Impact of the Rising Number of Rentable E-Scooter Accidents on Emergency Care in Berlin 6 Months After the Introduction: A Maxillofacial Perspective

Abstract

Study Design: Retrospective study of all patients presented at our emergency department after an accident while riding an e-scooter between 15 June 2019 and 15 December 2019. Out of this group, we subgrouped all patients with injuries to the head and neck area. Objective: Shared e-scooter systems have recently been introduced in many big cities worldwide and are becoming increasingly popular. This retrospective study aimed to give a detailed overview of clinical data on consequences of escooter accidents, with particular attention to the maxillofacial point of view. Methods: We performed a single-center retrospective study of all patients presented at our emergency department after an accident while riding an e-scooter between June 15, 2019 and December 15, 2019. Results: Within the observation period, 43 patients (mean age of 32 years; range: 17-64 years) suffered from an accident while riding an e-scooter. Of these, 25 patients (58%) required maxillofacial treatment whereby 9 patients (36%) suffered a fracture (56% fracture of the mandible; 33% fracture of the nasal bone; 11% fracture of the maxilla). Six patients required maxillofacial surgical treatment. Twelve patients (28%) stated to have been driving under the influence of alcohol at the time of the accident (blood alcohol level between 0.77 g/L and 2.32 g/L). None of the patients used body protection, and only one patient wore a helmet (2%). Conclusions: With the introduction of shared e-scooter systems, health-care facilities are faced with an increasing number of accidents related to the use of e-scooters, suffering from a high percentage of injuries in the maxillofacial region. Facial injuries might be reduced by the mandatory use of a helmet with faceguard. The trauma mechanism, in particular, seems to differ from other common trauma cases and needs to be examined more closely.

Introduction

Shared electronic scooters, also known as “e-scooters,” were introduced in Berlin after an amendment to the law in Germany became effective on June 15, 2019; they have flooded the urban centre since then. However, the rapid distribution of shared e-scooter services inaugurated a controversial public discussion among involved city councils and citizens.[1]

E-scooters were introduced in the United States (e.g. San Francisco, Washington D.C., and Los Angeles), at the end of 2018 for the first time, and other countries such as New Zealand followed soon.[2] Since then, the safety of these e-scooters has been questioned in many public discussions.[1,3] In Salt Lake City (USA), the number of reported e-scooter injuries rose by 161%.[2] Badeau et al. showed that e-scooter-related accidents and injuries often affect the whole body whereby superficial soft tissue injuries (40%), major (36%)/minor (34%) musculoskeletal injuries, major (8%)/minor (12%) head injuries represented the most common ones.[4] Of all patients, 28% presented with multiple injury types and received more than one classification which could explain the different findings concerning the most common injury types in other studies.[4]

Other studies concluded that fractures (31.7%) represented the most common injuries, of which the upper extremity (distal: 12.5%, proximal: 6.8%), distal lower extremity (4.4%), and face (5.5%) were mostly affected.[5] Trivedi et al. took a closer look at trauma following e-scooter accidents whereby injuries to the head and face, such as intracranial hemorrhage and loss of consciousness, were commonly found.[6]

Currently, e-scooter sharing services in Berlin are provided by at least five companies.[7] “Civity Managements Consultants,” an internationally operating company that focusses on improving life in public spaces, briefly analyzed the usage of the three leading e-scooter providers in Berlin from August 20, 2019 through September 30, 2019.[7] They found that Berlin has the highest numbers of e-scooters in Europe, with a total number within this period of 10 091 and 2.97 movements per day and e-scooter.[7] This represents more than 29 970 rides per day in Berlin and indicates the significant impact of e-scooters in daily traffic routine. With an average distance of 1.54 km,[7] e-scooters are mainly used for short distances and probably compete directly with bicycles and pedestrians. Due to the accumulation at traffic junctions, e-scooters seem to provide an easy solution for distances that seem too long to walk or if the destination is not well linked to the public transport network.[8] Despite the consequences and the possible influence of e-scooters on daily traffic and the ecological footprint of each individual, the effect of e-scooter-caused injuries to both the rider and pedestrians cannot be denied.[6,9] A first study of Uluk et al. investigated patients with e-scooter-related accidents during the first month after the admission in Berlin.[10] They found that injuries to the head (54%), the extremities (25%), and fractures appeared mostly.[10]

Few publications have studied e-scooter-related accidents in Europe. Blomberg et al. analyzed injuries related to manual and electric scooters within 3.5 years whereby regarding the face and neck area, facial bruising, and tooth trauma appeared frequently.[11] Since no previous publication focuses on the maxillofacial field,[2,4,6,11] the present study aimed to give a detailed overview of clinical injury patterns of e-scooter riders following an accident 6 months after a city-wide introduction from a maxillofacial point of view at a tertiary university hospital.

Methods

Ethics Statement

The Ethics Committee of the Faculty of Medicine Charité, Medical University Berlin, approved this study (EA4/216/19).

Study Design

We performed a single-center retrospective data analysis of all patients presenting at the Emergency Department of a Level I trauma centre in Berlin between June 15, 2019 and December 15, 2019 with the history of an e-scooterrelated accident. Medical records were reviewed retrospectively, using our patient management system (SAP Germany SE & Co. KG). Out of this group, we subgrouped all patients with injuries to the head and neck area. This research was done without patient involvement. Patients were not invited to comment on the study design and were not consulted to develop patient-relevant outcomes or interpret the results.

Results

Within the study period, a total of 9366 trauma patients presented at the Emergency Department, of which 43 patients (m:w 22:21) had a history of an e-scooter-related accident, representing an incidence of 0.5%. Of these patients, 25 persons (58%) had to be treated by our Department of Maxillofacial Surgery. During the observation period, 2342 maxillofacial emergencies presented at our Emergency Department, which corresponds to an incidence of 1.1%.

The mean age was 32 years (17-64 years; Figure 1). The accidents occurred mainly at the weekend (Saturdays: 14/43; 33%; Sundays: 13/43; 30%; Figure 2). A total of 67% (29 of 43) visited our Emergency Department during the on-call duty time between 05:00 PM and 07:30 AM (Figure 3). In all, 98% (42 of 43) of the patients were the rider of the e-scooter, while 1 patient (2%) was involved as a co-rider. One male patient (2%) was riding his own e-scooter wearing a helmet.

Following the Manchester Triage System (

Table 1. Level, nomenclature and waiting time for triage in the Emergency Department according to The Manchester Triage Group.[13]^.

Level	Nomenclature	Waiting time in minutes
1	Immediate	0 minutes, patients in life-threatening condition. In need of immediate attention.
2	Critical	10 minutes, patients that can develop into life threatening situations if they are kept waiting or are having extreme pain. In need of attention in a relatively short period of time.
3	Urgent	60 minutes, patients who have a medical condition but can wait some time before treatment without medical risk.
4	Standard	120 minutes, patients who are able to wait while others with more critical needs go before them in priority. No medical risk in waiting.
5	Nonemergency	240 minutes, patients who have symptoms of illness but are not in immediate medical need of attention.

),[12] all patients were sorted in the process of determining the individual priority for each patient (Figure 4). The most frequently used triage code was 3 (65%), followed by code 4 (16%) and code 2 (14%).

The most common symptoms described by the patients were pain and swelling, particularly at the extremities and/ or the face. For the equivalent period of the previous year (15 June, 2018 to 15 December, 2019), no registered e-scooter-related accidents could be found.

In 21 patients (49%), further diagnostic imaging was required. In such cases, computed tomography was mostly used (81%), followed by X-ray examination (19%).

Of all 43 patients, 18 patients (42%) did not require specialist maxillofacial treatment whereby 6 patients suffered non-maxillofacial-related fractures. Of these 6 patients, 4 suffered a fracture of the distal radius, 1 a collarbone fracture, and 1 a fracture of the tibial plateau, respectively.

A total of 25 patients (58%) were referred to our Department of Oral and Maxillofacial Surgery for clinical examination and/or further diagnostics in the course of emergency treatment. Within this group, 16 patients (64%) had minor injuries such as abrasions, dental trauma, contusion, and/or laceration of the face and merely required ambulatory treatment. However, 9 patients (36%) showed severe injuries in the head and neck area whereby 5 patients were diagnosed with a fracture of the mandible, 3 with a fracture of the nasal bone, and 1 with a fracture of the maxilla (see Figure 5).

The nine remaining patients suffered from severe injuries in the maxillofacial region, of which 6 (67%) required surgical treatment. Just 1 mandible fracture and 2 nasal fractures could be treated conservatively. In 1 of the 5 cases (20%), the observed fracture of the mandible bone comprised a rare fracture pattern: a compound fracture with multiple regions involved (paramedian fracture left and right, fracture of the left mandibular angle, fracture of both mandibular necks, and the left coronoid process). This patient needed 2 revision surgeries in the further course due to infection of the osteosynthesis.

Of all 25 maxillofacial patients presented at our Emergency Department following an e-scooter-related accident, 10 patients (40%) were hospitalized (duration: 1–7 days). Of these, 2 patients initially needed intensive care.

A total of 12 (28%) patients stated to be driven under the influence of alcohol. Of these, blood samples were taken of 7 (16%) with a mean blood alcohol level of 1.7g/L [0.77 g/L-2.32 g/L]. None of the patients used body protection, and only 1 patient wore a helmet (2%).

Discussion

This study describes the clinical data of patients treated due to an e-scooter-related accident from a maxillofacial point of view at a tertiary university hospital over 6 months. Within the study period, these injuries occurred with an incidence of 0.5% of all trauma patients and 1.1% among patients with maxillofacial injuries. Almost 60% of the included patients required maxillofacial treatment, mostly due to dental trauma, a fracture of the mandible or nasal bone.

Rentable e-scooter systems seem to be used in particular for short routes, in direct competition with bicycle and pedestrian traffic.[7] In this way, e-scooter accidents seem to increase the number of accidents whereby the amount of minor and significant injuries rises. Regarding the number of patients during the 6-month observation period and considering the number of approximately 29 970 e-scooter rides in Berlin per day, it reveals that the percentage of accidents requiring maxillofacial treatment is low.

Since almost all patients (42 of 43; 98%) did not wear a helmet, the question arises if wearing a helmet and/or further body protection should be mandatory by law. There is evidence that wearing a helmet significantly reduces the risk of traumatic brain and face injuries, especially in bicycle crashes.[14] To what extent a helmet could decrease the incidence and severity of maxillofacial fractures in e-scooter-related accidents needs further data, with a particular emphasis on the kinetics of these accidents.

Comparable studies that focused on craniofacial trauma showed that after bicycle accidents and falls, a mandible fracture was the most common one.[15] This is in line with our findings, with a fracture of the mandible being the most frequent injury in the orofacial region following e-scooter accidents. Since powered wheeler drivers are extremely vulnerable to road risks and most e-scooter drivers do not wear a helmet, compulsory legislation for helmet use with face guards for cyclists and motorcyclists has been stressed.[16,17] Interestingly, in 2016, standard helmets led to an increased number of mandible fractures,[18] which also could apply to e-scooter-related accidents and require attention.

Patient characteristics seem to be comparable to those in the study by Blomberg et al. who analyzed injuries related to manual and electric scooter use from January 2016 to July 2019 in Copenhagen, where 5.9% wore a helmet and 36.6% showed signs of alcohol intoxication.[11] In our study, among all patients, alcohol usage could be proved in 28%. Since earlier studies recorded alcohol usage in 16% to 27% of all scooter admissions,[4,6,19,20] the expected number of trauma cases in the maxillofacial region can be expected to be the highest during the night time and on weekends. Blomberg et al. pointed out that facial injuries occur in 38.4% of all e-scooter-related accidents.[11] In our study, 11 of the 25 patients requiring maxillofacial treatment showed fractures, which contrasts the results of Blomberg et al. and corresponds to the results of Trivedi et al., who characterized injuries associated with standing electric scooter use and the clinical outcomes of injured patients.[5,11] Blomberg et al. registered no maxillofacial fracture, merely 20.5% with minor head injuries and 38.4% with the face as the affected body part as opposed to Trivedi et al. who found 5.6% with facial fractures.[6,11] Since both studies used score 4 (Manchester Triage System) for triage acuity most often,[5,11] the trauma mechanism and/or the trauma itself registered in our study seem to differ, since 40% of all e-scooter riders visiting our Emergency Department suffered a fracture and most patients were classified as score 3 (64%) following the Manchester Triage System.

Usually, traumatic fractures in the maxillofacial area occur after motorcycle/bicycle traffic accidents, interpersonal violence, or falling.[21,22,23] Even though the fractures are usually caused by high impact forces on the maxillofacial bones, e-scooter-related accidents seem to lead to a high number of fractures of the mandible. This could be related to the small or nonexistent buffer zone of the—usually—upright standing e-scooter riders, especially if a car or bicycle is involved in the accident. Upright standing on the e-scooter and with both hands at the handlebars for steering (at waist level), e-scooter riding seems to be comparable to Segways.[5] The launch of Segways offered an innovative kind of transportation system, but it was associated with a significant risk of severe injuries.[5] In contrast to our results, Segway-associated injuries most often occur at the upper and lower extremities as well as the head, at which fractures of the radius are the most common ones.[24]

In accordance with the results of Civity, who describe a rise of about 30% to 40% on weekends,[7] the high number of e-scooter accidents (63% of the patients visited the Emergency Department on Saturdays and Sundays) during our observation period seems reasonable.

Regarding the fact that the road traffic act applies to e-scooters as well, the high percentage of patients (28%), who stated to be driven under the influence of alcohol, indicates a considerable number of legal offences, which could also be seen in earlier studies of e-scooter-related accidents.[4,5,6,19] Bekhit et al. investigated the regional health-care cost and burden and came to the conclusion that the introduction of e-scooters in New Zealand has had a significant impact on the primary urban trauma centre, community care facilities, and health-care cost.[19] Since e-scooter-related accidents seem to add on to “normal” and common accidents,[5,7] this impact and the associated financial burden for the German Health System should be comprehensively examined in further studies investigating all e-scooter-related trauma cases, not just maxillofacial trauma cases and injuries.

Conclusion

With the introduction of shared e-scooter systems, healthcare facilities are confronted with an increasing number of e-scooter accidents suffering from a high percentage of injuries in the maxillofacial region. A facial fracture was observed in 9 of all 43 patients (21%) whereby the mandible or the nasal bone was mostly affected. In one case, a compound fracture of the mandible with multiple regions involved was observed. Considering the high number of head injuries/fractures noted, helmet use with face guards should be considered as an effective tool in prevention. Since e-scooter-related accidents seem to be an addition to common accidents and amounted to 5% of additional mandible fractures in our observation time, this impact should be comprehensively examined in further studies investigating all e-scooter-related trauma cases, not just maxillofacial trauma cases and injuries. In particular, the economic impact on the health-care system could be of further interest, since rentable e-scooters will surely be introduced in additional cities.