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    Anatomy of an “accident”

    I was reading the causes of mortality and morbidity in children and noticed that beyond age 2 years, many of the most likely serious harms to children, especially death, are considered “accidents.” We hear of accidental drownings, being thrown from a car, playing with a lighter that starts a fire, or an accidental shooting. I began wondering about all those situations that we so readily call “accidents.”

    First, what is the definition of an “accident”?: an unfortunate event that is unexpected, happens by chance, without deliberate cause. The definition applies sometimes, but too often, it does not.

    In pediatric practice, is a child drowning, flying out of a car during a crash, playing with a lighter, or a firing a gun an “accident”? We may be calling an event an “accident” when these tragic events are not happening purely “by chance.” The circumstances might not be deliberate, but are more predictable.

    Many drownings happen when a toddler or young child falls into the family pool. An accident? If older, could the child have been taught to swim? Was the family pool up to code in terms of safety standards—ie, were the fence, the gate, locked? Why was the broken lock not repaired? Was the child thrown from the car during a crash in a child-protective seat or appropriately buckled? Why was a lighter available? Do the parents smoke and therefore have repeatedly demonstrated its use? Why was there a gun in the home? Why wasn’t it locked away? Why was it loaded rather than having the bullets in a separate, secure space?

    Why accidents happen

    The parents of these children certainly did not want any of these events to take place. They will experience their loss, grief, and guilt every day for the rest of their life. So, why do many of these “accidents” happen?

    Next: Should teens be treated at adult or pediatric trauma centers?

    In my experience, families experiencing major stress are preoccupied, overwhelmed, and distracted from taking care of their children. Parents dealing with marital discord will have an argument. The 3-year-old leaves the area and the rage of both parents distracts them so that a child can end up in a pool or picking up a lighter. A parent can be overwhelmed by worries or be depressed and, during a short car ride, yields to the child’s wishes to be unbuckled in the rear seat. Maybe that parent or another prioritizes a text or an emotionally difficult phone call while driving, resulting in an often high-speed crash. Sometimes substance use—alcohol that disinhibits good judgment or opioids that put a parent to sleep—result in ignoring the layers of protection needed when there is a gun in the home.

    There are many burdens on primary care practice, and we sometimes do not connect family stress with serious morbidity and death. Maybe by calling drownings, fires, car crashes, and children accessing guns all “accidents,” we are lowering our sense of responsibility, burden, or expectation.

    We should do what we can. Ask about marital discord, domestic violence, parental substance use, driving safety. Provide materials in the waiting room or through e-mail, alerting parents to the risks of pools, lighters, cars, and guns. Be available to encourage prevention of accidents. It is hard to prove success in preventing an accident, but the opportunity is gratifying.

    Michael S Jellinek, MD
    Dr. Jellinek is Professor of Psychiatry and of Pediatrics, Harvard Medical School, Boston, and Chief Executive Officer, Community ...


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