Outcomes one year after a road accident: Results from the ESPARR cohort

Objective

Reducing the rates of death, trauma and sequelae associated with road accidents is the prime goal of road safety authorities, and success requires having data on victims’ outcomes in the long term. The present study examined the outcome of adult road accident victims one year after their accident.

Design

A follow-up study.

Methods

The cohort comprised 886 injured road-accident victims, aged ≥16 years, and living in the Rhône administrative Département, France (taken from the ESPARR Cohort). Data were collected on victim characteristics at the time of crash, and self-reported outcomes one year later. The population of respondents at the one-year questionnaire follow-up was divided into two categories according to injury severity, as mild-to-moderate (M.AIS < 3) or severe (M.AIS 3+). Qualitative variables were compared between these 2 groups using Chi² or Fisher exact tests.

Results

At one year post-accident, 45% of the mild-to-moderate injury group versus only 20% of severely injured subjects reported full recovery of health (p < 0.001). 20% of the cohort, as a whole, reported permanent pain. More than half of the severely injured subjects reported that the accident had had an impact on the everyday life of their family; this was twice as many as in the mild-to-moderate injury group (55% vs. 22%). Most of the severely injured reported impact on leisure, projects and emotional life: 20% reported relational difficulties in the couple, 16% reported impaired sexual life, and the rate of separation was significantly higher than in the mild-to-moderate injury group (5% vs. 1%; p < 0.001). Mean time off work was significantly longer in the severe injury group: 245 ± 158 days vs. 75 ± 104 days (p < 0.001); and 32% of the severe injury group (p < 0.001) who had stopped work had not returned at 1 year, compared to 5% of the mild-to-moderate injury group.

Conclusions

One year after a road accident, the consequences for victims remain significant. In terms of physical impact, pain frequently persists, impairing daily life for many. There is an elevated rate of chronic PTSD (post-traumatic stress disorder) and a non-negligible impact on affective and occupational life.     

Risk factors for injury accidents among moped and motorcycle riders

Objective

To study and quantify the effect of factors related to the riders of powered two-wheelers on the risk of injury accident involvement.

Methodology

Based on national data held by the police from 1996 to 2005, we conducted a case–control study with responsibility for the accident as the event of interest. We estimated the odds ratios for accident responsibility. Making the hypothesis that the non-responsible riders in the study are representative of all the riders on the road, we thus identified risk factors for being responsible for injury accidents. The studied factors are age, gender, helmet wearing, alcohol consumption, validity of the subject's driving licence and for how long it has been held, the trip purpose and the presence of a passenger on the vehicle. Moped and motorcycle riders are analyzed separately, adjusting for the main characteristics of the accident.

Results

For both moped and motorcycle riders, being male, not wearing a helmet, exceeding the legal limit for alcohol and travelling for leisure purposes increased the risk of accident involvement. The youngest and oldest users had a greater risk of accident involvement. The largest risk factor was alcohol, and we identified a dose–effect relationship between alcohol consumption and accident risk, with an estimated odds ratio of over 10 for motorcycle and moped riders with a BAC of 2 g/l or over. Among motorcycle users, riders without a licence had twice the risk of being involved in an accident than those holding a valid licence. However, the number of years the rider had held a licence reduced the risk of accident involvement. One difference between moped and motorcycle riders involved the presence of a passenger on the vehicle: while carrying a passenger increased the risk of being responsible for the accident among moped riders, it protected against this risk among motorcycle riders.

Conclusion

This analysis of responsibility has identified the major factors contributing to excess risk of injury accidents, some of which could be targeted by prevention programmes.     

Road crash fatality rates in France: A comparison of road user types,taking account of travel practices

Background

Travel practices are changing: bicycle and motorized two-wheeler (MTW) use are rising in some of France’s large cities. These are cheaper modes of transport and therefore attractive at a time of economic crisis, but they also allow their users to avoid traffic congestion. At the same time, active transport modes such as walking and cycling are encouraged because they are beneficial to health and reduce pollution. It is therefore important to find out more about the road crash risks of the different modes of transport. To do this, we need to take account of the number of individuals who use each, and, even better, their travel levels.

Method

We estimated the exposure-based fatality rates for road traffic crashes in France, on the basis of the ratio between the number of fatalities and exposure to road accident risk. Fatality data were obtained from the French national police database of road traffic casualties in the period 2007–2008. Exposure data was estimated from the latest national household travel survey (ENTD) which was conducted from April 2007 to April 2008. Three quantities of travel were computed for each mode of transport: (1) the number of trips, (2) the distance traveled and (3) the time spent traveling. Annual fatality rates were assessed by road user type, age and sex.

Results

The overall annual fatality rates were 6.3 per 100 million trips, 5.8 per billion kilometers traveled and 0.20 per million hours spent traveling. The fatality rates differed according to road user type, age and sex. The risk of being killed was 20 to 32 times higher for motorized two-wheeler users than for car occupants. For cyclists, the risk of being killed, both on the basis of time spent traveling and the number of trips was about 1.5 times higher than for car occupants. Risk for pedestrians compared to car occupants was similar according to time spent traveling, lower according to the number of trips and higher according to the distance traveled. People from the 17–20 and 21–29 age groups and those aged 70 and over had the highest rates. Males had higher rates than females, by a factor of between 2 and 3.

Conclusion

When exposure is taken into account, the risks for motorized two-wheeler users are extremely high compared to other types of road user. This disparity can be explained by the combination of speed and a lack of protection (except for helmets). The differential is so great that prevention measures could probably not eliminate it. The question that arises is as follows: with regard to public health, should not the use of MTW, or at least of motorcycles, be deterred? The difference between the fatality risk of cyclists and of car occupants is much smaller (1.5 times higher); besides, there is much room for improvements in cyclist safety, for instance by increasing the use of helmets and conspicuity equipment. Traffic calming could also benefit cyclists, pedestrians and perhaps moped users.     

Early morning awakening and nonrestorative sleep are associated with increased minor non-fatal accidents during work and leisure time

Background

The relationship between a composite measure of insomnia and occupational or fatal accidents has been investigated previously; however, little is known regarding the effect of various insomnia symptoms on minor non-fatal accidents during work and leisure time.

Objective

We investigated the predicting role of insomnia symptoms on minor non-fatal accidents during work and leisure time.

Methods

Data from the 2005 Taiwan Social Development Trend Survey of 36,473 Taiwanese aged ≥18 years were analyzed in 2013. Insomnia symptoms, including difficulty in initiating sleep (DIS), difficulty in maintaining sleep (DMS), early morning awakening (EMA), and nonrestorative sleep (NRS) were investigated. A minor non-fatal accident was defined as any mishap such as forgetting to turn off the gas or faucets, accidental falls, and abrasions or cuts occurring during work and leisure time in the past month that do not require immediate medical attention. Multivariable logistic regression was performed to assess the odds ratios (ORs) and associated 95% confidence interval (CI) of minor non-fatal accidents (as a binary variable) for each insomnia symptom compared with those of people presenting no symptoms, while controlling for possible confounders.

Results

EMA and NRS increased the odds of minor non-fatal accidents occurring during work and leisure time (adjusted OR = 1.19, 95% CI = 1.08–1.32 and adjusted OR = 1.27, 95% CI = 1.17–1.37, respectively).

Conclusion

EMA and NRS are two symptoms that are significantly associated with an increased likelihood of minor non-fatal accidents during work and leisure time after adjusting for of a range of covariates.     

Increased traffic accident rates associated with shale gas drilling in Pennsylvania

Objectives

We examined the association between shale gas drilling and motor vehicle accident rates in Pennsylvania.

Methods

Using publicly available data on all reported vehicle crashes in Pennsylvania, we compared accident rates in counties with and without shale gas drilling, in periods with and without intermittent drilling (using data from 2005 to 2012). Counties with drilling were matched to non-drilling counties with similar population and traffic in the pre-drilling period.

Results

Heavily drilled counties in the north experienced 15–23% higher vehicle crash rates in 2010–2012 and 61–65% higher heavy truck crash rates in 2011–2012 than control counties. We estimated 5–23% increases in crash rates when comparing months with drilling and months without, but did not find significant effects on fatalities and major injury crashes. Heavily drilled counties in the southwest showed 45–47% higher rates of fatal and major injury crashes in 2012 than control counties, but monthly comparisons of drilling activity showed no significant differences associated with drilling.

Conclusions

Vehicle accidents have measurably increased in conjunction with shale gas drilling.     

The influence of demographic factors,processing speed and short-term memory on Iranian children's pedestrian skills

Objectives

Young children, children from lower socioeconomic status and boys have the highest risk of pedestrian injury. This study examined the relationship between cognition and specific pedestrian skills of these groups of children in Iran.

Methods

180 Iranian children aged 7 and 11 years from lower- and higher-socioeconomic status backgrounds participated in the study. A task to identify safe and dangerous road crossing sites and to plan a safe route to cross a road was administered to measure pedestrian skills. Coding and Digit Span subscales of WISC-R were administered to assess processing speed and short-term memory.

Results

Identifying safe/dangerous road crossing-sites and safe route-construction abilities increased with age. Boys scored higher than girls when identifying road crossing sites but did not differ to girls in route-construction. Lower socioeconomic status children scored higher than higher socioeconomic status children on the route-construction task. Girls from lower socioeconomic status backgrounds scored lowest on the identifying safe/dangerous sites task and girls from higher socioeconomic status backgrounds scored lowest on the route construction task. Speed of processing was a significant predictor for identifying crossing sites and socioeconomic status was a significant predictor for route-construction.

Conclusions

Pedestrian skills are complex and influenced by age, gender, socioeconomic status and cognitive development. Results are discussed in relation to child pedestrian safety research in Iran and road safety education for children.     

Powered two-wheeler drivers’ crash risk associated with the use of bus lanes

Context

Authorizing powered two-wheeler drivers to drive in lanes reserved to buses is a measure that is sometimes mentioned to improve mobility conditions for these users. But what effect would this measure have on the safety of these users and on the safety of the other users with whom they share the traffic space?

Objective

The objective of this study is to contribute elements to help answer this question. More precisely, the objective is to estimate the risk of having an accident per kilometer driven by powered two-wheeler drivers who drive in bus lanes and to compare this risk with that of powered two-wheeler drivers who drive in general traffic lanes.

Method

Using the bodily injury accidents recorded by the police over two years on 13 roads in the city of Marseille and a campaign of periodical observations of powered two-wheeler traffic, we estimated the risk per kilometer driven by powered two-wheeler drivers who drive in bus lanes and compared it with that of drivers who do not drive in them.

Results

The results show that the risk for powered two-wheeler drivers who drive in bus lanes of being involved in a bodily injury accident is significantly higher than the risk run by drivers who drive in general traffic lanes. For the 13 roads studied, it is on average 3.25 times higher (95% CI: 2.03; 5.21).

Conclusion

In the current situation, powered two-wheeler drivers who drive in bus lanes are less safe than those who drive in general traffic lanes. The analysis of police reports suggests that part of this increased risk comes from collisions between automobile drivers turning right and powered two-wheelers driving in the bus lane who continue straight ahead.     

Accident rates amongst regular bicycle riders in Tasmania,Australia

Purpose

To characterise the demographics, cycling habits and accident rates of adult cyclists in Tasmania.

Methods

Volunteers ≥18 years of age who had cycled at least once/week over the previous month provided information on demographics; cycling experience; bicycles owned; hours/km/trips cycled per week; cycling purpose; protective equipment used; and major (required third-party medical treatment or resulted ≥1 day off work) or minor (interfered with individuals’ regular daily activities and/or caused financial costs) accidents while cycling.

Results

Over 8-months, 136 cyclists (70.6% male) completed the telephone survey. Mean (standard deviation) age was 45.4 (12.1) years with 17.1 (11.4) years of cycling experience. In the week prior to interview, cyclists averaged 6.6 trips/week (totalling 105.7 km or 5.0 h). The most common reason for cycling was commuting/transport (34% of trips), followed by training/health/fitness (28%). The incidence of major and minor cycling accidents was 1.6 (95% CI 1.1–2.0) and 3.7 (2.3–5.0) per 100,000 km, respectively. Male sex was associated with a significantly lower minor accident risk (incidence rate ratio = 0.34, p = 0.01). Mountain biking was associated with a significantly higher risk of minor accident compared with road or racing, touring, and city or commuting biking (p < 0.05).

Conclusions

Physical activity of regular cyclists’ exceeds the level recommended for maintenance of health and wellbeing; cyclists also contributed substantially to the local economy. Accident rates are higher in this sample than previously reported in Tasmania and internationally. Mountain biking was associated with higher risks of both major and minor accidents compared to road/racing bike riding.     

Motorcycle-related injuries in the United Arab Emirates

Objectives

To study the anatomical distribution, severity, outcome, and age by nationality of hospitalized motorcycle-related injured patients in Al-Ain, United Arab Emirates so as to improve preventive measures.

Methods

All motorcycle riders involved in a road traffic collision and admitted to Al-Ain Hospital for more than 24 h or who died in hospital after arrival were studied. Patient data were retrieved from Al-Ain Hospital Trauma Registry. Data had been prospectively collected during four and half years (March 2003–October 2007). Demography of patients, Glasgow Coma Scale (GCS), Injury Severity Score (ISS), Hospital stay, mortality, nationality, time, day of week, and month of occurrence were analyzed.

Results

There were 95 patients (93 males). Mean (SD) age was 29.8 (11.5) years. 35% were United Arab Emirates (UAE) nationals. Upper limbs were most frequently involved (54%) followed by lower limbs (48%), head (41%), and face (30%). On arrival at hospital, median (range) ISS was 4.5 (1–36) and median (range) GCS was 15 (3–15). Mean (range) hospital stay was 8.8 (1–79) days. 14 patients (15%) were admitted to the Intensive Care Unit. In-hospital mortality was 6%. UAE national victims were significantly younger and had more abdominal injuries than expatriates, who had lower limb injuries.

Conclusions

The most common mechanism of motorcycle crashes was hitting a moving vehicle. Young UAE national motorcyclists are at a higher risk of being injured compared with non UAE nationals. This may be due to risk-taking behavior of young motorcyclists who are mainly riding for leisure. Extremities were the most common injured body region. Severe head injury was the main cause of death. This signifies the need for effective application of motorcycle helmet law in the UAE along with other preventive measures that might include increasing the licensing age.     

Alcohol consumption as an incremental factor in health care costs for traffic accident victims: Evidence in a medium sized Colombian city

Objectives

Identify the possibility that alcohol consumption represents an incremental factor in healthcare costs of patients involved in traffic accidents.

Methods

Data of people admitted into three major health institutions from an intermediate city in Colombia was collected. Socio-demographic characteristics, health care costs and alcohol consumption levels by breath alcohol concentration (BrAC) methodology were identified. Generalized linear models were applied to investigate whether alcohol consumption acts as an incremental factor for healthcare costs.

Results

The average cost of healthcare was 878 USD. In general, there are differences between health care costs for patients with positive blood alcohol level compared with those who had negative levels. Univariate analysis shows that the average cost of care can be 2.26 times higher (95% CI: 1.20–4.23), and after controlling for patient characteristics, alcohol consumption represents an incremental factor of almost 1.66 times (95% CI: 1.05–2.62).

Conclusions

Alcohol is identified as a possible factor associated with the increased use of direct health care resources. The estimates show the need to implement and enhance prevention programs against alcohol consumption among citizens, in order to mitigate the impact that traffic accidents have on their health status. The law enforcement to help reduce driving under the influence of alcoholic beverages could help to diminish the economic and social impacts of this problem.     

Some implications of an event-based definition of exposure to the risk of road accident

This paper proposes a new definition of exposure to the risk of road accident as any event, limited in space and time, representing a potential for an accident to occur by bringing road users close to each other in time or space of by requiring a road user to take action to avoid leaving the roadway. A typology of events representing a potential for an accident is proposed. Each event can be interpreted as a trial as defined in probability theory. Risk is the proportion of events that result in an accident. Defining exposure as events demanding the attention of road users implies that road users will learn from repeated exposure to these events, which in turn implies that there will normally be a negative relationship between exposure and risk. Four hypotheses regarding the relationship between exposure and risk are proposed. Preliminary tests support these hypotheses. Advantages and disadvantages of defining exposure as specific events are discussed. It is argued that developments in vehicle technology are likely to make events both observable and countable, thus ensuring that exposure is an operational concept.     

Predictive factors of chronic post-traumatic stress disorder 6 months after a road traffic accident

Background

This study sets out to identify risk factors for post-traumatic stress disorder (PTSD) after a road traffic accident with a view to improving prevention.

Methods

The study used a prospective cohort of road traffic accident casualties. All subjects over 15 years of age were recruited in the course of an interview conducted while they were receiving care in a hospital of the Rhône area administrative département. Six months after their accident, they answered a self-administered postal questionnaire that included the Post-traumatic Check-List Scale (PCLS) in order to evaluate PTSD. Multivariate logistic regression analysis was conducted to compare those subjects with a PCLS score of 44 or over with those with a lower score, in order to identify factors that might be associated with PTSD.

Results

592 subjects (out of 1168) returned the 6-month questionnaire and 541 completed the PCLS test. One hundred subjects had a PCLS score ≥44, suggesting PTSD, and 441 subjects did not. The factors associated with PTSD were initial injury severity, post-traumatic amnesia, the feeling of not being responsible for their accident and persistent pain 6 months after it. A lower odds-ratio was associated with users of two-wheel than four-wheel motor vehicles (OR = 0.4; 0.2–0.9).

Conclusion

Besides predictive factors for PTSD (injury severity, post-traumatic amnesia and the feeling of not being responsible for their accident), our study suggested a reduced risk of PTSD among two-wheel motor vehicle users.     

Burden of road traffic injuries: Disability-adjusted life years in relation to hospitalization and the maximum abbreviated injury scale

Background

The consequences of non-fatal road traffic injuries (RTI) are increasingly adopted by policy makers as an indicator of traffic safety. However, it is not agreed upon which level of severity should be used as cut-off point for assessing road safety performance. Internationally, within road safety, injury severity is assessed by means of the maximum abbreviated injury scale (MAIS). The choice for a severity cut-off point highly influences the measured disease burden of RTI. This paper assesses the burden of RTI in terms of disability adjusted life years (DALYs) by hospitalization status and MAIS cut-off point in the Netherlands.

Methods

Hospital discharge register (HDR) and emergency department (ED) data for RTI in the Netherlands were selected for the years 2007–2009, as well as mortality data. The incidence, years lived with disability (YLD), years of life lost (YLL) owing to premature death, and DALYs were calculated. YLD for admitted patients was subdivided by MAIS severity levels.

Results

RTI resulted in 48,500 YLD and 27,900 YLL respectively, amounting to 76,400 DALYs per year in the Netherlands. The largest proportion of DALYs is related to fatalities (37%), followed by admitted MAIS 2 injuries (25%), ED treated injuries (16%) and admitted MAIS 3+ injuries (18%). Admitted MAIS 1 injuries only account for a small fraction of DALYs (4%). In the Netherlands, the diseases burden of RTI is highest among cyclists with 39% of total DALYs. One half of all bicycle related DALYs are attributable to admitted MAIS 2+ injuries, but ED treated injuries also account for a large proportion of DALYs in this group (28%). Car occupants are responsible for 26% of all DALYs, primarily caused by fatalities (66%), followed by admitted MAIS 2+ injuries (25%). ED treated injuries only account for 5% of DALYs in this group.

Conclusions

When using admitted MAIS 3+ or admitted MAIS 2+ as severity cut-off point, 54% and 80% of all DALYs are captured respectively. Assessing the influence of different severity cut-off points by MAIS on the proportion and number of DALYs captured gives valuable information for guiding choices on the definition of serious RTI.     

Substance use and social,health and safety-related factors among fatally injured drivers

Objective

The aim of this study was to examine different socio-demographic, health and safety-related factors, and psychoactive substance use among fatally injured drivers in road traffic accidents in Finland during 2006–2008.

Methods

An accident information register maintained by the Traffic Safety Committee of Insurance Companies (VALT) of the Finnish Motor Insurers’ Centre was used as basic data, and the basic data were complemented with further toxicological analytical information retrieved from autopsy reports from the Department of Forensic Medicine, Helsinki University. The data included all the drivers (n = 556) who were driving a motor vehicle and who died in a road traffic accident in Finland during 2006–2008.

Results

Of all the 556 fatally injured drivers 43% (n = 238) had psychoactive substance findings. 51% (n = 121) of substance positive drivers had a finding for alcohol only, the rest had a finding for one or more illicit/medicinal drugs impairing driving ability, and possibly also alcohol. Fatally injured drivers with alcohol findings were significantly younger (mean age 34 years) than sober drivers (mean age 44 years) or drivers with findings for drugs (mean age 45 years). Socio-demographic background did not differ substantially among drunken/drugged and sober drivers, although drivers with alcohol findings had a slightly lower education and socioeconomic position. Previous substance abuse problems were highly prevalent among drivers with substance findings and mental or both mental and physical health problems were more common among drivers with drug findings. The non-use of safety equipment and driving at a high speed were more common among fatally injured drivers with substance findings.

Conclusions

Substance abuse and mental health problems, as well as reckless driving behavior were more pronounced among fatally injured drivers with substance findings when compared to sober drivers. Thus, prevention and early intervention concerning substance abuse, mental health problems and DUI are essential. Improved traffic safety cannot be achieved by means of traffic policy only, but integration with other policies, such as health and social policy should be strengthened.     

Injury incidence rates of cyclists compared to pedestrians,car occupants and powered two-wheeler riders,using a medical registry and mobility data,Rhône County,France

Purpose

In France, the bicycle's modal share is stabilizing after a decline; in some of France's major cities, it has even increased since the 1990s. It is hence relevant to improve the knowledge of the injury risk associated with cycling, compared with other means of transport such as car, walking and powered two-wheeler (PTW) riding.

Methods

The injury incidence rates were estimated by the ratio between accident data and mobility (exposure) data. Two accident data sources were used: police data and hospital-based data (outpatients and inpatients) from the Rhône road trauma Registry. This provides four injury categories: all-injury, hospitalization, serious-injury and fatal-injury. Exposure data were estimated from a regional household travel survey (RTS), using three measures of mobility: number of trips, distance traveled and time spent traveling. The survey was carried out from November 2005 to April 2006, on weekdays, outside school and public holidays; this seasonality was corrected using the 2007–2008 national household travel survey (NTS) that covered an entire year. Only information involving accidents and trips in, and residents of, the Rhône County (1.6 million inhabitants, including the city Lyon) were included in our study. Trends of injury rates were also evaluated in Greater Lyon, using previous travel surveys.

Results

The PTW riders had the highest all-injury, hospitalization, serious-injury and fatal-injury rates, followed by cyclists, and lastly by pedestrians and car occupants. The rates between men and women seemed similar among pedestrians and among car occupants. For car occupants, pedestrians and cyclists, the age group 18–25 years had higher all-injury rate compared with the age group 25–65 years. On the contrary, the age group ≥65 years seemed to have higher hospitalization and serious-injury rates, compared with the age group 25–65 years. For cyclists, the injury rates seemed higher in non-dense areas than in dense areas. Between 1996–1997 and 2005–2006 and with regards to time spent traveling, the all-injury, serious-injury and fatal-injury rates seemed to have decreased for car occupants and cyclists.

Conclusion

The higher risk for PTW riders is confirmed and quantified; it is very high. Decrease in injury rates seems more marked for cyclists; this may indicate the “safety in numbers” effect. Countermeasures for improving road safety could be implemented, especially for vulnerable road user types. However, they will not be sufficient to fill in the gap between the much higher risk for PTW riders and that of car occupants. Exposure-based injury rates can be a tool for monitoring and evaluating the effectiveness of policies and programs, and for comparisons between countries.     

The real number of road traffic accident casualties in The Netherlands: a year-long survey

Between August 1986 and July 1987 more than 24,000 households, containing nearly 67,000 persons, were surveyed by telephone about traffic injuries during the past three months. Expressed on an annual basis, approximately 430,000 people, or about 1 in 34 of the Dutch population, had suffered some sort of injury in a road accident. The road traffic morbidity was, therefore, 2,942 per 100,000 inhabitants. Of these, about 135,000 had to be treated in hospital (20,000 as inpatients). More than 100,000 did not need treatment. Cyclists formed by far the largest category of road user, but mopedists had the highest injury rate per kilometer travelled. 210,000 of these casualties fell within the definition for recording by the police. The police recorded only 49,748 traffic casualties, or about 25%, during the same period. The police data were not representative; the completeness declined according to severity of the injuries: inpatients, about 70%; outpatients 26%; extramural about 11%. Cyclists (11%), children (9%), and single vehicle accidents (5%) were very much underrepresented. The largest category of road user is cyclists, not car occupants as indicated by the police data. A number of recommendations are made for supplementing the police data and the existing hospital inpatient data. These include extending the Home Accident Recording System of outpatients and the General Practitioner Panel to include road accident victims. Together a representative sample of 95% of all those receiving medical treatment would thus be obtained.