Injuries sustained from high velocity impact with water: an experience from the Golden Gate Bridge

Murder by Pushing: An Exploratory Analysis of Homicidal Falls From a Height

The difficulty in classifying manner of death in falls from a height provides offenders an opportunity to avoid detection by having a homicide appear otherwise. Twelve fall homicides were qualitatively examined. Results showed that most homicidal falls occurred at remote outdoor locations, were planned by offenders who were in controlling intimate relationships with the victim, and were motivated by gain. Homicide was established using inconsistencies in offender's statements and the physical evidence, inappropriate postoffense behavior, evidence of planning, and improbable alleged victim behavior. Fall homicides pose unique challenges for investigators and may negatively impact on the criminal justice process.

An Anthropological Examination of the Types of Skeletal Fractures Resulting from Fatal High (˃3 m) Free Falls

Fatal falls from heights (˃3 m) often result in blunt force trauma (BFT) to the skeleton. The fracture patterns that result from this BFT mechanism are well understood in forensic anthropology and forensic pathology; however, details of the specific types of fractures that result remain poorly documented. The aim of this study was to provide a detailed examination of the types of fractures that may result from fatal high falls. Fractures were recorded from 95 full-body postmortem computed tomography scans of individuals known to have died from a high fall. Trauma was then analyzed taking into account the extrinsic and intrinsic variables known to influence a fall using multiple logistic regression. A total of 339 types of fractures were classified, of which 16 were significantly associated with this BFT mechanism. Classified fracture types will augment anthropological interpretations of the circumstances of death from BFT in cases of suspected high falls.

An Assessment of the Skeletal Fracture Patterns Resulting from Fatal High (˃3 m) Free Falls

The injury patterns resulting from fatal high (˃3 m) free falls have previously been documented in clinical and medico-legal contexts; however, details relating specifically to the skeletal blunt force trauma (BFT) have been limited. This study aimed to augment what is known of the skeletal fracture patterns resulting from fatal high free falls. Skeletal trauma was analyzed from full-body postmortem computed tomography scans of 95 individuals who died following a high free fall. Fracture patterns were documented using the five general anatomical regions, axial and appendicular regions, and postcranial unilateral and bilateral regions. Patterns were analyzed in the context of the extrinsic and intrinsic variables that may influence fractures using multiple logistic regression. Fracture patterns involved all aspects of the skeleton, with 98.9% exhibiting polytrauma, and were influenced primarily by the height fallen, manner of death, and landing surface. This improved understanding of fracture patterns will augment anthropological interpretations of the mechanism of BFT in cases of suspected high falls.

Trauma Patterns of Drowning after Falling from Bridges over Han River

Objective

Recently, the number of patients who fell or jumped from bridges over Han River has rapidly increased. However, the injury patterns and outcomes of these patients have been poorly characterized. The aim of this study was to determine the injury characteristics of these patients.

Methods

We reviewed the medical records of all patients who were transferred to the Emergency Room due to jumping or falling from bridges over Han River between 2011 and 2015.

Results

A total of 203 patients were included. Among them, 14 (6.9%) patients were dead on arrival, 51 (25.1%) patients were expired in the hospital, and 138 (70%) patients were discharged alive, including a patient who had severe neurologic sequelae after resuscitation. Skeletal and internal organ injuries were identified based on radiologic images. The most injured organ was thorax (58.1%), followed by spine (23.1%), abdomen (11.1%), extremity (7.7%), and cranium (5.2%). Chest tubing for pneumothorax or hemothorax was performed in four (2.9%) patients. Surgical intervention was needed for four patients (2.9%).

Conclusion

Trauma patterns were concentrating on the thorax and spine regions. Therefore, complete radiographic evaluation should be performed for these patients.

Planking or the "Lying-Down Game:" Two Case Reports

Background

The monitoring and management of risks regarding children and young people admitted to the emergency department as a result of dangerous behaviors distributed via the Internet should be based on clinical reasoning and knowledge about these social media–related phenomena. Here we examine 2 cases of teenagers who reported severe injuries while performing the “planking” craze, a challenge that consists in lying face-down stiffly like a board on any kind of surface.

Objective

Our objective is to examine and describe the Internet craze called planking, also known as the “lying-down game,“ through 2 case reports from our experience, enriching this study with information gained through discussions with secondary school teenagers.

Methods

Details of the 2 case reports were taken from electronic medical records giving information on care support processes, care management, and the costs of traumatic episodes. Demographic data, hemoglobin and serum lactate values, and Injury Severity Scores were evaluated. The study took place in secondary schools of our city from 2013 to 2014 during medical education courses, with the aim of analyzing the influence of social media on teenagers' activities and behaviors.

Results

Both patients suffered multiple trauma injuries and needed high-level health assistance. The first patient underwent a splenectomy and the second one a nephrectomy; both of them required a long hospital stay (14 and 20 days, respectively), and the costs for their management have been estimated at US $27,000 and US $37,000, respectively. Their decision to perform the planking in dangerous locations was due to their ambition to gain peers' acclaim through shared videos and pictures.

Conclusions

Reporting and understanding these cases may potentially help prevent future events occurring in similar circumstances: the scientific community cannot leave this problem unaddressed. There is also a role of education resources for health care professionals; for this, we must identify and follow up strange or misleading information found on websites. A key element of this research study was to report physicians’ misperceptions concerning planking and, with these cases used for teaching purposes, improve knowledge of the clinical and forensic aspects of this emerging problem.

Suicides by Jumping Off Istanbul Bridges Linking Asia and Europe

AIM

The aim of this study was to determine the injury spectrum and characteristics of people who committed suicide by jumping into water from the July 15th Martyrs Bridge and Fatih Sultan Mehmet Bridges in Istanbul, Turkey.

METHODS

This study included all of the jumpers from the July 15th Martyrs Bridge and Fatih Sultan Mehmet Bridge who were autopsied by the Council of Forensic Medicine, Istanbul Morgue Department, between 2000 and 2013. All of the data were collected from archived case files. Trauma scores were calculated from the traumatic findings of the autopsy reports using the New Injury Severity Score (NISS).

RESULTS

A total of 80 jumping suicides were identified. The male-to-female ratio was 9:1, and the mean age was 34.06 ± 9.6 years. Most suicides occurred in 2009. The suicide rates were higher in the winter, particularly in December. The most frequent injuries were skin lesions, rib fractures, and lung lacerations. In 12% of the cases, the trauma was minor (NISS range, 0-14; mean, 7 ± 5.67), and in 88% of the cases, it was major (NISS range, 17-66; mean NISS, 44.5 ± 12.46).

CONCLUSION

The sociodemographic features of the jumpers who committed suicide were quite similar to those reported in previous studies. Preventative measures (installation of barriers or banning pedestrian access to bridges) reduced the suicide rate but were not completely effective. Establishing early warning systems and rescue strategies could save the lives of jumpers who have minor trauma.

How seabirds plunge-dive without injuries

In nature, several seabirds (e.g., gannets and boobies) dive into water at up to 24 m/s as a hunting mechanism; furthermore, gannets and boobies have a slender neck, which is potentially the weakest part of the body under compression during high-speed impact. In this work, we investigate the stability of the bird's neck during plunge-diving by understanding the interaction between the fluid forces acting on the head and the flexibility of the neck. First, we use a salvaged bird to identify plunge-diving phases. Anatomical features of the skull and neck were acquired to quantify the effect of beak geometry and neck musculature on the stability during a plunge-dive. Second, physical experiments using an elastic beam as a model for the neck attached to a skull-like cone revealed the limits for the stability of the neck during the bird's dive as a function of impact velocity and geometric factors. We find that the neck length, neck muscles, and diving speed of the bird predominantly reduce the likelihood of injury during the plunge-dive. Finally, we use our results to discuss maximum diving speeds for humans to avoid injury.

Free fall trauma

In the abrupt vertical deceleration that occurs on impact after a free fall, tissue damage is caused by the absorption by the body of the energy accumulated during the free fall. Patients sustain a unique injury pattern that is predicatably different from that seen with other forms of blunt multiple trauma. The present paper reviews the pathophysiology and pattern of injury sustained following free fall.

Skeletal fractures resulting from fatal falls: A review of the literature

To investigate what is currently known about skeletal blunt force trauma (BFT) resulting from falls, and how valuable that research is in contributing to forensic anthropology investigations and interpretations of circumstances of death, a comprehensive review of forensic anthropology, forensic pathology and clinical medicine literature was performed. Forensic anthropology literature identified that establishing the type of fall from the analysis of BFT is difficult given the uniqueness of each fall event, the complexities involved with identify BFT and, in particular, the limited available research documenting fracture patterning and morphologies. Comparatively, skeletal BFT resulting from fatal falls is well documented in the forensic pathology and clinical medicine literature. These disciplines cover a wide range of fall types (free falls, falls in juveniles, specific fractures produced from falls, falls down staircases, falls resulting in impalements, and 'other' fall types), provide details on how the nature of the fall influences the skeletal fracturing, and documents the anatomical regions susceptible to fracturing. Whilst these contributions may assist forensic anthropologists, they provide limited details of fracture patterns and morphologies and thus further research investigating the details of skeletal BFT resulting from fatal falls is required.

The injury pattern in fatal suicidal falls from a height: an examination of 307 cases

Falls from a height are a common cause of suicidal death in urban settings. The aim of the present work is to describe and discuss a specific set of 307 autopsies performed in a metropolitan city such as Milan, Italy from 2006 to 2011, with a special focus on the relationship between the injury pattern and height of the fall, age at death and weight at death. The rib cage (92%), the lungs (76%), the heart (53%) and the liver (58%) turned out to be the most injured structures in the whole population. Age resulted statistically significant for heart, thoracic aorta, mesentery, kidney hilus, hip bones and right forearm injuries. Weight resulted statistically significant for subtentorial brain, facial skull, rib cage, lungs and liver injuries. Height was significant for the facial skull (including the jaw), lungs, heart, thoracic aorta, diaphragm, liver, cervical spine, sacroiliac joints, pubic symphysis, right arm and left leg. A simple Injury Extension Score was also calculated which showed a correlation with height. A great variability does exist across all the available forensic literature concerning falls from a height. As a strong common denominator for the injury pattern across all the available literature there is however the very low prevalence of neck injuries, the very high prevalence of rib cage fractures and a definite thorax and upper abdomen injury.

Analysis of the cost effectiveness of a suicide barrier on the Golden Gate Bridge

Background: The Golden Gate Bridge (GGB) is a well-known “suicide magnet” and the site of approximately 30 suicides per year. Recently, a suicide barrier was approved to prevent further suicides. Aims: To estimate the cost-effectiveness of the proposed suicide barrier, we compared the proposed costs of the barrier over a 20-year period ($51.6 million) to estimated reductions in mortality. Method: We reviewed San Francisco and Golden Gate Bridge suicides over a 70-year period (1936–2006). We assumed that all suicides prevented by the barrier would attempt suicide with alternative methods and estimated the mortality reduction based on the difference in lethality between GGB jumps and other suicide methods. Cost/benefit analyses utilized estimates of value of statistical life (VSL) used in highway projects. Results: GGB suicides occur at a rate of approximately 30 per year, with a lethality of 98%. Jumping from other structures has an average lethality of 47%. Assuming that unsuccessful suicides eventually committed suicide at previously reported (12–13%) rates, approximately 286 lives would be saved over a 20-year period at an average cost/life of approximately $180,419 i.e., roughly 6% of US Department of Transportation minimal VSL estimate ($3.2 million). Conclusions: Cost-benefit analysis suggests that a suicide barrier on the GGB would result in a highly cost-effective reduction in suicide mortality in the San Francisco Bay Area.

Patterns of skeletal trauma in suicidal bridge jumpers: a retrospective study from the southeastern United States

In the discovery of human remains from water environments, manner of death may not be immediately obvious to medicolegal investigators due to several factors, including lack of associated material evidence, nondescript contextual environment, or possible poor preservation of remains due to delayed recovery. The determination of patterns of skeletal trauma in suicidal bridge jumpers assists investigators in determining whether the manner of death was suicide versus non-suicide. This study reports on the patterns of skeletal trauma sustained in individuals who jumped from one of four large bridges in Charleston Harbor, South Carolina, and explores victim demographics, bridge height, position of the body upon impact, and velocity at impact on skeletal trauma for this suicide population. Data for all bridge jumpers were collected from coroner files spanning the years 1990-2011. Skeletal trauma is more heavily focused in the thorax/ribs (63%) and craniofacial (30%) regions. Fifty-six percent of jumpers sustained polytrauma. Comparative data on drowning victims, bodies recovered from boating/airplane accidents, and individuals who died by other suicidal means all show patterns of injury different than bridge jumpers.

Tracheal injury added to cervical bone destruction due to the impact of hitting the water surface: four immersed adult bodies

In the forensic examinations of cases of falling, two properties of the water surface, namely its nature as a hard, flat object and as a soft and ungraspable substance must be appreciated. Namely, at the moment of impact, the water surface exerts a greater resistance against relatively broad areas like the head, face and trunk than against the extremities that have a small area. Therefore, total resistance against the whole body would promote flexure. We experienced 72 autopsy cases of immersed bodies during a 4-year period. The cause of death for 64 of these with or without cervical vertebra fracture was drowning. In these cases, the various heights of the falls could often be estimated at the scene. A characteristic pattern of cervical injury with involvement of hyoid bone and thyroid cartilage in addition to cervical vertebra fracture plus rare involvement of the trachea was identified. When a fall from a relatively low height is broken by the water surface, to a certain degree physical findings that differ from those seen in falls to the ground from extreme heights are left mediated by different underlying mechanisms.

Retrospective analysis of free-fall fractures with regard to height and cause of fall

Free-fall fractures represent a specific form of blunt force trauma that can be hard to interpret because of the numerous factors that affect it. The aim of this study is to focus on skeletal injury patterns resulting from free-falls and to analyse the relationship between specific skeletal fractures, and the height and cause (accidental vs. suicidal) of the fall. A total of 179 autopsy reports of fatal free-falls from known heights were analysed at the Department of Forensic Medicine and Criminalistics, in Rijeka, Croatia. The location, type and frequency of fractures, as well as the number and distribution of fractured regions were analysed with regard to height and cause of fall. Height was found to be the major factor influencing fracture patterns in free-falls. In our sample, the frequencies of thoracic fractures, fractures to the extremities and those to the pelvis increased with height. Head fractures show no such relationship. However, types of fractures recorded in different anatomical regions, including the cranium, differ between height groups suggesting different injury mechanisms in each. Victims of falls generally sustained fractures in more than one body region, and the number of injured regions correlates significantly with height. Although no statistical difference was found in the number of fractured regions or frequency of fractures between accidental fallers and suicidal jumpers, jumpers showed a significantly higher number of bilateral extremity fractures when compared to victims of accidental falls. Logistic regression analyses also demonstrate a significant relationship between lower extremity fractures, and the cause of the fall. Our results highlight the need for further investigations of the influence that behaviour and height have in free-fall fractures.

Epidemiology of low-level bridge jumping in Pittsburgh: a 10-year study

BACKGROUND

Outcomes of patients who fall from bridges lower than 160 feet above water have been poorly characterized. Pittsburgh offers a unique setting in which to study these patients as the city has 41 major bridges, only four of which are above 70 feet.

OBJECTIVE

This study examined patients who fell or jumped from Pittsburgh bridges over a 10-year period for their characteristics, injury patterns, and the effects of prehospital care on outcomes.

METHODS

We conducted a retrospective cohort study of patients who jumped or fell from bridges in Pittsburgh, Pennsylvania, over a 10-year period. Subjects were identified through manual searches of three data repositories: City of Pittsburgh Bureau of Emergency Medical Services (EMS), Pittsburgh River Rescue, and Allegheny County Medical Examiner records. Data abstracted included patient name, age, gender, date of birth, and address; incident date, time, location, and river conditions; prehospital interventions; emergency department intervention; hospital disposition; evidence of prior or subsequent psychiatric admission; toxicology results or evidence of substance involvement; and causes of death.

RESULTS

Seventy-four subjects were identified. Most were male (80%) young adults (mean age 34.3 years) who lived near the bridges from which they jumped or fell. Mortality from bridges less than 50 feet high was 18%; mortality from bridges 180 feet high was 75%. All patients who required prehospital interventions beyond warming or intravenous (IV) fluids died. Injury patterns were similar to those described for high-bridge patients, concentrated in the trunk or skull, but low-bridge injuries were milder and less common. Cause of death was predominantly drowning (84%). More than a third (47.3%) of the patients had previous psychiatric histories, but evidence of a previous attempt to jump was uncommon (5.4%).

CONCLUSIONS

People who jump from low- to medium-rise bridges may suffer injuries, but most often die from drowning. EMS interventions beyond water rescue are typically not helpful, emphasizing the importance of prevention and a water rescue plan.

Drowning after falling from a medium-height bridge: multiple trauma victims

INTRODUCTION

Drowning following a fall from a bridge can lead to cardiac arrest caused by hypoxia, hypothermia, or severe traumatic injury. Every year patients are brought to our hospital who have nearly drowned in the local river after a jump from a bridge (approximate height 16-22 meters). We report traumatic injuries in patients admitted to our hospital for out-of-hospital cardiac arrest due to drowning.

METHODS

We retrospectively reviewed the charts of all patients admitted to the intensive care units of our hospital for out-of-hospital cardiac arrest due to drowning after a jump from a bridge in the Seine River between 2002 and 2010. All clinical or radiologic evidence of trauma was recorded.

RESULTS

A total of 37 patients where admitted to our hospital for out-of-hospital cardiac arrest due to drowning. Fourteen patients had radiologic examinations. Five of these examinations showed evidence of severe trauma. In one case, clinical examination showed evidence of severe peripheral neurologic trauma. Seven of these patients (19%) were discharged from the hospital alive.

CONCLUSIONS

Patients found nearly drowned in a river spanned by a medium-height bridge should undergo spinal immobilization and complete radiologic examination as soon as possible.

Predicting the postmortem submersion interval for human remains recovered from U.K. waterways

This article aims to increase accuracy in estimating the postmortem submersion interval (PMSI) for bodies recovered from rivers in the United Kingdom. Data were collected from closed case files, crime scene reports, and autopsy files concerning bodies recovered over a 15-year period from the River Clyde, Scotland, and the River Mersey and canals in northwest England. One hundred and eighty-seven cases met the study criteria and were scored by quantifying the overall amount of decomposition observed in each case. Statistical analysis showed that the duration of a body's submergence in water and the temperatures to which it was exposed, as measured in accumulated degree days (ADD), had a significant effect on the decay process. Further analysis indicated that there were no significant differences in decomposition between the waterways. By combining the data from all study samples, it was possible to produce a single linear regression model for predicting ADD from observed decomposition.

Prognostic factors in victims of falls from height

OBJECTIVE

Falls from height cause significant mortality in the urban environment, but reliable prognostic factors have not been identified. Even the intuitive relation between the distance fallen and mortality rate has been questioned. Our objective was to determine factors predictive of increased mortality rate in victims of falls from height.

DESIGN

Clinical observational study, retrospective for January 1998 to May 1999 and prospective from June 1999 to September 2000.

SETTING

The study population was drawn from Seine-Saint-Denis, an urban region near Paris with 1.3 million inhabitants treated by a French out-of-hospital medical emergencies unit.

PATIENTS

Patients were victims of falls from height >3 m, age >12 yrs. Study entry was performed on the scene by an emergency physician from the medical emergencies unit.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Studied data included age, gender, circumstances of fall, height of fall, nature of the impact surface (soft or hard), transient impact preceding final impact, and part of the body touching the ground first. The primary end point was mortality. The study included 287 patients, 116 (40%) during the retrospective phase and 171 (60%) during the prospective phase. Ninety-seven patients (34%) ultimately died. In multivariate analysis, age (mean, 41.6 +/- 16.6 yrs in patients who died vs. 34.9 +/- 14.9 in survivors; odds ratio, 1.05; p < .0005); height of fall (median, 5.0; 3.8-8.0 vs. 2.0; 1.2-3.0 floors; odds ratio, 1.24; p < .0001); nature of the impact surface (hard in 39% vs. soft in 22%; odds ratio, 2.7; p < .05); and head, anterior, and lateral body surfaces touching the ground first (with respectively mortality rates of 44%, odds ratio, 16.7, p = .0001; 57%, odds ratio, 10.6, p < 0.005; 32%, odds ratio, 11.1, p < .001) were independently correlated with the final mortality rate.

CONCLUSIONS

Patient age, height of fall, impact surface nature, and body part first touching the ground are independent prognostic factors in victims of falls from height.

Pathologic Features of Fatal Falls From Height

Deaths due to falls from height are common in urban settings. At the time the body is found, it is often unclear whether the mode of death is accident, suicide, or homicide. To assess the injury pattern in fatal falls from height with special regard to criteria that might be helpful in discrimination between accident, suicide, and homicide, respectively, we reviewed 68 medicolegal autopsy cases (22 females, 46 males, age range 13-89 years) of fatal falls from height regarding demographic data, findings at the death scene, results of the postmortem examination, psychiatric history, and toxicologic findings. Among the 68 cases, there were 34 suicides, 23 accidents, and 11 unclarified cases, in 3 of which homicide was suspected. In general, suicides were from greater heights than accidents (mean height 22.7 m for suicides and 10.8 m for accidents, respectively; 79% of suicides from more than 16 m). Strikingly, severe head injuries predominantly occurred in falls from heights below 10 m (84%) and above 25 m (90%), whereas in the group of falls from 10 to 25 m, these lesions were seen less frequently (28%). Neck injuries like muscle bleeds and fractures of the hyoid bone were found in 33% of falls from more than 10 m and did not occur from less than 10 m. Our data stress that the evaluation of pathologic features alone is not sufficient to assess the mode of death in fatal falls from height. Instead, postmortem findings have to be considered within the framework of the subject's social, medical, and psychiatric history in conjunction with findings at the death scene and toxicology results to obtain the clearest possible picture of the circumstances of death.

Fatal falls from heights in and around Diyarbakir, Turkey

Falls from high places, such as from a building, are frequently encountered in suicides, in some accidents, and sometimes in homicides. In this study, we evaluated the demographic data, mortality rates, fall causes, and post-mortem findings of individuals who fell from heights. Our cases were collected retrospectively from the files of the Branch of the Council of Forensic Medicine in Diyarbakir between 1996 and 2001. There were 431 accidental and 53 suicidal deaths due to blunt injury resulting from falls. Of the victims, 188 were female and 296 were male. The average age of the 484 victims was 27.05 years (range: 4 months-100 years). For buildings, the height ranged from 3 to 8 stories for suicides and from 1 to 8 stories for accidents. We proceeded to analyse the characteristics of accidental falls as follows. The majority of falls were from balconies or rooftops due to the tendency of people to sit and sleep on these places during the hotter months of the year. Some 54.5% of all falls occurred in May-August. The 53 suicidal jumps all occurred off buildings. The victims ranged in age from 15 to 70 years, and comprised 29 women and 24 men. One of the deceased jumped from the roof of a school in which he was boarding, and another from the seventh story of a hospital in which he was receiving treatment. The remaining 51 jumped from heights ranging from 3 to 8 stories. Psychiatric illness was reported in 18 (33.9%) of the suicide deaths, while 10 (18.8%) of the 53 suicides were single women. The results of this study were at variance with literature data with respect to the following: falls from heights were most common in the 0-5 year age group, females had a higher suicide rate than males, and the majority of accidental falls occurred at home rather than in the workplace.

Jumpers and fallers: a comparison of the distribution of skeletal injury

AIM

The aim of this study was to compare the distribution of injuries between patients who have fallen and those who have jumped from a height, and to relate the mechanism of injury to the fractures sustained.

MATERIALS AND METHODS

Three hundred and ninety-nine patients, admitted via Helicopter Emergency Medical Service (HEMS), classified as either having fallen or jumped from a height were included in the study. The radiographs from the primary survey, together with radiographs of specific injury sites were analysed. The distribution of injury was compared in the two groups.

RESULTS

Of the 399 patients, 342 were fallers and 57 were jumpers. Jumpers had a higher Injury Severity Score (ISS), death rate and number of fractures per person. Jumpers sustained more rib fractures (particularly on the right), pelvic and lower limb fractures but fewer skull fractures.

CONCLUSION

Jumpers tend to sustain different injuries to fallers. It is proposed that jumpers have a tendency to land feet-first and then try to break their falls on their dominant side, sustaining more right-sided rib fractures in the process. The patterns of injury that have emerged from this study have important implications for evaluating skeletal injuries in those who jump or fall from a height.

Suicides by jumping from Bosphorus Bridge in Istanbul

Suicide methods may differ widely. One of these methods is jumping from a height. The people who choose a high bridge for jumping may be considered as a special group. In this study, we evaluated the demographic data, mortality rates and postmortem findings of individuals who jumped from the 64m high Bosphorus Bridge of Istanbul. For this purpose, we reviewed registration forms of two police centers on both sides of the bridge, court archives, and postmortem examination reports of the deceased for a period of 10 years between 1986 and 1995. During this period, 65 people had jumped from the Bosphorus Bridge of Istanbul. The mortality rate was 96.9%, as two individuals survived their suicide attempt. The male/female ratio for attempts was 15:1 (61 males, four females) in this study in contrast to the male/female ratio of 1.6:1 for all suicidal cases in Turkey. The average age of subjects was 29.2 (median: 26, range: 16-54). The frequency was highest in the 15-24 age group with a rate of 38.4%. People who jumped from the bridge were younger than other reported cases of suicide. For all methods of suicide in Turkey 53.5% of subjects are under the age of 35. However, in our study, 75.8% of individuals who committed suicide from the Bosphorus Bridge were under the age of 35. Unmarried people accounted for 56% of the individuals whose marital status was known. 20.8% of the individuals whose employment status was known were unemployed. 59% of the cases whose education was known were high school graduates. The highest rate of suicide by jumping was in 1990, and occurred during the fall and winter months, primarily between the hours of 24.00 and 06.00. The Bosphorus Bridge is forbidden to pedestrians. Arrival method to the bridge was by a taxicab in 53.3% of the cases. 91% of the recovered bodies had been discovered during the first 2 days of jumping. Positions on impact with the water were estimated according to external and internal injuries. Among the cases in which the position of impact could be assessed by external and internal injury patterns, combined lateral and horizontal positions were most common.

Suicidal high falls

There are few data on committing suicide by jumping from a height. Information on suicidal high falls in southeast Scotland was prospectively gathered over 7 years (1992-1998). Data sources included ambulance, police, hospital and forensic records. Injuries sustained were scored according to the Abbreviated Injury Scale, generating Injury Severity Scores (ISS). Sixty-three individuals (50 males), appeared to have committed suicide by falling from a height. The backgrounds were diverse, but 44 individuals had known previous psychiatric illness, 18 having attempted suicide before. The most common locations were high bridges, with two accounting for 23 deaths (37%). Only nine individuals (14%) reached hospital alive. ISS range was 16-75, including 22 scores of 75. These individuals had a total of 24 injuries acknowledged to be unsurvivable, comprising 10 thoracic aortic ruptures, eight massive brain/brainstem injuries, four cardiac injuries, and two high spinal cord transections. The high rate of prehospital death reflects the heights of the falls and consequent major injuries. Prevention of suicide is acknowledged to be difficult - these results suggest that hospital treatment of injuries sustained has little to offer in terms of reducing the death rate from suicidal high falls.

Urban free falls and patterns of renal injury: a 20-year experience with 396 cases

OBJECTIVE

To determine the distribution and stage of renal injuries from free falls and to determine the appropriate methods for their evaluation and management.

MATERIALS AND METHODS

We reviewed the records of 423 patients with renal injuries after a fall from height. Twenty-seven patients did not survive their injuries and were removed from the study.

RESULTS

Based on the American Association for the Surgery of Trauma grading scale, 372 of the renal injuries (94%) were grade 1, whereas 24 injuries (6%) were grade 2 to 4. None of the injuries was grade 5. Of the patients with grade 2 to 4 renal injuries, nine patients had grade 2, three patients had grade 3, nine patients had grade 4, and one patients had a forniceal rupture, as well as two patients with ureteropelvic junction disruptions (one bilateral), four with segmental vascular injuries, and two with hilar vessel injuries. Mean height of free fall was 23.1 feet (range, 10-60 feet) and mean Injury Severity Score was 20.6. Neither the degree of renal injury nor the Injury Severity Score statistically correlated to the height of the free fall. Patients with grade 2 to 4 were more likely than patients with grade 1 renal injuries to be in shock and to have intra-abdominal injuries, gross hematuria, and higher Injury Severity Score(33%, 34%, 62%, 24.6 vs. 6%, 9%, 14%, 20.1, respectively). The degree of hematuria and the grade of renal injury, however, did not correlate. Grade 2 to 4 renal injuries had microscopic hematuria and no shock in 8.3% (2 of 24 patients) and no hematuria in 20.8% (5 of 24 patients). Thus, standard selection criteria for renal imaging of blunt trauma, namely gross hematuria or microhematuria and shock would have missed 7 or 29% of our grade 2 to 4 renal injuries, or 1.8% of all grade 1 to 4. Half of the patients with grade 2 to 4 renal injuries had associated multiple-system injuries, and half had flank ecchymosis or tenderness. Of the patients with grade 2 to 4 injuries, 9 patients (37%) underwent surgical exploration and repair of injury. All renal units were preserved and underwent successful reconstruction. Six of the nine patients initially were explored because of associated intra-abdominal injuries. No major urological sequelae were noted postoperatively or in follow-up of all renal injuries.

CONCLUSION

The height of the free fall cannot reliably predict the degree of the resulting renal injury. Despite the absence of hematuria or shock, vertical deceleration injuries, in particular those associated with multiple-system injuries and/or physical signs of potential renal injury (e.g., flank ecchymosis), demand renal imaging. After a fall from height, the ureteropelvic junction and renal vasculature should also be imaged for potential injury.

Fatal falls down stairs

Fatal falls down stairs in south-east Scotland were studied using prospectively collected data between 1992 and 1997. 51 individuals, comprising 27 men and 24 women with mean age 68.9 years, died following falls down stairs, 30 (59%) of which were unwitnessed. 43 (84%) individuals died following falls within their own homes. Overall, 27 (53%) fatal falls resulted in death at the scene of the accident. Analysis of injuries according to the Abbreviated Injury Scale yielded injury severity scores (ISS) of between 5 and 75, but only four individuals had injuries recognised to be unsurvivable (ISS = 75). Injury to the brain and/or spinal cord was responsible for the vast majority of most severe injuries. The results demonstrate that stairs represent a significant hazard for the elderly. Most of the deaths in the pre-hospital setting appeared to be more the result of the fact that the victim was alone and unable to summon assistance, rather than as a result of unsurvivable injuries. Consideration needs to be given to both how the safety of stairs can be improved and whether a particular elderly person can safely cope with stairs.

[Injury pattern in leaps from a window. A case analysis of 48 patients]

We report about 48 patients who sustained a deceleration trauma after jumping out of a window. The average free fall height was 11.6 m. 45.8% of the patients suffered from psychic disorders. 12.5% were addicted to opiates or hallucinogenics. The lethality of the analysed group was 12.5%. Within the group of spinal injuries (66.7%) compression- and bursting vertebra fractures of the thoracolumbar spine dominate. Injuries of the osseus pelvic ring (62.5%) and the thorax (64.6%) were equally often in all free falls. Abdominal- (25%) and head trauma (35.4%) occurred less at the patients in our clinic. At the extremities a predeliction of injuries of joint near and joint building osseus structures was noticeable. Out of the 103 injuries of the lower extremities 57.3% concerned foot, ankle and the distal lower leg. With increasing height of the falls the rate of multi-injuries and chain fractures raised. Out of the 37 injuries of the upper extremities 40.5% concerned hand and distal forearm and 29.7% the elbow.

Autokabalesis: a study of intentional vertical deceleration injuries

Suicidal jumping from a height appears to be a seasonal problem in Glasgow. A series of 58 individuals were studied, giving a total of 60 jumping incidents. Of these, 21 were killed outright, and of 31 reaching hospital a further 11 subsequently died. Many were young, single, unemployed, adult males, the majority of whom had a known psychiatric diagnosis. Jump heights ranged from 1 to 27 floors and jumps from more than 6 floors were almost always fatal. Below this height mortality was related to the attitude of fall. Overall, 50 per cent mortality occurred at the 3rd floor. A wide range of multiple injuries were sustained and the Injury Severity Score was used to grade these for quantitative comparison. This was found to be highly discriminating between survival and non-survival.

Azygos vein laceration following a vertical deceleration injury

A 41-year-old man presented with respiratory distress and hypotension after a 30-foot fall from a tree. Despite fluid resuscitation, the patient expired in the operating room. Autopsy revealed an azygos vein laceration at the junction of the superior vena cava as the cause of death. Azygos vein and superior vena caval lacerations are rare following blunt chest trauma, including vertical deceleration injury. Early suspicion of vascular injuries with aggressive fluid resuscitation and surgical intervention remain the only hope for survival from this highly lethal injury.

Vertical deceleration trauma. Principles of management

A highly complex interaction of several physical and biomechanical factors determines the patterns of injury and probability of survival in free falls. Falls from extreme heights result in massive visceral and vascular injuries, which are usually lethal. Urban falls tend to result in severe lower extremity, spinal, and pelvic fractures. Retroperitoneal hemorrhage is a significant cause of death and is best managed by emergency angiography and embolization. Early fixation of fractures reduces morbidity.

Small bowel injuries

Small bowel injuries are becoming more commonplace. Difficult to diagnose and treacherous when missed, small bowel injuries should be searched for assiduously in all patients at risk. Use of DPL or CT scanning, coupled with a low threshold for exploration, improves the diagnosis and treatment of small bowel injuries. A delayed diagnosis results in a progressive septic insult and markedly increased mortality. Early diagnosis is the key. After addressing life-threatening problems, the operation should include a thorough and systematic exploration to identify all injuries. Sound surgical technique includes debridement of nonviable tissue, restoration of small bowel continuity, generous irrigation, and placement of enteral feeding catheters. By adhering to the preceding principles and by exercising meticulous postoperative care and maintaining a low threshold to reoperate, catastrophic complications can be avoided.

Vertical trauma: injuries to patients who fall and land on their feet

We reviewed the patterns of injuries sustained by 12 consecutive fallers and jumpers in whom primary impact was onto the feet. The fall heights ranged from 20 to 100 ft. The 12 patients sustained 49 significant injuries. Skeletal injuries were most frequent and included 15 lower extremity fractures, four pelvic fractures, and nine spinal fractures. In two patients, paraplegia resulted. Genitourinary tract injuries included bladder hematoma, renal artery transection, and renal contusion. Thoracic injuries included rib fractures, pneumothorax, and hemothorax. Secondary impact resulted in several craniofacial and upper extremity injuries. Chronic neurologic disability and prolonged morbidity were common. One patient died; the patient who fell 100 ft survived. After initial stabilization, survival is possible after falls or jumps from heights as great as 100 feet It is important to recognize the skeletal and internal organs at risk from high-magnitude vertical forces.

The pathophysiology of free-fall injury

The spectrum of injuries created by a free fall are governed by distinct physical properties, of which the height of the fall and the nature of the impacted surface are the most important factors. Other determinants include the victim's age and weight and the position at landing. Orthopedic injuries frequently are encountered in falls from two stories and less, and are largely determined by the position at landing. Visceral trauma, produced by deceleration forces, frequently involves the liver, spleen, lung, heart and aorta, and must be suspected in falls from three stories and more regardless of the landing position. Mortality from a six-story fall onto a hard surface such as concrete is almost 100% for adults, although considerably less for children. Falls onto softer surfaces, including water, are better tolerated. By appreciating the physical principles that dictate the type and degree of injury, one may correctly diagnose and manage free-fall injuries.

Survival after free falls of 59 metres into water from the Sydney Harbour Bridge, 1930-1982

Between 1930 and 1982, 92 persons fell from the Sydney Harbour Bridge into the water, 59 metres below. The major problem among survivors was pulmonary trauma, often with severe respiratory failure. The position of impact influenced survival, the feet-first vertical position being the most favourable. Mortality rate from the fall was 85%. Rapid clinical assessment of victims, especially with reference to pulmonary injury, and prompt institution of ventilatory support, where required, may reverse respiratory failure. Intra-abdominal injuries, spinal column or central nervous system involvement and peripheral fractures should all be suspected.