| Abstract|| |
Context: Cycle rickshaw is an important means of transportation in Urban India. Pedestrians, rickshaw users, rickshaw pullers, two wheeled vehicle users and cyclists are among the most vulnerable road user groups in terms of injuries and fatalities resulting from road traffic accidents in India. Our objectives were to study characteristics of crashes and nature of injuries associated with cycle rickshaw. Patients and Methods: Between August 2008 to July 2009, a hospital based observational study was done of patients who presented to King George medical college trauma center with injury sustained due to cycle rickshaw in emergency department. Age, time of trauma, mode of trauma, contributing factors and type of injury were recorded. Results: The mean age of the patient was 32.1. Seventeen patients were rickshaw pullers and the rest were occupants of the rickshaw. Overloading with more than two passengers was found in 24 cases (28.5%). Most common cause of injury was collision with a moving vehicle (56 patients, %) followed by fall from rickshaw. The most common contributing factor was the overloading of rickshaw. On arrival to the hospital, the mean Injury severity score (ISS) was 3.5 ± 2.2 and the mean Glasgow coma scale (GCS) was 13.4 ± 4.3. Nine patients were admitted to ICU (Intensive care unit). The median ICU stay was 4 (1-24 days). Six of the ICU admitted patients had head injury. Conclusion: Rickshaw pullers and occupants are vulnerable to road traffic accidents. Urgent preventive measures targeted towards this group are needed to reduce the morbidity and mortality resulting from injuries involving rickshaws. The need for improved understanding of the risk characteristics of cycle rickshaw is emphasized.
Keywords: Bicycle, crashes, injury, rickshaw, trauma
|How to cite this article:|
Meena S, Barwar N, Rastogi D, Sharma V. Injuries associated with cycle rickshaws accidents. J Emerg Trauma Shock 2014;7:73-6
| Introduction|| |
India is passing through a major epidemiological transition and technological revolution during the past two decades. This has lead to a rapid growth in motorization and concomitant increase in road traffic injury (RTI) related mortality. , In actual numbers, over 105,700 people died and 452,900 were injured due to RTI in India in 2006 alone. 
Vulnerable road users (VRUs) are traditionally defined as slow-moving exposed/unprotected road users that are at higher risk of injury when involved in a crash.  Pedestrians, rickshaw users, rickshaw pullers, two wheeled vehicle users and cyclists are the most vulnerable road user groups in terms of injuries and fatalities resulting from road traffic accidents. ,,, These groups are contributing an increasing proportion of RTI in the developing countries. , Motorcycle accidents and pedestrian deaths remains one of the leading causes of fatality in third world countries. , Multiple studies from various countries have shown the vulnerability of motorcycle users and pedestrians to road traffic accidents ,,,,, Motorcycle riders are ten times more exposed to injury in comparison with those who use four-wheel vehicles.  Among those who are injured in a motorcycle crash, injury to head and leg is much more prevalent and the reasons are the small size of the vehicle and the pressure of the whole kinetic energy and the crash resulted pressure solely on the riders. ,
The cycle rickshaw is a popular means of transportation for short distances in India.  [Figure 1] It is estimated that close to 2 million cycle rickshaws ply on Indian roads carrying about 6-8 billion passenger km/years.  The exact number could be even greater, since there are no reliable records available. The characteristics of crashes and nature of injuries sustained in crashes involving cycle rickshaw is not well understood. Few hospitals in India cater to a population that allows cycle rickshaw related injury to be studied. In this study, we report data from a prospective study in King George Medical College trauma center in Lucknow city in North India.
| Patients and Methods|| |
A hospital based prospective study was done at King George Medical College trauma center in Lucknow city in North India. This is the biggest trauma center in the state of Uttar Pradesh. During the study period from Aug 2008 to July 2009, all the patients who presented to the emergency department with accidents involving the cycle rickshaw were identified and included in the study. Only patients who were either rickshaw puller or occupant of the rickshaw were included. In cases of collision of rickshaw with another vehicle, the occupants of other vehicle/automobile were not included. Detailed data on the demographics of those injured, characteristics of the crash, Glasgow coma score (GCS) on arrival at hospital, details of injuries sustained were documented.
Injuries were classified according to broad international classification of disease (ICD-10) classifications. Superficial injuries of the head and neck, and thorax and abdomen were combined, with the same process for open wounds, fractures, and other unspecified injuries sustained for ease of analysis and presentation. The patients were also questioned about the exact mode of trauma, contributing factors etc.
Data were entered into an MS access database. Analysis were conducted using the SPSS software package, version 16 (SPSS Inc., Chicago, IL, USA), and statistical significance was set at P = 0.05.
All the patients gave the informed consent prior being included into the study. The study was authorized by the Institutional ethical committee and was performed in accordance with the ethical standards of the 1964 declaration of Helsinki as revised in 2000.
| Results|| |
The patients were from all age groups with a majority in the 21-30 years age group [Table 1]. There were 84 patients, 60 (71.4%) males and 24 (28.5%) females. Mean age was 32.1 ± 10.3. Seventeen patients (20.2%) were rickshaw pullers and the rest were occupants of the rickshaw. Most common cause of injury was collision with a moving vehicle (56 patients, %) followed by fall from rickshaw, and other mechanisms [Table 2]. The injury pattern is given in [Table 3]. Ten patients had head injury, out of which 6 were admitted to ICU.
On arrival to the hospital, the mean ISS was 3.5 ± 2.2 and the median (range) GCS was 13.4 ± 4.3. 9 patients were admitted to ICU. The mean ICU stay was 4 ± 3.2 (1-24 days). Six of the ICU admitted patients had head injury.
The median of total hospital stay was 3 days (range 1-65) days. Out of 10 patients of head injury, 3 patients died, 2 in intensive care unit (ICU) and one in emergency department. Most accidents happened around 8 am in the afternoon and 5 pm, when rickshaws are frequently used by office goers.
The most common contributing factor was the overloading of rickshaw. Overloading with more than two passengers was found in 24 cases (28.5%).
| Discussion|| |
In this study, the peak age period was 21-30 years. This is the active age group was involved in the use of rickshaw for going colleges and offices. The road traffic accidents involving rickshaw are more likely to involve young adults and children <10 years. Since India has a majority of young population, so this may be the reason that majority of our patients were young. In India services of rickshaw are frequently taken by parents to ferry their children's to school. These rickshaws are generally overcrowded and overloaded with these schools going children. Subsequently they are more prone to accidents. Sex was heavily skewed towards males, as they are more mobile compared to women.
Cycle rickshaws are major means of transport in India. In the narrow lanes of towns and cities, probably they are the only transport system to provide point to point travel. In spite of being so common, there is little research on the characteristics and injury patterns in road traffic accidents involving cycle rickshaw.
Single vehicle crashes were dominated by overturning of rickshaw. The most common reasons for overturning were found to be overloading of rickshaw. Another significant cause was the poor road condition (Road bumps, excessive height of speed breaker and holes in roads). Poor vehicle design and poor road condition has already proven to be responsible for the majority of road accidents.  In developing countries, where economic realities force the population to make use of older and less reliable vehicles, the risk of accidents caused by some sort of mechanical failure increases.  This calls for improved design of vehicles and condition of roads. The accidents due to overloading may be prevented by strict enforcement of laws by the police. Our findings support the need for stricter enforcement of traffic laws amongst cycle rickshaw drivers, especially because they have been documented to be amongst the frequent traffic violators in India. Awareness among the general public and rickshaw pullers to avoid overloading is equally important. 
The collision partners in multi vehicle collisions tend to be light motor vehicle, buses or trucks. This pattern is well known for vulnerable road users. Most frequent automobile involved in collision were buses/heavy vehicle. Rickshaw accidents involved in collision with such automobiles were more likely to be reported as the patients involved in them sustained major injuries.
Crashes involving multiple vehicles were found to be associated with more severe injury as compared to the single vehicle injury. Mortality rates and the frequency of ICU admission was also more in the multiple vehicle crashes.
It is evident from this study that the majority of accidents took place in the evening and morning, as this is the time of children and adults to go to school and offices respectively. This is also the time of rush hour when there are maximum numbers of vehicles plying on the roads.
Jaiswal et al., in their study concluded that bicycle and cycle rickshaw injuries have a unique pattern of injury particularly affecting the individuals riding them in an unconventional way.  Majority of patients in their study sustained extensive soft tissue injury. However in our study, most of the limb injuries were located in the upper limb. The study population in the study by Jaiswal et al., predominantly comprised of young children. However in our study, majority of the patients were young adults. The upper limb injuries in our study population resulted from an attempt to prevent the fall from rickshaw.
As compared to other studies on motorized rickshaw our study shows fewer incidences of head and abdominal injury. This may be because the cycle rickshaw are manually driven and hence plies on road with a slow speed when compared to motorized rickshaw.  Due to this majority of the injuries are low energy injuries. One patient in our series had a cervical spine injury due to entangling of her dupatta (scarf) in the rear wheel of the rickshaw. Dupatta (scarf) is a part of the traditional dress for females in the Indian subcontinent. The dupatta hanging by the side of rickshaw can get entangled in the moving vehicle and cause cervical spine injury. Although special guards are available for motorcycles, their use is an exception rather than the rule. No such guards are available for the cycle rickshaw; therefore chances of injury in cycle rickshaw are greater. However, as the speed of cycle rickshaw is slow, it results in a less severe injury. 
In our study, the main cause of death and moderate disability were head injuries. Other common injuries included the musculoskeletal injuries, chest and abdominal injuries. Helmet may have reduced the incidence of brain injury, but unfortunately none of the rickshaw driver was wearing any helmet for protection. There is plethora of evidences in the literature that helmet reduces the risk of loss of consciousness and head injury. , Policy changes and educational programs that increase the use of helmets may prevent deaths. 
Both the rickshaw pullers and the passengers were nearly equally involved in the motorcycle injuries. This shows that the passengers as well as the puller share equal risk of getting injured. Any measure for prevention should target both the passengers and the rickshaw pullers.
Rickshaw occupants have an increased risk of being thrown off from the vehicle due to sudden application of brake or crash. This throwing off may lead to direct impact of head which may lead to head injury. Attempts may sometimes be made by the occupants to prevent the fall with his outstretched hand, which may lead to upper limb fractures. A major modification in the current rickshaw design is to have a bar between the driver seat and passenger seat. The passenger can get hold of this bar and may prevent their fall during crashes or sudden application of brake by holding this bar. Future research must include systematic vehicle-based investigations alongside in depth analysis at the crash scene to determine the potential to reduce the crash and injury risk by appropriate measures.
This study can serve as a reference for further research, to help identify research priorities, and assist in traffic planning and vehicle safety legislation for cycle rickshaw.
| Conclusion|| |
Rickshaw pullers and occupants are vulnerable to road traffic accidents. Urgent preventive measures targeted towards this group are needed to reduce the morbidity and mortality resulting from injuries involving rickshaws. These data on crashes and injuries sustained in crashes involving rickshaws can assist with planning to deal with the consequences as well as prevention of RTIs given the high use of rickshaws and substantial morbidity of related injuries in India. Improved understanding of the risk characteristics of cycle rickshaws is needed to develop safer cycle rickshaws.
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Dr. Sanjay Meena
Department of Orthopedics, All India Institute of Medical Sciences, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3]