A little nightclub medicine: The healthcare implications of clubbing

Chris Luke, C. Dewar, M. Bailey, D. McGreevy, H. Morris

Accident and Emergency Department, Royal Liverpool Hospital, Prescot Street, Liverpool, L7 8XP, UK.

(C. Luke) Accident and Emergency Department, University Hospital Cork, Wilton, Cork City, Ireland. Phone no: +353 219 22 414. E-mail: This e-mail address is being protected from spambots. You need JavaScript enabled to view it

Introduction

Difficulties have been consistently identified in getting fair, balanced coverage of the hazards associated with clubbing. As the owner of the Sydney club ‘Sublime’ says: "One of the greatest anxieties that a club owner has, is of an ambulance outside the club". It is bad for business and potentially, if things go seriously wrong (as with ‘Sublime’) and they have deaths from drugs, they face the loss of their licence at the very least. In July 1999, for example, Cream nightclub in Liverpool eventually and inevitably had their first ‘ecstasy death’. Happily, perhaps because of Cream’s very forward and honest approach to the drugs issue and other issues in clubbing there were no more adverse stories in the local press.

Clubbing has changed somewhat since the 1970s but some things do not change. It is basically about fun, and I am convinced clubbing is essentially good for you and fun is good for you. Over the last ten years or so clubbing has become radically transformed, at least in appearances and in intensity. We have seen the growth of icons of youth culture such as Fat Boy Slim and Pete Tong catering to a massive audience throughout the UK and Europe. In Berlin, the rave scene and the club scene is very, very strong. To give some idea of definition and skill, clubbing at the moment represents a fusion of Balearic beat, rave culture and ultimate absorption, as with most youth culture, into the mainstream. Although we have seen prohibition with drugs, there is a lot of hostility towards the club scene.

The original models in the UK were the Hacienda night club in Manchester (now defunct), Cream in Liverpool and The Ministry of Sound in London. To give an idea of the scale, in 1996 there were 18.5 million club attendances costing over £10 each. It is a very big industry. Interestingly, there were just 15.7 million attendances in 1998, so it would appear on first inspection to be in decline. Of course it is conceivable that we are just seeing a shift of the economy outwards right across Europe, particularly for example, in the case of Manumission and Cream and in Ibiza, and the globalisation of the clubbing industry which is a truly multi-million pound, multi-national industry.

With the economic prosperity and the popular success of clubbing, there have been some down sides, risks and adverse consequences of clubbing. Clearly drug taking is universal in modern clubs and alcohol is the predominant drug, despite its media trivialisation and sensationalisation over the last decade. The problem with drinking and drugs and the consequent behaviour is that it brings very, very bad publicity upon the clubbing industry. There was a major controversy in 1998 when the British consul in Ibiza resigned in protest because the consul had to keep picking up the bill for clubbers in Ibiza who had come to harm because of clubs.

My agenda is about the health care service in the UK. The health care system in the UK is arguably struggling to survive under the weight of lifestyle related illness. The Accident and Emergency Department at the Royal Liverpool University Hospital receives at least a thousand cases of clubbers each year during the early hours of Saturday and Sunday nights. The hospital is set in sprawling parklands in the eastern part of the city of Liverpool. It is a large mixed hospital. Between the famous Liver Buildings, the waterfront and the hospital, there are a total of one hundred and fifty clubs in the city centre and there are over eleven hundred registered doormen.

The most internationally famous of the Liverpool clubs is Cream which is situated in the heart of the old warehouse area in Liverpool. It recently celebrated its fifth birthday. In the beginning it had great difficulty in surviving, despite its enormous international reputation (Many students put their choice of University city as Liverpool because of its identification with Cream). In the mid-1990’s Cream was in big trouble because, like many clubs, they were facing major hostility from the police and the council because of licensing, mainly because of drug misuse and territorial disputes. Being pro-active, they reached out to various people. They went to the police, the city council and the local Accident and Emergency department. They asked us if we could advise them on immediate care and preventive strategies for the club itself.

We visited on a number of occasions and talked at length with the much-loved Dave McGreavy, who was our first aider and who tragically died in June 1999. Dave gave us the records of three or four years of his work in Cream and, unsurprisingly, this was how it broke down: about half of the cases coming to the first aid room were due to intoxication with drugs and with drink; about a quarter of the problems they were seeing were soft tissue injuries such as sprains and cuts; and the other quarter was a mixture of panic attacks, asthma, demand for ventolin and paracetamol and so on. It was not a surprising spectrum of illnesses. Predictably, the media made much trivialisation of this. They promptly reported ‘night-club nipple’ and ‘PVC bottom’ and undermined the whole issue.

The ‘real’ health hazards of clubbing

1. The most important medical problems that actually drive clubbers into hospital are actually minor injuries, particularly around the face. Violence is usually associated with alcohol use. Often protective eye wear is a good idea in the club environment, besides being a fashion accessory, because people are waving cigarettes when they are dancing and often the consequences are burns to the eye.

2. Dancing injuries are the same as they are on stage and over-use syndromes; torn calves, torn muscles and sprains are ten a penny.

3. ‘Night-club finger’ is a particularly male affliction; when dancing in a dark, crowded, smoky room, they think they have a cigarette butt on their trainers so they flick it off. Instead, however, it is usually a shard of glass, and they end up with a very painful, vertical nick of the finger tip which often needs stitches. We discovered to our surprise that clubs see half a dozen to a dozen of these each night in many parts of the UK so it is a minor thing but in terms of volume it is astonishingly important.

4. Because young girls will dance bare foot in the clubs, severe glass related cuts of the foot are not uncommon.

5. Increasingly, we are seeing the malicious use of CS gas in clubs. Recently in Leicester, twenty-five patients were brought in all at once to the accident department. It does not take a great deal of imagination to work out the extra burden on an already congested emergency department when you get twenty five people with streaming, painful, tearful eyes and burning air-ways and nostrils.

6. The ‘dingly, dangly thing’ at the back of your mouth is called the uvula. In one case, a young woman inhaled dry ice right to the back of her mouth and her uvula had to be amputated.

7. Probably the least dangerous drug on the market, apart from ‘cannabis’, is amyl nitrate or poppers. Poppers tend to carry hazard warning signs because they are basically full of nitrates and are first cousins of TNT. If you are inhaling poppers and some helpful character ignites a cigarette lighter in front of you, your face will go pop. It will also burn very severely if you spill the stuff directly onto the face. Nitrate is very corrosive.

8. The major hazards of clubbing begin and end in a sense with alcohol, which is responsible for the vast majority of problems that come into hospital. We only see about 10% of what the first aid rooms in the clubs are seeing, so the clubbers and first aiders tend to be able to deal with 90% on average of the problems that arise. These problems are largely self-limiting and are related to substance use but the problems that tend to need hospital care are usually related to alcohol, often due to cheap drink promotions. Alcohol is directly associated with the growing amount of violence in the UK which is said to be the fourth or fifth most violent country in the OECD. Violent injuries have now basically replaced all the gains made in the UK in the last two decades with seat belt legislation. In the 1970’s and 1980’s, there was a huge drop in the number of young men with facial injuries resulting from window screen injuries, but unfortunately because of the rising tide of violence in the UK, in and around clubs, we are now seeing more and more. Devastatingly, many people require plastic surgery and there are a very high number of incidences for long-term post-traumatic stress and psychological reactions with facial wounds of young people, particularly young women.

9. It goes without saying that drink driving after clubbing is associated with a very significant amount of deaths on the roads in the UK. A whole selection of tablets are sold as ecstasy and the drug content is completely erratic and unreliable. Interestingly, we tend not to see heat-related illness anymore and that is almost certainly due to the universal recognition both in law and in popular culture, and particularly by club owners, that if you do not provide a ‘chill out’ area and free water then you are bound to have your licence revoked. Taking over heat-related illnesses has been the growing numbers of ‘mitsubishi’ poisonings. Mitsubishis are hugely popular in Liverpool and in a recent month there were three, four or five extremely sick young people coming in as a result of taking mitsubishi, amongst other things, each weekend.

10. ‘GHB’ is becoming an increasing problem along with ‘ketamine’ in the UK. Although alcohol should be avoided with it, inevitably when we get them in people have had at least ten pints of beer before they have drunk the GHB. The GHB is causing a lot of problems, such as unexpected collapses and pressure on breathing which is very, very dangerous. The delirium in young clubbers when they come to hospital is very, very difficult to treat because it is unlike schizophrenic or manic delirium or the delirium associated with drink. These young people increasingly have taken four, five or six different substances. They normally have three or four bottles of designer larger, a few lines of cocaine, some ketamine, an ecstasy pill or two and perhaps other things. We can no longer keep up with what is in their blood stream. For example, we do not test for ketamine or GHB, so we have no idea except for the scale of the problem in Liverpool. Cocaine is our real worry because of the rise in the growth of use. Recently we have seen a lot of heart attacks and cardiac arrests in young people, with a whole series of young deaths, which happily were not hyped in the media. Of course, cocaine is also associated with a great deal of violence inside and outside the clubs.

Impacts on hospitals

It may be useful to note a few simple but worthy figures from the Accident and Emergency Department in Liverpool, which is already struggling with its workload. In 1997, 0.6 % of our work load of ninety five thousand cases were due to clubbing and by 1998 that had risen to nearly one percent, that is about a thousand cases a year. A group of 1,200 or so clubbers over a period of two years were analysed for a number of issues. 40% of them took an ambulance from the club to the hospital, and that is a considerable use of resources. Assaults accounted for more than half of the presentations, although happily those caused by doormen had been reduced by at least half since the introduction of the door supervisor registration scheme in Liverpool. Accidental injuries were divided equally between people falling down stairs in clubs and people sustaining glass injuries in darkened night clubs. In terms of major clinical intoxication, it was obvious that drink was a major problem in at least a third of the cases but interestingly drugs were only a major problem in about 4% of cases. The key message is that alcohol continues to be the major scourge of the health care system within modern clubbing.

The treatment required is very simple wound care for half, x-rays for about a fifth and medication for about another fifth of cases, and the rest divide up loosely between walking aids and tetanus injections and so forth. In terms of the actual main medical problems, face wounds (which can be disfiguring) account for a quarter of cases, head injuries sometimes requiring neuro surgery accounts for about a fifth, limb injury about a fifth, intoxication about 11% and a variety of miscellaneous medical problems another 10%. Finally, in terms of follow up, just over half of the clubbers discharged themselves from the hospital department or required no follow up, about 15% of them were actually admitted to the hospital so 15% had a fairly significant injury or illness.

Lessons

First and foremost, it is important to have a broad understanding of the health care requirements of clubbers. Alcohol is still a major health care concern around clubbing in the UK, followed by accidents, glass related violence and drug abuse. These are followed by panic attacks, exacerbation of chronic ailments like asthma, over-exertion and problems with the environment like CS gas, dry ice and cigarette burns.

A potential solution to reduce the burden on a struggling healthcare system in the UK is a national code of practice: a code of practice which demands certain environmental safety measures. For example, these involve the provision professional healthcare by experienced Accident and Emergency nurses in decent facilities in all the big clubs, which encourages collaborations in the private and public sectors. The clubs should provide the funding and we give them the advice. I would like to see the clubs looking after 99% of their clubbers on-site, and that would be something very popular with the clubbers and immensely popular with the health care system. There are already published guidelines in the North and South of England at the local level.

Another important collaboration in Liverpool is between that of HIT, the brewing companies, the hospitals and the clubs, who launched a poster campaign illustrating the very real complications and horrors of glass related attacks. Happily, since this was introduced in June 1999, the number of glass injuries have started to decline and also interestingly the brewing companies were persuaded to launch plastic bottles for the beer in Liverpool and in a year or two year’s time we will reap the rewards of this.

In terms of medical approaches to some of the problems it is also very important that we keep an eye on local intelligence, including urine toxicology results so that we can anticipate the development of problems with GHB and other new substances. The reason clubs should provide this level of care, why they should pay attention to the health hazards of clubbing, are twofold. A strategy for reducing the healthcare cost implications of clubbing offers major opportunities in terms of better customer care, lower healthcare and legal costs and it will reduce the problem of crime and violence within the clubs which threatens licences and gives rise to litigation. Moreover, an honest and constructive approach by all parties concerned from the police through to the health authorities and the clubbers themselves will basically eliminate the cavern that otherwise will open up between them and us.