Injury & Trauma

Injury & Trauma

In 2015 and 2016, more than 1,700 US citizens died from nonnatural causes in foreign countries, excluding deaths in the wars in Iraq and Afghanistan. Motor vehicle crashes—not crime or terrorism—are the number 1 cause of nonnatural deaths among US citizens living, working, or traveling abroad (Figure 3-1). In 2015 and 2016, 484 Americans died in vehicle crashes in foreign countries (28% of nonnatural deaths). Another 312 died of suicide (18%); 309 were victims of homicide (18%), and 307 drowned or died as a result of a boating incident (17%).

Figure 3-1.Leading causes of injury death for US citizens in foreign countries, 2015 & 2016 1, 2, 3, 4
Figure 3-1.Leading causes of injury death for US citizens in foreign countries, 2015 & 20161,2,3,4
1 Data from US Department of State. Deaths of US citizens in foreign countries by nonnatural causes. Washington, DC: US Department of State; [cited 2018 Mar 1]. Available from:
2 Excludes deaths of US citizens fighting wars in Afghanistan or Iraq, and deaths that were not reported to the US embassy or consulate.
3 “Motor Vehicle” includes deaths classified as “vehicle accidents,” including the following subcategories: auto, bus, motorcycle, pedestrian, train, and other.
4 “All Other” includes deaths classified as armed conflict, disaster, hostage-related, natural disaster, other accident, and undetermined/unknown.

Countries may lack emergency care that approximates US standards; trauma centers capable of providing optimal care for serious injuries are uncommon outside urban areas, if they exist at all. Travelers should be aware of the increased risk of certain injuries while traveling or residing internationally, particularly in low- and middle-income countries, and take preventive steps to reduce the chances of serious injury. (For information on motor vehicle crashes and road safety, see Chapter 8, Road & Traffic Safety.)

Violence-Related Injuries

Violence, including suicide and homicide, is a leading worldwide public health problem that affects US citizens traveling, working, or residing internationally. Each year >1.6 million people lose their lives to violence; only one-fifth of the total are casualties due to armed conflict. Rates of violent deaths in low- and middle-income countries are 3 times those in higher-income countries, although variations exist within countries. For longer-term travelers, social isolation and substance abuse, particularly in areas of poverty and rigid gender roles, may increase the risk of depression and suicide. See Mental Health later in this chapter for more detailed information on suicide prevention.

Mexico, the Philippines, Jamaica, and Haiti have the highest number of homicide deaths among US travelers; Mexico accounts for 50% of all homicide deaths in US citizens living or traveling in foreign countries. Criminals may view travelers to their country as wealthy, naïve targets, inexperienced and unfamiliar with the culture and less able to seek assistance once victimized. Traveling in high-poverty areas or regions of civil unrest, using alcohol or drugs, and visiting unfamiliar environments (particularly at night) each increase the likelihood that a traveler becomes a victim of violence (see Safety & Security Overseas in this chapter for more information).

Water and Aquatic Injuries

Drowning is often the leading cause of injury death to US citizens visiting countries where water recreation is a major activity. Although risk factors remain to be defined clearly, lack of familiarity with local water currents and conditions, inability to swim, and absence of lifeguards on duty likely contribute to drowning deaths. Rip currents can be especially dangerous. Diving into shallow water is a risk factor for head and spinal cord injuries, with young men affected disproportionately. Alcohol or drug use is a factor in some cases.

Boating can be a hazard, especially if boaters are unfamiliar with the equipment they are using, do not know proper boating etiquette or rules for watercraft navigation, or are new to the water environment in a foreign country. Many boating fatalities result from inexperience or failure to wear a personal flotation device (lifejacket); travelers should have enough lifejackets on board for all passengers. Children and weak swimmers should wear a lifejacket at all times while boating. Advise travelers not to ride in boats operated by obviously inexperienced, uncertified, or intoxicated drivers.

Scuba diving is a frequent pursuit of travelers to coastal destinations. Researchers estimate the death rate among divers worldwide to be approximately 16 deaths per 100,000 divers per year. Travelers should either be experienced divers or dive with a reputable dive shop and instructors. See Scuba Diving: Decompression Illness & Other Dive-Related Injuries later in this chapter for a more detailed discussion about diving risks and preventive measures.

Travelers should not swim alone or in unfamiliar waters and should wear appropriately sized and US Coast Guard–approved lifejackets whenever participating in water recreation activities. If travel includes planned water activities, travelers should consider bringing their own lifejackets with them. Improving swimming skills, learning safe rescue techniques (such as use of poles or ropes as rescue aids so responders can avoid entering the water), and taking cardiopulmonary resuscitation (CPR) classes can substantially increase the likelihood of survival in an emergency. See the World Health Organization drowning resources ( and the International Life Saving Federation ( for more information.

Other Unintentional Injuries

In developing countries where building codes are not enforced or do not exist, fires represent a substantial risk to traveler health and safety. Often there are no smoke alarms or access to emergency services, and the fire department’s focus is on putting out fires rather than on fire prevention or victim rescue.

To prevent fire-related injuries, travelers should select accommodations no higher than the sixth floor (fire ladders generally cannot reach higher than the sixth floor) and confirm that hotels have smoke alarms and, preferably, sprinkler systems. Travelers may want to bring their own smoke alarms with them, and they should always identify at least 2 escape routes from buildings. Crawling low under smoke and covering one’s mouth with a wet cloth are helpful in escaping a fire. Families should agree on a meeting place outside the building in case of a fire. The National Fire Protection Association has additional guidance on hotel fire safety for domestic travel that may also be useful internationally: see

Carbon monoxide (CO) inhalation, poisoning, and death can occur during fires but may also be the result of exposure to improperly vented heating devices. Travelers may want to bring a personal CO detector that can sound an alert in the presence of this lethal gas. Engine exhaust is a dangerous, unanticipated source of CO; remind travelers to avoid diving and swimming off the back of boats where exhaust fumes typically discharge.

Adventure activities such as mountain climbing, skydiving, whitewater rafting, off-roading, kayaking, skiing, and snowboarding are popular with travelers. A lack of rapid emergency trauma response, inadequate trauma care in remote locations, and sudden, unexpected weather changes compromise safety and hamper rescue efforts, delay care, and reduce survivability. For recreational activities with a risk of falling, helmet use is strongly encouraged; if helmets are unlikely to be available at the destination, travelers should bring them from home.

In 2017, 15 US citizens abroad died in aircraft crashes. Travel by local, lightweight aircraft in many countries can be risky. Travel on unscheduled flights, in small aircraft, at night, in inclement weather, and with inexperienced pilots carries the highest risk. Travelers should avoid using local, unscheduled, small aircraft, and refrain if possible from flying in bad weather and at night. If available, choose larger aircraft (>30 seats), as they are more likely to have undergone more strict and regular safety inspections. Larger aircraft also provide more protection in the event of a crash.

Travel Preparation Tips

Health care providers, vendors of travel services, and travelers themselves should consider taking the following actions when planning for a trip outside the United States:

  • Purchase special travel health and medical evacuation insurance if destinations include countries where there may not be access to good medical care (see Chapter 6, Travel Insurance, Travel Health Insurance & Medical Evacuation Insurance).
  • Learn basic first aid and CPR before traveling internationally with another person.
  • Bring a travel health kit, customized to anticipated itinerary and activities.
  • Review US State Department travel advisories and alerts (, and check the US embassy or consulate ( for country-specific personal security risks and safety tips.
  • Enroll in the US State Department’s Smart Traveler Enrollment Program ( Enrolled travelers receive emails about safety conditions at their destination and direct embassy contact in case of natural disasters and man-made emergencies, such as political unrest, rioting, and terrorist activity.


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Erin M. Parker, Erin K. Sauber-Schatz, David A. Sleet, Michael F. Ballesteros