Intended for healthcare professionals


Toxic complacency

BMJ 2002; 324 doi: (Published 11 May 2002) Cite this as: BMJ 2002;324:j

Motor Car Accidents: more dangerous than Bullets in civilian life?


Congratulation on your theme issue on road traffic crashes,
highlighting in particular the dangers of Motor Car Accidents (MCA).
“Toxic complacency” [1] and “War on the roads” [2] are factual commendable
editorials with justifiable titles. This is supported not only by the data
reported in BMJ theme issue but also by the following experience and data
that might allow some comparison, demonstrating MCA are more dangerous
than bullets in civilian lives.

Retrospective analysis of a decade experience with Genito-urinary
tract (GUT) trauma admitted to Urology Department, King Khalid Hospital,
Najran, at south Saudi Arabia is being in preparation. Data on insult
type, trauma category, organ involvement, emergency management and outcome
of 155 patients seen between November 1991 and February 2002, inclusive,
was made. Data neither included victims who died before arrival to
hospital nor who had permanent GUT morbidity as result of cerebrospinal
trauma paralysis.

Trauma affected all GUT organs of predominantly young males. Blunt
and penetrating trauma affected 121 (78%) and 19 (11.6%) patients,
respectively. Genital and Urological trauma accounted for 109 (70.3) and
46 (29.7%) cases, respectively. Blunt testis trauma of accidental, sports
and assault affected 56 (36%) cases and presented with acute Scrotum. Most
blunt testicular trauma healed conservatively. Blunt sex trauma of erect
penis due to rupture tunica albuginea (fracture penis) affected 31 (20%)
cases, presented with acute penis and treated surgically.

Urological trauma presented with haematuria. Blunt MCA caused 34
(21.9%) GUT injuries as part of poly-trauma patients of whom 4 died soon
after arrival. Kidney trauma affected 26 (16.8) and rupture urethra 8 of
whom 6 patients were left with permanent morbidity of impotence and
incontinence. Bullet injury was the main penetrating insult causing also
poly-trauma involving GUT and abdominal organs of 15 patients, including 7
kidneys, 5 bladder rupture with 4 vesico-rectal or colonic fistulae, one
extra-peritoneal bladder rupture and 3 penile amputations. Bullets caused
one death due to peritonitis complicating delayed repair of vesico-rectal

Management was organ specific that aimed at saving life, organ and
function, and avoiding further iatrogenic morbidity. Most kidneys were
salvaged except two of Bullet severed pedicle. Intra-peritoneal rupture of
bladder was managed by primary repair of perforated bowels and bladder in
two cases, and by supra-pubic catheter and colostomy with deferred fistula
repair in two cases that proved impossible. Complete urethral rupture
occurred with pelvis fracture of 6 patients, initially treated by supra-
pubic catheter in 4 and supra-pubic with railroaded urethral catheter in 2
cases explored for other abdominal trauma, all have permanent impotence
and incontinence. Other GUT trauma included: Amputated penis due to Bullet
injury successfully re-implanted in 2 cases but one burn necrosis of penis
duo to high voltage electric wire (also hit by Bullet) was lost.
Iatrogenic ureteral injuries of 12 cases and 2 vesico-vaginal fistulae
affected females at obstetric surgery were cured.

Saudi Health Statistical Yearbook 1998 reported 9052839 casualty
attendants Nationwide, of whom 1015022 (11.2%) were injuries and 78835
(7.8%) were MCA trauma. Males of 15-44 years of age accounted for 75% of
MCA trauma morbidity and mortality. Trauma is the second recognized cause
of 5094 (15.5%) annual deaths of which MCA contributed 2365 (46.4%) while
all cancers caused 5.8% deaths per year.

Latest figures of year 2001 from Najran area with 253115 population
of whom our hospital is serving 60% showed casualty attendants of 152594
(60%), injuries 19837 (13%) and MCA trauma 1227 (6.2%) of whom 38 (3.1%)
died. Najran population supply 2.2% MCA trauma and 7.3% mortality of
National figures. Saudi Arabia is arguably considered one of the safest
areas on Earth but also seem to be having a war on its roads. If anti-
smoking campaign ever worked, should vehicle manufacturers put the
warning: “Cars can seriously damage your health”?

Dr Ahmed N. Ghanem, MD, FRCS Ed.

I thank Dr Essam El-Din Helmy, PhD, Quality Assurance Consultant, for
providing data of the last paragraph.


1. Roberts I, Mohan D, Abbasi K. War on the roads BMJ 2002; 324: 1107-

2. Smith R. Editorial. Toxic complacency. BMJ 2002; 324: (11 May)

Competing interests: No competing interests

21 May 2002
Ahmed N. Ghanem, MD, FRCS Ed.
Consultant Urologist Surgeon
King Khalid Hospital, P O Box 1120, Najran, Saudi Arabia