Trauma season arrives in emergency departments

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As the bright days of spring and summer inspire people to enjoy the great outdoors - through such activities as sports, landscaping, and home repair - many of them land indoors instead: at the emergency department (ED).

In cities and towns around the country at this time of year, doctors see more patients with broken bones, heat exhaustion, Achilles tendon tears, dehydration, and other injuries and illnesses that typically increase as outdoor temperatures rise.

"This is when you get the weekend warrior injuries," says Jeff Baker, DO, an emergency physician and clerkship director at the Desert Regional Medical Center in Palm Springs, California. "You feel great. You're just happy to be out."

But sometimes enthusiasm exceeds preparation. Many people dive into those activities too quickly, too intensely, or without the right equipment. Some underestimate the impact of outdoor heat, don't drink enough water, drink too much alcohol, or don't pay enough attention as they use potentially dangerous tools.

"During the warmer months we see more orthopedic injuries in the emergency department," along with heat-related illnesses, says Venkat Subramanyam, MD, assistant professor of emergency medicine at the University of Connecticut Health Center. The patients are "overexerting themselves or spending too long outside while not having the appropriate hydration, breaks, or cooling periods."

Even when people prepare as best they can, the mere uptake in activity brings increased risk of harm.

"The injuries that we see with the warmer weather occur because the opportunity is there" to engage in more outdoor physical activities, says Spencer Tomberg, MD, an orthopedist and assistant professor of emergency medicine at the University of Colorado Anschutz School of Medicine.

Research backs up the observations of ED doctors.

• A study of Achilles tendon ruptures in the Journal of the American Academy of Orthopaedic Surgeons found the highest injury rate in the spring and the lowest in the fall, suggesting a surge as recreational athletes ramp up activity early in the season.
• Agricultural safety data from the Marshfield Clinic Research Institute in Wisconsin show that nearly 10,000 children and youth in the United States sustain lawnmower injuries annually, highlighting recurring seasonal risk.
• A study in the Orthopaedic Journal at Harvard Medical School found an increase in orthopedic trauma in the summer, both in terms of overall injuries and particularly with regard to compound fractures.
• Analyses of landscaping and groundskeeping injuries, reported by the U.S. Bureau of Labor Statistics, document a spike in injuries related to outdoor seasonal work, much of which ramps up in the spring and lasts for months.

The types of conditions and their causes vary by region: Mountain bike falls are common in Colorado; dehydration of hikers, in Palm Springs; heat exhaustion among new soldiers, at training bases in the South; running, racket sports, and landscaping injuries, all over the map.

The phrase "trauma season," as typically used in EDs, covers a wide range of incidents, including alcohol-impaired driving crashes that occur more in warmer weather, as people socialize more and later into the evening. Several academic ED doctors spoke with AAMCNews about the trauma season injuries and illnesses that result from recreational activities, focusing on what causes those conditions and how to avoid them.

Jumping in at 110%

The warm weather stirs people to fully jump into activities that call for a gradual ramp-up. That's especially risky in climates with cold fall and winter weather; many people exercise less during those periods, leaving them not in game-day shape at the start of warmer weather.

"Our weekend warriors, myself included, we don't do much during the winter," says Jon-Michael E. Caldwell, MD, a pediatric surgeon specializing in sports medicine at CommonSpirit-St. Anthony Hospital and at Panorama Orthopedics and Spine Center, both in Colorado.

"The weather turns nice, you go out on the basketball court, you go out for a run, you're starting to ramp up your activity, and you're doing that without much training," says Caldwell, the lead author in the study of Achilles tendon ruptures in the Journal of the American Academy of Orthopaedic Surgeons.

The injury and illness risk comes not just from the physical demands of the activity, but the sudden increase in exertion, he says: "You're not prepared for it. You don't have the muscle tone, you don't have the reflexes to accommodate those higher demands that you're putting on your various joints."

Aside from people who might be overconfident about their ramp-up into their routine activities, there are those who try new things. They're inspired to try distance cycling or pickleball.

"You're just getting into it, and the mind is willing, but the body's not ready," Caldwell says. "We tend to want to dive in to do something 110%. That's often where those injuries occur. Sometimes we get a little ahead of ourselves in terms of what we're ready to do."

Overexertion

Even for less intense activities, people routinely miscalculate the impact of heat and the need for hydration. In Palm Springs, Baker says, summer temperatures often rise above 100 degrees, catching outdoor enthusiasts off guard.

"We have heat-related injuries that happen as a result of people not understanding what 120 degrees means," he adds. "You can't walk up a canyon with one liter of water and be safe, which you could do in most other areas of the country. You may need three or four times the amount of hydration that you would need on a hike in Washington state."

"A lot of the emergencies are going to be the result of people getting stuck out somewhere and they are just not ready for the situation," says Ashely Alker, MD, MSc, adjunct assistant professor at the George Washington School of Medicine and Health Sciences in Washington, D.C., and author of 99 Ways to Die and How to Avoid Them, which is built on cases encountered in EDs. "They'll go to the Grand Canyon and they're not prepared. You get in over your head."

Adding to the risk is that temperatures can change significantly in the middle of an extended activity.

"You go for a long run and it's cool, but then the cloud cover disappears and the temperature rises. You could be running in a very different environment than when you started," Subramanyam says.

Ironically, people who prepare by drinking too much plain water can also fall ill.

"Water can be deadly if consumed improperly," Alker says.

She explains how: Extended strenuous activities deplete the body of electrolytes, such as sodium, potassium, and other minerals that are expelled through sweat. Overconsuming water without electrolytes further dilutes the percentage of those minerals in the body. The impacts range from muscle cramps to passing out and even to death. A study of the condition in marathon runners found that "hyponatremia has emerged as an important cause of race-related death and life-threatening illness."

Even those who are in top shape and experienced at extreme physical exertion can fall victim to warm-weather conditions. These include high school and college athletes, and new military recruits. Alker works near a Marine Corps base in Quantico, Virginia, and notes that the newcomers are immediately pushed to meet the demands of potential battlefields.

"They just enlisted, they're hiking 30 miles," she says. "They're under-hydrated and overextended."

Most make it through without going to the ED, but Alker routinely sees cases of rhabdomyolysis: a serious, potentially fatal syndrome caused by rapid muscle breakdown that can lead to kidney failure.

Dangerous activities

This is also the time of year when people attend outdoor concerts and festivals, that pose specific dangers.

Consider Coachella, the music and arts festival that occurs over two weekends each spring in Indio, California. Hospitals there see an influx of ED visits during the festival, many due to heat, dehydration, and alcohol indulgence. JFK Memorial Hospital reports that visits to its ED during the Coachella weekends increase significantly. It has reported treating 94 to 100 festivalgoers on the Coachella weekends and boosting the ED workforce to handle the load.

In general, however, hospitals do not change ED staffing during trauma season. The rise in visits due to trauma injuries is often offset by decreases in patients with contagious infections, such as respiratory illnesses, which tend to occur more in the fall and winter, Alker notes.

In cities, one growing risk during trauma season comes from electric scooters. Studies have found that scooter injuries rise in warmer months. The dangers stem largely from the fact that many of the users (such as tourists who rent them) are not used to the speed and controls of the devices. They often don't have, or decline to wear, safety equipment, like helmets.

"Nobody has a helmet" on the scooters that zip around Aurora, Colorado, home of the Anschutz School of Medicine, Tomberg says.

Advice

To avoid these or other trauma season ills, or to lessen their severity, academic ED physicians offer this advice.

• Gradually ramp up physical activities in the spring and into the summer. "Don't just go from zero to 100 [%]" in terms of effort, Caldwell says.
• That ramp-up is far easier for those who consistently exercise in the fall and winter as well. "It's the continual preparation that really matters," he adds.
• Stretch before and after the activity.
• In the midst of the activity, pay enough attention to your body's reactions to know when to pull back a bit. "It's about recognizing fatigue early and not trying to fight through it, especially as a recreational athlete," Caldwell says. "It's not trying to push through like you're trying to win a college championship."
• Carry along sufficient water, with electrolyte additives for particularly long or stressful activities. "If you are going to do any sort of long-term endurance activity, especially outdoors, in addition to water you should carry some solution that will offer electrolyte repletion," Subramanyam says.
• Use the right safety equipment. "If you're on something that moves fast, wearing a helmet makes sense," Tomberg says.

By all means, the doctors say, keep playing, hiking, and taking care of the yard to the extent that you are able.

"People should get out there and be active," Tomberg says. "Part of being active is that there's a risk. At some point we're going to have injuries, and there are people who help us recover."