"Most physicians practice good preventive medicine when it comes to influencing coronary artery disease, hypertension, strokes, and cigarette-related disease," says Arthur Kellermann, MD, director of Emory's Center for Injury Control and a member of The Emory Clinic Sectionof Emergency Medicine. "But we don't exercise a comparable degree of effort in addressing the potential for injuries in our patients. Yet injuries account for more potential years of life lost before the age of fifty than all kinds of cancer and heart disease combined. The Center for Injury Control is committed to reducing that grim statistic through research, education, and service. Specifically, physicians and researchers will use epidemiologic techniques to analyze the causes of injuries and to identify interventions," Kellermann explains.

The center will also study trauma systems design, while researching ways to improve acute care for treating and rehabilitating injury victims. Initially programs are being developed in three areas: violence, bicycle helmet utilization, and the incorporation of injury control principles into systems of managed care.

THE SCOPE OF THE PROBLEM

Statistics show that injuries take an enormous medical and economic toll on the country - a toll that has not been given enough emphasis in medical education, Kellermann believes. "Doctors with patients under age forty-five need to understand that injuries are the top health threat to this age group. And even in the elderly, it's the second leading cause of preventable health care costs."

"Injuries result in more than 142,000 deaths in the United States each year and permanently disable another 80,000 persons," points out Ricardo Martinez, MD, the center's former associate director, now on loan as administrator of the National Highway Traffic Safety Administration. "One out of every four patients who comes to an emergency department is there with an injury," he says, adding "the longest hospital stays are usually for injured patients."

Philip Graitcer, DMD, MPH, who heads the center's bicycle helmet initiative, points out that in 1991 there were 66 million visits to office-based physicians -10 percent of which were due to injuries. "Whether the injuries were caused by a drunk driver or failure to wear a bicycle helmet, the bottom line is that virtually all were preventable," says Graitcer, who was formerly at the Centers for Disease Control and Prevention in Atlanta, where he helped create the National Center for Injury Prevention and Control.

Graitcer says that Georgia's bicycle helmet law provides doctors with a good opportunity to discuss the importance of bicycle safety with their patients. "We have 800 to 900 bicycle-related deaths a year in the United States - about half of which are children - and some 600,000 emergency room visits for the treatment of injuries in bicycle crashes annually."

Graitcer asks physicians to encourage all their patients to use bicycle helmets and to show parents how to properly buckle a child into a car seat. "It only takes a few extra minutes of physician/patient contact to save lives," he says.

THE EPIDEMIOLOGY OF INJURIES

"Injuries have a staggering economic impact," emphasizes Martinez. "They result in more than $44 billion in direct health care costs. And because the young are affected disproportionately, injuries can result in an enormous loss of productivity to society," Martinez adds.

"We are beginning to realize that focusing only on treatment is not necessarily the best use of our money," he continues. "The good news is that we can do a lot to prevent injuries, save lives, and reduce health care costs."

"Injuries have not received the same serious scientific scrutiny as infectious diseases," Martinez believes, "because they have long been dismissed as unavoidable and accidental - the result of careless behavior or divine retribution.

"Instead, injury is the result of uncontrolled energy. This energy can be kinetic (like car crashes and assaults), but it can also be chemical, electrical, or thermal," he says.

"Learning to predict and control injuries can be accomplished using the same epidemiologic techniques that are used to track down hepatitis or AIDS," contends Kellermann. "Once we know the risk factors for injury in target groups, we can develop strategies to intercede."

An example of that approach was a landmark study published in October 1993 in the New England Journal of Medicine by Kellermann and colleagues at the University of Tennessee, where he was director of the Regional Medical Center's Emergency Department.

The study addressed risks associated with gun ownership. By using the tools of epidemiology, the research team found a number of important risk factors for homicides in the home. These include living alone, having a household member who was previously arrested or used illicit drugs, living in rental housing, and having been hurt in a family fight. However, even after adjusting for the effect of these risk factors, keeping one or more guns in the home was associated with an almost threefold increased risk of homicide in the home.

"The study was conducted to provide objective, scientific answers about the risks and benefits of gun ownership, which, up until now, have been answered by bumper stickers, rhetoric, and anecdote," says Kellermann, who calls gun-related violence a top priority for study at the center.

"There are the three basic of injury control: education, engineering (which includes product safety and environmental design), and enforcement of appropriate public health oriented regulations," Kellermann explains. "Evaluation of what works and what doesn't is important too. "

As for strategies for preventing school violence, such as metal detectors and conflict resolution programs, "Although they sound good, they may not be worth the diversion of money and class time," Kellermann explains. "By evaluating programs to ensure they are making a positive difference, the Center for Injury Control can make a real contribution."

INJURY CONTROL AND PRIMARY CARE

Kellermann and his colleagues emphasize that many strategies for preventing injury-induced disabilities and deaths are wll documented. With this information, clinicians can make an enormous contribution to the reduction of injury-caused morbidity and mortality.

"A physician doing any kind of health screening or ongoing care of patients not only should ask about cigarette smoking, alcohol intake, and other health related hazards but also should ask patients six or seven questions about injury risk behaviors. If they get positive answers, doctors should then follow-up with direct patient education," Kellermann explains.

He suggests asking patients if they buckle their seat belts regularly, if they wear bicycle or motorcycle helmets, and if they have functioning smoke detectors in their homes. "Are there kids in the household? Check to see if drugs are kept away from them in child-proof bottles. If elderly or disabled people live in the home, a comparable level of effort should be made to reduce tripping hazards and other causes of falls." Kellermann also urges physicians to emphasize to their patients the risks associated with guns in the home and to explore the potential for suicide and domestic violence. "Docs shouldn't be cops, but we need to do more than just patch up the battered," he states. "We need to inquire about these problems and help prevent them."

Health care's future focus will be on prevention, contends Martinez. "In a managed care system where physicians are paid a fixed fee, whether the patient is sick or well, those who do a better job of keeping their patients healthier and more productive than their counterparts, will do better economically.

"Under these circumstances," Martinez adds, "injury control is not only going to make moral and ethical sense, but financial and business sense as well."

Will ways be found to prevent all injuries? "Absolutely not," says Kellermann. "But we can control their impact and prevent many of them, just as we can prevent certain forms of heart disease, cancer, and infectious disease now."