HBO Presents "The Crash Reel": Examining The Enormous Impact Of Traumatic Brain Injury (TBI)

Traumatic Brain Injury (TBI) is a public health problem.  We hear about it a lot in relation to the members of our Armed Forces.  In fact, TBI has been "one of the signature injuries of troops in Afghanistan and Iraq".  There has also been much discussion in the media (and here on Pop Health) about the impact of TBI on National Football League (NFL) players.

On July 15, 2013 HBO premiered an incredible documentary called "The Crash Reel".  This film follows U.S. snowboarder Kevin Pearce as he rises through the ranks of the sport, dominates international competition in the run-up to the 2010 Olympics, survives a horrific training accident in Park City, Utah and launches a come-back to his life (and possibly) the sport he loves so much.

The documentary does an amazing job of examining both macro and micro public health issues as they relate to TBI.

Society:

During a poignant interview, Kevin's Dad says "we were all to blame" [for Kevin's injury].  The spectators, the families, the sponsors....he believes they all have a role in injury prevention and athlete safety. He asks why the halfpipe walls keep getting higher and higher (increasing speed, height, and risk of the tricks).

Risk culture and the role of spectators and sponsors in perpetuating this culture is called out in "Wrecks Over Reason", an article running in the August 5, 2013 issue of Sports Illustrated (SI).  Referencing the "X Games" specifically, athletes acknowledge that the audience is hoping to see crashes.  The author Austin Murphy writes, "Indeed, many of the events-at the X Games in particular and in the extreme sports world in general-seem designed to ensure a modicum of carnage.  That's what people are tuning in to see".  

Family and Friends:

Kevin's close-knit family is a big part of the documentary.  We hear them recount how they learned of his accident and through pictures and video, we see them assume the role of caretakers.  It is clear that TBI can have an enormous impact on a person's entire family.  His brother Adam quits his job to help Kevin through his rehabilitation.  His mother is by his side for almost every appointment.  His roommate helps to counter his memory loss by helping with organization and medication.

Having almost lost him and with their lives heavily impacted during his recovery, their fear is understandable when Kevin talks about getting back to snowboarding.   Although his physicians and family constantly reinforce the danger that a second head injury could bring (i.e., it could be fatal), Kevin is determined to return to the sport.  

Kevin:

The accident was caught on video and is horrific to watch. All things considered, Kevin makes a pretty amazing recovery.  He spends 3 months in the hospital and then participates in ongoing rehabilitation to address the lingering effects of his injury: double vision, impulse control problems, memory loss, and depression.  He wrestles with accepting that his injury is life-long and will forever change the trajectory of his life and career.

According to the Centers for Disease Control and Prevention (CDC), at least 1.7 million TBIs occur every year, either as an isolated injury or along with other injuries.  The costs of these injuries are huge- not just in terms of medical costs, but in terms of lost productivity for that individual (and their friends/family that serve as caretakers).  While it is important to focus on helmet use and other individual-level interventions, I applaud the tone of this documentary and the SI article above.  I hope they ignite a discussion of society-level (and sports-level) interventions for traumatic brain injury. 

Baby on Board Badges May Reduce Awkwardness...But Can They Also Increase Safety?

Yesterday many media outlets were thrilled to report that Kate Middleton, Duchess of Cambridge received a "Baby on Board" badge during a visit to the London Underground (the city's subway system).  The badge initiative, first piloted almost a decade ago, was developed after internal research by Transport for London (TfL) showed that pregnant women often felt awkward or uncomfortable asking if they could sit down.  The research also revealed that most travelers believed that mothers-to-be should be offered a seat.  The developers hoped that the badges would give women confidence to ask for a seat and encourage fellow passengers to offer theirs without being asked.

In all the coverage of this initiative, I have (unfortunately) not seen any discussion of evaluation.  The badges are used broadly in London (and other countries like Ireland use them as well).  However, we do not know if they have successfully increased women's confidence to ask for seats or increased a non-provoked seat offer by their fellow travelers.  In addition to these goals, I wonder about how these badges could also be connected to the safety of pregnant women riding public transportation.

This week I had the pleasure of meeting a friend's 11-week old son.  She rode the subway to work all through her pregnancy and we discussed the potential risks that the ride entailed.  While she was comfortable with the ride, her co-workers were often worried about her choice of transportation.  What if she couldn't get a seat?  What if she fell?  What if someone fell into her on the crowded train?  My friend described the experience of having a student's backpack pressed up against her belly late in her pregnancy...which then prompted her to take an alternate mode of transportation to work the next day.

So what if the "Baby on Board" badges could do more than just reduce awkwardness for pregnant women and their fellow passengers?  What if this badge initiative could also reduce the number of pregnant women standing on crowded trains, putting them at risk for falls and other injuries?

First, we would need strong baseline data to determine if a public transportation prenatal injury problem even exists.  Then we would need to evaluate that data during and after the initiation of a badge program in the U.S.  We would also need to evaluate the effectiveness of the badges as a visual cue (e.g., Do passengers recognize the badges?  Do they understand what action they should take upon seeing the badges? i.e.,- giving up their seats).

What do you think?

• Are you aware of research/studies on public transportation prenatal injury?  If so- please share!
• For those readers/friends/colleagues that have ridden public transportation while pregnant:  Did you feel at risk for injury?  Did you ever suffer an injury?
• What do you think about the potential for "Baby on Board" badges to prevent injury?  Are there other strategies that may be more effective?

 

Madonna's "MDNA Show Manifesto" Defends Using Guns on Tour: Do You Agree?

As we speak, Madonna is en route to my city- Philadelphia, to launch the North American leg of her "MDNA World Tour".  In advance of her arrival, she has released a statement to the local Metro defending one of the most controversial parts of her tour...the use of fake firearms in concert.  Here is a portion of that statement:

"It's true there is a lot of violence in the beginning of the show and sometimes the use of fake guns - but they are used as metaphors.  I do not condone violence or the use of guns.  Rather they are symbols of wanting to appear strong and wanting to find a way to stop feelings  that I find hurtful or damaging.   In my case its wanting to stop the lies and hypocrisy of the church,  the intolerance of many narrow minded cultures and societies I have experienced throughout my life and in some cases  the pain I have felt from having my heart broken".

Gun violence is (unfortunately) not a new problem.  However, the topic is quite timely due to increased U.S. media coverage following several mass shootings in the past few weeks- Aurora, CO, Oak Creek, WI, and New York, NY.  The issue of gun violence has reached crisis levels in Philadelphia where Madonna will be performing.  A new open source journalism project called http://guncrisis.org/ "contends that there is an epidemic of homicide by gunfire in Philadelphia and similar cities".  They are seeking solutions.

The solutions being sought by GunCrisis: Philadelphia and others involve taking a public health approach to gun violence.  The recent high profile shootings have produced several well-written pieces about gun violence and what we need to do next:

•  Prompt policy discussions about easy access to ammunition, high-capacity magazines, and assault weapons.
• Use our public health skills to conduct further research into the causes of firearm injuries.
• Examine gun violence as a social disease- one that stems from a society "saturated with guns".

Tell me what you think:

Do you believe that the gun "saturation" goes beyond those in our homes to include those used for entertainment?  E.g., Guns in movies or video games; Madonna's concert props

Is Madonna successful? Does using guns as a metaphorical image help her reach her goals and battle against hypocrisy and intolerance?

In addition to those listed above, what other strategies should we incorporate into a public health approach against gun violence?

Let's Talk Safety Climate and the Airlines: "Welcome Aboard"

I spent the past few weeks out on vacation in the beautiful Pacific Northwest (which explains my brief absence from Pop Health). While the trip was wonderful, it is quite nice to be back on the blog. And in fact, my trip provided me with the inspiration for this post. On my return flight home, I encountered an array of travel nightmares (delays, mechanical problems, cancelled flights, lost luggage). While many people may just consider these as an inconvenience, they also got me thinking about my safety. As we sat at the gate and waited for test after test, my husband assured me that they wouldn't put us on the plane if it wasn't safe. However, I wondered aloud if that was true. With the pressure for the airlines to have better on-time statistics and less angry customers, can we be put on a plane that is unsafe? My experience with USAirways, the similar experiences that I read about on Twitter, and the information I found regarding their dysfunctional relationship with their Pilots Association got me interested in the safety climate of the airline industry.

Everyday we encounter airline advertising that hopes to recruit our business by highlighting a company's high standards for safety, comfort, reasonable prices, and customer service. The ads also try to capitalize on things that we value, for example- freedom. Some memorable slogans include, "You are now free to move about the country" (Southwest); "We love to fly and it shows" (Delta); "Come fly the friendly skies" (United). While these slogans are catchy and convincing, they represent the "espoused values" of the airlines. Espoused values are values and norms stated by the organization. They can often be found in companies' strategic plans, goals, and/or taglines. For example, USAirways has an initiative called "Customers First" which strives to address key service elements that affect their customers.

In addition to espoused values, we also find "enacted values"; these are the norms that are actually exhibited by employees. These values may or may not be in line with the espoused values. That is why even though "Customers First" can be an espoused value, you can still end up bumped off a flight and sleeping in the airport because the rude gate agent told you there was no flight availability. In order to hear about other customers experiences with enacted values, I turned to Twitter and was amazed by what I saw. There were hundreds of comments to or about @usairways that were identical to mine- lots of mechanical failures ending in flight cancellations and luggage that was lost for days. I understand Twitter may be skewed towards the negative because people are less likely to tweet about the on-time departures...however, if you look at another airline (e.g., @southwestair) you see almost nothing about mechanical problems.

A less biased way to learn about employees' values and their level of congruence with the organization executives, is to hear from them directly. Just a few weeks ago, the US Airline Pilot Association- USAPA (the union that represents USAirways pilots), posted on their website to alert customers to the pressure they are receiving from USAirways executives to fly under unsafe conditions. On June 16, 2011, a pilot with 30-years of experience was escorted from the airport after she refused to fly a plane overseas after it failed multiple safety checks. A second group of pilots refused to fly the plane as well. This is not the first time that USAPA has spoken out against the executives. In 2008, they posted a customer alert in USA Today because they were being pressured to fly with less fuel in order to save money.

The examination and measurement of espoused/enacted values and their connection to safety outcomes (e.g., occupational injuries) is the exciting field of safety climate research. The term "safety climate" was coined in 1980 by Dr. Dov Zohar and has been prevalent in the Industrial and Organizational Psychology literature before making its way into the public health literature. For those interested, the journal Accident Analysis & Prevention recently dedicated an issue to safety climate and occupational health.

Safety climate research has been used to assess the climate of a variety of industries (e.g., healthcare). I propose that it is essential for examining the values within individual airlines and their connection to safety outcomes (e.g., worker injuries, passenger injuries, mechanical failures, near-misses, etc). The discrepancy discussed above between employee and company values can become a very dangerous combination.

Where Are the Helmets in the Home Run Derby?

Last night I returned home from a lovely dinner with my injury prevention colleagues to a sight that really caught me by surprise. My husband was watching the Major League Baseball (MLB) Home Run Derby. I tuned in for a moment before turning to him and asking, "Why aren't they wearing helmets?" I think we are all accustomed to seeing players in their batting helmets, so this looked strange to me- especially in contrast to the catcher, who was dressed in full protective gear. My husband informed me that helmets are not necessary because the pitches are much slower. However- I would disagree (and this is not the first time I have critiqued professional sports and their commitment to protecting players from head injuries).

First of all, concussions (which we must remember are a traumatic brain injury!) do not only occur when the ball is traveling 100 MPH. Therefore, a slower pitch does not equal safety. The catcher still wore full protective gear. The pitcher stood behind protective netting. So on some level it is acknowledged that hazards still exist at the Home Run Derby.

In addition, concussions (or more serious injuries) can happen even when you are not the batter. Therefore, helmets protect you when you are on deck, warming up, or coaching from the sidelines. Home Run Derby participants are still at risk for injury when they are not at bat. This is a lesson that many in baseball know far too well. In 2007, a minor league first base coach was killed when he was hit in the head with a line drive. This tragic accident resulted in a change in policy regarding required head protection for first and third base coaches.

Speaking of policy, I find it strange that their batting helmet practices vary based on the speed of the pitch. This is not an acceptable strategy in other areas of injury prevention, so why is that the strategy here? We don't tell people to only wear seatbelts if they are planning to drive faster than 40 MPH. We don't tell people to only avoid texting and driving if they are on the highway. The MLB seems to be accepting a high level of risk for their players in this context. This is especially surprising since MLB and the MLB Players Association have taken steps to prioritize safety regarding head injuries. They recently implemented a universal concussion policy (which went into effect on Opening Day 2011). The new policy dictates both how concussions are initially treated and when player/umpires are allowed to return to play. The most substantial change is the creation of a 7-day disabled list to allow players an appropriate amount of time to heal after a concussion. They are also introducing reinforced helmets that can withstand 100 MPH fastballs.

While the safety of the players is paramount, this discussion is also important because MLB players are role models. Therefore, it is important that they model acceptance and proper usage of personal protective equipment. If you looked at the stadium crowd at the Derby (and the lucky few invited to catch balls in the outfield), it was mostly kids. If the MLB and the players do not provide leadership on safety policies and equipment, it could have larger public health effects on the audiences that model their behavior (so don't get me started on the chewing tobacco issue).

Therefore, I strongly encourage MLB to review their policies regarding personal protective equipment and the grey "safe" areas they have identified, like the Home Run Derby. It appears to be a relaxed, fun event during the all-star break but in reality, they are unnecessarily putting the safety of their players at risk.