Rectal Blowout
Content
The Journal of Trauma: Injury, Infection, and Critical Care Issue: Volume 47(2), August 1999, pp 385-388 Copyright: © 1999 Lippincott Williams & Wilkins, Inc. Publication Type: [Case Reports] ISSN: 0022-5282 Accession: 00005373-199908000-00031 Rectal Blowout by Personal Watercraft Water Jet: Case Report and Review of Liter ature Philpott, Jonathan M. MD; Ng, Peter C. MD; Wixon, Christopher L. MD; Haisch, Car l E. MD; Hoey, Brian A. MD; Kiesnowski, Brian MD, MPH; Crombie, Courtney H. MD; Walker, Jamie S. MSN; Meade, Paul G. MD; Foil, M. Beth MD From the Department of Surgery, East Carolina University, School of Medicine, an d the University Health Systems of Eastern North Carolina, Greenville, North Car olina. Carl E. Haisch, MD, Professor of Surgery, Trauma & Critical Care, Department of Surgery, East Carolina University School of Medicine, Greenville, NC 27858. Injuries sustained from personal watercraft are becoming more frequent as the po pularity of the watercraft increases. [1-9] This is the first report of a trauma tic disruption of the external anal sphincter and a full thickness perforation o f the rectosigmoid colon caused by the water jet of a personal watercraft. This case emphasizes the potentially destructive force generated by these craft and r eiterates warnings from the United States Coast Guard (USCG) and industry manufa cturers recommending wet suit pants for personal watercraft occupants. CASE REPORT A 15-year-old female passenger on a personal watercraft (Waverunner; Yamaha Moto r Corp., Cypress, Calif) fell off the rear as the craft accelerated from rest. S he landed supine in the water and immediately experienced severe abdominal pain. As she was pulled into a nearby boat, her family noted her bathing suit wedged between her buttocks and watery, bloody stool running down her legs. She was tak en to a local hospital, where she underwent a brief period of resuscitation, and was then transferred to our regional Level I trauma center by air ambulance. On arrival, she complained of severe, diffuse abdominal and rectal discomfort. Phy sical examination revealed a rigid abdomen with rebound tenderness and guarding. Visual inspection of the perineum revealed perianal lacerations and watery, blo ody stool coming from the anus. Digital rectal examination demonstrated negligib le sphincter tone. The patient was taken to the operating room for examination under anesthesia. Sp eculum and bimanual examination revealed no obvious gynecological injuries. Rigi d sigmoidoscopy was attempted, but was unsuccessful because of an inability to k eep the rectum insufflated with air. As the examination continued, her abdomen b ecame increasingly distended and tympanic. We proceeded with exploratory laparotomy and encountered massive fecal contamina tion of the peritoneal cavity. Exploration revealed a 1 x 8 cm perforation of th e anterior rectum above the peritoneal reflection and a small 2 x 2 cm hematoma at the base of the mesentery. The rectal perforation was debrided and closed in two layers, and a proximal diverting colostomy was performed. No other injuries were noted, but peritoneal soilage was extensive. Stool was impacted under both hemidiaphragms and into the mesentery, omentum, and bowel wall. Despite 16 liter s of irrigation and vigorous scrubbing with laparotomy pads, stool remained impr egnated in the peritoneal tissues. At the end of the case, the rectosigmoid was irrigated with Betadine solution, and the presacral space was drained.
The patient's postoperative course was uncomplicated. By day 3, she was ambulato ry, her colostomy was functional, and she was begun on a progressive diet. Becau se of the extensive contamination, 7 days of antibiotics were administered; fort unately, she demonstrated no infectious complications. At discharge, anal sphinc ter tone and anal rectal reflex remained markedly abnormal. Outpatient manometric anorectal physiologic testing was performed on postoperati ve day 17. Resting sphincter pressure was 10 to 20 mm Hg (normal 60-90 mm Hg), a nd squeeze pressure was 25 to 70 mm Hg (normal 1.5-2.0 times the rest pressure). A rectal balloon could be sensed at 20 cc of air insufflation. Bilateral pudend al nerve terminal motor latency was normal (2.0 +/- 0.2 ms). Endorectal sonograp hy demonstrated a complete disruption of the external sphincter anteriorly. After 6 weeks, her perineal laceration was nearly healed, and her resting sphinc ter tone normalized. She was started on an intermittent enema-training program. After 4 months of training, she was able to remain continent to instilled water, and a repeat endorectal sonogram revealed that the external sphincter muscles h ad healed. She underwent colostomy takedown, and 5 months after injury, she was continent to both stool and flatus, and she resumed normal activity. DISCUSSION From 1990 to 1995, there was a fourfold increase in injuries related to personal watercraft use. Currently, the rate of occurrence of emergency department injur ies attributable to personal watercraft use is 8.5 times higher than that attrib utable to the use of motorboats. [1] The majority of these injuries involve coll isions with bridges, docks, or other watercraft, but occasional high-speed water impact injuries and water jet injuries have been described. This case represent s two previously undescribed injuries from the water jet of a personal watercraf t: a traumatic disruption of the external anal sphincter, and a full thickness r ectal perforation with extensive intraperitoneal soiling. Although similar mecha nisms of injury have previously been reported, they describe injuries to the uro genital tract (Table 1). [10-13] Graphic Table 1 The mechanism by which personal watercraft are propelled is a water jet generate d by an impeller located within the watercraft. Although the engines are compose d of two or three cylinders (65-135 horsepower), they generate enough thrust to propel the craft to speeds of 50 to 70 mph. [3,14,15,] This requires considerabl e force, given that a modern personal watercraft may weight between 300 and 600 pounds. [3,14,15] Although data available to consumers regarding the hydrodynami cs of personal watercraft are limited because most companies consider this infor mation to be professional "industry secrets," one company, Kawasaki Motor Corpor ation, does publish thrust specifications. [16] The thrust listed for the Kawasa ki line of crafts ranges between 595 and 800 psi, [16] a Figure justbelow the ra nge commonly used for industrial cleaning (1000-10,000 psi). The highly destructive potential of water jets has been previously well document ed; it includes major gastrointestinal, vascular, and soft tissue trauma. [17-22 ] The kinetic energy imparted by the water jet is equal to the product of the ma ss of the water and the velocity squared (KE = mv2). Given the high velocity of the water jets used in personal watercraft, it is not surprising that they can i mpart significant kinetic energy to a patient and cause significant injuries. The pattern of tissue damage described in industrial water jet case reports is a lmost identical to that seen in cases of high velocity missile trauma. [17-22] A lthough injuries typically involve small, innocent-appearing skin penetration si tes, devastating deep tissue trauma occurs as the kinetic energy from the water
jet disperses. In contrast to a high velocity missile, however, is the continuou s nature of the water jet. Injuries to the extent noted in this case are therefo re entirely consistent with the force generated by these vehicles. A highly similar pattern of injury to the one described in this case has been ob served in high velocity water impacts-the most common mechanism being a fall whi le water-skiing (Table 2). This event, also referred to as the "water skier's do uche," describes a douche of water forcefully injected into the vagina or rectum when a water skier falls backwards (typically while being pulled from a startin g position) and the perineum crashes into the water. In both water-skiing and pe rsonal watercraft jet injuries, the water is traveling at a high velocity relati ve to the individual. Predictably, the patterns of injury are similar as water i s forced into the vagina or the rectum. Twenty-three rectal and vaginal injuries similar to the ones in this case have been reported from all forms of high velo city water impacts [23-43] (Table 2). In no case was the victim wearing a wet su it. Graphic Table 2 As in the water impact cases, there are no reported cases of perineal or rectal water jet injuries occurring with the use of a wet suit. A wet suit is recommend ed during personal watercraft operation to provide protection against water jet contact, traumatic high velocity water impact, and also to protect the skin agai nst lacerations resulting from collisions with fixed objects. The Personal Water craft Industry Association and the USCG both recommend that the minimal attire i nclude a half or full wet suit and a USCG inherently buoyant Type II lifejacket, which will turn an unconscious person face up; a Type III lifejacket will not. [44-46] For maximum protection, they also recommend wearing gloves to protect fr om cuts and lacerations, and goggles to protect from traumatic water impact inju ries to the eyes. [44-47] These safety recommendations, however, remain largely ignored by the public -- p rimarily as a result of a serious degree of public ignorance of the potential da ngers involved in personal watercraft use and inadequate regulation of personal watercraft use. The recent explosive popularity of personal watercraft has made effective public safety education and regulation extremely difficult. The personal watercraft industry needs to promote public education of required s afety equipment and the dangers of improper personal watercraft use. Although on e owner's manual does specifically warn of potential "serious rectal or vaginal injuries" that could result from the water jet, [47] the mention is brief, and t he ultimate potential for injury is not clearly defined. In addition, we were un able to locate any scientific reports detailing the capability of a wet suit to protect against 800 pounds of thrust. Will all brands of wet suits provide adequ ate protection, or just some of them? Personal watercraft manufactures and the P ersonal Watercraft Industry Association should take a leading role in wet suit t esting so that industry safety standards can be developed and promoted. CONCLUSION This is the fifth reported injury from a personal watercraft water jet. The inju ry could have been prevented or minimized if the occupant had worn proper protec tive equipment. Her lack of protective equipment is attributable to inexperience and ignorance of the dangers involved in personal watercraft use, and is repres entative of the fundamental lack of consumer knowledge regarding the potential d angers involved in personal watercraft use. A wet suit should be required as min imal equipment to guard against high velocity water impact and water jet injurie s.
Acknowledgments The authors acknowledge Dr. Jean Luc Scemaa, Gunda Smith, and Per K. Audresen, f or their assistance with the translation of the French and Swiss articles cited in the bibliography. REFERENCES 1. Branche CM, Conn JM, Annest JL. Personal watercraft-related injuries. A growi ng public health concern. JAMA. 1997;278:663. Bibliographic Links [Context Link] 2. Hamman BL, Miller FB, Fallat ME, Richardson JD. Injuries resulting from motor ized personal watercraft. J Pediatr Surg. 1993;28:920. Bibliographic Links [Cont ext Link] 3. Tyler BC, Garrison HG. Injuries associated with personal watercraft. An emerg ing epidemic in need of legislative action. N C Med J. 1997;58:284. Bibliographi c Links [Context Link] 4. Gomez GA, Martin LC, Castro MR. Nautical accidents. Unique injuries. Surg Cli n North Am. 1991;71:419. Bibliographic Links [Context Link] 5. Francis RA, Vize R. Personal watercraft injuries: experience at a community h ospital. Mo Med. 1994;91:241. Bibliographic Links [Context Link] 6. Swinburn EE. Serious injuries in jet skiers. Med J Aust. 1996;165:606. Biblio graphic Links [Context Link] 7. Jeffery RS, Caiach S. Waterbike injuries. Br J Sports Med. 1991;22:128. [Cont ext Link] 8. Vernberg D, Fine EG. Personal watercraft injuries. JAMA. 1989;261:1883. Bibli ographic Links [Context Link] 9. Barch P, Baum E. Personal watercraft-related injuries. JAMA. 1998;279:433. [C ontext Link] 10. Wein P, Thompson DJ. Vaginal perforation due to jet ski accident. Aust N Z J Obstet Gynaecol. 1990;30:384. Bibliographic Links [Context Link] 11. Muller RJ. Jet-ski injury: a case history. J La State Med Soc. 1993;145:27. [Context Link] 12. Haefner HK, Anderson HF, Johnson MP. Vaginal laceration following a jet-ski accident. Obstet Gynecol. 1991;78(5Pt2):986. Ovid Full Text Request Permissions Bibliographic Links [Context Link] 13. Fauconnier A, Legier JP, Nicoloso E. Vaginal pressure trauma: a complication of jet-skis. J Gynecol Obstet Biol Reprod (Paris). 1995;24:604. Bibliographic L inks [Context Link] 14. Argetsinger A. Deaths rise as more people ride the waves. Washington Post. A ugust 27, 1995: A1,6,7. [Context Link] 15. Mulholland E, Fitzgerald D. Three's not a crowd. Splash. 1997;10:58. [Contex t Link] 16. 1997 Jet Ski[registered sign] Watercraft Series Specifications Brochure. 199 6. Kawasaki Motors Corporation USAP/N 99969-2556. [Context Link] 17. Calder IM, Boustred D. High-pressure water jet injury. BMJ. 1980;280:1620. B ibliographic Links [Context Link] 18. De Baux JL. High-pressure water jet injury. BMJ. 1980;280:1417. [Context Lin k] 19. Kon M, Sagi A. High-pressure water jet injury of the hand. J Hand Surg [Am]. 1985;10:412. [Context Link] 20. Niell RW, George B. Penetrating intra-abdominal injury caused by high-pressu re water jet. BMJ. 1969;2:357. [Context Link] 21. Harvey RL, Ashley DA, Yates L, et al. Major vascular injury from high-pressu re water jet. J Trauma. 1996;40:165. Ovid Full Text Request Permissions Bibliogr aphic Links [Context Link] 22. Walker WA, Burns RP, Adams J Sr. High-pressure water injury. J Trauma. 1989; 29:258. Ovid Full Text Request Permissions Bibliographic Links [Context Link] 23. Pfanner D. Salpingitis and water-skiing. Med J Aust. 1964;1:320. Bibliograph ic Links [Context Link] 24. Brisbane Gynaecologist. The dangers of water-skiing. Med J Aust. 1968;1:616. [Context Link]
25. McCarthy GF. Hazards of water-skiing. Med J Aust. 1969;1:481. Bibliographic Links [Context Link] 26. Morton D. Gynaecological complications of water-skiing. Med J Aust. 1970;1:1 256. Bibliographic Links [Context Link] 27. Tweedal PG. Gynecological hazards of water-skiing. Can Med Assoc J. 1973;108 :20. Bibliographic Links [Context Link] 28. Eddington RF. Vaginal injuries due to water-skiing. Can Med Assoc J. 1978;11 9:310. [Context Link] 29. Kizer KW. Medical hazards of the water skiing douche. Ann Emerg Med. 1980;9: 268. Bibliographic Links [Context Link] 30. Gray HH. A risk of waterskiing for women. West J Med. 1982;136:169. [Context Link] 31. Knutz WD. Water-ski spill and partial avulsion of the uterine cervix. N Engl J Med. 1983;309:990. [Context Link] 32. Mavrelis PG, Wylie RR. Water-ski colon. N Engl J Med. 1984;311:1128. Bibliog raphic Links [Context Link] 33. Gensburg RS, Wojeik WG. Vaginally induced pneumoperitoneum during pregnancy. AJR Am J Roentgenol. 1988;150:595. Bibliographic Links [Context Link] 34. David SK Jr, Guarisco JL, Coulon RA. Pneumocephalus secondary to a high-pres sure water injury to the nose. Arch Otolaryngol Head Neck Surg. 1990;116:1435. B ibliographic Links [Context Link] 35. Kalaichandran S. Vaginal laceration: A little known hazard for women watersk iers. Can J Surg. 1991;34:107. [Context Link] 36. Niv J, Lessing JB, Hartuv J, Peyser MR. Vaginal injury resulting from slidin g down a water chute. Am J Obstet Gynecol. 1992;166:930. Bibliographic Links [Co ntext Link] 37. Lee RY, Miller S, Thorpe C. Intrarectal tear from water skiing. Am J Gastroe nterol. 1992;87:662. Bibliographic Links [Context Link] 38. Rudoff JC. Vulvovaginal water-sking injury. Ann Emerg Med. 1993;22:1072. Bib liographic Links [Context Link] 39. Johnson LB. A case report: peritonitis after water-skiing. Lakartidningen. 1 993;90:2383. Bibliographic Links [Context Link] 40. Perlman SE, Hertweck SP, Wolfe WM. Water-ski douche injury in a premenarchea l female. Pediatrics. 1995;96:782. Bibliographic Links [Context Link] 41. Smith BL. Vaginal laceration caused by water skiing. J Emerg Nurs. 1996;22:1 56. Ovid Full Text Bibliographic Links [Context Link] 42. Synder RG, Snow CC. Fatal injuries resulting from extreme water impact. Aero sp Med. 1967;38:779. Bibliographic Links [Context Link] 43. Synder RG. Human tolerance limits in water impact. Aerosp Med. 1965;36:940. Bibliographic Links [Context Link] 44. Calkin, Jo [[email protected]]. Outreach Coordinator, Office of Boating Safety, United States Coast Guard. E-mail to the author, September 19, 1997. [C ontext Link] 45. United States Coast Guard Office of Boating Safety Homepage. Available at: h ttp.//www.USCGboating.org/index1.html. Accessed December 12, 1997. [Context Link ] 46. Personal Watercraft Industry Association Homepage. Available at: http://www. sea-doo.com/sd/safety/pwia.html. Accessed February 19, 1998. [Context Link] 47. 1997 Yamaha Waverunner Owner's Manual, pp 1-1 to 1-10. 211 Yamaha Motor Co, LTD, Shizuoka-Ken Japan. [Context Link] 48. Ramey JR. Intrarectal tear with bleeding from water skiing accident. J Fla M ed Assoc. 1974;61:162. Bibliographic Links
The patient's postoperative course was uncomplicated. By day 3, she was ambulato ry, her colostomy was functional, and she was begun on a progressive diet. Becau se of the extensive contamination, 7 days of antibiotics were administered; fort unately, she demonstrated no infectious complications. At discharge, anal sphinc ter tone and anal rectal reflex remained markedly abnormal. Outpatient manometric anorectal physiologic testing was performed on postoperati ve day 17. Resting sphincter pressure was 10 to 20 mm Hg (normal 60-90 mm Hg), a nd squeeze pressure was 25 to 70 mm Hg (normal 1.5-2.0 times the rest pressure). A rectal balloon could be sensed at 20 cc of air insufflation. Bilateral pudend al nerve terminal motor latency was normal (2.0 +/- 0.2 ms). Endorectal sonograp hy demonstrated a complete disruption of the external sphincter anteriorly. After 6 weeks, her perineal laceration was nearly healed, and her resting sphinc ter tone normalized. She was started on an intermittent enema-training program. After 4 months of training, she was able to remain continent to instilled water, and a repeat endorectal sonogram revealed that the external sphincter muscles h ad healed. She underwent colostomy takedown, and 5 months after injury, she was continent to both stool and flatus, and she resumed normal activity. DISCUSSION From 1990 to 1995, there was a fourfold increase in injuries related to personal watercraft use. Currently, the rate of occurrence of emergency department injur ies attributable to personal watercraft use is 8.5 times higher than that attrib utable to the use of motorboats. [1] The majority of these injuries involve coll isions with bridges, docks, or other watercraft, but occasional high-speed water impact injuries and water jet injuries have been described. This case represent s two previously undescribed injuries from the water jet of a personal watercraf t: a traumatic disruption of the external anal sphincter, and a full thickness r ectal perforation with extensive intraperitoneal soiling. Although similar mecha nisms of injury have previously been reported, they describe injuries to the uro genital tract (Table 1). [10-13] Graphic Table 1 The mechanism by which personal watercraft are propelled is a water jet generate d by an impeller located within the watercraft. Although the engines are compose d of two or three cylinders (65-135 horsepower), they generate enough thrust to propel the craft to speeds of 50 to 70 mph. [3,14,15,] This requires considerabl e force, given that a modern personal watercraft may weight between 300 and 600 pounds. [3,14,15] Although data available to consumers regarding the hydrodynami cs of personal watercraft are limited because most companies consider this infor mation to be professional "industry secrets," one company, Kawasaki Motor Corpor ation, does publish thrust specifications. [16] The thrust listed for the Kawasa ki line of crafts ranges between 595 and 800 psi, [16] a Figure justbelow the ra nge commonly used for industrial cleaning (1000-10,000 psi). The highly destructive potential of water jets has been previously well document ed; it includes major gastrointestinal, vascular, and soft tissue trauma. [17-22 ] The kinetic energy imparted by the water jet is equal to the product of the ma ss of the water and the velocity squared (KE = mv2). Given the high velocity of the water jets used in personal watercraft, it is not surprising that they can i mpart significant kinetic energy to a patient and cause significant injuries. The pattern of tissue damage described in industrial water jet case reports is a lmost identical to that seen in cases of high velocity missile trauma. [17-22] A lthough injuries typically involve small, innocent-appearing skin penetration si tes, devastating deep tissue trauma occurs as the kinetic energy from the water
jet disperses. In contrast to a high velocity missile, however, is the continuou s nature of the water jet. Injuries to the extent noted in this case are therefo re entirely consistent with the force generated by these vehicles. A highly similar pattern of injury to the one described in this case has been ob served in high velocity water impacts-the most common mechanism being a fall whi le water-skiing (Table 2). This event, also referred to as the "water skier's do uche," describes a douche of water forcefully injected into the vagina or rectum when a water skier falls backwards (typically while being pulled from a startin g position) and the perineum crashes into the water. In both water-skiing and pe rsonal watercraft jet injuries, the water is traveling at a high velocity relati ve to the individual. Predictably, the patterns of injury are similar as water i s forced into the vagina or the rectum. Twenty-three rectal and vaginal injuries similar to the ones in this case have been reported from all forms of high velo city water impacts [23-43] (Table 2). In no case was the victim wearing a wet su it. Graphic Table 2 As in the water impact cases, there are no reported cases of perineal or rectal water jet injuries occurring with the use of a wet suit. A wet suit is recommend ed during personal watercraft operation to provide protection against water jet contact, traumatic high velocity water impact, and also to protect the skin agai nst lacerations resulting from collisions with fixed objects. The Personal Water craft Industry Association and the USCG both recommend that the minimal attire i nclude a half or full wet suit and a USCG inherently buoyant Type II lifejacket, which will turn an unconscious person face up; a Type III lifejacket will not. [44-46] For maximum protection, they also recommend wearing gloves to protect fr om cuts and lacerations, and goggles to protect from traumatic water impact inju ries to the eyes. [44-47] These safety recommendations, however, remain largely ignored by the public -- p rimarily as a result of a serious degree of public ignorance of the potential da ngers involved in personal watercraft use and inadequate regulation of personal watercraft use. The recent explosive popularity of personal watercraft has made effective public safety education and regulation extremely difficult. The personal watercraft industry needs to promote public education of required s afety equipment and the dangers of improper personal watercraft use. Although on e owner's manual does specifically warn of potential "serious rectal or vaginal injuries" that could result from the water jet, [47] the mention is brief, and t he ultimate potential for injury is not clearly defined. In addition, we were un able to locate any scientific reports detailing the capability of a wet suit to protect against 800 pounds of thrust. Will all brands of wet suits provide adequ ate protection, or just some of them? Personal watercraft manufactures and the P ersonal Watercraft Industry Association should take a leading role in wet suit t esting so that industry safety standards can be developed and promoted. CONCLUSION This is the fifth reported injury from a personal watercraft water jet. The inju ry could have been prevented or minimized if the occupant had worn proper protec tive equipment. Her lack of protective equipment is attributable to inexperience and ignorance of the dangers involved in personal watercraft use, and is repres entative of the fundamental lack of consumer knowledge regarding the potential d angers involved in personal watercraft use. A wet suit should be required as min imal equipment to guard against high velocity water impact and water jet injurie s.
Acknowledgments The authors acknowledge Dr. Jean Luc Scemaa, Gunda Smith, and Per K. Audresen, f or their assistance with the translation of the French and Swiss articles cited in the bibliography. REFERENCES 1. Branche CM, Conn JM, Annest JL. Personal watercraft-related injuries. A growi ng public health concern. JAMA. 1997;278:663. Bibliographic Links [Context Link] 2. Hamman BL, Miller FB, Fallat ME, Richardson JD. Injuries resulting from motor ized personal watercraft. J Pediatr Surg. 1993;28:920. Bibliographic Links [Cont ext Link] 3. Tyler BC, Garrison HG. Injuries associated with personal watercraft. An emerg ing epidemic in need of legislative action. N C Med J. 1997;58:284. Bibliographi c Links [Context Link] 4. Gomez GA, Martin LC, Castro MR. Nautical accidents. Unique injuries. Surg Cli n North Am. 1991;71:419. Bibliographic Links [Context Link] 5. Francis RA, Vize R. Personal watercraft injuries: experience at a community h ospital. Mo Med. 1994;91:241. Bibliographic Links [Context Link] 6. Swinburn EE. Serious injuries in jet skiers. Med J Aust. 1996;165:606. Biblio graphic Links [Context Link] 7. Jeffery RS, Caiach S. Waterbike injuries. Br J Sports Med. 1991;22:128. [Cont ext Link] 8. Vernberg D, Fine EG. Personal watercraft injuries. JAMA. 1989;261:1883. Bibli ographic Links [Context Link] 9. Barch P, Baum E. Personal watercraft-related injuries. JAMA. 1998;279:433. [C ontext Link] 10. Wein P, Thompson DJ. Vaginal perforation due to jet ski accident. Aust N Z J Obstet Gynaecol. 1990;30:384. Bibliographic Links [Context Link] 11. Muller RJ. Jet-ski injury: a case history. J La State Med Soc. 1993;145:27. [Context Link] 12. Haefner HK, Anderson HF, Johnson MP. Vaginal laceration following a jet-ski accident. Obstet Gynecol. 1991;78(5Pt2):986. Ovid Full Text Request Permissions Bibliographic Links [Context Link] 13. Fauconnier A, Legier JP, Nicoloso E. Vaginal pressure trauma: a complication of jet-skis. J Gynecol Obstet Biol Reprod (Paris). 1995;24:604. Bibliographic L inks [Context Link] 14. Argetsinger A. Deaths rise as more people ride the waves. Washington Post. A ugust 27, 1995: A1,6,7. [Context Link] 15. Mulholland E, Fitzgerald D. Three's not a crowd. Splash. 1997;10:58. [Contex t Link] 16. 1997 Jet Ski[registered sign] Watercraft Series Specifications Brochure. 199 6. Kawasaki Motors Corporation USAP/N 99969-2556. [Context Link] 17. Calder IM, Boustred D. High-pressure water jet injury. BMJ. 1980;280:1620. B ibliographic Links [Context Link] 18. De Baux JL. High-pressure water jet injury. BMJ. 1980;280:1417. [Context Lin k] 19. Kon M, Sagi A. High-pressure water jet injury of the hand. J Hand Surg [Am]. 1985;10:412. [Context Link] 20. Niell RW, George B. Penetrating intra-abdominal injury caused by high-pressu re water jet. BMJ. 1969;2:357. [Context Link] 21. Harvey RL, Ashley DA, Yates L, et al. Major vascular injury from high-pressu re water jet. J Trauma. 1996;40:165. Ovid Full Text Request Permissions Bibliogr aphic Links [Context Link] 22. Walker WA, Burns RP, Adams J Sr. High-pressure water injury. J Trauma. 1989; 29:258. Ovid Full Text Request Permissions Bibliographic Links [Context Link] 23. Pfanner D. Salpingitis and water-skiing. Med J Aust. 1964;1:320. Bibliograph ic Links [Context Link] 24. Brisbane Gynaecologist. The dangers of water-skiing. Med J Aust. 1968;1:616. [Context Link]
25. McCarthy GF. Hazards of water-skiing. Med J Aust. 1969;1:481. Bibliographic Links [Context Link] 26. Morton D. Gynaecological complications of water-skiing. Med J Aust. 1970;1:1 256. Bibliographic Links [Context Link] 27. Tweedal PG. Gynecological hazards of water-skiing. Can Med Assoc J. 1973;108 :20. Bibliographic Links [Context Link] 28. Eddington RF. Vaginal injuries due to water-skiing. Can Med Assoc J. 1978;11 9:310. [Context Link] 29. Kizer KW. Medical hazards of the water skiing douche. Ann Emerg Med. 1980;9: 268. Bibliographic Links [Context Link] 30. Gray HH. A risk of waterskiing for women. West J Med. 1982;136:169. [Context Link] 31. Knutz WD. Water-ski spill and partial avulsion of the uterine cervix. N Engl J Med. 1983;309:990. [Context Link] 32. Mavrelis PG, Wylie RR. Water-ski colon. N Engl J Med. 1984;311:1128. Bibliog raphic Links [Context Link] 33. Gensburg RS, Wojeik WG. Vaginally induced pneumoperitoneum during pregnancy. AJR Am J Roentgenol. 1988;150:595. Bibliographic Links [Context Link] 34. David SK Jr, Guarisco JL, Coulon RA. Pneumocephalus secondary to a high-pres sure water injury to the nose. Arch Otolaryngol Head Neck Surg. 1990;116:1435. B ibliographic Links [Context Link] 35. Kalaichandran S. Vaginal laceration: A little known hazard for women watersk iers. Can J Surg. 1991;34:107. [Context Link] 36. Niv J, Lessing JB, Hartuv J, Peyser MR. Vaginal injury resulting from slidin g down a water chute. Am J Obstet Gynecol. 1992;166:930. Bibliographic Links [Co ntext Link] 37. Lee RY, Miller S, Thorpe C. Intrarectal tear from water skiing. Am J Gastroe nterol. 1992;87:662. Bibliographic Links [Context Link] 38. Rudoff JC. Vulvovaginal water-sking injury. Ann Emerg Med. 1993;22:1072. Bib liographic Links [Context Link] 39. Johnson LB. A case report: peritonitis after water-skiing. Lakartidningen. 1 993;90:2383. Bibliographic Links [Context Link] 40. Perlman SE, Hertweck SP, Wolfe WM. Water-ski douche injury in a premenarchea l female. Pediatrics. 1995;96:782. Bibliographic Links [Context Link] 41. Smith BL. Vaginal laceration caused by water skiing. J Emerg Nurs. 1996;22:1 56. Ovid Full Text Bibliographic Links [Context Link] 42. Synder RG, Snow CC. Fatal injuries resulting from extreme water impact. Aero sp Med. 1967;38:779. Bibliographic Links [Context Link] 43. Synder RG. Human tolerance limits in water impact. Aerosp Med. 1965;36:940. Bibliographic Links [Context Link] 44. Calkin, Jo [[email protected]]. Outreach Coordinator, Office of Boating Safety, United States Coast Guard. E-mail to the author, September 19, 1997. [C ontext Link] 45. United States Coast Guard Office of Boating Safety Homepage. Available at: h ttp.//www.USCGboating.org/index1.html. Accessed December 12, 1997. [Context Link ] 46. Personal Watercraft Industry Association Homepage. Available at: http://www. sea-doo.com/sd/safety/pwia.html. Accessed February 19, 1998. [Context Link] 47. 1997 Yamaha Waverunner Owner's Manual, pp 1-1 to 1-10. 211 Yamaha Motor Co, LTD, Shizuoka-Ken Japan. [Context Link] 48. Ramey JR. Intrarectal tear with bleeding from water skiing accident. J Fla M ed Assoc. 1974;61:162. Bibliographic Links
