22-Year History of Treating Golden Gate Bridge Fall Victims at Marin Health Medical Center

John Maa, MD and Edward Alfrey, MD

Over the 85-year history of the Golden Gate Bridge (GGB) since it opened on May

28, 1937, an estimated 1,800 victims have taken their lives through an intentional fall from the bridge walkway into the San Francisco Bay1. The bridge is 1.7 miles long and 90 feet wide, over which 40 million motor vehicles drive annually2 . The GGB is reportedly the most photographed structure in the world, and also one of the most common destinations for suicides in the world. A fall from the GGB is one of the most effective ways to commit suicide, as the average rate of speed upon entering the water is 75 mph. The mortality from the 220foot fall has been estimated over the years from longitudinal studies around 98%3 .

For many years, victims recovered by the Coast Guard were transported to Letterman Hospital in the Presidio, untilLetterman’sclosurein19914. After 1991, patients were transported to San Francisco General Hospital if recovered on the San Francisco side of the Bay, or to Marin General Hospital (MGH) if they were retrieved on the Marin County side of the Bay. More recently, a change in emergency medical services triage policy resulted in all patients being transported to MGH, as the sole receiving facility. MGH was renamed Marin Health Medical Center (MHMC) in 2019.

MHMC is an American College of Surgeons (ACS) Level III verifiedtraumacenterwith24/7neurosurgicalcoveragelocated in Greenbrae in Marin County. A trauma activation results in the in-hospital response by emergency medicine, trauma surgery, with the availability of surgical specialists, critical care, interventional radiology, blood banking, nursing services and support services. The institution has become adept at the resuscitation and care of this patient population, as the primary receiving facility for most of the past decade.

Over the past 22 years, MHMC cared for 26 patients who still had signs of life after being recovered by the Coast Guard following a fall from the GGB. Of these, 14 survived, and 12 expired. There were seven consecutive deaths from 2002 to 2010, whereas 8 of the 9 most recently treated patients between 2017 and 2022 survived. Our survivors averaged nine years younger than those who died (24 versus 33). Ten of the fourteen survivors were aged 25 or younger. The injury severityscorewassignificantly lower over the past decade (43.9 vs 22.8). For the entire 22-year period, the leading injuries were: hemo/pneumothorax 70.8%, spine fractures 62.5%, lung contusions 50%, and rib fracture 50%. Major cardiovascular injuries were associated with an 87.5% mortality, and intracranial injury with a 66.7% mortality. About half of the patients with a hemothorax, pneumothorax, or pulmonary contusion died. A spine injury was associated with death in 26.6% of cases. Five patients required transport to a higher level (ACS Level I) of care for treatment of either unstable pelvic fractures or advanced orthopedic injuries. Survivorsweremorelikelytohaveinjuriesconfinedtothe ribs, vertebral spine, and pelvis, which are associated with a higher survival. Massive intra-abdominal or intra-thoracic hemorrhage, cardiac injury or disruption of the great vessels, tensionpneumothorax,flailchestandintracranialinjuryare less likely to be survivable. Associated injuries such as long bone injuries, friction burns, multiple contusions, and less complex orthopedic trauma were frequently noted, and more likely to be associated with survival.

In the literature, three previous studies have focused on the traumatic injuries sustained after a fall from the GGB, through either autopsy series and/ or chart review. The largest published series of survivors (n=16) was from Letterman Hospital in 19954 . As the hospital closest to the Golden Gate Bridge, Letterman cared for many of the GGB patients before its closure in 1991. In their comparison of survivors (n=16) to fatalities (n=281), they observed that major cardiovascular and intracranial injuries were uniformly lethal.

The previous studies noted key patterns of death – some patients sustain minimal injuries from the fall, but then drown, or are attacked by sharks or other marine wildlife. Those who survive the initial fall and then brought to the hospital are noted to have a high rate of mortality, including delayed death after a period of initial relative stability after being admitted (most often from pulmonary contusion). A third category of patients

represent deceased patients whose bodies are not recovered for days or weeks after the fall, and suffer from the ravages of marine wildlife.

Among survivors – a pattern of injury and mechanism of survival has been described. The fatally injured patients often enter the water horizontally, experiencing maximal deceleration with the largest body surface area exposed to the violent impact. Survivors often report entering the water in a vertical position, feetfirst,ataslightangleandwithmoregradualdeceleration. Distributing the force of the impact over a longer distance allows the kinetic energy to be transferred. One survivor reported touching the bottom of San Francisco Bay. A vertical impact may result in a spine injury or long bone fracture that is more likely to be survivable. Acapulco cliff divers who plunge 150 feet intothePacificOceandemonstratethatverticalentryintothe water can result in minimal injuries, so long as the divers are not caught by winds and land horizontally. Inthefirst26yearsofthebridge’shistory(until1963), there were only two survivors seen after nearly 303 deaths, for a mortality of 99.3% percent. Our published study5was referenced in the San Francisco Chronicle6, and brings the number to approximately 40 known survivors in the history of the Bridge. The majority of survivors were seen after 1968, and the modern reported survival rate around 2% likely reflectstheimprovementsinemergencymedicalresponseand the capabilities of modern medicine, which include Advanced Trauma Life Support, care coordination, and the advances of interventional radiology, trauma surgery, critical care/ anesthesia, and emergency medical services.

We observed a decrease in the injury severity score over the lastdecadeonpresentationtoMHMC(whichmaybereflected in the improved outcomes), which likely resulted from two key factors. First, there was a change in the practice of the Marin Coroner’sOffice.Before2011,allGGBfallvictimswhodidnot surviveunderwentanautopsytoconfirmanatomicinjuries, which resulted in a higher ISS. As of 2010 the practice of routine autopsy was discontinued by the Coroner, and as a result the ISS for deceased patients afterwards were lower as they are based onclinicalandradiologicfindingsalone.Second,theaverage age of the patients in the past decade was nearly ten years younger, which may have contributed to their lower severity of injury. One might also speculate that better organization in care resultedinimprovedoutcomesandefficiencies.Weidentified system improvements after individual cases that strengthened the care processes and increased survival for future patients.

The lethality of a fall from the GGB has catalyzed a number of suicide prevention efforts including a safety net which is now under construction and scheduled to be completed in 20236 . Hopefully these types of injuries will no longer be witnessed afterwards,andourrecentpaperwillrepresentthefinalchapter in this portion of the history of the Golden Gate Bridge.

John Maa, MD, a general surgeon, is an SFMMS past-president.

Edward Alfrey, MD is a General Surgery Specialist.

References

1. https://www.marinij.com/2019/12/12/golden-gatebridge-suicide-barrier-could-be-delayed-two-years/

Accessed May 22, 2022. 2. Blaustein M, Fleming A. Suicide from the Golden Gate

Bridge. Am J Psychiatry. 2009 Oct; 166(10):1111-6. 3. Bateson J. The Final Leap, University of California Press 2012. 328pp 4. Lafave M, LaPorta AJ, Hutton J, Mallory PL 2nd. History of high-velocity impact water trauma at Letterman Army

Medical Center: a 54-year experience with the Golden Gate

Bridge. Mil Med. 1995 Apr;160(4):197-9. 5. Maa J, Levin J, Minnis J, Stahl B, Carroll M, Pajari L, Alfrey A.

Surgery Open Science, In Press 2022. 6. Swan, Rachel. Doctors studied more than 2 decades of

Golden Gate Bridge jumps. Their research shows why some managed to survive. San Francisco Chronicle, Mar 22, 2022.