VEHICULAR FATALITIES IN CUYAHOGA COUNTY, OHIO, U.S.A. Twenty Years Experience ( )

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1 VEHICULAR FATALITIES IN CUYAHOGA COUNTY, OHIO, U.S.A. Twenty Years Experience ( ) by S. R. GERBER* Orientation THE c o u n t y of Cuyahoga in the State of Ohio encompasses an area of slightly more than 450 square miles and has a current population of approximately 1,700,000 people living in 62 municipalities which include 35 cities, 23 villages and 4 townships. This is essentially an urban district with 869,000 persons residing in Cleveland, the principal city. Four of the other cities in the county individually have populations in excess of 60,000. In the State of Ohio the coroner is an official of county government, administering his office in compliance with the laws of the State which require that the coroner shall investigate any death apparently caused, or suspected to be caused, by violent means, deaths occurring suddenly when in apparent good health or in any suspicious or unusual manner. Accordingly, all deaths resulting from accidents are investigated by the Coroner s Office. Development of Testing Programme When the author of this paper first assumed the office of Coroner in 1937, the practical applications of chemical analyses for determining the quantity of alcohol present in body fluids were being investigated. Persons interested in promoting safety on the highways recognized the importance of accurate scientific data to reveal contributory factors in accident causation. As one who served on the committee on Definitions for the National Conference on Uniform Traffic Statistics and on the National Safety Council s Committee on Chemical Tests for Intoxication, it was obvious to this coroner that alcohol determinations performed on victims of vehicular accidents would be significant in investigation of individual deaths and, also, that accumulation of data would reflect the incidence of alcoholic influence in fatal accidents. Recognizing that determinations of alcohol in body fluids had similar significance in investigation of all deaths under jurisdiction of the coroner, the following regimen of testing was developed and has been routine procedure at the Cuyahoga County Coroner s Office for more than 20 years. Continuity and consistency in this programme has been insured by the sustained interest of the coroner and his loyal staff. Specimens of blood from the heart and, whenever possible, specimens of urine from the bladder are withdrawn from every person over 15 years of age dying within 12 hours following onset of the fatal condition. When circumstances indicate feasibility, specimens may be taken from persons who survive longer. Specimens from vehicular fatalities are usually obtained at autopsy. For more than 20 years thorough autopsies have been performed on all victims of vehicular accidents. Autopsies were performed on 76% of the cases tested for alcohol in the 20-year period considered in the study presented here. All bodies are stored in refrigerated crypts from the time of admission to the morgue until autopsy. Validity of the data is supported by the fact that both blood and urine were analysed in 40% of the negative cases and 61% of the positive cases in this study. The primary purpose in conducting alcohol determinations on coroner s cases is to elicit evidence pertinent to the official investigation into the mode and manner of death. Accumulation of statistical data is accessory. From the viewpoint of the possibility of eliciting positive evidence of alcoholic intoxication it is advisable to test persons surviving 12 hours and, in special circumstances, even longer. In occasional instances alcohol has been found in blood of persons who survived hours. In only 1% of the cases tested alcohol was present in the urine but not in the blood; M.D., LL.B., L.H.D., LL.D.(H), Coroner, Cuyahoga County (Cleveland), Ohio. 38

2 S. R. GERBER 39 half of these cases survived less than one hour and none survived more than 12 hours after injury. All such cases were tabulated with the negative cases. Whenever positive results are obtained in tests on persons who survive for any period following an accident such results are considered merely as evidence that the decedent had been drinking alcoholic beverages prior to death, and no attempt is made to incorporate into the record any calculations as to the probable blood alcohol level at the time of injury. Effectiveness of Regimen Consistent strict adherence to this regimen has resulted in testing 58% of the 3,785 fatalities attributable to vehicular accidents in the 20-year period, inclusive. The cases not tested were distributed as follows: 29% survived too long to test, 11% were under 15 years of age, and for miscellaneous reasons 2% were not tested. Actually 64% of the cases over 15 years of age were tested. Statistical Records The statistical department in the Coroner s Office has maintained separate case records since 1941 with sufficient uniformity to ensure accurate compilation of data. Keysort cards were used until 1958 when IBM data processing equipment was installed. Yearly reports published and distributed contain a variety of data reflecting the circumstance of all types of death investigated by the Coroner s Office; the major emphasis has been placed upon the alcohol incidence as related to the mode and manner of death, the age and sex of the decedents, the month, day of week and hour of occurrence of the fatal accident. Compilation of data imposed the requirement to devise categories for grouping the blood alcohol concentrations. From 1941 through 1952 results of analyses were classified in the following categories: Negative no alcohol present in the blood; Low group 0-04% or less; Middle group %; and High group 0-20% and over. It is apparent that the blood alcohol concentrations in the middle group ranged from the lowest concentration generally acknowledged to exert detectable influence on some persons to that concentration at which it is generally acknowledged that all persons are affected. This wide range obscured the concentrations above and below 0-15% which came to be accepted in the United States of America as the arbitrary demarcation at and above which driving ability is impaired. However, these categories were retained in order to accumulate comparative data. Since 1953 the results of analyses have been classified in the following classifications: Negative; %; %; %; and 0-25% and over. In addition, the cases that were not tested have been tabulated according to the three reasons for not testing: survived too long; under-age; and other. Reports of research studies have stimulated interest more recently in the evidence of impaired functions at blood alcohol levels of %. Accordingly, in the United States of America, the National Safety Council s Committee on Chemical Tests for Intoxication currently recommends standardisation of classifications in reported data to facilitate comparison and compilation of data from various sources. The recommended classifications are: Negative, %; %; %; %; 0-25% and over. The Committee further recommends that reported data be limited to results of analyses performed on specimens drawn from individuals who survive less than six hours. These recommendations stimulated us to re-study our statistical records since this information was not readily obtainable by the coded categories either currently or formerly in use. It has been emphasized repeatedly in our published reports that the data contained therein should not be interpreted as reflecting the true alcohol incidence in non-fatal accidents or other acts of violence without ensuing death. Attention has been called to the fact that the death of these victims in an undetermined number of cases resulted from acts by other persons; therefore, while the victim might not be under the influence of alcohol, the person whose act, directly or indirectly, inflicted the injury might be under the influence of alcohol. Furthermore, due to the fact that some of the victims survived a sufficient length of time to metabolize alcohol present at the time of injury, it was presumed that the alcohol incidence reported in these reports was less than the actual alcohol incidence. Thus the influence of survival period on the validity of our statistics had been a proposed study project that had been postponed until the accumulated number of cases was sufficient to warrant a significant analysis.

3 40 THE ALCOHOL FACTOR IN ROAD ACCIDENTS (2) Explanation of Terminology The term vehicular fatalities is used to denote inclusion of deaths from accidents in which the s involved were nonmotor s and, also, accidents which occurred within the boundaries of privately owned property as distinguished from traffic accidents which originated or terminated on a public traffic-way. In the 20- year period considered here, fatalities from these non-motor and non-traffic accidents constituted less than 1% of the total vehicular deaths. The term driver as used in the statistics to be cited also requires some explanation since motorcyclists and bicyclists are included in this classification. Bicyclists constituted 6% of the total number of drivers, and 84% of these were under 15 years of age and, therefore, do not contribute significantly to the tested cases to be considered here. In the 20-year period, alcohol was found present in the blood of only one bicyclist. Motorcyclists contributed 9% to the total of drivers; 42% were not tested due to survival beyond the testing limit of time; 33% of those tested had alcohol present in the blood. Blood Alcohol Level correlated with Survival Period The coroner s records contain accurate information concerning the exact time of injury and the time of arrival at a hospital. Every area in the county has ready access to one or more of the 26 hospitals in the county which provide emergency services. Seriously injured persons are transported from the scene of a vehicular accident to a hospital, usually in less than 30 minutes after the occurrence. Almost without exception, all victims, even though they may appear to be dead at the scene, are transported to a hospital where they are examined by a physician who determines that death has occurred. The exact time of this pronouncement is recorded officially as the time of death. When victims die in a hospital, the time of death is recorded accurately. It is apparent that the coroner s records furnish information sufficiently accurate for a study of the survival period of vehicular fatalities. When the tested cases were Telated to survival periods it was found that 86% of the total tested had survived less than six hours. Considering the negative and positive cases separately, it was noted that a higher proportion of the positive cases died within the six-hour survival period, 92% of the positives as contrasted with 81% of the negative cases. Studying the tested fatalities according to their activity as drivers, passengers and pedestrians, revealed only slight variance. The percentage of total tested cases within each classification within the six-hour survival period was as follows: 89% of the drivers, 87% of the passengers and 85% of the pedestrians survived less than six hours. The proportions of negative drivers and negative passengers surviving less than six hours were identical: 82%. However, 94% of the positive drivers died within six hours as contrasted with 91% of the passengers and a similar proportion of pedestrians. It has long been recognized that there is a high frequency of older pedestrians in the fatally injured. The National Safety Council s Committee on Chemical Tests for Intoxication recommend a separation of reported statistics for pedestrian fatalities into two age groups: years and 65 years and older. In Cuyahoga County, in the 20-year period under consideration, pedestrians 65 years and older contributed 37% of the total pedestrian fatalities tested for alcohol. A comparison of the survival periods of these two age groups revealed that 88% of the tested cases of the older age group survived less than six hours as compared with 84% of the year age group. A significant influence on the alcohol incidence was noted in the fact that whereas 12% of the negative cases in the pedestrians over 65 survived more than six hours, the proportion of negative cases in the younger group exceeding the six-hour survival limitation was nearly twice as great 23%, and the proportion of positive cases surviving more than six hours was one-and-a-half times greater in the younger group 9% contrasted with 6% of the older pedestrians with positive tests. Early in this study of survival periods of the vehicular fatalities tested for alcohol we were impressed with the large proportion who were pronounced dead on arrival at the hospital or survived less than one hour. These were found to constitute 64% of all cases tested. This finding strengthened confidence in the validity of our statistics previously published. Confining consideration only to those cases tested within the six-hour survival limitation it was found that 79% of the drivers, 77% of the passengers and 73% of the pedestrians were pronounced dead on the scene or on arrival at the hospital, or died less than one hour after the accident.

4 S. R. GERBER 41 A study of the negative cases in the same time interval revealed that 71% of the drivers, 66% of the passengers and 63% of the pedestrians surviving less than six hours and in whom no alcohol was found, actually died within one hour after injury. In every classification, a higher proportion of positive cases survived less than one hour 84% of the positive drivers, 83% of the positive passengers and 80% of the positive pedestrians. These findings demonstrate that, under circumstances extant in Cuyahoga County, alcohol incidence computed on the basis of consideration of victims surviving as long as six hours will be less than that computed on those within one-hour survival period. Although in most classifications of victims the decrease was not statistically significant, in the pedestrians between the ages of years the alcohol incidence in those who survived less than one hour was 36-3% as contrasted with 26-6% in those who survived up to six hours. Similarly, the alcohol incidence in the age group over 65 years of age decreased from 44% in the one-hour limitation to 35-3% in the sixhour survival interval. In nearly every classification there was less than 1% difference in the alcohol incidence computed on cases surviving less than six hours and those surviving up to eight hours. In accordance with these findings, the alcohol incidences reported here are based on cases that survived less than one hour. Alcohol Incidence All cases over the age of 15 years that survived less than one hour were tested for presence of alcohol. These constituted nearly one-half (49-5%) of the total vehicular fatalities received in the 20-year period. Alcohol was present in 52% of these cases. When these fatalities were classified according to their activity as drivers, passengers and pedestrians, the following distribution was noted: 34% were drivers, 20% were passengers and 46% were pedestrians. This distribution was similar to the total fatalities over 15 years of age in which 30% were drivers, 19% were passengers and 51% were pedestrians. The alcohol incidence in the tested cases wherein survival was less than one hour was 60% in the drivers, 47% in the passengers and 51% in the pedestrians. Drivers The National Safety Council s Committee on Chemical Tests for Intoxication proposes seven categories for classification of driver fatalities. We added an eighth category in order to survey the collisions with trains at railroad crossings. The frequency rates of these categories in the total cases tested for alcohol were as follows: Category Per cent of Total Tested Cases I (Only one involved) 39-4 II (More than one involved, but only one in motion. Driver fatality in moving ) 4 0 III IV V VI (More than one moving involved. Driver fatality in responsible ) 25-7 (More than one involved, only one in motion. Driver fatality in raw-moving ) 10 (More than one moving involved. Driver fatality in nonresponsible ) 7-9 (More than one moving involved. Responsibility not stated)* 12-8 (More than one moving, two or more driver fatalities) 1 0 VII vm (Collision with train at railroad crossing) 8-2 Information on statistical records does not indicate responsible. In four of these categories (1, II, III and VIII) the driver fatalities were at fault. Nearly three-fourths (74%) of the driver fatalities were classifiable in these categories. Alcohol was present in the blood of 65% of these who survived less than one hour. Considering the categories separately, the alcohol incidence varied from 75% in Category I, where only one was involved, to 37% in Category VIII involving collision with a train. If the latter had been included in Category I, the alcohol incidence in that category would have been reduced from 75% to 68%; had they been included in Category III (two moving s, driver fatality responsible) the alcohol incidence in that category would have been reduced similarly from 59% to 52%. In Category II (fatality drove into non-moving ) 67% had alcohol present; in all positive cases in this category the alcohol levels were above 100 mg./loo ml. of blood (0-10%). Of the four categories only in Category VIII were there any positive cases with blood alcohol levels less than 50 mg./loo ml. (0-05%); 12% of the positive cases in this category were in this range of mg./ 100 ml. ( %). Distributed in the range of mg./loo ml. ( %) were 7% of the positives of Category 1,3% of Category III and 12% of Category VIII. In the next higher range, mg./loo ml. ( %) we find 16% of the positive driver fatalities of one- accidents, 18% of the positives of Category III and 18% of the positives in Category VIII. The highest frequency of positive cases in

5 42 THE ALCOHOL FACTOR IN ROAD ACCIDENTS (2) Category II appear in this range, 41% of the positive fatalities who drove into non-moving s. More than half of the positive cases in Categories I and III had blood alcohol concentrations in excess of 200 mg./100 ml. (0-20%), (53% of Category I and 57% of Category III). The highest frequency of positives in Categories I and III appeared in the range of blood alcohol levels of mg./100 ml. ( %); 32% of the positive driver fatalities in one- accidents and 35% of the positive driver fatalities at fault in accidents involving two or more s. Seventeen per cent of the positive drivers in Category II and 24% of the positive drivers in the collision with trains, Category VIII, had blood alcohols in this range. Driver fatalities between 20 and 40 years of age contributed 63% of the total of Category I and an identical proportion of the positive cases. The age group of years contributed 22% of the total and 23% of the positive driver fatalities in the single category. This age group was less prominent in the other three categories; in Category III, 11% of the total and 16% of the positive driver fatalities were 20 to 24 years of age. In both categories, the alcohol concentrations of the drivers in this age group approximated the distribution pattern for the total of all ages. The highest alcohol incidence within age groups in Category I was seen in the years age group, 86%; with years age group with 83%. The alcohol incidence in the years age group was 77%; in the years group it was 67% (73% for the decade). Alcohol incidence in the and decades were 68% and 67% respectively. In Category III, 51% of the total and 56% of the positive driver fatalities were between 30 and 50 years of age. In the years age group the alcohol incidence was 66%, and in the years it was 60%. The highest alcohol incidence in the age groups in Category III appeared in the years group, 85%; however, in the years group the alcohol incidence was 58%, and the incidence for the tenyear span was 72%. Passengers The distribution pattern demonstrated in the passenger fatalities was approximately the same as seen in the driver fatalities. Three-fourths (76%) of the passenger fatalities resulted from accidents classified according to driver responsibility as defined previously (Categories I, II, III and VIII). Forty-two per cent of the passenger fatalities who survived less than one hour resulted from single- accidents; all were tested and alcohol was found present in 60%. Pedestrians All pedestrians over 15 years of age who survived less than one hour were tested for alcohol. In the total of these tested cases the alcohol incidence was 51%. Comparison of the age groups years with those over 65 years showed alcohol incidence in the former to be 54% and 44% in the latter. Closer attention to age groups in decades revealed a sharp drop in alcohol incidence from 56% in the year-olds to 37% in those 70 years or older. This latter age group constituted one-fifth (20-7%) of the total pedestrian victims who survived less than one hour as contrasted with year-olds who constituted one-sixth (13%). The only other age group showing a higher frequency rate was the year decade which constituted nearly one-fourth (23%) of the total. Alcohol was present in 55% of these, and 67% of the positive cases in this age group had alcohol concentrations in excess of 200 mg./loo ml. (0-20%). In the ages over 70 years 43% had alcohol concentrations of this magnitude. The highest alcohol incidence in any single age group was seen in the years wherein 71% of the victims were under the influence of alcohol. More than half (56-5%) of the positive cases in this age group had blood alcohol levels above 200 mg./loo ml. The only significant variation in the concentration levels was noted in the fact that of the positive cases of age 70 years and older, 10% were in the range of mg./loo ml. ( %), and an identical number were in the range of mg./loo ml. ( %). By contrast, less than 3% of the positive cases under 65 years of age were seen in each of these two categories. In the next range of concentration, mg./loo ml., there were 20% of the positives in the 70 years and older group and 9% of those under 65 years of age. The age group of distribution was approximately the same as that seen in the ages under 65 years. Summary The testing regimen which prescribes withdrawing blood and, whenever possible,

6 S. R. GERBER 43 urine samples from all persons over 15 years of age who die within 12 hours subsequent to injury, is expedient for coroners investigations. Adhering to this regimen in the Coroner s Office of Cuyahoga County, Ohio, U.S.A., 64% of vehicular fatalities over 15 years of age were tested for presence of alcohol. This survey correlating the results of analyses with the survival intervals revealed that nearly two-thirds (64%) of all the tested cases died less than one hour after injury. Therefore, restricting consideration to deaths occurring within one hour following injury constitutes fair and adequate sampling for statistical studies of alcohol incidence in traffic fatalities in Cuyahoga County, Ohio, U.S.A. (Personal communication with Raymond Harris, Coroner of St. Louis County, Missouri, U.S.A., disclosed a similar proportion of traffic fatalities in that county survived less than one hour.) Alcohol was present in 60% of the drivers, 47% of the passengers and 51% of the pedestrians who survived less than one hour. In every one of these classifications more than half of the positive cases had blood alcohol levels in excess of 200 mg./ 100 ml. Blood alcohol levels of less than 100 mg./loo ml. were infrequent except in the pedestrians over 70 years of age; in these cases 20% of the positive tests were in this range. A study of the driver fatalities as related to responsibility revealed that nearly 40% of the driver fatalities resulted from accidents in which the decedent s was the only one involved. Three-fourths (76%) of these drivers were under the influence of alcohol. Nearly four-fifths (78-8%) of the driver fatalities were attributable to culpable negligence on the part of the decedent. A survey of the age distribution in these vehicular fatalities suggests that attention should be focused on five-year increments in the younger and older age groups, i.e , 20-24, and 60-64, 70 and older. In closing, the author of this paper proposes that this assemblage give consideration to drafting standards for uniform reporting of data pertinent to alcohol incidence in road traffic. For purposes of evoking such consideration the following standards are suggested for statistical studies of alcohol incidence in traffic fatalities: I. Major division according to activity, i.e. Driver, Passenger, Pedestrian. A. Categories for reporting total number of fatalities in each major division: 1. Cases Tested a. Negative b. Positive 2. Cases Not Tested a. Survived too long b. Under age c. Other reasons for not testing B. Categories for tabulation of blood alcohol levels: 1. Negative 2. Positive (increments of 50 milligrams from 10 mg.% to 30 mg.%) a % d % b % <? % c % / % g. 0-30% and over C. Categories for correlation of blood alcohol levels and survival period: hour hours hours hours hours 6. Over 12 hours D. Age groups for correlating blood alcohol levels, survival period and age: years years years years years years years years years and older E. Categories for classification of accidents resulting in death of drivers or passengers. (Drivers and passengers to be tabulated separately): 1. Fatality occupant in responsible a. Only one involved b. More than one involved, but only one in motion. Driver or passenger fatality in moving c. More than one moving involved. Driver or passenger fatality in responsible d. Collision with train at railroad crossing. 2. Fatality occupant in non-responsible a. More than one involved, only one in motion. Driver or passenger fatality in non-moving 1. Non-moving parked a. Legally b. Illegally

7 S. R. GERBER b. More than one moving involved. Driver or passenger fatality in non-responsible 3. Responsibility not determined. 4. More than one moving involved, multiple fatalities a. Fatalities occupants in one b. Fatalities occupants in separate. F. Categories for classification of pedestrian fatalities 1. Pedestrian negligent: ignored traffic controls and safety measures 2. Pedestrian fatality due to negligent driving.