severe lacerations and/or avulsions with
dangerous hemorrhage
30-50t surface 2° or 3° burns

Head and Neck

Cerebral injury with or without skull
fracture, with unconsciousness of more than
15 minutes, with definite abnormal
neurological signs: post-traumatic amnesia 3-
12 hours

Compound skull fracture

Open chest wounds; flail chest;
pneumomediastinum; myocardial contusion
without circulatory embarrassment;
pericardial injuries

Abdominal

Minor laceration of intra-abdominal contents
(to include ruptured spleen, kidney, and
injuries to tail of pancreas)
Intraperitoneal bladder rupture

Avulsions of the genitals

Thoracic and/or lumbar spine fractures with
paraplegia

Extremities

Multiple closed long-bone fractures
Amputation of limbs

 

Police‘
Code

 

69

 

 

 

 

 

 

 

 

Severity Severity Category/Injury Description Police
Code - Code
5 Critical (Survival Uncertain) A

General
Over 50\ body surface 2° or 3° burns
Head and Neck
Cerebral injury with or without skull
fracture with unconsciousness of more than 24
hours; post-traumatic amnesia more than 12
hours; intracranial hemorrhage; signs of
increased pressure (decreasing state of
consciousness, brady-cardia under 60,
progressive rise in blood pressure or
progressive pupil inequality)
Cervical spine injury with quadriplegia
Major airway obstruction
Chest
Chest injuries with major respiratory
embarrassment (laceration of trachea,
hemomediastinum, etc.)
Aortic laceration
Myocardial rupture or contusion with
» circulatory embarrassment
Abdominal
Rupture, avulsion or severe laceration of
intra-abdominal vessels or organs, except
kidney, spleen or ureter ’
Extremities
Multiple open limb fractures
6 Fatal (Within 24 Hours) K
Fatal lesions of single region of body, plus
injuries of other body regions of Severity Code 3
or less
Fatal from burns regardless of degree
7 Fatal (Within 24 Hours) A
Fatal lesions of single region of body, plus
injuries of other body regions of Severity Code 4
or S
8 Fatal R
2 fatal lesions in 2 regions of body
9 Fatal X
3 or more fatal injuries
Incineration by fire
99 Severity Unknown

 

Injured, but severity not known

 

 

7O

    

Severity Severity Category/Injury Description

Code

IIIIIIIIIIIiiiiiiIiiiiiHIIIIIIIlllllllllllllllllllllll'Illlllll
,_1?F93223219£1§B_B£_.ESEM59289- , _

         

APPENDIX B

MACKINAC ISLAND INJURY SURVEY

71

MACKINAC ISLAND INJURY SURVEY

Incident Date

 

Incident Location

 

(Be specific)

Incident Time AM PM
Circle one: AM: 6am-12 noon PM: 12 noon-8pm NOC: 8pm-6am

 

 

Incident Type (list all that apply):

 

1. Bicycle/Bicycle 2. Bicycle/Horse 3. Bicycle/Pedestrian
4. Bicycle alone 5. Other: (describe)

Incident Severity: (1-5)

 

Victim able to continue on Yes No
Victim taken to Island clinic Yes No
Ambulance called Yes No
Victim taken off island due to Yes No
severity of injury

Weather conditions Rainy Yes No

Snow Yes No

No precip. Yes No
Fatality Yes No

Victim Name

 

Victim Age years Gender M F

Did victim visit Health clinic Yes No
within 24 hours following accident

Write a brief description of injuries

APPENDIX C

MODIFIED MACKINAC ISLAND INJURY SURVEY

72

MODIFIED MACKINAC ISLAND INJURY SURVEY

Incident Date
Incident Location

Incident Time
Circle one: AM: 6am-12noon PM: 12noon-8pm NOC: 8pm-6am

Incident Type (list all that apply)
Bicycle/Bicycle
Bicycle/Horse_____
Bicycle/Pedestrian
Bicycle alone

Other (Describe)

 

Incident Severity

Critical (Survival uncertain or Fatal)
Severe (Incapacitating)
Non-Incapacitating

_____Minor

No Injury

 

 

 

 

Anatomical Location of Injury
Victim Age Victim Gender

 

 

Did victim visit health clinic within 24 hours following

accident
Yes No

 

 

Write a brief description of injuries

APPENDIX D

MODIFIED ABBREVIATED INJURY SCALE

73

MODIFIED ABBREVIATED INJURY SCALE

Severity Code
Fatal - corresponds to #6 on AIS

Incapacitating - survival uncertain must be transported off
island, corresponds to AIS 3,4, 85. Includes a wide
range of injuries due to limited ability of island
health clinic to treat critical or serious injury.

Non-incapacitating - corresponds to AIS 2.

Possible or Minor - corresponds to AIS 1.

No injuries - corresponds to Code 0 on AIS Scale.

APPENDIX E

AIS - 6 SEVERITY CODE

1.

2.

4.

5.

6.

74

AIS-6 SEVERITY CODE
Minor
Moderate
Serious
Severe
Critical
Maximum injury - virtually unsurvivable given our
present medical capabilities, specific knowledge of the
severity of injury must be available, not merely

knowledge that death occurred.

Unknown

 

APPENDIX F

UCRHIS Approval

 

 

OFHCEOF
RESEARCH
AND
GRADUATE
STUDIES

Mdfiefihmumwsm
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flBfldMfi
517355-2181
FAX:517/432-1171

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75

MICHIGAN STATE

UNIVERSITY

September 30, 1997

TO: Ma Hu hes
B 311 DgWest Fee

 

RE: 1R8“: 97-552
TITLE: INJURY PATTERNS IN ADULT AND PEDIATRIC BICYCLE
RIDERS ON MACKINAC ISLAND
REVISION REQUESTED: N/A
CATEGORY: 1-7
APPROVAL DATE: 09 29/97

The University Cmittee on Research Involving Bmaan Sub ects' (UCRIBS)
review of this project is complete. I am pleased to adv so that the
rights and welfare of the human subjects appear to be adequately
rotected and methods to obtain info consent are a ropriate.
Eggrefore, the UCRIHS approved this project and any rev sions listed
V8.

RININAL: UCRIHS approval is valid for one calendar year, beginning with
hown o

the approval date a above. Investigators plann
continue a project he nd one year must use the green renewal
form (enclosed with original a roval letter or when a

project is renewed) to seek u te certification. There is a
maximum of four such expedite renewals ssible. Investigators
wishin to continue a roject beyond the time need to submit it
again or complete rev ew.

REVISIONS: UCRIHS must review an changes in rocedures involving human
subjects, rior to in tiation of t e change. If this is done at
the time o renewal, please use the green renewal form. To
revise an ap roved protocol at an o her time during the year
send your written request to the CRIHS Chair, requesting revised
approval and referencin the project's IRB fl and title. Include
in your request a descr ption of the change and any revised
ins ruments, consent forms or advertisements that are applicable.

FROBLIIS/

CHANGES: Should either of the followin arise during the course of the
work, investigators must noti UCRIHS romptly: (1) roblems
(unexpected side effects comp aints, e c.) involving uman
subjects or (2) changes in the research environment or new
information indicating greater risk to the human sub ects than
existed when the protocol was prev1ously reviewed approved.

If we can be of any future help, lease do not hesitate to contact us
at (517)355-2180 or FAX (517)! 2- 171.

, \3

avid E. Wright, Ph.D
CRIHS Chair

:bed

Sincer y,

cc: Robert Prodi er
Elizabeth x1e n
Mary Wilger

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