Abstract
Aim
To clarify the characteristics of injuries caused by falling into an open drain.
Methods
A medical chart review was retrospectively carried out of all patients in East Shizuoka, Japan, who were injured due to falling into an open drain, and who were subsequently transported to hospital by ambulance or a physician‐staffed helicopter, between January 2013 and December 2014. The patients were divided into two groups, those treated as outpatients and those who were admitted to hospital.
Results
During the investigation period, there were 33 patients who had accidentally fallen into an open drain. The ages of the subjects ranged from 10 to 90 years, with an average age of 58.8 years. The average age of the subjects, the ratio of female patients, and the average injury severity score in the admission group were higher than that of the outpatient group. One patient in the admission group who had cardiac arrest due to a cervical cord injury eventually died.
Conclusion
Falls into open drains are especially frequent in elderly people and female patients, and older patients tend to more frequently require admission due to severe injury. To prevent injuries of this type, some measures are required to improve the safety of open drains.
Keywords: Drain, injury prevention, open drain, outcome, Shizuoka, trauma
Introduction
A drain is water tract along one or both sides of the road for the drainage of rain or domestic water. In Japanese cities, drains are covered with concrete to create walking spaces and prevent odor. In rural areas, however, due to budget limits or to reduce the labor of cleaning, such drains are often left open. Accidental falls into open drains are a constant occurrence in rural areas. There are previous case reports in Japan1, 2, 3, 4, 5, 6, 7, 8, 9 that have described the various injuries caused by falls into open drains; however, few reports have investigated the characteristics of injuries caused by such falls.36 Accordingly, we carried out a retrospective study in our institute on the nature of the injuries caused by falls into open drains in East Shizuoka, Japan.
Methods
This retrospective study protocol was approved by the review board of Juntendo Shizuoka Hospital (Izunokuni, Japan), and the examinations were carried out according to the standards of good clinical practice and the Helsinki Declaration.
A physician‐staffed helicopter emergency medical service commenced in the eastern part of Shizuoka Prefecture in 2004 and has been supported by our hospital, which has 552 beds, serves as the base hospital, and is responsible for the eastern region of Shizuoka Prefecture, including the Izu Peninsula. This region, approximately 4,090 km2 in area, with a population of approximately 2 million, is mountainous, with only a few hospitals. The journey from the southern tip of the peninsula to the critical care medical center of our hospital takes 1.5 h by ambulance but only 15 min by helicopter. Currently, the most severe cases are transported using this helicopter emergency medical service to our hospital.37, 38, 39, 40
A medical chart review was retrospectively carried out of all patients who were injured due to falling into an open drain, and who were subsequently transported to our hospital by ambulance or a physician‐staffed helicopter, between January 2013 and December 2014. We investigated the following data: patient age, sex, situation of injury (walking, cycling, motorcycling, or driving), daytime or night time, season, lag‐time between fall and rescue, drowning or not, diagnosis, injury severity score (ISS), whether the patient was treated as an outpatient or admitted to hospital, length of stay in the intensive care unit, length of hospitalization at our hospital, and Cerebral Performance Category scale at discharge from our hospital. The Cerebral Performance Category scores equated as follows: (i) no major disability, (ii) moderate disability, (iii) severe disability, (iv) coma or vegetative state, (v) death. The patients were divided into two groups, those treated as outpatients and those who were admitted to hospital. The following variables were each analyzed as two groups: age, sex, situation of injury (walking or non‐walking), ISS, and survival rate.
The χ2‐test, Mann–Whitney U‐test, or unpaired Student's t‐test were used for the statistical analyses, as appropriate. A P‐value < 0.05 was considered to indicate a statistically significant difference. All data are presented as the mean ±standard error.
Results
During the investigation period, 9,841 patients were transported to our hospital by ambulance or a physician‐staffed helicopter. Of these patients, 33 who had accidentally fallen into an open drain were treated as subjects. A physician‐staffed helicopter was used to transport 2 of the 33 patients.
The diagnoses of all 33 patients are listed in Table 1. Craniofacial injuries were the most frequent injury type, following injuries of the extremities and truncal injuries. The background characteristics of the subjects are shown in Table 2. The ages of the subjects ranged from 10 to 90 years, with an average age of 58.8 years. The average age of the subjects in the admission group was higher than that of the outpatient group. However, this difference was not statistically significant (P = 0.1). The number of male subjects was higher than that of female subjects. The ratio of females in the admission group was significantly greater than that in the outpatient group. Nineteen cases had fallen while walking, three of them had fallen into the open drain while stepping out of the way of a car, and other three had fallen due to the influence of alcohol. Six cases fell while cycling, seven cases while driving a car, and one case while driving a tractor. In all of the cases involving a car or tractor, the side of the vehicle was trapped by the open drain after crashing into buildings or after the vehicle had fallen directly into the open drain. The average ISS in the admission group was significantly higher than that in the outpatient group. One patient in the admission group, who had cardiac arrest due to a cervical cord injury that she suffered when she fell into an open drain under the influence of alcohol, obtained return of spontaneous circulation. However, she eventually died due to hypoxic encephalopathy after admission.
Table 1.
Numbers and types of injuries due to falls into open drains in East Shizuoka, Japan, according to outpatient and admission groups, January 2013 to December 2014
| Diagnosis | AIS | Outpatient, n = 19 | Admission, n = 14 | Major intervention |
|---|---|---|---|---|
| Head or facial soft tissue injury | 1 | 11 (57%) | 8 (57%) | Conservative 19 |
| Cerebral concussion | 2 | 0 | 4 (28%) | Conservative 4 |
| Craniofacial fracture | 2 | 0 | 2 (14%) | Conservative 2 |
| Cervical sprain | 1 | 1 (5%) | 0 | Conservative 1 |
| Cervical cord injury (arrest) | 6 | 0 | 1 (7%) | Mechanical ventilation 1 |
| Chest contusion | 3 | 5 (26%) | 3 (21%) | Conservative 8 |
| Rib fractures | 2 or 3 | 2 (10%) | 2 (14%) | Conservative 4 |
| Sternoclavicular dislocation | 2 | 1 (5%) | 0 | Conservative 1 |
| Pneumohemothorax | 3 | 0 | 2 (14%) | Chest drainage 1 |
| Liver injury | 2 or 3 | 0 | 2 (14%) | Embolization and operation 1 |
| Aortic dissection | 4 | 0 | 1 (7%) | Conservative 1 |
| Pelvic fracture | 3 | 0 | 1 (7%) | Conservative 1 |
| Lower thoracic spine fracture | 2 | 1 (5%) | 0 | Conservative 1 |
| Contusion of extremity | 1 | 5 (26%) | 6 (42%) | Conservative 10 and operation 1 |
| Fracture of extremity | 2 | 2 (10%) | 5 (35%) | Internal fixation 7 |
| Tarsus | Distal radium x2 | |||
| Humerus | Bilateral forearm | |||
| Ulnar | Femoral neck | |||
| Humerus |
AIS, Abbreviated Injury Scale.
Table 2.
Comparison between outpatient and admission groups of patients who were injured due to falls into open drains in East Shizuoka, Japan, January 2013 to December 2014
| Outpatient, n = 19 | Admission, n = 14 | P‐value | |
|---|---|---|---|
| Age, years | 51.7 ± 4.9 | 63.6 ± 5.7 | 0.13 |
| Sex (male / female) | 14/5 | 5/9 | 0.03 |
| Gate / non‐gate | 11/8 | 8/5 | n.s. |
| Bicycle | 2 | 4 | |
| Car | 6 | 1 | |
| Tractor | 0 | 1 | |
| Daytime (yes) | 11 (58%) | 10 (71%) | n.s. |
| Season | |||
| Spring | 4 | 2 | n.s |
| Summer | 4 | 2 | |
| Fall | 5 | 6 | |
| Winter | 6 | 4 | |
| Lag time (yes) | 0 | 3 (21%) | 0.06 |
| Drowning (yes) | 0 | 0 | n.s. |
| Alcoholic intoxication | 2 (10%) | 1 (7%) | n.s. |
| Accidental hypothermia | 0 | 2 (14%) | n.s. |
| Injury severity score | 2.6 ± 0.5 | 13.0 ± 4.9 | 0.02 |
| Duration of ICU stay, days | 0 | 2.1 ± 1.9 (0‐27) | n.s. |
| Duration of hospitalization, days | 0 | 12.5 ± 5.7 | <0.01 |
| Cerebral Performance Category | 5 | 4.5 ± 0.3 | n.s. |
| Survival rate | 19 (100%) | 13 (92.8%) | n.s. |
ICU, intensive care unit; n.s., not significant.
Discussion
This report shows that the injuries associated with falls into open drains are especially frequent in elderly people who are walking or driving a vehicle. Forty‐two percent of the patients in this study required admission due to the severity of their various injuries, which, on some occasions, were lethal. This report also showed that female and older patients tended to more frequently require admission due to severe injury. Failure to detect the open drain due to cognitive decline might explain the reason for the high frequency of injuries in elderly patients.41 Elderly female patients also tend to have poor defensive reactions during falls compared with younger male patients.41 Furthermore, female and elderly people tend to experience conditions that involve fragility of tissue, such as osteoporosis, compared to male and young people. These tendencies might explain why female patients and the elderly tended to more frequently require admission due to severe injury.
The severity of injury may depend on not only age and gender but also the depth of the drains, drowning or not, or time lag from the injuries to the emergency call. Unfortunately, due to the nature of the retrospective study, we could not collect data on the depth of drain. Nosaka et al. reported that, in ditch‐related injuries, the depth of ditch was not so important, compared with the occurrence of head and spinal injuries, for poor prognostic factors.36 In our study, there were no cases of drain‐related drowning. However, Nosaka et al. and Miyaishi et al. reported a fatal case due to drain‐related drowning.42 Accordingly, the drain‐related drowning and environmental temperature when the drain‐related drowning occurs, which may lead to accidental hypothermia, may be an important prognostic factor.
The 33 patients in the present study were treated in our hospital. We believe that all of the life‐threatening cases that were related to falling into open drains in East Shizuoka were transported to our hospital. However, we did not investigate all of the patients who were transported by ambulance in East Shizuoka. In addition, minor or moderate injury cases might have been transferred to local hospitals. Accordingly, there was a bias in that the 33 patients in this study represented only the patient population in East Shizuoka.
We summarize the published Japanese case reports, describing the injuries suffered by patients due to falls into open drains, in Table 3,1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35 excluding Nosaka's report.36 Table 3 reveals the various types of injuries and their severity. There were seven cases who died or who experienced sequelae. Four cases out of these seven had injuries of the central nervous system. Nosaka et al. reported that head and spinal injuries predominated among 13 cases of ditch‐related injuries, with eight vertebral column injuries, three skull fractures, and three intracranial hemorrhages. These cases also had poor neurological outcomes.
Table 3.
Summary of published case reports on injuries due to falls into open drains
| No. | Primary author | Year of publication | Age, years | Sex | Situation | Diagnosis | Outcome |
|---|---|---|---|---|---|---|---|
| 1 | Furukawa | 2013 | 62 | M | Gait | Facial neck penetrating injury | Survival |
| 2 | Harada | 2012 | 80 | F | Gait | Multiple fxs at extremities, cervical disc injury, fat embolism | Death |
| 3 | Wajima | 2012 | 14 | F | Bicycle | Axonal injury, dislocation of neck and pelvis, clavicular fx | Sequelae |
| 4 | Tanishi | 2012 | 68 | M | Gait | Femur shaft fx | Survival |
| 5 | Komatsu | 2012 | 61 | F | Gait | Calcaneus fx | Survival |
| 6 | Kato | 2011 | 78 | M | Car | Diaphragmatic rupture | Survival |
| 7 | Ohzono | 2011 | 43 | M | Gait | Humeral fx | Survival |
| 8 | Kashibara | 2008 | 64 | F | Gait | Elbow sprain | Survival |
| 9 | Nakamura | 2009 | 69 | F | Gait | Femur shaft fx | Survival |
| 10 | Yamaguchi | 2009 | 66 | F | Gait | Shoulder dislocation | Survival |
| 11 | Kinugasa | 2009 | 68 | M | Gait | Subastragalar dislocation | Survival |
| 12 | Kariya | 2009 | 52 | M | Gait | Knee sprain | Survival |
| 13 | Hashimoto | 2009 | 70 | M | Gait | Tibial fx | Survival |
| 14 | Usumoto | 2008 | 40 | F | Car | Subclavian and vertebral arterial injury | Death |
| 15 | Miyawaki | 2008 | 39 | M | MC | Thoracic spinal fx | Survival |
| 16 | Tsumura | 2008 | 68 | M | Bicycle | Skull fx, cerebral contusion | Sequelae |
| 17 | Kawamoto | 2007 | 70 | F | Gait | Patella fx | Survival |
| 18 | Sakamoto | 2007 | 66 | M | Gait | Cervical cord injury | Sequelae |
| 19 | Shiozuka | 2005 | 41 | M | Car | Pneumothorax | Survival |
| 20 | Itabashi | 2005 | 80 | F | Bicycle | Gall bladder injury | Survival |
| 21 | Matsuzaki | 2005 | 49 | M | Gait | Patella fx | Survival |
| 22 | Yoshikda | 2004 | 68 | M | Gait | Subastragalar dislocation | Survival |
| 23 | Kotani | 2003 | 15 | F | Bicycle | Humerus fx | Survival |
| 24 | Kuwabara | 2003 | 82 | F | Gait | Subdural hematoma | Survival |
| 25 | Haga | 2003 | 42 | M | MC | Penetrating eye ball injury | Survival |
| 26 | Hara | 2002 | 72 | F | Car | Cervical spinal dislocation | Survival |
| 27 | Kikuchi | 2001 | 54 | F | Car | Sacroiliac dislocation, fx of condyle of femur | Survival |
| 28 | Tuchida | 2001 | 60 | M | Gait | Dislocation of knee | Survival |
| 29 | Momokawa | 2001 | 20 | M | Car | Diaphragmatic rupture | Survival |
| 30 | Kanazawa | 2000 | 74 | F | Gait | Femoral neck fx | Survival |
| 31 | Nakamura | 2000 | 39 | F | Gait | Anterior cruciate ligament injury | Survival |
| 32 | Miyaishi | 1999 | 70 | F | Gait | Back contusion, drowning | Death |
| 33 | Konobu | 1999 | 78 | F | Gait | Femur fx, intestinal stenosis | Survival |
| 34 | Sato | 1997 | 70 | M | Gait | Tear of the basilar artery, dislocations of spine | Death |
| 35 | Nakajima | 1993 | 47 | M | Gait | Dislocation of list | Survival |
| 36 | Yoshioka | 1985 | 52 | F | Gait | Alcoholic, edema of vocal cord | Death |
F, female; fx, fracture; M, male; MC, motorcycle.
A PubMed search using the key words “drain”, “ditch”, and “trauma” was undertaken to look for case reports, other than those written by Japanese authors. Only four reports were found that described injuries due to falls into open drains.43, 44, 45, 46, 47 Three of these four were case reports concerning spinal cord injury, lethal delayed cardiac rupture, and duodenal injury.43, 44, 45 The other cases that we found in the search focused on fatalities due to machine rollovers or the reporting system profile for incidents of drowning, which included falling accidents involving open drains. From the standpoint of the results of this study and previous reports, falling into an open drain can more easily result in severe or lethal consequences due to injury severity or drowning than a simple fall to the ground. Our hypothesis for this severity is as follows: when a human falls into an open drain, the concrete corner of the drain hits a part of his or her body. The transfer of energy from the end of the concrete corner, with a small cross‐sectional area, to a small field on the body may lead to more severe injuries of the internal organs than one might predict, similar to a handlebar or horse kick injury.48 We will prospectively collect data concerning ditch‐related injuries (Investigation of etiology of injuries induced by open ditch, UMIN000017535) and we will check the body surface of ditch‐related injuries to test whether our hypothesis is correct. Based on our hypothesis, we advocate that injuries caused by falls into open drains be treated as high energy injuries and that patients choose an appropriate trauma center in the prehospital setting, especially when the patients have head, neck, or truncal injuries.
From the point of drain‐ or ditch‐related injury prevention, Nosaka et al. suggested considerable local government intervention.36 However, as the scale of the problem is immense because of the area involved, the government response will need to be assisted with educational campaigns. Therefore, preventive educational action should be undertaken across multiple fields. While in Chicago (USA), property owners and tenants are obligated to exercise reasonable care in locating hidden dangers on their property and warning the public of any foreseeable or existing harm such as injuries from a pothole, ditch, or other open area on the property (https://chicagoinjurycenter.com/premises-liability/). There were no recently published reports concerning drain‐ or ditch‐related injuries in the USA. Accordingly, to prevent injuries of this type, we think open drains should be covered with concrete. However, when drains are covered, several issues need to be resolved in terms of agricultural water use and ecological or biological system damage. Although the width of the road might be a little narrower, building fences might also be a preventative measure. In addition, the installation of streetlights or warning signs could also be helpful and might be less expensive.
Conflict of interest
None.
Acknowledgements
None.
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