Halloween may make for a memorable night at the emergency department
- By: Alexander Isted
You scan the bustling waiting area for your next patient. Among what seem to be the usual cases of myocardial infarction, deep vein thrombosis, ankle sprain, and abdominal pain, you see a cluster of patients—their clothes torn, and their faces ghostly white, covered in copious amounts of blood. On any other day this would concern you, but today you carry on unfazed. Halloween, with its gruesome imagery of blood and gore, is one of the key calendar events that emergency departments prepare for every year.
Katie Archer, speaking on behalf of the Emergency Medicine Trainee Association, sets the scene. “When you’ve just got comfortable in your new hospital after the August rotation, the UK decides it’s time to party again—and not only party, but party dressed up like they’re patients on an ATLS [advanced trauma life support] trauma course. The waiting room looks like ‘Thriller’ and everyone has an axe, knife, or arrow sticking out of their heads. ‘Blood’ is flowing from every inch of skin imaginable and someone is always carrying a decapitated head.” Of course it’s business as usual for the most part, with the typical cases still presenting like any other night of the year, but is there more to this holiday than just fancy dress?
Trick or treat?
Halloween is among the four most likely days of the year that children will be admitted to the emergency department in the United States. The American Academy of Pediatrics reported that the commonest holiday specific reasons for hospital admission on Halloween were road accidents, eye injuries, and burns.
Halloween activities traditionally take place after dark. These activities, coupled with dark and physically restricting costumes that often obscure vision and hearing, put children at a heightened risk of accidents. In the US, children have been found to be four times more likely to be hit by a car on Halloween than any other night of the year. Distraction can also play a part, because children rush to acquire the most treats, in addition to erratic patterns of crossing the road from house to house rather than at designated crossings or corners—a known risk factor for pedestrian collision.
Halloween has been the top holiday for sugary treat sales, and Americans are expected to have spent $2.4bn (£1.5bn; €1.8bn) on candy this Halloween, the most spent in the past decade. The Halloween confectionary market in the United Kingdom has also grown, as the holiday has gained greater popularity. According to confectionary company Cloetta, Halloween generates £39.6m annually for the convenience sector, with confectionary sales the biggest contribution. With trick or treating for sweets and chocolates being a central theme of the festivities, children with diabetes are at risk. Hyperglycaemia is a concern, as is being overcautious with insulin risks causing a hypoglycaemic episode, particularly when children are not supervised in their sweet consumption. One paediatric department in Pennsylvania hosts an annual Halloween diabetic candy exchange, where children can exchange their trick or treat spoils with a sweet-free gift bag. Sugar free or low sugar substitutes for sweets, which may seem to be good alternatives, have their downsides. A Postgraduate Medicine case report of so called “Halloween diarrhoea” has pointed out that when sorbitol— a compound often used as a low calorie sweetener in sweets and cakes—is eaten in excess, it has a profound laxative effect and can cause abdominal pain.
Burns caused by fireworks at Halloween and Guy Fawkes night are common, but there have been instances of costumes causing similar morbidity. Halloween costumes tend to be made of cheap, largely disposable or even homemade items, and as a result they are at high risk of being flammable. Unfortunately, naked flames play a large part in this holiday’s decoration—in particular, candles and carved pumpkin jack o’lanterns. In 1997, Sunil Choudhary, a senior house officer in plastic surgery, published an unusual case report describing a harrowing costume gone wrong. A teenager’s improvised costume of an Egyptian mummy—consisting of layers of toilet paper wrapped round and taped to his body—ignited when it came into contact with a candle and left him with severe extensive burns covering 15% of his body.
For the real fancy dress aficionado, no costume is complete until the eyes are customised to match. Decorative contact lenses can colour the pupil a ghoulish white or the iris a “Hulk” green. However, products with poor quality control, combined with an often novice lens user, risk damage to the eyes during application and the potential for infections. Cosmetic lens users have been found to be at much greater risk of developing acute infections threatening vision, owing to poor lens hygiene and corneal scrape trauma from inexperienced application. In the largest study of cosmetic lens wearers so far, researchers found an 85-fold increased chance of developing microbial keratitis in lens wearers who acquired them from a friend, a market, or online, compared with those wearing prescription lens.
According to Robert Glatter, an emergency doctor in the US, the act of dressing up itself might pose additional risk. He says: “When people dress up in unusual costumes and step out of their normal lives, they may feel that it is then okay to experiment with drugs and alcohol.
“The potential for injuries and falls as a result of loose-fitting costumes and special masks or hats, which may hinder vision and hamper the ability to walk carefully, coupled with mood-altering substances, is a recipe for injury and harm.” 
One Halloween related injury, despite being niche, is the subject of surprisingly extensive research: pumpkin carving injury. Any use of a knife under the influence is a clear risk for trauma to the hand, and a 2004 study identified the most common maladies that orthopaedic surgeons faced after pumpkin carving mishaps. These include deep puncture wounds and lacerations to the hand—commonly caused when the knife is accidentally pushed too far; cutting the opposing hand when holding the pumpkin steady; and cutting the taut flexor tendons in the palm—a potentially devastating trauma, when the cutting hand slips forward from the handle along the blade.
Fight or fright?
Halloween has seen an increased number of assault victims presenting in emergency departments. Sadly, hand trauma is not confined to pumpkin craftsmanship, with those who don’t fall under the “happy drunk” category getting involved in a fight or two, followed in short succession by a hospital visit. According to Glatter, fracture of the fourth or fifth metacarpal (known as “boxer’s fracture”) is common, alongside fight bites, where the punch recipient’s tooth breaks the skin, posing serious infection risk.
The practice of throwing eggs at unsuspecting pedestrians is widely considered unacceptable for 364 days a year, but on Halloween this particular brand of public nuisance becomes commonplace. The eyes are highly vulnerable to the practice of “egging,” and the consequences of being hit by such a missile are potentially severe. A study at Liverpool Royal Infirmary recorded 13 ocular injuries caused by egg throwing on Halloween, with more than half being major injuries and four patients having permanent visual impairment.
Although the spooky costumes and decorations might seem frightening to children, most adults might claim to be totally fearless on Halloween. However, a study conducted at Yale University made an interesting finding in maternity departments on Halloween. Of nearly two million births taking place during the Halloween period over 11 years, researchers determined a 5.3% decrease in spontaneous births and a 16.9% decrease in caesarean births on 31 October, compared with the weeks leading up to and following Halloween. The investigators speculated that the heavily pregnant mothers-to-be are subconsciously more susceptible to anxiety from negative Halloween imagery.
Whether these various hazards have translated into greater admission rates on Halloween is difficult to say, because most emergency departments do not monitor admission frequencies on a daily basis. But regardless of whether an emergency department becomes busier, there are likely to be some memorable patients. Anusa Sabanathan, an emergency physician at University College London Hospital, shared her experience of patients who have lived up to their costumes. These included vampires whose biting sprees had resulted in injury, unconscious zombies intoxicated by alcohol, trick or treating adults who later realised that coloured tablets in clubs are not always candy, and witches who fall out and lose both their wigs and own hair. Halloween can also be a surreal experience for observers: “There are the ‘normal’ demographics of patients who sit next to the costumes, wondering what it’s all about, and at about 4 am, so am I,” she says.Alexander Isted, third year medical student
1King’s College London
Correspondence to: firstname.lastname@example.org
Competing interests: none declared.
Provenance and peer review: Commissioned; not externally peer reviewed.
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Cite this as: Student BMJ 2013;21:f6337
- Published: 25 October 2013
- DOI: 10.1136/sbmj.f6337