Antecedence to Injury

Who ends up in the ER?

by Alan Bavley

Science is all about asking questions, but the answers scientists find often lead to still more questions. That's what Daniel Vinson has been discovering on a quest he's pursued for more than a decade.

Another researcher's study of heart attacks gave Vinson the idea to take a fresh look into the relationship between alcohol abuse and accidental injuries. Working with the often surprising data from that study, he came up with some equally thought-provoking findings on an entirely different subject: the physical hazards of a hostile attitude.

"Every well-done study will generate at least two more questions," says Vinson. "What we've done is intriguing. It's provocative, I hope, provoking people to do more research."

Vinson, 57, is an MU professor of family and community medicine. He's a wiry man, an avid cyclist with a gray beard and a wry sense of humor. The son of a small-town general practitioner in North Carolina, Vinson didn't seem destined to follow in his father's footsteps. He started as a physics major at Davidson College. But a year of study in Germany got him off that track and he turned to doctoring instead.

After medical school and residency at the University of North Carolina, Chapel Hill, Vinson practiced family medicine for about 10 years in Banner Elk, a small town in western North Carolina. It was a satisfying life, but Vinson wanted more.

"It took me a while to realize I really enjoy the teaching and research, although I'd miss the clinical side if I didn't do it," he says.

In 1988, he came to MU for an academic family medicine fellowship and then joined the faculty in 1990. Vinson's current research quest was triggered in December 1993, when two articles in the New England Journal of Medicine addressed an issue that interested him keenly: Does exercise prevent or provoke heart attacks?

The researchers had interviewed patients who were hospitalized for heart attacks and a control group of patients who were in the hospital for other reasons. They asked the patients about their usual exercise habits and whether they had exercised in the hours just before their heart attack and 24 hours earlier.

The researchers found that an episode of exercise more than doubled the risk of a heart attack for people who exercised regularly, but it increased the risk more than 100-fold for those who exercised less than once a week. Vinson saw that the strategy these investigators used -- interviewing patients shortly after a well-defined medical event -- worked well for measuring risks associated with intermittent exposure to potential hazards. "Then a light bulb went off in my head,'' he says. "Alcohol and injury."

Alcohol abuse and dependence is a growing problem. It affects more than 17 million adults in the United States, up from about 14 million just a decade ago. With trauma responsible for 40 percent of the 85,000 alcohol-related deaths each year, injury prevention was a subject urgently in need of more study.

Vinson had become interested in alcohol research while treating alcoholic patients as an inpatient attending resident at University Hospital. In the summer of 1994, he and a team of medical students did a small pilot study at the hospital's emergency room. That led to a $1.1 million grant from the National Institute on Alcohol Abuse and Alcoholism to pursue the research on a larger scale.

Late in the winter of 1998, Vinson and his research team descended on the emergency departments of University Hospital, Boone Hospital Center and Columbia Regional Hospital. They interviewed more than 2,500 injured patients: People with workplace injuries and sports injuries; people who had fallen down stairs or cut themselves with a kitchen knife; and people with sprained ankles, mild concussions or cuts needing stitches.

The patients were asked about their alcohol consumption immediately before their injury and what they had to drink the day before. Each interview lasted about half an hour and resulted in page after page of data. "The beauty of this approach is that it controls for everything that is stable from day to day, such as a person's age, sex, economic status," Vinson says. "It's perfectly controlled because it's the same person."

Vinson also employed professional phone interviewers to collect similar information from about 1,800 people randomly dialed in Boone and surrounding counties. Then came the data analysis, which Vinson concedes was "somewhat tedious," to compare the patients' experiences on the day of their injury and the day before to the experiences of the control group reached by telephone.

The results, Vinson found, were anything but boring. In fact, he says, they were remarkably consistent. "The association of alcohol and injury is strong and clean and it's consistent over race and gender," And the risks kicked in much faster than Vinson expected.

Having just two drinks over a period of six hours -- not much by most social drinkers' standards -- doubled the risk of injury. "I'm not sure that's a public health message the country is ready to hear," Vinson said. "We're not talking about people who are falling down drunk."

With additional alcohol, the risks of injury took exponential leaps. Three to four drinks were associated with a four-to six-fold increase in risk. Five or six drinks with a 10-fold risk. Many of alcohol's effects may account for these risks, Vinson says. Alcohol is known to impair judgment and hand-eye coordination, to increase reaction time and to reduce attention span and attentiveness.

One thing Vinson found still puzzles him: There was no association between alcohol abuse or dependence and the risk of injury. "Not alcoholism, but the number of drinks is the risk factor for injury," he says. "I still can't get my mind around that."

Cheryl Cherpitel, associate director of the National Alcohol Research Center in Berkeley, Calif., collaborated with Vinson on his alcohol and injury research. She described Vinson's methodology as ground-breaking in the field of alcohol studies.

"Dan was the first to use this methodology in the substance use area, and his studies were seminal in advancing the area of alcohol and injury research in emergency department populations," Cherpitel says.

Vinson's findings already have prompted other researchers to examine the connection between drinking and injury. In Australia, researchers at the University of Queensland replicated Vinson's study and came up with similar results. People who drank alcohol were up to four times more likely than non-drinkers to suffer physical injuries. The Australian researchers also found that people who sustained serious injuries were more likely to have been drinking beer and to have done their imbibing at a bar or tavern.

Vinson's alcohol study also yielded an unexpected bonus: data linking anger to injury. When Vinson's research team was interviewing people for the alcohol study, they asked a series of questions to help people remember what they'd been doing the day before: Where were they? What had they been up to? Were they feeling irritated, angry or hostile? If so, how intensely?

"When we plugged in everything I had measures for, there was this connection between anger and injury," Vinson says. "And the more angry someone was, the higher the risk."

Someone who reported being "quite a bit angry" had nearly twice the risk of injury as someone who had been in a good mood. Someone who was "extremely angry" had seven times the risk.

Vinson's findings were published last fall in an Annals of Family Medicine article co-written with MU medical student Vineesha Arelli. The results could be interpreted in several ways, Vinson says. Doing something that makes you angry may lead to an injury, he suggests. Engaging in rough, competitive sports, for example. Or a night out at a rowdy bar. Or an argument with a mother-in-law. ("I loved my mother-in-law. She was wonderful," Vinson says in a quick aside.)

But equally possible, the injury itself may have made you angry. Or the anger and injury may have occurred at the same time, but be unrelated. "Anger was associated with injury," Vinson cautions. "'Associated' is jargon, but it's necessary jargon."

Some of Vinson's findings seem obvious. Getting into an argument is a real hazard, for example. "If I get angry, I increase the risk of someone else injuring me -- by a lot," Vinson says. He found also that the association of anger and injury was much stronger among men than women. "All I can do is speculate," Vinson says. "When women get angry they respond in a different way than men. A man may be more likely to do something physical when he's angry. A woman may talk it out."

But there were surprises. Road rage, for example, may not be as physically dangerous as we've come to assume. The study didn't find a relationship between anger and traffic injuries. "That really puzzles me. For one thing, traffic makes most of us angry. And motor vehicles are a dangerous weapon, if you make them into one," Vinson says. "Maybe it's because people who get angry driving decide 'I don't want to put a dent in my car.' It might be that the great majority of people who get angry driving react that way."

Another revelation was how generally disgruntled people say they are. Among those in Vinson's telephone survey, 33 percent said they were irritable and eight percent reported feeling hostile. Vinson wouldn't link that pervasive anger to intermittent explosive disorder, the latest psychiatric condition that's been making headlines. "I would be willing to bet that, of the 33 percent who were at least irritable, very few would have a disorder of explosive anger. I would bet most are just normal folks who get angry from time to time," Vinson says. "But it makes me think we live in a pretty angry society."

Vinson's research has gotten some good-natured ribbing in the scientific community. Earlier this year, his alcohol and anger studies were critiqued in the journal Nature in a column devoted to "seemingly pointless" research.

"When we get angry we're more likely to hurt things, and, crucially, ourselves. Pretty much common sense, really," the columnist wrote. "So why do we need a newly published scientific study to hammer home the message?" Vinson sighs impatiently when he hears criticism like this. "That's the 'well, duh,' argument," he says. "But two drinks doubling the risk of injury, that's no 'well, duh.' People don't know that."

In fact, at least among students, knowledge about responsible drinking is lacking, Vinson has found. After seeing a "Know When to Say When" bumper sticker on a beer truck, Vinson asked student patients what the phrase meant to them. "They said 'When I pass out,' 'When I throw up,' or 'When I can't find my way to the keg anymore.' Nobody said one or two drinks, or three or four drinks. Nobody had a fixed limit in mind," Vinson recalls.

Vinson says there are two "take-home messages" from his research. "First, it's changed my definition of 'moderate' drinking. Drinkers probably should be having just one or two drinks at a time, instead of three or four."

And the second message? "Maybe men should be more like women, at least in anger management," Vinson says. "Just look at the arrest reports in the newspapers. Violent crime is mostly perpetrated by men. The issue is not 'don't get angry,' but when you do get angry, 'what do you do?' "

Vinson is now pursuing a new alcohol research project. This time, his work was inspired by a group of Seattle researchers who found that giving injured adolescents a brief counseling session in the emergency room improved the odds that they would use seat belts and bicycle helmets in the future.

Working with MU medical student Adam Stevens, Vinson has been helping patients who come through the University Hospital emergency room with drinking problems to get counseling from a health educator or psychologist. They will follow up with these patients to see if they actually make an appointment and go through a counseling session.

Vinson has always focused his research on preventive medicine, helping doctors help their patients lead healthier lives. It's important work, but it may lack some of the glamour of high-tech medicine. He doesn't mind. "Somebody has to do the coronary bypass surgeries," he says. "But somebody also has to be talking to folks about stopping smoking, cutting back on drinking and getting more physical activity. There's lots left to be done."

It's an approach that has long impressed his colleagues such as Cheryl Cherpitel: "I have felt so many physicians in this field are those who have somewhat given up clinical practice for the allure of research," she says "Dan has always struck me as a physician first, who has managed to also obtain grants to carry out research which has both intellectual and clinical impact."

Vinson has confidence that patients can remake their lives for the better. He just has to recall how he flunked physical education as an undergraduate because he couldn't run 600 yards. He's fit enough now that he and his wife, Linda, completed a bicycle trip four years ago that spanned the continent, from Virginia to the state of Washington.

"I turned out OK," he says. "I know people can change."