MOPEDS: Motorized Objects PropellingEthanol Drinking SubjectsA. BRITTON CHRISTMAS, M.D., RITA A. BRINTZENHOFF, M.D., THOMAS M. SCHMELZER, M.D.,KAREN E. HEAD, R.N., B.S.N., RONALD F. SING, D.O.

From the F.H. "Sammy" Ross, Jr. Trauma Center, Department of Surgery,Carolinas Medical Center, Charlotte, North Carolina

Mopeds are not subject to the same laws and jurisdiction as cars or motorcycles, including therequirement of a driver's license. We undertook this study to examine the influence of alcohol(ETOH) on moped crashes. We retrospectively reviewed adult moped injuries compared withmotor vehicle crashes (MVCs) and motorcycle crashes (MCCs) from 1995 through 2006. De-mographics, severity of injury, mortality, and serum ETOH levels were recorded. Data were an-alyzed using tbe Student f test for continuous data and the x^ test for proportional data. Motorvehicle crashes accounted for 7186 admissions. MCC and moped crashes numbered 973 and 113,respectively. Although not statistically significant (P = 0.064), moped crashes yielded the highestmortality (9.7%) compared with MCCs (8.5%) and MVCs (6.7%). An increased association of bloodETOH levels witb moped crashes, however, was statistically significant (P = 0.004). Serum ETOHlevels above 0.05 g/dL were observed in 1681 MVCs (23.4%), 241 MCCs (24.8%), and 44 mopedcrashes (39%). In tbis study, we discovered tbat moped crashes demonstrate a significantly higherETOH involvement than either MVCs or MCCs representing a previously unrecognized publicsafety risk.

T HE POTENTIAL INFLUENCE of alcohol intoxication ontrauma, including homicide, assault, and motorvehiele eollisions. has been well doeumented. In the1997 National Highway Traffie Safety Administra-tion's (NHTSA) Current Research in Alcohol, it wasestimated that half of all trauma admissions to U.S.hospitals involved patients who were injured whileunder the influence of alcohol.' Speeifieally in 2007,the NHTSA reported that 32 per eent of all motor ve-hicle collision fatalities, 12,998 deaths, were the resultof aleohol-intoxieated drivers with a blood aleoholeoneentration (BAC) of 0.08 g/dL or higher.- The per-centage of alcohol-related injuries specific to motorcy-cle collisions has also been doeumented. Soderstromand eoUeagues-* reported in 1993 that 53 per eent ofinjured motorcycle drivers exhibited positive BAC.

Reeently, we identified another group of intoxieateddrivers that have yet to be studied: moped drivers.Mopeds are a class of motorized vehieles with a de-fined engine eapaeity of less than 50 em"' that may notexeeed a speed of 30 miles per hour. Moped operator

Presented at the 2008 annual meeting of the American Collegeof Surgeons, October 12-16. 2008, San Francisco, CA.

Address correspondence and reprint requests to A. BrittonChristmas, M.D.. Department of Surgery, Carolinas MedicalCenter. P.O. Box 32861, Charlotte, NC 28232. E-mail: ashley.christmas@carolinashealthcare.org.

requirements and lieensing laws eurrently vary amongthe states. Furthermore, in many states, an individualean legally obtain a moped lieense even if his or herdriver's lieense has been previously suspended or re-voked. For this reason, these drivers represent a sub-stantial potential publie safety risk. We undertook thisstudy to assess the association between moped colli-sions and drivers' positive serum ethanol levels com-pared with automobile and motorcycle eollisions.

Methods

We retrospeetively reviewed the reeords of patientsinjured by motor vehiele eollisions from 1995 to 2006as identified by the Carolinas Medieal Center traumaregistry database. Carolinas Medieal Center is a re-gional Level I trauma eenter serving an area of 6147square miles and a population of over three millionresidents of North Carolina and South Carolina. Dataeolleetion ineluded patient demographies. Injury Se-verity Seore (ISS), mortality rates, and serum ethanollevels of all patients admitted to the trauma servieeafter motor vehicle collisions. These eollisions wereeategorized as automobile, motoreyele, or moped. Bloodaleohol eoneentration testing was measured at the timeof presentation for all persons involved in motor vehieleerashes in eonjunetion with North Carolina state law. Forthis study, a positive serum ethanol test was deñned as

304

No. 3 MOPEDS

BAC greater than 0.05 g/dL. Data were analyzed usingthe Student / test for continuous data and the x" test forproportional data. Results were considered significant atP < 0.05.

Results

From 1995 through 2006, there were 8272 admissionsfor injuries caused by motor vehicle collisions. Motorvehicle crashes involving automobiles or trucks (MVCs)accounted for 7186 admissions (87%), and motorcyclecrashes (MCCs) and moped crashes (MOPED) num-bered 973 ( 12%) and 113 ( 1 %), respectively (Fig. 1 ). Asexpected, the mean ISS was slightly lower for MVCs(13.7) compared with MCCs (16.3) and MOPED (15.8).However, these differences were not statistically differ-ent. Mortality among the groups was also similar with6.7 per cent MVCs, 8.5 per cent MCCs, and 9.7 percent MOPED. Interestingly, alcohol intoxication rates,defined as serum ethyl alcohol levels greater than 0.05g/dL, varied significantly among the groups. Although23.4 per cent of automobile/truck operators and 24.5per cent of motorcycle operators were intoxicated, 39per cent of moped operators were intoxicated (P =0.0004) (Table 1 ).

We further compared the motorcycle and mopedgroups. Although both groups exhibited similar Glas-gow Coma Scale scores, hospital length of stay, andintensive care unit length of stay, significant differ-ences were observed with respect to age and BAC.Moped riders were significantly older (45 ± 14 years)than their motorcycle counterparts (37 ± 12 years). Asubanalysis of intoxicated riders demonstrated a sig-nificantly higher BAC in the moped group (0.185 ±0.096 g/dL) compared with the motorcycle group(0.122 ± 0.090 g/dL) (Table 2).

Discussion

The relationship between alcohol use, injuries, andfatalities after motor vehicle collisions has been welldocumented.'"^ Many laws have been enacted to protectdrivers and pedestrians from intoxicated motor vehicleoperators, including convictions for driving under theinfluence (DUI) with BAC of greater than 0.08 g/dL,license suspension, and eventual license revocation forrepeat offenders. These laws, however, seldom apply tomoped operators. In many states, an individual can le-gally obtain a moped license irrespective of the status ofhis or her driver's license. Some states do not requirea license at all. As such, repeat offenders whose drivers'licenses have been suspended or revoked can continueto operate these motorized vehicles.

In 2(X)6, the NHTSA deinonstrated that drivers witha BAC greater than 0.08 g/dL involved in a fatal collision

Christmas et al.

Motor Vehicle Collision Admissions N= 8272

305

0 AUTO 87%

• MCC1296

D MOPED 196

Fro. 1. Motor vehicle collision admissions, 1995 to 2006.Auto, automobile/truck crash. MCC, motor cycle crash. MOPED,moped crash.

TABLE I. Comparison of Injury Severity, Mortality, andAlcohol Intoxication by Category of Collision

Automobile Motorcycle Moped F Value

Injury SeverityScore

MortalityAlcohol

intoxication

13.7

6.7%23.4%

16.3

8.5%24.8%

15.8

9.7%39%

0.064O.(X)O4*

* P < 0.05 comparing automobile and motorcycle withmoped.

TABLE 2.Drivers

Comparison between Moped and Motorcycle

MotorcycleMean (SD)

MopedMean (SD) P Value

AgeGCSH LOSICU LOSBAC

37(12)12(5)10(12)6(8)

0.122(0.090)

45 (14)12(5)12(17)6(9)

0.185(0.096)

306 THE AMERICAN SURGEON March 2011 Vol. 77

therefore, deereased mortality in the moped groupbeeause, by definition, these vehicles cannot achievespeeds greater than 30 miles per hour. Although theISS was similar between groups, the moped group wassignificantly older than the motorcycle group. Fur-thermore, when the effects of alcohol are introdueed.many plausible explanadons arise. It is well docu-mented that alcohol use is associated with deereasedinhibitions and. subsequently, many other risk faetorsfor injury.̂ Prior studies have shown that intoxicatedmotoreyelists are much less likely to wear helmets thansober riders.**- '^ Furthermore, House and colleagues'°demonstrated that intoxicated drivers are more likelyto drive at higher speeds and in more hazardous eir-eumstances than sober drivers. These findings, in com-bination with the impaired psyehomotor effeets of al-eohol, eould certainly account for the trend towardinereased mortality in this population.

Although DUI laws have become more stringent,some authors estimate that only three to five arrests areactually made for every 1000 DUI episodes. ' ' Of greateoneern is that for those who are ultimately arrestedand convieted, mopeds offer an alternative mode oftransportation with fewer restrictions and regulations.Furthermore, the BAC of moped drivers is significantlyhigher than motorcycle drivers. The ability to remainconscious with a BAC approaehing 0.200 g/dL impliesprior development of high aleohol tolerance, depen-deney, and likely reeidivism.'- Because there are cur-rently no laws in effeet to prevent potential recidivistsfrom operating mopeds. they will likely continue to doso until either severe injury or behavior modificationoccurs. Similar to Li and colleagues,^ we reiterate thatdrinking behavior persists across activity domains. Theassociation, therefore, is less likely to be a causai re-lationship and is more likely the result of behaviorpatterns.

As in any elinieal study, our study has several lim-itations. First, this is a single-institutional study thathas not been subjected to muld-institutional analysis.Seeond. we acknowledge potendal deficiencies in anytrauma registry database. We recognize that data entryis subject to human error and potendal omissions. It isalso possible that the BACs reeorded in our registrymay aetually be lower than the BACs at the time ofinjury. We recognize that potential delays, particularlyfor patients transferred from regional facilities, allowmore time for metabolism and, subsequently, mayyield lower BACs. Furthermore, in this retrospectivestudy, we have no way to verify that every patient un-derwent BAC testing at the time of arrival. At present.

we do not have license suspension or revoeadon data onthe moped drivers idendfied in this study.

Conclusion

In this study, we diseovered a greater associationbetween moped collisions and positive serum ethanollevels eompared with automobile and motorcycle eol-lisions. Although we strongly suspeet that many of theseriders are drunk driving recidivists, we do not havelicense suspension data. The next step in studying thispublie health issue is to obtain reeords from the De-partment of Motor Vehicles to confirm the nationwidetrends of DUI recidivism in moped operators. With thisinformation, we hope to gain support in our effort torevise current moped laws and to close a potentialloophole for DUI recidivists.

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