OVER THE PAST six months I've carried out an informal survey among patients who come to me for treatment after receiving a head injury in an auto accident. Among those over 35 very few were seeking care for their first accident. Many had had two or three accidents. On occasion, individuals have admitted to as many as half a dozen.
In addition, I discovered that often these same people have also been involved in other kinds of mishaps: falls, work-related injuries and accidents at home such as burns or scaldings.
Why is it, I asked myself, that the same people are repeatedly involved in accidents of one kind or another?
A goodly portion of the "accident prone" suffer, I believe, from what I've informally labelled neurobehavioral impairment or NBI, for short. Although people afflicted with NBI don't suffer from any diagnosable brain disease, their behavior suggests subtle neurologic impairments. Typically, they are described as "awkward," "gawky," "clumsy," "klutzy," "ungainly," "erratic" and "unpredictable" in their movements.
Perhaps the most famous example of The Klutz Syndrome was Gerald Ford when he was president. Ford's misadventures -- on the ski slopes, getting out of the presidential helicopter -- provided almost weekly material for satire on Saturday Night Live 10 years ago. Such people, and Ford is a good example, frequently fall, trip or are otherwise upended (personal injury lawyers garner a goodly portion of their income among those with NBI who with regularity "slip and fall" in a restaurant or in front of someone's house).
In most instances, people afflicted with NBI can't help it, didn't choose it, aren't even aware most of the time that anything is wrong with their coordination and responsiveness. At best, they admit on occasion to being "clumsy" or one of the other adjectives already mentioned.
The problem is that these people -- especially when they are behind the wheel of a car -- can do deadly harm to themselves and everyone around them. We must recognize this, and devise a test that can eliminate these klutzes from situations in which they threaten society.
At present no one can say for sure why some people are clumsier than others. Poor eye-hand coordination; a slower reaction time; an impaired ability to anticipate changes in the environment; inattention or day dreaming; a disturbance in "judgment" -- whatever the cause something always seems to go wrong with the victim of The Klutz Syndrome.
He or she acts too fast or not fast enough; steps on the accelerator when the intention is to put on the brake; slips the gear into reverse instead of forward; comes to a full stop when the sign merely indicates "yield". In all cases, the response is almst but not quite appropriate to the situation. And it's this gap between what the NBI sufferer intends and what he actually does that leaves a wake of dented fenders, sore necks and inflamed tempers.
What makes NBI worthy of notice is the havoc it can introduce into other people's lives. On the highways people afflicted with NBI are dangerous to themselves and others. Surely you've encountered on the road one or more persons with The Klutz Syndrome. Recall the last time your were driving behind a slow and erratically moving car. Finally, and to your relief, the driver signaled a turn to the left. But a moment later, he or she turned to the right. Depending on the speed or your reactions (and assuming you're not suffering from NBI as well), you may (or may not) have avoided a collision with a Klutz Syndrome sufferer.
Recognition of NBI has a patchy history in this country. Doctors have recognized for years that certain individuals have motor, perceptual and learning difficulties of a subtle nature. These individuals exhibit types of neurobehavioral impairment that fall short of a diagnosis of outright "brain damage." Because the phenomenon that I'm talking about isn't given official recognition (you can't read about thit in any medical textbook), efforts to understand NBI have operated along the lines of the proverbial blind man examining the elephant. He knows there's something there but isn't properly equipped to appreciate the full significance of what's at the end of his fingers.
The most vigorous efforts against a form of NBI are the current programs aimed at removing drunk drivers from the highway. Alcohol intoxication, you see, is an acute, reversible form of the syndrome: Stop drinking, wait a few hours, and your NBI goes away.
What makes such programs inadequate is their emphasis on alcohol and its detection (via breath tests) rather than the more sensible goal of determining NBI, whatever the cause. So far, tests are not readily available at roadside checkpoints aimed at other causes of acute NBI: "pot," "PCP," "tranquilizers," "barbiturates," "whatever turns you on" In most states, if an erratically performing driver passes the breath test, he or she is free to get back on the road.
More enlightened and far ranging programs are needed (going beyond "don't drink and drive"), aimed at detecting and eliminating from the road individuals who, as a result of NBI, are at risk of killing or maiming their fellow citizens. Currently available measures are hand-me-downs from the days of the Model T and the Stutz Bearcat.
Take, for instance, driving tests that are administered, usually, only once in a person's lifetime. Typically, an individual takes such a test in his or her teens and has only to demonstrate a modicum of hand-eye coordination. Over the next 60-odd years, nothing more is demanded in most instances than periodic evaluations of vision along with paper-and-pencil exams aimed at testing "judgment" or "attitude": "Another driver flicks his high beams at you, do you do the same thing back at him?"
As a result of failure to detect NBI, the highway death statistics in this country are skewed toward those most likely to be suffering from the disorder. The two age groups most frequently involved in fatal accidents are the very old (over 75) and the young (under 20). Studies by the National Highway Traffic Safety Administration reveal that very old drivers (75 and over) have higher accident and fatality rates per mile and are more likely to be injured or killed in a collision than younger drivers, except those under 25 who have the highest rates of all.
With the older driver, accidents are the result of a fall-off in reaction time and brain- eye-hand coordination. This assertion isn't a slap at the elderly, merely a statement that has been borne out by innumerable tests of reaction time. To put it at its baldest, a significant percentage of the elderly suffer from The Klutz Syndrome. In contrast to the drunk driver, however, the elderly person with NBI isn't suffering from a temporary but from a permanent problem. The public is at risk whenever such a driver takes to the road.
In the case of young drivers (below 25 years of age) their road accidents are merely the most conspicuous aspect of the hyperactivity, attention difficulties and learning problems that are present within this age group. Popular opinion to the contrary, these conditions are not limited to children and adolescents.
Further, young adults afflicted with NBI often act quickly enough but their responses are erratic. They have problems dealing with more than one situation at a time. Reading and interpreting a road sign while traveling at 50 mph may take an unduly long time for processing, thus necessitating a last second lurch of the wheel towards the exit ramp.
Think of the late teenager or young ault who can't go from one end of the living room to another without bumping into a coffee table or knocking into the potted plant. Why would their coordination be any better at the wheel of several tons of metal as it careens along the freeway?
Another segment of the population that comprises a large proportion of those suffering from NBI are those individuals who regularly take medication that affects the brain. Included are tranquilizers, antiepileptic agents, "sedatives" and some drugs used to control hypertension. Coordination and prompt responsiveness may be impaired as the result of the use of such drugs.
Further, the impairment may vary tremendously from time to time due to such factors as dosage, the time of day the drug is taken, and the amount of sleep a person has gotten recently. All these factors make it extremely difficult to be certain that such individuals may not, on occasion, suffer from a degree of NBI which would make it inadvisable for him or her to operate a motor vehicle.
In addition to the difficulties in determining who may suffer from The Klutz Syndrome there are attitudinal problems as well. It's not at all unsual for a patient who has been declared "totally disabled" from any work (rendering them essentially unemployable) to appear in a physician's office requesting certification in writing that they may safely drive a car. Persuasion and logic in such instances ("If you're too impaired to work, how can you drive?") is usually to no avail. The patient goes off in search of a physician who sees things his way.
Nor are motor vehicle bureaus as much help as they could be in keeping those with NBI off the road. Rarely are licensed drivers called in for a road test of their driving abilities. Instead, when doubts exist about a driver's physical or mental capacity, most motor vehicle bureaus are willing to accept a letter from a physician stating that the person is road-worthy. In those instances where the physician refuses to submit such a letter, the person afflicted with NBI merely shops around for a more "cooperative" doctor.
But how can any doctor possibly make such a complex determination simply from talking and examining a patient? The only real way of assessing a driver's ability is to conduct a road test.
What's needed on the part of law enforcement and motor vehicle licensing bodies are vigorous efforts that go beyond the inadequate concept of merely developing more sophisticated "breath tests" to detect drunk driving, the most conspicuous and publicized form of NBI. The challenge is to derive and apply a test to detect all forms of the Klutz Syndrome.
For a start, why not develop simulators wherein drivers can be tested under non-hazardous conditions? For several years now airline pilots have been required by law to present themselves for periodic testing of their performance.
In a simulator the driver would sit behind the wheel of a car that is real in every way except that it doesn't go anywhere. Computer-generated images would then test the drivers' responses to such things as other cars suddenly pulling out in front, children dashing into the street, somebody running a red light at an intersection. The driver responds to these test situations just as he would in real life. The correctness and timing of his responses could then be compared with those of other people of the same age and a kind of "klutziness quotient" or KQ arrived at. Through the use of a simulator it would be possible to detect the neurobehaviorally impaired without damage to life, limb or property.
Obviously, it is not possible from a practical point of view to perform these tests on the millions of drivers in this country. But why not start with those most likely to be suffering from NBI: Those who are repeatedly involved in accidents, those over 75, those under 20, those with known "learning" and "performance" disabilities, those who regularly take medication known to affect alertness and coordination?
Such a program isn't going to be easy to implement. Most people believe -- public information efforts to the contrary -- that driving is a "right" instead of a privilege. Secondly, although people with NBI frequently cause accidents they often aren't technically "at fault". For example, the NBI sufferer may slam on his brakes suddenly and unpredictably thus precipitating a collision from the car following behind. The driver of the second car may well be charged with the accident despite the NBI driver's having reacted erratically. Indeed, in my informal office survey individuals with The Klutz Syndrome were often involved in multiple accidents but were rarely charged. Technically, they were correct, therefore, in declaring "none of the accidents was my fault."
For this reason, any record-keeping system based on who is "at fault" in an accident is likely to miss a goodly proportion of neurobehaviorally impaired drivers.
What is needed at this point is official recognition of NBI, a legal-medical definition coupled with sensible measures aimed at reducing the risk to the The Klutz Syndrome sufferer and those around him.
Certain individuals, through no fault of their own, are simply too poorly coordinated and too klutzy to be operating a motor vehicle. It's about time that we identify these people and, for their safety as well as everyone elses', get them off the roads.