BYOB helmet

Look around any major U.S. city these days and you are likely to see bicycle rental stations, where an individual can rent a bicycle for a fee that is tied to distance and time. This is a wonderful way to get around congested urban areas, and these bike-sharing services provide an inviting recreational activity option for tourists and city dwellers alike.

The world’s first bicycle-sharing program hit the streets of Amsterdam in 1965, but the concept was slow to spread elsewhere until the 1990s. Growth has primarily occurred in Europe over the last two decades, but the U.S. is quickly catching up. At present, bicycle-sharing services offer more than 500,000 bicycles in more than 500 cities spread across 49 countries.*

Bring your own

Credit card readers are installed at rental station kiosks, which simplifies the process of renting a bicycle. Visitors to a city who are unfamiliar with its layout, local traffic patterns, or available bicycle paths can walk up to one of these stations, swipe a credit card, and start riding. When renting one of these bicycles in most U.S. cities, though, a bicycle helmet is conspicuously absent from the picture.

As a trauma surgeon in a city with extensive bicycle paths, I have had the misfortune of treating numerous injured bicyclists over the years. The most severely injured have been helmetless. There may be statistics and studies that weigh the benefits of riding a bicycle from a physical fitness perspective versus the risk of head injury without a bicycle helmet; however, it seems like common sense to do whatever it takes to protect oneself from potential head injuries by using a properly fitted bicycle helmet, especially in congested urban areas. Boston, MA, has taken the lead in pioneering the use of a bicycle helmet rental program with vending machines placed at locations adjacent to the bicycle rental kiosks. These helmets are used and then returned to a collection bin, inspected, sanitized, and placed back in the vending machines to be rented again.

According to the U.S. Centers for Disease Control and Prevention, bicyclists have a higher risk of crash-related injury and death than occupants of motor vehicles. In 2010, an estimated 515,000 bicycle-related injuries requiring an emergency department visit occurred in the U.S. Nearly 800 cyclists died, and many more suffered non-fatal life-altering brain injuries. Adolescents and young adults ages 15 to 24 and adults ages 45 and older have the highest bicycle-related death rates. Children five to 14 years old and adolescents have the highest rate of non-fatal bicycle-related injuries, accounting for almost 60 percent of these injuries. Males are more likely to be injured or killed, and most deaths occur in urban areas and at non-intersection locations.

In the event of a crash, bicycle helmets reduce the risk of head and brain injuries. All cyclists, irrespective of age, can help protect themselves by wearing a properly fitted bicycle helmet every time they ride.

Biking under the influence

To examine the occurrence of bicyclist injuries where a protective device was involved, we searched the National Trauma Data Bank® (NTDB) research dataset for 2013 admissions medical records using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnoses codes. Specifically searched were records for pedal cyclist injuries identified with external cause of injury codes (E-code) E810–E819 (Motor vehicle traffic crashes) with a post decimal value of .6 for a pedal cyclist; E820–E825 (Motor vehicle non-traffic crashes) with a post decimal value of .6 for a pedal cyclist; and E826–E829 (Other road vehicle crashes) with a post decimal value of .1 for a pedal cyclist. These records were then searched for a valid protective device field value of either 1 (non-helmet) or 7 (helmet). A total of 24,760 records for pedal cyclist injuries were found; 18,682 records contained a valid protective field device value, including 11,954 with no helmet use and 6,729 with helmet use. The no-helmet group was younger (mean age 31 versus 42), had more than a two-fold increase in mortality (1.48 percent versus .71 percent), and for those tested for alcohol there was an almost four-fold increase in those individuals testing positive (39 percent versus 11 percent) when compared with the group that used helmets. Among those pedal cyclists who died, 79 percent were not wearing a helmet (see Figures 1 and 2).

Figure 1. Alcohol Use

NTDB Alcohol use

Figure 2. Pedal Cyclist Deaths

NTDB helmet deaths

Other protective measures

Helmets are not the only products that improve bicycle safety. Cyclists are encouraged to wear fluorescent clothing to increase visibility during daytime hours and retro-reflective clothing to make the rider more visible at night. Bikes should also be equipped with active lighting, including front white lights and rear red lights, to make the bicycle more visible at night or on overcast days.

Cities can contribute to bicyclist safety by implementing roadway engineering measures that go beyond simply painting a white line on a street next to a string of parked cars with an image of a bicycle. Several cities have sophisticated bicycle lanes with dividers and their own traffic lights.
While all of these safety precautions are important, at the head of the list is a properly fitted bicycle helmet. So, the next time you are looking to share a bicycle, make sure you BYOB (bring your own bike) helmet.

Throughout the year, we will be highlighting these data through brief reports in the Bulletin. The National Trauma Data Bank 2013 Annual Report is available on the ACS website as a PDF file at In addition, information about how to obtain NTDB data for more detailed study is available on the website. To learn more about submitting your trauma center’s data, contact Melanie L. Neal, Manager, NTDB, at


Statistical support for this article has been provided by Chrystal Caden-Price, Data Analyst, and Alice Rollins, NTDB Coordinator.

*Cyclehop, LLC. Bike share hits significant global milestone. April 26, 2013. Available at: Accessed June 6, 2014.

Centers for Disease Control and Prevention. Home and recreational safety: Bicycle-related injuries. Available at: Accessed June 6, 2014.

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