F you suffered a severe head injury in Bermuda 17 years ago, you had a more than 50 per cent chance of dying as a result of it.

Thanks mainly to improvements made in the management of such cases, from the scene of the accident all the way through to rehabilitation, as well as factors such as better crash helmets, you would now have a more than 85 per cent chance of survival.

Dr. Andrew Spence is the director of intensive care at KEMH and in his 15 years at the hospital has been involved in making those great strides forward to a head injury mortality rate comparable with centres of population in the US and Europe.

"There have been major changes in the management of head trauma cases over the last 15 years," Dr. Spence said. "We are a long way from the nearest neurosurgeon so we've got to have a good plan.

"We have a protocol that relies on co-ordination and teamwork involving many people and goes right from the pick-up of the patient to the emergency ward to the resuscitation room to intensive care management and after that.

"What we have found is that a certain amount of damage happens in the impact. But there can also be a lot of secondary injury, caused by swelling of the brain, for example, that we can do something about."

Dr. Spence believed that with more care and common sense, the vast majority of these life-threatening injuries could have been avoided. "By far the commonest scenario I see involves motorcycles and alcohol ? a wicked combination," Dr. Spence said.

"Properly fitting helmets are also a factor. In many cases, the helmet has flown off the victim's head, or the helmet was of inferior quality.

"More and more in recent years we have been seeing assault victims who've been hit with a baseball bat. We also see children who've fallen off bicycles.

"With motorcycle crash victims, there are two main categories. First, there are the tourists or older drivers who are likely to have been involved in lower-speed collisions.

"Then there are the local, younger riders, who have crashed at a higher speed. That isn't to say that a lower-speed injury will not be serious. If you come off a bicycle at ten to 15 miles per hour and your head hits the kerb, it can kill you."

Of the 38 head injury victims to be treated in the intensive care unit in 2002, 14 were classed as severe. Twenty-one were adults who had been involved in motorcycle accidents. Their average age was 19.

Six of the victims were children aged between two and 12, who had either come off a bicycle when they had not been wearing a helmet or were injured as motorcycle passengers. One, a two year old, had driven his toy car into a wall and another fell at school.

Only one head injury victim was driving a car when injured, while two had been driving golf carts.

There were six assault victims, one of whom died, and two patients had suffered substantial falls, one from a roof and one from a ladder.

The highest total of serious head injuries seen in recent years was in 1998, when there were 60. In 1992, there were close to 50 and the lowest in the past decade was 33 in 1996.

The last three years for which records were available showed that there were 38 serious head injuries in 2000, 44 in 2001 and 38 in 2002.

Helmets are the first line of defence against head injuries and last year the Government introduced new legislation to ensure that retailers could sell helmets only of standards equivalent to those in the US and Europe.

Safety Council chairman Dr. Joseph Froncioni was one of those urging the Government to bring in that law ? under the Motorcycles and Auxiliary Bicycles (Special Measures of Control) Amendment Act 2003.

But he warned that helmets inevitably deteriorated with time and that riders should replace them every three years.

"If you wear a good helmet properly, then there is a good chance it will protect you in any crash except the most severe cases," Dr. Froncioni said.

"The standard of helmets in Bermuda is quite low and that is why we recommended the new law."

The law specifies that any helmet sold by a retailer must meet one of four standards. Three of them are objectively tested, the European / United Nations ECE standard, the British BS 6658 standard and the Snell standard.

The fourth standard the law allows is the US Department of Transport (signified by a "DOT" sticker on helmets). This test is carried out by the helmet manufacturer, who also decides whether to pass or fail.

The law has also helped to encourage riders to secure their helmets correctly, after the Magistrates' Court fine for those failing to wear a helmet properly went up from $50 to $250 last year.

"If you have a helmet that's more than three years old, you should replace it," Dr. Froncioni said. "Helmets deteriorate from knocks and nicks and the energy and oils from the head can make the energy-absorbent material inside the helmet less effective.

"Everyone should aim to get the very best helmet they can. I always tell parents they spend more on school shoes than helmets. How does that make sense?"

The design of a protective helmet incorporates four main elements and many different materials. The outer casing (shell) provides the primary defence against impact and keeps all the components together. It also spreads the loads imposed upon it and prevents objects penetrating it.

Within this is the crushable liner that is made of an energy-absorbing material. The dissipation of the impact energy is shared between the outer casing and inner liner hence preventing as much energy as possible reaching the wearer's head.

Then there is the padding that provides for a secure and comfortable fit. The securing strap, and sometimes a visor as well, complete the package.

All these components are as important as one another as they work in unison. Where one element fails or is sub-standard, the protection provided will be substantially reduced.

Most of a helmet's materials will suffer from some form of deterioration over time. For example, the glues used in a helmet may lose their bond and the solvents may affect the inner liner material. Natural hair oils and sweat contribute to the general helmet degradation, as does natural wear and tear.

The Snell Foundation, well known for its stringent testing of crash helmets, recommends a five-year life for a helmet.

The high cost of treating head trauma victims eats significantly into the budget of KEMH. And the cost of permanent disabilities suffered by some victims, the cost to employers and the upward pressure on health insurance premiums is incalculable.

Dr. Froncioni said the financial aspect was another negative repercussion of avoidable head injuries.

"Head injuries gobble up health care dollars," Dr. Froncioni said. "The average head injury patient spends five days in intensive care at a cost of more than $3,000 a day.

"That's an average of over $15,000 for each patient just for the initial care. We have been experiencing between 40 and 60 head injuries in a year.

"After the five days, they may need more care. Some may need some form of care for the rest of their lives."