Surgeons sick of dealing with the drink and the damage done Another Friday night: This young man refused treatment from doctors after attending the emergency department at St Vincent's Hospital. Every year an estimated 70,000 Australians are injured in alcohol-fuelled assaults. The Foundation for Alcohol Research and Education estimates the cost of those injuries, including through lost productivity, at $36 billion. In Victoria, in the past decade there has been a 37 per cent increase in the number of patients coming into emergency departments with an alcohol-related injury. Another victim: The emergency department team at St Vincent's works on a young man who was attacked during his night out. The NSW figures are not as clear. A trauma surgeon at Liverpool Hospital, John Crozier, says that information is not automatically recorded when patients are brought into emergency departments across the state. Regardless, Crozier says, the number of alcohol-related injuries are on the rise throughout the country. Particularly concerning, he says, is that 20,000 alcohol-related domestic violence cases every year involve children. In response to what it sees as governments' reluctance to act against the powerful alcohol and hoteliers' lobbies, The Royal Australasian College of Surgeons is campaigning against what it calls an epidemic of avoidable tragedies. Here four surgeons provide a snapshot of how alcohol trauma is playing out in operating theatres around the country. Dr Mahiban Thomas. DR MAHIBAN THOMAS Maxillofacial and oral surgeon, Royal Darwin Hospital. Thomas's introduction to working in Darwin eight years ago left him "a bit shaken up." "I had 50 cases of people with injured and broken faces in 30 days," he says. Associate professor Graham Gumley. Since then, I've been carefully recording all patients who come in with facial trauma. In 85 per cent of cases, that trauma involves alcohol. The Northern Territory has the highest incidence of facial trauma in the world, Thomas (right) says, with some patients coming back with similar injuries just months later. In the past week, Thomas has mended 12 broken faces. Ten of those cases involved alcohol - drunk people punching others, or falling and hurting themselves. In the past year, he has has operated on 285 broken jaws. Sixty per-cent of those injured were indigenous females - victims of drunken, domestic violence. The Northern Territory may be a unique situation, with alcohol related deaths three times the national average. But Thomas says the increasing amount of broken faces involving alcohol is an Australia-wide issue. Professor Jeffrey Rosenfeld. Photo: John Woudstra "I am setting up a worldwide epidemiological study into this issue, and everybody who is anyone in the field of facial trauma agrees - growing facial trauma due to alcohol is happening everywhere," he says. Thomas says the high alcohol content of many Australian wines, and their often cheap pricing were two areas in dire need of reform, with intoxicated people harming themselves and others considerably. Two weeks ago, one of Thomas's patients was so drunk he had stabbed himself in the neck, leading to a lengthy operation to sew severed tendons back together. Dr John Crozier. "Alcohol related trauma is an ongoing battle, whether your a plastic surgeon or a paediatric surgeon," Thomas says. But as much as you hate binge drinking causing all this damage and that people do this to themselves again and again, you look after them. The patients I treat who are angry and irrational when they're drunk are some of the loveliest human beings without the influence of alcohol. If released from those harms, they can be wonderful members of our community," he says. ASSOCIATE PROFESSOR GRAHAM GUMLEY Hand surgeon, Macquarie University Hospital and Hand Unit, Sydney. Gumley (right) knows how complex mending the delicate bones, tendons, muscles, nerves and blood vessels that comprise the hand can be. Up to half of the injuries he sees involve alcohol, he says, which can also be some of the trickiest cases. "We see people who have become intoxicated and punched walls ... punched people," he says. So it's people with fractured hand bones or open injuries with major lacerations in the tendons and nerves of the hand and forearm. If people get drunk and get into fights, it is not only the person they hit that is injured, but the puncher themselves. I've seen teeth lodged into knuckles ... leading to infected joints and a cut tendon. A tooth in the knuckle can lead to impairment of the joint forever. He describes alcohol as being "a steady and common" association with hand trauma. But it is not necessarily frequent, heavy drinkers who come in with injuries. "Most of the people I see are just normal people in the community who have had too much to drink," he says. It's not always the case that it's a chronic alcoholic getting harmed - it's often the causal, social drinker. But it's a big burden socially and financially because treating a hand is time consuming, tying up operating room staff for a long time, often after hours. It diverts care away from illnesses and injuries that are not as preventable. Gumley emphasises that no matter how the injury was acquired, he wants the best outcome for all of his patients. Many were regretful when they realised the harm they had caused, he says. But it could be distressing to see so much preventable harm. "People may get drunk and then trip and fall while holding a glass, which will shatter," he says. The impact of landing on the shattered glass cuts nerves, tendons and blood vessels. This leads to often very deep, traumatic lacerations. Gumley says he did not want to be a wowser or "cocoon people in bubble-wrap." But we need a more sensible community approach to safe drinking limits and a community understanding of the risks to people, their families and their livelihood. PROFESSOR JEFFREY ROSENFELD Director of Neurosurgery, Alfred Health. Melbourne. When a drunk person strikes someone with a king-hit, landing that blow at a certain angle will twist the other person's head rapidly, causing them to fall to the ground. "They will lose consciousness or become dazed, lose their reflexes," Rosenfeld says. They may hit their head hard on the concrete and that can kill them. We have seen innocent bystanders trying to break up a fight between two drunken louts, and in trying to protect someone else from being belted, they get hit and they die. Even if people did survive such a blow, they could end up with permanent brain damage, Rosenfeld (above) says. While punch-ups didn't always always involve alcohol, he says alcohol-fuelled violence was an increasing problem. "The thing about people getting into punch-ups is that it doesn't just cause brain injury," he says. There are broken noses, cheekbone and eye injuries. But the most devastating is the punch that hits the head and causes the person to black-out and die. That's a devastating thing that could easily have been prevented. A neurosurgeon since 1984, Rosenfeld says he also deals with a lot of alcohol-related car accidents, including drunken pedestrians who wander across the road, oblivious to the vehicle about to hit them. "A large percentage of bad accidents involving cars involves alcohol and other drugs," he says. If only we could get people to stop drinking when they're supposed to be driving. Educating people - especially the young - about the dangers of excess drinking was not about turning people into teetotallers, Rosenfeld says, but encouraging safe drinking. "We need to ask people, what happens if things go wrong and you kill someone else?," Rosenfeld says. Which is so often the case. It's about saying, this is what happens if you do not look after yourself and the people around you. Given the work Rosenfeld does on a daily basis, it is perhaps no surprise that he is worried about the ill effects of alcohol and doesn't drink anything himself. He has performed surgery to remove too many blood-clots, relieve swelling and treat fractures, often the results of a drunken blow or fall. "I'm probably an old fogy," Rosenfeld says. But I don't mind if people have a drink. I just don't want them hurting themselves or others. DR JOHN CROZIER Vascular and trauma surgeon, Liverpool Hospital, Sydney. There are several cases in his career as a trauma surgeon that Crozier (above, right) will never forget, including two that occurred within the last five years. A boy, just 15, came into the emergency department at Liverpool Hospital after getting so drunk at a licensed premises that he jumped off the hotel's roof. Miraculously, he survived. "The other case was a young man, in his 20s, whose leg I had to amputate through the hip joint," Crozier said. He had been drinking in a hotel and then bought two slabs of beer, put them is his vehicle and drove. He crashed within 100 metres of the hotel and with such force he lost his leg. Trying to have that conversation with his mum ... it was very difficult. These are just two cases that indicate the risky behaviour that drunk young people in particular will engage in, Crozier says. He was seeing rises in levels of risky drinking in 15- to 17-year-old men. "And much more worrying than that is the rise we're seeing in 12- to-15 year old males as well," he says. This is in part due to the subtle, coercive way alcohol companies are making drinking alcohol seem like a normal part of life. We see Jack Daniel's-branded potato chips in food aisles, ice-creams with names like 'champagne' Magnums. What the industry is doing is coercively introducing to children that alcohol is a normal part of the tapestry of everything. Like many public health experts, doctors and awareness groups, Crozier is calling for alcohol to be taxed according to volume rather than beverage type, making drinks like cheap wine more expensive. He also wants liquor-licensing reforms to reduce the availability of alcohol late at night. "We are seeing people come through the hospital younger and younger, often involved in severe, alcohol-related interpersonal violence," he says. The volume of low price alcohol being sold, combined with an exploding number of licenses and increased hours of trade, means even the best epidemiological based efforts from surgeons won't come close to the impact alcohol reforms could have.