TOPIC 1: What do we know about injury and mortality from cycling?

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1 1 Cycling Seminar Can advances in medicine and research at Barts Health impact the number of killed or seriously injured people from cycling incidents? A hotly debated topic with wider implications across health, the environment and the economy, for individuals, for society and politically, the seminar on 31st January 2014 bought together a unique group of experts and thought-leaders from a broad range of disciplines. Experts on data collection and analysis, trauma, rehabilitation and cycling from Barts Health NHS Trust and beyond gave presentations on four key topics, followed by round-table discussions and conclusions. This resulted in a truly exceptional event with some shocking revelations, alongside real ideas for innovations for change. TOPIC 1: What do we know about injury and mortality from cycling? The unfortunate reality is that our knowledge is extremely limited, especially for less serious incidents and less severe injuries, which sit under the tip of an enormous iceberg. Currently we obtain data from a variety of sources, but all have their shortcomings. For example, the trauma and emergency teams collect data on the sex of a patient, the types of injuries sustained and whether a vehicle was involved. However, we could be gathering information about the road layout, whether there was a pothole in the road, whether the person was wearing high-vis clothing, the location of the incident, the type of vehicle involved, the events leading up to the incident, how much cycling experience the person had, the weather conditions.the list goes on. Unsurprisingly data on deaths is the most robust, and the good news is that mortality is going down. In fact, over the last 27 years, all transportation related deaths have fallen. However, cycling as a percentage of transport deaths has increased. Why? We re not sure, but with better data we can understand the factors involved and answer this question with authority. Shouldn t all cyclists and road users be better informed? It is easy to speculate, but it is only knowledge that will offer the best chances of taking control of our safety, our children s safety and the safety of other road users. The data is appalling and we need to improve it if we re going to do anything at all about injury prevention and injury monitoring. Professor Allyson Pollock We are in the early stages of an exciting project - to create the UK s first tailor-made database for detailed injury data collection, enhanced by an innovative smartphone-based app to collect data from patients. This would arm us with more knowledge than we ve ever had about the circumstances surrounding injury. Using cyclists treated at the Royal London Hospital as a starting point, the project would extend to victims of all road traffic collisions, falls, interpersonal violence, and playground and sporting injuries.

2 2 The potential of such a project is huge, the ultimate aim being to create a near real time database of serious injuries across the UK. This would result in effective injury prevention, impacting death and injury from trauma nationally currently the biggest killer of children and young adults.. TOPIC 2: How do our trauma and emergency teams save lives? Through fast response, preparedness, pioneering models of care and innovative techniques, we save thousands of lives every year, but we could be doing more The Major Trauma Centre at The Royal London Hospital (RLH) admits over 2400 seriously injured patients every year more than any other hospital in Europe and is a flagship centre in the UK. Not only is it the busiest trauma centre in the UK, it also boasts the highest rate of survival for critically injured patients. Across all trauma and emergency departments at Barts Health, 350,000 patients (of all severity) are seen annually. If an incident occurs, what happens after the call comes in? The trauma team immediately mobilises. While the pre-hospital team attends the scene the surgeons must be ready for any and all injuries - head to toe - preparing everything from instruments to blood. Although the number of cyclists has significantly increased over the years, mortality rates for cycling related incidents has significantly dropped due to improvements in trauma care at the Royal London Hospital. However there is still much work to be done to save even more of these precious, young lives. Around three quarters of seriously injured cyclists seen at The Royal London Hospital have collided with a car or HGV, with HGVs associated with severe injuries and death as a result of uncontrollable bleeding i.e. haemorrhage (which accounts for approx. 40% of all deaths from major trauma). Pelvic injury and bleeding is particularly common in cyclists involved in HGV collisions, and this is a major cause of death (ref MANSONet al 2012, see press page).

3 3 Barts Charity are seeking funding for a project which represents the most exciting recent innovation in pre-hospital care across the globe. This new technique will enable cutting edge treatment on the roadside to help stop fatal bleeding, something which was previously only possible once a patient had been transported to hospital. In more serious cases this means the difference between life and death, and is particularly relevant to cyclists who have sustained very bad pelvic injuries after being run over. TOPIC 3: How can we use collected data to inform and evaluate prevention strategies? We already know that improved data collection is necessary for targeted injury prevention strategies and interventions; however, how should we be using this data to move us towards a safer cycling climate? Spatial and epidemiological analysis is a good first step to inform prevention strategies. This would allow us to identify: (a) Higher risk areas to create a comprehensive map of hotspots for all injury types and severity (b) The type of individual who is at greatest risk We also need clarity on denominator values - such as the number of people who cycle, the distance travelled and the number of trips made - if we are to make this data relative and meaningful. A number of large scale systematic reviews demonstrate what we know about the effectiveness of current interventions such as infrastructure (e.g. multi-lane roundabouts, separate cycle tracks, shared paths and pavements, dedicated bike routes, minor vs. major streets) and protective clothing (e.g. helmets). Interestingly, no trials exist assessing the effect of visibility aids on pedestrian and cyclist-motor vehicle collisions. In addition, bicycle skills training for children and adolescents does not appear to reduce injury rates. However with all interventions, more data is needed for conclusive evaluation of their efficacy, especially in the UK. Out of the 35 studies reviewed for the seminar, only four were conducted in the UK. To help evaluate the effectiveness of local authority cycling injury interventions, Barts Charity would like to work on a project with injury data and prevention specialists at our medical school in partnership with Hackney Council. Hackney represents the London borough with the highest uptake of cycling. The pilot project would involve the development of an innovative modelling toolkit, easily adapted and user-friendly, to predict how local cycling injury incidence, prevalence and outcomes may change given various intervention scenarios. The project has the potential to be rolled out across London, informing city wide cycling injury prevention.

4 4 TOPIC 4: How are we addressing long-term outcomes and the need for rehabilitation? Patient rehabilitation is a complicated and layered process. Due to improved clinical intervention more trauma patients are surviving multiple injuries, with a large percentage requiring long-term care. Mary was injured by a lorry whilst cycling to work on Nov 4th 2011, suffering traumatic brain and complex orthopaedic, chest and pelvic injuries. She required prolonged critical and was in the hospital for 7 ½ months. Now in a nursing home, Mary requires long term specialist rehab care and remains in a minimally conscious state, with only fleeting awareness and little ability to communicate. Mary s father said It s not like if Mary had been killed on November 4. I would go through a cycle of bereavement and eventually come to terms with it. Something like this, there will never be closure because Mary will always be there and I will always be conscious of her suffering. Unfortunately many cyclists suffer similar outcomes but their stories go unnoticed, as they are not part of the mortality statistics. Only two thirds of patients return to full time work 4-6 months after injury. This impaired quality of life not only seriously affects their physical, psychological and social wellbeing, but can shatter the lives of everyone around them, and also has wider economic implications. As our seminar thought-leader James Moore, Journalist from The Independent and trauma survivor, said in his interview for Radio 4, People have their lives wrecked by serious injuries. Many patients speak of falling off the therapeutic cliff when they leave hospital and go home after receiving around the clock care and support. Not only are they at risk of severe physical discomfort, but also of developing feelings of extreme isolation and depression. The odds of suicidal activity following major trauma are 4:1. Clinicians and researchers at Barts Health NHS Trust are working on a special project idea which would give trauma survivors a new lifeline. The innovative web-based resource would provide essential support for long term trauma survivors and their families. Evidence shows that this could dramatically reduce odds of depression, and the tool could be used by trauma survivors and trauma specialists cross the UK to improve the care and rehabilitation offered to these often forgotten individuals. All trauma survivors who attended the seminar unanimously agreed that this invaluable resource would transform rehabilitation provision in this country. For more information about how to get involved please To donate, click here.

5 5 This was an extraordinary multi-disciplinary seminar in which I, as a cyclist, and a journalist learned an enormous amount about the risks and consequent clinical responses to traumatic cycling incidents. I was impressed by the commitment, integrity, and evident skills of those who contributed In all, it was a stimulating and impressive exercise from which I think everybody present, however seasoned, emerged having learned something, and having seen ways to improve trauma services" - Jon Snow, presenter, journalist and cycling champion

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