To the Editor:
We write to draw attention to the potential hazards of handheld electronic devices. With ever-increasing affordability and portability, these units are now more commonplace than ever. Music, movies, and games are accessible on one's palm or tucked away in a small pocket and attached to discreet earphones. While convenient, these devices have generated concerns regarding auditory injury and consequences of distraction. 1 However, little attention has been focused on the increased risk of trauma caused by distraction in sports and wilderness settings.
Since the development of portable audio devices in the 1980s, concerns have been raised about damage to the auditory system as a result of prolonged or intense sound exposure. Indeed, extended battery life, expanded capabilities, and increased portability have led to increased frequency and length of use. Youth particularly tend to listen at higher volumes, and the contemporary in-ear headphone designs amplify damage. 2 Furthermore, listening volume is typically increased in an outdoor setting and during exercise. 3
Beyond direct auditory injury, handheld electronic devices and headphones distract users from their physical environment and associated safety cues. 4 This risk of distraction has garnered enough attention to motivate legislation, as most states now disallow use of handheld telephones, headphones, or text-messaging while driving.5,6 Headphone use has recently been demonstrated as a factor in pedestrian injuries, attributed to masking of noises and distraction.7,8 In sports and wilderness environments, these risks may be amplified because of the importance of auditory and visual cues from the physical environment, other people, and wildlife.
There is no published evidence focusing on distraction in the outdoors, wilderness, and sports, but we have experienced notable incidents that raise concern. One case involved an 11-year-old boy who was walking to school while listening to headphones and engaged with an handheld electronic device. He walked past a railroad crossing and was struck by a freight train. Emergency Medical Services was on the scene within 5 minutes, and he arrived at our Level 1 pediatric trauma center within 15 minutes. Despite this rapid care, his injuries included massive cranial trauma and were deemed unsalvageable, so resuscitation efforts were terminated.
This child had been healthy, with no vision or hearing problems, nor any history of depression. Bystander reports indicated that the boy was walking without difficulty, but appeared absorbed with the device in his hands. He walked past the flashing signals without responding to the train's whistle, shouts of witnesses, or the squeal of the train's emergency brake. He walked into the path of the train as a result of environmental inattention in a situation with multimodal cues (physical barrier, visual markers, and audible deterrents). This was a completely preventable death.
On a less dramatic scale, in our role as alpine ski patrollers we have responded to numerous skier collisions and near misses in which at least one individual was wearing headphones. We have observed that difficulty in getting the attention of a skier or snowboarder to warn them of a hazard has often been associated with headphone use. The music is sometimes so loud that it can be heard clearly an arm's length away. Similar awareness and safety problems have been noted at the ski lift loading areas.
Objective data on effects of distraction in sports and wilderness settings are lacking. Nonetheless, the potential risks of distraction in dynamic environments are easy to imagine, and this is reflected in the policies of some sports organizations. For example, the Road Runners Club of America guidelines recommend against the use of headphones in running events and group training. USA Triathlon's rules specifically disallow personal audio devices in articles 3.4i, 5.8, and 6.3. USA Track & Field rule 144.3 also banned headphone use, though this was amended in 2008. The amendment gives race directors the discretion to allow headphones; however, the USA Track & Field emphasis remains “rooted in a concern for athlete and volunteer safety.” 9 The National Ski Patrol and National Ski Areas Association have no official rules on the matter. The Skier Responsibility Code states “ski in control,” but this is a general directive open to interpretation. Many people believe that wearing headphones is a personal choice that has no impact on the safety of others or themselves.
Accidental trauma is the leading cause of death in children and young adults of both sexes. In the first 3 decades of life, death from accidental injury is 1.5 to 4 times more common than the second leading causes. 10 Morbidity is reduced by use of protective gear such as helmets and by prompt transport to regionalized trauma centers. However, the greatest gains in minimizing traumatic injury derive from primary prevention: avoidance of the incident altogether. Headphones and handheld electronic devices distract users from their environments. This puts users at increased risk of accidental harm, particularly in dynamic settings with inherent risk such as near moving vehicles, while playing sports, or while engaged in wilderness activities.
We hope that sharing our observations and concern may generate interest in directing further attention to this matter. Formal study is warranted to determine the prevalence of headphone and handheld electronic device use in these settings, as well as the relative risk of injury associated with use of the devices. In the meanwhile, we recommend counseling participants in active and wilderness events to maintain focus on the task at hand, and either forgo earphones or at least wear them on just 1 ear. If it is quantitatively substantiated that risk of injury is increased with headphone use, the question will arise of whether restrictive policies are required, or whether heightened awareness alone would effect voluntary changes in behavior.