Expert Commentary Alcohol related work place injuries: More Questions than Answers! David Mountain1,2 Department of Academic Emergency Medicine, School of Primary, Aboriginal and Rural Health Care, University of Western Australia, 2Staff Specialist in Emergency Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia This paper is an interesting and useful addition to the very limited literature on alcohol-related work place harms It uses data from a single semi-rural regional trauma center allowing comparisons between workplace environments and mechanisms of injuries looking for differences in blood alcohol concentration (BAC) detection rates, associated injuries, and outcomes.[1] The paper itself has significant methodological issues, as all retrospective longitudinal data set analyses The most significant of these are, retrospective data, data extractors unblinded to outcome, limited methodology described for data extraction, no confounding or regression analyses, and finally being a single center with an interesting demographic By the nature of such a paper, almost all the findings are hypothesis generating associations with conclusions/discussions being speculative This is best seen in the finding that BAC+ patients have less insurance cover than BAC– or untested patients The authors may know anecdotally that insurance is routinely withdrawn for BAC+ patients, but the dataset is unable to provide evidence for this conclusion, for example, other factors may be driving this finding such as more casual work arrangements, drinkers not claiming, etc The most important issue however for this paper (and I suspect most trauma centers) was that the majority (>60%) of patients were untested for BAC and that different subgroups by both type of work and type of accident had very different rates of BAC testing So why read on and consider this paper at all? Address for correspondence: Assoc Prof David Mountain, E-mail: dmount63@gmail.com.au Access this article online Quick Response Code: Website: www.onlinejets.org DOI: 10.4103/0974-2700.150649 Journal of Emergencies, Trauma, and Shock I 8:1 I Jan - Mar 2015 This study has some important findings deserving further attention and research, and an increased focus on this issue; generally the only reason for this type of retrospective data research Firstly, very high rates of BAC+ were found in agricultural workers (16% of all agricultural injuries and 27% of those tested) Perhaps more concerning for legislators and the general public given the very high risk of increased crashes with BAC >0.08 (odds ratio (OR) 5-24), around 10% of all those injured working on public roads were BAC+ (16% of those tested).[2] It is also interesting, perhaps suggesting high rates of alcohol usage were already a concern in this group, that 58% of agricultural workers were tested, nearer to road incidents (70%) where testing is mandated in most jurisdictions; whereas, only 36% of industrial/construction workers were tested Rates of BAC+ were four times higher amongst tested agricultural workers than industrial workers and six times if the denominator was attendances The high rates of testing in the vehicular and agricultural workers suggest we can have reasonable confidence that rates of alcohol use before injury were a minimum of 10 and 16%, and possibly 16 and 27% if the tested rates apply These rates of BAC+ in injured patients are two to four times the estimated prevalence of drinking at work in other research, suggesting BAC+ workers have significantly increased risks of incidents causing significant injury.[3] Of course it is possible that this region just has higher rates of drinking on the job due to local attitudes, regional differences, or work patterns There is no way of knowing unless there is other data available for this region about prevalence of at (or pre–) work drinking Of great concern, the vast majority of these patients were intoxicated, even by the lenient Texan 0.08 g/dL definition.[4] Many European and Australian legislations use 0.05 for intoxication with some applying lower levels for professional drivers (e.g., 0.02 to zero) given the major public safety issues.[2,4] The other interesting finding of this study was that BAC+ did not seem to be associated with worse outcomes, injuries, or more complications The numbers of intensive care unit (ICU) days, complications, and Injury Severity Score (ISS) scores were not much different from the whole populations Mountain: Alcohol related work place injuries: More questions than answers! and sometimes significantly less than the BAC– group This “protective” effect of alcohol in injury has been suggested in some studies, although others have suggested worse outcomes as well.[5,6] These findings are significantly confounded by the poor insurance coverage of BAC+ patients giving good reasons (consciously or subconsciously) as to why providers might not document problems, speed up discharge, and avoid rehabilitation However, it is hard to see why this would affect measures such ISS, mortality, and possibly ICU length of stay (LOS) and some of the more serious complication which were all lower It may also be that drunken patients get higher initial physiological scores or worse neurosurgical assessments, seeming sicker than they truly are, so seemingly doing better when alcohol wears off This study certainly does not suggest alcohol per se causes people to have worse injuries or worse early outcomes than there sober coworkers (who as the authors point out may protect their drunken colleagues by doing the more dangerous work), and should be an area for future prospective research Overall this paper should be seen for what it is, a collection of interesting retrospective data titbits, by no means allowing clear conclusions, but certainly whetting the appetite It should spur on researchers, physicians, policy officers, and jurisdictions to more, or facilitate more good quality, prospective, and multicenter research at trauma units or preferably trauma regions This work is needed to better define high risk groups such as agricultural workers (and others), how much injury is caused by workplace alcohol, what might be protective factors (including alcohol itself!), whether insurance withdrawal is happening for BAC+ patients and more importantly if this is good policy We should also seriously consider mandatory BAC testing for all work-related injuries either as institutions or more likely as jurisdictions Starting to ask the right questions is the first step to getting answers and this paper asks or raises good questions, it just could not give definitive answers REFERENCES Foster CA, Dissanaike SD Prevalence and consequences of positive blood alcohol levels among patients injured at work J Emerg Trauma Shock 2014;7:268-73 Kuypers KP, Legrand SA, Ramaekers JG, Verstraete AG A case-control study estimating accident risk for alcohol, medicines and illegal drugs PLoS One 2012;7:e43496 Pidd K, Roche AM, Buisman-Pijlman F Intoxicated workers: Findings from a national Australian survey Addiction 2011;106:1623-33 International Centre for Alcohol Policy: Policy issues; drinking and driving BAC table Available from: http://www.icap.org/PolicyIssues/ DrinkingandDriving/BACTable/tabid/199/Default.aspx [Last accessed and viewed 2013 Jan 8] Friedman LS Dose-response relationship between in-hospital mortality and alcohol following acute injury Alcohol 2012;46:769-75 Hadjizacharia P, O’Keeffe T, Plurad DS, Green DJ, Brown CV, Chan LS, et al Alcohol exposure and outcomes in trauma patients Eur J Trauma Emerg Surg 2011;37:169-75 How to cite this article: Mountain D Alcohol related work place injuries: More Questions than Answers! J Emerg Trauma Shock 2015;8:3-4 Received: 11.02.14 Accepted: 14.02.14 Source of Support: Nil Conflict of Interest: None declared Journal of Emergencies, Trauma, and Shock I 8:1 I Jan - Mar 2015 Copyright of Journal of Emergencies, Trauma & Shock is the property of Medknow Publications & Media Pvt Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission However, users may print, download, or email articles for individual use ...Mountain: Alcohol related work place injuries: More questions than answers! and sometimes significantly less than the BAC– group This “protective” effect of alcohol in injury has... Trauma Emerg Surg 2011;37:169-75 How to cite this article: Mountain D Alcohol related work place injuries: More Questions than Answers! J Emerg Trauma Shock 2015;8:3-4 Received: 11.02.14 Accepted:... high risk groups such as agricultural workers (and others), how much injury is caused by workplace alcohol, what might be protective factors (including alcohol itself!), whether insurance withdrawal